PNHP

Houston retirees face 50 percent premium increase

Houston retirees face 50 percent premium increase

Parker increases insurance premiums of city retirees

By Bradley Olson
Houston Chronicle
March 29, 2010

Working to close a looming $100 million budget shortfall projected for next year, Mayor Annise Parker has sharply increased the monthly insurance premiums that thousands of retired city of Houston employees must pay, prompting outrage from retirees.

Beginning May 1, more than 4,000 retirees under 65 will face a nearly 50 percent increase in their insurance premiums, a budget fix the mayor imposed without consulting City Council.

Parker said the city decided to restructure the benefit payments because retirees under 65 have far higher use of insurance claims than active employees or retirees over 65, whose insurance is subsidized by Medicare.

“People are being priced out of benefits. I’m hoping City Council will take another look at this thing,” said (Bill Elkin, executive director of the Houston Police Retired Officers Association)

http://www.chron.com/disp/story.mpl/front/6935520.html

Comment: 

By Don McCanne, MD

So paraphrasing Mayor Annise Parker of Houston, the greater health care needs of the retirees made it important to restructure their premiums to make them even more unaffordable.

Now think about how the new health reform legislation would address this problem. It looks like these retirees under 65 would have to keep the insurance they have, without the choice of other options, and pay 50 percent higher premiums.

What if everyone were covered by an improved Medicare program? There would not be an issue here.

The point is that we have not reformed our health care financing system; we’ve only tweaked it. We have to keep working to be sure that people understand what didn’t happen this time around.

Houston retirees face 50 percent premium increase

Parker increases insurance premiums of city retirees

By Bradley Olson
Houston Chronicle
March 29, 2010
Working to close a looming $100 million budget shortfall projected for next year, Mayor Annise Parker has sharply increased the monthly insurance premiums that thousands of retired city of Houston employees must pay, prompting outrage from retirees.
Beginning May 1, more than 4,000 retirees under 65 will face a nearly 50 percent increase in their insurance premiums, a budget fix the mayor imposed without consulting City Council.
Parker said the city decided to restructure the benefit payments because retirees under 65 have far higher use of insurance claims than active employees or retirees over 65, whose insurance is subsidized by Medicare.
“People are being priced out of benefits. I’m hoping City Council will take another look at this thing,” said (Bill Elkin, executive director of the Houston Police Retired Officers Association)
http://www.chron.com/disp/story.mpl/front/6935520.html

So paraphrasing Mayor Annise Parker of Houston, the greater health care needs of the retirees made it important to restructure their premiums to make them even more unaffordable.
Now think about how the new health reform legislation would address this problem. It looks like these retirees under 65 would have to keep the insurance they have, without the choice of other options, and pay 50 percent higher premiums.
What if everyone were covered by an improved Medicare program? There would not be an issue here.
The point is that we have not reformed our health care financing system; we’ve only tweaked it. We have to keep working to be sure that people understand what didn’t happen this time around.

Who is Donald Berwick?

Obama to nominate Berwick to head CMS

By the Associated Press
ModernHealthcare.com
March 28, 2010

An administration official says President Barack Obama will nominate healthcare scholar Donald Berwick to be CMS administrator.

Berwick, a pediatrician and noted health policy expert, is president and CEO of the not-for-profit Institute for Healthcare Improvement in Cambridge, Mass.

Berwick is also a professor of pediatrics and healthcare policy at the Harvard Medical School and a professor of health policy and management at the Harvard School of Public Health.

An elected member of the Institute of Medicine of the National Academy of Sciences, Berwick served as a member of the IOM’s Committee on Quality of Health Care in America, which launched the slowly building revolution in healthcare quality improvement. The committee published in November 1999 To Err is Human: Building a Safer Health System, which gave the healthcare industry one of its most totemic phrases: “At least 44,000, and perhaps as many as 98,000 Americans, die in hospitals each year as the result of medical errors.”

http://www.modernhealthcare.com/article/20100328/NEWS/303279991/-1

And…

Donald Berwick speaks up

Quote of the Day
November 18, 2005

‘A Deficiency Of Will And Ambition’: A Conversation With Donald Berwick

By Robert Galvin
Health Affairs
January 12, 2005

Donald Berwick is president and chief executive officer of the Institute for Healthcare Improvement (IHI) in Boston, Massachusetts. Bob Galvin is director, Global Health Care, at the General Electric Company in Fairfield, Connecticut.

Excerpts

Galvin: I’m interested in your thoughts on the impact of the Leapfrog Group, an effort organized by the purchasers of health care, both private-sector employers and public purchasers. The Leapfrog agenda has focused on… benefit incentives that engage consumers and patients in the quality and cost of care…

Berwick: The one part of the (Leapfrog) plan that I am absolutely against at the moment is the shifting of burden to individual patients. I do not believe that making the individual American patient more “cost-sensitive” has any rationale in science, ethics, or evidence. It will fail, and it will fail miserably. It will result in a shifting of care away from the people who need it the most. It is a displacement of responsibility for changing the system. You know, if CalPERS or Xerox or GE can’t change care through using its purchasing power, then I absolutely promise you that Mrs. Jones can’t. The idea that she will now be more sensitive because she pays an extra ten bucks out of pocket is, to me, nearly stupid. So I really disagree with that element of the agenda.

Internationally, when one looks at high-performing systems around the world – and ours is nowhere near the highest-performing one – it is almost a routine characteristic of the best systems that they have first-dollar coverage, and there is no attempt to make patients pay more when they’re sick, which is a stupid thing to do.

****

Galvin: The conceptual basis of this is – as unsettling as it may be to “dangle money” to increase motivation-grounded in personality and motivation theory. In private industry, we would simply call it understanding what makes people tick. People respond to incentives. So part of the pay-for-performance movement is based on this idea that clinicians are really no different than other people and that they’ll respond to incentives.

Berwick: At the individual level, I don’t trust incentives at all. I do not think it’s true that the way to get better doctoring and better nursing is to put money on the table in front of doctors and nurses. I think that’s a fundamental misunderstanding of human motivation. I think people respond to joy and work and love and achievement and learning and appreciation and gratitude-and a sense of a job well done. I think that it feels good to be a good doctor and better to be a better doctor. When we begin to attach dollar amounts to throughputs and to individual pay, we are playing with fire. The first and most important effect of that may be to begin to dissociate people from their work. That’s really where we’ve come to, and we’ve done it by pay-for-performance in terms of throughput measurements and manipulating payment schemes.

****

Galvin: Let me move to another issue, and that is the explosion that’s about to play out in biomedical innovation. If you talk to patients… they are also interested in innovations that can cure them or their loved ones. They speak about it with pride and passion…

Berwick: I do think this: We have a learning disability in this country with respect to the difference between technologies that really do help and technologies that are only adding money to the margins of the companies that make them, without essentially paying their way in value. One of the drivers of low value in health care today is the continuous entrance of new technologies, devices, and drugs that add no value to care. If we had strong national policy, it would allow us to know the difference, and I would more fully support what I think you’re correctly proposing, which is an innovations value. We need to help the public know the difference. There’s a big agenda here, possibly for government, to help create a public awareness that more is not necessarily better. Frequently it’s worse. So we can be smart about what we buy and what we choose not to buy.

****

Galvin: Many of us on the purchaser side see radically improving the efficiency of the system as a way to free up capital to cover the uninsured and to fund innovation. How do you think efficiency fits into the quality agenda?

Berwick: Let’s define efficiency as making sure that every dollar you spend gets a dollar of value back, so that efficiency is the opposite of waste. Right from the start, it has been one of the great illusions in the reign of quality that quality and cost go in opposite directions. There remains very little evidence of that. There may be some innovations that raise cost while raising quality, but many, many improvements reduce costs.

What puzzles me is how to access efficiency as a social agenda in health care. There are couple of problems. The first is that a lot of people make a lot of money on inefficiency – on production of things that have no value. So the minute you try to become truly efficient, you’re going to run into stakeholders who are going to tell you that you’re harming care, and the knee-jerk reactions of doctors and others will be to reinforce that idea. And they include you. I mean, GE pays out of one pocket and then makes money on products and services that do not add real value.

****

Galvin: There’s a threshold issue with most purchasers when you talk about getting a patient financially engaged. That is that no one ends up paying more because they’re sick. The only option would be to pay less. Let me give you an example: Many employer-sponsored benefit plans across the country have hospital copays as part of their cost sharing. This means that there is a fee of a hundred or several hundred dollars when one is admitted to a hospital. In these benefit designs, while most people have pretty free choice of what hospital they go to, going to the one that objective data demonstrate is of superior quality and efficiency would result in a waiver of the copay.

Berwick: Well, I can be an empiricist about it. Go ahead and try it. I shudder to think about what may happen, because in the end, that s
ick patient arriving at that hospital is in the absolutely weakest position at that particular point to decide, “Aha, I’m going to save a hundred dollars and go elsewhere.” That person is more likely to be poor, more likely to be black, more likely to be a low-wage earner. I think it’s regressive social policy, and I predict that it won’t work. It’s a displacement of responsibility from the stewards who actually have the job of crafting systems to meet the needs of the people who come to them for help. I think it’s a bad, bad policy, and I don’t see it playing out productively in other countries, either.

Full interview:
http://content.healthaffairs.org/cgi/content/full/hlthaff.w5.1/DC1

https://pnhp.org/news/2005/november/donald-berwick-speaks-up

And…

Checking in with Donald Berwick, President and CEO, Institute for Healthcare Improvement

Kaiser Health News
November 12, 2009

An interview of Donald Berwick (video 8:39)

http://www.kaiserhealthnews.org/Multimedia/2009/November/111209Berwick.aspx

And…

Video Segments of Dr. Donald Berwick from the Documentary “Money Driven Medicine”

Health Beat by Maggie Mahar
The Century Foundation
March 26, 2010

Nine video clips (total 9:38)

http://www.healthbeatblog.com/2010/03/video-segments-of-dr-donald-berwick-from-the-documentary-money-driven-medicine.html

Comment: 

By Don McCanne, MD

Soon everyone will know what Donald Berwick is – a Harvard professor and head of the Institute for Healthcare Improvement, about to become the administrator of CMS (Centers for Medicare and Medicaid Services), assuming that he survives the acrimonious vetting process in our highly politicized Congress.

More importantly than what, today’s message tries to show who he is by repeating a prior Quote of the Day extracted from an interview of him published in Health Affairs five years ago. Also included are links to more recent video interviews of him (total less than 20 minutes).

The state’s single-payer solution

By Benjamin Day and Peter Hiam
The Boston Globe, March 29, 2010

NOW THAT Congress has passed a national health reform bill that will not fully kick in until 2014, attention will focus again on this state’s effort to make a success of near-universal coverage.

Governor Patrick and the Legislature are moving forward with plans to control health care costs here. They are the highest in the nation and crippling state, municipal, business, and household budgets. The effort is desperately needed, but the proposals under consideration will not work because they don’t go far enough.

We know because we’ve already tried them in Massachusetts. Overwhelming evidence suggests that nothing will work short of adopting a “single payer’’ system — under which all residents are covered by a public, comprehensive plan — or regulating the private health insurance system under a uniform set of rules and an effective budget that allows public control over the resources allocated to the health care industry.

Patrick has proposed regulating the rates that hospitals can charge for services, as well as scrutinizing health care premium hikes for small businesses. This was essentially the state’s policy from 1975 to 1991, when the Massachusetts Rate Setting Commission set rates for the state’s purchase of health care services and products, placed budget constraints on hospitals, and gave the Division of Insurance the power to deny premium increases in some cases. Two legislative task forces have recently recommended paying providers on an annual per patient basis (capitation) instead of per service (fee-for-service) to control costs. This was a hallmark of early managed care — the practice legislators hoped would control costs when they abandoned rate setting during the 1990s, but which generated significant backlash from doctors and patients. Rate setting was neither bad nor completely ineffective when we had it, but neither rate setting nor capitation addressed the root causes of our rising health care costs, and both allowed costs to continue climbing at unsustainable rates.

The United States spends almost twice as much per person on health care as any other country in the world, and yet has some of the worst health outcomes of all developed nations. This means we spend a lot on care that does not contribute to better care, and there is extraordinary room for cost control that does not reduce access to or quality of care. However, we often pursue cost control strategies that are not based on evidence, and are designed to limit political opposition from the health care industry, for which our high costs are its high income. These efforts either don’t work at all, or don’t work on a scale that will have a noticeable impact on a system with double-digit premium inflation.

To a large extent, our high spending is due to a fragmented system where providers deal with hundreds of different insurers, all with different rules. This drives up administrative costs in the system, and means we lack what other jurisdictions have to effectively control costs: the ability to budget the health care system and publicly plan the allocation of limited resources to the communities and areas of care that need them most. This is why only nations with uniform payment systems and an extraordinary level of public oversight have been able to “bend the cost curve’’ without hurting health outcomes.

Effective cost control has proven to be politically impossible, particularly in Massachusetts. However, another failed attempt at cost control is unaffordable for the state, our municipalities, businesses, and households. If Patrick and the Legislature hope to avoid joining the company of their predecessors, they must do more than rehash the state’s cost control programs of the last 30 years.

Benjamin Day is the executive director of Mass-Care: The Massachusetts Campaign for Single Payer Health Care. Peter Hiam was chairman of the Rate Setting Commission from 1978 to 1982 and commissioner of insurance for Massachusetts from 1983 to 1987. 

http://www.boston.com/bostonglobe/editorial_opinion/oped/articles/2010/03/29/the_states_single_payer_solution/

In Big Pharma's grasp

Physicians first in line to be manipulated

By ROB KIEFNER
Letter to the editor, Concord (N.H.) Monitor
March 28, 2010

While the unholy and enigmatic alliances between lobbyists, insurance companies and their friends in Congress are responsible in large part for the unsettling vicissitudes of health care reform, Big Pharma must surely share in the blame game as well.

No doubt we have all been beneficiaries of research and development, which has led to major breakthroughs in all fields of medicine. We are living longer and, some would argue, healthier lives as a result of medications that forestall the damage due to age-related illness and self-neglect, or bail us out of situations that would have knocked off our grandparents.

But these days Big Pharma is throwing billions of dollars into marketing drugs that really don’t do anything new or exciting. In a disturbing trend, pharmaceutical companies are in the business of manufacturing a diagnosis to their drug, rather than working on a new drug for an existing condition. From a physician’s point of view, we’re seeing resources shifting from the development of important new drugs to the marketing of “me too” variants of existing drugs. In an effort to gain or expand upon patent protection, an existing drug might be tweaked or repackaged ever so slightly, at great cost but relatively little benefit to the public.

So how do drug companies manage to sell drugs we don’t need for conditions we don’t have? Ah, the power of multilevel marketing.

Sadly, physicians are first in line to be manipulated. Our medical journals consist almost entirely of glossy pharmaceutical ads, with an occasional scientific article thrown in to justify their publication. And there are always those cozy and questionable relationships between physician researchers in academic medical centers who run the “objective” clinical trials for the drug companies. In the marketing world, a minor improvement in outcomes for an expensive “me too” drug is tantamount to the discovery of penicillin.

How does this information of dubious value make its way to the office-based physician? At times, the message is transported on the wings of angels – willowy twentysomething supermodels turned drug reps who ordinarily wouldn’t talk to a frumpy old guy like me. The trouble is, after meeting with them, I can’t remember which drug they were promoting. But there’s a drug for that, too.

The next level of marketing involves the lavish spending by pharmaceutical companies upon members of Congress, which amounted to approximately $275 million last year. Lots of money can coax our elected representatives to feign horror at the prospect of decreasing the duration of patents, or importing cheaper drugs from elsewhere in the

world. A lobbyist’s dream come true was the provision in the Medicare drug benefit (Part D) that has prohibited the government from negotiating pricing on drugs for Medicare recipients.

Finally, and perhaps most flagrantly, drug companies are able to convey their convoluted messages to the public with direct-to-consumer advertising. The United States and New Zealand are the only countries that permit DTC advertising of prescription drugs.

At an estimated cost of $4 billion in the United States last year, DTC advertising is another colossal waste of money in our health care system.

During a recent 30-minute evening network news program, I counted 10 separate pharmaceutical commercials, all with happy people cured of their depression, high cholesterol, peripheral vascular disease and asthma. These smiling and confident folks don’t even break stride as the narrator rattles off a few dozen potentially fatal side effects in the last half of the commercials.

Patients then bring their requests to the doctor’s office. With little time, and less energy to object, doctors take the path of least resistance and write the costly prescription. Mission accomplished.

No wonder physicians who have been practicing for a while are suffering from therapeutic nihilism.

A more comprehensive cure for all the aforementioned conditions is to get off the couch and stop watching TV.

It’s a bitter pill to swallow, but Big Pharma has us all in its grasp.

And, by the way, gentlemen, if widely advertised medications do what they are supposed to do for more than four hours, please don’t call your doctor. Dust off the Rolodex or dig out the little black book and see if any of those old girlfriends want to hear about it.

(Rob Kiefner is a family physician in Concord.)

http://www.concordmonitor.com/apps/pbcs.dll/article?AID=/20100328/OPINION/3280323&template=single

In Big Pharma’s grasp

Physicians first in line to be manipulated

By ROB KIEFNER
Letter to the editor, Concord (N.H.) Monitor
March 28, 2010

While the unholy and enigmatic alliances between lobbyists, insurance companies and their friends in Congress are responsible in large part for the unsettling vicissitudes of health care reform, Big Pharma must surely share in the blame game as well.

No doubt we have all been beneficiaries of research and development, which has led to major breakthroughs in all fields of medicine. We are living longer and, some would argue, healthier lives as a result of medications that forestall the damage due to age-related illness and self-neglect, or bail us out of situations that would have knocked off our grandparents.

But these days Big Pharma is throwing billions of dollars into marketing drugs that really don’t do anything new or exciting. In a disturbing trend, pharmaceutical companies are in the business of manufacturing a diagnosis to their drug, rather than working on a new drug for an existing condition. From a physician’s point of view, we’re seeing resources shifting from the development of important new drugs to the marketing of “me too” variants of existing drugs. In an effort to gain or expand upon patent protection, an existing drug might be tweaked or repackaged ever so slightly, at great cost but relatively little benefit to the public.

So how do drug companies manage to sell drugs we don’t need for conditions we don’t have? Ah, the power of multilevel marketing.

Sadly, physicians are first in line to be manipulated. Our medical journals consist almost entirely of glossy pharmaceutical ads, with an occasional scientific article thrown in to justify their publication. And there are always those cozy and questionable relationships between physician researchers in academic medical centers who run the “objective” clinical trials for the drug companies. In the marketing world, a minor improvement in outcomes for an expensive “me too” drug is tantamount to the discovery of penicillin.

How does this information of dubious value make its way to the office-based physician? At times, the message is transported on the wings of angels – willowy twentysomething supermodels turned drug reps who ordinarily wouldn’t talk to a frumpy old guy like me. The trouble is, after meeting with them, I can’t remember which drug they were promoting. But there’s a drug for that, too.

The next level of marketing involves the lavish spending by pharmaceutical companies upon members of Congress, which amounted to approximately $275 million last year. Lots of money can coax our elected representatives to feign horror at the prospect of decreasing the duration of patents, or importing cheaper drugs from elsewhere in the

world. A lobbyist’s dream come true was the provision in the Medicare drug benefit (Part D) that has prohibited the government from negotiating pricing on drugs for Medicare recipients.

Finally, and perhaps most flagrantly, drug companies are able to convey their convoluted messages to the public with direct-to-consumer advertising. The United States and New Zealand are the only countries that permit DTC advertising of prescription drugs.

At an estimated cost of $4 billion in the United States last year, DTC advertising is another colossal waste of money in our health care system.

During a recent 30-minute evening network news program, I counted 10 separate pharmaceutical commercials, all with happy people cured of their depression, high cholesterol, peripheral vascular disease and asthma. These smiling and confident folks don’t even break stride as the narrator rattles off a few dozen potentially fatal side effects in the last half of the commercials.

Patients then bring their requests to the doctor’s office. With little time, and less energy to object, doctors take the path of least resistance and write the costly prescription. Mission accomplished.

No wonder physicians who have been practicing for a while are suffering from therapeutic nihilism.

A more comprehensive cure for all the aforementioned conditions is to get off the couch and stop watching TV.

It’s a bitter pill to swallow, but Big Pharma has us all in its grasp.

And, by the way, gentlemen, if widely advertised medications do what they are supposed to do for more than four hours, please don’t call your doctor. Dust off the Rolodex or dig out the little black book and see if any of those old girlfriends want to hear about it.

(Rob Kiefner is a family physician in Concord.)

http://www.concordmonitor.com/apps/pbcs.dll/article?AID=/20100328/OPINION/3280323&template=single

That reform sure doesn't go very far

Perhaps Minnesota can take the lead by embracing truly universal care

By Nick Coleman
Minneapolis Star Tribune, March 27, 2010

After she was diagnosed with kidney cancer, my mother was given a prescription for a daily chemotherapy pill that has been shown to extend the lives of patients with that cancer. When I went to pick up the medicine, the pharmacist asked if I had received financial counseling. No, I said, wondering why we were talking finances, not health care. Just how much is this prescription?

I almost needed a doctor when she told me: The first 28 pills would cost my mother $4,607 — a full 40 percent of her meager annual income from Social Security.

I ended up buying one week’s worth — seven pills — giving me time to try to figure out how we could afford a month’s supply of a medicine that is fully covered in England and France: Kidney cancer patients in those countries do not have to pay for the medicine my mom needed. Perhaps that’s the kind of anti-American thing that Gov. Tim Pawlenty had in mind when he denounced the Obama administration’s health care reform bill as a foreign measure built on a “European approach” — you know, the funny idea that people shouldn’t be bankrupted by their medical care.

My mother passed away before I had to go back to the pharmacy for more pills, dying days before the health care reform bill passed. But I doubt she would have been comforted to find out that the great reform effort would mean she would get a whopping $250 rebate on that $4,607 chemo bill, or that if she lived until 2020, the “donut hole” in her Medicare drug coverage would finally be eliminated.

If this is “reform,” it is at a snail’s pace, a mammoth effort to bring forth a mouse.

Give President Obama credit for getting the bill passed over the shouts of temper-tantrum Tea Partiers and their red-faced enablers in the GOP. But the final bill fell far short of what was first proposed, has gaping holes, leaves gluttonous insurance companies still in charge of health care (Minnesota-based UnitedHealth Group posted a $3.8 billion profit last year) and doesn’t even require insurance companies to insure adults with preexisting medical conditions until 2014. If they’re still alive.

Still, passage of the national measure, as limited as it may be, gives us a glimmer of an idea of what real reform might one day look like. And one promising part of that picture might emerge in Minnesota, where the Minnesota Universal Health Care Coalition (www.muhcc.org), an alliance of physicians, unions and reformers, is pushing for a single-payer system.

Minnesota could become the next Saskatchewan. And that would be good.

Saskatchewan was the first Canadian province to adopt a single-payer health care system, paving the way for Canada’s universal Medicare system. The plan remains so popular that the man who led Saskatchewan’s reform, Tommy Douglas, was voted greatest Canadian of all time in 2004 (Wayne Gretzky, the putative “Great One,” finished 10th).

The hope of reformers here is that Minnesota can help blaze a path to universal health care in this country.

“We’ve lost sight of what we’ve been fighting for,” says John Marty, a DFL state senator from Roseville who is chief author of legislation that would create something called the Minnesota Health Plan. Marty is running for governor on a strong health-care reform platform and criticizes DFLers who aren’t fully committed to universal care. “If the country had approached slavery like we have approached health care,” he says, “we’d still have slavery, but Democrats would be bragging that the slaves only work 40 hours a week now. We haven’t fixed the problem. There will still be people dying from lack of health care, and going broke.”

The Minnesota Health Plan would fully cover all Minnesotans with a single-payer system like Canada’s. A similar plan has been approved by the California Legislature but was vetoed by Gov. Arnold Schwarzenegger. More than a third of Minnesota’s legislators support the proposed plan. If he is elected governor, Marty says, he will make the Legislature stay in St. Paul until the bill is passed.

Minnesota used to be proud to lead the nation. Maybe it should take the lead again.

The plan passed by Congress “is not nearly good enough,” says Elizabeth Frost, a Minneapolis doctor who is one of the leaders of Physicians for a National Health Program and who says the biggest beneficiary of the plan is the health insurance industry. “There will be 32 million more people with health insurance, but the real question is whether the insurance will be any good. If you have to pay too much out of pocket, people don’t go to the doctor. The fight for reform isn’t over.

“Last Sunday wasn’t the end. It was the beginning.”

Nick Coleman is a senior fellow at the Eugene J. McCarthy Center for Public Policy & Civic Engagement at the College of St. Benedict/St. John’s University.

http://www.startribune.com/opinion/commentary/89301787.html

That reform sure doesn’t go very far

Perhaps Minnesota can take the lead by embracing truly universal care

By Nick Coleman
Minneapolis Star Tribune, March 27, 2010

After she was diagnosed with kidney cancer, my mother was given a prescription for a daily chemotherapy pill that has been shown to extend the lives of patients with that cancer. When I went to pick up the medicine, the pharmacist asked if I had received financial counseling. No, I said, wondering why we were talking finances, not health care. Just how much is this prescription?

I almost needed a doctor when she told me: The first 28 pills would cost my mother $4,607 — a full 40 percent of her meager annual income from Social Security.

I ended up buying one week’s worth — seven pills — giving me time to try to figure out how we could afford a month’s supply of a medicine that is fully covered in England and France: Kidney cancer patients in those countries do not have to pay for the medicine my mom needed. Perhaps that’s the kind of anti-American thing that Gov. Tim Pawlenty had in mind when he denounced the Obama administration’s health care reform bill as a foreign measure built on a “European approach” — you know, the funny idea that people shouldn’t be bankrupted by their medical care.

My mother passed away before I had to go back to the pharmacy for more pills, dying days before the health care reform bill passed. But I doubt she would have been comforted to find out that the great reform effort would mean she would get a whopping $250 rebate on that $4,607 chemo bill, or that if she lived until 2020, the “donut hole” in her Medicare drug coverage would finally be eliminated.

If this is “reform,” it is at a snail’s pace, a mammoth effort to bring forth a mouse.

Give President Obama credit for getting the bill passed over the shouts of temper-tantrum Tea Partiers and their red-faced enablers in the GOP. But the final bill fell far short of what was first proposed, has gaping holes, leaves gluttonous insurance companies still in charge of health care (Minnesota-based UnitedHealth Group posted a $3.8 billion profit last year) and doesn’t even require insurance companies to insure adults with preexisting medical conditions until 2014. If they’re still alive.

Still, passage of the national measure, as limited as it may be, gives us a glimmer of an idea of what real reform might one day look like. And one promising part of that picture might emerge in Minnesota, where the Minnesota Universal Health Care Coalition (www.muhcc.org), an alliance of physicians, unions and reformers, is pushing for a single-payer system.

Minnesota could become the next Saskatchewan. And that would be good.

Saskatchewan was the first Canadian province to adopt a single-payer health care system, paving the way for Canada’s universal Medicare system. The plan remains so popular that the man who led Saskatchewan’s reform, Tommy Douglas, was voted greatest Canadian of all time in 2004 (Wayne Gretzky, the putative “Great One,” finished 10th).

The hope of reformers here is that Minnesota can help blaze a path to universal health care in this country.

“We’ve lost sight of what we’ve been fighting for,” says John Marty, a DFL state senator from Roseville who is chief author of legislation that would create something called the Minnesota Health Plan. Marty is running for governor on a strong health-care reform platform and criticizes DFLers who aren’t fully committed to universal care. “If the country had approached slavery like we have approached health care,” he says, “we’d still have slavery, but Democrats would be bragging that the slaves only work 40 hours a week now. We haven’t fixed the problem. There will still be people dying from lack of health care, and going broke.”

The Minnesota Health Plan would fully cover all Minnesotans with a single-payer system like Canada’s. A similar plan has been approved by the California Legislature but was vetoed by Gov. Arnold Schwarzenegger. More than a third of Minnesota’s legislators support the proposed plan. If he is elected governor, Marty says, he will make the Legislature stay in St. Paul until the bill is passed.

Minnesota used to be proud to lead the nation. Maybe it should take the lead again.

The plan passed by Congress “is not nearly good enough,” says Elizabeth Frost, a Minneapolis doctor who is one of the leaders of Physicians for a National Health Program and who says the biggest beneficiary of the plan is the health insurance industry. “There will be 32 million more people with health insurance, but the real question is whether the insurance will be any good. If you have to pay too much out of pocket, people don’t go to the doctor. The fight for reform isn’t over.

“Last Sunday wasn’t the end. It was the beginning.”

Nick Coleman is a senior fellow at the Eugene J. McCarthy Center for Public Policy & Civic Engagement at the College of St. Benedict/St. John’s University.

http://www.startribune.com/opinion/commentary/89301787.html

Who is Donald Berwick?

Obama to nominate Berwick to head CMS

By the Associated Press
ModernHealthcare.com
March 28, 2010
An administration official says President Barack Obama will nominate healthcare scholar Donald Berwick to be CMS administrator.
Berwick, a pediatrician and noted health policy expert, is president and CEO of the not-for-profit Institute for Healthcare Improvement in Cambridge, Mass.
Berwick is also a professor of pediatrics and healthcare policy at the Harvard Medical School and a professor of health policy and management at the Harvard School of Public Health.
An elected member of the Institute of Medicine of the National Academy of Sciences, Berwick served as a member of the IOM’s Committee on Quality of Health Care in America, which launched the slowly building revolution in healthcare quality improvement. The committee published in November 1999 To Err is Human: Building a Safer Health System, which gave the healthcare industry one of its most totemic phrases: “At least 44,000, and perhaps as many as 98,000 Americans, die in hospitals each year as the result of medical errors.”
http://www.modernhealthcare.com/article/20100328/NEWS/303279991/-1

And…

Donald Berwick speaks up

Quote of the Day
November 18, 2005

‘A Deficiency Of Will And Ambition’: A Conversation With Donald Berwick

By Robert Galvin
Health Affairs
January 12, 2005
Donald Berwick is president and chief executive officer of the Institute for Healthcare Improvement (IHI) in Boston, Massachusetts. Bob Galvin is director, Global Health Care, at the General Electric Company in Fairfield, Connecticut.
Excerpts
Galvin: I’m interested in your thoughts on the impact of the Leapfrog Group, an effort organized by the purchasers of health care, both private-sector employers and public purchasers. The Leapfrog agenda has focused on… benefit incentives that engage consumers and patients in the quality and cost of care…
Berwick: The one part of the (Leapfrog) plan that I am absolutely against at the moment is the shifting of burden to individual patients. I do not believe that making the individual American patient more “cost-sensitive” has any rationale in science, ethics, or evidence. It will fail, and it will fail miserably. It will result in a shifting of care away from the people who need it the most. It is a displacement of responsibility for changing the system. You know, if CalPERS or Xerox or GE can’t change care through using its purchasing power, then I absolutely promise you that Mrs. Jones can’t. The idea that she will now be more sensitive because she pays an extra ten bucks out of pocket is, to me, nearly stupid. So I really disagree with that element of the agenda.
Internationally, when one looks at high-performing systems around the world – and ours is nowhere near the highest-performing one – it is almost a routine characteristic of the best systems that they have first-dollar coverage, and there is no attempt to make patients pay more when they’re sick, which is a stupid thing to do.
****
Galvin: The conceptual basis of this is – as unsettling as it may be to “dangle money” to increase motivation-grounded in personality and motivation theory. In private industry, we would simply call it understanding what makes people tick. People respond to incentives. So part of the pay-for-performance movement is based on this idea that clinicians are really no different than other people and that they’ll respond to incentives.
Berwick: At the individual level, I don’t trust incentives at all. I do not think it’s true that the way to get better doctoring and better nursing is to put money on the table in front of doctors and nurses. I think that’s a fundamental misunderstanding of human motivation. I think people respond to joy and work and love and achievement and learning and appreciation and gratitude-and a sense of a job well done. I think that it feels good to be a good doctor and better to be a better doctor. When we begin to attach dollar amounts to throughputs and to individual pay, we are playing with fire. The first and most important effect of that may be to begin to dissociate people from their work. That’s really where we’ve come to, and we’ve done it by pay-for-performance in terms of throughput measurements and manipulating payment schemes.
****
Galvin: Let me move to another issue, and that is the explosion that’s about to play out in biomedical innovation. If you talk to patients… they are also interested in innovations that can cure them or their loved ones. They speak about it with pride and passion…
Berwick: I do think this: We have a learning disability in this country with respect to the difference between technologies that really do help and technologies that are only adding money to the margins of the companies that make them, without essentially paying their way in value. One of the drivers of low value in health care today is the continuous entrance of new technologies, devices, and drugs that add no value to care. If we had strong national policy, it would allow us to know the difference, and I would more fully support what I think you’re correctly proposing, which is an innovations value. We need to help the public know the difference. There’s a big agenda here, possibly for government, to help create a public awareness that more is not necessarily better. Frequently it’s worse. So we can be smart about what we buy and what we choose not to buy.
****
Galvin: Many of us on the purchaser side see radically improving the efficiency of the system as a way to free up capital to cover the uninsured and to fund innovation. How do you think efficiency fits into the quality agenda?
Berwick: Let’s define efficiency as making sure that every dollar you spend gets a dollar of value back, so that efficiency is the opposite of waste. Right from the start, it has been one of the great illusions in the reign of quality that quality and cost go in opposite directions. There remains very little evidence of that. There may be some innovations that raise cost while raising quality, but many, many improvements reduce costs.
What puzzles me is how to access efficiency as a social agenda in health care. There are couple of problems. The first is that a lot of people make a lot of money on inefficiency – on production of things that have no value. So the minute you try to become truly efficient, you’re going to run into stakeholders who are going to tell you that you’re harming care, and the knee-jerk reactions of doctors and others will be to reinforce that idea. And they include you. I mean, GE pays out of one pocket and then makes money on products and services that do not add real value.
****
Galvin: There’s a threshold issue with most purchasers when you talk about getting a patient financially engaged. That is that no one ends up paying more because they’re sick. The only option would be to pay less. Let me give you an example: Many employer-sponsored benefit plans across the country have hospital copays as part of their cost sharing. This means that there is a fee of a hundred or several hundred dollars when one is admitted to a hospital. In these benefit designs, while most people have pretty free choice of what hospital they go to, going to the one that objective data demonstrate is of superior quality and efficiency would result in a waiver of the copay.
Berwick: Well, I can be an empiricist about it. Go ahead and try it. I shudder to think about what may happen, because in the end, that sick patient arriving at that hospital is in the absolutely weakest position at that particular point to decide, “Aha, I’m going to save a hundred dollars and go elsewhere.” That person is more likely to be poor, more likely to be black, more likely to be a low-wage earner. I think it’s regressive social policy, and I predict that it won’t work. It’s a displacement of responsibility from the stewards who actually have the job of crafting systems to meet the needs of the people who come to them for help. I think it’s a bad, bad policy, and I don’t see it playing out productively in other countries, either.
Full interview:
http://content.healthaffairs.org/cgi/content/full/hlthaff.w5.1/DC1
https://pnhp.org/news/2005/november/donald-berwick-speaks-up

And…

Checking in with Donald Berwick, President and CEO, Institute for Healthcare Improvement

Kaiser Health News
November 12, 2009
An interview of Donald Berwick (video 8:39)
http://www.kaiserhealthnews.org/Multimedia/2009/November/111209Berwick.aspx

And…

Video Segments of Dr. Donald Berwick from the Documentary “Money Driven Medicine”

Health Beat by Maggie Mahar
The Century Foundation
March 26, 2010
Nine video clips (total 9:38)
http://www.healthbeatblog.com/2010/03/video-segments-of-dr-donald-berwick-from-the-documentary-money-driven-medicine.html

Soon everyone will know what Donald Berwick is – a Harvard professor and head of the Institute for Healthcare Improvement, about to become the administrator of CMS (Centers for Medicare and Medicaid Services), assuming that he survives the acrimonious vetting process in our highly politicized Congress.
More importantly than what, today’s message tries to show who he is by repeating a prior Quote of the Day extracted from an interview of him published in Health Affairs five years ago. Also included are links to more recent video interviews of him (total less than 20 minutes).

India's outsourcers outsource to U.S.

US healthcare reform is boon for India outsourcing companies

By Taylor Barnes
The Christian Science Monitor
March 25, 2010

President Obama signed into existence not just a historic healthcare reform law but also monumental piles of paperwork: New member registration forms. More claims. Ever-expanding databases.

The bulge in administrative work may look like a nightmare to American insurance firms and government employees. But to outsourcing executives here in India, it’s heaven-sent.

The addition of 32 million insured Americans is “very significant” for Indian outsourcers, says Ananda Mukerji, chief executive officer of Firstsource Solutions in Mumbai. Companies like his will see “increased opportunities” as US health insurers and hospitals scramble to reorganize to comply with the new law.

This extra work will include processing new enrollments, organizing bigger member databases, processing more claims, providing more support services, and managing more revenue, he says.

The US healthcare reform offers a “natural extension” of the back-office outsourcing that Indian companies already specialize in, says Tu Packard, a senior economist with Moody’s Economy.com.

But some services in the US healthcare industry cannot be outsourced beyond America’s borders due to regulations. That’s one reason major Indian outsourcing firms have set up shop in the United States. In a twist, America’s outsourcers are now outsourcing back to America.

http://www.csmonitor.com/World/Asia-South-Central/2010/0325/US-healthcare-reform-is-boon-for-India-outsourcing-companies

Comment: 

By Don McCanne, MD

President Obama and Congress rejected the administratively efficient model of single payer, and have now enacted into law the most expensive and most administratively complex model of reform. In the ultimate of ironies, India is now outsourcing to the United States the profusion of health care administrative services outsourced to them. It reminds you of why Willie Sutton robbed banks.

India’s outsourcers outsource to U.S.

US healthcare reform is boon for India outsourcing companies

By Taylor Barnes
The Christian Science Monitor
March 25, 2010

President Obama signed into existence not just a historic healthcare reform law but also monumental piles of paperwork: New member registration forms. More claims. Ever-expanding databases.

The bulge in administrative work may look like a nightmare to American insurance firms and government employees. But to outsourcing executives here in India, it’s heaven-sent.

The addition of 32 million insured Americans is “very significant” for Indian outsourcers, says Ananda Mukerji, chief executive officer of Firstsource Solutions in Mumbai. Companies like his will see “increased opportunities” as US health insurers and hospitals scramble to reorganize to comply with the new law.

This extra work will include processing new enrollments, organizing bigger member databases, processing more claims, providing more support services, and managing more revenue, he says.

The US healthcare reform offers a “natural extension” of the back-office outsourcing that Indian companies already specialize in, says Tu Packard, a senior economist with Moody’s Economy.com.

But some services in the US healthcare industry cannot be outsourced beyond America’s borders due to regulations. That’s one reason major Indian outsourcing firms have set up shop in the United States. In a twist, America’s outsourcers are now outsourcing back to America.

http://www.csmonitor.com/World/Asia-South-Central/2010/0325/US-healthcare-reform-is-boon-for-India-outsourcing-companies

Comment: 

By Don McCanne, MD

President Obama and Congress rejected the administratively efficient model of single payer, and have now enacted into law the most expensive and most administratively complex model of reform. In the ultimate of ironies, India is now outsourcing to the United States the profusion of health care administrative services outsourced to them. It reminds you of why Willie Sutton robbed banks.

Health bill will only entrench power of the insurance industry

By Claudia Chaufan
Viewpoints, Sacramento Bee
March 26, 2010

To those led to believe that, as President Barack Obama claimed, the passage of the health care bill is “comparable to the passage of Medicare and Social Security” and that “every American will be guaranteed high quality, affordable health care coverage” as a result of it, my advice is to hold off on uncorking the champagne.

For one, Social Security and Medicare were public programs that from their inception offered immediate benefits to millions of ordinary Americans, who for the first time could rely on old-age pensions and access health care services that until then had been completely out of reach.

By contrast, this “historic bill,” instead of eliminating the root of our health care woes, further enriches and entrenches a profit-driven health insurance industry that makes money when it succeeds in not paying medical bills.

How so? It forces millions of Americans to buy the insurance industry’s shoddy products or pay a fine, even as it offers eligible ones subsidies – courtesy of taxpayers – to purchase those products.

Sound familiar? It should. The bill consolidates the transfer of wealth from Main Street to Wall Street of the last decades, only second to the recent, similar transfer implemented under the dubious claim that otherwise the economy would disintegrate.

I’m the vice president of the California branch of Physicians for a National Health Program, a group that advocates for a publicly financed, privately delivered national health program.

Some of us have been called party spoilers by continuing to criticize Obama’s health reform plan. Yet here are some facts about the bill that supporters of reform need to consider:

• Millions of middle-income people will be mandated to buy commercial health care policies costing up to 9.5 percent of their income. Yet those policies will cover as little as 60 percent of “covered services,” leaving them vulnerable to financial ruin if they become seriously ill. So yes, over 30 million Americans will be “covered” by this bill, but by an umbrella full of holes under pouring rain.

• People with employer-based coverage will be locked into their plans’ “preferred providers’ networks.” So yes, workers will “keep their plans if they like them” (assuming they can afford the ever-increasing prices and don’t lose their jobs, or their employers don’t drop their plans), yet will have to keep them even if they don’t like them.

• Insurers will be handed at least $447 billion in taxpayer money to subsidize the purchase of these policies, which will further empower the insurance industry and its ability to block future reform.

• Health care costs will continue to skyrocket because the bill will do nothing to reduce the $400 billion wasted every year pushing paper to market thousands of plans and separate people according to eligibility criteria, services covered, etc.

• The much-vaunted insurance regulations – e.g. ending denials on the basis of pre-existing conditions – are riddled with loopholes. For instance, older people can be charged up to three times more than their younger counterparts, and large companies with a predominantly female work force can be charged higher gender-based rates at least until 2017. Policies can still be canceled in case of “fraud or intentional misrepresentation,” the No. 1 excuse insurers use to cancel policies today.

• About 23 million people will remain uninsured nine years out, according to the Congressional Budget Office. That translates into about 23,000 unnecessary deaths annually.

Did it need to be like this? Not at all. All the good provisions in the bill, such as funding community health centers, could have been adopted as stand-alone measures.

Instead, Congress and the Obama administration have chosen to burden ordinary people with a “uniquely American” individual obligation to buy flawed private products.

Social health insurance in the form of single-payer health care will sooner or later have to be adopted, not because it is politically feasible, but because it is inevitable.

As Harvard professor William Hsiao (the brain behind Taiwan’s single-payer system) argued, you can have universal coverage, lower costs, and improve the quality of care, but you need a single-payer system to achieve that.

© Copyright The Sacramento Bee. All rights reserved.

Dr. Claudia Chaufan is an assistant professor of health policy and sociology at the University of California, San Francisco.

Read more: http://www.sacbee.com/2010/03/26/2634340/health-bill-will-only-entrench.html#ixzz0jIFT1Bxt