PNHP

Prior Authorization: Less Care, More Illness, Higher Profits

Prior Authorization: Less Care, More Illness, Higher Profits

Aetna creates new obstacle to care for seniors, highlighting need for prior authorization reform, California Medical Association, August 10, 2021

One of the nation’s largest health insurance companies has created new bureaucratic hurdles for patients that could prevent many from receiving cataract surgery – part of a trend of insurance companies creating new “prior authorization” requirements that create hurdles for patients and physicians, reduce availability of health care services, and increase insurance company profits at the expense of patient care.

It has become common practice for health insurance companies to create new obstacles for patients, in hopes of not having to provide essential health care to those who need it. The reason for these types of obstacles is simple: Fewer surgeries performed translates to larger insurance company profits.

Like other insurance companies, Aetna has enjoyed record profits through the COVID-19 pandemic. The company, which was acquired by CVS Health in 2018, saw its operating income increase from $1.06 billion in 2019 to $3.07 billion in 2020.

Prior authorization requirements can be challenging for patients, creating  barriers to care and increasing administrative burdens for physicians who must spend time and resources to get approvals as insurance companies design and administer increasingly complex prior authorization systems.

The time delays and administrative burdens also continue to undermine health care outcomes. Most startlingly, in a 2020 American Medical Association survey, 30% of physicians reported that prior authorization led to a serious adverse event for a patient in their care such as hospitalization, medical intervention to prevent permanent impairment, or even disability or death.

Comment:

By Don McCanne, M.D.

Creating barriers to care in order to increase profits is a prime function of private insurers. To them, it is more important than taking measures to be sure that patients receive the care that they need. Prior authorization is a method designed to prevent patients from receiving the care that has been recommended.

How would a public insurance program, such as single payer Medicare for All, differ? Such programs are structured to enable everyone to obtain the care that they need, whereas insurer profits don’t even exist.

Why do our national policies continue to support private insurers through ACA insurance exchanges, Medicare Advantage plans, tax preferences for private employer-sponsored plans, and other government support of private insurance entities?

Health care justice for all is a primary goal of a universal public insurance program. That has to be preferred to the more expensive, inequitable, profit-driven system that we now have that leaves so many without the care they need while driving others into medical debt, not to mention the potential for disability or even death. Doesn’t our government care about us, the people?

http://healthjusticemonitor.org…

Stay informed! Subscribe to the McCanne Health Justice Monitor to receive regular policy updates via email, and be sure to follow them on Twitter @HealthJustMon.

Medicine’s undeniable role in U.S. racism

By Brenda Gazzar
Code Wack Podcast, August 16, 2021

Featuring Dr. Linda Rae Murray, MD, MPH, former Chief Medical Officer – Primary Care for the Cook County Bureau of Health Services & “full-time troublemaker,” discussing the artificial separation between social, structural, and personal racism.

Transcript

Welcome to Code WACK!, your podcast on America’s broken healthcare system and how Medicare for All could help. I’m your host, Brenda Gazzar.

How has American medicine played a role in propagating racism? How does racism put Black people and Native Americans at a higher risk for illness and death? To find out, we spoke to Dr. Linda Rae Murray, a physician who spent 40 years in clinical practice helping the medically underserved. She retired in 2014 from her post as the chief medical officer for the Cook County Department of Public Health of the Cook County Health & Hospital System in Illinois. She’s been a voice for social justice and health as a basic human right for more than fifty years. 

Welcome to Code WACK!, Dr. Murray.

Murray: My pleasure.

Q: So I’d love to hear a little bit about you. When you graduated from medical school in 1977, what was the landscape like for female African American physicians?

Murray: Well, I don’t think there’s anything unusual about that time period. In 1977, we were entering a period of retrenchment in the United States. Conservatism and Reaganism was coming to the fore but the situation for Black physicians of all genders has never been good, so it wasn’t good then. This is a period as I started my residency training where the public sector was under attack. Public hospitals were being defunded. We lost a number of hospitals around the country and we lost a number of public hospitals in St. Louis, Philadelphia and other places.

Q: One of the biggest problems in American healthcare has been racism. It’s well documented, but still many Americans don’t acknowledge it. Can you give us some examples of social and structural racism in health care?

Murray: Well, the medical care system, and health care in general is a part of our culture and society and so structural racism is the underpinning of what goes on in America and so I am always concerned about how that racism seeps into the structure of a country. So I don’t care what you start with, you can start with where services are available. When I was a resident, only the United States and South Africa were the only ones that didn’t try to provide universal coverage for its population. Today it’s only us in terms of rich countries.

And so when you talk about structural racism in medicine, American medicine plays a special role in propagating through up until really the 1950s the notion that (Black people) were biologically inferior — that was a major strong strain of American medicine, and how the structure is set up with everything we do, what kind of jobs you have or don’t have, what kind of exposures you have, an inability to access diagnostic services and curative services. These are all things that are obvious in medical care settings, but the real harm that structural racism does goes far beyond the medical setting, far beyond the hospital or the exam room. It goes into all aspects of American life.

Q: Hmmm. Thank you. This idea that people of color are biologically inferior, how does and how did that manifest itself?

Murray: So I want to be careful here about our language again. Western racism in the modern era, in the past couple of 100 years, is based on a hierarchy and so all of those hierarchies put Africans at the bottom of racial hierarchy so when we say people of color, that’s an important political concept but in terms of racial hierarchy, Africans are at the bottom — and so I don’t care whether you’re talking about the Bell Curve, which argues that that’s why Blacks have poor education outcomes, or whether you’re talking about old-fashioned “eugenics movement,” this is a notion that has run through our history so from a medical point of view in terms of American medicine, this notion that these negative traits and positive traits, they are inherited and that far outweighs whatever else happens to people.

So that concept we still have today whether you’re talking about outcomes at the Olympics or sportscasters that argue that, you know, Blacks are somehow differently made as beings. And, you know, so a Black basketball player will be skilled, a white basketball player would be smart. You see these kinds of differences that exist all along. I am concerned as we look at modern genetics. We’ve done some studies as recently as 2016 that showed an extraordinarily surprising number of medical students and residents believe certain myths about African Americans, about Blacks. For example, the notion that our skin is thicker. Nowhere in medical schools is that taught but that notion was there among, like I said, a surprising number of physicians and medical students. That’s also the nature of structural problems. They are baked into the society, and most people are unaware that they’re even there. They just are considered part of the normal universe and so those things are still with us and they’re still a major concern.

Q: Right. And so how are these myths most detrimental to Black patients?

Murray: Well, they’re most detrimental for Black people because we die younger and from diseases that can be prevented, I mean that’s the very nature, that’s the very definition of health inequity, and here I want to bring back other people who are not white, in terms of that hierarchy. So, for example, Native Americans, our Indigenous groups in North America, have mortality rates and often health outcomes that are equal to or worse than Blacks depending on which disease entity you look at so there’s no question that racism kills people, to put it bluntly.

It doesn’t just mean it kills people when police shoot you. It kills people with everyday things, whether you don’t get your blood pressure treated, whether you don’t have access to cancer screening, whether you’re just stressed out by the fact that you’re unemployed, and you don’t have good nutrition and all of these activities of life, all of these things in our society imprint themselves on our bodies, and when you have societies that are unequal, where oppression is going on, where people are under stress, then those show up. So it’s not an accident for example with COVID, people who had to go to work, who did not have the privilege of working remotely, are the people who got COVID more frequently, and if you didn’t have spacious living quarters with nutrition, good transportation, all of the things that we know put you at higher risk, then you got COVID and you’re more likely to get sick from it and be hospitalized and die.

Q: Okay, thank you so much. Social and structural racism in health care obviously differ from personal racism. How do you think the three work together to negatively impact Black Americans’ experience with health care?

Murray: I think we try to make too much of an artificial separation between these things and let me just say that, personally mediated racism at the personal level changes. So, you know, 100 years ago, the use of the N word might be considered normal and not even in certain parts of the country, just a normal descriptor. Today, what the young people call microaggressions, which I think is a euphemism, it’s still racism, the level of which these things are expressed in polite society changes. So again, things that might be said about women when I was a young woman would not be acceptable to say today in a public setting, that doesn’t mean they’re still not said. It doesn’t mean those ideas still aren’t there. We as individuals live in a societal setting. And so, all of those levels of which racism operates reinforce each other, they’re not separate, and so it doesn’t do any good to have people be polite, if in fact you are not allowing Black people to vote. It doesn’t matter if you’re polite, if educational opportunities are different, or where you can live are different. So those structural conditions haven’t changed, I think, in any measurable way so we still are being impacted.

It’s almost like climate change, you know, you might have people talking more intelligently about climate change today but as we’ve just seen from our recent report, the climate is still getting warmer and we’re still changing at a more and more rapid rate so we have to address not only structural racism, we also have to address class biases, and gender biases in our society and unless we do them all together and really, really reject the basis on which our country operates, which is an individualistic profit-driven perspective, then we’re going to be killing lots of people. These things also kill lots of white Americans. They are just unaware of it or choose to ignore it. It’s not an accident that the life expectancy for example for white Americans has been dropping, and it’s part of those same structural problems that are going on.

Thank you Dr Linda Rae Murray. 

Find more Code WACK! episodes on ProgressiveVoices.com and on the PV App. You can also subscribe to Code WACK! wherever you find your podcasts. This podcast is powered by HEAL California, uplifting the voices of those fighting for health care reform around the country. I’m Brenda Gazzar.

https://heal-ca.org…

The Financial & Health Hazards of Medicare Advantage

Medicare Advantage Boom Times, Axios, August 11, 2021, by Bob Herman

“Medicare Advantage continued to grow during the pandemic, and it’s increasingly likely a majority of all Medicare enrollees will be in private plans in a few years despite Medicare Advantage’s deep, longstanding problems…

The federal government paid almost $350 billion to MA insurers for this year, a 10% increase from 2020. Every year since 2015, annual spending growth on MA plans has outpaced annual enrollment growth…

Medicare Advantage is consuming more membership and more of the Medicare trust fund, but many enrollees are not sticking with their plans until the end.”

Comment:

By Isabel Ostrer, M.D.

Enrollment in Medicare Advantage (MA) is soaring. Why is this a problem? For starters, the program is costly (for both patients and the government). But perhaps more importantly, access to care is severely restricted.

Upfront, it appears that MA plans offer a better financial deal to seniors than traditional Medicare does. Because there are no limits on out-of-pocket spending in traditional Medicare, beneficiaries often buy Medigap policies to the tune of about $2000 per year to buffer against unforeseen costs. MA plans appear to offer a financially viable alternative with low monthly fees and annual limits. But the reality is quite different. The out-of-pocket maximum in 2021 is a whopping $7550. And, according to a recent KFF report, over half of MA enrollees would be on the hook for more money than their traditional Medicare counterparts for a 6-day hospital stay. As we pointed out recently in HJM, this means sick enrollees face major financial barriers.

It’s not just patients who pay big prices for MA – the federal government does too. As Herman points out in his Axios piece, the federal government is seeing large year over year increases in the amount they owe MA insurers. This is a lucrative business for insurers. With annual gross margins that are nearly double the margins in individual and group markets, it’s no wonder new MA insurers are popping up left and right.

But Medicare Advantage isn’t just costly, it’s also deadly. A recent Government Accountability Office report found that MA beneficiaries in the last year of life disproportionately disenrolled to join traditional Medicare. As Eagan Kemp wrote in a recent HJM piece, “Medicare Advantage plans — as they also do with other high-cost patients in poor health — are finding ways to avoid paying the high costs of end-of-life care. They often do this through limiting access to specialized care through narrow networks or other unscrupulous means.”

Private insurers should not exist in Medicare, plain and simple.

http://healthjusticemonitor.org…

Stay informed! Subscribe to the McCanne Health Justice Monitor to receive regular policy updates via email, and be sure to follow them on Twitter @HealthJustMon.

The other pandemic is underinsurance

By Marvin Malek, M.D., M.P.H.
VTDigger, August 15, 2021

A study published in the July 21 issue of the Journal of the American Medical Association reported that 17.8% of Americans had medical-related debt that had been sent to debt collections agencies.

Since there is nearly always a lag of three months or more before unpaid debt is sent to collections, this statistic would reflect care provided prior to the Covid pandemic.

This represents a striking increase in America’s medical debt burden — nearly twice as large as the percentage reported in 2009. Millions of Americans lost their incomes and health coverage as a result of the pandemic, so the situation is likely worse now.

Since the number of uninsured Americans was actually a little lower in early 2020 than in 2009, this increase in unpayable debt reflects underinsurance: Coverage that is so poor that families cannot afford their deductibles and copays when someone in the family actually gets sick.

Note that this 17.8% reflects only a fraction of Americans burdened by medical costs. Many others pay off high medical bills by skipping sending their kids to summer camp, aborting plans for a vacation or foreclosing on their mortgages. Many others work out burdensome payment arrangements with hospitals, and will remain underwater for years to come as additional medical bills accumulate.

But these are numbers. It is up to us to use our imaginations to translate them into the day-to-day lives of American families. How many potential business enterprises won’t be happening because medical debt prevents access to credit? How many couples will experience marital stress and even divorce due to these debt burdens?

Numerous studies have demonstrated that families with medical debt typically skimp on paying for food, clothing and other basic necessities, and that half of bankruptcies are filed because of unaffordable medical bills.

How many Americans will avoid needed medical care to avoid incurring further debt? At least 25,000 excess deaths occur each year among the uninsured, Uninsured Americans who are experiencing a heart attack are 37% more likely to delay care, placing themselves at risk of an immediately fatal outcome.

But we don’t yet have accurate data that reflects how many deaths occur due to underinsurance. At the very moment in one’s life when one is contending with major illness, Americans find themselves deluged with medical bills. Ours is the only developed country where we kick people when they’re down in this manner. It violates one’s sense of decency.

But now let’s try to push our imaginations in a different direction: Let’s imagine living in a country where every single citizen has health coverage and there is literally no one in the entire country with unaffordable medical debt — a reality in England, France, Spain, Scandinavia, Taiwan, and many other countries.

July 31 was the 56th anniversary of the implementation of our Medicare program. Now let’s imagine a Medicare program without copays, and which enrolls every single American.

This is not a dream. Legislation that would implement a Medicare for All program is in the docket in both houses of the U.S. Congress. These bills should be passed and implemented as soon as possible. Every American should work to clear away the political obstacles that have been placed in the way of this legislation by the health insurance companies, big pharma, and other lobbies.

There has never been a logical policy reason why Americans wait until age 65 to enroll in Medicare, neither in 1965 nor currently. But the price tag both in financial distress of American families and foregone care has risen dramatically since 1965. Last week’s JAMA article provided evidence of this distress.

Let’s all work toward a future in which a subsequent study published in 2030 will reveal that no American family has collection agencies harassing them just because they were seeking needed medical care. We can do better — if we mobilize our imaginations, our sense of basic decency and our voices.

This commentary is by Dr. Marvin Malek, a general internist practicing hospital medicine in Springfield, Vt.

https://vtdigger.org…

Medicare for All Explained Podcast: Episode 62

Interview with Dr. Ashley Duhon

August 14, 2021

Bronx-based OB/GYN resident Dr. Ashley Duhon shares the Sister Song definition of reproductive justice as “the human right to maintain personal bodily autonomy, have children, not have children, and parent the children we have in safe and sustainable communities.”

She adds that “we are failing our patients in every aspect of [reproductive justice], and a lot of that has to do with access to health care.”

Additional episodes will be uploaded twice monthly. Subscribe in iTunes, or access a complete archive of the podcast, below.

https://medicareforallexplained.podbean.com

Private Equity Is Buying Up Health Care: Patients (and Doctors) Beware

REPORT TO THE CONGRESS: Medicare and the Health Care Delivery System; Chapter 3 – Congressional request: Private equity and Medicare, MedPAC, June 21, 2021

We examined PE business models in three key sectors: hospitals, nursing homes, and physician practices. PE firms have made investments in each sector but have a limited presence: We found that PE firms own about 4 percent of hospitals and 11 percent of nursing homes. We do not have a comparable figure for physician practices. At least 2 percent of practices were acquired by PE firms from 2013 to 2016, but that figure does not account for previous PE acquisitions and appears to have grown since then.

Because there is no single comprehensive source of ownership information, researchers compile data about PE ownership from proprietary datasets and public announcements. As a result, the estimated numbers of health care providers with PE backing are likely too low.

Global Healthcare Private Equity & M&A Report 2021, Bain & Co., 2021

At a Glance:

  • Healthcare private equity deal volume increased by 21% to a total of 380 deals in 2020, compared with 313 the year earlier, despite a 14% decline in total global PE activity.
  • The healthcare provider and biopharma sectors were the most active, despite Covid-19’s damage to patient volumes and provider margins, with nearly 150 deals in each sector.

Comment:

By David Himmelstein, M.D. and Steffie Woolhandler, M.D., M.P.H.

Private equity firms pool outside investors’ funds and a small amount of their own money to buy assets (e.g. hospitals, nursing homes, doctors’ practices or Toys“R”Us), which they hold “privately”, i.e. their stock is not for sale to the public. That private ownership excuses them from the disclosure requirements applicable to publicly-traded firms.

Private equity purchases are usually funded mostly by loans that amplify the investors’ money, with the acquired asset – not the private equity firm or investors – liable for the debt. So when a private equity firm buys a nursing home, the nursing home is on the hook for repayment, not the investors. The private equity firm usually collects large annual “management fees”, assuring that it takes home profits, and aims to sell off the asset in 3-5 years. In the meantime it seeks to gin up profitability in order to drive up the eventual sale price.

The COVID-19 pandemic has apparently fueled an increase in private equity purchases of physician practices that were struggling because of decreased patient volumes. But exactly how many doctors they own is a mystery, because private equity operates behind a veil of secrecy. Indeed, even MedPAC, Congress’ official Medicare advisory body, couldn’t penetrate that veil.

What is clear is that private equity owns tens of thousands of emergency physicians, a major chunk of dermatologists, and an increasing number of primary care doctors.

The galloping private equity takeover of medical assets should ring alarm bells. These corporate raiders’ only interest is in short term profits. Dentists they own have been pressured to drill healthy teeth in children, dermatologists have been pushed to amp up lucrative procedures, and private equity-owned ED staffing firms are largely responsible for “surprise bills” for ED care. The private equity firm that purchased Hahnemann Hospital – a vital safety net provider in inner city Philadelphia – ran the hospital into the ground, but made a killing by selling off the hospital’s real estate before it crashed into bankruptcy.

In the short term, Congress should lift the veil of secrecy around private equity ownership of medical assets, e.g. by requiring full disclosure of the ownership structure of firms that bill Medicare. (California already requires pharmacies to publicly report the names of individuals and  organizations with any share of ownership, as well as the property owner, management company, and administrator). In the longer term, investor ownership of health care facilities and practices should be banned.

http://healthjusticemonitor.org…

Stay informed! Subscribe to the McCanne Health Justice Monitor to receive regular policy updates via email, and be sure to follow them on Twitter @HealthJustMon.

Dr. Adam Gaffney on “All In”

PNHP immediate past president Dr. Adam Gaffney appeared on “All In” on MSNBC on August 12, 2021. Dr. Gaffney pushed back against a proposal to charge unvaccinated Americans higher health insurance premiums. He argued that more expansive access to vaccines (and access to medical care in general, under Medicare for All), coupled with occupational mandates, would be more effective.

The Rice Family Health Reform Legacy

Health Insurance Systems: An International Comparison, Academic Press, 2021, by Thomas Rice

Chapter 16, Some Insights

Health outcomes: How much a country invests in its health care system does not have a strong influence on the outcome measures examined here. That is further exemplified by the fact that the United States spends by far the most, but performed among the worst in avoidable mortality, and was the poorest in measures of safe care.

Satisfaction: The most glaring finding regards the US system, which was far more unpopular than any of the others. There are many likely reasons for this. One centers on the economic insecurity people face not only by the lack of comprehensive benefits, but also by the prospect of being without coverage if they lose their jobs.

A second reason for the US system’s unpopularity is likely to be its expense, which requires not only considerable patient cost sharing but also high premiums from employers and employees, and considerable taxes to support Medicare and Medicaid.

A third and more general reason is that the American people do not share a common view on issues such as health care being a right.

Final thoughts: There is little agreement about what aspects of health insurance systems are the highest priority for reform. Different researchers reach entirely different conclusions about what are the overall best health care systems. Nine of the ten countries have, at least broadly speaking, reached similar conclusions about the necessary and desirable underpinnings of their health insurance systems. These include (1) building systems based on the ethic of affordable, equitable access to care, (2) having a single, publicly mandated insurance system to promote fairness and efficiency, (3) using government for health care planning activities involving the supply of resources and constraining prices, and (4) employing economic tools to determine covered benefits and prices, especially for pharmaceutical products. There is a great deal of variety in how each country implements each of these; nevertheless, it would be hard to deny that there is strong international agreement in such critical areas. The United States is a notable exception.

Dorothy Rice, Pioneering Economist Who Made Case for Medicare, Dies at 94, The New York Times, March 4, 2017

Dorothy Rice, a pioneering government economist and statistician whose research about the need of the aged for health insurance helped make the case for the passage of Medicare in 1965, died on Feb. 25 in Oakland, Calif. She was 94.

Health Law Kickoff May Be More Challenging Than Medicare’s Start, capradio, September 30, 2013

Dorothy Rice says California’s implementation of the law (Affordable Care Act) may go more smoothly, because of the state’s rigorous efforts. But she hopes eventually the national health care system will look more like Medicare.

Comment:

By Don McCanne, M.D.

Years ago, our California chapter of Physicians for a National Health Program had the honor of a visit from a most distinguished guest: Dorothy Rice, who had laid the foundations leading to the Medicare program. She really admired what we were doing. We hit it off so well that she had us over to her home for a garden party where we celebrated the prospect of providing Medicare to everyone. As documented above, she hoped that we would have a national health care system that looked like Medicare.

Dorothy’s son, Tom, a respected UCLA health policy professor, recently published a book seeking policy insights from the United States and several other countries. Although many of the lessons drawn would logically lead to advocacy for a single payer Medicare for All system, Tom maintains that all successful systems have lessons for us. He does not recommend single payer; he sees building on the ACA.

We do have one lesson for Tom: Listen to your Mom. She understood the need for Medicare, and, more recently, the need for Medicare for All. We are pleased that you have provided us with the policy science that supports Medicare for All. We invite you to avidly echo your mother’s advocacy for health justice for all via single payer.

http://healthjusticemonitor.org…

Stay informed! Subscribe to the McCanne Health Justice Monitor to receive regular policy updates via email, and be sure to follow them on Twitter @HealthJustMon.

U.S. Health System Implosion / Tipping Point

U.S. longevity down to 78.5 years, other nations 81-84.
U.S. pervasive race disparities in private insurance and health.
U.S. health spending twice the wealthy country average.
U.S. uninsured = 33 million pre-COVID; underinsured = 1/3 of insured.
U.S. healthcare access & outcomes the worst among wealthy countries.
U.S. financial barriers to care for sick high in Medicare Advantage.
U.S. medical debt skyrocketing, impoverishing and imperiling lives.
U.S. insurer profits skyrocketing for years and during COVID.
U.S. ambulance services separate, costly, & unreliable.
U.S. doctors burning out from billing-laden EHR.

Comment:

By Jim Kahn, M.D., M.P.H.

Our “system” is no system.
Thousands of health plans, summing to premature death and massive profits.
By no useful metric is it succeeding.
Unbridled corporate greed prevails.
It’s imploding in front of us.

Is it sustainable?
It can’t be.
When is the tipping point?
To a simple, logical, efficient & generous, equitable, humane solution.
Single payer.
Now.

(thanks to Eli Marx-Kahn for input)

http://healthjusticemonitor.org…

Stay informed! Subscribe to the McCanne Health Justice Monitor to receive regular policy updates via email, and be sure to follow them on Twitter @HealthJustMon.

U.S. Health System a Pitiful Last Among Wealthy Nations

Mirror, Mirror 2021: Reflecting Poorly; Health Care in the U.S. Compared to Other High-Income Countries, The Commonwealth Fund, August 4, 2021, by Eric C. Schneider et al.

Issue: No two countries are alike when it comes to organizing and delivering health care for their people, creating an opportunity to learn about alternative approaches.

Goal: To compare the performance of health care systems of 11 high-income countries.

Methods: Analysis of 71 performance measures across five domains — access to care, care process, administrative efficiency, equity, and health care outcomes — drawn from Commonwealth Fund international surveys conducted in each country and administrative data from the Organisation for Economic Co-operation and Development and the World Health Organization.

Key Findings: The top-performing countries overall are Norway, the Netherlands, and Australia. The United States ranks last overall, despite spending far more of its gross domestic product on health care. The U.S. ranks last on access to care, administrative efficiency, equity, and health care outcomes, but second on measures of care process.

Conclusion: Four features distinguish top performing countries from the United States: 1) they provide for universal coverage and remove cost barriers; 2) they invest in primary care systems to ensure that high-value services are equitably available in all communities to all people; 3) they reduce administrative burdens that divert time, efforts, and spending from health improvement efforts; and 4) they invest in social services, especially for children and working-age adults.

Comment:

By Isabel Ostrer, M.D.

The Commonwealth Fund compared health systems in 11 high-income countries to identify what policies and practices are associated with better performance. The countries were Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States.

The overall health care system ranking is striking: the U.S. ranks last in every domain except care process. (This includes preventive care, e.g., rates of mammography and influenza vaccination.)

In access to care, which includes affordability and timeliness, we’re last because individuals here are most likely to experience insurance denials, high out of pocket costs, difficulty paying medical bills, and delays in seeing a provider.

To add insult to injury, health care spending in the U.S is uniquely high. In 2019, the U.S. spent 16.8% of its GDP on health care. The next highest spender, Germany, clocked in at 11.7% .

What do we get for all this spending? The U.S. is dead last in health care outcomes. We have the highest infant mortality rate, the highest rate of maternal mortality, and the highest rate of preventable mortality.

So what can we learn from our peer countries? For starters, they all have universal health coverage and no cost barriers. The U.S. has 30 million uninsured … and 40 million underinsured.

The evidence speaks loudly. Sinking more money into a multi-payer health care system serves only to inflate U.S. health care costs without improving access or outcomes. A truly patient-centered system is one that provides universal coverage and shields patients from unnecessary cost-sharing.

http://healthjusticemonitor.org…

Stay informed! Subscribe to the McCanne Health Justice Monitor to receive regular policy updates via email, and be sure to follow them on Twitter @HealthJustMon.

Why Antitrust Enforcement Can Only Go So Far in Health Care

Executive Order on Promoting Competition in the American Economy, The White House, July 9, 2021

Stop Playing Health Care Antitrust Whack-A-Mole, Bill of Health, May 17, 2021, by Jaime S. King

The Sleeper Health Cost Policy, KFF, July 22, 2021, by Drew Altman

Comment:

By Allison K. Hoffman, J.D. and Hannah Leibson

In early July, the Biden Administration issued this high-level executive order focused on promoting competition in the American economy. The order urged the FTC and DOJ to significantly ramp up antitrust enforcement to prohibit future mergers and divest existing anti-competitive arrangements.

The order states in part, “whereas decades of industry consolidation have often led to excessive market concentration, this order reaffirms that the United States retains the authority to challenge transactions” in violation of the antitrust laws.

The problem is that it’s likely too little too late for health care.  For the past few decades, health care consolidation has been on the rise.

Jaime S. King points out that the rate of consolidation has increased so dramatically that up to 95 percent of metropolitan areas have highly concentrated hospital markets. Private equity investment has driven much of this trend.

As Drew Altman explains, consolidation is negatively impacting quality of care and significantly driving up health care costs for consumers—as much as 50 percent in some hospital systems. When one or two large hospital systems are running the show in a city or region, insurers don’t have any leverage to negotiate lower prices. Consumers have no choice but to pay the higher prices or travel far distances to seek care.

Things like choices of insurance plans or transparency, both mentioned in the Biden Executive Order, will not solve these structural problems on their own. In the months ahead, the impact of COVID-19 will likely accelerate consolidation in many economically disadvantaged regions where hospitals are already deep in the red.

Amped up antitrust enforcement will only go so far in health care, especially considering thin government resources. It could prevent further consolidation. More aggressively, the administration could review merged entities and unravel those that have proven anticompetitive.

All of these measures could be beneficial, but ultimately, comprehensive price regulation is the only way to control the rising health care costs associated with provider consolidation. As Altman highlights, drugs comprise just 10% of health care spending while hospitals represent a whopping 34%. More and more, physician groups are also merging or are affiliating with hospitals and will benefit from their hefty negotiating power to command higher prices.

One option is a federal all-payer system to set price caps or limits on total hospital spending. It could eliminate the large gap between Medicare rates and those commercial insurers are forced to accept in highly consolidated hospital markets. Medicare for All is another means to set rates federally, in one fell swoop, and it would also eliminate the administrative costs associated with having many different payors.

Another option is rate setting at the state level, but this approach would be more difficult to enact and less coordinated. The state of Maryland already has such a model in place, and has seen positive outcomes since it was launched by CMS as a pilot program in 2014. From 2014 to 2019, Medicare spending in Maryland fell 2.8 percent and the state has seen a 4.1 percent decrease in total health care costs. Alongside these cost savings, quality benchmarks across several dimensions have surpassed expectations. This model could inform policy design at the federal level, just as Massachusetts’s reform informed the design of the Affordable Care Act.

Antitrust enforcement is but one piece of the puzzle of controlling health care price inflation, and, unless the FTC and DOJ aggressively unwind the consolidation of the past decades, it is only a very small piece.

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