Promise vs. Practice: the Actual Financial Performance of Accountable Care Organizations, Journal of General Internal Medicine, August 13, 2021, by James G. Kahn and Kip Sullivan

We collect and compare financial performance data from all four CMS ACO programs from 2005 to 2018, examining net CMS cost. …

We found that overall, ACO programs roughly broke even from the CMS perspective. That is, when bonuses CMS paid to ACOs are subtracted from gross savings, the programs lost money or saved no more than a few tenths of a percent. …

[I]t is time to draw the ACO experiment to a close. We now have a decade of impressive empirical evidence demonstrating minimal if any benefit from ACOs of several designs. This model arose from laudable goals, drawing on theories of human and organizational behavior. However, reality as measured in formal evaluations failed to align with theory. ACOs have not worked for Medicare and will not work for the broader health care system. Indeed, CMS recently ended the Next Generation ACO program. However, CMS is launching another unproven program, direct contracting, to replace the open structure of traditional Medicare.

We propose instead turning to empirically proven tools used by other high-income nations to control health care costs. These include uniform benefits, simplified financing that dramatically reduces payer and provider overhead, removal of profit for primary insurance, regulation of pharmaceutical prices, and public control of capital investments.

Comment:

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

This article (full disclosure: I’m an author) settles once and for all the results of this CMS foray into financially incentivizing physician behavior. It didn’t work. This could have been predicted, and indeed was by HJM contributors Steffie Woolhandler and David Himmelstein in 2012, as cited in the article. But CMS wasn’t listening.

Now CMS is pursuing another unproven and misguided idea about how to manipulate health systems using managed care: direct contracting in traditional Medicare. I wrote about it in this space. It won’t save money, and it will shift health care dollars to managers and shareholders. Do we really need to wait another 15 years for the failure of another misguided experiment?

Let’s follow the advice of the authors: “uniform benefits, simplified financing…, removal of profit for primary insurance, regulation of pharmaceutical prices, and public control of capital investments.”

How do we get there? Single payer.

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Trends in Diabetes Treatment and Control in U.S. Adults, 1999–2018, New England Journal of Medicine, June 10, 2021, by Fang M et al.

Methods: We conducted a cross-sectional analysis of data from adults with diabetes in the United States participating in the National Health and Nutrition Examination Survey (NHANES) to assess national trends in diabetes treatment and risk-factor control from 1999 through 2018.

Results: Diabetes control improved from 1999 to the early 2010s among the participants but subsequently stalled and declined. Between 2007–2010 and 2015–2018, the percentage of adult NHANES participants with diabetes in whom glycemic control (glycated hemoglobin <7%) was achieved declined from 57.4% to 50.5%. … From 2011–2014 to 2015–2018, the percentage of participants in whom blood-pressure control (<140/90 mm Hg) was achieved decreased from 74.2% to 70.4%.

Trends in Blood Pressure Control Among US Adults With Hypertension, 1999-2000 to 2017-2018, JAMA, September 9, 2020, Muntner P et al.

Design, Setting, and Participants: Serial cross-sectional analysis of National Health and Nutrition Examination Survey data, weighted to be representative of US adults, between 1999-2000 and 2017-2018…

Results: …the age-adjusted estimated proportion with controlled BP increased from 31.8% in 1999-2000 to 48.5% in 2007-2008 (P < .001 for trend), remained stable and was 53.8% in 2013-2014 (P = .14 for trend), and then declined to 43.7% in 2017-2018 (P = .003 for trend).

NOTE: Confidence intervals removed to improve readability.

Comment:

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

Hypertension and diabetes are the most common causes of excess mortality in the US for which excellent treatments are available. Yet despite two decades of health policies allegedly focused on quality improvement, control of both conditions has deteriorated. The only plausible explanation is worsening access to care. This compelling indictment of the US healthcare system mandates fundamental reexamination of how we pay for, organize and deliver care.

To quote the sign Archie Cochrane (the true founder of evidence based medicine) carried to a demonstration in the 1930s, “All effective treatments must be free.”

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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?

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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.

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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.

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