PNHP

Winners and losers in balance billing

Winners and losers in balance billing

DMHC Builds on Efforts to Protect Patients from Unfair and Unexpected Bills

State of California
Department of Managed Health Care
August 1, 2008

The California Department of Managed Health Care (DMHC) today announced that it has finalized new regulations to restrict the practice of “balance billing” in emergency care settings — a practice that makes patients, not providers or health plans, responsible for paying the disputed difference between their provider’s bill and the health plan’s coverage. The regulations restrict balance billing by making it an unfair billing practice, thus allowing DMHC enforcement actions against those providers who engage in activities that unfairly burden consumers.

“Consumers, employers and taxpayers pay millions of dollars each year in health care premiums in exchange for a promise to protect them from unexpected bills when a health emergency strikes,” said Cindy Ehnes, Director of the DMHC. “The practice of balance billing breaks this promise to consumers and is unacceptable.”

Balance billing happens most often when an HMO patient receives emergency care from a physician or hospital that is not contracted with their health plan.

The DMHC has a strong record of aggressively protecting consumers from unfair balance billing. It recently filed a lawsuit in the Orange County Superior Court to stop Prime Healthcare Services, a Southern California-based hospital chain, from balance billing more than 3,500 HMO patients for services received at its hospitals.

http://www.hmohelp.ca.gov/library/reports/news/prbbregs.pdf

Comment:

By Don McCanne, MD

The issue of balance billing stems from a conflict between contracts (health plans) that patients have with their managed care organizations and contracts that physicians and hospitals do not have with the managed care organizations covering patients that they are required to provide services for in emergency situations.

This action by the California Department of Managed Care requires that hospitals and physicians comply with contracts between patients and their managed care organizations, even though a contract to provide services has never been negotiated with these private managed care entities. Thus the providers are required to accept fees that may be lower than their costs – fees that are dictated by the private health plan.

The example of Prime Healthcare Services demonstrates why it was necessary to adopt regulations to prevent patients from being gouged at unfair rack prices. But this action, in protecting patients, also protected the private managed care organizations, often at the cost of ripping off the health care providers.

In contrast, our public insurance program, Medicare, does set rates with which providers must comply (with slight variations depending on accepting assignment or contracting as a provider). Recently, in many regions, Medicare rates have been declining in relation to provider costs. A greater effort must be made by the administrators of Medicare to establish rates that cover legitimate costs and provide fair profits. Only then is it fair to demand compliance with government regulated rates.

If we had a universal single payer national health program, a unified effort would be made to demand fair compensation at a level that would ensure that our health care delivery system would be there when we need it. What we don’t need is private intermediaries that manipulate patients and providers to accomplish their business goals. We’ve had enough of that.

Seniors have a special interest in single-payer health care

By William Klepack
Guest Column
The Ithaca Journal
July 31, 2008

In early July, Congress passed a bill to prevent a scheduled cut in Medicare payments to doctors. Although I am pleased with the outcome of this vote, there are several reasons that senior citizens should be concerned about the political maneuvering affecting their care that surrounded this bill and be very interested in single-payer health care.

First, Senators voting against the bill were protecting insurance industry profits at the expense of seniors. The bill reduced insurance company profits by an amount necessary to balance the Medicare budget. Senators voting against this bill were, effectively, manipulating seniors’ health care to benefit the insurance companies’ bottom line.

Second, seniors should be upset because this was just the most recent threat in a long pattern of erosion of payments to their personal physicians, and this trend is starting to have an impact on seniors’ access to care. Primary care doctors (family physicians and internists) have worked tirelessly on behalf of Medicare patients, even as Medicare compensation for their services has stagnated since 2001. Physicians have experienced large increases in overhead costs during that period, and primary care doctors simply cannot continue to sustain their businesses when costs rise and payments do not keep pace with both those costs and inflation.

The result of this ongoing trend is that seniors are having more difficulty finding a physician. In March, the Medical Group Management Association reported that nearly 24 percent of all physicians had begun limiting or not accepting new Medicare patients. In December, the Medicare Payment Advisory Commission reported that, nationally, three out of 10 Medicare patients had trouble finding a primary care physician.

Since having access to health care is the single most important factor influencing health, these adverse trends point out serious problems with our current system.

Seniors should support single-payer health care because, under such a system, patients’ access to health care would not be subject to manipulation for insurance company profits. Private insurance companies would not be raking in exorbitant profits — profits that deliver no health care.

Another reason seniors should support single-payer health care is because a health-ministry-type system would no longer be the political football that the current system has been in recent years. If a nonpolitical health ministry were making health care funding decisions, then the power of the insurance industry to influence legislation ensuring their profits would cease.

Seniors should also support single-payer health care because it would establish payment levels that enable their doctors to keep their doors open and simultaneously make the health care dollar deliver more health care. A national board charged with negotiating with physicians would come to an agreement on rates.

The current Medicare insurance card has no value unless there is a doctor in the house. We not only need a doctor in the house; we need every dollar to go farther in delivering care.

Dr. William Klepack is a family physician practicing in Dryden and is medical director of the Tompkins County Health Department. The opinions expressed above are his personal ones and do not reflect Health Department or Tompkins County policy.

http://www.theithacajournal.com/apps/pbcs.dll/article?AID=/20080731/OPINION02/807310306

Medicare national coverage determinations

New list offers sneak peek into agenda of device, pharmaceutical industries

By Jeffrey Young
The Hill
July 31, 2008
The Centers for Medicare and Medicaid Services (CMS) has published its first-ever quarterly list of drugs, medical devices and procedures that Medicare patients may no longer be able to access.
The list, posted on CMS’s website this week, provides an unprecedented glimpse into what companies or sectors might be celebrating or mourning in the months ahead. It’s the Medicare national coverage determinations, or NCDs, that can be the difference between whether a drug- or device maker sees a huge return on research and development or a crushing bust.
And in an effort to improve transparency and public input, all members of the public — whether business interests, healthcare providers or patients — will able to provide CMS with comments.
CMS lists 19 potential topics for national coverage determinations in the next quarter-year. These topics include drugs to treat anemia, “proton beam therapy” to treat prostate cancer, and tiny, implantable devices that keep coronary arteries open while dispensing medication, called drug-eluting stents.
Not only does Medicare command a large portion of the healthcare marketplace, private insurance companies regularly adopt the same or similar coverage policies based on Medicare’s decisions.
CMS’s regional contractors make the vast majority of coverage determinations. In most cases when the agency’s headquarters steps in, it is in response to a request by manufacturers or medical providers seeking greater clarity on Medicare’s coverage policies based on variations in the locally made decisions. Other times, CMS will initiate a national coverage determination based on agency staff recommendations when they see, for example, new clinical evidence that they believe merits a reconsideration of an old decision.
Based on the statutory standard of whether the new technology or procedure is “reasonable and necessary,” the resultant policy then applies to Medicare providers and patients across the country.
(CMS Chief Medical Officer Barry) Straube stressed that the actual NCD process will not change and that CMS does not intend to centralize coverage determinations. “We have no plans right now to change the national coverage-versus-local coverage decision process,” he said, noting that CMS lacks the financial resources to take over for the regional contractors.
http://thehill.com/the-executive/new-list-offers-sneak-peek-into-agenda-of-device-pharmaceutical-industries-2008-07-31.html

Medicare national coverage determinations (NCDs) are inevitably controversial. Decisions on what procedures, devices and drugs are to be covered must balance the wishes of patients to have unlimited access to all possible care, regardless of demonstrated benefit or lack thereof, with the responsibility of the stewards of our tax funds to not waste them on care that is of no benefit and often is detrimental.
The ethics are fairly straightforward. Medicare, being a publicly-financed program, has an obligation to fund appropriate care, but also has an obligation to prevent misuse of our public funds. Inappropriate care should never be considered to be a right of an individual when the taxpayer would have to pick up the tab.
Generally, a national health program would macro-manage the health care funds, whereas micromanagement of the patient’s care would be provided by the patient’s personal health care professionals. But high-tech care has been the largest contributor to the continuing escalation in health care costs. We are at a point where we should no longer permit the unquestioned use of public funds for unlimited, expensive high-tech care that has not been demonstrated to be of benefit, and sometimes causes harm.
Opponents of government health programs frequently charge that such coverage decisions deny patients life-saving care. Care that might be reasonably expected to reduce suffering or even save a life is not the care that is denied. A cancer drug that has a reasonable probability of providing a significant remission or even a cure is never withheld. Rather, an expensive cancer drug that has not been demonstrated to provide improved outcomes might well be denied. Spending $100,000 of taxpayer funds to provide a false sense of hope where there is no hope is not only wasteful, but it is also cruel because of the adverse effects of such therapies, and the dashed hopes that follow. “Well, we don’t know whether this $100,000 drug will do any good, but let’s try it anyway” should no longer be adequate justification for using public funds for therapeutic whims, even in tragic cases.
It is often said that a national health insurance program should be administered on a regional basis rather than nationally. But this does not necessarily mean that national coverage determinations must rest with regional contractors as they now often do in the Medicare system. Some of the complaints about Medicare stem from the inconsistencies in coverage decisions.
Claiming that CMS lacks the financial resources to centralize national coverage determinations is certainly a feeble excuse for not providing taxpayers with oversight of spending on expensive, unproven, high-tech services. Hopefully 2009 will bring us more enlightened national leaders.

Medicare national coverage determinations

New list offers sneak peek into agenda of device, pharmaceutical industries

By Jeffrey Young
The Hill
July 31, 2008

The Centers for Medicare and Medicaid Services (CMS) has published its first-ever quarterly list of drugs, medical devices and procedures that Medicare patients may no longer be able to access.

The list, posted on CMS’s website this week, provides an unprecedented glimpse into what companies or sectors might be celebrating or mourning in the months ahead. It’s the Medicare national coverage determinations, or NCDs, that can be the difference between whether a drug- or device maker sees a huge return on research and development or a crushing bust.

And in an effort to improve transparency and public input, all members of the public — whether business interests, healthcare providers or patients — will able to provide CMS with comments.

CMS lists 19 potential topics for national coverage determinations in the next quarter-year. These topics include drugs to treat anemia, “proton beam therapy” to treat prostate cancer, and tiny, implantable devices that keep coronary arteries open while dispensing medication, called drug-eluting stents.

Not only does Medicare command a large portion of the healthcare marketplace, private insurance companies regularly adopt the same or similar coverage policies based on Medicare’s decisions.

CMS’s regional contractors make the vast majority of coverage determinations. In most cases when the agency’s headquarters steps in, it is in response to a request by manufacturers or medical providers seeking greater clarity on Medicare’s coverage policies based on variations in the locally made decisions. Other times, CMS will initiate a national coverage determination based on agency staff recommendations when they see, for example, new clinical evidence that they believe merits a reconsideration of an old decision.

Based on the statutory standard of whether the new technology or procedure is “reasonable and necessary,” the resultant policy then applies to Medicare providers and patients across the country.

(CMS Chief Medical Officer Barry) Straube stressed that the actual NCD process will not change and that CMS does not intend to centralize coverage determinations. “We have no plans right now to change the national coverage-versus-local coverage decision process,” he said, noting that CMS lacks the financial resources to take over for the regional contractors.

http://thehill.com/the-executive/new-list-offers-sneak-peek-into-agenda-of-device-pharmaceutical-industries-2008-07-31.html

Comment:

By Don McCanne, MD

Medicare national coverage determinations (NCDs) are inevitably controversial. Decisions on what procedures, devices and drugs are to be covered must balance the wishes of patients to have unlimited access to all possible care, regardless of demonstrated benefit or lack thereof, with the responsibility of the stewards of our tax funds to not waste them on care that is of no benefit and often is detrimental.

The ethics are fairly straightforward. Medicare, being a publicly-financed program, has an obligation to fund appropriate care, but also has an obligation to prevent misuse of our public funds. Inappropriate care should never be considered to be a right of an individual when the taxpayer would have to pick up the tab.

Generally, a national health program would macro-manage the health care funds, whereas micromanagement of the patient’s care would be provided by the patient’s personal health care professionals. But high-tech care has been the largest contributor to the continuing escalation in health care costs. We are at a point where we should no longer permit the unquestioned use of public funds for unlimited, expensive high-tech care that has not been demonstrated to be of benefit, and sometimes causes harm.

Opponents of government health programs frequently charge that such coverage decisions deny patients life-saving care. Care that might be reasonably expected to reduce suffering or even save a life is not the care that is denied. A cancer drug that has a reasonable probability of providing a significant remission or even a cure is never withheld. Rather, an expensive cancer drug that has not been demonstrated to provide improved outcomes might well be denied. Spending $100,000 of taxpayer funds to provide a false sense of hope where there is no hope is not only wasteful, but it is also cruel because of the adverse effects of such therapies, and the dashed hopes that follow. “Well, we don’t know whether this $100,000 drug will do any good, but let’s try it anyway” should no longer be adequate justification for using public funds for therapeutic whims, even in tragic cases.

It is often said that a national health insurance program should be administered on a regional basis rather than nationally. But this does not necessarily mean that national coverage determinations must rest with regional contractors as they now often do in the Medicare system. Some of the complaints about Medicare stem from the inconsistencies in coverage decisions.

Claiming that CMS lacks the financial resources to centralize national coverage determinations is certainly a feeble excuse for not providing taxpayers with oversight of spending on expensive, unproven, high-tech services. Hopefully 2009 will bring us more enlightened national leaders.

Make original Medicare the foundation for health care reform

By JOHN GEYMAN and MALINDA MARKOWITZ
Guest Columnist
Seattle Post Intelligencer
Thursday, July 31, 2008

As Medicare celebrates its 43rd birthday this week, it’s time to take stock of one of the most popular government programs of all time that guarantees all Americans 65 years of age and older universal coverage of comprehensive health care benefits.

At the time of its passage, American seniors were having great difficulty affording health care, especially the costs of hospitalization. They were paying 15 percent of their annual income on health care. Many millions were unable to afford either insurance or their medical bills. Enactment of Medicare gave them access to a set of benefits defined by law, as an earned right for which they contributed, without regard to their health status or income.

Medicare today covers about 43 million American seniors and the disabled, paying about one-half of their health care expenses. Amidst an increasingly unaffordable health care market, Medicare recipients have a solid rock of coverage. The program is administered with an overhead of about 3 percent, less than one-fifth the overhead of competing private programs, while offering defined benefits with free choice of physician and hospital.

A survey by the Commonwealth Fund in 2002 found that Medicare beneficiaries rate the program much higher than private health insurance in terms of quality, help with access to care and payment of their medical bills. A binding social contract has been established and kept with eligible beneficiaries that they can trust and depend on. Even at that, seniors are paying much more out of pocket now than they were in 1965 for health care — 22 percent of their annual income.

Despite its many successes, Medicare has been under relentless attack by conservatives, market stakeholders and their lobbyists pushing to “save” Medicare by killing it. Their agenda is to siphon off more affluent seniors to private plans and shrink Medicare to a much smaller program. There is no ambiguity in this goal. As then Speaker of the House Newt Gingrich said at the time, this kind of “reform” could “solve the Medicare problem” and cause the program to “wither on the vine.”

Private Medicare plans have proven themselves to be more expensive and less reliable. Despite their claims of more choice, better benefits and value, their track record is one of exploitation, made possible only by generous subsidies by the government. The original premise was that these plans would save the government money, but that soon fell by the wayside. Private insurers lobbied early and successfully for generous overpayments. Today’s overpayments average about 12 percent, with the fastest growing private fee-for-service plans at 19 percent.

What do we get for this privatization boondoggle? In the late 1990s, 2.4 million seniors were forced to find new coverage, and often to change doctors, when many Medicare plus Choice plans left the market due to insufficient profits. The 2003 Medicare Prescription Drug Improvement and Modernization Act continued generous government subsidies while also prohibiting the government from negotiating bulk discounts from drug manufacturers as the VA does so effectively with discounts of about 45 percent.

The Government Accounting Office has concluded that private Medicare plans are more expensive, offer fewer benefits than claimed and are of questionable value as public policy.

All incremental efforts to control health care costs have failed over the last 30 years. There are now 75 million uninsured and underinsured, both categories which are growing rapidly with no end in sight. Access to health care for middle-class Americans is seriously threatened, and medical bills have become a leading cause of bankruptcy.

Amidst this deteriorating landscape, original Medicare stands as a shining example of a needs-based program that has consistently served the public interest. Despite being weakened by privatizing, it gives us a solid foundation for real health care reform, when access to necessary health care is even more difficult than in the 1960s.

It is time to expand Medicare as a social insurance program for all Americans through a single risk pool of all 300 million of us. This is the most efficient, fair and sustainable way to insure us all against the costs of illness and injury, coupled with the strengths of our private delivery system. Expansion and improvement is the best way to “save” Medicare.

John Geyman is professor emeritus of family medicine, University of Washington, and past president, Physicians for a National Health Program. Malinda Markowitz is co-president of the California Nurses Association/National Nurses Organizing Committee.

What About Single Payer?

An Answer to the Question About How to Reform Our Health Care System

By Drs. Edward P. Ehlinger and Susanne L. King
Your Voice
MetroDoctors
The Journal of the East and West Metro Medical Societies
July/August 2008

In discussions of health care reform, consensus is rapidly developing around the urgent need for universal health care coverage in the United States. There is also an almost universal understanding that this coverage is not feasible without cost containment. Given the facts that over 47 million people in the U.S. are uninsured and an even greater number are underinsured and that the percentage of the U.S. Gross Domestic Product (GDP) going to health care is over 16 percent, it’s not surprising that the issues of access and cost have become priority issues in our country.

An increasing number of health care professionals and policy makers are claiming that a single-payer system is the only rational approach that can actually contain costs, achieve universal coverage, and maintain or improve quality. They argue that only a single-payer approach can address the economic pressure on businesses and the rising costs of health care for individuals and still be able to expand coverage to everyone. However, these statements are guaranteed to bring forth a series of questions about single payer. Here are responses to some of the questions that are frequently raised.

1) What is single-payer health care?

“Single payer” means that there is one payer — one insurer — who reimburses health care providers for their services. This is in contrast to the current system that provides payment through multiple insurance companies. This one payer has the authority to negotiate limits on what providers, pharmaceutical companies, and equipment manufacturers charge just as insurance companies do now. This payer could be either the state or the federal government. Every industrialized country in the world, other than the U.S., has some form of nationally administered health coverage. Medicare is a single-payer system that has been in place in the U.S. since 1966. However, Medicare is a less than ideal single-payer system because it cannot set budgets for hospitals nor negotiate prices with pharmaceutical companies.

2) Is single payer socialized medicine?

Single payer is not socialized medicine because hospitals and clinics would still be privately owned, rather than owned by the government, and doctors would still be in private practice. “Single payer” simply refers to the taking in and paying out of the health care dollars, which would replace the current multiple-payer system dominated by private insurance companies. Single payer refers to the mechanism used to pay for health care services not how the services are delivered. Many industrialized countries have a single-payer system; some provide services through a national health service, but most provide services through physicians in private practice. All of the leading single-payer bills introduced in the U.S. at the federal and state level would leave the health care provider sector in the hands of private practitioners.

3) Doesn’t Medicare have big problems?

Traditional Medicare has worked very well for patients and they have been happy with it. Because the traditional Medicare program spends a lot less money on administrative functions than private-sector insurers, Medicare is the most efficient health insurance program, public or private, in America. However, the partial privatization of Medicare since the 1980s and the recent total privatization of the Medicare drug benefit have raised costs and brought prosperity to many health plans and insurance companies. Their administrative costs have created an economic burden for the program of billions of dollars per year. Subsequently, payments to doctors, the actual providers of care, have been cut.

In many ways it is the actual need for Medicare that is causing some concern. As the U.S. population ages, there will be an increase in demand for Medicare services. That means there will be an increased need for funding to provide those services. This is not a crisis but a predictable occurrence that needs to be addressed by policy makers and health care planners.

There is a need to find a way to finance that increase in services. Reducing administrative waste through a single payer would be one of the mechanisms of doing that. Funding Medicare Part B (which is the primary revenue source for the physician and drug parts of Medicare) from general revenues rather than payroll taxes would also help eliminate the illusion that somehow Medicare Part B could “go bankrupt.” Imminent bankruptcy is never a concern for government programs, like the Pentagon, which are financed by general revenues.

4) Can we afford single payer, if that means covering 47 million uninsured people?

Compared to other countries, the United States already pays enough to provide comprehensive coverage for everyone. However, coverage for everyone isn’t realized because 31 percent of our health care spending goes for administration through the patchwork of private for-profit and not-for-profit insurance companies and health plans. Potential savings from eliminating the administrative waste and marketing expenditures of insurance carriers have been estimated at $350 billion per year.

5) Won’t there be waiting lines or rationing with single payer?

A poll done in the late 1990s showed that rationing was worse in the United States than in Canada, which has a single-payer system. At that time, 12 percent of Americans said they couldn’t get necessary health care in the previous year compared to 8 percent of Canadians. In 2005, the median wait for specialists or elective surgery was four weeks. A 2007 study highlighted the fact that 37 percent of Americans reported being unable to get necessary medical care “because of cost during the past year” versus 12 percent in Canada.

The United States already rations care based on ability to pay and 18,000 Americans die every year because they lack health insurance. Canadians live longer and are more satisfied with their health care than Americans, while paying half as much per person. If waiting problems in Canada are an issue, it’s because the health care system is underfunded rather than because it is single payer. No single-payer advocate is proposing that the United States lower health care spending to Canadian levels.

6) Won’t our aging population break the bank in a single-payer system?

Japan and European countries have a higher percentage of elderly citizens, yet they spend much less on health care than we do — and have better outcomes. Universal access to health care will improve the health of the population. The issue is what is the best way to get to that universal access in a way that is economically sustainable? A single-payer approach is the most likely approach to achieve that goal.
A single-payer system that provides universal access would also be better able to address the lifestyle and behavior issues, like obesity and tobacco and alcohol use that are major contributors to health care costs.

7) Some people believe that their insurance is meeting their needs; why should they change?

While some people may be comfortable with their present insurance coverage, that coverage is unstable and often inadequate when it is most needed. Because our current system is tied to employment, if people change or lose jobs, their coverage and care is disrupted. Others find their coverage fails when they get sick: 75 percent of the one million Americans experiencing medical bankruptcy each year were insured when they got sick. Insurance premiums are going up every year for policies that cover less and less.

8) How would single payer be financed?

There are a variety of ways that a single-payer system could be financed. Currently, about 60 percent of our health care system is publicly financed (via our taxes), 20 percent is financed by private employers, and 20 percent is financed by individuals. With a state or national single-payer health program, that funding formula could be maintained as a way to finance universal access.

Another option would be a payroll tax on employers (approximately 7 percent) and an income tax on individuals (approximately 2 percent). The payroll tax would replace all other employer expenses for employee health care. The income tax would take the place of all current insurance premiums, co-pays, deductibles, and any other out-of-pocket payments. For the vast majority of people, a 2 percent income tax is less than what they now pay for insurance premiums and out-of-pocket payments. This is particularly true for anyone who has had a serious illness or has a family member with a serious illness. Small employers would also benefit from this payroll tax approach since many now have to pay 25 percent or more of payroll for health insurance compared to the 8.5 percent currently paid by large employers.
While most people and businesses would pay less with a single-payer approach, everyone would have more comprehensive coverage. In addition to medical care and drugs, benefits would include mental health care, dental care, and long-term care.

9) Who would run a single-payer plan?

It is a myth that with national health insurance the government will be making the medical decisions. The government would only be the administrator of the health care funds. In a publicly financed, universal health care system, medical decisions are left to the patient and doctor. Cost containment measures like negotiating limits on what providers, pharmaceutical companies, and equipment manufacturers could charge would be publicly managed by an elected and appointed body. This body, in consultation with medical experts in all fields of medicine, would decide on the benefit package, negotiate doctor fees and hospital budgets, and be responsible for health planning and the distribution of expensive technology. Right now, insurance companies make many health care decisions behind closed doors. Their primary interest is in profits, not the health of the people.

10) Won’t doctors dislike a single-payer system?

Because of its administrative burdens and the hurdles to care created by insurance companies, most physicians are very dissatisfied with the current health care system. Physicians would like to make medical decisions with their patients, without the intrusion of profit-motivated insurance companies. In addition, when patients are unable to pay because they are uninsured or underinsured, doctors often provide care for which they don’t get reimbursed. More and more physician groups are also supporting single payer.

In 2007, almost 60 percent of physicians supported government legislation to establish National Health Insurance — a 10 percent increase in support since 2002. This level of support is similar to that found among physicians in Minnesota and Massachusetts where two-thirds of physicians support single payer. This increase in support for National Health Insurance is distributed across every medical specialty. The largest increase was seen among physicians who “strongly support” National Health Insurance; now almost twice as many physicians support it as oppose it. It has been reported that the number of physicians currently supporting National Health Insurance is much larger than the entire membership of the American Medical Association.

In addition to individual physicians, a single-payer approach is supported by multiple professional organizations like the American College of Physicians, the American Medical Student Association, the National Medical Association, the American Public Health Association, and the American Nurses Association to name just a few.

11) How would we get to a single-payer system?

There are multiple paths to achieving a single-payer system. The most logical would be to develop an expanded and improved “Medicare for all” approach at the national level. National single-payer legislation (HR676) has been introduced and has more supporters than any other proposal for health care reform.

While a full-scale conversion seems unlikely in the short-term, there are steps that could move the country and states in that direction. One approach at the national level would be to add children to Medicare followed by adults. In Minnesota, single-payer legislation could be adopted for children with adults gradually added. Another Minnesota option would be to open MinnesotaCare to small employers and individuals and then expand it to large employers.

Single-payer legislation for Minnesota (SF2324) has been introduced in the Minnesota legislature by Senator John Marty and has garnered a great deal of support. In Canada, single-payer health legislation was introduced province by province, rather than at the national level which gives credence to this state-based approach as a way of moving toward a national single-payer system in the U.S.

Support for single-payer health care is increasing as people learn about the benefits of this solution for our ill-conceived health care system.

Edward P. Ehlinger, M.D., MSPH is the director of Boynton Health Service in Minneapolis, MN. Susanne L. King, M.D. is a child and adolescent psychiatrist in Lenox, Massachusetts.

Reprinted with permission, MetroDoctors, the Journal of the East Metro and West Metro Medical Societies, July/August 2008.

International Resources

Thanks to Joel A. Harrison, Ph.D., MPH for compiling the list of links below.

International Links

  • European Observatory on Health Care Systems This is a phenomenal asset. Using a set format to allow comparisons between countries, each report is about 150 pages including history, legislation, organization, delivery, financing, process and outcomes, current problems and future trends. Shorter summaries for each of the countries are also available. In addition, they have specific reports on a number of topics, including international comparisons of efforts to improve quality, etc.

International Comparisons — Process, Outcomes, Costs

The Commonwealth Fund Commission on a High Performance Health System. Why Not the Best? Results from the National Scorecard on U.S. Health System Performance, 2008. New York, July 2008. [based on both national and international benchmarks, this study covers topics such as quality, access, outcomes, cost, and timeliness. We often here about wait times in other countries without a compared to what? This study found that in a ranking of 6 nations, the U.S. ranked last on “ability to see doctor same/next day when sick or need medical care,” and “[getting] care after hours without going to the emergency room.]
http://www.commonwealthfund.org/publications/publications_show.htm?doc_id=692682

Nolte E, McKee M. Measuring the health of nations: analysis of mortality amenable to health care. BMJ 2003; 327: 1129-33. http://www.bmj.com/cgi/content/full/327/7424/1129

Nolte E, McKee CM. Measuring the health of nations: updating an earlier analysis. Health Affairs 2008; 27(1): 58-71
https://pnhp.org/PDF_files/Measuring%20the%20Health%20of%20Nations%20-%20Updating%20An%20Earlier%20Analysis.pdf

Gusmano MK, et al. A New Way to Compare Health Systems: Avoidable Hospital Conditions in Manhattan and Paris. Health Affairs. 2006; 25(2): 510-520. https://pnhp.org/PDF_files/A%20New%20Way%20to%20Compare%20Healh%20Systems%20-%20Avoidable.pdf

Links by Country

Multiple Countries Summaries & Additional Sources

Australia

Belgium

Canada

Denmark

Finland

France

Books & Monographs

Articles

  • Rodwin VG. The Health Care System Under French National Health Insurance: Lessons for Health Reform in the United States. American Journal of Public Health. 2003; 93(1): 31-37. http://www.ajph.org/cgi/content/full/93/1/31

Germany

New Zealand

Norway

Spain

Sweden

  • Glenngård AH, Hjalte F, Svensson M, Anell A, Bankauskaite V.
    Health Systems in Transition: Sweden. Copenhagen, DK: WHO Regional
    Office for Europe on behalf of the European Observatory on Health
    Systems and Policies, 2005. http://www.euro.who.int/Document/E88669.pdf
  • Rae D. Getting Better Value for Money from Sweden’s Healthcare System. Economics Department Working Papers No. 443. Paris, FR: OECD.
    http://www.olis.oecd.org/olis/2005doc.nsf/LinkTo/NT000040B2/$FILE/JT00189812.PDF
    This OECD document “Getting Better Value . . .” is quite good. One flaw is its discussion of the one for-profit hospital in Stockholm. While it is true that this particular hospital provides quality care at a low cost, it has to. In an environment hostile to for-profit medicine, one lone hospital has to mind its Ps and Qs or their charter would be revoked. Once the system becomes dominated by the for-profit industry, it’s an entirely different ballgame, as we know from the U.S. experience. Research shows that private, investor-owned hospitals have higher costs and higher mortality rates than private, non-profit hospitals in the U.S. The author of the document doesn’t take this into account.

Switzerland

Taiwan

United Kingdom

MedPoint and IntelliScript – harmful additions to the administrative excesses

They Know What’s in Your Medicine Cabinet

by Chad Terhune
BusinessWeek
July 23,2008
That prescription you just picked up at the drugstore could hurt your chances of getting health insurance.
An untold number of people have been rejected for medical coverage for a reason they never could have guessed: Insurance companies are using huge, commercially available prescription databases to screen out applicants based on their drug purchases.
Most consumers and even many insurance agents are unaware that Humana, UnitedHealth Group , Aetna (AET), Blue Cross plans, and other insurance giants have ready access to applicants’ prescription histories.
An investigation last year by the Federal Trade Commission found that the two companies supplying these pharmacy profiles—MedPoint and IntelliScript—violated federal law for years by keeping the system hidden from consumers. But the FTC has merely required disclosure if prescription information causes denial of coverage or some other adverse action; the agency imposed no penalties.
MedPoint and IntelliScript buy the data they disseminate mostly from another group of middleman companies known as pharmacy-benefit managers (PBMs). Large PBMs, such as Medco Health Solutions, provide services to insurers and employers. In playing that role, the PBMs gain broad access to prescription information from drugstores.
http://www.businessweek.com/print/magazine/content/08_31/b4094000643943.htm

MedPoint and IntelliScript represent the type of administrative services that the private insurance industry is selling us. These services are not for the purpose of assisting individuals in gaining access to the health care that they need. These services are for the purpose of allowing the insurance industry to exclude from their plans anyone who might actually need health care. And we’re paying more in administrative costs to defeat this risk pooling function of insurance.
Some say that all we have to do is to increase regulatory oversight of this industry in order to use private insurance as the framework of comprehensive reform. The problem with this reasoning is that business model of private insurers in the United States has nothing in common with the model of private insurers used in some other nations with comprehensive systems. Other nations use private plans to bring everyone in under the umbrella of insurance coverage. We use private plans to keep premiums affordable while shoving those who need health care out into the storm to either fend on their own or to be picked up by taxpayer-financed safety net programs.
We will not achieve our goal of universal health care merely by increasing regulatory oversight of the insurers. We will have to totally transform the private insurance industry from a “successful” business model where success is measured by not paying for health care that people need, to a public service model where success is measured by seeing that all of us get the care we need.
Rather than disassembling these companies and rebuilding them as new private insurance entities within a social insurance system, it would be far easier, more efficient, more equitable and less expensive to dismiss them and replace them with our own publicly-financed and publicly-administered program.
If we leave them in place and merely increase regulation, their business model will dictate that they must introduce yet more innovations that circumvent regulation for the purpose of enhancing their business outcomes while shifting more of the responsibility of financing health care to the taxpayers. We can’t afford it any more. We need an efficient system that actually gets people the health care that they need.

MedPoint and IntelliScript – harmful additions to the administrative excesses

They Know What's in Your Medicine Cabinet

by Chad Terhune
BusinessWeek
July 23,2008

That prescription you just picked up at the drugstore could hurt your chances of getting health insurance.

An untold number of people have been rejected for medical coverage for a reason they never could have guessed: Insurance companies are using huge, commercially available prescription databases to screen out applicants based on their drug purchases.
Most consumers and even many insurance agents are unaware that Humana, UnitedHealth Group , Aetna (AET), Blue Cross plans, and other insurance giants have ready access to applicants’ prescription histories.

An investigation last year by the Federal Trade Commission found that the two companies supplying these pharmacy profiles–MedPoint and IntelliScript–violated federal law for years by keeping the system hidden from consumers. But the FTC has merely required disclosure if prescription information causes denial of coverage or some other adverse action; the agency imposed no penalties.

MedPoint and IntelliScript buy the data they disseminate mostly from another group of middleman companies known as pharmacy-benefit managers (PBMs). Large PBMs, such as Medco Health Solutions, provide services to insurers and employers. In playing that role, the PBMs gain broad access to prescription information from drugstores.

http://www.businessweek.com/print/magazine/content/08_31/b4094000643943.htm

Comment:

By Don McCanne, MD

MedPoint and IntelliScript represent the type of administrative services that the private insurance industry is selling us. These services are not for the purpose of assisting individuals in gaining access to the health care that they need. These services are for the purpose of allowing the insurance industry to exclude from their plans anyone who might actually need health care. And we’re paying more in administrative costs to defeat this risk pooling function of insurance.

Some say that all we have to do is to increase regulatory oversight of this industry in order to use private insurance as the framework of comprehensive reform. The problem with this reasoning is that business model of private insurers in the United States has nothing in common with the model of private insurers used in some other nations with comprehensive systems. Other nations use private plans to bring everyone in under the umbrella of insurance coverage. We use private plans to keep premiums affordable while shoving those who need health care out into the storm to either fend on their own or to be picked up by taxpayer-financed safety net programs.

We will not achieve our goal of universal health care merely by increasing regulatory oversight of the insurers. We will have to totally transform the private insurance industry from a “successful” business model where success is measured by not paying for health care that people need, to a public service model where success is measured by seeing that all of us get the care we need.

Rather than disassembling these companies and rebuilding them as new private insurance entities within a social insurance system, it would be far easier, more efficient, more equitable and less expensive to dismiss them and replace them with our own publicly-financed and publicly-administered program.

If we leave them in place and merely increase regulation, their business model will dictate that they must introduce yet more innovations that circumvent regulation for the purpose of enhancing their business outcomes while shifting more of the responsibility of financing health care to the taxpayers. We can’t afford it any more. We need an efficient system that actually gets people the health care that they need.

They Know What's in Your Medicine Cabinet

How insurance companies dig up applicants’ prescriptions–and use them to deny coverage

by Chad Terhune
Business Week
July 23, 2008

That prescription you just picked up at the drugstore could hurt your chances of getting health insurance.

An untold number of people have been rejected for medical coverage for a reason they never could have guessed: Insurance companies are using huge, commercially available prescription databases to screen out applicants based on their drug purchases.

Privacy and consumer advocates warn that the information can easily be misinterpreted or knowingly misused. At a minimum, the practice is adding another layer of anxiety to a marketplace that many consumers already find baffling. “It’s making it harder to find insurance for people,” says Jay Horowitz, an independent insurance agent in Overland Park, Kan.

The obstacle primarily confronts people seeking individual health insurance, not those covered under an employer’s plan. Walter and Paula Shelton of Gilbert, La., applied to Humana (HUM) in February. They were rejected by the large Louisville insurer after a company representative pulled their drug profiles and questioned them over the telephone about prescriptions from Wal-Mart Stores (WMT) and Randalls, part of the Safeway grocery chain, for blood-pressure and anti-depressant medications.

Mental Health Is a Red Flag

Walter Shelton, a 57-year-old safety consultant in the oil and gas industry, says he tried to explain that the medications weren’t for serious ailments. The blood-pressure prescription related to a minor problem his wife, Paula, had with swelling of her ankles. The antidepressant was prescribed to help her sleep–a common “off-label” treatment doctors advise for some menopausal women. But drugs for depression and other mental health conditions are often red flags to insurers.

Despite his efforts to reassure Humana, the phone interview with the company representative “just went south,” Walter recounts. He and his wife remain uninsured.

“I want to know what’s in there if there’s a black mark against us,” Walter says. Paula, 51, adds: “We can’t get health insurance because we’re taking medications that were prescribed by our doctors. I don’t think that’s right.”

A spokesman for Humana says the company uses “data regarding pharmacy history as part of our assessment process.” But he adds that the insurer has a policy of not commenting on particular cases, such as the Sheltons’ failed application.

FTC Investigation

Traditionally, applicants have been asked to provide insurers with a description of past illnesses. About 30% are deemed uninsurable because of their histories, according to industry veterans. Prescription profiles could add another hurdle, making it especially difficult for the 47 million Americans who lack insurance to acquire coverage. Some 18 million people are now covered by individual policies.

Most consumers and even many insurance agents are unaware that Humana, UnitedHealth Group , Aetna (AET), Blue Cross plans, and other insurance giants have ready access to applicants’ prescription histories. These online reports, available in seconds from a pair of little-known intermediary companies at a cost of only about $15 per search, typically include voluminous information going back five years on dosage, refills, and possible medical conditions. The reports also provide a numerical score predicting what a person may cost an insurer in the future.

An investigation last year by the Federal Trade Commission found that the two companies supplying these pharmacy profiles–MedPoint and IntelliScript–violated federal law for years by keeping the system hidden from consumers. But the FTC has merely required disclosure if prescription information causes denial of coverage or some other adverse action; the agency imposed no penalties. MedPoint and IntelliScript say they are now fully complying with the FTC’s order.

Two-thirds of all health insurers are using prescription data–not only to deny coverage to individuals and families but also to charge some customers higher premiums or exclude certain medical conditions from policies, according to agents and others in the industry. Some carriers are also using the data to charge small employers higher group rates. Separately, some 20% of life insurance companies are relying on prescription histories when reviewing applications, according to experts in that business.

Designed for Emergency Use

“The fundamental breakthrough is that this is the first time ever we have had near-instantaneous access to objective, third-party information,” says Tia Goss Sawhney, an actuary and consultant to the health insurance industry. She says she tested the prescription profiles last year while designing a new insurance policy for American Community Mutual Insurance in Livonia, Mich.

IntelliScript says it sells prescription data to more than 75 health, life, and long-term-care insurance companies. Milliman, a large Seattle consulting firm, acquired the company in 2005. A rival service, MedPoint, has been offered by UnitedHealth’s Ingenix data-mining unit since 2002. MedPoint says it has access to more than 5 billion pharmacy claims.

The data were originally sought to help inform doctors treating patients, especially in emergencies. But that use hasn’t widely caught on, and today the information is primarily employed by insurance companies.

MedPoint and IntelliScript buy the data they disseminate mostly from another group of middleman companies known as pharmacy-benefit managers (PBMs). Large PBMs, such as Medco Health Solutions, provide services to insurers and employers. In playing that role, the PBMs gain broad access to prescription information from drugstores. Some retail chains operate their own PBMs. No privacy laws or other regulations prevent the gathering of this data, according to the FTC.

Fodder for Denials

In its marketing to the insurance industry, MedPoint says prescription histories help “identify high-risk individuals, reduce costs, lower loss ratios, and increase revenue.” Despite that pitch, John Stenson, an Ingenix executive who helps oversee MedPoint, says he doubts that his company’s information causes insurers systematically to reject more people for coverage. “This is about insurance companies getting at the information quickly and clearly,” he says.

BlueCross BlueShield of Tennessee, the state’s biggest insurer, has used MedPoint since April 2007, ordering prescription profiles for about 75% of individual applicants. Since February, when the federal disclosure requirement went into effect, BlueCross says it has notified 1.5% of applicants that their prescription reports have resulted in denial or other negative action. But the company acknowledges that it doesn’t alert consumers if the profiles lead to requests for more medical information that result in subsequent denial. “This doesn’t make it any harder for consumers,” Kevin Ashpole, director of individual products at Tennessee BCBS, maintains. “It ensures the right decision is made.”

But skeptics worry that more people inevitably will be turned down for coverage as a result of growing reliance on prescription histories. Most consumers would be shocked to learn that information about their past prescriptions is being bought and sold–and could come back to haunt them, says Gary Claxton, director of the Health Care Marketplace Project, a research organization run by the Kaiser Family Foundation in Washington, D.C. Rejection by one insurer commonly becomes grounds for denial by others, and the industry has ready access to who has been turned down through a separate database.

Is Disclosure Enough?

When applying for insurance, individuals routinely sign paperwork allowing providers to review their medical history. To comply with the privacy provisions of the federal Health Insurance Portability & Accountability Act, most insurers have now added a reference to prescription history in the lengthy fine print consumers are instructed to read.

The FTC forced the industry to begin disclosing the use of prescription information under a different federal statute, the Fair Credit Reporting Act. Insurers now are required to tell applicants the address of the company that assembled the data. Copies of prescription reports are supposed to be available to consumers at no charge under federal law.

“As soon as we were alerted by the FTC, we cooperated fully, and we began sending out notices to [insurance industry] clients of their obligations” under federal law, says Mark Franzen, managing director of IntelliScript. “This wasn’t the result of a consumer complaint or privacy being violated.” The FTC confirms that its investigation didn’t stem from consumer concern but won’t say what did spark the inquiry.

Insurance companies say that they use prescription data responsibly and that it isn’t the sole basis of decisions to deny coverage. A spokesman for UnitedHealth (UNH) adds that when there are discrepancies between the data and information provided directly by applicants, “the applicant is contacted and given the opportunity to provide additional information.”

But privacy watchdogs and some insurance agents question how insurance carriers can guarantee that they are obtaining accurate prescription histories, especially for people with highly common names. The skeptics also worry about whether legitimate off-label use of prescription drugs by patients such as Paula Shelton could hurt some applicants unfairly.

IntelliScript’s Franzen says it’s the responsibility of the insurance company to deal with issues such as off-label use. He says IntelliScript has reported the wrong person’s drug file in several instances but that mistakes occur in fewer than 1 in 10,000 cases. MedPoint says it has had only “two cases of matching errors in more than 2 million queries.” Most searches include full name, date of birth, Social Security number, and address.

“Is it perfect? No,” Franzen says. “But it’s pretty darn good.”

Julius Richmond, surgeon general under Carter, dies

Note from PNHP: Dr. Richmond was an ardent supporter of single payer national health insurance

By Bryan Marquard
Globe Staff
July 29, 2008 06:34 PM

Poverty undercuts the ability of the young to learn, Dr. Julius B. Richmond realized during research half a century ago, and he drew from his findings to launch Project Head Start, a federal program that has helped millions of children since its inception in 1965.

“It really is a remarkable legacy to his career, how many graduates of Head Start programs there are all over the country who have benefited from early childhood care and education,” said Allan Brandt, dean of the Graduate School of Arts and Sciences at Harvard University.

Dr. Richmond, who also served as US surgeon general under President Jimmy Carter, died in his Chestnut Hill home Sunday. He was 91 and as recently as May was still spending a few hours each day in his office at Harvard, where was a professor emeritus, despite having been diagnosed with cancer a couple of years ago.

“Jimmy and I are saddened to learn of the loss of our dear friend and colleague Dr. Julius Richmond,” Rosalynn Carter, the former first lady, said in a statement issued today. “Julie was a wonderful and compassionate champion in the fight to improve health, mental health, and educational opportunities for our nation’s children. All Americans have benefited from his decades of leadership in advancing the health care needs of our country.”

In a career that ranged from serving as a flight surgeon in the Army Air Corps during World War II to serving as surgeon general from 1977 to 1981, Dr. Richmond left few areas of medicine untouched.

Even at 90, Dr. Richmond was weighing in on national medical issues, decrying the lack of universal health coverage.

“The financiers don’t want government intervention,” Dr. Richmond told the Globe in October 2006. “It’s such an embarrassment that I think the issue will resurface, but it’s difficult for the political figures in Washington to formulate a plan.”

The intersection of public need, political will, and public policy was something Dr. Richmond thought about frequently.

“He often used three variables to describe the most significant elements of public policy,” Brandt said. “He would ask, ‘Do we know enough, what’s the knowledge base?’ Then he would ask, ‘Is there the political will to apply what we know?’ Then he would ask, ‘Do we have a social strategy to bring the knowledge and the politics together in a productive way?’ He was a great analytic thinker and was always thinking about what we need to do to improve a particular situation.”

The family plans to hold a private service and Harvard will announce a public memorial service.

Can't Get No Health Care Satisfaction

by Pat LaMarche
Bangor Daily News
Wednesday, July 30, 2008

A Fox News anchor said Saturday that if Mick Jagger was from the United States he’d finally qualify for Medicare.

She’s kidding — right?

The anchor made a pretty lame attempt at highlighting the rock star’s advancing age. She did, however, do a good job of pointing out how backward the U.S. health care system is.

See, Mick Jagger’s from the United Kingdom and he’s had universal government medical benefits since he was five. That’s because 60 years ago the United Kingdom instituted their National Health Service.

George Bernard Shaw once said that “England and America are two countries separated by a common language.” And that distinctive terminology doesn’t just lend itself to cute little linguistic differences like how they say “lorry” when we say “truck.”

There is also the language used in the U.S. that doesn’t have corresponding lingo in the UK. One example of jargon unique to the U.S. is the term “redlining.” In the U.S., redlining is when an insurance company denies you health care coverage because of a pre-existing condition. In the UK, redlining doesn’t exist.

In fact, according to Health Affairs, “the number one cited health policy journal devoted to publishing original, peer-reviewed research and commentary,” medical redlining is quantified as the “denial rate among applicants for non-group coverage.” Health Affairs lists conditions frequently redlined and the rates at which people are denied access to further coverage. Two of the patient subsets most commonly redlined are breast cancer survivors, 43 percent of the time and HIV patients 100 percent of the time.

There’s a neat organization in the world. It’s called the Organization for Economic Co-operation and Development, OECD. The group consists of 30 member countries that embrace the notion of “democracy” and support a “free market” economy. It used to be called the Organization for European Economic Cooperation and it began as a result of the Marshall Plan – America’s effort to rebuild Europe after World War II. The OECD compiles statistics: Statistics that illuminate the economic conditions and comparatives among their representative democracies.

OECD statistics state that in 2003, the per capita out-of-pocket expenses for healthcare in the U.S. were $722; while in the UK they were only $208.

The Brits aren’t just saving money, they’re living longer. Again, according to OECD, folks in the UK live about 11 months longer than folks in the U.S. This means that in Mick Jagger’s lifetime, with numbers extrapolated for inflation, the average resident of the UK would have saved somewhere around $30,000 over their U.S. counterpart. Think of it as money they could use to live on during that extra year of life.

But that’s just the difference in out-of-pocket expenses. Out-of-pocket costs are nothing compared with a nation’s overall medical expenses. Here the numbers get really staggering.

Again, according to the same smart data-gathering agency that we created under the Marshall Plan, the 2005 per capita cost for health care in the U.S. was $5,290 while in the UK it was only $2,230. That’s $3,060 per person per year. Over the course of a lifetime that sort of money adds up. In simple terms it means that Mick Jagger’s lifetime health needs will cost his society about $180,000 less then our own John Mellencamp will cost us.

All together, between out-of-pocket and regular health expenditures, some London rocker’s health care is almost a quarter of a million dollars cheaper — again adjusted for inflation — than our rock star from Seymour, Ind.

But those expenses are national averages. Ordinary people aren’t as capable of making up the difference as rock stars are. Statistics show that middle income folks still chip in their share of health care costs but go without needed services.

According to a 2002 survey of U.S. taxpayers earning between $25,000 and $50,000 per year conducted by National Public Radio, the Kaiser Family Foundation and Harvard’s Kennedy School of Government, 22 percent of middle class Americans postponed receiving care. Twenty-three percent had problems paying for the care they did receive and 13 percent did not get necessary drug prescriptions filled.

Remember Mick Jagger singing, “Mother’s little helper?” In the U.S. it isn’t just a “drag” getting old — it’s also a little less likely and enormously more expensive.

Pat LaMarche of Yarmouth is the spokesperson for the Evergreen Mountain Resort & Casino referendum campaign. She’s the author of “Left Out in America” and may be reached at PatLaMarche@hotmail.com.