PNHP

Obama speaks out on issues

Obama speaks out on issues

KCPNews

KPC (questioners): Health care is an important issue for most voters. More and more physicians are turning to national health insurance as a solution to our health insurance coverage gaps. According to a survey reported last month by Indiana University, of more than 2,000 doctors surveyed, 59 percent said they support legislation to establish a national health insurance program such as “Medicare for all” to insure all Americans. Why do you think your plan which continues our current patchwork of both public and private insurance is better than expanding Medicare into a “Medicare for all” universal health insurance plan?

Obama: I have said in the past if I were designing a system from scratch I would probably prefer a single-payer system. I think the administrative advantages are significant and by having patients in a single system they are much more likely to benefit from preventive care because the person providing the care has an incentive (to keep people in the system well). There are significant advantages.

The problem is we are not starting from scratch. A sizable percentage of the population gets health insurance from their employers and I think we are going to have to see changed attitudes before we would see a single payer system. I also think there is some advantage to the marketplace being involved and increased competition. So I have said if you are in an employer based plan currently, then we will work with your employer to lower premiums. If you don’t have health insurance then you can buy into a plan that is similar to the plan I have as a member of Congress, and there won’t be exclusions for preexisting conditions. If you can’t afford the plan, then we will subsidize you.

There will be tight regulations on insurers to make sure that we are reimbursing for preventive services, that we are emphasizing the management of the care of the chronically ill more effectively and that we are investing in information technology to reduce bureaucracy, reduce error and improve quality. If we do all those things, we can save as much as $100 – $150 billion per year that we can then use to subsidize those currently without care. These principles have to be applied to Medicare and Medicaid, as well…

This is the most effective way to provide the help people need immediately, and I think this is something we can accomplish within my first term as president of the United States of America.

Health Care System Profiles

Author(s): Karsten Vrangbaek, Isabelle Durand-Zaleski, Reinhard Busse, Niek Klazinga, and Anders Anell
Commonwealth Fund
March 2008

Descriptions of Health Care Systems: Denmark, France, Germany, The Netherlands, Sweden, and the United Kingdom

The work of the Commonwealth Fund’s international program highlights the valuable lessons the U.S. can learn from the health care systems in other industrialized countries. These country profiles provide overviews of the health care systems of several countries, including Denmark, France, Germany, the Netherlands, Sweden, and the U.K. Each profile includes descriptions of how each country organizes, finances, and delivers health services and highlights quality, efficiency, and cost-controlling policy initiatives and reforms

Health Care Horror Stories

Paul Krugman
The New York Times
April 11, 2008

Not long ago, a young Ohio woman named Trina Bachtel, who was having health problems while pregnant, tried to get help at a local clinic.

Unfortunately, she had previously sought care at the same clinic while uninsured and had a large unpaid balance. The clinic wouldn’t see her again unless she paid $100 per visit — which she didn’t have.

Eventually, she sought care at a hospital 30 miles away. By then, however, it was too late. Both she and the baby died.

You may think that this was an extreme case, but stories like this are common in America.

Back in 2006, The Wall Street Journal told another such story: that of a young woman named Monique White, who failed to get regular care for lupus because she lacked insurance. Then, one night, “as skin lesions spread over her body and her stomach swelled, she couldn’t sleep.”

The Journal’s report goes on: “Mama, please help me! Please take me to the E.R.,” she howled, according to her mother, Gail Deal. “O.K., let’s go,” Mrs. Deal recalls saying. “No, I can’t,” the daughter replied. “I don’t have insurance.”

She was rushed to the hospital the next day after suffering a seizure — and the hospital spared no expense on her treatment. But it all came too late; she was dead a few months later.

How can such things happen? “I mean, people have access to health care in America,” President Bush once declared. “After all, you just go to an emergency room.” Not quite.

First of all, visits to the emergency room are no substitute for regular care, which can identify and treat health problems before they get acute. And more than 40 percent of uninsured adults have no regular source of care.

Second, uninsured Americans often postpone medical care, even when they know they need it, because of expense.

Finally, while it’s true that hospitals will treat anyone who arrives in an emergency room with an acute problem — and it’s wonderful that they will — it’s also true that hospitals bill patients for emergency-room treatment. And fear of those bills often causes uninsured Americans to hesitate before seeking medical help, even in emergencies, as the Monique White story illustrates.

The end result is that the uninsured receive a lot less care than the insured. And sometimes this lack of care kills them. According to a recent estimate by the Urban Institute, the lack of health insurance leads to 27,000 preventable deaths in America each year.

But are they really preventable? Yes. Stories like those of Trina Bachtel and Monique White are common in America, but don’t happen in any other rich country — because every other advanced nation has some form of universal health insurance. We should, too.

All of which makes the media circus of a few days ago truly shameful.

Some readers may already have recognized the story of Trina Bachtel. While campaigning in Ohio, Hillary Clinton was told this story, and she took to repeating it, without naming the victim, on the campaign trail. She used it as an illustration of what’s wrong with American health care and why we need universal coverage.

Then The Washington Post identified Ms. Bachtel, the hospital where she died claimed that the story was false — and the news media went to town, accusing Mrs. Clinton of making stuff up. Instead of being a story about health care, it became a story about the candidate’s supposed problems with the truth.

In fact, Mrs. Clinton was accurately repeating the story as it was told to her — and it turns out that while some of the details were slightly off, the essentials of her story were correct. After all the fuss, The Washington Post eventually conceded that “Bachtel’s medical tragedy began with circumstances very close to the essence” of Mrs. Clinton’s account.

And even more important, Mrs. Clinton was making a valid point about the state of health care in this country.

In other words, this was a disgraceful episode. It was particularly sad to see a number of Obama supporters (though not the Obama campaign itself) join enthusiastically in the catcalls against Mrs. Clinton’s good-faith effort to put a human face on the cruelty and injustice of the American health care system.

Look, I know that many progressives have their hearts set on seeing Barack Obama get the Democratic nomination. But politics is supposed to be about more than cheering your team and jeering the other side. It’s supposed to be about changing the country for the better.

And if being a progressive means anything, it means believing that we need universal health care, so that terrible stories like those of Monique White, Trina Bachtel and the thousands of other Americans who die each year from lack of insurance become a thing of the past.

AHIP's definition of equity

The Principles of Pricing Health Insurance

America’s Health Insurance Plans (AHIP)

Equity

Some insureds make more claims than others, and consequently the cost of providing coverage is different for different insureds. The premium amount each insured pays must reflect the expected cost of providing coverage to that insured. Why? Suppose an insurer charged some insureds less than the expected cost of providing coverage to them. That insurer would have to charge other insureds an extra amount to make up for those paying less than cost. Those insureds paying extra would go to other insurers that would not charge them extra. The original insurer would be left only with insureds paying less than costs and could go out of business.

http://www.ahiphiwire.org/HealthInsurance/LearningCenter/Feature.aspx?doc_id=159743

Comment:

By Don McCanne, MD

What is “equity,” as the term would apply to our health care system?

The American Heritage Dictionary defines equity as “something that is just, impartial, and fair.” Merriam-Webster defines it as “something that is equitable,” and equitable as “dealing fairly and equally with all concerned.”

In an article from the Journal of Epidemiology and Community Health (2003;57:254-258), P. Braveman and S. Gruskin define equity in health as “the absence of systematic disparities in health (or in the major social determinants of health) between groups with different levels of underlying social advantage/disadvantage — that is, wealth, power, or prestige.”

And how does the private insurance industry define equity in the pricing of health insurance premiums? The premium that “EACH insured pays must reflect the expected cost of providing coverage to THAT insured,” but not “an extra amount to make up for those paying less than cost.”

So let’s see how that would work in a system that finances health care for everyone. The 80 percent of individuals (243 million people) who use 20 percent of our national health expenditures ($479 billion) would each be responsible for $1970 in an equitable system, according to the insurance industry’s version. The other 20 percent of individuals (61 million people) who use 80 percent of our national health expenditures ($1,915 billion) would each be responsible for $31,400 in AHIP’s version of equity.

So the private insurance industry, in order to establish equity, would set their premiums based on health care costs of $1970 each (plus administrative costs and profits, less cost-sharing) for four-fifths of us. But what about the one-fifth with health care costs averaging $31,400 each? They simply avoid that market.

Thus the insurance industry’s definition of equity is making premiums fair by excluding the costs of those needing health care, which equates with excluding them from coverage under their plans. Those with high costs can use their wealth, power, or prestige to obtain care. But what about those without? Doesn’t that stretch the definition of equity to well past the breaking point?

AHIP’s definition of equity

The Principles of Pricing Health Insurance

America’s Health Insurance Plans (AHIP)

Equity

Some insureds make more claims than others, and consequently the cost of providing coverage is different for different insureds. The premium amount each insured pays must reflect the expected cost of providing coverage to that insured. Why? Suppose an insurer charged some insureds less than the expected cost of providing coverage to them. That insurer would have to charge other insureds an extra amount to make up for those paying less than cost. Those insureds paying extra would go to other insurers that would not charge them extra. The original insurer would be left only with insureds paying less than costs and could go out of business.

http://www.ahiphiwire.org/HealthInsurance/LearningCenter/Feature.aspx?doc_id=159743

Comment:

By Don McCanne, MD

What is “equity,” as the term would apply to our health care system?

The American Heritage Dictionary defines equity as “something that is just, impartial, and fair.” Merriam-Webster defines it as “something that is equitable,” and equitable as “dealing fairly and equally with all concerned.”

In an article from the Journal of Epidemiology and Community Health (2003;57:254-258), P. Braveman and S. Gruskin define equity in health as “the absence of systematic disparities in health (or in the major social determinants of health) between groups with different levels of underlying social advantage/disadvantage — that is, wealth, power, or prestige.”

And how does the private insurance industry define equity in the pricing of health insurance premiums? The premium that “EACH insured pays must reflect the expected cost of providing coverage to THAT insured,” but not “an extra amount to make up for those paying less than cost.”

So let’s see how that would work in a system that finances health care for everyone. The 80 percent of individuals (243 million people) who use 20 percent of our national health expenditures ($479 billion) would each be responsible for $1970 in an equitable system, according to the insurance industry’s version. The other 20 percent of individuals (61 million people) who use 80 percent of our national health expenditures ($1,915 billion) would each be responsible for $31,400 in AHIP’s version of equity.

So the private insurance industry, in order to establish equity, would set their premiums based on health care costs of $1970 each (plus administrative costs and profits, less cost-sharing) for four-fifths of us. But what about the one-fifth with health care costs averaging $31,400 each? They simply avoid that market.

Thus the insurance industry’s definition of equity is making premiums fair by excluding the costs of those needing health care, which equates with excluding them from coverage under their plans. Those with high costs can use their wealth, power, or prestige to obtain care. But what about those without? Doesn’t that stretch the definition of equity to well past the breaking point?

Health reform lessons from Chile

Chile's Neoliberal Health Reform: An Assessment and a Critique

By Jean-Pierre Unger, Pierre De Paepe, Giorgio Solimano Cantuarias, Oscar Arteaga Herrera
PLoS Medicine
April 1, 2008

Summary Points

* The Chilean health system underwent a drastic neoliberal reform in the 1980s, with the creation of a dual system: public and private health insurance and public and private provision of health services.

* This reform served as a model for later World Bank–inspired reforms in countries like Colombia.

* The private part of the Chilean health system, including private insurers and private providers, is highly inefficient and has decreased solidarity between rich and poor, sick and healthy, and young and old.

* In spite of serious underfinancing during the Pinochet years, the public health component remains the backbone of the system and is responsible for the good health status of the Chilean population.

* The Chilean health reform has lessons for other countries in Latin America and elsewhere: privatisation of health insurance services may not have the expected results according to neoliberal doctrine. On the contrary, it may increase unfairness in financing and inequitable access to quality care.

The Impact of the Reform: Efficiency

Here the evidence is clearer. ISAPRES (the private system) has hardly contained costs, and the ISAPRES companies never intended to do so: they have few incentives to be efficient buyers of health services for their clients. Instead, they work hard to be efficient in the selection of their clients (they are allowed to refuse clients). Their focus is on low-risk, high-income patients, with the goal of making a profit. They spend ten times as much on administration per member and about two times as much on health care per member than FONASA (National Health Fund, a public agency), even though ISAPRES members are in better health and need less care. To deliver care, ISAPRES companies rely on a burgeoning private sector, reimbursed on a fee-for-service basis, which induces an increased supply of unnecessary but profitable services.

http://medicine.plosjournals.org/perlserv/?request=get-document&doi=10.1371/journal.pmed.0050079

Comment:

By Don McCanne, MD

This article is worth reading in its entirety because of the important lessons that would apply to reform in the United States.

But do we really need Chile to provide us with these lessons? Just look around. With our $2.4 trillion/year experiment, we’ve already demonstrated the same results here. And yet we keep doing the same thing?

Medicare's failed experiment with disease management

Medicare Finds How Hard It Is to Save Money

By Reed Abelson
The New York Times
April 7, 2008

An ambitious three-year experiment to see whether the Medicare system could prevent expensive hospital visits for people with chronic conditions like congestive heart failure and diabetes has suggested that such an approach may cost more than it saves.

The test borrowed a practice long available through private health plans. Nurses periodically place phone calls to patients to check whether they are taking their drugs and seeing the right doctors. The idea is that keeping people healthier can help patients avoid costly complications.

After paying eight outside companies about $360 million since mid-2005 to try to improve such patients’ health, Medicare is still trying to figure out whether the companies were able to keep people healthier. But the preliminary data indicate that the government is unlikely to save money.

Several of the companies, including two that specialize in disease management, Healthways and Health Dialog, are pressing Medicare to continue the project in some fashion beyond the end of this year, saying the government mishandled the experiment.

“We haven’t proven anything,” said Dr. Jeffrey L. Kang, a former Medicare official who is now the chief medical officer for the insurer Cigna. The companies say Medicare signed up patients who were much sicker than they had expected. Instead of giving companies a chance to intervene before someone went to the hospital, Dr. Kang said, most of the patients were already so ill that it was “no longer a preventive program.”

George B. Bennett, the chief executive of Health Dialog, which is overseeing about 15,000 Medicare patients in western Pennsylvania, favors continuing the experiment, but with adjustments. He wants Medicare to give the companies more flexibility to manage patients in ways they say have already been proven to work among the employees they cover in commercial plans. Such measures, he said, include giving the insurer a bigger role in selecting the patients, with an eye toward identifying the ones most likely to be helped.

Medicare is already exploring other ideas, like the development of so-called “medical homes,” where a doctor with a team of other professionals oversees a patient’s care. A few doctors’ groups involved in a separate Medicare experiment have reported some success in saving the government money by more actively managing their patients’ care.

http://www.nytimes.com/2008/04/07/business/07medicare.html?hp

Comment:

By Don McCanne, MD

The presidential candidates claim that they will pay for expanding coverage to everyone by using the savings made possible though chronic disease management. But what is disease management, and will it save money?

The Medicare experiment with disease management has demonstrated what it should not be. The comments of the executives in the industry contracted by Medicare provide us with an understanding of the flaws of this model. They imply that Medicare was unfair because they selected patients with chronic disease to be managed by these private chronic disease managers. What?

To make the experiment work, the disease managers want to be able to select the patients themselves. We already have ample experience with this industry to know what that means. They want to select the healthy, low-cost patients and turn the expensive, high-needs patients over to the taxpayers. Cream skimming is already rampant in the private insurance industry. We certainly don’t need any more of it.

So what should disease management look like? The establishment of medical homes within a well-functioning primary care infrastructure would be the ideal model for chronic disease management. Although we are approaching a crisis in the shortage of primary care physicians, well trained nurse practitioners, as part of the primary care team, would be well positioned to use standard protocols plus clinical judgement to assist patients in the management of their chronic conditions.

Of course, that would be much simpler through a single payer national health program in which our abundant resources could be realigned to achieve this crucial goal. Imagine… using our resources more efficiently while achieving the goals of a high-performance system. Pipe dream? Don’t think so.

Most Doctors Support National Health Insurance Updated

by DrSteveB
DailyKos
Mon Mar 31, 2008 at 01:54:14 PM PDT

I have always wanted to do a “Breaking” headline. Well this is from a press release embargoed until just now on an article in the professional peer reviewed journal Annals of Internal Medicine (aka: the green journal; it’s generally considered the 3rd most prestigious American medical journal). It reports on a methodologically valid survey of American doctors.

The survey, conducted last year of 2,193 physicians across the United States, showed 59% “support government legislation to establish national health insurance,” while 32% oppose & 9% are neutral. That’s a solid majority of American doctors, and up 10% from 49% in 2002 when a similar study was last done. We have all gotten pretty sick of the insurance companies!

So, yeah for us docs, for getting it! Now if only the Dems running for president were as progressive! Fortunately there is HR-676 in Congress.

UPDATE: For those who want the full original journal article, methods, etc. the full text of the article just went online here: https://pnhp.org/docsurvey/annals_physician_support.pdf

More on the study:

As you know, such plans typically involve a single, federally administered social insurance fund that that guarantees health care coverage for everyone, much like Medicare currently does for seniors. The plans typically eliminate or substantially reduce the role of private insurance companies in the health care financing system, but still allow patients to go the doctors of their choice.

From the Physicians for a National Health Program (PNHP) press release:

The findings reflect a leap of 10 percentage points in physician support for national health insurance (NHI) since 2002, when a similar survey was conducted. At that time, 49 percent of all physician respondents said they supported NHI and 40 percent opposed it.

Support among doctors for NHI has increased across almost all medical specialties, said Dr. Ronald T. Ackermann, associate director of the Center for Health Policy and Professionalism Research at Indiana University’s School of Medicine and co-author of the study.

“Across the board, more physicians feel that our fragmented and for-profit insurance system is obstructing good patient care, and a majority now support national insurance as the remedy,” he said.

Support for NHI is particularly strong among psychiatrists (83 percent), pediatric sub-specialists (71 percent), emergency medicine physicians (69 percent), general pediatricians (65 percent), general internists (64 percent) and family physicians (60 percent). Fifty-five percent of general surgeons support NHI, roughly doubling their level of support since 2002.

Doctors have often expressed concern about lack of patient access to care due to rising costs and patients’ insufficient levels of insurance. An estimated 47 million Americans currently lack health insurance coverage and another 50 million are believed to be underinsured. At the same time, health care costs in the United States are rising at the rate of about 7 percent a year, twice the rate of inflation.

The health care issue continues to rank high among voter concerns in the 2008 elections, placing third in a recent poll after the economy and Iraq.

The current study by the Indiana University researchers is the largest survey ever conducted among doctors on the issue of health care financing reform. It is based on a random sampling of names obtained from the American Medical Association’s master list of physicians throughout the country.

In addition to measuring attitudes toward NHI, the survey also asked doctors about their views about “more incremental reform,” often interpreted as state- or federal-based programs requiring or “mandating” that consumers buy health insurance from private insurance companies, legislative measures providing tax incentives to businesses to provide coverage for their employees, or similar steps.

Fewer physicians (55%) were in support of “incremental” reform. Moreover, virtually all those opposed to national health insurance also opposed incremental reform to improve access to care. In fact, only 14% of physicians overall oppose national health insurance but support more incremental reforms. Ironically, many medical organizations and most politicians have endorsed only incremental changes.

Dr. Aaron E. Carroll, Director of Indiana University’s Center for Health Policy and Professionalism Research and lead author of the study, commented: “Many claim to speak for physicians and reflect their views. We asked doctors directly and found that, contrary to conventional wisdom, most doctors support the government creating national health insurance.”

Other signs indicate that attitudes among doctors are changing. The nation’s largest medical specialty group, the 124,000-member American College of Physicians, endorsed a single-payer national health insurance program for the first time in December.

By the way, earlier state-level surveys have found that 64% of physicians in Minnesota support single payer. In New Hampshire the figure is 67% supporting single payer!

Admittedly, PNHP’s membership is only around 15,000 nationwide. But did you know that the AMA memberhsip is down to 25% of American physicians and dropping.

Journal Reference for the article in the press release:
“Support for National Health Insurance among American Physicians: Five Years Later,” Aaron E. Carroll and Ronald T. Ackermann, Annals of Internal Medicine, April 2008. Dr. Aaron Carroll is a member of the Board of Directors of PNHP.

Physicians for a National Health Program, a membership organization of over 15,000 physicians (and also many other non-physicians), supports a single-payer national health insurance program. PNHP physician experts are available for interviews and can speak about the health care crisis in your state and options for reform at both the state and national level (e.g. on the leading Presidential candidates health plans).

To contact groups supporting single payer and/or a physician-spokesperson in your state, click here: PNHP-State Actions or call 312-782-6006.

Medicare’s failed experiment with disease management

Medicare Finds How Hard It Is to Save Money

By Reed Abelson
The New York Times
April 7, 2008

An ambitious three-year experiment to see whether the Medicare system could prevent expensive hospital visits for people with chronic conditions like congestive heart failure and diabetes has suggested that such an approach may cost more than it saves.

The test borrowed a practice long available through private health plans. Nurses periodically place phone calls to patients to check whether they are taking their drugs and seeing the right doctors. The idea is that keeping people healthier can help patients avoid costly complications.

After paying eight outside companies about $360 million since mid-2005 to try to improve such patients’ health, Medicare is still trying to figure out whether the companies were able to keep people healthier. But the preliminary data indicate that the government is unlikely to save money.

Several of the companies, including two that specialize in disease management, Healthways and Health Dialog, are pressing Medicare to continue the project in some fashion beyond the end of this year, saying the government mishandled the experiment.

“We haven’t proven anything,” said Dr. Jeffrey L. Kang, a former Medicare official who is now the chief medical officer for the insurer Cigna. The companies say Medicare signed up patients who were much sicker than they had expected. Instead of giving companies a chance to intervene before someone went to the hospital, Dr. Kang said, most of the patients were already so ill that it was “no longer a preventive program.”

George B. Bennett, the chief executive of Health Dialog, which is overseeing about 15,000 Medicare patients in western Pennsylvania, favors continuing the experiment, but with adjustments. He wants Medicare to give the companies more flexibility to manage patients in ways they say have already been proven to work among the employees they cover in commercial plans. Such measures, he said, include giving the insurer a bigger role in selecting the patients, with an eye toward identifying the ones most likely to be helped.

Medicare is already exploring other ideas, like the development of so-called “medical homes,” where a doctor with a team of other professionals oversees a patient’s care. A few doctors’ groups involved in a separate Medicare experiment have reported some success in saving the government money by more actively managing their patients’ care.

http://www.nytimes.com/2008/04/07/business/07medicare.html?hp

Comment:

By Don McCanne, MD

The presidential candidates claim that they will pay for expanding coverage to everyone by using the savings made possible though chronic disease management. But what is disease management, and will it save money?

The Medicare experiment with disease management has demonstrated what it should not be. The comments of the executives in the industry contracted by Medicare provide us with an understanding of the flaws of this model. They imply that Medicare was unfair because they selected patients with chronic disease to be managed by these private chronic disease managers. What?

To make the experiment work, the disease managers want to be able to select the patients themselves. We already have ample experience with this industry to know what that means. They want to select the healthy, low-cost patients and turn the expensive, high-needs patients over to the taxpayers. Cream skimming is already rampant in the private insurance industry. We certainly don’t need any more of it.

So what should disease management look like? The establishment of medical homes within a well-functioning primary care infrastructure would be the ideal model for chronic disease management. Although we are approaching a crisis in the shortage of primary care physicians, well trained nurse practitioners, as part of the primary care team, would be well positioned to use standard protocols plus clinical judgement to assist patients in the management of their chronic conditions.

Of course, that would be much simpler through a single payer national health program in which our abundant resources could be realigned to achieve this crucial goal. Imagine… using our resources more efficiently while achieving the goals of a high-performance system. Pipe dream? Don’t think so.

2008 Dartmouth Atlas of Health Care

Tracking the Care of Patients with Severe Chronic Illness

Lead Author: John E. Wennberg
Co-Authors: Elliott S. Fisher, David C. Goodman, and Jonathan S. Skinner
The Dartmouth Atlas of Health Care 2008

Nowhere are the system’s failings more apparent than in the care of the chronically ill. More than 90 million Americans live with at least one chronic illness, and seven out of ten Americans die from chronic disease. Among the Medicare population, the toll is even greater: about nine out of ten deaths are associated with just nine chronic illnesses, including congestive heart failure, chronic lung disease, cancer, coronary artery disease, renal failure, peripheral vascular disease, diabetes, chronic liver disease, and dementia. Treating chronic disease is both enormously costly and not particularly effective. Most patients with chronic disease are treated in episodic fashion by multiple physicians, who rarely coordinate the care they deliver. As chronic disease progresses, the amount of care delivered and the costs associated with this care increase dramatically. Patients with chronic illness in their last two years of life account for about 32% of total Medicare spending, with much of it going toward physician and hospital fees (Medicare Part A and Part B) associated with repeated hospitalizations.

This edition of the Dartmouth Atlas will focus on disentangling the phenomenon known as “unwarranted variation,” or variation in different regions of the country that is not explained on the basis of illness, patient characteristics or preferences, or the dictates of evidence-based medicine. Like the last edition, it focuses on supply-sensitive care delivered to chronically ill Medicare beneficiaries in the last two years of life.

Concerning feasibility

Given the complex, entangled web of economic incentives and false assumptions that currently operate in today’s health care system, is it possible to successfully address the underlying major structural problems behind the unwarranted variation phenomenon: poor science, poor coordination of care, and overuse of care, particularly of acute care hospitals? The first step, we suggest, is to understand the causes and consequences of variation in the way chronic illness is managed from state to state, from region to region, and from provider to provider. Much of this edition of the Atlas has been devoted to this task. The next step is to implement reforms that can address unwarranted variation. In this chapter, we have outlined a general approach to reducing variation. The end game is the establishment of science-based, cost-effective, and coordinated management of chronic illness through care that is also sensitive to patient preferences and supported by adequate infrastructure. An adequate infrastructure includes the personnel and technology that serve as the means for both guiding and monitoring quality and efficiency. Eventually, reimbursement should be determined on the basis of these measures.

A strategy for improving the scientific basis of clinical care

Today, there is virtually no clinical research that focuses on variation in care intensity. The nation needs a crash program to transform the management of chronic illness to a rational system where what happens to patients is based primarily on illness severity, medical evidence, and the patient’s wishes, and where resource allocation and Medicare spending can be guided more and more by knowledge of what is needed to produce cost-effective, high-quality care.

The support of such research needs to be the responsibility primarily of federal science policy. It makes no sense for the government to invest in biomedical research (such as most of the research funded by the National Institutes of Health) without complementary research aimed at determining how new and existing treatments affect the outcomes of care, the lives of patients, and the efficiency of clinical practice.

How hospitals might respond

Using the Dartmouth Atlas database, hospitals can learn quickly where they stand on the relative efficiency scale, and those with acute hospital resource inputs and utilization that are substantially in excess of efficient practice benchmarks set by providers like the Mayo Clinic and Intermountain Healthcare will understand that in the long run, CMS may penalize them for providing high-cost, high-intensity, chaotic care. Under the shared savings model, CMS would offer a strong financial incentive for hospitals to organize their care.

How physicians might respond

The primary care “medical home” could provide a model for coordinating care among sectors and ensuring that patients’ transitions between sectors run smoothly. In this role, primary care physicians would have an advantage, because in today’s health care markets, most primary care physicians do not have entangling owner relationships with acute care hospitals, skilled nursing facilities, or long-term care facilities. They are thus in a better position to help reduce the remarkable variation among these sectors of care. We believe that CMS should develop strong financial incentives for primary physicians to assume a leadership role in coordinating care and reducing overuse of acute care hospitals.

http://www.dartmouthatlas.org/

The Dartmouth Atlas of Health Care 2008:
http://www.dartmouthatlas.org/atlases/2008_Chronic_Care_Atlas.pdf

Comment:

Don McCanne, MD

Uwe Reinhardt has said that for the past few decades John Wennberg has been howling in the wind. So what is the noise all about? It is about the hundreds of billions of dollars that we are wasting on poor quality, intensive high-tech care that does not improve outcomes.

Wennberg’s group tends to dismiss national health insurance as being an inadequate response to our needs, instead suggesting solutions such as deciding that “that only accountable care organizations capable of providing evidence-based care would be eligible for Medicare reimbursement for routine management of chronic illness.” Such an approach would not only perpetuate our highly-flawed, fragmented system of financing health care, but would further compound the fragmentation of our health care delivery system.

That is not to dismiss the very great importance of the contributions of John Wennberg and his associates. They have provided us with a data base that provides an opportunity to shift spending from wasteful, poor quality excesses to higher quality care that benefits everyone. They have demonstrated the importance of establishing a primary care medical home.

To achieve that goal, we really do need to reform our health care financing system. Just imagine how effective a single payer national health program would be in “transforming the management of chronic illness to a rational system where what happens to patients is based primarily on illness severity, medical evidence, and the patient’s wishes, and where resource allocation can be guided more and more by knowledge of what is needed to produce cost-effective, high-quality care.”

Local doctor not alone in favoring national health insurance

By JOHN BULGER
Idaho Statesman
Apr 4, 2008
jbulger@journalnet.com

Pocatello physician Bill Woodhouse delivers a grim prognosis on the state of health care in America.

“We’re dealing with a catastrophe of the first order,” Woodhouse said.

Woodhouse is not alone in his opinion. A recent study in Annals of Internal Medicine reported that a solid majority — 59 percent — of U.S. physicians support national health insurance.


Local physician Dr. Bill Woodhouse advocates the adoption of
a national health care plan.
JOURNAL PHOTO BY JOHN BULGER

An estimated 47 million Americans currently lack health insurance coverage, and 50 million more are believed to be underinsured. Health care costs are rising approximately 7 percent per year, twice that of inflation.

“It’s the greatest moral failing of our times,” Woodhouse said.

Woodhouse is a family physician, a past president of the Idaho Academy of Family Physicians, and a former opponent of a single-payer health care system that many industrialized nations employ. But Woodhouse experienced a change of heart a few years ago.

“I got tired of going to bed thinking I was part of something corrupt,” he said.

Woodhouse is now active in state and national groups advocating for health care reform. He speaks on the topic frequently, armed with statistics which are troubling.

* The U.S. spent $2 trillion on health care in 2007. And $1 trillion of that amount went to administrative costs.

* We pay nearly twice as much per person for health care than Switzerland, the second-most expensive nation.

* More than 50 percent of U.S. bankruptcies are now medically related.

Woodhouse points to a 2000 study in Seattle which encompassed 2,777 patients. The patient pool had 755 individual insurance plans, with differing benefits, co-payments, deductibles and coverage rules.

The upshot of such a fragmented pay system?

“It costs three times more to administer a practice here than in Canada,” Woodhouse said.

Canadian health care providers never need question where to bill insurance. It goes to the province’s health care provider. Every Canadian citizen is insured under the Canada Health Act’s tax-supported system.

Canada’s tax spending was $880 per person in 2002. The U.S. spent $2,130 per person.

A poll by the World Health Organization found 54 percent of Canadians were satisfied, while only 49 percent of Americans were pleased with their overall care.

Woodhouse notes the vicious cycle of cost shifting that occurs in our system. Fixed costs rise, which result in higher premiums. Higher premiums result in more people being uninsured or underinsured, many of whom delay seeking treatment until forced to visit a doctor. The illnesses are then more acute, resulting in higher costs. Unable to pay for the services out of pocket, the health care system absorbs the charge and fixed costs increase. And upward it spirals.

“We put people in the hospital every week who wouldn’t be there if they had primary care,” Woodhouse said.

And the results are sobering. More than 18,000 deaths are attributed annually to lack of insurance.

“That’s six 9/11s every year,” he said.

A visit to the Pocatello Free Clinic illustrates the problems with the system. Go there any day, he said, and the clinic is crowded with women between 50 and 65 years of age.

“Their chronic medical conditions are patched together until they can qualify for Medicare (at age 65),” Woodhouse said. “And most people down there? They’re working one or two jobs.”

Personal finances shouldn’t be part of the thought process when seeking medical care, Woodhouse said. He argues we need to start treating health care as a common good, similar to education, fire prevention and road maintenance.

“Two o’clock in the morning, your chest starts hurting. What happens next is not a business transaction,” he said.

Despite the daunting challenge of reform, Woodhouse remains optimistic, although he does not see a banner carrier for a single-payer system among current policy makers. But he believes change is inevitable in a broken system.

“What’s the tipping point?” he muses. “We’re getting there.”

An unheard majority for national health insurance

By Jess Fiedorowicz and Dennis Fiedorowicz
Guest Opinion
Iowa City Press-Citizen
Saturday, April 5, 2008

The adjective “broken” has so frequently been used to describe our healthcare system as to become a cliché. Recently an important new study was published in the Annals of Internal Medicine that reveals a growing consensus among medical professionals on a path forward. A solid majority of doctors, now 59 percent, support national health insurance.

National health insurance plans typically involve a single, federally-administered social insurance fund that guarantees health care coverage for everyone. This may effectively eliminate or at least reduce the role of private insurance companies in health care financing, while still allowing patients to choose their personal physician. This growing consensus of the medical community on the need for national health insurance may reflect two values upon which our system fails: social justice and fiscal responsibility.

System’s current flaws

Our current system is unjust. An estimated 47 million Americans now are without health insurance, and more than 50 million are “underinsured.” In Iowa, more than a quarter million are uninsured. Health care should represent a community value. The public invests in schools, emergency services and transportation infrastructure. These goods and services are distinctly different from others in the “free market.” These services are required for public safety and to facilitate participation in a democracy. Health care should not only represent a public need, but also a human right. All Americans deserve access to comprehensive and preventative health care. Our current system has failed in its stewardship, squandering our resources by fostering the growth of a wasteful system, which has lost its focus on advocacy for quality health care. We can empower our citizens through access to comprehensive healthcare.

Our current system is inefficient and fiscally irresponsible. Per capita, we pay the most for health care in the industrialized world yet have poorer health outcomes. We, in fact, spend more public funds per capita on health care than countries providing access to all. The private insurance industry consumes nearly one-third of every U.S. health care dollar on bureaucratic paperwork and overhead. Physicians also have witnessed a deterioration in the quality of patients coverage or patients losing coverage altogether, often leading to their financial ruin. In fact, medical bills cause half of all bankruptcies in the country, and three-quarters of those bankruptcies happen to those with health insurance.

It is time for those seeking the presidency to stop avoiding the barriers posed by special interests, such as private insurance, to delivering affordable, quality health care for all. Unfortunately, our leading candidates for president fail to offer a sound approach to solving the crisis.

Proposed changes

Republican Sen. John McCain’s solution has been described as missing in action. He proposes tax incentives to encourage the uninsured to buy coverage. These subsidies, however, fall short of the cost of adequate insurance. Senator McCain says his plan would let the “free market” work to bring down health costs. In fact, his plan would dis-incentivize businesses from providing coverage for their workers.

Democratic Senators Hillary Clinton and Barack Obama are offering “mandate” models for reform. Under these models, the government would require individuals (or their employers) to purchase private coverage, effectively penalizing the uninsured, while offering an expanded Medicaid-like program for the poor and near-poor. They appeal to social justice through use of the term “universal” though they fall short of delivering health care for all.

The incremental changes suggested by these candidates cannot solve our problems because they leave large private insurance companies in place. State plans based on similar incremental models have faltered or failed. Previously, both Clinton and Obama have voiced support for a single-payer national health insurance system as a solution to the health care crisis, but they have apparently determined it is not politically feasible today. We cannot afford to waste time with incremental solutions that don’t work while our health care system continues to deteriorate.

As the American proverb states, “It doesn’t work to jump a 20-foot chasm in 10-foot jumps.”

Radical reform needed

National health care will require radical reform, a threat to powerful special interests. Insurance companies have added cost with executives assuming huge profits. They have not been good stewards. Insurance companies have created confusion and made our system unnecessarily complex.

Many “insured” are but one major illness away from bankruptcy. The insurance industry spends a great deal of time and effort in constructing barriers or denying payment for testing and procedures physicians request. Physician time is squandered in negotiation with insurance representatives who do not know the patient and lack an ethical duty or fiduciary responsibility to the patient.

Does this make sense?

The new survey of the nation’s doctors suggests otherwise — that national health insurance is not only necessary but also increasingly popular. The findings dovetail with an Associated Press/Yahoo public opinion poll from last December showing nearly two-thirds of Americans favor a similar approach. These polls point the way forward.

The time has come for our political leaders to stand up for the health of the American people and implement a non-profit, single-payer national health insurance system. Will they leap or fall into the chasm? Will we advocate and educate others to allow this socially just and fiscally responsible solution to become politically feasible?

Jess G. Fiedorowicz is a psychiatrist and clinician-investigator at the University of Iowa. Dennis D. Fiedorowicz works as a purchasing agent in manufacturing and lives in Pound, Wis.