Friday, July 30, 2010

qotd: Lawmakers vow to continue fight for Medicare for All

The following text is an open letter to the single-payer community from Rep. Dennis Kucinich of Ohio, Rep. John Conyers Jr. of Michigan and Sen. Bernie Sanders of Vermont. It was released on the eve of Medicare's 45th anniversary.

Congress of the United States
July 29, 2010

Dear friends of health care for all,

Now that a new health care bill has been signed into law, it has never been more important to have a strong movement behind Medicare for All.

Many health care experts have expressed concern that the Patient Protection and Affordable Care Act does not adequately contain costs for American families and businesses. If they are correct, and we believe they are, additional legislative cost containment measures will be necessary in the future.

When it is time for Congress to try to control health care costs again, the demand for Medicare for All must be undeniable. There is substantial support for a federal Medicare for All solution, embodied by H.R. 676, the National Health Care Act, and S. 703, the American Health Security Act, in the Congress and around the country. We believe that this support can and will continue to grow.

The truth is not enough. We already know that such a health care system has repeatedly proven to control costs more effectively, cover everyone or almost everyone, and deliver care of significantly higher quality than health care systems that tolerate the presence of private health insurance companies. Now we must make it so that the truth can no longer be ignored.

During the health care debate, the movement created significant momentum on which to build. Its voice was heard in multiple Congressional hearings – it won historic victories in a House vote to grant an ERISA waiver to a state that passes a Medicare for All-like plan and in a Senate provision allowing a waiver from the Exchanges for states to innovate with health coverage such as a state-based Medicare for All-like system that was included in the new law.

The latter victory created a new opening. Though the effective date for the Exchange waiver was pushed back to 2017 by the Congressional Budget Office to avoid driving up the estimated cost of the bill, the waiver's presence sent a clear message: if a state thinks it can do better, Congress wants to see it.

We are encouraged by the progress already garnered in multiple states toward guaranteed health care and we will continue to work hard in Congress to clear any obstacles in the way. The 2017 date can be changed at the same time Congress considers all of the other waivers from federal laws that will be required for the state to move forward. That can happen either before or after a state passes a Medicare for All-like bill.

Regardless of the legislative path, we vow to continue to fight alongside you for health care justice at the both the federal and state levels. We believe that Medicare for All is inevitable in the United States. It is up to all of us to determine when the inevitable becomes the reality.


Rep. Dennis J. Kucinich

Rep. John Conyers Jr.

Sen. Bernie Sanders

Comment:  On the 45th anniversary of Medicare it is reassuring to know that the vision of President Lyndon Johnson and the 89th Congress for an America that ensures health care for everyone, through a comprehensive Medicare for all, not only still lives, but is an inevitability.

Thursday, July 29, 2010

qotd: The Obama administration supports closed enrollment

The White House
July 28, 2010
Giving Our Kids the Care they Need
By Nancy-Ann DeParle

One important change in the new law is a provision that prevents insurance companies from discriminating against children with pre-existing conditions.

Some state insurance commissioners expressed concern that, without an open enrollment period that was widely communicated, people might wait until their children got sick to enroll them in coverage, causing plans' costs to increase. And we were concerned when last week, some indicated that insurance companies would choose to stop offering policies for children rather than cover kids with pre-existing conditions.

Today, the Administration is releasing new guidance to health insurance plans to help ensure children get the high-quality care they need. The new FAQ document notes that insurance companies may establish an open enrollment period for children with pre-existing conditions.


U.S. Department of Health & Human Services
July 27, 2010
Questions and Answers on Enrollment of Children Under 19 Under the New Policy That Prohibits Pre-Existing Condition Exclusions

Question #2: Do these interim final rules require issuers in the individual health insurance market to offer children under 19 non-grandfathered family and individual coverage at all times during the year?

A: No.  To address concerns over adverse selection, issuers in the individual market may restrict enrollment of children under 19, whether in family or individual coverage, to specific open enrollment periods if allowed under State law.  This is not precluded by the new regulations.


The Hill
July 29, 2010
Insurers back down on child-coverage stance
By Julian Pecquet

Health insurance plans across the country on Wednesday began to backtrack on their decision to pull out of the child-only coverage market after the Obama administration addressed their concerns about the potential damage to their bottom lines.

The Department of Health and Human Services (HHS) on Tuesday clarified regulations mandating that insurance plans agree to cover sick children. HHS made it clear that plans are free to set up specific enrollment periods for their insurance plans if allowed under state laws.

"We think this policy will ensure that children get the comprehensive coverage they need while avoiding this unintended consequence," Scott P. Serota, president and CEO of the Blue Cross and Blue Shield Association, said in a statement. "This is consistent with other public and private health insurance programs."

Karen Ignagni, president and CEO of America's Health Insurance Plans, followed suit.

"Today's announcement will help ensure millions of children have access to affordable healthcare coverage," she said. "For years, structured enrollment periods have been used in the Federal Employees Health Benefits Program, Medicare and in employer-based coverage to minimize disruption for families, seniors and small businesses. Health plans are committed to working with federal and state officials to ensure consumers are aware of all of their coverage options, including how and when they are able to sign up for coverage."

Comment:  A Quote of the Day message earlier this week described how private insurers were getting around the requirement to provide coverage to children with preexisting disorders. The insurers intended to avoid this obligation simply by closing enrollment to new applicants. It is important to understand the counter-response of the Obama administration because it exemplifies just how dysfunctional the private insurance model is that President Obama and Congress chose for us.

From a business perspective, the insurers' complaint was quite valid. If a child was guaranteed insurance no matter the circumstances, it would be a wise decision to save money by forgoing insurance while healthy, but then purchasing the coverage only when needed. Adverse selection (concentrating high-cost patients within a plan) results in the death spiral of insurance premiums (shutting down the plan because it is no longer economically viable).

The insurers said that they could provide coverage for children with preexisting disorders only if open enrollment periods were established. As an example, December could be set aside as the one month in which a child could enroll for the following year. If the parents decided not to enroll the child that month, they could not change their minds during the next twelve months. If something serious came up, that's too bad. They should have known better than to gamble with their child's health.

Whoa! Wasn't the original intention of the reform effort to be sure that each and everyone of us could have the health care that we need without having to face financial hardship? But now the Obama administration is giving its stamp of approval to a policy that will make access worse, not better.

"Open enrollment" is a business concept that serves the insurance industry well, but it is a very deceptive term. Instead of having open enrollment throughout the year, the insurers have really established the concept of "closed enrollment" for most of the year. From the patient's perspective, instead of improving access to insurance products, it greatly impairs access - the opposite of what reform was supposed to bring us. We should change the rhetoric to "closed enrollment," because that's really what they are promoting.

As expected from the industry, the statements of Scott Serota of the Blue Cross and Blue Shield Association and Karen Ignagni of America's Health Insurance plans are very supportive of closed enrollment. Of course, it's in their business interests, even if not in the interests of patients who are shut out.

Suppose we had a single payer national health program - an improved Medicare for all. The concept of closed enrollment totally vanishes since everyone is automatically enrolled.

Imagine a couple of generations from now explaining to someone that there was a time in America that private companies prohibited you from having the insurance you needed because of a quirky rule that closed enrollment for most of the year. Isn't that weird? I mean... like... enrollment is only once... for life!

Wednesday, July 28, 2010

qotd: John Geyman's "Hijacked"

The Huffington Post
July 27, 2010
Hijacked: Stolen Health Care Reform V
By John Geyman

On the positive side of the ledger, the PPACA (Patient Protection and Affordable Care Act) brings some welcome changes.

On the negative side of the ledger, however, these are some of the reasons that the PPACA will fall so far short of needed health care reform that it is not much better than nothing:

• Surging health care costs will not be contained as cost-sharing increases for patients and their families.

• Uncontrolled costs of health care and insurance will make them unaffordable for a large and growing part of the population.

• At least 23 million Americans will still be uninsured in 2019, with tens of millions more underinsured.

• Quality of care for the U. S. population is not likely to improve.

• Insurance "reforms" are so incomplete that the industry can easily continue to game the system.

• New layers of waste and bureaucracy, without added value, will further fragment the system.

• With its lack of price controls, the PPACA will prove to be a bonanza for corporate stakeholders in the medical-industrial complex.

• Perverse incentives within a minimally-regulated market-based system will still lead to overtreatment with inappropriate and unnecessary care even as millions of Americans forego necessary care because of cost.

• The "reformed" system is not sustainable and will require more fundamental reform sooner than later to rein in the excesses of the market.

(Adapted from "Hijacked: The Road to Single Payer in the Aftermath of Stolen Health Care Reform," 2010, with permission of the publisher Common Courage Press. John Geyman is Professor Emeritus of Family Medicine at the University of Washington School of Medicine.)

The Road to Single Payer in the Aftermath of Stolen Health Care Reform
by John Geyman
(Hijacked can be ordered now, at discount, for delivery in September.)


"A trenchant and highly readable account of how the special interests sabotaged health reform, leading to a law that won't provide universal care nor control escalating costs. Geyman shows us the way to real reform when the current law implodes. An eye-opening book."

--Marcia Angell, M.D., Senior Lecturer in 
Social Medicine, Harvard Medical School,
former editor-in-chief, New England Journal of Medicine

"By reading John Geyman's very timely Hijacked, those who are uncomfortable with the reform process that took place will be able to understand more precisely what went wrong. He explains why our concerns are fully warranted, but, instead of abandoning hope, he provides us with a road map for reform that will ensure that all of us will have the health care that we need."

--Don McCanne, M.D., family physician, Senior Health Policy Fellow,
Physicians for a National Health Program (PNHP)

Tuesday, July 27, 2010

qotd: Private insurers shut doors on children with preexisting disorders

The New York Times
March 30, 2010
Insurers to Comply With Rules on Children
By Robert Pear

Under pressure from the White House, health insurance companies said Tuesday (March 30) that they would comply with rules to be issued soon by the Obama administration requiring them to cover children with pre-existing medical problems.

"Health plans recognize the significant hardship that a family faces when they are unable to obtain coverage for a child with a pre-existing condition," said Karen M. Ignagni, president of America's Health Insurance Plans, a trade group. Accordingly, she said, "we await and will fully comply with" the rules.

The White House immediately claimed victory.

In a Twitter message, Robert Gibbs, the White House press secretary, scored the tug of war as "Kids 1, insurance 0."

July 27, 2010
Some insurers stop writing new coverage for kids
By Ricardo Alsonso-Zaldivar

Starting later this year, the health care overhaul law requires insurers to accept children regardless of medical problems - a major early benefit of the complex legislation. Insurers are worried that parents will wait until kids get sick to sign them up, saddling the companies with unpredictable costs.

The major types of coverage for children - employer plans and government programs - are not affected by the disruption. But a subset of policies - those that cover children as individuals - may run into problems. Even so, insurers are not canceling children's coverage already issued, but refusing to write new policies.

In Florida, Blue Cross and Blue Shield , Aetna, and Golden Rule - a subsidiary of UnitedHealthcare - notified with the insurance commissioner that they will stop issuing individual policies for children, said Jack McDermott, a spokesman for McCarty.

(Blue Cross and Blue Shield of Florida) vice president Randy Kammer said the company's experts calculated that guaranteeing coverage for children could raise premiums for other individual policy holders by as much as 20 percent.

"We believe that the majority of people who would buy this policy were going to use it immediately, probably for high cost claims," said Kammer. "Guaranteed issue means you could technically buy it on the way to the hospital."

Kammer said the company did not make the decision lightly. "We were looking at all our other individual policy holders who pay a lot for coverage, and we didn't think it was fair to give them that kind of an increase to benefit a small population that receives a greater advantage than they do," she said.

Comment:  In several speeches about the Patient Protection and Affordable Care Act, President Obama extolled the immediate end of insurers denying coverage to children with preexisting conditions. He was wrong. His miscalculation stems from the fact that he seemed to trust the insurers to do the right thing for patients instead of continuing to place their own business interests first.

Although the insurers can no longer reject a child with preexisting disorders, they can close the plan to new enrollees. As a business decision, that is what many are doing. A social good is not part of their business model.

Although White House press secretary Robert Gibbs scored this as "Kids 1, Insurance 0," it's really "Insurance 1, Kids disqualified." 

That the insurers placed business first should come as no surprise to anyone. AHIP's lobbyist Karen Ignagni continued with the "await and comply" position on the regulations that former WellPoint vice president Liz Fowler is helping to write. Compliance is easy for them when the rules are written to support the insurers' business model.

Proving that the private insurers have learned nothing, Blue Cross and Blue Shield of Florida vice president Randy Kammer repeats the long held position of private insurers that they didn't think that it was fair to increase premiums for all of the policy holders merely "to benefit a small population that receives a greater advantage" than the rest of the policy holders. Because it interferes with their business model, they refute the fundamental principle that the primary purpose of health insurance is to transfer funds from the many willing who are healthy to the few who have greater health care needs.

The exchanges won't be in effect until 2014, and yet we're already seeing this sterile, perverse behavior on the part of the insurers. Denying children with health care needs the right to buy insurance is only the bare beginning. There is absolutely no way that the regulators can preempt the negative impact of the unlimited innovations that insurers will introduce, especially after the insurance exchange infrastructures are solidly in place.

Businesses do what businesses have to do. Voters need to do what voters have to do. We have to eliminate the private business intermediaries and establish our own public insurance program that has a social mission of patient service.

Monday, July 26, 2010

qotd: AHIP on medical loss ratios

America's Health Insurance Plans (AHIP)
July, 2010
Implementing Medical Loss Ratio (MLR) Requirements to Improve Quality, Promote Choice, and Avoid Disruptions in Coverage

The "Patient Protection and Affordable Care Act" (PPACA) requires health plans, beginning in 2011, to meet a medical loss ratio (MLR) requirement of 80 percent in the individual and small group markets and 85 percent in the large group market. This means that plans must spend a specified percentage of premium revenue on either reimbursement for clinical services provided to enrollees or "activities that improve health care quality."

Goal #1

Ensure That Existing Efforts to Improve Quality are Allowed to Continue and New Initiatives to Support the Goals of PPACA are Not Discouraged

(Examples: nurse care managers, maternity managed care programs, and imaging managed care programs, as programs that improve quality)

Goal #2

Recognize That Quality Improvement Efforts Will Be Advanced By ICD-10 Implementation

The startup costs associated with implementing the International Classification of Diseases 10 classification system (ICD-10) by 2013 should be defined as an "activity that improves health care quality."

ICD-10 is a quality, not a claims payment, initiative.

Goal #3

Include Fraud Prevention and Detection Activities that Improve Quality

The definition of "activities that improve health care quality" should include the expenses health plans are required to make for fraud prevention activities.

Goal #4

Implement a Transition Plan to Maximize Consumer Choice

PPACA provides for the implementation of comprehensive insurance market reforms in 2014, including the creation of state health insurance exchanges. Until that time, consumers in the individual market will rely on brokers to review their insurance options and consider which ones best suit their needs. For health plans, four-fifths of the individual market will remain medically underwritten, guided by the rules and regulations in each state. A transition policy is needed to move from the current system to the new system that will be created in 2014 and to allow individuals to maintain their coverage.

The NAIC (National Association of Insurance Commissioners) is charged with the responsibility to develop MLR methodologies that take into account special circumstances. This means that Congress intended for the NAIC to exercise its expertise to make adjustments to the MLR to ensure that consumers are not harmed and that competition is not decreased.

Comment:  In what might be perceived as private insurer chicanery, the industry's lobby organization, AHIP, is capitalizing on phrasing in the Patient Protection and Affordable Care Act that defines the minimum percent of benefits that the insurers must pay out (medical loss ratio or MLR) as including not only reimbursement for clinical services but also for "activities that improve health care quality."

Thus any of their administrative functions that they can pass off as improvements in quality will not apply to the 15 percent (large group) or 20 percent (individual or small group) caps on administrative spending. That allows the industry to perpetuate its pattern of profound administrative excesses and very high profits (outrageously high when considered as a percentage of their actual product - the administrative services that they are selling us).

In this report, what are they trying to pass off as quality? 1) Intrusive care managers who are employed to save money. 2) Implementation of diagnostic codes used for claims payments. 3) Administrative functions to detect fraud. 4) Perpetuating medical underwriting during the transition to cover "special circumstances" to ensure that "consumers are not harmed and that competition is not decreased." That's code for perpetuating the perversities of adverse selection.

The impact of this relabeling of administrative services as quality improvements is to allow the insurers to retain a greater percentage of the premium dollars for their own intrinsic purposes. The consumer pays for this either through higher premiums or decreased health care benefits.

An extremely important unintended consequence of fixed medical loss ratios has been mentioned here before, but seems to have escaped the mainstream media, so it is being repeated: Once the MLR rules are established, the primary method by which insurers can increase the services they sell us, while increasing their profits, is by increasing gross revenues, since they are guaranteed a fixed percentage of those revenues. The most effective way to increase gross revenues is to increase the amount of health care services authorized and paid for.

If the insurers change provider incentives to double the amount of health care that is being delivered, they can double their own total revenues, keeping even more as profit because of the smaller marginal administrative costs of paying for more care. This incentive of the insurers to increase total health care spending is the exact opposite of the reform goal of slowing future health care cost increases

All of this is good business. But that's the problem. Our elected representatives chose a business model to finance health care when what we desperately need is a service model.

"Medical loss ratio" is a term that needs to be moved into the history books of failed policy concepts. Instead, we need our own public service model - an improved Medicare for everyone.

Friday, July 23, 2010

qotd: Using single payer to establish political credibility
July 21, 2010
Democrats spar over health care claim

The gloves are off in the fight for the Democratic nomination for governor (Vermont). Former State Senator Matt Dunne is calling out Senator Peter Shumlin for what he says is a troubling misstatement.

Peter Shumlin first said it two weeks ago in an online questionnaire, then again this week in a mailing to voters: "I am the only candidate who sponsored a single-payer health care bill." Dunne says that is simply not true.

"The facts are that I also sponsored a single-payer health care bill," Dunne told reporters outside the Statehouse Wednesday.

He did. During the 1993-1994 legislative session when Dunne was serving as a State Representative he co-sponsored a bill that would have created a single-payer system. He wants a public retraction of Shumlin's claim and is requesting that Shumlin send out another mailer with the correction.

"It is critically important that Peter Shumlin take action and take action quickly to correct the record, to be clear in public that he was factually wrong," says Dunne.

Comment:  When two candidates for governor are engaged in a political skirmish as to which one is the bona fide single payer supporter, then we know that single payer is back on the table (at least in Vermont).

Thursday, July 22, 2010

qotd: It's back - H.R. 5808 - the public option

The Library of Congress
H.R. 5808 - To amend the Patient Protection and Affordable Care Act to establish a public health insurance option. 
Introduced July 21, 2010 by Rep. Lynn C. Woolsey, with 128 cosponsors

  (a) (1)  ESTABLISHMENT- For years beginning with 2014, the Secretary of Health and Human Services (in this subtitle referred to as the `Secretary') shall provide for the offering through Exchanges established under this title of a health benefits plan (in this Act referred to as the `public health insurance option') that ensures choice, competition, and stability of affordable, high-quality coverage throughout the United States in accordance with this section. In designing the option, the Secretary's primary responsibility is to create a low-cost plan without compromising quality or access to care.


Congressional Budget Office
July 22, 2010
Letter from Douglas W. Elmendorf, Director
To: Honorable Fortney Pete Stark, Chairman, Subcommittee on Health, Committee on Ways and Means

Under the proposal (H.R. 5808), a public health insurance plan would be established and administered by the Secretary of Health and Human Services (HHS), and it would have to charge premiums that fully cover its costs for benefit payments and administrative expenses.

The Congressional Budget Office (CBO) estimates that the public plan's premiums would be 5 percent to 7 percent lower, on average, than the premiums of private plans offered in the exchanges.

In deciding whether to enroll in the public plan, potential subscribers would consider those premium differences along with various other factors, including the number of providers who chose to participate in that plan. CBO expects that some providers would decline to participate in the public plan because its payment rates would be lower, on average, than private plans' payment rates. Even so, many providers would be likely to participate, in part because they would expect a plan administered by HHS to attract a substantial number of enrollees.

Taking into account all of the relevant factors, CBO estimates that roughly one-third of the people obtaining coverage through the insurance exchanges would enroll in the public plan. CBO estimates that about 25 million people would purchase coverage individually through the exchanges in the 2017–2019 period under the proposal; in addition, about 13 million people would be expected to obtain employment-based coverage through the exchanges — so total enrollment in exchange plans would be about 38 million. Total enrollment in the public plan would thus be roughly 13 million.

Compared with projections of enrollment under current law for the 2017–2019 period, CBO estimates that about three-quarters of a million more people would obtain individually purchased coverage and about three-quarters of a million fewer would have employment-based coverage. The proposal would have minimal effects on the number of people with other sources of coverage and on the number of people who would be uninsured.

CBO and the staff of the Joint Committee on Taxation (JCT) estimate that the proposal would reduce federal budget deficits through 2019 by about $53 billion. That estimate includes a $37 billion reduction in exchange subsidies and a $27 billion increase in tax revenues that would result from changes in employment-based coverage, partly offset by an $11 billion increase in costs for providing tax credits to small employers.

Comment:  So here is the stand-alone bill for the public insurance option that created so much controversy during the reform process. As we look closer at this option, we can see that the great tragedy of the public option debate was that this almost worthless proposal diverted our attention away from the debate that we should have been having - a debate over whether or not we should enact a single, universal public insurance program.

Let's look first at the very narrow impact of the features of the public option, and then we'll look at the very broad and crucial implications of returning to this debate instead of the one that we should be having.

First of all, what impact would this have on the numbers of insured? The additional three-quarters of a million individuals net who would obtain individually purchased coverage would be offset by approximately the same number who would no longer have employer-sponsored coverage. Enacting the public option will produce no net gain in the numbers of individuals insured.

CBO estimates that premiums for the public option will be 5 to 7 percent lower than the premiums for the private plans offered in the exchanges. This savings is from a combination of lower administrative costs for the public option, and the ability of the government to extract greater price and fee concessions from the providers of health care. Paying a slightly lower premium may not be wise if the providers start bailing out of the system.

Also, the supporters of this measure shouldn't pretend that the very modest reduction in administrative costs of these public plans somehow addresses the profound administrative waste throughout our system. The single payer model would be effective in reducing this waste by hundreds of billions of dollars, whereas H.R. 5808  merely takes a paring knife to plans that would cover only about 4 percent of us, while neglecting the profound administrative waste of the other insurers and the administrative burden that they place on the health care delivery system. The public option is merely another plan in the insurance exchange markets, and, as such, fails to provide the fundamental structural financing reform that we need.

Further, the 5 to 7 percent difference could easily be lost in the fog of comparing the government subsidies for the exchange plans with the employers' contributions to the premiums of employer-sponsored plans. A policy that has a very modest benefit for 13 million people is unimpressive when we are trying to fix a system so that it takes care of all 310 million of us.

CBO estimates that the measure would reduce the federal budget deficits through 2019 by about $53 billion, partly by decreasing subsidies in the exchanges and increasing income and payroll taxes for those losing employer-sponsored coverage. This reduction in government spending results in increased costs to individuals - a trend that already is having a negative impact on affordable access to health care. Nevertheless, 53 billion dollars is hardly a blip when you consider that we'll be spending about 30,000 billion dollars on health care through 2019. Besides, though CBO is required to estimate the impact on the federal budget, what we really care about is our total national health expenditures (NHE) and not the portion that passes through a government budget.

So the narrow impact is that the public option fails to meet the goals of reform since it does nothing to increase the net numbers of individuals with insurance, and it doesn't even provide a blip in our NHE. 

The broader impact of H.R. 5808 is much more consequential. Considerable political capital will be consumed in efforts to enact it. The managers of the bill would understand that any consideration of a single payer national health program would have to be left off of the table since that model actually would accomplish the goals of reform. To go through another process that alienates so many colleagues in the health care justice camp risks creating an impasse to real reform that could last many years or perhaps even a decade or two.

The financing infrastructure of the Patient Protection and Affordable Health Care Act cannot work to achieve equitable health care financing for everyone. We can't afford to waste political capital on a legislative amendment that merely appeases those who lost the public option debate, but does nothing to build the solid financial infrastructure that we need.

Let's spend all of our political capital on real reform: a single payer national health program - an improved Medicare for everyone.

Wednesday, July 21, 2010

qotd: Cigna's CareToday clinics

Cigna Medical Group
July 19, 2010
Cigna Medical Group Announces Grand Opening of CMG CareToday Clinic in South Chandler, Ariz.

Cigna Medical Group has announced the opening of its newest CMG CareToday convenience care medical clinic in South Chandler, Ariz. This brings the total number of clinics to 10 since CMG CareToday's launch in 2007.

Staffed by board-certified nurse practitioners and physician assistants, the clinics offer walk-in medical care for unscheduled patients with low acuity conditions such as colds, flu, sore throat, lower back pain, ear aches, bladder infections and pink eye. In addition, the clinics offer pregnancy tests and child and adult immunizations, including flu shots. School, sports and camp physicals are also available. 
"CMG CareToday is a convenient alternative that can accommodate local residents who may be unable to see their primary care physician because of time or other issues," said Corinne Bell, DO, MBA, medical director of CMG CareToday. "Expanding the number of clinics Valleywide gives residents a place to go for non-emergency care and provides quick relief for common illnesses."

First time visits to any CMG CareToday location are $29 retail; subsequent visits are $59. Lab services range from $10 to $15 and a select number of generic prescription medications are available for $10 or $15. CIGNA customers, and individuals covered under other accepted health plans, pay only their office visit co-pay or co-insurance. Additionally, Cigna Medical Group patients who visit CMG CareToday will have their medical records transferred seamlessly through an electronic health record directly to their primary care physician for future follow-up.

About Cigna Medical Group

Cigna Medical Group, the multi-specialty group practice division of CIGNA HealthCare of Arizona, Inc., is one of the Valley's largest group practices with more than 30 offices located throughout Metropolitan Phoenix, including three Urgent Care centers and 10 CMG CareToday convenience care clinics. To learn more about Cigna Medical Group and the services they provide, please visit

About CIGNA Corporation

CIGNA (NYSE: CI), a global health service company, is dedicated to helping people improve their health, well being and sense of security. CIGNA Corporation's operating subsidiaries provide an integrated suite of medical, dental, behavioral health, pharmacy and vision care benefits, as well as group life, accident and disability insurance, to approximately 46 million people throughout the United States and around the world. To learn more about CIGNA, visit

Comment:  Cigna is no longer simply one of the largest, for-profit, private insurance corporations in the nation, it is now a component of the health care delivery system. From the Cigna Medical Group website: "CIGNA is the only managed care organization in Arizona that operates multi-specialty centers designed to help you conveniently receive care and move on with your busy day."

With tighter regulation under the Patient Protection and Affordable Care Act, the private insurers are looking for innovative solutions that will ensure a bright future for their executives and shareholders. What better opportunity is there than to expand their intrusion into health care delivery? Imagine the expansion of a chain of nurse practitioner- and physician assistant-staffed convenience care clinics with CIGNA branding in bright neon lights.

What next? Accountable care organizations (ACOs) with full control of physicians and hospitals? Imagine each hospital in your community with a building-top mounted branding neon sign - WELLPOINT, UNITEDHEALTH, AETNA, CIGNA, HEALTH NET, HUMANA, though further consolidation could leave us with maybe just three market choices: WellPoint, UnitedHealth, and Kaiser Permanente. Maybe we could end up with only one: UnitedWellPoint.

Though this seems farcical, instead of simply controlling the puppet strings of health care - the insurance function - these national corporations would like to take over the puppets as well.

You say that's impossible? I remember telling my colleagues what we could expect when the legislation passed that enabled the managed care revolution. They said that the scenario I described was impossible, and, besides, they would never sign the contracts anyway. It didn't take long.

How could we end up with one or more UnitedWellPoints? The steamrollers for ACOs are fired up and beginning to roll. Physicians will have almost no say in this transformation. The fight for control will be between the hospitals and the major private insurers. What kind of a contest will that be with thousands of local hospitals competing for control with a few large national insurance companies that already hold the money?

Wouldn't it be much safer to give entire control of the purse strings to an improved Medicare? At least then any redesign of the health care delivery system would benefit patients rather than shareholders.

Tuesday, July 20, 2010

qotd: Will Medicare rates rescue Medicaid?

America's Health Insurance Plans (AHIP)
June 23, 2010
Medicaid Provision Could Turn Into 'Another SGR,' Some Advocates Fear
By Amy Lotven, Inside Health Reform

Under the reform law, starting in 2013 Medicaid payments for primary care physicians must equal 100 percent of Medicare payments, but Congress only funded the policy for two years due to fiscal constraints.

The Republican Study Committee (RSC), in a March 26 policy brief on the health reform law, calls the payment boost a "budget gimmick" and notes that "history has shown that this two-year increase will likely be increased every year after the 'sunset date,' thus hiding the true cost of the provision."

"While many conservatives may believe that physicians in Medicaid should be paid more, many may believe that we should not be expanding this flawed program to begin with."

The RSC also notes that the provision could be seen as "just another SGR," referring to the annual congressional move to stave off physician payment cuts resulting from Medicare's sustainable growth rate.

But primary care stakeholders are already working to mitigate the issue. The American Academy of Family Physicians says that it will be asking lawmakers to extend the provision to cover a longer period. "It is likely that any extension will be of specified duration because of its impact on the federal budget," AAFP writes on its web site. "Nonetheless, physicians are not likely to begin taking Medicaid patients if they know that the higher payment rates are not going to continue. As Medicaid coverage expands, this will create an untenable situation in which more patients will be covered but have no physician practice that can take them," the site adds.

The provision in the final legislation was obviously crafted so as to address fiscal constraints, AAFP President Lori Heim said. Essentially, the legislation expands Medicaid to an estimated 17 or so million people starting in 2014 and as of now the funding is slated to end that same year. If all of these people gain access to physicians at that point, what will happen in 2015? Heim asked.


California HealthCare Foundation
July 2010
Physician Participation in Medi-Cal

While 90% of California physicians are accepting new patients and 73% accepting new Medicare patients, only 57% reported accepting new Medi-Cal patients.

Medi-Cal patients are concentrated in a small share of practices, with 25% of physicians providing care to 80% of Medi-Cal patients.

Comment:  Medicaid, being a welfare program with piddling political support, has been chronically underfunded. Yet, in the reform legislation, expansion of Medicaid eligibility is one of the more salient policies, designed to extend Medicaid coverage to perhaps 17 million more individuals. Will we have enough willing primary care professionals to take care of them?

Close to half of physicians already are unwilling to accept any Medicaid patients at all, and the patients who do receive care tend to be concentrated amongst one-fourth of physicians. 

Congress recognized that there would be a reluctance on the part of primary care physicians to absorb this influx of Medicaid patients, so they increased payment rates for primary care services to the same level as Medicare. But the increase is scheduled for only two years merely because an arbitrary federal spending limit constrained the reform policies. 

The increased fees will apply the year before and the first year of the Medicaid expansion. Physicians are already unhappy with the continued uncertainties over the future of Medicare payments since Congress has repeated failed to enact a revision to the SGR formula (sustainable growth rate), without which physicians could see dramatic reductions in Medicare payments. Physicians do not see Congress as reliable partners.

Why would any physician sign up a large number of new Medicaid patients in 2014, if the next year rates will be reduced to levels that already have caused physicians to refuse to participate in the program? It is likely that the one-fourth of physicians who already are dedicated to caring for Medicaid patients will be inundated, and at a time when we already have a serious primary care crisis.

The increased funding for community health centers may provide some relief, but serious logistical problems may impair adequate access - problems such as health center location and transportation to it, the shortage of primary care professionals to staff the centers, and the continual struggle with funding. Also, whether Medicaid patients are seen in primary care practices or community health centers, access to specialized care is very limited, primarily because of a lack of willing providers.

Medicaid is branded with the stigma of being a welfare program because it is a welfare program, quite unlike Medicare which is a social insurance program. Not only is Medicaid humiliating for the patients, it also creates fiscal problems for the health care delivery system because of chronic underfunding.

The Medicaid problem could be eliminated quite easily. It would be much more efficient, equitable, and less costly overall to have a social insurance program that covered absolutely everyone - an improved Medicare for all.

Monday, July 19, 2010

qotd: Respond to the NYT on insurers further limiting choice of health care

The New York Times
July 17, 2010
Insurers Push Plans That Limit Choice of Doctor
By Reed Abelson

As the Obama administration begins to enact the new national health care law, the country's biggest insurers are promoting affordable plans with reduced premiums that require participants to use a narrower selection of doctors or hospitals.

The plans, being tested in places like San Diego, New York and Chicago, are likely to appeal especially to small businesses that already provide insurance to their employees, but are concerned about the ever-spiraling cost of coverage.

But large employers, as well, are starting to show some interest, and insurers and consultants expect that, over time, businesses of all sizes will gravitate toward these plans in an effort to cut costs.

The tradeoff, they say, is that more Americans will be asked to pay higher prices for the privilege of choosing or keeping their own doctors if they are outside the new networks. That could come as a surprise to many who remember the repeated assurances from President Obama and other officials that consumers would retain a variety of health-care choices.

But companies may be able to reduce their premiums by as much as 15 percent, the insurers say, by offering the more limited plans.

Many insurers also expect the plans to be popular with individuals and small businesses who will purchase coverage in the insurance exchanges, or marketplaces that are mandated under the new health care law and scheduled to take effect in 2014.

Prominent officials like Mr. Obama and Hillary Rodham Clinton learned to utter the word "choice" at every turn as advocates of overhauling the system.

But choice — or at least choice that will not cost you — is likely to be increasingly scarce as health insurers and employers scramble to find ways of keep premiums from becoming unaffordable. Aetna, Cigna, the UnitedHealth Group and WellPoint are all trying out plans with limited networks.

The size of these networks is typically much smaller than traditional plans. In New York, for example, Aetna offers a narrow-network plan that has about half the doctors and two-thirds of the hospitals the insurer typically offers. People enrolled in this plan are covered only if they go to a doctor or hospital within the network, but insurers are also experimenting with plans that allow a patient to see someone outside the network but pay much more than they would in a traditional plan offering out-of-network benefits.

The insurers are betting these plans will have widespread appeal in the insurance exchanges as individuals gravitate toward the least expensive options.

The new health care law offers some protection against plans offering overly restrictive networks, said Nancy-Ann DeParle, head of the office of health reform for the White House. Any plan sold in the exchanges will have to meet standards developed to make sure patients have enough choice of doctors and hospitals, she said.

How widespread these plans will become is anybody's guess, and some benefits consultants wonder if these plans represent any real solution to high medical costs. The narrow network, if it is based on the insurers' ability to demand low prices, may be "just another short-term fix," warned Barry Schilmeister, a consultant at Mercer.

But many insurers say they are still figuring out how to persuade people to choose these plans rather than force them to enroll. "What's not changed are the old techniques of black-belt managed care," said Mark T. Bertolini, Aetna's president. "We have to create the same kind of model without the 'Mother, may I.' What we want is the 'Mother, should I.' "

Comment:  The managed care revolution brought us restricted networks of physicians, hospitals and other health care services. These restrictions, which limited patients' choices of their health care professionals and facilities, did produce a one-time notch in the curve of rising health care costs. The insurers did this by contracting lower rates with health care providers, and then imposing financial penalties on patients who chose their care outside of the networks.

Patients were not pleased with limitations placed on their choices, but generally were not rebellious since they were often able to continue to see their own physicians, or, if not, were usually satisfied with their in-network substitutes. 

The major insurers have been experimenting for some time with much more restrictive networks - networks in which they could contract for much lower rates in exchange for a higher patient volume. Individuals and employers have not responded to these market efforts because the restrictions were too severe. They excluded popular health care professionals and hospitals, sometimes completely, or sometimes by requiring unaffordable coinsurance payments by the patients.

But the environment has changed. The premiums for health plans are now very close to being truly unaffordable for most individuals and employers. With individuals being mandated to purchase insurance, and employers being exposed to penalties if their employees purchase plans in the exchanges, the market for plans with affordable premiums is being forced. The insurers must come up with plans that will meet the test of the market. The deeply-discounted, more tightly restricted plans are now finding their market.

These plans are terrible. Many will lose their primary care professionals. They will often not be able to use their local hospitals and many of their local specialists. Most referrals to centers of excellence will be prohibited. Although the Patient Protection and Affordable Care Act (PPACA) will require that provider networks provide choice, the law does not prohibit intolerably Spartan networks.

This, of course, is a setup for the death spiral of adverse selection for the plans with more adequate networks. Individuals with more significant problems will select plans that can better meet their needs, while the healthy will flee to the plans with Spartan networks once the premiums skyrocket.

When individuals shift to the more restricted plans, what will happen to the large number of physicians and hospitals that are denied contracts? Obviously their financial viability would be threatened, and many would shut down. As if we didn't already have enough problems with the deterioration in our primary care infrastructure, much of the entire health care delivery infrastructure could begin to crumble.

PPACA contains many measures designed to improve the functioning of the private insurers, but most of them will drive premiums even higher. Insurance innovations such as the Spartan provider networks were fully predictable.

What should really alarm us is that the business world thrives on innovation. Think of the possibilities that the private insurance industry can devise. Actually, it is very difficult for us who are trying to figure out how to get patients the care they need to come up with innovative concepts that will protect the business model of the private insurance industry, no matter the cost to patient care. It isn't in our DNA.

But there is absolutely no doubt whatsoever that we will see innovation, and it won't be healthy for patients, nor for their health care professionals.

TAKE ACTION:  The article provoked a large number of responses on The New York Times website, many supportive of Medicare for all, single payer, national health program, and health care justice in general. ADD YOUR RESPONSE. Go to the article (link above) and post your opinion, even if only a sentence or two. If you are not registered, it is easy to do, so don't let that deter you. The New York Times needs to hear from us so that they will investigate why there is such broad support for a national health program. (At least click "Recommend" on response # 232.)

Friday, July 16, 2010

qotd: Public sector workers now seeing deterioration in their health plans

The Sacramento Bee
July 15, 2010
Public sector workers paying more of their health care costs
By Bobby Caina Calvan

Workers in private industry have felt the sting of rising health insurance premiums and out-of-pocket costs for decades. Now, as government budgets bleed, public employees are starting to share the pain.

In the past year, Sacramento's largest school districts have trimmed health care coverage. Local and state government officials also are looking for ways to save.

And while public employee unions have made preserving health benefits a priority, they have been pressed to give ground or face more layoffs.

In his proposed budget, Gov. Arnold Schwarzenegger is seeking to cut $152.8 million in health premium expenses by requiring the California Public Employees' Retirement System to offer lower-cost coverage, possibly with fewer benefits, or give the state authority to do so.

Health insurance costs have "reached the point where we can't sustain those benefits," said Lynelle Jolley, spokeswoman for the state Department of Personnel Administration.

Comment:  Private employers have continued to shift more of the costs of health care to their individual employees. This has had deleterious financial and health impacts since it has made health care access less affordable. Now, even with union representation, public employees also are experiencing deterioration in their coverage.

That's a one-way street. Plans for public employees will never improve but will likely further deteriorate to match the 60 to 70 percent actuarial value plans to be offered by the state insurance exchanges.

"After all, why should we taxpayers have to buy these people good insurance when we have to put up with our lousy plans?" But those who express this sentiment have it backwards. Why should they have put up with crappy insurance when we could all have a program that works even better than most plans for public employees? 

As we've said many times, the private insurance model doesn't work anymore. We can have that program that works for all of us, if we, as voters, demand it.

Thursday, July 15, 2010

qotd: Policy issues for the health insurance exchanges

The Commonwealth Fund
July 15, 2010
Health Insurance Exchanges and the Affordable Care Act: Key Policy Issues
By Timothy Stoltzfus Jost, J.D.

Health insurance exchanges are the centerpiece of the private health insurance reforms of the Patient Protection and Affordable Care Act of 2010 (ACA). If they function as planned, these exchanges will expand health insurance coverage, improve the quality of such coverage and perhaps of health care itself, and reduce costs. Previous attempts at creating health insurance exchanges, however, produced only mixed results. This report identifies the earlier attempts' problems, enumerates the key issues that are critical for overcoming those problems, analyzes in detail the ACA's provisions addressing these issues, and discusses further policy options.

As part of successfully implementing the new exchanges, the U.S. Department of Health and Human Services (HHS) and the states must address issues that undermined the earlier attempts. These issues are:

• Adverse selection.

• Numbers of participants.

• Market coverage and structure.

• Choice without complexity.

• Transparency and disclosure.

• Competition.

• Administrative costs.

• Market or regulator?

• Administering subsidies and mandates.

• State, regional, or national exchanges?

• Governance.

• Relationships with employers.

• Cost control.

Comment:  "Health Insurance Exchanges and the Affordable Care Act: Key Policy Issues," by Timothy Stoltzfus Jost, should be read in full (44 pages) by everyone who cares about the future of our health care system. The Executive Summary alone is not adequate to understand the implications of the issues he discusses. Every page requires attentive reading since each is covered with red flags, far too many to cover in a qotd commentary.

It is an especially important report for those who believe that the health insurance exchange model is a satisfactory compromise for moving forward, while dismissing further efforts to create a public national health program. It is also important for single payer advocates (improved Medicare for all) since it is important to understand the red flags raised by this report, and be able to debate them with others.

Many of the issues listed would disappear under a single payer system. For instance, in spite of the measures in the law, adverse selection (concentrating high-cost patients in health plans) cannot be eliminated by the insurance exchanges, yet it would disappear in a single universal risk pool. That is especially important since adverse selection has destroyed previous insurance exchanges in numerous states.

The numbers of participants in the exchange plans are also crucial. A few unhealthy individuals can wipe out a plan if there isn't a large number of healthy individuals to absorb the costs through the plan premiums. It has been estimated that 24 million people will obtain their coverage through the exchanges. Distribute that amongst the fifty states, and then divide those numbers up amongst the "large" selection of plans in the "robust" markets of the exchanges, and you can see that many plans would likely fail due to the small numbers of insured.

Although an important goal of reform was administrative simplification, insurers will still have most of their administrative costs, as will the physicians and hospitals, and yet another layer of administration is added in the operation of the exchanges.

The premium subsidies, cost-sharing subsidies, and the mandates and penalties, in a system with ever-shifting eligibilities, creates a complex financing structure that is totally unnecessary. It is far simpler to finance the entire health care system through equitable taxes.

The reform act was designed to perpetuate the employer role in providing health care coverage, but increasing costs and increasing fragmentation through various public and private programs is increasing the complexity of the decision process for employers, creating an uncertain future for employer-sponsored plans. It would be far easier to remove the employer as keeper of the health plan, and simply provide a single, comprehensive public plan for everyone.

And cost control? It didn't happen.

You likely don't have time to read the full report now, but download it and read it this weekend, or at any other time that you have a break.

Wednesday, July 14, 2010

qotd: Drew Altman on what conservatives are winning

Kaiser Family Foundation
July 14, 2010
What Conservatives Are Winning
By Drew Altman, Ph.D., President and CEO

But for all of the frustration and even anger within the conservative movement about where health care is headed, the fact of the matter is that they are winning more than even they may realize in the current health care equation. That's because the nature of health insurance itself is being redefined and moving gradually but seemingly inexorably in the direction conservatives have long advocated: more consumer "skin in the game" through higher patient deductibles. 

Item: In our recent survey of people in the non-group insurance market, we found that the average deductible for an individual policy is now $2,498, and for families it's $5,149. These are very high thresholds by any standard. Consider, for example, that a family with median income facing such a deductible would be spending almost 10% of their annual income just for their deductible before their insurance kicked in. 

Item: The percentage of workers facing high deductibles -- $1,000 or more for single coverage --  has been growing rapidly. It doubled from 10 percent to 22 percent between 2006 and 2009, and increased from 16 percent to 40 percent in small firms. 

Item: Indications are that the share of workers with high deductibles is continuing to grow, a trend I expect our 2010 employer survey to confirm when we release it in September as we have every year for more than a decade now. And a substantial number of these high deductible plans are paired with tax-advantaged savings accounts, which conservatives have long advocated. Facing cost pressures without alternative answers, employers are moving to plans with less comprehensive coverage to reduce their expenses for employee benefits.

Item: Health reform is unlikely to reverse these trends. Large employers will continue to look for ways to address the rising cost of health care. And, for the basic "bronze" insurance plan that people will be required to buy, deductibles could run several thousand dollars for individuals and double that for families. To be sure, other aspects of health reform cut the other way. For example, there will be no cost sharing for preventive services in newly-purchased plans, and insurers will be required to cap consumer out-of-pocket costs at defined levels. And, of course, there are substantial subsidies to reduce premium and out-of-pocket costs for lower-income people. But, for the first time, the government will be defining the threshold that decent insurance must meet, and that minimum coverage will have the kind of high deductibles that conservatives favor. 

For several years we have seen moderate increases in premiums for employment-based health insurance. I suspect that rising deductibles and other out-of-pocket costs are one explanation for this. It's simple arithmetic that employers can buy down premium increases by switching to less comprehensive coverage and shifting more costs to workers. Plus, these higher out-of-pocket costs exert downward pressure on utilization – in some cases for the better, in some cases for the worse -- and thus on premiums as well. At the same time, people have never been more upset about their own rising health care costs, as the coverage they get offers less and less financial protection.

Looked at through a political lens, liberals have gained through passage of major health reform legislation, including expanded coverage and increased government oversight of the health insurance system. But increasingly, the insurance itself is looking more and more like the vision advanced by conservatives – less comprehensive with more skin in the game. That's where conservatives may be winning more than they realize in the ongoing battle over the future of health care.

Comment:  Regular readers of the Quote of the Day have seen this theme expressed relentlessly in these weekday messages: We are experiencing a massive shift to underinsurance products, and this policy of making individuals sensitive to health care costs through greater out-of-pocket spending has long been on the agenda of the conservatives.

The importance of today's message is that it comes from a highly credible individual, Drew Altman, President and CEO of Kaiser Family Foundation, which serves as a "non-partisan source of facts, information, and analysis for policymakers, the media, the health care community, and the public." It is a very objective observation of the reality of the reform that is now law, and it's the same message that we have been delivering over and over.

Building on the current system, which we just did, is the most expensive and one of the least effective models of achieving the goal of affordable, high quality care for everyone. Yet one of the least expensive and most effective models is a single payer national health program - an improved Medicare for all. Most of the measures in the enacted legislation have not yet taken place. We can still change course and do it the right way.

Tuesday, July 13, 2010

qotd: England's liberation of the NHS

Quote of the Day
August 17, 2009
Conservative leader David Cameron on the NHS

"One of the wonderful things about living in this country is that the moment you're injured or fall ill – no matter who you are, where you are from, or how much money you've got – you know that the NHS will look after you. That's why we as a Party are so committed not just to the principles behind the NHS, but to doing all we can to improve the way it works in practice."

(Since this quote, Conservative David Cameron was elected Prime Minister.)


July 12, 2010
NHS shake-up grants new powers to doctors and patients
By Rebecca Smith

GPs are to be handed £80bn of the NHS budget to buy care from hospitals and other doctors for patients in their area, as hundreds of middle-management organisations are swept away.

Family doctors will be responsible, in consortiums, for commissioning the care for patients in their area by buying treatment from hospitals, charities and other doctors.

Under the new Coalition government's health white paper, ministers will step back from the day-to-day running of the health service and hand power to the front line.

Andrew Lansley, Health Secretary, said the white paper represented a "vision based on the principles of freedom, fairness and responsibility".

However, there was immediate criticism from Labour and the unions, saying handing £80bn to GPs who are private contractors was a mistake and that the plan was a 'Trojan horse' for widespread privatisation.

The document entitled Equity and Excellence: Liberating the NHS includes wide-ranging reforms covering all aspects of the NHS and healthcare.

Mr Lansley said 'process-driven' Labour government targets, such as the 18-week waiting time between GP referral and hospital treatment, will be scrapped and the focus will instead be on quality of outcomes for patients.

All hospitals are to become a Foundation Trust or part of one, giving them far greater freedoms from Whitehall and allowing them to earn more money from private patients.

Management costs are to be cut in half but the Government has already admitted that the NHS would be forced to make staff redundant. It is estimated that around 25,000 jobs could be lost.

Nigel Edwards, acting chief executive of the NHS Confederation, which represents all NHS organisations, said the changes would represent a huge upheaval.

"It is hard to stress just how radical this is. The NHS will look much more like the gas, electricity or telecom's market than it will the monolithic state bureaucracy we have come to understand," he said.

Dr Jennifer Dixon, director of the think thank, the Nuffield Trust, said handing billions of pounds of taxpayer's money to GPs was 'risky' and is a significant change from their current role.

Andy Burnham, Shadow Health Secretary, called the white paper a 'giant political experiment' and warned that the government were taking an '£80bn gamble with the great success story that is out National Health Service today'.

"At a stroke, you are removing public accountability and opening the door to unchecked privatisation; you are demoralising NHS staff at just the time you need them at their motivated best," he told Mr Lansley in the House of Commons.

David Fleming of Unite, said: "This is an untested, expensive Trojan Horse in political dogma that will give private companies an even greater stake in the NHS – this way of operating has already happened in the USA.

"Before the election, the Tories promised no major reorganisation of the health service – within three months that pledge to the British people, the majority of whom did not vote for further privatisation of the NHS – has been broken. So much for the 'new politics'."


Department of Health (England)
July 2010
Equity and excellence: Liberating the NHS

5. Cutting bureaucracy and improving efficiency

The scale of the NHS productivity challenge may prompt calls during this Parliament for even bigger increases in NHS resources; but the reality is that there is no more money.

So our first task is to increase the proportion of resource available for front-line services, by cutting the costs of health bureaucracy. Over the past decade, layers of national and regional organisations have accumulated, resulting in excessive bureaucracy, inefficiency and duplication. The Government will therefore impose the largest reduction in administrative costs in NHS history. Over the next four years we will reduce the NHS's management costs by more than 45%.

The Department will shortly publish a review of its arm's-length bodies. Subject to Parliamentary approval, we will abolish organisations that do not need to exist. We will streamline those functions that need to remain, to cut cost and remove duplication and burdens on the NHS. In future, the Department will impose tight governance over the costs and scope of all its arm's-length bodies.

The Government will cut the bureaucracy involved in medical research. We have asked the Academy of Medical Sciences to conduct an independent review of the regulation and governance of medical research. In the light of this review we will consider the legislation affecting medical research, and the bureaucracy that flows from it, and bring forward plans for radical simplification.

We are moving to a system of control based on quality and economic regulation, commissioning and payments by results, rather than national and regional management. Within that context, we are committed to reducing the overall burdens of regulation across the health and social care sectors. We will therefore undertake a wide-ranging review of all health and social care regulation, with a view to making significant reductions.

Equity and excellence: Liberating the NHS (61 pages):

Comment:  The British National Health Service (NHS) is one of the most effective health care systems in the world. That is a remarkable achievement considering that they devote only half as much funds to their health care as does the United States (percent of GDP in 2008: UK 8.7% versus US 16.0%). Yet in their white paper, "Equity and excellence: Liberating the NHS," the Conservative government of Prime Minister David Cameron states, "the NHS productivity challenge may prompt calls during this Parliament for even bigger increases in NHS resources; but the reality is that there is no more money."

No more money!? Excuse the vulgarity, but... bullshit!

The Cameron government is using this false claim to dramatically pull back the government's role in the NHS, and to push privatization. They are not only cutting back on essential government administrative functions (as opposed to the profound administrative waste in the U.S. system), but they are also failing to honor their duty as stewards of the taxpayers' funds to maintain adequate regulatory oversight of their public health care system.

They are even going so far as to reduce the government's role in medical research. Could you imagine the Congress of the United States defunding our National Institutes of Health merely because it is a composite of government bureaucracies?

Is this really what the people of England voted for?

Monday, July 12, 2010

qotd: AHIP on "plan-provider collaborations"

America's Health Insurance Plans
July 12, 2010
Plan-Provider Collaborations Promise Improved Care Delivery
By Louise Kertesz

"Despite many challenges, health plans are well positioned to drive improvements" in care delivery through collaborations with providers. "Health plans have an enormous amount of assets" in the form of data and relationships they can leverage to improve care, said Jeremy Nobel, MD, adjunct lecturer, health policy and management, Harvard School of Public Health.

To drive improvement, plans can contract with providers to deliver value-based care, with reimbursement linked to performance. Plans can help establish medical homes, accountable care organizations, and episode pricing, he said.

They can also offer providers online tools to improve care delivery effectiveness and efficiency, such as e-prescribing, registries, computerized order entry, and electronic health records. Plans can "be an active infomediary between members and providers, supporting collaborative and value-based care through care gap alerts and shared personal health records."

Rushika Fernandopulle, MD, a principal at Renaissance Health, has been involved in installing disease management processes for patients with chronic conditions in physician practices in Seattle and Atlantic City. His group has used predictive modeling to identify patients, brought in health coaches, and set up a three-tier payment model (in Seattle) and global budgets (in Atlantic City).

Putting DM processes - usually reserved for health plans and DM vendors - into physician offices is "next-generation disease management," he said.

"This sort of close payer-provider partnership is not easy, but it is very rewarding when done right. It's a very active process—more than writing a check and walking away. Plans need to be willing to invest enough, and be patient. There needs to be strong, ongoing connections at multiple levels, including personal relationships; one person needs to own this and go between" physicians and plan, he said.

Comment:  Now that Congress has codified a permanent role in health care for the private insurance industry, what will be the next entrepreneurial innovations of the private insurance/managed care industry? "Plan-provider collaborations" that are "not easy" but "very rewarding when done right."  Be afraid. Be very afraid!

Friday, July 9, 2010

qotd: What is an Accountable Care Organization?

Health Affairs
July 2010
How The Center For Medicare And Medicaid Innovation Should Test Accountable Care Organizations
By Stephen M. Shortell, Lawrence P. Casalino and Elliott S. Fisher

The Patient Protection and Affordable Care Act of 2010 directs the Centers for Medicare and Medicaid Services (CMS) to create a national voluntary program for accountable care organizations (ACOs) by January 2012. ACOs are provider groups that accept responsibility for the cost and quality of care delivered to a specific population of patients cared for by the groups' clinicians.

Accountable Care Models

Accountable care organizations will be largely based on physician practices that, in turn, may be organized as patient-centered medical homes. Many ACOs will also include hospitals, home health agencies, nursing homes, and perhaps other delivery organizations. There are at least five different types of practice arrangements that could serve as ACOs. These are the integrated or organized delivery system, multispecialty group practices, physician-hospital organizations, independent practice associations, and "virtual" physician organizations, all described below.

1. Integrated Delivery Systems

Integrated delivery systems involve a common ownership of hospitals, physician practices, and—in some cases—an insurance plan. Some examples are Kaiser Permanente, Group Health Cooperative of Puget Sound, and Geisinger Health System. These systems typically have aligned financial incentives, electronic health records, team-based care, and resources to support cost-effective care.

2. Multispecialty Group Practices 

Multispecialty group practices usually own or have a strong affiliation with a hospital. Examples of this type of arrangement include Mayo Clinic and Cleveland Clinic. They usually do not own a health plan but, rather, have contracts with multiple health plans in their areas. Most have a long history of physician leadership and highly developed mechanisms for providing coordinated clinical care.

3. Physician-Hospital Organizations 

These organizations are a subset of the hospital's medical staff. One example is Advocate Health in Chicago. Most were formed in the 1990s in response to managed care pressures to negotiate with health plans. Some function like multispecialty group practices, focusing on reorganizing the delivery of care to achieve more cost-effective coordination. Although they may be less well suited than integrated delivery systems or multispecialty practices to qualify as ACOs, many could structure themselves to meet the criteria for that type of organization.

4. Independent Practice Associations 

Independent practice associations consist of individual physician practices that came together largely for purposes of contracting with health plans. Over time, however, many of these have evolved into more-organized networks of practices that are actively engaged in practice redesign, quality improvement initiatives, and implementation of electronic health records. One example is Hill Physicians Group, in Northern California. Such organizations could qualify as ACOs, and that might encourage other independent practice associations to evolve similarly, given sufficiently strong financial incentives and technical assistance.

5. Virtual Physician Organizations 

Finally, a number of small, independent physician practices, many located in rural areas, can organize to become "virtual" physician organizations, such as Community Care of North Carolina. This process can be led by individual physicians in rural areas or by a local medical foundation, state Medicaid agency, or similar organization that can provide the leadership, infrastructure, and resources to help small practices develop disease registries; implement electronic health records; share information; and provide better-coordinated, cost-effective care. These virtual networks could qualify as ACOs and serve as models for other groups of small practices.

Physicians can choose one or more of the above models, depending on what best fits their needs and local circumstances. But because there are so many options, the payment systems that the CMS creates for ACOs should evolve with the models chosen. Specifically, the more-integrated forms of accountable care, such as integrated delivery systems and multispecialty group practices, are capable of assuming the greatest risk. This would make them natural candidates for capitation or bundled payments, in which providers assume a relatively greater share of risk.

In contrast, less structurally integrated forms of ACOs, such as virtual physician organizations and more loosely organized independent practice associations, are best suited—at least initially—to low degrees of risk. For them, a form of limited, partial capitation for selected illnesses may be most appropriate.

To facilitate delivery system transformation and focus attention on desired health outcomes, payment systems need to change. Payment based on outcomes achieved, rather than on volume of services provided, will be the motivation for providers to focus their attention on improving the underlying systems of care.

Considerable technical assistance will be needed to implement the learning system for the development of ACOs. This will be particularly true for loosely organized independent practice associations and virtual physician networks, which currently lack the size and resources to become ACOs.


Health Affairs
July 2010
Analyzing Shifts In Economic Risks To Providers In Proposed Payment And Delivery System Reforms
By Jeff Goldsmith


These innovative payment methods all share the assumption of broader responsibility — either formally or informally — by hospitals or physicians for reducing Medicare expense through better coordination and management of care. Sadly, these diverse approaches do not appear to fit together seamlessly to encompass the entire continuum of health care.

Policy makers are unlikely to find a single "silver bullet" they can use to replace Medicare fee-for-service payment. They might have to tolerate multiple, overlapping, and partial solutions, and substantial regional variation in the mechanisms that are feasible.

Nonetheless, for better or worse, hospitals are going to play a much larger role in organizing or reorganizing care in their communities. The most promising innovations are those that build on hospitals' existing information technology and organizational infrastructure. The key to successful innovation will be extending risk assumption to follow suit.

Comment:  "Accountable care organization" (ACO) is an abstract concept of organizing health care providers into single entities that are responsible for delivering a broad continuum of care for specific patients, while bearing financial risk for the care provided. Moving beyond that abstraction, there really isn't much new on the policy front.

Most of the types of entities that might actually be able to serve as ACOs already exist, ranging from independent practice associations to fully integrated delivery systems. Even the concept of bundling payments already has applications ranging from Medicare's DRG prospective payments (diagnosis related groups) to capitation payments for comprehensive health care services. 

So what is new? Would payment systems be designed to require that all reimbursement be provided through ACOs? If so, what would happen to the sector of the health care delivery system that would be excluded from the ACOs that controlled the health care delivery in a given region? Would those providers simply become bankrupt and shut down? Could we afford to lose them, especially with the existing deficiencies in our primary care infrastructure?

Shortell, Casalino and Fisher suggest that the establishment of "virtual physician organizations" would address that concern, but here "virtual" seems to refer to the computer term of "not physically existing as such but made by software to appear to do so." Of course, the providers would actually exist, but they would never function as a unified ACO providing the full range of services, including hospital services, for a given population requiring at least 5000 patients with accountable care protocols for each clinical entity.

Basically, the concept of the accountable care organization is merely a relabeling of various existing policy efforts to try to control inappropriate spending in our dysfunctional health care system. Since our goal is to provide health care for everyone while slowing the growth in spending to sustainable levels, clearly these policies have failed us.

Let's go with a system that actually works to achieve the goal of affordable health care for everyone - a single payer national health program.

Thursday, July 8, 2010

qotd: KFF's health subsidy calculator

Kaiser Family Foundation
Health Reform Subsidy Calculator
Premium Assistance for Coverage in Exchanges

An example for a 50 year old with a family of four, with income at 401% of federal poverty level:

$93,934 - Projected income in 2014

$16,858 - Unsubsidized health insurance premium in 2014

N/A - Maximum % of income the family has to pay for the premium

$16,858 - Actual family required premium payment

$0 - Government tax credit

$12,500 - The maximum out-of-pocket costs the person/family will be responsible for in 2014 (not including the premium)

$29,358 - Premium plus out-of-pocket costs

31% - Percent of income for premium plus out-of-pocket costs

Comment:  This calculator is useful for determining anticipated individual and family costs for insurance premiums plus out-of-pocket expenses for plans obtained through the insurance exchanges, if execution of the program is optimal.

Uncertainties arise since 1) premiums are not guaranteed and could be much higher if private insurers fail to restrain cost increases, and 2) out-of-pocket costs could be much higher based on plan design, limitations of provider networks, and expenses for disallowed services and products.

Furthermore, most individuals and families will not even be allowed to purchase plans through the exchanges.

What kind of reform is this? We could have covered everyone without the need to create personal financial hardship had we adopted a single payer national health program. In fact, we can still do that.

Wednesday, July 7, 2010

qotd: PPACA's redistributive aspects are at great risk

Health Affairs
July 2010
The Political Challenges That May Undermine Health Reform
By Theda Skocpol


As with all major social legislation, years of decisions and disputes over implementation lie ahead for the Patient Protection and Affordable Care Act. Opponents at the state and national levels may seek the law's judicial overturn or repeal. However, a far more serious effort to undermine the law will come about through challenges to various administrative arrangements, taxes, and subsidies to fund expansions of coverage. The redistributive aspects of health reform will be especially at risk, as business interests and groups of more-privileged citizens press for lower taxes, looser regulations, and reduced subsidies for low-income people.

The Staying Power Of Redistributive Reform

As the New York Times reporter David Leonhardt has observed, the new health reform legislation "is the federal government's biggest attack on economic inequality since inequality began rising more than three decades ago." The American rich have been getting richer; meanwhile, in contrast to the situation in many other nations attempting to mitigate rising market inequalities, the U.S. government in recent decades has exacerbated them through tax cuts that disproportionately benefit the rich. But the 2010 health reform promises subsidies to millions of working people of modest means, whose employers do not provide health insurance and who cannot afford to buy it themselves in the existing marketplace. Most of the revenues to pay for coverage expansion come from Americans making more than $250,000 a year, as well as from fees on businesses and cuts in subsidies to private insurers involved in Medicare.

Anti-Reform Interests 

Cheering as this aspect of reform may be to analysts concerned about rising inequality in the United States, the political storms to come should not be underestimated. Many aspects of the U.S. political system give vastly disproportionate leverage to the privileged and well-organized wealthy interests. These are the very groups and interests that Obama is asking to pay for health care for their less-fortunate fellow citizens. They don't like it, and they have potent weapons at their disposal to fight back: money for media campaigns, legions of lobbyists, and now, with the recent Supreme Court Citizens United decision that the government may not ban political spending by corporations in elections, an unlimited ability to contribute to candidates.

With every resource at their disposal, these groups will weigh in as regulations are written at the federal level—and also as rules for insurance exchanges are devised in multiple states. They will use the system to elect representatives, senators, governors, and state legislators who share their sympathies. They will lobby politicians' staffs to make changes in taxes, subsidies, and rules. Much of this will happen out of public view; it will be complicated and might not gain much attention from the news media.

Subtle Efforts To Undermine The Law 

In the end, the clamorous campaign to have provisions of health reform declared unconstitutional may distract attention from subtler efforts to undermine the law. We will not know for a decade or so how far opponents will succeed in stripping away fees and higher taxes on the privileged, undercutting regulations on private insurers, and reducing redistributive subsidies to the less privileged. But we can predict that much of the intended redistribution will be reversed, because it is so easy and tempting for public officials of either party to enact tax breaks for the rich or to adjust regulations and subsidies as demanded by well-heeled business interests. Each individual change will seem small enough so that particular legislators, even Democrats, can rationalize their votes, but the changes will add up.


The generational redistribution implied in the new health reform will also work to the advantage of those who seek leverage to reverse key provisions. Americans slated to get more help tend to be younger and poorer. Meanwhile, seniors on Medicare, especially rich ones, are not only relatively satisfied with the pre-2010 status quo, but they are also responsive to claims that reforms will hurt their health care. Senior citizens are reliable voters, and over the coming months, they may become even more anxious if discussions are launched about how to cut the deficit by reducing spending growth on Social Security or Medicare. Republicans may face difficulties if they have to explain how the nation can simultaneously oppose any tax increases and prevent cuts to Medicare. In short, the arguments they are using now to fight "Obamacare" may come back to haunt them.

But the logic here may be political, not fiscal. The preferred course for both Republicans and the increasing numbers of senior citizens who may vote for them in 2010 and 2012 may be to get rid of or greatly reduce federal subsidies for the uninsured. These subsidies could shrink well before they are delivered in 2014 and beyond, thus making reform much less redistributive in the end.

Battle Is Not Over 

In short, the bitter U.S. war over comprehensive health reform is far from finished. It remains to be seen if the promise of the legislation can be realized in a polity divided by class and generation. A century-long quest for reform may have achieved an uneasy breakthrough. But no one who follows the politics of U.S. health care should think that the battle is over.

(Theda Skocpol is the Victor S. Thomas Professor of Government and Sociology at Harvard and an internationally recognized analyst of comparative and American politics. Skocpol's books on social revolution and the state are considered fundamental texts and have been translated into several languages.)

Comment:  Today's comment is very brief in order to give you more time to read these important excerpts from Theda Skocpol's article. The redistributive aspects of any health financing reform are absolutely crucial, yet under the Patient Protection and Affordable Care Act, redistribution is at great risk. A single payer national health program would have much greater immunity against the vicious but opaque assault that will be taking place under the current law.