Friday, August 30, 2013

Fwd: qotd: Off topic: On Syria

Quote-of-the-day mailing list

-------- Original Message --------
Subject: qotd: Off topic: On Syria
Date: Fri, 30 Aug 2013 06:05:47 -0700
From: Don McCanne <>
To: Quote-of-the-Day <>

Note: Today's message is not on the topic of a single payer national
health program. Rather it is on the broader topic of health: Health of
the people of Syria; health of society - nationally and internationally.
It is a plea for us to promote a healthy world society - for war is not
healthy for children and other living things.

Carnegie Middle East Center
August 28, 2013
Bracing for Impact in Syria
By Paul Salem

After two years of virtual inaction on Syria, the administration of U.S.
President Barack Obama appears on the verge of launching a direct
military strike on key Syrian military sites following a chemical
weapons attack by the Assad regime. The imminent and much-discussed
strike should deter Syria from repeat use of chemical weapons but is
unlikely to be a game changer in the course of the Syrian conflict.

The U.S. administration has said that the attack would be a response to
the use of chemical weapons; regime change would not be the aim. Obama
feels the need to act to protect the global nonproliferation regime and
prevent the use of weapons of mass destruction, but he does not want to
get dragged into the long Syrian conflict. The exceptionally tough
language that has come from high administration officials might provide
a way for Obama to amplify the attack's importance, get it done quickly,
and then put it behind him.

The attack would not tie in directly to Washington's longer-term Syrian
strategy to strengthen the moderate elements in the Syrian opposition
and, along with Saudi Arabia, Qatar, Jordan, Turkey, and others, to
train and strengthen the rebel Free Syrian Army. That process might take
many months or years to bear fruit. The strike might weaken the regime
somewhat, but is unlikely to dramatically alter the balance of power.

Meanwhile, the rebel-held areas in Syria are dominated by radical
Islamist forces that the United States and Syria's neighbors Israel,
Jordan, and Turkey do not favor. Some key U.S. allies—particularly
Israel and Jordan—have serious fears that if Assad loses Damascus
tomorrow, the radicals will be on their borders. So for Washington, it
is important that the Assad regime not collapse too quickly. Rather, the
goal is to temper the violence, de-escalate the conflict, and press the
regime to join political talks sometime in the near future.

If talks fail, and if strengthening the moderate rebels eventually
succeeds, the United States could become more serious about toppling the
Assad regime. In the meantime, Washington might have a preference for
upholding the basic status quo between the regime and the rebels,
provided the regime refrains from using weapons of mass destruction and
ratchets down its assaults on civilians—actions that trigger
international action and cause destabilizing refugee flows.

The Syrian regime appears to be bracing for the attack. Because of the
ample warning time, it presumably has moved whatever personnel and
matériel it can out of the way of expected targets. The attack is likely
to involve cruise missiles launched from naval units already positioned
in the eastern Mediterranean and to target airfields, chemical plants,
and other military or official command and control centers. The
expectation among local media is that the attack will last for a few
days (or nights)—enough to damage but not seriously cripple the regime.
Some Western powers might join in the operation, but the involvement of
regional powers might be constrained in order to avoid direct regional

Regime officials have been full of bluster, but they are likely to
absorb the blow and not respond or retaliate in a major way. Syria does
not have the capacity to intercept cruise missiles or other advanced
weaponry that the United States might deploy. And if the regime can't
avoid the attack, it will simply hope the United States will get it over
with and go home. Retaliation or escalation would just spur the United
States to become more engaged in war in Syria, which is not at all in
the regime's interest. Washington has largely ignored the conflict for
two years; the regime would like to return to that condition.

Furthermore, the regime's options for retaliation are limited. It could
attack Israel, or get its ally Hezbollah to do so, but that would only
invite a large-scale Israeli attack, which neither Syria nor Hezbollah
wants. Contemplating direct retaliation against U.S. forces in Jordan or
the Gulf is unrealistic, and U.S. troops have already left nearby Iraq.
If Turkey or Arab states do not join in the attack, Syria would not have
sufficient warrant to retaliate against them.

So the regime is likely to limit its response to making much political
hay and denouncing the U.S. attack. Its regional and international
allies—particularly Iran and Russia—will likely join in the criticism.
The regime will say that the attack proves that the Syrian rebellion is
an "American-Zionist-Salafi" plot, and Damascus's allies will decry the
violation of international law and sovereignty, highlighting the
inevitable destruction, loss of life, and "collateral damage."

The Syrian regime will survive and will go back to trying to consolidate
its hold on the capital and the central and western parts of the country
that it controls. The rebels, meanwhile, will continue to hold much of
the north and east of the country as well as Deraa in the south, and
they will continue to fight within the capital.

Although the attack might cause enough heat to create momentum for the
convocation of a Geneva II meeting in the fall, the Syrian conflict
seems fated to go on for several more years. The regime is content to
hunker down in its areas of influence and is not interested in
negotiating with the rebels; and the rebels are too divided and
generally too radical to contemplate or be able to enter serious

The imminent U.S. attack might be necessary to deter the use of chemical
weapons in the future. But it is unlikely to dramatically change the
course of the Syrian conflict.

Harper's Monthly
November 1916

The War Prayer

March 1905

by Mark Twain

Editor's note (from The Religious Society of Friends): Outraged by
American military intervention in the Philippines, Mark Twain wrote this
and sent it to Harper's Bazaar. This women's magazine rejected it for
being too radical, and it wasn't published until after Mark Twain's
death, when World War I made it even more timely. It appeared in
Harper's Monthly, November 1916.

It was a time of great and exalting excitement. The country was up
in arms, the war was on, in every breast burned the holy fire of
patriotism; the drums were beating, the bands playing, the toy pistols
popping, the bunched firecrackers hissing and spluttering; on every hand
and far down the receding and fading spread of roofs and balconies a
fluttering wilderness of flags flashed in the sun; daily the young
volunteers marched down the wide avenue gay and fine in their new
uniforms, the proud fathers and mothers and sisters and sweethearts
cheering them with voices choked with happy emotion as they swung by;
nightly the packed mass meetings listened, panting, to patriot oratory
which stirred the deepest deeps of their hearts, and which they
interrupted at briefest intervals with cyclones of applause, the tears
running down their cheeks the while; in the churches the pastors
preached devotion to flag and country, and invoked the God of Battles
beseeching His aid in our good cause in outpourings of fervid eloquence
which moved every listener. It was indeed a glad and gracious time, and
the half dozen rash spirits that ventured to disapprove of the war and
cast a doubt upon its righteousness straightway got such a stern and
angry warning that for their personal safety's sake they quickly shrank
out of sight and offended no more in that way.

Sunday morning came -- next day the battalions would leave for the
front; the church was filled; the volunteers were there, their young
faces alight with martial dreams -- visions of the stern advance, the
gathering momentum, the rushing charge, the flashing sabers, the flight
of the foe, the tumult, the enveloping smoke, the fierce pursuit, the
surrender! Then home from the war, bronzed heroes, welcomed, adored,
submerged in golden seas of glory! With the volunteers sat their dear
ones, proud, happy, and envied by the neighbors and friends who had no
sons and brothers to send forth to the field of honor, there to win for
the flag, or, failing, die the noblest of noble deaths. The service
proceeded; a war chapter from the Old Testament was read; the first
prayer was said; it was followed by an organ burst that shook the
building, and with one impulse the house rose, with glowing eyes and
beating hearts, and poured out that tremendous invocation

God the all-terrible! Thou who ordainest! Thunder thy clarion and
lightning thy sword!

Then came the "long" prayer. None could remember the like of it
for passionate pleading and moving and beautiful language. The burden of
its supplication was, that an ever-merciful and benignant Father of us
all would watch over our noble young soldiers, and aid, comfort, and
encourage them in their patriotic work; bless them, shield them in the
day of battle and the hour of peril, bear them in His mighty hand, make
them strong and confident, invincible in the bloody onset; help them to
crush the foe, grant to them and to their flag and country imperishable
honor and glory --

An aged stranger entered and moved with slow and noiseless step up
the main aisle, his eyes fixed upon the minister, his long body clothed
in a robe that reached to his feet, his head bare, his white hair
descending in a frothy cataract to his shoulders, his seamy face
unnaturally pale, pale even to ghastliness. With all eyes following him
and wondering, he made his silent way; without pausing, he ascended to
the preacher's side and stood there waiting. With shut lids the
preacher, unconscious of his presence, continued with his moving prayer,
and at last finished it with the words, uttered in fervent appeal,
"Bless our arms, grant us the victory, O Lord our God, Father and
Protector of our land and flag!"

The stranger touched his arm, motioned him to step aside -- which
the startled minister did -- and took his place. During some moments he
surveyed the spellbound audience with solemn eyes, in which burned an
uncanny light; then in a deep voice he said:

"I come from the Throne -- bearing a message from Almighty God!"
The words smote the house with a shock; if the stranger perceived it he
gave no attention. "He has heard the prayer of His servant your
shepherd, and will grant it if such shall be your desire after I, His
messenger, shall have explained to you its import -- that is to say, its
full import. For it is like unto many of the prayers of men, in that it
asks for more than he who utters it is aware of -- except he pause and

"God's servant and yours has prayed his prayer. Has he paused and
taken thought? Is it one prayer? No, it is two -- one uttered, the other
not. Both have reached the ear of Him Who heareth all supplications, the
spoken and the unspoken. Ponder this -- keep it in mind. If you would
beseech a blessing upon yourself, beware! lest without intent you invoke
a curse upon a neighbor at the same time. If you pray for the blessing
of rain upon your crop which needs it, by that act you are possibly
praying for a curse upon some neighbor's crop which may not need rain
and can be injured by it.

"You have heard your servant's prayer -- the uttered part of it. I
am commissioned of God to put into words the other part of it -- that
part which the pastor -- and also you in your hearts -- fervently prayed
silently. And ignorantly and unthinkingly? God grant that it was so! You
heard these words: 'Grant us the victory, O Lord our God!' That is
sufficient. the whole of the uttered prayer is compact into those
pregnant words. Elaborations were not necessary. When you have prayed
for victory you have prayed for many unmentioned results which follow
victory -- must follow it, cannot help but follow it. Upon the listening
spirit of God fell also the unspoken part of the prayer. He commandeth
me to put it into words. Listen!

"O Lord our Father, our young patriots, idols of our hearts, go
forth to battle -- be Thou near them! With them -- in spirit -- we also
go forth from the sweet peace of our beloved firesides to smite the foe.
O Lord our God, help us to tear their soldiers to bloody shreds with our
shells; help us to cover their smiling fields with the pale forms of
their patriot dead; help us to drown the thunder of the guns with the
shrieks of their wounded, writhing in pain; help us to lay waste their
humble homes with a hurricane of fire; help us to wring the hearts of
their unoffending widows with unavailing grief; help us to turn them out
roofless with little children to wander unfriended the wastes of their
desolated land in rags and hunger and thirst, sports of the sun flames
of summer and the icy winds of winter, broken in spirit, worn with
travail, imploring Thee for the refuge of the grave and denied it -- for
our sakes who adore Thee, Lord, blast their hopes, blight their lives,
protract their bitter pilgrimage, make heavy their steps, water their
way with their tears, stain the white snow with the blood of their
wounded feet! We ask it, in the spirit of love, of Him Who is the Source
of Love, and Who is the ever-faithful refuge and friend of all that are
sore beset and seek His aid with humble and contrite hearts. Amen.

(After a pause.) "Ye have prayed it; if ye still desire it, speak!
The messenger of the Most High waits!"

It was believed afterward that the man was a lunatic, because
there was no sense in what he said.

Comment: War is always wrong.

We are observing from afar the atrocities of war. So our response is...
more atrocities of war.

War is always wrong.

Thursday, August 29, 2013

Fwd: qotd: The tycoons seem to care less about our health care

Quote-of-the-day mailing list

-------- Original Message --------
Subject: qotd: The tycoons seem to care less about our health care
Date: Thu, 29 Aug 2013 11:29:42 -0700
From: Don McCanne <>
To: Quote-of-the-Day <>

National Business Group on Health
August 28, 2013
Large U.S. Employers Project a 7% Increase in Health Care Benefit Costs
in 2014, National Business Group on Health Survey Finds

The cost of providing employee health care benefits at the nation's
largest employers is projected to increase 7% in 2014 – the third
consecutive year employers have budgeted this amount, according to a new
survey by the National Business Group on Health, a non-profit
association of more than 365 large U.S. employers. The survey – one of
the industry's first look at costs and plan design changes for 2014 –
also found that some employers believe health insurance exchanges could
be a viable option for certain populations. Additionally, more companies
plan to offer workers a consumer-directed health plan as their only
health benefits option in 2014.

While large employers will not be eligible to participate in state
health exchanges until 2017 at the earliest, employers expect that
certain populations may find exchanges to be a viable option on an
individual basis in 2014. Roughly four in ten (41%) employers believe
COBRA plan participants might find public health exchanges to be the
most cost effective option. Additionally, more than one-fourth (26%)
felt that some pre-65 retirees might opt to join exchanges, while 20%
believe that some part-time employees will do the same.

"Private exchanges are another option some employers are considering. In
the last year, there has been an increase in the number of private
exchanges that are being launched. And while some employers are
considering private exchanges for active employees sometime in the
future, very few (3%) are considering eliminating health care coverage
entirely," said Darling.

More Employers Embracing Total Replacement CDHPs

The survey found that implementing a consumer-directed health plan
(CDHP) was considered the most effective tactic to control rising costs,
cited by more than one-third of respondents (36%). In fact, nearly
three-quarters of employers (72%) now offer at least one CDHP. This
number has remained relatively steady over the last couple of years.
However, the number of employers that are offering only a CDHP to
employees continues to rise, with 22% planning to implement a total
replacement CDHP next year, up from 19% this year.

(The National Business Group on Health members are primarily Fortune 500
companies and large public sector employers — including the nation's
most innovative health care purchasers — who provide health coverage for
more than 55 million U.S. workers, retirees, and their families.)

Comment: The National Business Group on Health survey is important
because it represents the views of the nation's largest employers who
provide coverage for over 55 million workers and their families -
supposedly the best health benefit programs available. Three findings in
this survey should have us concerned.

1) The costs of providing health care benefits have increased at the
rate of 7 percent for each of the past three years, considerably higher
than the rate of inflation. This indicates that health care costs
continue to increase at unsustainable rates, regardless of the
implementation of several programs supposedly designed to slow spending

2) Although large employers cannot use the state health exchanges until
2017, interest in both private exchanges and state exchanges is
increasing. A major attraction of the exchanges is that employees are
most likely to select plans with actuarial values of only 60 to 70
percent because of their lower premiums. This offers employers the
opportunity to shift from defined health benefits to defined
contributions for the exchange plans. This shifts more of the health
care costs to employees.

3) About three-fourths of employers now offer consumer-directed health
plans (CDHPs), and next year 22 percent will offer CDHPs as the only
option. CDHPs are high deductible plans that shift more costs to
employees and their families. Some may be associated with a health
spending account, but that is little more than a tax gimmick that favors
higher income employees. Whether these accounts are funded by direct
employee contributions or by employer contributions representing forgone
wage increases makes little difference as far as whether or not health
care is more affordable. It is ultimately the employee that is
responsible for the increases in out-of-pocket costs.

The National Business Group on Health represents two-thirds of the
Fortune 100 companies - the biggest of the biggest. They should be
offering the very best. But instead, these trends should make us want to
accelerate our movement away from employer control of individual health
plans and toward enactment of a single, publicly-financed national
health program that would include everyone and treat all of us fairly.
The tycoons seem to be losing interest in the welfare of their
employees, so what chance would the rest of us have without converting
to an improved Medicare that covered everyone?

Wednesday, August 28, 2013

Fwd: qotd: The Des Moines Register is back on message

Quote-of-the-day mailing list

-------- Original Message --------
Subject: qotd: The Des Moines Register is back on message
Date: Wed, 28 Aug 2013 13:43:00 -0700
From: Don McCanne <>
To: Quote-of-the-Day <>
August 27, 2013
The Register's Editorial: Why tie insurance to jobs?

In many households, one spouse buys health insurance through a job for
the entire family. Now United Parcel Service Inc. has announced it
intends to cut this coverage for working spouses of nonunion employees
next year.

A UPS spokesman said the change is necessary to keep costs down.

Denying insurance to workers' spouses will certainly create a financial
burden for families, particularly if companies don't reduce the premiums
for workers when they implement such a change. Now the family needs to
purchase two policies to cover both adults in the home. Also, the health
insurance offered by the spouse's employer may not cover needed services
or may impose higher co-payments and deductibles.

Unfortunately, this is how things work in a country that has tied health
insurance to employment. We have long recognized that is a bad idea.
Your employer doesn't select and subsidize your homeowner's insurance or
your car insurance.

The practice burdens U.S. businesses and puts them at a disadvantage in
a global economy. In other countries, the government facilitates
coverage for everyone.

Employer-based health insurance creates problems for workers. They are
at the mercy of their company when it comes to which plans are available.

In some ways, the health reform law addresses some of these problems.

Yet the Affordable Care Act is built on a broken system. As the
Register's editorial board wrote for years prior to the passage of the
health law in 2010, this country needs a single-payer health care system
with coverage facilitated by the government. Similar to Medicare,
everyone could contribute through taxation and everyone would be
covered. Instead of such a change, Congress cemented in place the
practice of tying health insurance to jobs by requiring many companies
to offer it.

The long term result will likely be more companies doing exactly what
UPS is doing.

Comment: We already knew that The Des Moines Register held an editorial
position in favor of single payer reform, but this reiteration of their
position is highly significant.

Much of the activity in support of single payer has faded as attention
has turned to implementation of the Affordable Care Act. The prevailing
attitude is that, well, we tried and this is the best that we could get.
We can work on trying to patch this system, but forget trying to
negotiate the major barriers erected by obdurate politicians. Even if
current laws and regulations have locked up much of the nation's health
care funds, we'll just try to muddle our way through with incremental
steps using some future form of magical waivers which we will need since
the currently available waivers, including those in the Affordable Care
Act, cannot change the basics of the fundamentally flawed, fragmented
infrastructure of multiple public programs and private plans, or no
plans at all for far too many of us.

What is so important about today's message is that the Register's
editorial board sees through this nonsense. "The Affordable Care Act is
built on a broken system." Congress has "cemented" into place this
highly dysfunctional infrastructure. Incremental steps cannot work when
we are heading down the wrong pathway.

As the Register states, "This country needs a single-payer health care
system with coverage facilitated by the government - similar to
Medicare, everyone could contribute through taxation and everyone would
be covered."

The Des Moines Register is back on message. We have to get back on
message as well.

Tuesday, August 27, 2013

Fwd: qotd: High-deductibles cause men to avoid ED use for high-severity conditions

Quote-of-the-day mailing list

-------- Original Message --------
Subject: qotd: High-deductibles cause men to avoid ED use for
high-severity conditions
Date: Tue, 27 Aug 2013 10:53:58 -0700
From: Don McCanne <>
To: Quote-of-the-Day <>

Medical Care (APHA)
August 2013
The Impact of High-deductible Health Plans on Men and Women: An Analysis
of Emergency Department Care
By Kozhimannil, Katy B. PhD, MPA; Law, Michael R. PhD, MSc;
Blauer-Peterson, Cori MPH; Zhang, Fang PhD; Wharam, James Frank MB, BCh,


Background: Prior studies show that men are more likely than women to
defer essential care. Enrollment in high-deductible health plans (HDHPs)
could exacerbate this tendency, but sex-specific responses to HDHPs have
not been assessed. We measured the impact of an HDHP separately for men
and women.

Methods: Controlled longitudinal difference-in-differences analysis of
low, intermediate, and high severity emergency department (ED) visits
and hospitalizations among 6007 men and 6530 women for 1 year before and
up to 2 years after their employers mandated a switch from a traditional
health maintenance organization plan to an HDHP, compared with
contemporaneous controls (18,433 men and 19,178 women) who remained in
an health maintenance organization plan.

Results: In the year following transition to an HDHP, men substantially
reduced ED visits at all severity levels relative to controls (changes
in low, intermediate, and high severity visits of −21.5% [−37.9 to
−5.2], −21.6% [−37.4 to −5.7], and −34.4% [−62.1 to −6.7],
respectively). Female HDHP members selectively reduced low severity
emergency visits (−26.9% [−40.8 to −13.0]) while preserving intermediate
and high severity visits. Male HDHP members also experienced a 24.2%
[−45.3 to −3.1] relative decline in hospitalizations in year 1, followed
by a 30.1% [2.1 to 58.1] relative increase in hospitalizations between
years 1 and 2.

Conclusions: Initial across-the-board reductions in ED and hospital care
followed by increased hospitalizations imply that men may have foregone
needed care following an HDHP transition. Clinicians caring for patients
with HDHPs should be aware of sex differences in response to benefit design.

Comment: One of the most important changes in health care financing
taking place today is the tremendous surge in the use of high-deductible
health plans. This is yet one more study that shows that we should
question the wisdom of this policy intervention.

Males whose employers switched them from a traditional HMO to a
high-deductible health plan reduced their use of emergency department
high-severity visits by 34 percent. That is, they did not go to the
emergency department when the severity of their condition clearly
warranted it. That was followed a year later by a 30 percent increase in
hospitalizations. Lead author Katy Kozhimannil stated, "The trends
suggest that men might have put off needed care after their deductible
went up, leading to more severe illness requiring hospital care later
on" (American Medical News, Aug. 26).

High-deductible health plans not only cause financial hardship, they
also maim and kill people. And they aren't even necessary as a means to
control spending. We can control costs more effectively and far more
humanely through a publicly-administered single payer program that
provides first-dollar coverage.

Fwd: qotd: Obamacare architects reap windfall as lobbyists

Quote-of-the-day mailing list

-------- Original Message --------
Subject: qotd: Obamacare architects reap windfall as lobbyists
Date: Mon, 26 Aug 2013 12:42:03 -0700
From: Don McCanne <>
To: Quote-of-the-Day <>

The Hill
August 25, 2013
ObamaCare's architects reap windfall as Washington lobbyists
By Megan R. Wilson

ObamaCare has become big business for an elite network of Washington
lobbyists and consultants who helped shape the law from the inside.
More than 30 former administration officials, lawmakers and
congressional staffers who worked on the healthcare law have set up shop
on K Street since 2010.

Veterans of the healthcare push are now lobbying for corporate giants
such as Delta Air Lines, UPS, BP America and Coca-Cola, and for
healthcare companies including GlaxoSmithKline, UnitedHealth Group and
the Blue Cross Blue Shield Association.

Ultimately, the clients are after one thing: expert help in dealing with
the most sweeping overhaul of the country's healthcare system in decades.

Experts say that those able to fetch the highest salaries have come from
the Department of Health and Human Services (HHS) or committees with
oversight power over healthcare.

"After passage of major legislation, those who have networks on Capitol
Hill take exceedingly lucrative jobs with the same industries subject to
the legislation," said Craig Holman, a lobbyist for Public Citizen. "It
raises questions about the [bill's] integrity."

Comment: We need lobbyists, that is lobbyists such as Craig Holman of
Public Citizen. But what about administration officials, lawmakers and
congressional staffers who helped to create a profoundly wasteful health
care financing system that falls tragically short of reform goals, and
then left government employment to accept windfalls as private lobbyists
representing clients who must deal with Obamacare? As Holman says, it
raises questions about the bill's integrity.

Lobbying integrity that makes the difference? "Public Citizen serves as
the people's voice in the nation's capital." Public Citizen is already
on record as supporting a single payer system:

Friday, August 23, 2013

Fwd: qotd: Is Medigap for wealthy people who want more health care?

Quote-of-the-day mailing list

-------- Original Message --------
Subject: qotd: Is Medigap for wealthy people who want more health care?
Date: Fri, 23 Aug 2013 14:14:56 -0700
From: Don McCanne <>
To: Quote-of-the-Day <>

JAMA Internal Medicine
August 19, 2013
The Future of Medicare Supplemental Insurance
By Gail R. Wilensky, PhD

Even these highly regulated versions of Medigap have problems. They are
expensive and, frequently, are not a very good buy. And Medigap
insurance imposes significant costs on the Medicare program. Because
Medigap plans pay for the deductibles, coinsurance, and copayments
associated with Medicare, they frequently are paying for low-cost,
routine care. Such payments are prepayments, rather than "real
insurance," but Medigap plans have to set premiums to cover the costs of
this expected use, as well as the administrative costs associated with
the insurance.

More than half of the people who buy Medigap insurance buy one of the 2
most expensive plans—"C" or "F." These plans pay almost all of the
beneficiaries' costs, thus providing first-dollar coverage, which has
been the cause for congressional concern.

Currently, the Obama administration and Congress are focused on the
costs that Medigap insurance imposes on the Medicare program. Because
the plans typically cover all or most cost sharing, seniors with
supplemental insurance use more medical services than seniors without
supplemental insurance.

The Patient Protection and Affordable Care Act (Pub L No. 111-148)
requires the National Association of Insurance Commissioners to review
the benefit designs of plans C and F and introduce cost sharing for
physician services for plans purchased as of 2015.

President Obama's fiscal year 2014 budget proposal introduces a $100
home health copayment and a 30% surcharge on Part B premiums for new
Medicare beneficiaries who purchase Medigap policies with low
cost-sharing requirements.

The National Commission on Fiscal Responsibility and Reform (known as
the Fiscal Commission) recommended that Medigap plans not be allowed to
cover the first $550 per year in cost sharing and cover no more than
half of the cost sharing up to $5500 per year.

The health care cost containment initiative of the Bipartisan Policy
Center recommended a prohibition on first dollar supplemental insurance
and a more coherent and rational cost-sharing benefit structure for
traditional Medicare, as part of broader changes to the US health care

Medicaid would protect low-income beneficiaries, but other high users of
Medicare services would be more likely to incur higher costs.

Not surprisingly, many of these proposals raise concerns about
inappropriate reductions in the use of health care and increased costs
for some Medicare beneficiaries. According to a Kaiser Family Foundation
study, the majority of elderly persons would have reduced costs, but 20%
would have higher costs.

Neither the outdated structure of Medicare nor the costs imposed on the
program by Medigap insurance are new issues. Medicare needs to be a
viable program, while providing insurance coverage appropriate for the
21st century. Congress and the Obama administration know that reforms to
supplemental insurance are needed, and the specific types of changes
that make most sense.

June 2013
Health Care Spending and the Medicare Program

Chart 5-6. Out-of-pocket spending for premiums and health services per
beneficiary, by insurance and health status, 2009

Beneficiaries who report they are in good, very good, or excellent health:

Medicare only

$1,079 Premium
$1,643 Out-of-pocket

Medicare plus Medigap

$3,264 Premium
$1,900 Out-of-pocket

Beneficiaries who report they are in fair or poor health:

Medicare only

$1,128 Premium
$3,446 Out-of-pocket

Medicare plus Medigap

$3,191 Premium
$3,382 Out-of-pocket

Comment: Former HCFA Administrator Gail Wilensky has long been a
supporter of patient cost sharing as a means of discouraging use of
health care services, hopefully reducing spending in government health
programs such as Medicare. She has particularly targeted Medigap plans
because they remove cost sensitivity by providing first-dollar coverage.
So do we need to prohibit Medigap plans from providing full coverage of
deductibles and other cost sharing, as she recommends?

MedPAC has provided us with the numbers that indicate how patients
respond to Medigap incentives. When Medicare beneficiaries elect to
purchase Medigap plans, their premiums triple, no matter the status of
their health. But look at their out-of-pocket expenses, excluding the
premiums. If they are healthy, the out-of-pocket expenses are not much
different, whether or not they are enrolled in a Medigap plan. If they
are not healthy, the out-of-pocket expenses are quite a bit higher, but
still with not much difference between those with and those without a
Medigap plan.

According to the MedPAC report, "Insurance that supplements Medicare
does not shield beneficiaries from all out-of-pocket costs.
Beneficiaries who report being in fair or poor health spend more out of
pocket for health services than those reporting good, very good, or
excellent health regardless of the type of coverage they have to
supplement Medicare."

The report also speculates that "this result likely reflects the fact
that beneficiaries who have Medigap have higher incomes and are likely
to have stronger preferences for health care." Rich people want more
health care? It is much more likely that these numbers represent two
other factors: 1) the actual dollar benefit of Medigap plans is truly
paltry (except for a cap on the costs of catastrophic events), and 2)
Medicare benefits are quite spartan, covering on average only about half
of seniors' health care costs.

Considering their high premiums, administrative excesses, and relatively
paltry benefits, Medigap plans don't need revision; they need to be
eliminated, with the benefits being rolled into the traditional Medicare

Perhaps the most telling comment in Wilensky's article is her statement
that Medicare plus Medigap payments are "prepayments, rather than 'real
insurance.'" The consumer-driven advocates have created the meme that
"real insurance" is catastrophic insurance only; it should not pay for
routine medical care. That arbitrary definition is nonsense. Insurance
is pooling risk, and you can include all health care costs in that pool,
including routine and preventive care. Perhaps a better term is "prepaid
health care."

Regardless, when routine care exposes too many individuals to financial
hardship, the system needs to be changed, and certainly not by
increasing that exposure, as Wilensky recommends. Her diversionary
strategy is to prevent us from considering a program that really would
work for all of us - a government-run (OMG!) single payer, improved
Medicare for all.

Why is she and her ilk so opposed? Is adhering to their ideology really
more important to them than preventing physical suffering and financial
hardship for the rest of us? I've tried to understand them, but I'll
never get it.

Thursday, August 22, 2013

Fwd: qotd: More definitive report confirming that most physicians accept Medicare

Quote-of-the-day mailing list

-------- Original Message --------
Subject: qotd: More definitive report confirming that most physicians
accept Medicare
Date: Thu, 22 Aug 2013 13:59:06 -0700
From: Don McCanne <>
To: Quote-of-the-Day <>

U.S. Department of Health & Human Services
Office of the Assistant Secretary for Planning and Evaluation
August 2013
Access to Physicians' Services for Medicare Beneficiaries
By: Adele Shartzer, Rachael Zuckerman, Audrey McDowell, and Richard Kronick

Key Findings:

- According to federal survey data, the percentage of all office-based
physicians who report accepting new Medicare patients has not changed
significantly between 2005 and 2012, with 87.9% of physicians accepting
new Medicare patients in 2005 and 90.7% in 2012.

- The percentage of physicians who report accepting new Medicare
patients is similar to, and in recent years slightly higher than, the
percentage accepting new privately insured patients.

- Medicare beneficiary access to care is high and has remained stable
over the past five years.

According to Centers for Medicare and Medicaid Services (CMS) data,
there were about 650,000 physicians who participated in the Medicare
program in 2011 and nearly 1 million participating providers in total
(including non-physician providers such as nurse practitioners). It is
clear from the data the percentage of all physicians who accept new
Medicare patients has been stable from 2005 to 2012. To the extent that
there may have been a very small increase in the number of providers
'opting out', that increase has been mitigated by an increase in the
share of other physicians who accept new Medicare patients. Further, the
total number of providers participating in and billing Medicare has
steadily increased since 2007.

These findings allay concern that the number of physicians 'opting out'
of Medicare has increased in recent years.[4] (Footnote 4: Beck, M.
"More Doctors Steer Clear of Medicare", Wall Street Journal 7/29/13
p.A1, vCCLXII #24. This article reported that the number of physicians
opting out of Medicare increased from 3,700 in 2009 to 9,539 in 2012.)

A 2005 study examining characteristics of providers opting out of
Medicare found that overall less than one percent of providers eligible
to opt out of Medicare did so, and the two specialties with the highest
opt out percentages were psychiatrists (with 1.11% opting out) and
plastic and reconstructive surgeons (with 1.56% opting out). In
contrast, about a third of one percent of primary care physicians
(0.35%) opted out of Medicare.

In its March 2013 Report to Congress, based on this and other federal
surveys, MedPAC noted that Medicare beneficiaries report good access to
care, and access to physicians' services has remained stable over the
past five years. Similarly, the large majority of beneficiaries had no
problems getting an appointment with a new physician, and again the
results are comparable to those for people with private insurance.
Additionally, Medicare beneficiaries were less likely than the privately
insured to report forgoing needed medical care (8% vs. 11%) in 2012.

Approximately 90% of all office-based physicians report accepting new
Medicare patients. The percentage of physicians who report accepting new
Medicare patients is similar to the percentage of physicians who report
accepting new privately insured patients. In addition, the share
accepting new Medicare patients has been relatively stable over the
2005-2012 period and shows a slight increase in 2011-2012 based on
initial NAMCS data. Beneficiary reports of access to care, including
the ability to find a physician and see a doctor in a timely manner, are
also favorable. Again, these results are comparable to reports by
patients with private insurance and have been stable over time. Overall,
Medicare beneficiary access to care has been consistently high over the
last decade and continues to be high today.

Comment: This highly credible report lays to rest the nonsense
perpetrated by media reports such as the recent Wall Street Journal
article, "More Doctors Steer Clear of Medicare." Although some
physicians have stopped accepting new Medicare patients because of
overload, over 90 percent still do, more than those who accept new
privately insured patients. A few isolated anecdotes do not alter the truth.

Opponents of an improved Medicare for all have suggested that physicians
would bale out in droves if that were the only insurance program in the
U.S. But where would they go?

Everyone automatically would be enrolled in the Medicare program. Why
would patients want to buy a private plan duplicating Medicare benefits
when they are already paying obligatory taxes for the Medicare program?
There would be no market for such plans, not to mention that consumers
would be protected by making them illegal.

It would not be long before the physicians who opted out for a cash-only
practice would discover that there would not be enough cash to support
them. In fact, today 20 percent of concierge practices fail and that
number has been increasing.

Under a Medicare for all program there simply would not be enough
patients who would want to pay more than they would already be paying in
taxes to support more than a minute contingency of cash-only concierge
practices. Virtually all physicians would accept Medicare, without
giving it a second thought, though the Wall Street Journal might then
have to turn to the contrived scandal of the physician glut in Medicare.

Wednesday, August 21, 2013

Fwd: qotd: Modest premium increases hide important part of story

Quote-of-the-day mailing list

-------- Original Message --------
Subject: qotd: Modest premium increases hide important part of story
Date: Wed, 21 Aug 2013 12:47:52 -0700
From: Don McCanne <>
To: Quote-of-the-Day <>

Kaiser Family Foundation
August 20, 2013
2013 Employer Health Benefits Survey

Employer-sponsored insurance covers about 149 million nonelderly people.
To provide current information about employer-sponsored health benefits,
the Kaiser Family Foundation (Kaiser) and the Health Research &
Educational Trust (HRET) conduct an annual survey of nonfederal private
and public employers with three or more workers.


In 2013, the average annual premiums for employer-sponsored health
insurance are $5,884 for single coverage and $16,351 for family
coverage. The single premium is 5% higher and the family premium is 4%
higher than the 2012 average premiums. During the same period workers'
wages increased 1.8% and inflation increased 1.1%.

There is significant variation around the average single and family
premiums, resulting from differences in benefits, cost sharing, covered
populations, and geographical location. Twenty-one percent of covered
workers are in plans with an annual total premium for family coverage of
at least $19,622 (120% of the average family premium), while 21% of
covered workers are in plans where the family premium is less than
$13,081 (80% of the average family premium).

As with total premiums, the share of the premium contributed by workers
varies considerably among firms. For family coverage, 42% of covered
workers are in plans that require them to make a contribution of less
than or equal to a quarter of the total premium and 14% are in plans
that require more than half of the premium, while only 5% are in plans
that require no contribution at all for family coverage.


Seventy-eight percent of covered workers have a general annual
deductible for single coverage that must be met before most services are
reimbursed by the plan.

Among covered workers with a general annual deductible, the average
deductible amount for single coverage is $1,135.

Almost three-in-four covered workers pay a copayment (a fixed dollar
amount) for office visits with a primary care physician (74%) or a
specialist physician (72%), in addition to any general annual deductible
their plan may have.

Most workers also face additional cost sharing for a hospital admission
or an outpatient surgery episode. The average coinsurance rate for
hospital admissions is 18%, the average copayment is $278 per hospital
admission, the average per diem charge is $264, and the average separate
annual hospital deductible is $436.

Conclusion (excerpt)

The emergence of new exchanges, or marketplaces, also may portend
important changes for employer-sponsored health insurance. Through an
exchange, an employer can provide employees with a larger number and
type of health plan options. Exchanges also facilitate the use of
defined contributions or other strategies that encourage employees to
choose lower cost plans or pay the difference in costs themselves. New
SHOP exchanges will offer coverage options to small employers beginning
in 2014, although employee choice will be limited in the federal SHOP
exchanges until 2015. Large employers have the option of offering
coverage through one of several exchanges being sponsored by benefit
consulting organizations. While these approaches are new and differ
across different exchanges, the common theme is to devolve some benefit
choices, and some of the financial responsibility for those choices, to
employees. Whether this new way of purchasing coverage works for
employers and their employees, and how it affects benefits and plan
costs, will be among the more important stories for the employer health
insurance market over the next few years.

Comment: Many of the media reports about this annual Kaiser survey of
employer-sponsored plans are expressing relief that the increases in
premiums are relatively modest - only about 4 or 5 percent. But these
numbers are not so reassuring when you consider that they are over twice
the rate of wage increases and four time the rate of inflation. Workers
continue to fall behind.

Also of concern is the fact that plans requiring high deductibles have
increased and the amounts of those deductibles also have continued to
increase. Thus the percentage increase in the premiums can be quite
deceptive if you ignore the increase in out-of-pocket expenses that
workers and their families are experiencing.

Also many employers are now considering private insurance exchanges
which will allow them to convert their premium contributions into
defined contributions, requiring employees to pick up the additional
costs for plans that have more than minimal benefits.

Also there is considerable variation in the premiums, benefits, cost
sharing, and covered populations of employer-sponsored health coverage.
As if the average expenses that the employees must cover weren't bad
enough, many of them will find that the cost variations will be
intolerably burdensome, even if some are better off.

These trends have been going on so long that they've become quite
boring, but the cumulative impact on wage earners can be quite
distressing. Giving a new definition to "catastrophic insurance," the
costs shifted to the workers can be catastrophic. Instead of
catastrophic plans leaving people precariously exposed, what we really
need is prepaid coverage that removes financial barriers to health care
(i.e., single payer).

Tuesday, August 20, 2013

Fwd: qotd: AHIP seeks reversal of "any willing provider" clauses

Quote-of-the-day mailing list

-------- Original Message --------
Subject: qotd: AHIP seeks reversal of "any willing provider" clauses
Date: Tue, 20 Aug 2013 07:45:25 -0700
From: Don McCanne <>
To: Quote-of-the-Day <>

American Medical News
August 19, 2013
Insurers seek limited insurance exchange plan networks
By Jennifer Lubell

Health plans are focused on being ready "and doing what we need to do"
as states set up their respective marketplaces, said Karen Ignagni,
president and CEO of America's Health Insurance Plans.

But some policy concerns remain. Many states, for example, "still have
restrictions on our ability to actually provide high-performing networks
for individuals to be able to access high-performing doctors and
hospitals to make sure again we're stretching those dollars. That will
have to be looked at," she said.

Ignagni was referring to the "any willing provider" clause, a mandate in
some states that requires health plans to allow health care
professionals to participate in a health plan's network if the
professional agrees to a plan's contract terms, limits and conditions.

She also encouraged giving nurses a broader role, joining them with
other professionals as part of health care teams, "so that we can try to
customize health care and make it very patient-centered, and again
stretch those dollars."

Comment: Insurer opposition to "any willing provider" clauses is yet
one more example of why we should question leaving coverage decisions in
the hands of the private insurance industry.

Any willing provider clauses allow care provided by any qualified
physician to be covered even if that physician is not contracted by the
insurer but is still willing to accept payment based on contracted
rates. The advantage of such clauses is that patients may choose to
continue to see their own physician as long as the physician agrees to
the insurer's rates.

Why would insurers want to prohibit patients from having that right? It
has to do with their current strategy of switching to narrow network
plans - plans that have fewer choices of health care professionals. They
say that they can extract even greater discounts from physicians who
believe that they will have more patients referred to them by the
insurer. Although it is questionable as to just how much further the
insurers can ratchet down rates, these limited network plans have the
advantage for the insurer of further impairing accessibility, thereby
resulting in savings from forgone care, no matter how important that
care might be.

Besides reducing the number of physicians in their networks, they also
want to increase the number of nurse practitioners, presumably because
they can negotiate even lower rates with them than they can with primary
care physicians. That assumes that the current movement by nurse
practitioners to gain equal pay for equal work will fizzle when the
insurers offer the bait.

When they say this isn't about the money, but it's about quality… No,
wait, they do say that this is about "stretching those dollars." But how
should those dollars be stretched? Should we take away choices of
physicians and substitute nurses unwillingly, or should we consider
eliminating this egregiously wasteful industry with its unwelcome
intrusions? The latter would not only produce immensely more savings, it
would also be much more beneficial for patients.

Monday, August 19, 2013

Fwd: qotd: The fallacy of balancing cooperation and competition

Quote-of-the-day mailing list

-------- Original Message --------
Subject: qotd: The fallacy of balancing cooperation and competition
Date: Mon, 19 Aug 2013 06:42:36 -0700
From: Don McCanne <>
To: Quote-of-the-Day <>

The New England Journal of Medicine
August 14, 2013
Coordination versus Competition in Health Care Reform
By Katherine Baicker, Ph.D., and Helen Levy, Ph.D.

Many current proposals to increase the value of care delivered in the
U.S. health care system focus on improved coordination — and with good
reason. Badly coordinated care, duplicated efforts, bungled handoffs,
and failures to follow up result in too much care for some patients, too
little care for others, and the wrong care for many. A host of current
reform efforts aim to reduce these inefficiencies in both public and
private markets. These efforts range from penalizing hospitals with
higher-than-expected readmission rates, to rewarding primary care
providers when patients receive higher-value care, to providing
incentives for the adoption of electronic health records. Accountable
care organizations (ACOs) and bundled payments are designed to create
monetary incentives for coordinated care. The hope is that coordination
will improve value by ensuring that the right care is provided in the
right place at the right time.

These laudable efforts, however, may unintentionally be at odds with
another strategy for improving value: promoting competition in health
care markets. In general, less competition means higher prices; one
well-publicized symptom of the lack of competition in U.S. health care
is providers' ability to charge different prices for the same service.
Competition may drive higher quality, particularly when prices are
constrained. The benefits of competition in private markets may even
spill over to higher quality in Medicare, for which the Centers for
Medicare and Medicaid Services (CMS) sets prices. A number of policy
interventions, such as quality-reporting and price-transparency
initiatives, are based on the idea that better information can promote
competition and lead to greater value, and these initiatives have the
potential to be very effective when patients have a choice of providers.

Well-integrated provider networks may promote coordinated care that
improves the allocation of health care resources, but they are likely to
undermine competitive pressures to keep prices down while maintaining
high quality. Coordinated systems may thus deliver the right care to the
right patient at the right time, but at the wrong price. Competitive
markets may do a better job of keeping prices low, but with the
well-documented drawbacks of fragmentation.

The current suite of policies for addressing the ills of the health care
system does not embody a unified approach to the roles of coordination
and competition. In part, this lack of coherence reflects the fact that
our insurance "system" is really several different systems, including
moderately competitive private insurance markets for the nonelderly,
nondisabled population and a single government payer, Medicare, for the
elderly and disabled that largely pays providers set prices on a
fee-for-service basis. These two payers currently pursue different
approaches to reform. The most recent round of Medicare reform
initiatives focuses on coordination, with ACOs as the prime example. In
fact, the FTC has signaled that it will weigh the benefits of
integration in improving quality against the potential harms of reduced
competition. For the privately insured sector, the current focus is on
enhancing competition through price transparency and "skin in the game"
for consumers.

So what should policymakers do? We offer three broad prescriptions that
may help strike the right balance between coordination and competition.
First, we can look for the win–win opportunities to enhance both
competition and coordination. As noted, health IT may be an example of
such an opportunity if it is implemented well. There may also be
win–draw opportunities in which either coordination or competition may
be enhanced without harming the other. For example, the contracting
processes that CMS uses for Medicare Advantage plans, Medicare Part D,
and durable medical equipment have some competitive aspects but do not
fully leverage the forces of competition to promote quality without
sacrificing coordination. These processes could be improved.

Second, the courts and regulatory agencies that are tasked with
enforcing antitrust law could focus explicitly on this trade-off when
they examine health care and health insurance markets. After decades of
relatively unsuccessful attempts to prevent hospital mergers, the FTC
has recently had a string of successes in that arena. Similar vigilance
is needed in other areas, particularly in the new realm of ACOs. As we
gain insight into the reasons for the price dispersion in health care
markets that transparency initiatives are bringing to light, we should
explore whether this dispersion results not just from variation in
quality and efficiency but potentially from anticompetitive behavior.

Third, policymakers could systematically look across silos to consider
the effects that an initiative in one sector will have on consumers in
another — and on providers overall. To do so, they must have a clear
understanding of the trade-offs at hand and the interaction of multiple
policies and regulations aimed at improving quality and value.
Coordination may foster delivery of the right quantity of care to each
patient, while competition may help keep the prices for that care as low
as possible. It is not obvious a priori what point on the
competition–coordination spectrum provides the highest value in terms of
quality of care and health benefit per dollar of spending. But total
spending depends on both quantity and price. We need to evaluate the net
effect of the suite of new public and private insurance-market policies
on both price and quantity as we consider which policies might restore
federal health care spending to a fiscally sustainable path.

Journal Sentinel (Milwaukee)
August 12, 2013
Competitive bidding is no Medicare fix
By John Teevan

Recently, the Centers for Medicare and Medicaid Services (CMS)
substituted its current pricing methodology with an unfair new process
for setting prices known as "competitive bidding." The idea behind this
policy is to lower costs and reduce fraud in the system, and these are
commendable goals. But what resulted was bad public policy that not only
fails to fix the problems it was meant to solve but also creates a host
of new problems.

When round 1 of this program was put into place, it was limited to just
a few test markets. But in July, it expanded to about 100 more,
including one in southeastern Wisconsin. The effects will be devastating
for health care providers, health care systems and the patients we
serve. If round 1 was any predictor of the future under round 2,
numerous providers will go out of business.

Even more troubling, this "competitive bidding" program will lead to
less freedom of choice and access for our patients, and, I believe, a
possible decrease in the quality of care for them. Many Medicare
beneficiaries — seniors over 65 and disabled Americans — have come to
rely on their local health care provider to be there for them when they
are at their most vulnerable. Local providers are there for their
patients during power outages, equipment malfunctions and other
potentially life-threatening moments. When many of these local providers
are put out of business by "competitive bidding," it will be the
patients who suffer the most.

As smaller, local providers disappear, patients will potentially be
forced to rely on providers many miles away. This may mean a delay in
Medicare approval of regular services, as well as longer wait times in
the case of emergency or equipment failure that could leave the patient
stranded, waiting for critical equipment like a wheelchair or oxygen tank.

Not only will this unfair pricing scheme be harmful to health care
providers, health care systems and patients, it also will be more
expensive for taxpayers. Reducing access to in-home medical care will
result in more emergency room visits, delayed discharges and unnecessary
hospital stays. Keeping patients in their homes means significant
savings to the Medicare trust fund; "competitive bidding" does just the

Comment: Many policies today are aimed at providing
cooperation/integration/coordination as a means of improving quality
while obtaining greater value in health care. Although some of the
models are inappropriately directed more to business aspects and less to
patient care quality, nevertheless, everyone working together seems like
a good idea. Free market ideologues may also agree that these efforts
are laudable, but they remain emphatic that, above all, marketplace
competition must be relied upon to drive higher quality and lower prices.

This is not an idle, intellectual exercise. Pro-market enthusiasts are
driving much of our health care system today with the result that health
care is outrageously priced, is of mediocre quality, and has impaired
access for tens of millions due to financial barriers that the market
model has erected. Let's look a little bit closer at the call of
ideologues Katherine Baicker and Helen Levy to "fully leverage the
forces of competition" by injecting more competition into coordinated

They mention Medicare Advantage, Medicare Part D, and the purchase of
durable medical equipment as CMS programs that have introduced
supposedly beneficial competition, although not enough in their opinion.
We already know that Medicare Advantage costs more than the traditional
Medicare program, while taking away patients' choices of their health
care providers. The Medicare Part D drug program was designed to promote
competition between drug plans, yet we are paying much more than we
would be with government purchasing programs such as we have with
Medicaid and the VA system.

Now CMS is expanding its competitive bidding program for durable medical
equipment. The suppliers who win the bids will likely do well when
measured by business standards. But many of the losing firms will be
forced out of business simply because CMS will take away the largest
sector of their clientele - the Medicare beneficiaries. Many patients
will lose the services of their own medical suppliers and have to rely
on other suppliers who may not be readily accessible because of
distances that must be traveled, or who may provide inferior services
simply because they cut back too much in order to win the bid based
strictly on lower prices.

The government is in a unique position to administer pricing on a
take-it-or-leave-it basis. The process is based on an analysis of actual
costs plus fair margins. Health care providers would be foolish to
reject fair prices. If pricing proved to be too low, threatening
sustainability of the providers, it would be the responsibility of
government to adjust prices to make sure that services and products were
there when patients needed them. For those who say that this process
results in $1000 toilet seats, all you need to do is compare costs in
the traditional Medicare program with the higher costs through private
insurance plans, including Medicare Advantage, or compare VA drug
pricing with pricing through Part D plans or even higher pricing through
the open competitive market.

Baicker and Levy offer three policy prescriptions that have a goal of
being sure that competition remains the driving force, yet they seem to
muddle through delivery system reform in order to protect competition.
To no surprise, they remain totally silent on a far more effective
solution - dump price competition and establish a universal program of
government administered fair pricing. It works in all other wealthy
nations; it should certainly work here.

Friday, August 16, 2013

Fwd: qotd: Are nurse practitioners a solution for the cognitive/procedural pay gap?

Quote-of-the-day mailing list

-------- Original Message --------
Subject: qotd: Are nurse practitioners a solution for the
cognitive/procedural pay gap?
Date: Fri, 16 Aug 2013 11:19:36 -0700
From: Don McCanne <>
To: Quote-of-the-Day <>

JAMA Internal Medicine
August 12, 2013
Medicare Payment for Cognitive vs Procedural Care
By Christine A. Sinsky, MD and David C. Dugdale, MD

Conclusions and Relevance

Our analysis indicates that Medicare reimburses physicians 3 to 5 times
more for common procedural care than for cognitive care and illustrates
the financial pressures that may contribute to the US health care
system's emphasis on procedural care. We demonstrate that 2 common
specialty procedures can generate more revenue in 1 to 2 hours of total
time than a primary care physician receives for an entire day's work.

The medical literature has highlighted the decline in the number of
physicians entering cognitive specialties, with accompanying warnings
about the impending collapse of primary care. The number of physicians
in training who choose the primary care field of internal medicine
dropped by 50% from 1998 to 2003, and primary care physicians (PCPs) in
practice are leaving at a faster rate than other specialties. Increased
workloads, administrative hassles, demanding time commitments, and low
compensation relative to other specialties are major contributing factors.

Fewer physicians are choosing primary care fields while the needs of an
aging population with multiple chronic diseases are projected to require
an increase in the supply of primary care by at least one-third. This
mismatch between supply and demand for PCPs has serious implications for
the future of US health care. Health care costs in the United States are
among the highest in the world and continue to rise. The quality of
health care that Americans receive has been questioned. Worldwide and
within the United States, health care costs are lower and quality is
higher in regions with more PCPs. In addition, the quality of care is
higher and costs are lower for patients whose first contact with the
medical system is with a PCP.

The US health care reimbursement system rewards procedural services
while providing financial disincentives for physicians to spend time on
cognitive care, the main professional activity of PCPs and other
nonprocedural specialists. In a comparison of international health
payment systems, Wilson concluded that "the current system in the United
States offers little incentive for PCPs to provide the kind of care
coordination that is known to improve health quality."

Several proposed or implemented changes, including an increase in the
relative value of evaluation and management (E&M) codes,
pay-for-performance programs, and primary care adjustment, may modestly
address this issue, but each of these policy changes is projected to
increase PCP compensation by only 1% to 10%. Herein we identify the
magnitude of the payment gap for physician time spent on common
procedures vs cognitive tasks.

The Washington Post
August 15, 2013
Wonkbook: Doctors for higher health-care costs!
By Ezra Klein and Evan Soltas

Everyone knows American health care costs too much.

Identifying the problem is easy. Doing anything about it is hard. But
there's one thing states can do that isn't particularly hard: Allow more
nurse practitioners — who charge much less than doctors — to treat
patients directly, without a physician's oversight.

Doctor's groups oppose this strenuously. They say patient safety is at
risk. What's really at risk is their incomes.

This is a protection racket. Any state legislature that extends it is
choosing higher health-care prices — and health-care costs — for no good

The New England Journal of Medicine
May 16, 2013
Perspectives of Physicians and Nurse Practitioners on Primary Care Practice
Karen Donelan, Sc.D., Catherine M. DesRoches, Dr.P.H., Robert S. Dittus,
M.D., M.P.H., and Peter Buerhaus, R.N., Ph.D.

Proposals that focus on the potential for nurse practitioners to help
meet current and expected future gaps in the supply of primary care
providers have met with wide interest and considerable controversy. At
the core of the controversy is whether nurse practitioners have the
education and experience to provide high-quality services and lead
clinical practices without supervision by a physician.

Respondents in the two groups were far apart in their views on equal pay
for providing the same services. Physicians' opposition to equal pay is
consistent with their perception, expressed in these data, that for any
given service, they provide a higher quality of care than do nurse
practitioners. Nurse practitioners' support for equal pay is consistent
with their majority view that physicians do not provide a higher quality
of care for any given service. These survey data cannot provide evidence
of the relative value of the training and expertise of these
professionals. Nevertheless, the data suggest that physicians do not
think that increasing the supply of nurse practitioners would have a
positive effect on either the cost or the effectiveness of care, whereas
more than 80% of nurse practitioners believe that increasing their
numbers would improve the cost savings and quality of health care. From
a societal perspective, we might consider whether expanding the supply
of nurse practitioners and paying them equally for the same services
that physicians provide would negate current savings from the
disproportionately lower payments nurse practitioners now receive. More
information is needed on the economic implications of the division of
work between physicians and nurse practitioners before policymakers can
definitively answer the question of whether employing a greater number
of nurse practitioners and expanding their role would result in overall
cost savings.

Our data provide evidence to inform ongoing public debates among
physicians and nurse practitioners about their roles, responsibilities,
and scope of practice. Both physicians and nurse practitioners will be
needed to address the many challenges of developing a workforce that is
adequate to meet the need for primary care services. It is our hope that
the stark contrasts in attitudes that this survey reveals will not
further inflame the rhetoric that has been offered by some leaders of
the two professions but rather will contribute to thoughtful solutions
for health care workforce planning and policy.

Comment: With concerns about our very high health care costs, we have
to ask if procedure-oriented specialists are overpaid, or if the
cognitive services of primary care physicians are underpaid? Further,
are nurse practitioners underpaid when they are providing many of the
same services as primary care physicians?

It seems that the consensus in the popular literature is that
specialists are overpaid for procedures, whereas, listening to cynics
like Klein and Soltas, primary care physicians are also overpaid when
you consider that they can be replaced by nurse practitioners "who
charge much less than doctors." They contend that limiting the
independence of nurse practitioners is a "protection racket."

Yet nurse practitioners want their pay to be comparable to that of
primary care physicians, "equal pay for equal work." They do not want
pay for cognitive services to be decreased;, they want their own pay for
these services to be increased.

What about the fundamental issue of filling the void in primary care
with independent nurse practitioners? Even if medical schools increased
the numbers of graduating physicians who would want want to become
primary care physicians, there is a lack of residency programs and
clinical training sites to train the numbers that we need. So does that
mean that there is a plethora of comparable clinical training programs
for nurse practitioners that would fill the void? Where are those
programs that will produce an adequate number of nurse practitioners
through training that will provide them with the same level of
competence as primary care physicians? It is specious to assume that
there is a paucity of clinical training programs for primary care
physicians in a country that supposedly has a great abundance of
comparable comprehensive training opportunities that are limited to
nurse practitioners, while excluding physicians.

Try this mind game. Define primary care physician. Define nurse
practitioner. Except for the duration and intensity of their training
programs, are they exactly the same? If not, what are their differences?
Should these differences be reflected in either their clinical
independence or in their pay?

There is absolutely no dispute that nurse practitioners are an important
addition to the clinical team that includes primary care physicians,
specialists, and other health care professionals. It should not be
difficult to integrate all clinical health services into a well oiled
machine, as long as we can set aside turf issues. But we need to
chastise the Ezra Klein's of the nation who would throw a monkey wrench
into the machine by characterizing this as a "protection racket." It's
the patients who need protection through improved integration of our
health care system.

Thursday, August 15, 2013

Fwd: qotd: Massachusetts shows us that we can have higher premiums with fewer benefits

Quote-of-the-day mailing list

-------- Original Message --------
Subject: qotd: Massachusetts shows us that we can have higher premiums
with fewer benefits
Date: Thu, 15 Aug 2013 12:45:54 -0700
From: Don McCanne <>
To: Quote-of-the-Day <>

Commonwealth of Massachusetts
Center for Health Information and Analysis
August 2013
Annual Report on the Massachusetts Health Care Market

In a continuing trend, the health coverage available through
Massachusetts employers in 2011 cost more and had lower benefit value.
Between 2009 and 2011 premiums rose by 9.7% to pay for benefits that
decreased by 5%. Consistent with this trend, employees are paying
increasingly more out-of-pocket for their health care. Deductibles have
grown in Massachusetts by more than 40% between 2009 and 2011.

This dual trend – increasing premiums and decreasing benefit levels –
was consistent across market sectors, but the effect was not the same
for all sectors. The effect of increased premiums coupled with benefit
declines was most pronounced in the small group market sector, where the
benefit value started out lower and decreased faster (-7.5%) than in
other market sectors. Although the small group market sector accounted
for just 16% of the Massachusetts commercial insurance market, it
included the greatest number of businesses. This sector is one of the
most vulnerable to cost increases and has been the focus of policy
interventions at both the state and federal levels.

The Wall Street Journal
August 14, 2013
Many Health Insurers to Limit Choices of Doctors, Hospitals
By Anna Wilde Mathews

The new consumer marketplaces created by the federal health law... Many
of the plans will include relatively few choices of doctors and hospitals.

Insurers are betting that consumers who buy plans on the exchanges will
be willing to trade some choice and flexibility in order to get cheaper
premiums. Smaller networks of providers generally translate to lower

A spokeswoman for the federal Department of Health and Human Services
said that in the new marketplaces, "plans will compete side by side, and
consumers can compare based on the factors that are important to them to
find the plan that best fits their needs and budget."

Comment: Under Massachusetts health care reform, the largest sector of
health insurance - employer-sponsored plans - continues to cost more
while benefits decrease in value. Just in the two years from 2009 to
2011, the average increase in premiums along with the decrease in
benefits resulted in a decline in value of 14.7 percent!

Nationally, the same process is underway, and it is fully predictable
that it will increase under Obamacare - a model of reform very similar
to that in Massachusetts. We will all be paying more to get less.

Worse yet, we will have even fewer choices of our physicians and
hospitals as insurers shift more to narrow-network plans.

Don't worry though. HHS assures us that with competitive plans we will
be able to "to find the plan that best fits (our) needs and budget." We
will have our choice of a selection of plans with higher premiums, lower
benefits, and less choice of our health care providers.

Of course we could have had, and still can have, an improved Medicare
for everyone that would replace premiums with equitable taxes, provide
comprehensive benefits, and give us free choice of our health care
professionals and institutions. Too bad that we believe our politicians
when they tell us that single payer isn't politically feasible. Come to
think of it, whose politics is that anyway?

Wednesday, August 14, 2013

Fwd: qotd: American Medical News to cease publication

Quote-of-the-day mailing list

-------- Original Message --------
Subject: qotd: American Medical News to cease publication
Date: Wed, 14 Aug 2013 08:33:58 -0700
From: Don McCanne <>
To: Quote-of-the-Day <>

Chicago Tribune
August 12, 2013
Chicago-based American Medical News will cease publication
By Peter Frost

American Medical News, the long-running biweekly publication of the
American Medical Association, will fold after it prints its last edition
Sept. 9.

The AMA, the nation's largest professional organization for doctors,
blamed the closure on a persistent and irreversible decline in print
advertising revenues used to support its editorial operation, as well as
increasing fragmentation and competition in the medical news market.

Tom Easley, senior vice president and publisher of periodic publications
at the Chicago-based nonprofit association, said the publication, also
known as AM News, has lost money in each of the past 10 years.

AM News said about 90 percent of its recipients were physicians. Its
reporters covered news related to the medical field, with a focus on
serving primary care doctors with topics that included business, policy,
public health and legal issues.

"While we've been able to generate some usage online and a small online
advertising revenue stream, there really was no opportunity for us to be
able to cover all of our expenses with an online-only model," Easley
said. "I have a reverence for good journalism, and AM News was still
producing very good journalism. That made today's decision especially

Comment: American Medical News (AM News) isn't just a trade newspaper.
It is a highly credible and meticulously produced information resource
for physicians, sponsored by the AMA, but with total editorial
independence. When you read it in AM News, you know you can rely on it.
Sadly, now it is being shut down with the familiar explanation of
declining print advertising revenues.

Regular readers of the Quote of the Day messages may have noted that a
great many of them were derived from AM News articles. They regularly
produced reports that are useful to the policy community, and, of course
they were useful to practicing physicians. About 230,000 physicians
specifically requested to be on the subscription list. There are many
other medical news sources, but none of them have the intensity of focus
of AM News. Cessation of publication of this icon would be a great loss.

The costs of newsprint and surface mail distribution are significant. In
this age of electronic communication it is reasonable to make the
conversion. We really don't need hard copies anymore.

What makes AM News great is its reporting and editorial staff. Although
there are costs involved in maintaining this staff, those costs
certainly should be within the means of the AMA. The publication should
not be held to the standard of profit, but rather it should be held to a
standard of service. Although online publishers are finding it difficult
to generate revenues that pay all costs plus generate profits, in this
instance, if the business model should fall short of that goal, it still
would meet the goal of service - for physicians and, by extension,
patients. And aren't patients what our health care system is all about?

Let's save American Medical News, even if we have to let go of the bird
cage version.

Fwd: qotd: Complexity of catastrophic cap on losses causes delay in full implementation

Quote-of-the-day mailing list

-------- Original Message --------
Subject: qotd: Complexity of catastrophic cap on losses causes delay in
full implementation
Date: Tue, 13 Aug 2013 10:04:30 -0700
From: Don McCanne <>
To: Quote-of-the-Day <>

The New York Times
August 12, 2013
A Limit on Consumer Costs Is Delayed in Health Care Law
By Robert Pear

In another setback for President Obama's health care initiative, the
administration has delayed until 2015 a significant consumer protection
in the law that limits how much people may have to spend on their own
health care.

The limit on out-of-pocket costs, including deductibles and co-payments,
was not supposed to exceed $6,350 for an individual and $12,700 for a
family. But under a little-noticed ruling, federal officials have
granted a one-year grace period to some insurers, allowing them to set
higher limits, or no limit at all on some costs, in 2014.

Under the policy, many group health plans will be able to maintain
separate out-of-pocket limits for benefits in 2014. As a result, a
consumer may be required to pay $6,350 for doctors' services and
hospital care, and an additional $6,350 for prescription drugs under a
plan administered by a pharmacy benefit manager.

Some consumers may have to pay even more, as some group health plans
will not be required to impose any limit on a patient's out-of-pocket
costs for drugs next year. If a drug plan does not currently have a
limit on out-of-pocket costs, it will not have to impose one for 2014,
federal officials said Monday.

The health law, signed more than three years ago by Mr. Obama, clearly
established a single overall limit on out-of-pocket costs for each
individual or family. But federal officials said that many insurers and
employers needed more time to comply because they used separate
companies to help administer major medical coverage and drug benefits,
with separate limits on out-of-pocket costs.

In many cases, the companies have separate computer systems that cannot
communicate with one another.

United States Department of Labor
February 20, 2013
FAQs about Affordable Care Act Implementation Part XII

Q2: Who must comply with the annual limitation on out-of-pocket maximums
under PHS Act section 2707(b)?

The Departments have determined that, only for the first plan year
beginning on or after January 1, 2014, where a group health plan or
group health insurance issuer utilizes more than one service provider to
administer benefits that are subject to the annual limitation on
out-of-pocket maximums under section 2707(a) or 2707(b), the Departments
will consider the annual limitation on out-of-pocket maximums to be
satisfied if both of the following conditions are satisfied:

a. The plan complies with the requirements with respect to its major
medical coverage (excluding, for example, prescription drug coverage and
pediatric dental coverage); and

b. To the extent the plan or any health insurance coverage includes an
out-of-pocket maximum on coverage that does not consist solely of major
medical coverage (for example, if a separate out-of-pocket maximum
applies with respect to prescription drug coverage), such out-of-pocket
maximum does not exceed the dollar amounts set forth in section 1302(c)(1).

Comment: One of the most important benefits of Obamacare is the
establishment of maximum out-of-pocket spending that any individual or
family would have to face in any given year. Although the amounts will
still be unduly burdensome for far too many, nevertheless, it does
provide some protection against catastrophic loss.

For the first year, 2014, the administration is allowing maximums to
apply separately to both major medical coverage and prescription drug
coverage, so patients could face twice the maximum in out-of-pocket
spending. This transitional relaxation of the rules is to allow insurers
to coordinate their computers that currently administer medical benefits
and drug coverage separately.

We've discussed before the fact that losses in excess of the maximums
may still occur because of limitations in benefits covered or from
services provided outside of health plan networks. This one year
transition not only will add to that exposure, but it also provides yet
another example of the excessive administrative complexity of Obamacare.
Wasting resources on excessive administrative services while exposing
patients to potential financial hardship would be greatly diminished by
changing to a single payer national health program.