qotd: Physicians & Medical Students: Sign the open letter on the truth about Medicare-for-All

The Huffington Post

February 28, 2016

Setting the Record Straight on Medicare for All: An Open Letter From 560
Physicians and Medical Students

By Steffie Woolhandler and David Himmelstein



/The following statement has been signed by more than 560 physicians and
medical students. It was crafted by Andrea Christopher, M.D., Fellow in
General Internal Medicine at Harvard Medical School, Adam Gaffney, M.D.,
Fellow in Pulmonary and Critical Care Medicine at Massachusetts General
Hospital and Harvard Medical School, and the two of us, Drs. Steffie
Woolhandler and David U. Himmelstein. Other physicians and medical
students are invited to read and sign the statement here:
//medicare-for-all.us/ <http://medicare-for-all.us/>



*Setting the Record Straight on Medicare for All: An Open Letter From
560 Physicians and Medical Students*


The renewed debate over the merits of single-payer health reform has
been marred by misleading claims that such reform is unnecessary and
unaffordable. We write to set the record straight.


Despite the advances of the Affordable Care Act (ACA), the health care
financing system continues to inflict needless suffering on our
patients. Nearly 30 million Americans remain uninsured, and co-payments,
deductibles and insurers' narrow networks obstruct care for many more.
Insurers skim billions from premiums, and impose expensive and
time-consuming paperwork on doctors, nurses and hospitals.


Studies in the most trusted journals have quantified the bureaucratic
savings achievable through single payer reform. We devote31 percent of
medical spending to administration, vs. 16.7 percent in Canada
<http://www.nejm.org/doi/pdf/10.1056/NEJMsa022033> - a difference of
$350 billion annually. And single-payer systems in Canada, the UK and
Australia all use their bargaining clout to get discounts of 50 percent
<http://content.healthaffairs.org/content/32/4/753.abstract> from the
prices drug companies charge our patients. The potential savings on
bureaucracy and drugs are enough to cover the uninsured, and to upgrade
coverage for all Americans - a conclusion affirmed over decades by
multiple analysts <http://www.pnhp.org/facts/single-payer-system-cost>,
including the Congressional Budget Office and the Government
Accountability Office.


Recent critics of Medicare for All warn of large increases in government
spending, but fail to note
<http://www.huffingtonpost.com/david-himmelstein/kenneth-thorpe-bernie-sanders-single-payer_b_9113192.html>
that these would be fully offset by savings on private insurance
premiums and out-of-pocket costs. Their forecasts of massive surges in
doctor visits and hospital care conflicts with past experience of
coverage expansions. When 15 million Americans gained insurance under
the ACA in 2014, hospital admissions
<http://www.aha.org/research/rc/stat-studies/fast-facts.shtml> didn't
budge <http://www.aha.org/research/reports/tw/chartbook/ch3.shtml>. No
surge in hospital use
<https://www.census.gov/library/publications/1975/compendia/hist_stats_colonial-1970.html>
or doctor
<http://www2.census.gov/library/publications/1975/compendia/hist_stats_colonial-1970/hist_stats_colonial-1970p1-chB.pdf>
visits
<http://www2.census.gov/library/publications/1968/compendia/statab/89ed/1968-02.pdf>
occurred when Medicare and Medicaid were rolled out, or when Canada's
single-payer system started up
<http://www.nejm.org/doi/full/10.1056/NEJM197311292892206>; doctors saw
sick and poor patients more often, but their healthy, wealthy patients a
bit less often.


Experience in many nations over many decades
<http://stats.oecd.org/index.aspx?DataSetCode=HEALTH_STAT> provides
convincing evidence that single-payer reform is both medically necessary
and economically advisable.


/In addition to Drs. Gaffney, Himmelstein, Christopher and Woolhandler,
this statement has been signed by //more than 560 other/
<http://medicare-for-all.us/endorsers/>/physicians and medical students./


http://www.huffingtonpost.com/steffie-woolhandler/setting-the-record-straig_24_b_9341782.html


***



Comment by Don McCanne


With the recent often inaccurate and ill-advised debate taking place in
the media over the financing of single payer it is imperative that the
record be set straight on the basic, irrefutable facts of single payer.
Physicians and medical students who are well informed on the true facts
should sign this open letter so that the nation understands clearly that
we can ensure that absolutely everyone has free choice of health care in
a system that is affordable for everyone, through an improved
Medicare-for-All.


Go to /medicare-for-all.us <http://medicare-for-all.us>/to sign the letter.


Colleagues should be encouraged to sign as well. Non-physicians are also
encouraged to endorse this letter by signing on to a companion list at
this same website.


In a separate release, Steffie Woolhandler explains the background that
makes this action an imperative:


"The recent attacks on single payer reform by some liberal economists
and politicians are mystifying. When I met with Hillary Clinton some
years ago she acknowledged that single payer would be the cheapest and
most efficient way to cover all Americans. Her only objection then was
that single payer wasn't politically feasible. Now she's charging that
the numbers don't add up. And economists who once projected large
savings from single payer, are now saying the opposite, without citing
any new data. They're playing political games at the expense of the
truth."


Again, please go immediately to /medicare-for-all.us
<http://medicare-for-all.us> /to sign the open letter.

qotd: AP-GfK poll on single payer spreads falsehoods

AP GfK
February 25, 2016
AP-GfK Poll: Support shaky for Sanders 'Medicare for all'
By Ricardo Alonso-Zaldivar and Emily Swanson

At first blush, many Americans like the idea of "Medicare for all," the
government-run health system that's a rallying cry for Democratic
presidential candidate Bernie Sanders.

But mention some of the trade-offs — from higher taxes to giving up
employer coverage — and support starts to shrivel.

That's the key insight from an Associated Press-GfK poll released
Thursday. The survey also found that people's initial impressions of
Sanders' single-payer plan are more favorable than their views of
President Barack Obama's health care overhaul.

A slim plurality of 39 percent supports replacing the private health
insurance system with a single government-run, taxpayer-funded plan that
would cover medical, dental, vision and long-term care, with 33 percent
opposed. Only 26 percent say they support Obama's hard-won health care law.

Asked whether they would continue to support Sanders' plan if their own
taxes went up, under a third of initial supporters of the plan would
keep backing it. About 4 out of 10 flipped to opposition.

About the same share of initial backers would ditch single-payer if it
meant that people had to give up employer coverage. Twenty-eight percent
would continue to support it.

Higher taxes and an end to employer coverage are both a given under the
Sanders plan, which would replace private coverage with a
taxpayer-funded program, while also offering more generous benefits such
as no deductibles and no copayments, as well as coverage for long-term care.

"That's pie in the sky," said Patricia Combs, a retired junior-high math
teacher from Springboro, Ohio. "It sounds really good, but I don't think
it's attainable … people would complain about their taxes being raised."

Elizabeth Medina of Chicago, an office manager not currently working,
said she worries that quality would slip.

"Overall it sounds terrific," she said. "Yeah! Let's go for it! But
Europe and Canada have their problems with the single-payer system …
it's subpar."

The poll found that 51 percent of initial single-payer backers would
switch to opposition if it took longer for new drugs and treatments to
become available. Only 14 percent would continue to support the plan.
Such an outcome could happen if drugmakers were required to prove that
new medications are therapeutically superior to existing ones. The
current standard is that new drugs be safe and effective.

Additionally, 47 percent of initial supporters would reconsider if
"Medicare for all" meant longer wait times for non-emergency medical
services. That could happen if budget-conscious administrators
encouraged doctors and hospitals to be parsimonious in using high-tech
imaging. Only 18 percent of poll respondents would continue to support
the plan in that case.

Overall, the poll found that health care remains a top issue for
Americans, with three-fourths calling it extremely crucial or very
important.


Topline

HC15. Would you favor or oppose replacing the current private health
insurance system in the United States with a single government-run and
taxpayer-funded plan like Medicare for all Americans that would cover
medical, dental, vision, and long-term care services?

39% Total support
18% Strongly support
21% Somewhat support

26% Neither support nor oppose

33% Total oppose
12% Somewhat oppose
22% Strongly oppose

2% Refused/Not answered

HC15a. Would you support or oppose replacing the health insurance system
in the United States with a single government-run plan if it meant:

Your own taxes would increase
28% Support
32% Neither support nor oppose
29% Oppose

Some people needed to switch doctors
33% Support
37% Neither support nor oppose
29% Oppose

It took longer for new drugs and treatments to become available
14% Support
34% Neither support nor oppose
51% Oppose

Longer wait times for nonemergency medical services
18% Support
35% Neither support nor oppose
47% Oppose

People needed to give up other coverage like employer coverage
28% Support
32% Neither support nor oppose
39% Oppose

The new system would replace Medicare for seniors
37% Support
35% Neither support nor oppose
26% Oppose


http://ap-gfkpoll.com/featured/findings-from-our-latest-poll-32

Topline
http://ap-gfkpoll.com/main/wp-content/uploads/2016/02/AP-GfK_Poll_February-2016-topline_health.pdf

***


Comment by Don McCanne

Most polls place support for a single payer Medicare-for-all national
health program at about 60%, with some variation based on labels,
framing, and polling technique. Yesterday's Kaiser poll placed it at
50%. This new Associated Press GfK poll places it at about 40%, but it
is unusual in that over one-fourth of those polled expressed no
preference. Of those expressing a preference, 54% were supportive and
46% opposed. But there was something else that was also very unusual
about this poll.

Yesterday's Kaiser poll demonstrated that the views on single payer were
malleable. When asked about negative features that allegedly are
associated with single payer, support declined, whereas support
increased when asked about positive features. In this AP-GfK poll they
were asked only about allegedly negative features, and support declined.
But what were these negative features?

* /Your own taxes would increase/ - But no mention was made of the
savings in premiums, out-of-pocket expenses and other taxes that would
more than offset the new taxes, resulting in a net savings.

* /Some people needed to switch doctors/ - But that is a characteristic
of private plans with their narrow networks whereas single payer
provides free choice of health care professionals.

* /It took longer for new drugs and treatments to become available/ -
There is no way that the pharmaceutical industry is going to walk away
from a $3 trillion market.

* /Longer wait times for nonemergency medical services/ - Responsible
stewards would use capacity adjustment and queue management to prevent
excessive queues, as has been done successfully in several other nations.

* /People needed to give up other coverage like employer coverage/ - But
they would be trading that for a superior program with more
comprehensive coverage, reduced out-of-pocket costs and greater choices
in health care.

* /The new system would replace Medicare for seniors/ - Who would want
to continue with the current Medicare program that pays for only about
half of health care when you could have an *improved* Medicare with more
generous benefits?

Why would the Associated Press conduct such a deceptive poll at a risk
of impairing its credibility? When you read the AP release, you can't
help but come to the conclusion that it was designed to slam
presidential candidate Sen. Bernie Sanders and his support of Medicare
for all. They even included a gratuitous comment from an unemployed
office manager to the effect that the single payer system is "subpar"
like in "Europe and Canada" - an absolute falsehood.

Whatever the intentions of the Associated Press, we must make every
effort to dispel the deceptions and disseminate the true facts about
single payer Improved Medicare for All. The health of America is at stake.

qotd: Lessons from Kaiser poll on single payer

Kaiser Family Foundation
February 25, 2016
Kaiser Health Tracking Poll: February 2016
By Bianca DiJulio, Jamie Firth, Ashley Kirzinger, and Mollyann Brodie

The February Kaiser Health Tracking Poll asked the public about broad
options for changing the health system that are currently being
discussed and finds more Americans (36 percent) say policymakers should
build on the existing law to improve affordability and access to care
than any other option presented. Sixteen percent say they would like to
see the health care law repealed and not replaced, 13 percent say it
should be repealed and replaced with a Republican-sponsored alternative,
and 24 percent say the U.S. should establish guaranteed universal
coverage through a single government plan.

As debate continues over the idea of universal coverage through a single
government plan, the survey finds the public divided, with half saying
they favor the idea and 43 percent saying they oppose it, and some
opinions swayed after hearing counterarguments. In addition, majorities
of Democrats and independents favor the idea, compared to just 20
percent of Republicans. Most Americans think that if guaranteed
universal coverage through a single government plan was put into place,
uninsured and low-income people would be better off, but there is little
consensus among the public about how it would impact their care personally.

This month's poll also explores the public's reaction to a few terms
used to describe the idea of expanding health insurance coverage to all
Americans. Majorities say they have a positive reaction to the terms
"Medicare-for-all" and "guaranteed universal health coverage" and fewer
say the same for "single payer health insurance system" and "socialized
medicine." About half (53 percent) of Democrats say they have a very
positive reaction to "Medicare-for-all" compared with 21 percent who say
the same for "single payer health insurance system."

Next Steps for the Health Care System

While health care ranks fourth as an important voting issue,
presidential hopefuls have proposed a range of visions for the future of
the health care system, from the full repeal of the Affordable Care Act
(ACA) to the adoption of a universal government plan. The survey finds
that when given four broad approaches for the future of the health care
system that are currently being discussed, Americans opinions are split
with the largest share reporting that they favor building on the ACA and
the existing system. Overall, 36 percent say lawmakers should build on
the existing law to improve affordability and access to care, 24 percent
say the U.S. should establish guaranteed universal coverage through a
single government plan, 16 percent say they would like to see the health
care law repealed and not replaced, and 13 percent say it should be
repealed and replaced with Republican-sponsored alternative.

A closer look at views across parties shows that a third of Democrats
(33 percent) favor the idea of universal coverage through a single
government plan but more Democrats (54 percent) say they would prefer to
build on the existing health care law. A roughly similar share of
independents (26 percent) say the U.S. should establish guaranteed
universal coverage through a single government plan, and 36 percent say
lawmakers should build on the existing health care law. The majority of
Republicans (60 percent) say they would like to repeal the health care
law whether it's replaced or not, although 21 percent say they would
like to build on the existing law and 9 percent say they would like
universal coverage through a government plan.

How Malleable are Americans' Opinions of Guaranteed Health Coverage From
a Government Plan?

Although half of the public says they favor having guaranteed health
insurance coverage through a single government health plan, some can be
swayed by counterarguments made by critics. For instance, 20 percent
overall shift their opinion from favor to oppose after hearing that
guaranteed coverage through a single government plan would "require many
Americans to pay more in taxes," 20 percent say they now oppose the idea
after hearing that it would "give the government too much control over
health care," and 14 percent say they now oppose it after hearing that
it would "eliminate or replace the current health care law." On the
other side of the debate, those who originally said they opposed the
idea were also persuaded by arguments, although fewer changed their
opinions after hearing the arguments. About one in 10 changed their
stance from oppose to favor after hearing that guaranteed coverage would
"ensure that all Americans have health insurance as a basic right" (13
percent), that it would "reduce health insurance administrative costs"
(11 percent), and that it would "eliminate all private health insurance
premiums, co-pays, and deductibles paid by employers and individuals"
(11 percent).

Impact of Coverage Through Single Government Plan

Most Americans think that if guaranteed universal coverage through a
single government plan was put into place, uninsured and low-income
people would be better off (60 percent and 57 percent, respectively).
Fewer say that middle class people (34 percent) and people like them (31
percent) would be better off, which is roughly similar to the shares who
say these same groups will be worse of or not be impacted much at all.
Most (63 percent) say it would not have much impact on wealthy people,
just 14 percent say they would be better off and 18 percent say they
would be worse off. Democrats and independents are more likely than
Republicans to report that all people would be better off through a
single government plan.

The country has not had a substantial public debate about single payer
legislation recently and there is little consensus among the public
about how enacting guaranteed universal coverage through a single
government plan would impact their personal health care. Roughly four in
10 say that they think the cost, quality, availability of health care
treatments, and choice of doctors and hospitals would stay about the
same as it is under the current health care system. About a third say
these measures would get worse if universal coverage was put into place
and around two in 10 think these measures would get better. Not
surprising considering their stances on the idea of guaranteed universal
coverage, majorities of Republicans say each measure would likely get
worse if such a plan was enacted, while at least half of Democrats say
each would likely stay about the same. Additionally, those under age 50,
Black and Hispanic Americans, and those with lower incomes are more
likely than their counterparts to say that these measures will get better.

Wording Matters

Politicians and pundits use a variety of terms to describe the idea of
expanding health insurance coverage to all Americans and this month's
poll explores the public's reaction to a few of these terms. Nearly
two-thirds (64 percent) of Americans say they have a positive reaction
to the term "Medicare-for-all" and more than half (57 percent) say they
have a positive reaction to the term "guaranteed universal health
coverage." Less than half of Americans report a positive association
with the phrases "single payer health insurance system" (44 percent) and
"socialized medicine" (38 percent).

Similar to the public at large, more Democrats report having a positive
reaction to "Medicare-for-all" and "guaranteed universal health
coverage" than say the same about "socialized medicine" or "single payer
health insurance system." Additionally, more Democrats have positive
reactions to all of the terms than Republicans and independents do.
Around half of Democrats report a very positive reaction to
"Medicare-for-all" (53 percent) and "guaranteed universal health
coverage" (44 percent), while fewer Republicans say the same for each
(17 percent and 9 percent, respectively). Two in 10 Democrats report
very positive reactions to "socialized medicine" (22 percent) and
"single payer health insurance system" (21 percent), while fewer than
one in 10 Republicans do.


Topline

4. Which of the following comes closest to your view of the future of
the US health care system?

16% The health care law should be repealed and NOT replaced

13% The health care law should be repealed and replaced with a
Republican-sponsored alternative
36% Lawmakers should build on the existing health care law to
improve affordability and access to care

24% The U.S. should establish guaranteed universal coverage through
a single government plan

6% None of these/Something else

4% Don't know/refused


5. Do you favor or oppose having guaranteed health insurance coverage
in which all Americans would get their insurance through a single
government health plan?

50% Favor
27% Strongly favor
23% Somewhat favor

43% Oppose
13% Somewhat oppose
30% Strongly oppose

7% Don't know/Refused


19. I am going to read you a list of terms. Please tell me if you have
a positive or negative reaction to each term.

a. Socialized Medicine

38% Positive
15% Very positive
23% Somewhat positive

49% Negative
19% Somewhat negative
30% Very negative

12% Other

b. Medicare-for-all

64% Positive
36% Very positive
27% Somewhat positive

29% Negative
15% Somewhat negative
14% Very negative

6% Other

c. Single payer health insurance system

44% Positive
15% Very positive
29% Somewhat positive

40% Negative
21% Somewhat negative
19% Very negative

17% Other

d. Guaranteed universal health coverage

57% Positive
28% Very positive
29% Somewhat positive

38% Negative
15% Somewhat negative
22% Very negative

6% Other



Report:
http://kff.org/health-reform/poll-finding/kaiser-health-tracking-poll-february-2016/

Topline:
http://files.kff.org/attachment/topline-methodology-kaiser-health-tracking-poll-february-2016

***


Comment by Don McCanne

About half of Americans would prefer a single government health plan for
everyone, according to this poll. However, when offered several choices,
more would prefer to build on the current system (36%) than would prefer
to establish a single government plan (24%). Also, followup questions
show that the opinions of a single government plan are quite malleable,
depending whether the query has a positive or negative slant.

The malleability of opinion and the poor understanding of the benefits
of single payer demonstrate that the public still has a relatively weak
understanding of precisely what a single payer system is. We need to
intensify our educational efforts.

Perhaps more disconcerting is that more people would prefer to build on
the Affordable Care Act than to establish a single government plan. The
message of the incrementalists seems to be carrying the day. People
believe that we can simply tweak the current system and achieve the same
goals as single payer.

What people haven't grasped are the fundamental differences between the
financing infrastructures of our fragmented multi-payer system and a
well designed single payer system. Recent Quote of the Day messages
describing some of the flaws in our current system have asked the
question, "What incremental change would fix this particular problem?"
The answers don't come easy.

It's easy to say that we can build on the Affordable Care Act by
gradually covering more people and by controlling spending by
eliminating waste, but these are wishes, not policies. In most
instances, there is no simple patch that would work, but rather most
changes increase the administrative complexity, add significantly to the
costs, and fall short of fully correcting the specific problems addressed.

This is a very important message that we have to deliver. Our current
financing infrastructure is not particularly amenable to incremental
patches. It is imperative that we replace our flawed infrastructure with
one that automatically addresses the problems that we still face in
health care financing. Single payer would do that.

This poll also tested labels for a single payer system. Close to
two-thirds had a positive reaction to the term, "Medicare-for-all."
People also had a positive reaction to "guaranteed universal health
coverage," but that doesn't mean much and has been misused as a label
for systems that are neither guaranteed nor universal. Yet people seem
to be split or confused by the term, "single payer health insurance system."

"Medicare-for-all" does seem to be preferred, but some opponents are
quick to point out the deficiencies in our Medicare program. Adding
"improved," as in "Improved Medicare for All," defuses that challenge.

So do not let people get away with saying that we'll simply build on the
system we have. Demand that they define the precise incremental steps
and how each would move us significantly closer to truly affordable care
for absolutely everyone. If you keep pushing them they'll eventually
have to describe a single payer system because patches to our current
system just won't get us there.

qotd: ACA reform has not eliminated bad debt for hospitals

Bloomberg Business
February 23, 2016
Bad Debt Is the Pain Hospitals Can't Heal as Patients Don't Pay
By John Lauerman

A type of pain that hospitals thought they had relieved has come back
with a vengeance: it's called bad debt.

Hospitals have long struggled to collect bills when patients aren't
covered by insurance -- creating delinquent accounts. The Affordable
Care Act was supposed to relieve some of that strain by helping pay for
coverage for millions of Americans and expanding Medicaid in some states
to cover the poor.

Yet while millions of people have gained coverage since Obamacare became
law in 2010, there's also been an increase in insurance that comes with
high deductibles and cost-sharing. Under those plans, the first few
thousand dollars of annual medical expenses come out of patients'
wallets. That's money that hospitals like Childress Regional Medical
Center in the Texas Panhandle region are unlikely to collect.

"It feels like a sucker punch," said John Henderson, the nonprofit
hospital's chief executive. "When someone has a really high deductible,
effectively they're still uninsured, and most people in Childress don't
have $5,000 lying around to pay their bills."

The rate of uninsurance in the U.S. has fallen to 9.1 percent from 15.7
percent in 2009. Yet in the first nine months of 2015, about 36 percent
of the U.S. insured were covered by high-deductible or consumer-directed
health plans that can require considerable out-of-pocket payments,
compared with about 25 percent in 2010, according to a CDC survey.

Hospitals are feeling the pressure from those patients. Community Health
Systems Inc. operates 195 hospitals in 29 states and is the U.S.'s
second-biggest for-profit U.S. hospital chain. This month, it revised
its fourth-quarter 2015 provision for bad debt up by $169 million -- and
said that 40 percent, or about $68 million of that amount, was from
patients being unable to pay deductibles and co-payments. Patient
bankruptcies also contributed, the company said.

While higher out-of-pocket charges can lower what insurance costs up
front, it means more costs for patients on the back end. Under
individual Obamacare mid-level "silver" plans, the annual deductible was
$2,556, and under less expensive, low-level "bronze" plans it was $5,328
in 2015, according to the Kaiser Family Foundation.

Outside of Obamacare, deductibles are becoming more common, as well.
Last year, 81 percent of coverage people got through work came with a
deductible, up from 70 percent in 2010, according to Kaiser. The average
deductible in a high-deductible, individual plan gained through work was
$2,099 last year.

Rural hospitals have been hit particularly hard. Minnesota has long had
high rates of care coverage, and many employers have switched to high
deductible offerings, according to Joe Schindler, vice president of
finance for the Minnesota Hospital Association. Last year, bad debt rose
by 20 percent to $425 million at the association's 140 member hospitals.

http://www.bloomberg.com/news/articles/2016-02-23/bad-debt-is-the-pain-hospitals-can-t-heal-as-patients-don-t-pay

***


Comment by Don McCanne

The Affordable Care Act (ACA) was supposed to make health care
affordable, yet many hospitals are finding that patients are generating
more bad debt. A large portion of that is due to the inability of
patients to pay the high deductibles and other cost sharing required by
their insurance plans. Patient bankruptcies also compound the problem.

Deductibles are used by insurers to shift some of the spending to
patients so that the insurers can keep the premiums for their plans
competitive. But much has been written about how these deductibles
create financial burdens for patients. And when the patients cannot pay
the deductibles, physicians and hospitals are faced with bad debt. With
greater use of higher deductibles, the problems with debt will surely
increase.

This is a problem inherent in the model of reform perpetuated by ACA.
Various policies such as the deductibles are developed to comply with
the private insurance model. How would the incrementalists fix this
problem? There are too many moving levers.

What we should have instead is a system in which the policies are
developed to comply with the needs of patients. Deductibles can be
eliminated if we do away with premiums as a means of financing health care.

The financing of a single payer system is not through individual
premiums but rather is through a single universal risk pool that is
funded equitably through progressive taxes, making health care
affordable for everyone. Medical debt simply goes away.

qotd: Hillary Clinton resurrects public option, or not?

Politico Pulse
February 23, 2016
Clinton resurrects public option
By Dan Diamond

Hillary Clinton is bringing back the "public option," a liberal health
reform that so far has gotten little attention this campaign cycle as
Bernie Sanders has pushed an even more progressive single-payer plan.

The public option — initially conceived as a government-run alternative
to private insurance — was backed by Clinton in her 2008 campaign and
was the subject of intense debate during the drafting of the Affordable
Care Act. However, Democrats abandoned the measure after Senate
moderates said they wouldn't vote for it because it expanded the
government's role in health care too far.

Clinton is again making clear she supports a version of the public
option. This time, though, she wants to allow states to opt in,
according to a newly updated policy position on her campaign website.

How would it work — and why now?

Clinton appears to be suggesting that states could use the ACA's 1332
waivers to "empower states to establish a public option choice" in 2017.
It's plausible that liberal governors and legislatures would opt in,
while keeping the fight over this progressive idea largely out of
Washington.

It's unclear exactly what Clinton's thinking is on this, however. The
campaign didn't respond to repeated requests from POLITICO to clarify
its new policy language.

Just last month: Clinton said 'we couldn't get the votes' for public option.

While Clinton's spokesperson told PULSE that she has consistently backed
the public option since the 2008 campaign, Clinton pointed out just last
month that Congress wasn't able to get it through during the ACA. "There
was an opportunity to vote for what was called the public option,"
Clinton said during a debate in South Carolina, after she rebuked
Sanders' plan as impractical. "But even when the Democrats were in
charge of Congress, we couldn't get the votes for that."

http://www.politico.com/tipsheets/politico-pulse/2016/02/clinton-resurrects-public-option-califf-nomination-moves-forward-how-the-election-could-shape-the-market-212836

***

Hillary for America

Affordable health care is a basic human right.

Hillary has never given up on the fight for universal coverage—and she
won't stop now. Building on the Affordable Care Act to expand coverage
for millions of Americans, Hillary will:

* Continue to support a "public option" — and work to build on the
Affordable Care Act to make it possible. As she did in her 2008 campaign
health plan, and consistently since then, Hillary supports a "public
option" to reduce costs and broaden the choices of insurance coverage
for every American. To make immediate progress toward that goal, Hillary
will work with interested governors, using current flexibility under the
Affordable Care Act, to empower states to establish a public option choice.

https://www.hillaryclinton.com/issues/health-care/

***

Physicians for a National Health Program
May 26, 2009
Public Plan Option in a Market of Private Plans
By David Himmelstein, M.D. and Steffie Woolhandler, M.D., M.P.H.

The "public plan option" won't work to fix the health care system for
two reasons.

1. It forgoes at least 84 percent of the administrative savings
available through single payer. The public plan option would do nothing
to streamline the administrative tasks (and costs) of hospitals,
physicians offices, and nursing homes, which would still contend with
multiple payers, and hence still need the complex cost tracking and
billing apparatus that drives administrative costs. These unnecessary
provider administrative costs account for the vast majority of
bureaucratic waste. Hence, even if 95 percent of Americans who are
currently privately insured were to join the public plan (and it had
overhead costs at current Medicare levels), the savings on insurance
overhead would amount to only 16 percent of the roughly $400 billion
annually achievable through single payer — not enough to make reform
affordable.

2. A quarter century of experience with public/private competition in
the Medicare program demonstrates that the private plans will not allow
a level playing field. Despite strict regulation, private insurers have
successfully cherry picked healthier seniors, and have exploited
regional health spending differences to their advantage. They have
progressively undermined the public plan — which started as the single
payer for seniors and has now become a funding mechanism for HMOs — and
a place to dump the unprofitably ill. A public plan option does not lead
toward single payer, but toward the segregation of patients, with
profitable ones in private plans and unprofitable ones in the public plan.

http://pnhp.org/blog/2009/03/26/himmelstein-and-woolhandler-on-a-public-plan-option/


Comment by Don McCanne

You remember the public option. During the drafting of the Affordable
Care Act (ACA), efforts were made to include a public option - a
government-run plan that would compete with the private health plans in
the insurance marketplace. If the private plans proved that they could
provide greater value, then they would prevail. If the government could
do a better job, then the public option could expand by demand and
eventually become the single payer for the nation, so supporters believed.

The original concept for the public option was to allow individuals to
buy into the Medicare program instead of purchasing private insurance.
There were some obvious problems. Medicare lacked some important
features required of the private plans such as catastrophic coverage -
establishing a maximum out-of-pocket responsibility of paying for health
care. Also, the existing Medicare pool was composed of the elderly and
those with long term disabilities - expensive groups to insure. The
exorbitant premium that would have to be charged could not be
competitive with the private plans.

It was then decided to establish a new public insurance program that was
designed like the private plans and that would have to follow the same
rules. The insurance industry immediately opposed this since it would be
"unfair" competition considering the government resources backing up the
public plan, and the inherently higher administrative costs that the
private insurers face, not to mention the need to profit from their
operations - profit not being a feature of a publicly-owned insurer.
Several (anti-competitive) features were proposed for the public option
which would give the private insurers a "fair" playing field.

The insurers were still concerned that they could not compete against
even a restricted government plan, and thus they continued to oppose it.
There is a basis for that concern since the private Medicare Advantage
plans are able to "compete" with the traditional Medicare program only
because of the overpayments that are being made to the private plans. If
they were in the same playing field, the private plans would perish.
Nevertheless, the issue of the private option became moot when Sen.
Joseph Lieberman, with no votes to spare, threatened to kill the entire
Affordable Care Act if the public option were included.

We were left with the co-ops as a substitute for the public option. The
co-ops are non-profit organizations in which the insured members are the
owners. Congress, under the Republicans, has refused to provide promised
funds, and half of them have collapsed. They are now being used by
opponents of single payer to "prove" that the government would be
incapable of running a single payer system - an obvious non sequitur.

Since the enactment of ACA there have been endless calls to add a public
option. Single payer failed to gain traction because of the pervasive
meme that single payer was not politically feasible. But if we could
just get a public option, that would automatically evolve into a single
payer system, they said.

Then along came Bernie Sanders. He carried the message that not only was
single payer politically feasible, it was a moral imperative to achieve
health care justice for all.

To the surprise of Hillary Clinton and her campaign staff, Bernie
Sanders came out of nowhere and gained traction carrying the single
payer banner, and, as a result, has become a genuine challenge to her
candidacy.

Hillary Clinton has always been an opponent of single payer and instead
has supported the private insurance industry. Some have misinterpreted a
statement of hers many years ago as supporting the fact that we would
have single payer in the United States. But that statement was not in
support of single payer but rather was her threat to us that if we did
not accept her managed competition model of reform, we would have single
payer.

So what was her campaign to do? They decided to bring back the concept
of a public option to appease those who were turning to Sanders because
of his advocacy of single payer. They are relying on the meme that the
public option is our door to single payer (even though it is not true).
But look at what her version of the public option is.

She says we should build on ACA. She has proposed no new federal public
option legislation but she is merely suggesting that the states look at
Sec 1332 of ACA which authorizes waivers for limited innovations on a
state level. Imagine the difficulties that states would have, within the
confines of Sec 1332, in building their own intra-state public plan.
Unless they used private insurance innovations such as high deductibles,
narrow provider networks, and tiered services, the premiums would be
unaffordable to most. A single payer system would be funded equitably
through progressive taxes, but you could not do that with a public
option since that is only one plan in a multi-payer system.

In 2009, David Himmelstein and Steffie Woolhandler explained in very
brief terms why the public option is a flawed concept (reproduced
above). Hillary Clinton is now showing us how it is a diversion from the
reform we really need - single payer. It is up to us, the people, to
convince our politicians that single payer is what we want. It will not
happen without us.


/Physicians for a National Health Program (PNHP) is a nonpartisan
educational organization. It neither supports nor opposes any candidates
for public office./
/
/

qotd: Gov. Pence insists on consumer-driven principles for low-income patients

Indianapolis Star
February 21, 2016
Pence seeking help from Congress in Medicaid dispute
By Maureen Groppe

Gov. Mike Pence wants Congress to get involved in his dispute with the
Obama administration over the evaluation of Indiana's alternative
Medicaid program.

Pence has accused the administration of hiring an evaluator that is
biased against Indiana's approach.

Indiana is one of a handful of states that received permission to not
follow some federal rules when expanding Medicaid coverage under the
Affordable Care Act.

One of the conditions of such waivers is that the demonstration program
be evaluated to see whether it's meeting the expected result. Indiana
must submit an interim evaluation of the program by mid-2016.

For example, Indiana is testing whether requiring participants to make
monthly contributions to a health account that can be rolled over if not
used for health care reduces the use of unnecessary care.

That feature is based on high-deductible insurance plans with health
savings accounts that are becoming increasingly common in private
insurance coverage.

Pence argues that the Urban Institute, one of the evaluators chosen by
the federal government to assess Indiana's plan, has previously been
skeptical of using the health savings account model for Medicaid recipients.

Pence wrote Health and Human Services Secretary Sylvia Burwell in
December, asking that the federal review be dropped as the Healthy
Indiana Plan has already been evaluated by a state-hired contractor.

In a Feb. 10 response, Burwell said the federal evaluation will not
duplicate the state's analysis, and a rigorous evaluation will help the
federal government determine whether other states should be allowed to
use Indiana's model.

Pence said he is "wholly unsatisfied" with that response, and will ask
the GOP-controlled Congress to review the agency's vendor selection process.

While Pence said Burwell always worked in good faith with him while they
negotiated the terms of Indiana's alternative program, there are people
"deep in the bureaucracy" who are "very antagonist towards consumer
driven health care."

"The administration wanted Indiana — and still wants every state — to
just expand traditional Medicaid," he said. "We have the most
significant Medicaid reform in the 50-year history of the program, and
it's working."

A coalition of health care and other advocacy groups wrote a letter last
month in support of the federal government's evaluation of HIP 2.0. The
coalition — which includes Families USA, the March of Dimes and the
American Cancer Society Cancer Action Network — said there can be a
conflict of interest with state-contracted evaluations.

"When a state pays an organization to assess the merits of its own
program there is the potential that the evaluator's objectivity will be
compromised," the coalition wrote to the director of the Center for
Medicaid and CHIP Services.

The groups said aspects of Indiana's program are potentially harmful to
beneficiaries and need to be evaluated before the federal government
decides whether other states can adopt them. Those features include the
option of charging monthly payments to recipients below the poverty
line, blocking coverage for those above poverty who miss their monthly
payments, and the overall complexity of HIP 2.0.

http://www.indystar.com/story/news/2016/02/20/pence-seeking-help-congress-medicaid-dispute/80663058/

The RWJF/Urban Institute report that Pence argues shows a bias against
using healthy savings accounts in Medicaid:

http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2015/rwjf420603

***


Comment by Don McCanne

Gov. Mike Pence of Indiana wants to select his own facts for a report to
CMS confirming that their consumer-directed health program for Medicaid,
authorized by a Sec. 1115 waiver, is meeting Medicaid requirements for
the patients.

They have already independently contracted with the Lewin Group to
provide a report to CMS, but numerous organizations have expressed the
concern that this report could be biased because of the conflict of
interest. CMS has contracted with the Urban Institute, but Gov. Pence
objects because Urban has produced a previous report expressing some
concerns about the option to charge premiums for individuals living in
poverty and about the administrative costs and inefficiencies of health
savings accounts that are used in Indiana's program. Also there is
concern about Medicaid patients being locked out of care if they are in
arrears with their premium payments.

Indiana's program is driven by ideology rather than by objective
application of health policy principles. Pence touts their success at
"applying consumer-health care principles to the Medicaid population."
It is more important for him to require patients to demonstrate
individual responsibility through sharing in the costs of care than it
is to ensure that they do receive the care that they need. It has been
demonstrated that requiring payments creates barriers to care,
particularly for low-income individuals.

Imagine instead having one national standard program that automatically
includes everyone, gives them free choice of their health care
professionals, and removes financial barriers to care. We could have
that with a single payer national health program, as long as we keep
ideologues like Pence out of the way.

qotd: CMS will likely continue to overpay Medicare Advantage plans

Center on Budget and Policy Priorities
February 16, 2016
Making Medicare Advantage Payments More Accurate
By Edwin Park

Anticipating the Centers for Medicare and Medicaid Services' (CMS)
expected announcement Friday of preliminary payment rates and policies
for Medicare Advantage insurers in 2017, insurers have pushed for
changes to the "risk adjustment" system — which raises or lowers
payments to plans based on their enrollees' health. Insurers claim the
system undercompensates them for high-cost enrollees with chronic
conditions. We favor making the system as accurate as possible, but
that should include reducing overpayments to insurers as well.

To be sure, risk adjustment tends to underpredict health spending for
high-cost individuals in poorer health. The Medicare Payment Advisory
Commission (MedPAC) suggests that CMS make several changes to better
account for higher spending by people with multiple chronic conditions
and low-income beneficiaries eligible for both Medicare and Medicaid.

But Medicare Advantage risk adjustment also overcompensates insurers for
healthier, low-cost enrollees. For example, Avalere Health research,
which insurers have cited favorably, shows risk adjustment
overpredicting spending among people with no chronic conditions by 26.9
percent and among people with one or two chronic conditions by 5.1
percent. That's critical because Medicare Advantage enrollees are
healthier than those in traditional Medicare, on average.

CMS could reduce Medicare Advantage overpayments by doing more to
address "upcoding," which the Congressional Budget Office, the
Government Accountability Office (GAO), and academic research cite as a
long-standing problem. The risk adjustment system measures enrollees'
health using a "risk score" based on patient diagnoses; upcoding occurs
when the risk scores that plans submit for their enrollees rise over
time — making enrollees appear increasingly unhealthy — without actual
changes in their health.

Risk scores have risen 9 percent faster in Medicare Advantage, on
average, than in traditional Medicare for comparable beneficiaries,
MedPAC estimates. This leads to excessive payments to Medicare
Advantage plans.

To compensate for upcoding, health reform requires CMS to adjust
Medicare Advantage's risk adjustment system by at least a minimum amount
each year. CMS has only applied the minimum required adjustment in
recent years. A larger adjustment, which MedPAC believes is warranted,
would reduce overpayments to Medicare Advantage plans.

CMS could also reduce upcoding by excluding health assessments from risk
score calculations unless they're later confirmed in treatment settings,
as MedPAC will likely recommend in its March report to Congress.
Medicare Advantage plans increasingly provide health assessments of
their enrollees; for example, a nurse may come to a patient's home to do
a physical exam. CMS has found that some insurers mainly use these
assessments to "collect" diagnoses in order to raise enrollees' risk
scores for purposes of risk adjustment, rather than to improve follow-up
care or identify illnesses requiring treatment. In fact, CMS had
proposed excluding these kinds of assessments but dropped this change in
the face of industry opposition.

http://www.cbpp.org/blog/making-medicare-advantage-payments-more-accurate

***

CMS.gov
February 19, 2016
2017 Medicare Advantage and Part D Advance Notice and Draft Call Letter

Today, CMS released proposed updates to the Medicare Advantage (MA) and
Part D programs through the 2017 Advance Notice and Draft Call Letter.
Through these policies, CMS is proposing updates to the program designed
to improve the accuracy of payments to plans serving beneficiaries who
are dually eligible for Medicare and Medicaid.

CMS is proposing updates to the Risk Adjustment Model used to calculate
payments to Medicare Advantage plans and to the Star Rating system used
to evaluate plan performance. In both cases, the updates reflect a
public process through which CMS shared research findings and solicited
public comment.

Expected Average Change in Revenue: 3.55%

Risk Adjustment Model

CMS is proposing to implement a new Risk Adjustment Model for 2017. The
proposed new model has separate coefficients for partial benefit dually
eligible beneficiaries, full benefit dually eligible beneficiaries, and
non-dually eligible beneficiaries. These proposed changes will improve
the precision of the payments made to plans, including increases in
payments for plans serving full benefit dually eligible beneficiaries.

Coding Pattern Adjustment

Each year, as required by law, CMS makes an adjustment to plan payments
to reflect differences in diagnosis coding between Medicare Advantage
organizations and fee-for-service (FFS) providers. In CY 2017, CMS
proposes to make an adjustment reflective of the statutory minimum.

Using Encounter Data

CMS calculates risk scores using diagnoses submitted by FFS providers
and by Medicare Advantage organizations. Historically, CMS has used
Medicare Advantage diagnoses submitted into CMS' Risk Adjustment
Processing System (RAPS). In recent years, CMS began collecting
encounter data from MA organizations to develop more accurate payment
models. In 2016, CMS began using diagnoses from encounter data to
calculate risk scores, by blending encounter data-based risk scores with
RAPS-based risk scores. In 2017, CMS is proposing to continue using a
blend, using a higher percentage of encounter data-based risk scores.

Star Ratings – Adjusting for Socioeconomic Status

CMS is proposing to implement a new analytical adjustment for a subset
of Star Rating measures that is meant to adjust for plans serving dually
eligible enrollees and/or enrollees receiving the low income subsidy, as
well as enrollees with disabilities. Through this interim adjustment,
CMS seeks to more accurately capture true plan performance, while work
continues by the HHS Assistant Secretary for Planning and Evaluation
(ASPE) and measure stewards in this important area.

https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-02-19.html

CMS Advance Notice of Methodological Changes for Calendar Year (CY) 2017
for Medicare Advantage (MA) Capitation Rates, Part C and Part D Payment
Policies and 2017 Call Letter (over 220 pages):

https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Downloads/Advance2017.pdf

***

AHIP
January 28, 2016
AHIP, Coalition for Medicare Choices Launch Nationwide Ad and Grassroots
Campaign to Protect Medicare Advantage

As CMS prepares to release proposed Medicare Advantage payment policies,
AHIP's Coalition for Medicare Choices (CMC) is launching a
coast-to-coast mobilization of its 2 million Medicare Advantage
beneficiaries who are calling on Washington to protect their coverage
from further cuts.

"Medicare Advantage is the game-changer. It's the foundation for
innovative, high-quality care delivery that seniors and the country
demand," AHIP President and CEO Marilyn Tavenner said. "CMS should
protect millions of beneficiaries who depend on Medicare Advantage and
strengthen -- not undermine -- the program moving forward."

https://www.ahip.org/News/Press-Room/2016/AHIP,-Coalition-for-Medicare-Choices-Launch-Nationwide-Ad-and-Grassroots-Campaign-to-Protect-Medicare-Advantage.aspx

***


Comment by Don McCanne

Today CMS released proposed updates for the 2017 Medicare Advantage (MA)
plans. It appears that, once again, CMS will be co-conspirators with the
insurance industry in increasing net MA payment rates when the
Affordable Care Act requires reduction of the MA overpayments.

The Medicare Payment Advisory Commission (MedPAC) has recommended that
CMS apply a larger adjustment to the MA risk adjustment system to reduce
overpayments to the MA plans. Yet, once again, as with prior years, CMS
is making "an adjustment reflective of the statutory minimum."

Another example is that the MA plans have been using "encounter data" to
upcode the diagnoses of the MA patients. Home visits are made, not by
the health care providers but by representatives of the MA insurance
plans, in order to find other disorders that can be used to pad the
diagnostic list, making these patients appear sicker than they really
are, thus qualifying the MA plans for higher payments than warranted.
MedPAC is expected to recommend excluding encounter data from risk score
calculations unless they are later confirmed in treatment settings. Yet,
CMS is instead proposing to use a higher percentage of encounter
data-based risk scores.

Instead of a reduction in payments, CMS is proposing a 3.55% increase.

CMS invites comments through March 4, 2016 before the final publication
on April 4, 2016. During that time, AHIP, the insurance lobby
organization, will be negotiating with CMS for further adjustments that
will favor the MA plans. Each year that has resulted in additional
innovative chicanery that further thwarts the intent of ACA to reduce MA
overpayments. Since the new President and CEO of AHIP is Marilyn
Tavenner, the former Administrator of CMS, it is anticipated that the
negotiations on behalf of the MA plans will be quite successful.

Ensuring success of the MA plans is part of the plot to eventually
privatize Medicare - converting it into a premium support system
(vouchers) for a market of private plans that will displace the
traditional Medicare program. The value of the voucher equivalents will
erode with time, shifting ever more of the costs to the Medicare
beneficiaries. It will be disastrous.

By this time it was expected that MA plan enrollment would begin to
decline since the private insurance industry is incapable of providing
comparable benefits at the same or lower costs than traditional
Medicare, because their administrative costs are significantly higher
than those of the traditional program, plus they need to return a profit
to their investors. They have been profitable only because they have
continued to be successful in enrolling healthier, less costly patients
while at the same time receiving overpayments from the government.

Thus this conspiracy reenacted each year to use innovative payment
schemes (chicanery) is vital to this industry. Members of AHIP's
Coalition for Medicare Choices will, once again, pressure members of
Congress to cajole CMS into "saving" the Medicare Advantage plans
through whatever accounting tools they can find (all with a wink and a
nod). What is surprising is that this has not provoked the outrage of
taxpayers. But maybe this is not so surprising after all since hardly
anyone recognizes the terrible crime that is taking place before our
very eyes.

qotd: Return on investment in health care

The New England Journal of Medicine
February 18, 2016
Asymmetric Thinking about Return on Investment
By David A. Asch, M.D., Mark V. Pauly, Ph.D., and Ralph W. Muller, M.A.

Lately, we've attended many conferences about providing health care to
patients with high medical and social needs — people with chronic
illnesses who are frequently readmitted to the hospital. It seems as if
every presentation refers to "return on investment" (ROI), which is
invariably presented as a constraint — as in "Our program kept people
out of the hospital, but we just couldn't get the ROI to work." Heads
nod understandingly, and then participants move on to other topics.

At conferences about providing care for patients with cancer or other
acute illnesses, by contrast, we almost never hear the term ROI.
Instead, people talk about clinical gains, using understandable and
patient-centered terms like "survival." Though high drug prices are
sometimes mentioned, no one ever says the ROI is prohibitive. No one
mentions ROI at all.

There is no obvious reason why ROI is more relevant to some clinical
situations than to others. So why do we focus so heavily on ROI when the
topic is chronic illness but rarely mention it when the topic is cancer?
A huge amount of the cancer care we deliver provides such small personal
and social gains that, were those gains monetized, the endeavor's ROI
would be deeply negative. And yet we ask, "What's the ROI of that
program that keeps chronically ill patients out of the hospital?" but
not "What's the ROI of treating advanced lung cancer?"

Providing cancer care and averting hospitalizations are financed
differently. It's hard to create a favorable ROI for reducing volume in
a system dominated by fee-for-service payments for delivering care.
Sometimes a favorable ROI is achieved passively when, for example,
avoiding care frees up capacity for patients whose care is more
profitable. More actively, the avoidance of care can be financed by
establishing punishments for delivering avoidable care (penalties for
readmissions, for example) or by shifting its cost to the providers
themselves (e.g., through capitated or bundled payments).

It might seem that we could make the ROI for appropriate care more
favorable if we imposed higher penalties on inappropriate care, just as
we could make the ROI for treating cancer less favorable by paying less
for cancer treatments. Despite that apparent symmetry, the choice of
financing mechanisms — payments versus penalties — determines how much a
health care goal will be advanced. If the ROI didn't work for some form
of cancer care — because the payment received was lower than the cost
incurred — doctors and hospitals would almost certainly argue for higher
payments. But when the ROI doesn't work for keeping challenging patients
with chronic disease out of the hospital, it's implausible that doctors
or hospitals will plead for increased readmission penalties. There isn't
any mathematical reason to prefer payment in the form of rewards over
payment in the form of avoided penalties, but you can typically generate
more advocates for your cause by paying people to follow you than by
penalizing them for going the other way.

So when advocates and organizations devoted to keeping people out of the
hospital lament their inability to make the ROI work, they should know
that the game is rigged against them. In the highly regulated context of
health care, the amount and structure of financing are chosen rather
than preordained. The ROI is favorable or unfavorable not because of the
workings of some invisible hand, but because of choices someone —
usually a private or public insurer — has made regarding what amounts
will be paid for various types of care and what form payments will take.

What if the financing of cancer care and of efforts to achieve
population health goals traded places? Suppose doctors and hospitals
were paid for cancer care by capitation or bundles or through penalties
for undesired outcomes and were paid directly and adequately to keep
people out of the hospital. Oncologists might begin lamenting that
although new approaches to cancer care helped patients, they just
couldn't get the ROI to work. And the outlook for population health
might become less financially gloomy.

Rewards and penalties have the same ultimate effect on investment
income, but they influence thinking in different ways. We might
encourage greater effort and innovation in keeping people out of the
hospital and coordinating care if we reframed its financing as positive
payments for noble work rather than punitive revenue reductions. As U.S.
health care financing begins again to shift risks to hospitals and
physicians through bundled payments or readmission penalties, the
financing of the care for our most challenging patients might be better
shifted in the other direction.

http://www.nejm.org/doi/full/10.1056/NEJMp1512297

***


Comment by Don McCanne

The concept of return on investment (ROI) in health care may represent
what is wrong with our system that causes it to be so expensive yet
often mediocre by international standards.

Most health care professionals and institutions are largely fixated on
their efforts to provide the best patient care they can with the given
resources. But much of the medical-industrial complex is fixated on ROI,
as is obvious by the examples of the private, for-profit insurers and
the pharmaceutical firms with their egregiously high profits.

The authors of this article discuss trying to take care of cancer
patients in which ROI standards are not considered since "monetized"
gains for cancer patients would be "deeply negative." They contrast that
with readmissions of patients with chronic illnesses in which the ROI is
important based on the penalties assessed for failing to prevent the
readmissions.

On the one hand, the professionals and institutions are simply paid for
providing appropriate care. On the other, attempting to provide
appropriate care is complicated by a necessity to consider the potential
of a negative ROI because of financial considerations - penalties -
which have nothing to do with the actual medical care being provided.

Instead of ROI driving motivation, the authors suggest that we reframe
health care financing as "positive payments for noble work rather than
punitive revenue reductions."

They conclude, "As U.S. health care financing begins again to shift
risks to hospitals and physicians through bundled payments or
readmission penalties, the financing of the care for our most
challenging patients might be better shifted in the other direction."

Noble provision of health care services - a prime goal of a single payer
national health program.

qotd: Return on investment in health care

The New England Journal of Medicine
February 18, 2016
Asymmetric Thinking about Return on Investment
By David A. Asch, M.D., Mark V. Pauly, Ph.D., and Ralph W. Muller, M.A.

Lately, we've attended many conferences about providing health care to
patients with high medical and social needs — people with chronic
illnesses who are frequently readmitted to the hospital. It seems as if
every presentation refers to "return on investment" (ROI), which is
invariably presented as a constraint — as in "Our program kept people
out of the hospital, but we just couldn't get the ROI to work." Heads
nod understandingly, and then participants move on to other topics.

At conferences about providing care for patients with cancer or other
acute illnesses, by contrast, we almost never hear the term ROI.
Instead, people talk about clinical gains, using understandable and
patient-centered terms like "survival." Though high drug prices are
sometimes mentioned, no one ever says the ROI is prohibitive. No one
mentions ROI at all.

There is no obvious reason why ROI is more relevant to some clinical
situations than to others. So why do we focus so heavily on ROI when the
topic is chronic illness but rarely mention it when the topic is cancer?
A huge amount of the cancer care we deliver provides such small personal
and social gains that, were those gains monetized, the endeavor's ROI
would be deeply negative. And yet we ask, "What's the ROI of that
program that keeps chronically ill patients out of the hospital?" but
not "What's the ROI of treating advanced lung cancer?"

Providing cancer care and averting hospitalizations are financed
differently. It's hard to create a favorable ROI for reducing volume in
a system dominated by fee-for-service payments for delivering care.
Sometimes a favorable ROI is achieved passively when, for example,
avoiding care frees up capacity for patients whose care is more
profitable. More actively, the avoidance of care can be financed by
establishing punishments for delivering avoidable care (penalties for
readmissions, for example) or by shifting its cost to the providers
themselves (e.g., through capitated or bundled payments).

It might seem that we could make the ROI for appropriate care more
favorable if we imposed higher penalties on inappropriate care, just as
we could make the ROI for treating cancer less favorable by paying less
for cancer treatments. Despite that apparent symmetry, the choice of
financing mechanisms — payments versus penalties — determines how much a
health care goal will be advanced. If the ROI didn't work for some form
of cancer care — because the payment received was lower than the cost
incurred — doctors and hospitals would almost certainly argue for higher
payments. But when the ROI doesn't work for keeping challenging patients
with chronic disease out of the hospital, it's implausible that doctors
or hospitals will plead for increased readmission penalties. There isn't
any mathematical reason to prefer payment in the form of rewards over
payment in the form of avoided penalties, but you can typically generate
more advocates for your cause by paying people to follow you than by
penalizing them for going the other way.

So when advocates and organizations devoted to keeping people out of the
hospital lament their inability to make the ROI work, they should know
that the game is rigged against them. In the highly regulated context of
health care, the amount and structure of financing are chosen rather
than preordained. The ROI is favorable or unfavorable not because of the
workings of some invisible hand, but because of choices someone —
usually a private or public insurer — has made regarding what amounts
will be paid for various types of care and what form payments will take.

What if the financing of cancer care and of efforts to achieve
population health goals traded places? Suppose doctors and hospitals
were paid for cancer care by capitation or bundles or through penalties
for undesired outcomes and were paid directly and adequately to keep
people out of the hospital. Oncologists might begin lamenting that
although new approaches to cancer care helped patients, they just
couldn't get the ROI to work. And the outlook for population health
might become less financially gloomy.

Rewards and penalties have the same ultimate effect on investment
income, but they influence thinking in different ways. We might
encourage greater effort and innovation in keeping people out of the
hospital and coordinating care if we reframed its financing as positive
payments for noble work rather than punitive revenue reductions. As U.S.
health care financing begins again to shift risks to hospitals and
physicians through bundled payments or readmission penalties, the
financing of the care for our most challenging patients might be better
shifted in the other direction.

http://www.nejm.org/doi/full/10.1056/NEJMp1512297

***


Comment by Don McCanne

The concept of return on investment (ROI) in health care may represent
what is wrong with our system that causes it to be so expensive yet
often mediocre by international standards.

Most health care professionals and institutions are largely fixated on
their efforts to provide the best patient care they can with the given
resources. But much of the medical-industrial complex is fixated on ROI,
as is obvious by the examples of the private, for-profit insurers and
the pharmaceutical firms with their egregiously high profits.

The authors of this article discuss trying to take care of cancer
patients in which ROI standards are not considered since "monetized"
gains for cancer patients would be "deeply negative." They contrast that
with readmissions of patients with chronic illnesses in which the ROI is
important based on the penalties assessed for failing to prevent the
readmissions.

On the one hand, the professionals and institutions are simply paid for
providing appropriate care. On the other, attempting to provide
appropriate care is complicated by a necessity to consider the potential
of a negative ROI because of financial considerations - penalties -
which have nothing to do with the actual medical care being provided.

Instead of ROI driving motivation, the authors suggest that we reframe
health care financing as "positive payments for noble work rather than
punitive revenue reductions."

They conclude, "As U.S. health care financing begins again to shift
risks to hospitals and physicians through bundled payments or
readmission penalties, the financing of the care for our most
challenging patients might be better shifted in the other direction."

Noble provision of health care services - a prime goal of a single payer
national health program.

qotd: Link to today's Quote of the Day

Link to Huffington Post article, "Medicare's History Belies Claim That
Medicare-for-All Would Disrupt Care":

http://www.huffingtonpost.com/steffie-woolhandler/medicares-history-belies-_b_9245484.html

qotd: Medicare's History Belies Claim That Medicare-for-All Would Disrupt Care

The Huffington Post
February 16, 2016


Medicare's History Belies Claim That Medicare-for-All Would Disrupt Care


By Steffie Woolhandler and David Himmelstein


ASSOCIATED PRESS

*It Disrupted Jim Crow, but Otherwise the Transition Was Smooth*

Hillary Clinton and others charge that Bernie Sanders' Medicare-for-All
plan would disrupt and threaten Americans' health care. But the smooth
rollout of Medicare-for-Seniors in 1965 -- which many had also predicted
would bring chaos -- belies that charge.

Medicare, signed into law on July 30, 1965, went live just 11 months
later. By then, 18.9 million seniors had signed up, 99 percent of those
eligible.

To accomplish this feat (largely without computers) the Social Security
Administration mailed an information leaflet and sign-up cards
<https://www.ssa.gov/history/ssa/lbjmedicare3.html> preprinted with each
individual's name and Social Security number (see example below) to
seniors on the Social Security and railroad retirement rolls, as well as
Civil Service annuitants and a million other seniors identified through
IRS records.

2016-02-16-1455651003-9836566-Medicareenrollmentcard.jpg
<http://images.huffingtonpost.com/2016-02-16-1455651003-9836566-Medicareenrollmentcard.jpg>

Image: Social Security Administration History Archives

To contact hard-to-reach seniors, the federal government reached out to
nursing and retirement homes, employers, unions and civic organizations
offering to help people apply; organized hundreds of local information
meetings; and enlisted postal workers, forest rangers and agricultural
representatives to help locate residents of remote areas. The Office for
Economic Opportunity hired 5,000 low-income seniors who went
door-to-door in their neighborhoods.

All told, Medicare's overhead costs for the first year totaled only $120
million (equivalent to $882 million in 2015). By comparison, setting up
the insurance exchanges for private coverage under Obamacare cost more
than $6 billion
<http://healthaffairs.org/blog/2014/01/02/medicares-rollout-vs-obamacares-glitches-brew/> --
about seven times as much. But even the modest figure for Medicare's
start-up costs is an overstatement since it includes the cost of
processing six months' worth of medical bills, not just the enrollment
costs. Moreover, Medicare and Medicaid (which was passed at the same
time) displaced several smaller federal health assistance programs,
saving about $383 million (in 2015 dollars) on their overhead costs.

Even as it became clear that Medicare enrollment was proceeding
smoothly, many saw disruption ahead. The Association of American
Physicians and Surgeons (AAPS), a group to the right of the American
Medical Association (AMA), threatened that 50,000 doctors would boycott
Medicare. (Today, the AAPS is sounding the alarm that Medicare-for-All
would take away "what remains of your doctor's liberty.") Wall Street
Journal headlines warned that "Most MDs Won't Cooperate," and foresaw a
"Patient Pileup," as "flocks of Medicare beneficiaries ... suddenly clog
the nation's 7,200 hospitals."

None of this came to pass. Doctors continued to care for elderly
patients, mostly accepted Medicare payment, and soon came to rely on
Medicare as an economic pillar of their practices. Even the AMA, which
had spent millions fighting Medicare's passage (including an infamous ad
campaign <https://www.youtube.com/watch?v=Bejdhs3jGyw> featuring
then-actor Ronald Reagan) cooperated in the program's implementation.
Hospitals ran smoothly, with only a handful reporting more than minor of
problems.

But Medicare did cause a major disruption, it disrupted Jim Crow
hospital care.

The 1964 Civil Rights Act banned racial discrimination in facilities
receiving federal funds (which included most hospitals), but enforcement
was lax until Medicare.
<http://www.hhnmag.com/articles/4179-u-s-hospitals-and-the-civil-rights-act-of-1964>Many
hospitals, particularly in the South, still refused to care for black
patients at all, while others relegated them to separate entrances and
shabby basement wards. Black physicians were often barred from hospital
staffs, and in many locales ambulance services were separate, and
distinctly unequal.

With Medicare on the horizon, federal officials made it clear to
hospitals that segregated hospitals would be excluded from the program.
In the spring of 1966, three months before Medicare took effect, 51
percent of American hospitals were still segregated. By August of that
year, 99.5 percent had desegregated.

While Medicare ended overt racial segregation in hospitals, segregation
by insurance remains legal and common -- and often perpetrates de facto
racial segregation. Most of New York City's prestigious academic medical
centers -- and many hospitals elsewhere -- maintain separate clinic
systems
<http://digitalcommons.law.umaryland.edu/cgi/viewcontent.cgi?article=1113&context=jhclp>,
and even separate wards, for Medicaid patients (the 33 million uninsured
need not apply).

Medicare-for-All would give all Americans complete and equal coverage,
completing the disruption of hospital segregation that Medicare began a
half century ago.

Aside from that welcome disruption, Medicare-for-All would greatly
simplify life for hospitals and doctors. Instead of the laborious and
expensive task of billing patients and their insurers for each Band-Aid
and aspirin tablet, hospitals would receive a lump-sum budget, much as
we pay for a fire station. Doctors would bill one plan, using one
billing form instead of the dozens of complex billing schemes -- each
with its own rules and redundant documentation requirements -- that we
face today.

Most important, Medicare-for-All would end many of the disruptions that
our patchwork coverage system currently inflicts on patients. All
Americans would, for the first time enjoy a free choice of doctor and
hospital, and would never again be forced to change doctors merely
because their insurance changed, or their doctor was dumped from their
insurer's network. And patients' lives would no longer be disrupted by
financial ruin from medical bills
<http://www.pnhp.org/new_bankruptcy_study/Bankruptcy-2009.pdf>.

/Drs. Steffie Woolhandler and David U. Himmelstein, professors of health
policy and management at the City University of New York School of
Public Health at Hunter College and Lecturers in Medicine at Harvard
Medical School, co-founded Physicians for a National Health Program, a
nonpartisan organization. The opinions expressed do not necessarily
reflect those organizations'./


Comment by Don McCanne:

"Nuf said. Time for Medicare-for-All.

qotd: Why haven’t the exchanges done more for us?

Associated Press
February 15, 2016
Cancer Patients Snagged in Health Law's Tangled Paperwork
By Ricardo Alonso-Zaldivar

Hundreds of thousands of people lose subsidies under the health law, or
even their policies, when they get tangled in a web of paperwork
problems involving income, citizenship and taxes. Some are dealing with
serious illnesses like cancer. Advocates fear the problems, if left
unresolved, could undermine the nation's historic gains in health insurance.

The government says about 470,000 people had coverage terminated through
Sept. 30 last year because of unresolved documentation issues involving
citizenship and immigration. During the same time, more than 1 million
households had their financial assistance "adjusted" because of income
discrepancies. Advocates say "adjusted" usually means the subsidies get
eliminated.

"When people get that bill for a full-price plan, they panic and they
cancel the insurance," said Elizabeth Colvin of Foundation Communities,
an Austin nonprofit that serves low-income people. Some worry the
problem could undermine the law's insurance markets, now in their third
year.

"These problems can grow, and they can contribute to undermining
consumer faith in the system, and that could lead to attrition," said
Rachel Klein of Families USA, an advocacy group that supports the health
law.

Pressured by a Republican-led Congress hostile to Obama's overhaul, the
administration is highly sensitive to criticism that some people may be
getting benefits they're not legally entitled to. But Health and Human
Services Secretary Sylvia M. Burwell recently acknowledged the paperwork
tangle is more likely to trap the innocent than fraudsters.

http://hosted.ap.org/dynamic/stories/U/US_HEALTH_OVERHAUL_PAPERWORK_TRAP

***

USA TODAY
February 16, 2016
Costs, changes led Obamacare enrollment to fall short of earlier estimates
By Jayne O'Donnell

The number of people who signed up for health insurance for 2016 on the
state and federal exchanges was up to 40% lower than earlier government
and private estimates, which some say is evidence that the plans are too
expensive and that people would rather pay a penalty than buy them.

In 2010, the non-partisan Rand Corporation estimated 27 million people
would have exchange policies this year and the Congressional Budget
Office at that time was estimating 21 million for 2016. CBO even said
last June that 20 million people would have plans purchased on the
exchanges this year. Just 12.7 million signed up for plans, however, by
the end of open enrollment Jan. 31 and about 1 million people are
expected to drop their plans — or be dropped when they don't pay their
premiums.

http://www.usatoday.com/story/news/nation/2016/02/15/costs-changes-led-obamacare-enrollment-fall-far-short-estimates/80061050/

***


Comment by Don McCanne

Participation in the ACA exchanges is coming in at a much lower level
than were the original predictions. Furthermore, significant numbers
drop out each year, and many find that they receive significantly less
financial assistance than they expected at enrollment.

Since the exchanges are not working as hoped, perhaps we need
incremental innovations that would improve their functioning - you know,
those incremental improvements some politicians and policy wonks keep
telling us is all that we need to make ACA a universal, affordable system.

But what incremental change would expand coverage to absolutely
everyone? What incremental change would make the plans affordable for
everyone? What incremental change would ensure that access to care is
affordable when facing very high deductibles? What incremental change
would ensure that everyone would remain covered by their plans
throughout the year, especially when there are so many different reasons
that individuals lose their plans?

As mentioned many times before, the flawed health care financing
infrastructure is not amenable to simple incremental patches. Keeping
the same infrastructure will only perpetuate the severe deficiencies of
our dysfunctional financing model. Many will remain uninsured. Many will
not be able to afford health care, even if insured. And, worst of all,
many will suffer and die.

Maybe we should start tallying the financial hardship, suffering and
death in increments so that we can gradually feed that information to
the incrementalists who insist this is a small price to pay for keeping
intact the model that protects so well our private insurance industry.
Maybe then they will understand the evil of defaulting to incrementalism.

Single payer would fix it.

qotd: Concierge medicine at Mass General

The New York Times
February 12, 2016
Founded for the Poor, Mass General Looks to the Wealthy
By John Hanc

Can a hospital founded more than 200 years ago to treat the poor also
adopt a form of medicine some criticize as health care for the rich?

The answer may come in August, when Massachusetts General Hospital, the
third-oldest general hospital in the nation, plans to open a concierge
medicine practice.

Based in Boston, the hospital, whose $800 million annual research budget
is among the nation's biggest, is affiliated with Harvard Medical School
and is perennially ranked No. 1 in many categories of U.S. News & World
Report's listings of the country's best hospitals.

Despite its reputation, Mass General — as it is known — was established
in 1811 to care for the city's poor and indigent. Patients in concierge
medicine are likely to be anything but that.

The idea of wealthy people paying doctors a retainer for exclusive
service is not new. With concierge medicine, which was introduced in the
1990s, patients pay physicians a monthly or annual retainer and expect
more personalized care and greater access. "A concierge patient who
signs up for a practice is not only looking for quality care, they are
looking for unfettered access to their provider," said Dr. Michael R.
Jaff, the medical director of Mass General's Center for Specialized
Services and a professor at Harvard Medical School.

There are pros and cons to concierge medicine — or direct primary care,
a similar model — which, according to the industry trade magazine
Concierge Medicine Today, is embraced by about 6,000 doctors across the
country.

"The upside is that it gives more time for patient-physician
interaction, and the data shows that generally the more time a patient
has with a physician, the better the outcome," said Dr. Wanda D. Filer,
president of the American Academy of Family Physicians. "The downside is
that it can be very exclusive and difficult for middle- and low-income
patients to afford. So there's a concern that you'll have a two-tier
system."

In recent years, concierge medicine and similar types of programs have
spread from private practices to hospitals. Mass General's embrace of it
may prove influential.

To critics of concierge medicine, Mass General's foray into the field is
no cause for celebration. "It's worrisome, unless you're rich," said
Pauline Rosenau, professor of public health at the University of Texas
Health Science Center in Houston. As for the hospital's historical
mission, she added, "I'd say it's in jeopardy."

The proximity to the main hospital will give concierge patients easy
access to Mass General's specialists (something not typically offered in
private concierge services). "We've made the institutional commitment
that these patients will get the best of the best at a phone call," Dr.
Jaff said. "So if I call and say I need a general surgeon, they'll have
a world-class general surgeon that day."

As for benefits of the concierge practice for the rest of the hospital's
patients (Mass General has about 1.5 million outpatient visits a year),
Dr. Jaff admitted they were a little less tangible, though still
critical. "With dwindling reimbursement," he said, "there needs to be
other sources of revenue to help us support our mission to the community
at large."

What some call "health care for the rich," the hospital says it
believes, can be one such source.

http://www.nytimes.com/2016/02/14/your-money/founded-for-the-poor-mass-general-looks-to-the-wealthy.html?ref=health

***


Comment by Don McCanne

Say it isn't true. Mass General? Concierge hospital? Two-tier medicine?
Selling the front of the queue to the wealthy?

Is the payment of a bribe to gain better health care access access
ethical just because Mass General has given its stamp of approval? They
say the money will help support their mission to the community at large,
but how does pushing the entire queue back by giving the wealthy a
ticket to butt in in front of everyone else help those with low or
moderate incomes?

It gives a new meaning to triage. As we organize the delivery of care
based on need and urgency, we now have a new paramount guideline, "Let
the money in first!"

Under a more egalitarian single payer system, at least the bribes would
not be so flagrant.