Saturday, March 23, 2013

NEJM — Netherlands and Managed Competition


The myth that competition has been key to cost containment in the Netherlands has obscured a crucial reality. Health care systems in Europe, Canada, Japan, and beyond, all of which spend much less than the United States on medical services, rely on regulation of prices, coordinated payment, budgets, and in some cases limits on selected expensive medical technologies, to contain health care spending.5 Systemwide regulation of spending, rather than competition among insurers, is the key to controlling health care costs. The Netherlands, after all, spent much less on medical care than the United States with virtually universal insurance coverage long before it began experimenting with managed competition in 2006.
The Dutch experience provides a cautionary tale about the place of private insurance competition in health care reform. The Dutch reforms have fallen far short of expectations — a reminder that policy intentions should not be confused with outcomes and that managed competition is hardly a panacea. The idea that the Dutch reforms provide a successful model for U.S. Medicare to emulate is bizarre. The Dutch case in fact underscores the pitfalls of the casual use (and misuse) of international experience in U.S. health care reform debates.5 Before we learn from other countries' experiences with medical care, we first need to learn about them.

Sphere: Related Content

Saturday, March 16, 2013

Will Boomers Bankrupt Our Health Care System? Myths and Facts | Health Beat by Maggie Mahar

Will Boomers Bankrupt Our Health Care System? Myths and Facts | Health Beat by Maggie Mahar

Well worth reading, with some great Uwe Reinhardt graphics!

When the three-day conference ended yesterday, it also was apparent that developed countries share many of the same problems.  One that stands out is the fact that our populations are aging. Each country faces the same question: how will a shrinking workforce possibly pay for the medicine their nations’ retirees will need?
This brings me to Princeton economist Uwe Reinhardt’s speech on the very first day of the conference. The only American to speak at WHCCE, Reinhardt focused on what he called “the folklore that people bring to the health care policy table.” By nature an iconoclast, Reinhardt spent the next 20 minutes shattering some of the myths that have become part of the received wisdom among policy-makers.
Begin with the notion that an aging population is a major factor driving health care inflation.  In the U.S. this is accepted as a justification for why the nation’s health care bill now equals more than $2 trillion dollars—and why we must expect it to climb ever higher.
Bad news is often more gripping  than good news, and  “if you want to be a popular speaker you need to feed the paranoia of your audience,” Reinhardt  observed, pointing to the first slide of his Power Point presentation—a  chart illustrating just how quickly we can expect a horde of wrinkly boomers to take over the nation. Some stooped and shriveled, others proudly bloated, these former members of the Pepsi generation will be far more demanding, we’re told, than the World War II veterans who preceded them.

Sphere: Related Content

Report calls for doubling nation's public health spending - The Hill's Healthwatch

Report calls for doubling nation's public health spending - The Hill's Healthwatch

The United States spends more on healthcare but lags behind the rest of the industrialized world in life expectancy and childhood mortality because the government "chronically" underfunds public health systems, the Institute of Medicine argues in a new report out Tuesday.
The report calls for doubling federal spending on public health from $11.6 billion to $24 billion a year "as a starting point to meet the needs of public health departments." The report points out that Americans spent $8,086 per person in medical care in 2009 versus $251 in public health spending.
The IOM's Committee on Public Health Strategies to Improve Health goes on to recommend that government advisers develop a "minimum package of public health services" that every community should receive from its state and local health departments. It suggests creating a new transaction tax on medical care services to help pay for the increased spending, which over time could lower healthcare costs by reducing obesity and tobacco use.

Sphere: Related Content

Monday, March 11, 2013

Primary care still waiting on ACA Medicaid pay raise -

If the states manage to screw this up, and prevent pay improvement for primary care, it could jeopardize the success of the ACA…

Washington Primary care physicians who qualify for higher Medicaid payments under the Affordable Care Act might not see these rate increases as quickly as anticipated this year.

The Medicaid program has had a long-standing reputation for paying doctors at rates far below what Medicare pays for the same services. The ACA aimed to address this problem by directing states to bump rates for primary care services provided by primary care doctors up to 100% of Medicare rates for calendar years 2013 and 2014. Because the final rule on the provision was issued in late 2012 with an effective date of Jan. 1, many family doctors were hoping to see an immediate boost in their claims payments. However, “there could be a lag of several months even from now” for the enhanced Medicaid rates to take effect, said Jeffrey Cain, MD, president of the American Academy of Family Physicians.

Some physician organizations are concerned that states are missing the opportunity to prop up primary care because they aren't moving quickly enough to pay these higher fees.

Several administrative steps are needed first at the state and federal levels, said Neil Kirschner, senior associate of regulatory and insurer affairs for the American College of Physicians. States have until March 31 to modify their Medicaid plans accordingly and submit those changes to the federal government, which then has an additional 90 days to approve the plans. “It's unclear how many states have done that,” he said.

In recent letters to the National Governors Assn. and the National Assn. of Medicaid Directors, the American Medical Association and other organizations representing primary care doctors called on states to enact the pay bump expeditiously and engage in active communication with physicians to notify them about the timing of the pay increase.

With the ACA provision in effect for only two years, any implementation delays will make it harder for the government to collect data to see if patient access is improving by raising Medicaid payments, Kirschner said. The longer states take, the longer physicians must wait for these enhanced payments, which could affect decisions whether to take new Medicaid patients, he said.

Primary care still waiting on ACA Medicaid pay raise -

Sphere: Related Content

Saturday, March 9, 2013

Special Report: Behind a cancer-treatment firm's rosy survival claims

Wed, Mar 6 2013

By Sharon Begley and Robin Respaut

(Reuters) - When the local doctor who had been treating Vicky Hilborn told her that her rare cancer had spread throughout her body, including her brain, she and her husband refused to accept a death sentence. Within days, Keith Hilborn was on the phone with an "oncology information specialist" at Cancer Treatment Centers of America.

Hilborn had seen CTCA's website touting survival rates better than national averages. His call secured Vicky an appointment at the for-profit, privately held company's Philadelphia affiliate, Eastern Regional Medical Center. There, the oncologist who examined Vicky told the couple he had treated other cases of histiocytic sarcoma, the cancer of immune-system cells that she had.

"He said, ‘We'll have you back on your feet in no time,'" Keith recalled.

Vicky's cancer treatment was forestalled by an infection and other complications that kept her at Eastern Regional for three weeks. In July 2009, when she got back home, things changed. Despite Keith's calls, he said, CTCA did not schedule another appointment. As his wife got sicker, Keith, a former deputy sheriff in western Pennsylvania, was reduced to begging.

The oncology information specialist "said don't bring her here," he recalled. "I said you don't understand; we're going to lose her if you don't treat her. She told me I'd just have to accept that."

Vicky Hilborn never got another appointment with CTCA. She died on September 6, 2009, at age 48.

CTCA is not unique in turning away patients. A lot of doctors, hospitals and other healthcare providers in the United States decline to treat people who can't pay, or have inadequate insurance, among other reasons. What sets CTCA apart is that rejecting certain patients and, even more, culling some of its patients from its survival data lets the company tout in ads and post on its website patient outcomes that look dramatically better than they would if the company treated all comers. These are the rosy survival numbers that attract people like the Hilborns.

Business & Financial News, Breaking US & International News |

Sphere: Related Content

Friday, March 8, 2013

Testimony for PA Senate Democratic Appropriations Committee Public Hearing on Medicaid Expansion, March 8, 2013

Good morning. Thank you for conducting this session and for inviting me to speak. I am Dr. Chris Hughes, state director for Doctors for America, a nation-wide group of physicians advocating for high quality, affordable health care for all. I have been an intensive care physician for my entire career, now approaching 25 years, and within the past year I have also begun practicing hospice and palliative medicine. I am a former Trustee of the Pennsylvania Medical Society and Chair of the Patient Safety Committee. I have completed graduate studies in health policy at Thomas Jefferson University, and I am now teaching there, in the Graduate School of Population Health.

I tell you this to let you know that I can get down in the weeds with you about the nuts and bolts of implementation of the Affordable Care Act, and I know a fair amount about health care financing, access, cost shifting, and all the rest. But you have fine panelists assembled here today who have been doing this for you, and I know you all know your way around these topics as well. That’s why you’re here.

I am here as a physician and a representative of my profession. Every doctor you know, and every nurse and pharmacist and social worker and everyone in the front lines of health care, for that matter, can tell you stories of how our health care system has failed someone. Our system fails people regularly, and often spectacularly, and often cruelly, day in, day out.

I've had patients who work full time in jobs that fall far short of the American dream. They get by, but they can't afford health insurance.

I'll give you a few of my patients’ stories here, not just to point out the obvious- that we are mistreating our fellow human beings – but that we are misspending countless dollars on the wrong end of the system.

There's the cabbie who recognizes his diabetes and determines to work harder and longer so he can buy insurance before he is stricken with the label even worse than diabetes: preexisting condition! He doesn't make it and ends up in the ICU with diabetic ketoacidosis.

There's the construction worker who has a controllable seizure disorder that goes uncontrolled because he can’t afford to go to the doctor. He ends up in the ICU, on a ventilator – life support - multiple times.

There's the woman who stays home to care for her dying mother and loses her insurance along with her job. When her mother is gone and she finally gets to a doctor for herself, her own cancer is far advanced. She goes on hospice herself.

The laid-off engineer whose cough turns bloody for months and months before he “accesses” the health care system – through the Emergency room and my ICU with already far advanced cancer.

Shona’s attendant, of course. [Shona Eakin, Executive Director of Voices for Independence, in her earlier testimony.]

These are people who are doing the right thing – working, caring for family members – and still have to go begging for health care. How many hours does an American have to work to “deserve” health care? 40? 50? 60? We, as a society, are telling these people that their work, their lives, are not valuable enough to deserve access to health care until they meet some standard of employment in a job that has health insurance.

While doing some research on Medicare cost savings, I ran across a paper from US Sen. Tom Coburn with this quote: "Medicaid is a particular burden on states, consuming on average 22 percent of state budgets." I don’t quibble with the number, I quibble with the mindset that leads one to think that the suffering of millions is a non-factor in the decision making. And the fate of patients is not mentioned in his paper.

Not long ago, expanding access to health care was a nonpartisan goal. As recently as 2007, a bipartisan group of U.S. senators, including Republicans Jim DeMint and Trent Lott, ( let me repeat that, “Jim DeMint and Trent Lott” ) wrote a letter to then-President George W. Bush pointing out that our health care system was in urgent need of repair. "Further delay is unacceptable as costs continue to skyrocket, our population ages and chronic illness increases. In addition, our businesses are at a severe disadvantage when their competitors in the global market get health care for 'free.' "

Their No. 1 priority? It was to "Ensure that all Americans would have affordable, quality, private health coverage, while protecting current government programs. We believe the health care system cannot be fixed without providing solutions for everyone. Otherwise, the costs of those without insurance will continue to be shifted to those who do have coverage."

Medicaid expansion and the Affordable Care Act will get us closer to this than at any time in our history.

You will hear some physicians speak out against all of this. But what you generally will not hear is their leadership and organizations speaking out against it, except perhaps in the deep south. There is a reason for this. As leaders of our profession, we have to come to terms with the idea that we are not just in it for ourselves. We are in it for our profession as well, and that means we have to put our patients’ interests above our own, and that means we have to do our best to ensure that everyone has access to high quality, affordable health care. Don’t just take my word for it. The American Board of Internal Medicine Foundation and other organizations put together a Charter on Medical Professionalism about ten years ago, specifically making this, fair distribution of health care resources, a part of our professional responsibility. If you go to their website, you will find that virtually every physician organization you can think of has endorsed it. That means the anesthesiologists and orthopedic surgeons as well as the pediatricians and the family practitioners.

For Medicaid expansion specifically, we should note here that the major national physician organizations, including the AMA, and the organizations representing internists, family practice, pediatricians, psychiatry and more, all endorse Medicaid expansion. On the state level, all of these organizations state chapters endorse it as well, with the exception of the Pennsylvania Medical Society, which I am chagrined to say, has endorsed general terms of expansion only.

But this concept is really not controversial among physicians and health care providers. We see everything from the catastrophes to the small indignities. They are tragic, unnecessary, and we are on the road to ending them.

Some in the provider community have expressed concerns about Medicaid in particular as the way we are providing access, so I would like to take a moment to address the concerns we hear most often.

First, that Medicaid is “bad” insurance. What is bad about Medicaid is largely fixed in the ACA. Namely, it is very poorly reimbursed for providers. You’ve already heard from others why hospitals want it, why advocates want it, but for providers in primary care, the frontlines of health care, they get a major boost in reimbursement under the new law. Pennsylvania has historically had awful reimbursement in the Medicaid program, among the worst in the nation. Now, reimbursement will go to par with Medicare reimbursement, a huge incentive for providers to take on Medicaid patients whom they may have been reluctant to see previously. There are other new innovations such as Patient Centered Medical Homes, the new Medicaid Health Homes (which, by the way, we have also not begun implementing in PA – maybe another panel?), and other innovations, coming down the pike, that should really give people who previously had no chance at excellent care, a chance to avoid complications, avoid the ER and avoid the hospital. To live in good health.

I’ve also heard the strange claim that having Medicaid is worse than having no insurance. I suppose that in a vacuum where there is no good data, and where one sees, like I do, patients with no insurance or Medicaid, who don’t know how or aren’t able to access a doctor, you could look at patients who get very sick and mistake that association and attribute that to Medicaid, but we do have data now. In Oregon, due to a fairly bizarre set of circumstances a few years ago, Medicaid eligibility was determined by lottery, creating a natural experiment of haves and have-nots. In the first year, those who were enrolled were 70 percent more likely to have a usual source of care, were 55 percent more likely to see the same doctor over time, received 30 percent more hospital care and received 35 percent more outpatient care, and much more. Incidentally, I heard a cable talking head complain about the Oregon data because it didn’t examine outcomes, such as deaths and such. A fair point if we had more than a year’s worth of data! I, and most other health professionals, would argue that the results they have seen already are impressive and worthwhile in and of themselves.

People often ask me why I am so passionate about this, and I always tell them, “I blame the nuns.” Growing up Catholic, there was nothing so drilled into me as Matthew 25. We used to sing a hymn based on it, “Whatsoever you do to the least of my brothers,” on a regular basis at Mass. And we went to Mass before school every day!

It turns out this is a pretty universal sentiment. I checked. Go to the websites of every mainstream religious denomination – Anglican, Methodist, Mormon, you name it - and it will be in there somewhere: The Social Gospel and Social Justice. Dignity of the individual. Our duties to the less fortunate. It is part of our national Judeo-Christian heritage, and a component of every major religion and philosophy in the world, with one notable exception – Ayn Rand’s. And I mention Ayn Rand and her most famous book, Atlas Shrugged, because it is perennially listed as the second most influential book in America, after the Bible. A damning fact for us.

In spite of that, I am glad that social justice and a commitment to the fair distribution of our health care resources is integral to the sense of duty of my profession, the nursing profession and all health professions.

I often say that I encourage debate about how we get to universal health care, but I refuse to accept that America, alone among all modern nations, and Pennsylvania in particular, will reject the idea that we need to get there.

A final thought from health care economist Uwe Reinhardt, regarding all of the reasons given about why we cannot achieve universal health care; he says, “Go tell God why you cannot do this. He will laugh at you,”

Right now, Medicaid expansion, the Health Insurance Exchanges and many other components of the Affordable Care Act are our best hope. Let’s not squander it.

Thank You.

Sphere: Related Content

Thursday, March 7, 2013

In Conservative Arizona, Government-Run Health Care That Works - Kaiser Health News


APACHE JUNCTION, Ariz. – In a low-slung building in the vast desert expanse east of Phoenix, a small school of tropical fish peer out, improbably, from a circular tank into the waiting lounge of the Apache Junction Health Center. The hallways of the nursing home are still. Only half of the rooms are filled, and the men and women who live here seem surely in life’s final season. “These are folks that have chronic cognitive and physical disabilities that are not going to improve,” said George Jacobson, administrator of the nursing home.

That this nursing home is sparsely filled with residents too disabled in mind or body to return home is a stunning achievement for Arizona’s public health insurance agency. A decade ago, 60 percent of Arizonans covered by Medicare and Medicaid, and deemed sick, frail or disabled enough to live in a nursing home, resided in a skilled nursing facility. Today, only 27 percent of them do, and the rest – nearly three out of four– live in assisted living facilities or at home with the help of nurses, attendants and case managers provided by government-paid health plans.

As Congress debates an ambitious and far-reaching effort by the Obama administration to streamline medical care and rein in spending for the nation’s sickest and most expensive patients, Arizona – with its finger-wagging Republican governor and Tea Party enthusiasts – is occupying an unusual place in the national landscape: as a model for how a generously-funded, tightly regulated government program can aid vulnerable, low-income patients.

In Conservative Arizona, Government-Run Health Care That Works - Kaiser Health News

Sphere: Related Content

Monday, March 4, 2013

Mental health minimum benefits bolstered -

Mental health minimum benefits bolstered - Millions more will get psychiatric coverage

The Affordable Care Act’s minimum benefits mandate and a federal parity law will combine to provide mental health and substance abuse coverage to more than 32 million Americans who didn’t have any before, according to the Obama administration.

Insurance statusHave benefitsWill gain benefitsTotal with parity benefits
Individual plan7.1 million3.9 million11 million
Small-group plan23.3 million1.2 million24.5 million
Uninsurednone27 million27 million
All30.4 million32.1 million62.5 million

Source: “Affordable Care Act Will Expand Mental Health and Substance Use Disorder Benefits and Federal Parity Protections for 62 Million Americans,” Office of the Assistant Secretary for Planning and Evaluation, Dept. of Health and Human Services, Feb. 20 (link)

Sphere: Related Content