THIS SUMS IT UP LIKE NOTHING I'VE SEEN BEFORE

In 1961, The American Medical Association was so upset about the approach of Medicare, that, as part of "Operation Coffee Cup," it hired the young Ronald Reagan to record on a vinyl LP (remember those?)  an attack on this legislation as the harbinger of a "Socialist Dictatorship."  In those days, I saw the AMA as the essence of die-hard, rock-ribbed conservatism. 

Boy, have things changed!  On February 13 of this year, Howard Bauchner, MD, the Editor in Chief of the Journal of the American Medical Association, published an editorial titled

Rationing of Health Care in the United States -- An Inevitable Consequence of Increasing Health Care Costs

In this editorial, the good doctor surveys the history of healthcare in this country since the sixties. He shows that advances in science have come with concomitant increases in healthcare costs, with every indication that these advances, and these costs, will continue to increase way beyond the rate of inflation -- providing increasingly critical challenges to our society. 

Don McCanne MD,, who comments on this editorial, says that before reading his commentary, you should read Bauchner's last three paragraphs.  So I'm supplying these paragraphs here,  followed by all of McCanne's commentary -- for me, both Bauchner and McCanne sum up what's going on. 

Here's Dr. Bauchner:

The United States is mired in a great philosophical debate. Is health care a right or a privilege? In part this debate is embedded in the historical, underlying sociopolitical discourse in the United States — is this a nation that champions individual rights and achievement at the expense of the common good? This philosophical debate plays out in health care. Rationing of health care is likely always going to occur, but for those who maintain that health care is a privilege, attention to rationing and attempts to ensure that rationing is minimized may not be a priority. Yet, even for those who assert that health care is a right and that health care coverage should be provided to all individuals in a more just and fair way, unless the relentless increase in the cost of health care is addressed, rationing of health care is likely to become more common.

Identifying approaches to mitigate the increase in health care costs has been elusive. Debates about waste in health care, prices of drugs and devices, volume, fraud, defensive medicine, inappropriate testing, and misaligned incentives have been ongoing for more than a decade. Each of these potential areas of cost containment provides income for specific groups, making change difficult. However, there is one area — administrative costs — about which there is broad agreement that it adds needlessly to the cost of health care, frustrates physicians and other clinicians, provides little benefit beyond employment, and clearly is one area in which the United States leads the world. These costs involve, but are not limited to, billing, excessive documentation, and the need to obtain prior approval for certain medications, radiological procedures, and specialty referrals. Although there is uncertainty about what percentage of the $3.5 trillion in annual health care spending is accounted for by administrative costs, if that amount is 10%, and could be reduced to 5%, an estimated $175 billion could be saved or redirected to provide care to patients and avoid rationing of some health care services. Reducing administrative costs should be the major focus of national efforts to reduce waste in health care and help control increases in health care spending.

For the United States to prosper in the 21st century, controlling health care costs is critical — indeed, it is the single most important challenge facing health care. Greater rationing of care is inevitable if health care costs continue to increase. Controlling health care costs is the only way to ensure appropriate investment in other areas, such as education, the environment, and infrastructure, and to provide a more equitable, just, and fair distribution of the remarkable health care advances that have been achieved with even more on the horizon. It has been said many times that in the richest country in the world, in which many of the greatest scientific and medical advances are developed, it is a blight on the US soul that each of its residents does not fully benefit from available health care.

https://jamanetwork.com/journals/jama/fullarticle/2725150

And here's Dr. McCanne:

For those of you who skip the quoted text and go right to the comment (often a wise move as a time-saver), please pause here and read the last three paragraphs of Howard Bauchner's editorial, and then return here.

How many times have you heard the opponents of single payer Medicare for All say that if we adopt such a system here then we'll have rationing like the socialist health care systems of other nations? Yet the irony is that we already have a major problem with rationing, and it is perhaps the cruelest version of all since we ration by ability to pay in spite of spending far more on health care than any other nation.

So how did we end up with both high spending and rationing? Quite simply we have the most administratively complex health care financing system of all nations, which is very expensive to run, wasting funds that could be used on health care for those who are victims of rationing, not to mention that our financing system is profoundly inefficient. Remember that tens of millions of US residents remain uninsured, tens of millions more face excessive financial barriers to care due to excessive out-of-pocket spending, and personal bankruptcy due to medical debt has not declined with the implementation of the Affordable Care Act.

Bauchner has defined the problem: profound administrative excesses. We know the solution: administrative efficiency through a publicly-administered, equitably funded Single Payer Medicare for All program.

There has been a surge in support for a public option such as a Medicare buy-in, but that only adds one more player to our administratively complex, wasteful system. There is also support being expressed for our employer-sponsored plans and for other private approaches such as the Medicare Advantage plans, but these perpetuate our costly, dysfunctional, multi-payer approach to health care financing.

So what about rationing? With Single Payer Medicare for All we would essentially eliminate rationing by insurance design, rationing by restriction of benefits covered, rationing by prohibition of obtaining care outside of narrow provider lists, rationing by unaffordable out-of-pocket cost sharing, or rationing by administrative barriers such as prior authorization requirements. These forms of administered rationing are harmful and should be done away with. Inability to pay for care would no longer be a barrier since a Single Payer Medicare for All program finances care equitably such that it is affordable for everyone. Maldistribution of health care professionals and institutions would be corrected through central planning and equitable distribution of our health care resources. Although all nations, including ours, must deal with queues, other nations have shown that the delays can be minimized by improving distribution of health care resources and funds, and also by simply applying the science of queue management, though that requires that we select to run our government stewards who actually care.


Bauchner says, "it is a blight on the US soul that each of its residents does not fully benefit from available health care." But we can fix this, and the sooner the better.

Near the end his commentary McCanne stresses the importance of electing to our government stewards who actually care.  I added the emphasis, because I think that requirement is paramount. What we too often get are people who claim to be stewards, but whose chief concern is staying in power. But to get some who actually care? I know they're out there. We just have to find them.

In his final comment, McCanne returns to Bauchner's comment that our failure to ensure that each of our residents benefits from available health care is "a blight on the US soul."

To heal that blight is our cause -- and it's a noble one. It won't be easy: Arrayed against us are the vast power of our corporate culture and even some of our leaders. 

They are banking on their privilege.

We are fighting for our lives.

Dio

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NOT THE WAY TO CONTROL COSTS

In my post of 12/21/2018 (Why Is American Healthcare Se Expensive -- Part Two), I cited my heroes Woolhandler and Himmelstein, who said, "Medicare's (and other payers') Pay for Performance initiatives impose substantial costs on providers, with no evidence that they've improved patients' outcomes in any setting." [Emphasis added.]

This would seem to conflict with the assertions of those touting what they claim is the success of Medicare’s Hospital Readmissions Reduction Program (HRRP) in lowering risk-adjusted readmission rates for targeted conditions at general acute care hospitals.

But now (in January, 2019) comes a Paper in Health Affairs titled Decreases In Readmissions Credited To Medicare’s Program To Reduce Hospital Readmissions Have Been Overstated. The  Paper's abstract presents a statistical analysis far beyond my sphere of competence. But Don McCanne of the PNHP (Physicians for a National Health Program) comments:  "This study shows that, at a minimum, the benefits of penalizing hospitals for readmitting patients have been tremendously overstated."  Moreover, he points out the additional concern that

patients are often held on observation status rather than being readmitted, sometimes to avoid the readmission penalties. This can significantly increase out-of-pocket costs for the patient since they are billed as outpatients (Part B), with greater cost-sharing, rather than as inpatients (Part A). More importantly, there is also the risk that the patient may receive less care as an outpatient when the patient's condition warrants full inpatient services. Thus the readmission reduction program may be causing significant patient harm, both physically and fiscally.

In conclusion, he states :

The government bureaucrats and the policy community are fixated on these various programs that they just thought up out of the blue that supposedly would control spending, even though their track record overall is dismal. Yet they keep avoiding a proven solution that would reduce our uniquely outrageous administrative waste that costs hundreds of billions of dollars. That solution is a single payer national health program, an improved Medicare that would cover everyone. We should at least enact that and then we could examine other innovations as long as they are designed to truly benefit patients.

Of course he is right:  Single-Payer would save administrative costs more reliably than any of  our government's fiscal schemes, which have proved so far to be, in  McCanne's words, "a dismal failure."  But whether Single-Payer in New York State (NYHA) would control non- administrative costs -- such as hospitals gaming the system in order to make profits, and whether payments to hospitals would reflect current market realities (e.g. regional differences in payscales, etc.) and different standards of excellence (e.g. Memorial Sloan Kettering vs a provincial outfit like Poughkeepsie's Vassar Hospital) has not yet, to my knowledge, been figured out.

The last time I checked, the House of Representatives proposal for Single-Payer adopted Woolhandler and Himmelstein's suggestion that medical facilities such as hospitals should NOT be privately owned and should be compensated NOT by procedure, but should be publicly owned and compensated globally for operating expenses, with capital expenses (MRI machines, etc) awarded by government grants, not by any profits or surpluses, which they would not be supposed to make.  Sanders' Senate Bill keeps the current setup, where hospitals are expected to make profits and are tacitly encouraged to game the system in order to do so. But the House proposal, as I understand it, is currently being rewritten, with results yet to be announced. And how the NYHA would treat these matters is yet to be determined.

With all these uncertainties, why go to single-payer, or for that matter any new system?  The answer is simple: Our current system is fiscally unsustainable and morally bankrupt. Single-Payer seems the best avenue forward. Inaction is not an option. Hence this blog.

Dio

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IT’S INEVITABLE

Dr. K. was one of the most conscientious family doctors I have ever met.  Her physical examinations were unrivaled in their thoroughness, and she knew how to listen; her patients – of whom my wife and I were two – felt they had in her a sympathetic friend of the family.  She was so popular, so good at what she did, that she was forced to stop taking new patients.

I’ve used the past tense because she’s no longer our doctor:  She has quit private practice to become the physician tending to the students at a local university. She misses her old patients, and misses the opportunity to follow patients as they continue through life.  But on balance, she feels that the move she made was right for her.  Her great strength is as a physician, but she was daunted by having to wrestle with insurance companies whose business aim, it seemed to her, was not in providing care but in denying it.

Her successor, Dr. D., is likewise a superb physician, but unlike her predecessor, is less daunted by the red tape that modern medicine – in this country – is heir to.  Once I had occasion to see her, and so I asked her what she thought about single-payer healthcare. Her mouth tightened, and after a pause she said, “well, the current system is broken, that’s for sure.”  I took that to mean that while something had to be done to solve this problem, she wasn’t sure that adopting single-payer was the right solution.

I got a more positive response at the ophthalmological clinic of Dr. F., who recently performed the cataract surgery that is allowing me to post this blog tonight.  The day of the surgery, I asked his anesthesiologist what he thought of single-payer.  He sighed, and said, “it’s inevitable.”  The next day, in a follow-up visit, I asked the surgeon himself about his opinion of the New York Health Act. Immediately he replied, “I’d prefer it to be a national program.”

“So would I,” I said. “But that’s not going to happen any time soon.”

He nodded, then said, “well, I’d have to say that...” then he paused, then continued: “yes, I do support it. It’s inevitable.”

Doctor F. and his anesthesiologist are not the only doctors who feel this way.  Earlier this year, the New England Journal of Medicine published a poll stating that the majority of American doctors now favor single-payer.  That’s quite a change from 57 years ago, when the American Medical Association hired Ronald Reagan to attack Medicare as “socialized medicine.” What has happened since then?

According to Meagan Day, writing in the American socialist magazine JACOBIN, it can be summed up in two words: “Physician Burnout,” which is defined, she says, by the University of California Riverside School of medicine as “1) a feeling of a lack of accomplishment; 2) feelings of cynicism; and 3) a loss of zeal, zest, and enthusiasm for work.” 

Ms. Day writes that “In our current system, there are usually three parties involved in every medical decision: the doctor, the patient, and the insurer. The doctor and patient may agree on a course of treatment, but the insurer decides whether it will be covered. And since many Americans can’t afford ever-growing out-of-pocket medical costs,  that often means that insurers have the final say in whether the treatment will be administered at all.

The majority of Americans receive health coverage from a private insurance company. And while doctors and patients are both theoretically focused on patient health, the insurer is driven by an entirely different motivation: to maximize profit. Insurance companies are financially motivated to deny claims, and they do it all the time, even in life-or-death situations. One in four patients with a chronic or persistent illness or condition have had claims for medication, tests, or procedures denied by their insurer. In 70 percent of those cases, the condition was described as serious. Only 1 percent of patients said they trusted their health insurance provider’s judgment over their doctor’s or their own — and yet the buck stops with insurance companies.

When they deny claims, insurers give doctors and patients all kinds of excuses packaged in obscure industry terminology: formulary exclusion, prior authorization. But the simple fact is that patients aren’t getting the care they need — and doctors aren’t getting the opportunity to actually do their job. All too often, this is deadly for patients. For doctors, it’s depressing and demotivating. It hinders physicians’ ability to practice medicine, makes them feel powerless at work, and divests them of a feeling of personal accomplishment.”

Ms. Day adds to that what she characterizes as a “jigsaw insurance network system” which often forces one to change doctors whenever one changes jobs, or when one’s employer changes insurance companies, resulting in a situation where, ”seeing little purpose in getting to know patients intimately, doctors can become cynical. The lack of continuity leads to feelings of alienation and disinvestment for physicians who may have been attracted to the profession by the prospect of helping and healing people.”

And even if all the above were not so, the sheer labor involved in dealing with a plethora of insurance companies, each with its own requirements and protocols, is a significant drain on every medical practice in this country today. In NEJM’s CATALYST magazine, Marilyn Serafini cites a 2009 study by Lawrence Casalino, MD, PhD, Professor of Health Care Policy and Research at Weill Cornell Medical College.  “[He] put a dollar figure on the time that practitioners were devoting to administrative tasks. He estimated that physicians were spending 3 hours a week interacting with health plans (add another half hour for primary care), and that nursing and clerical staff spent 19.1 hours per week per physician. He estimated the national time cost at as much as $31 billion each year.”

When you take into account all the above, it’s little wonder that so many of our doctors are in favor of Single-Payer.  Now: If we can get the electorate to be aware of NYHA, and to see it – passionately -- as the medical salvation for all of us, then Single-Payer will be, indeed, inevitable.

ACCORDING TO SPECTRUM,

SINGLE-PAYER MAY NOT PASS

EVEN WITH DEMOCRATS IN CONTROL

Just this morning, I got a link which you all should read:

Single-Payer May Not Pass Even With Democrats in Control

It lists 3 reasons -- (1) The cost, (2) The wariness of some unions, and (3) Cuomo's unwillingness to take risks.

The money figure -- $139 Billion -- in indeed formidable. But the article describes that cost as "just to establish the program" (implying that future costs might well be more), and a graphic is presented showing that $139 Billion virtually swallowing up the annual state budget (as if it would cost $139 Billion every year). The article's presentation so far, in my opinion, betrays its corporate slant, although it does concede that once implemented, the plan is expected to save taxpayers money, but finding the dollars for the initial startup could prove very challenging. The article does not mention how much money NYHA would save tax payers, which has been estimated in the billions. 

Granted, finding the start-up money will  be challenging, but that problem is not limitless; it is finite, which means it is possible to solve: Where there's a will, there's a way.

The wariness of some unions in endorsing NYHA is something we discussed in the previous post.  (If you haven't seen it, I encourage you to check it out). But I want to note here that the Spectrum camera shows the initial sponsor of the legislation, Gustavo Rivera, earnestly explaining that the latest version of the bill "is still being drafted. 'It's not ready yet,'"  It's hard to conceive that Rivera, the likely incoming Chair of the Senate Health Committee, would allow this bill to come to a vote if he thought it wouldn't pass. This is where the negotiations come in. We are going to find out that where there's a will, there's a way.

As for Cuomo, yes of course he's known to be cautious, but he is shown telling the Spectrum reporter that there would be a transition, there would be things he agreed with, things he disagreed with, "but one thing is for sure: we will make rapid, remarkable change."

How rapid? How remarkable? 

Well, here's my take on all this: The start-up cost, the union's reluctance, and Cuomo's caution -- each of these things will be brought up by members who in past years gladly got brownie points by voting for the bill, safe in the knowledge that with the conservative control of the Senate, it never would pass. But now that things are changed, these members will very likely remember the source of the money that got them elected -- much of it from corporate donors,  much in fact from the healthcare industry itself.  Indeed, the same can very likely be said of Cuomo himself. And his action, just as State lawmakers action, will depend on how much they see the electorate demanding it. 

That's where we come in, as activists, and as every day citizens. It's a call to action: We must work all the harder -- the feet of our lawmakers, and our Governor, must be held to the fire!

We must demonstrate  that for ALL our sakes, things can't go on the way they have been -- if for no other reason than its too wasteful of our treasure, not to mention our lives.  Let us raise up the general consciousness so  we can prove once again: 

IF WE HAVE THE WILL, THEY WILL FIND THE WAY.

Dio

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The Event in Troy, New York

Yesterday, a coalition of  healthcare professionals, unions, and activist groups gathered at the Troy Hilton Garden Inn to picket the annual conference of the New York Health Plan Association, a trade association for the state's health insurance companies. It was frigid out there, but my wife and I were glad we showed up, pickets in hand. We wielded our home-made placards, which read,

BIG PROFIT$

FROM

PAIN?

$HAME 

ON YOU!

and we shouted chants like

HEALTHCARE IS A HUMAN RIGHT --

NOT JUST FOR THE RICH AND WHITE!

Sometimes, in the hope that the the NYHPA would hear us, the Chant Leader aimed his bullhorn up to where they were meeting. They had assembled, after all, mainly to figure out more ways to oppose Single Payer healthcare in New York, by promoting what they called the "realities" of Single Payer.

In the first page of our Press Packet I found the following powerful snippet:

But even more striking was the testimony of a nurse, delivered powerfully through the bullhorn:

"We nurses get to see pain and suffering up close. One day, when I was tending to a patient, I overheard through the partition what was going on with his roommate. This poor man, a truck driver, had a 95% blockage in his heart. His nurses were trying to ready him for the surgery, and they told him that the operating room was being prepared  for him. But he told them that he'd rather not have the surgery because he doubted his insurance would pay for it. They begged him to go through with it: After all this was a life he was talking about -- his own life -- which was priceless. But he said no -- he'd rather leave. And he did -- he just got dressed and walked out the door. I never knew what happened to him."

But my wife and I felt that we knew. Rather than saddle his family with crushing debt, this poor man felt it was better to die. Effectively he was committing suicide.  He felt that he was too poor to live.

Alexandria Ocasio-Cortez famously has said that nobody should be too poor to live, and I agree with her. 

After all that, the "big secret" that I touted in yesterday's "teaser" turned out not so important.  But for what it's worth, not only did our group have demonstrators outside, I learned that we had operatives on the inside as well. Through an ingenious scheme that I'm not at liberty to disclose, they found a way to infiltrate the meeting, and some had even volunteered to disrupt the meeting, even though it could mean being arrested. There was even someone appointed to tend to these people should they land in jail!

But so far as I knew, none of this came to pass. The "suits" somehow got wind of the resistance outside, and just to be safe, they ended the meeting an hour early, whereupon a few of our leaders went to the Aetna headquarters in Troy. What happened there I have yet to find out.

There was a brief  break for lunch; our host was a personable young actor and writer. I asked him if he thought this was a class struggle. 

"Certainly I would," he replied. It's been going on for years, but only now are we wising up to it."

"Class warfare?" I offered.

"That, too. People are dying."

Dio

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