Galluping In the Wrong Direction: Higher Cost Barriers & Lower Quality

Health Justice Monitor - January 21, 2023 No Commentson Galluping In the Wrong Direction: Higher Cost Barriers & Lower Quality Summary: National polls show that the US is losing ground on two major indicators of health system performance: access to care and perceived quality. Who thought it could get worse? Gallup shows we’re galloping to disaster. Record High in U.S. Put Off Medical Care Due to Cost in 2022 Gallup January 17, 2023 By Megan Brenan The percentage of Americans reporting they or a family member postponed medical treatment in 2022 due to cost rose 12 points in one year, to 38%, the highest in Gallup’s 22-year trend. Americans were more than twice as likely to report the delayed treatment in their family was for a serious rather than a nonserious condition in 2022. In all, 27% said the treatment was for a “very” or “somewhat” serious condition or illness, while 11% said it was “not very” or “not at all” serious. [This] 16-point gap in the perceived seriousness of forgone treatment in 2022 is the second largest on record … Americans Sour on U.S. Healthcare Quality Gallup January 19, 2023 By Lydia Saad For the first time in Gallup’s two-decade trend, less than half of Americans are complimentary about the quality of U.S. healthcare, with 48% rating it “excellent” or “good.” The slight majority now rate healthcare quality as subpar, including 31% saying it is “only fair” and 21% — a new high — calling it “poor.” Americans’ evaluations of the quality of healthcare they personally receive are also at a low ebb — albeit higher than their U.S. rating — with 72% giving it excellent or good marks. This low reading has been two years in the making, with the metric falling six points to 76% in 2021 and another four points in the past year. Comment by: Jim Kahn This pair of national Gallup polls demonstrates our health care is headed in the wrong direction. The care is less affordable and lower quality. Why less affordable? In brief, under-insurance. As the Kaiser Family Foundation showed in its 2022 annual survey of job-based insurance, deductibles continue increasing (Fig. 7.18), even as employee premium contributions rise or stay flat (Fig. 6.23). Drug prices are extraordinarily high due to the industry’s relentless pursuit of profit, and cost controls in the Inflation Reduction Act are anemic. A commentary from last week noted that drug cost-sharing under the now ubiquitous pharmacy benefit managers (PBMs) can be devastating for patients who depend on expensive brand-name medicines with no generic options. Two main causes: First, a shift from fixed co-payments to percentage-of-cost coinsurance, which is based on inflated list prices. Second, exclusion of manufacturer patient assistance from deductible credit. The difference for patients can be tens of thousands of dollars a year (see sample calculations here). Wendell Potter wrote recently on the painful results for patients. Financial barriers have clinical consequences. Research by Gaffney et al in late 2022 found rationing of insulin by 17% of patients or 1.3 million US adults. Research by Chandra et al in 2021 found that a 34% ($10) rise in out-of-pocket cost for seniors reduces drug use by 23% and increases mortality by one-third, specifically for statins and antihypertensives. Why lower quality? It’s multi-factorial. Clearly COVID has burdened health care capacity, leading to worker stress, burnout, and staffing shortages. But I believe patient frustration also carries over from the financial challenges. When people have to pay more – which they can barely afford – they demand and expect more. When the system is failing in multiple ways, it feels like it’s completely falling apart. Which it is. Saddle up for single payer.

The Problems with Job-Based Insurance

http://healthjusticemonitor.org/2023/01/05/the-problems-with-job-based-insurance/ January 5, 2023 No Commentson The Problems with Job-Based Insurance Summary: The Chamber of Commerce uses the results of its online poll to claim overwhelming worker support for job-based health benefits. However, the methods and reporting are biased. Survey findings by the Commonwealth Fund tell a far more worrisome story. New Poll of American Workers Reveals Tremendous Value Placed on Workplace Health Benefits U.S. Chamber of Commerce December 15, 2022 Health insurance is the most important benefit an employer can offer workers and their families, according to a new survey on how American workers view employer-sponsored health coverage. Workers report that they overwhelmingly prefer to receive health insurance directly from an employer rather than through other means. The poll found that as high as 96% of Americans believe it is important that a job offer health insurance. Ninety-three percent of respondents said they were satisfied with their insurance. Employer-sponsored health insurance remains far more popular than insurance plans available on the individual market: 89% of Americans expressed a preference for obtaining their health coverage through an employer than through other means. 81% of respondents reported that they would rather receive their insurance from an employer than a government-provided health plan. “I expected there to be a high level of satisfaction with employer health benefits, but I was stunned by the level of intensity,” said Matt George of Seven Letter Insight, who ran the survey. “It is not an exaggeration to say Americans love, trust, and rely on their workplace health care coverage.” The survey was commissioned by the Protecting American’s Coverage Together (PACT) campaign, a coalition including the U.S Chamber of Commerce, Business Roundtable, Vermeer Corporation, The National Association of Manufacturers and Council for Affordable Health Coverage. PACT represents leading employer voices focused on strengthening the ESI system and protecting the coverage and benefits that American families depend on for their health. The State of U.S.Health Insurance in 2022 The Commonwealth Fund September 29, 2022 By Sara R. Collins, Lauren A. Haynes, Relebohile Masitha Forty-three percent of working-age adults were inadequately insured in 2022. These individuals were uninsured (9%), had a gap in coverage over the past year (11%), or were insured all year but were underinsured, meaning that their coverage didn’t provide them with affordable access to health care (23%). Twenty-nine percent of people with employer coverage and 44 percent of those with coverage purchased through the individual market and marketplaces were underinsured. Among the world’s high-income countries, the U.S. stands alone for the complexity of its health insurance system. Americans are eligible for different types of coverage depending on whether their employer offers it, what their income level is and what their age and health care needs are. There is no national enrollment mechanism for people who don’t have employer coverage; they must know which program they are eligible for and then sign up for coverage. Consequently, people can experience insurance gaps at different points in their lives, like when they lose a job. The average insurance deductible for employer health plans with single coverage is more then $1,000 ($1,434 for all covered workers in 2021), and out-of-pocket maximums average $4,272 for single coverage in employer plans. Half of survey respondents said they would not have the money to cover an unexpected $1,000 medical bill within 30 days. Comment by: Don McCanne & Jim Kahn With our inordinately high costs of health care and persistent gaps and inequities in access, many hope that 2023 is going to be the year that we finally start to enact and implement health care justice for all. Remarkably, however, there is still resistance to the tested and proven concept that will get us there: single payer Medicare for All. Some argue that Medicare has too many defects, but we know what they are and can revise the program to meet widely accepted standards of care. Other nations have shown that to achieve the goals of equity, accessibility, and affordability for all, the government must have a central role. To those who advocate for reliance on a private sector strategy, we point to its clear failings. Our health system failings reflect the shift of health care funds from patient care to wealthy investors, such as through public fund privatization (eg Medicare Advantage and Medicaid managed care) and the massive acquisition of providers by private equity. That’s why we must pay for health care through public insurance on the model of traditional Medicare. Employers and insurer organizations tout the benefits of employer-sponsored health insurance. Admittedly, these plans provide a welcome financial backstop for expensive medical problems, such as a heart attack or a fracture requiring surgery. Unsurprisingly, workers value getting health benefits with a significant employer contribution. Yet most job-based plans have large deductibles (thousands of dollars) and provider networks are limited. This mixed picture is evident in the Commonwealth poll and reports by the Kaiser Family Foundation and others. The Chamber of Commerce poll and report grossly exaggerate the level of support for job-based coverage. It’s biased, in four ways (please excuse geek detour): 1) Biased sample of respondents: it’s an online survey, with no sampling frame or response rate specified. This is a red flag for self-selection: the individuals who see and participate in the poll have a special perspective. The report doesn’t indicate the recruitment message, but if it was something like “What do you like about your health insurance?” or “Do you appreciate your health benefits?”, who do you think would click over to the survey? 2) Biased presentation: Statistics are presented in a way that favors the pro-benefits view. E.g., 52% do NOT strongly agree that insurance is affordable, and a similar % do NOT say that it’s high quality. More than 70% do NOT say it’s comprehensive or convenient. 3) Unfair comparison with public insurance like single payer. Respondents are asked if they prefer private work-based coverage or “government insurance”. No hint at what that means – is it Medicaid? The responses would be quite different if phrased fairly, e.g., “an improved Medicare for All, with coverage for all medical needs; no premiums, deductibles, or copays; and increased taxes only if you earn >$250,000”. 4) Omission. They don’t ask if workers are pleased that employer contributions to health benefits come out of wage or salary levels. (They do, to a very large degree.) Polling as advocacy isn’t real information. Ok geek mode off. Single payer would enable access to the entire health care system whenever needed. In contrast, employer insurance depends, first of all, on employment status and employer benefit plans. Second, details of the insurance contract matter: there may not be freedom to choose health care providers, hospitals, pharmacies, or even what care is covered. Workers may fall prey to job lock, required to stay in a job because insurance may not be available if they quit. Voluntary and highly varied job-based insurance guarantees that coverage is inequitable and unreliable, in contrast to the equity and universality of single payer. It is understandable how, through the years, individuals have liked employer sponsored plans, since they have been among the better options to provider, under the right circumstances, heath care for workers and for their families. (Less true these days due to the skyrocketing deductibles, and obscuring the lower wage effect.) Also, taking solace in decent job-based insurance undermines a principle that most of us care about: solidarity. Most of us really would like to see health care for everyone. Not long ago, we experimented on a large scale with trying to fix the private insurance approach. The Affordable Care Act aimed to preserve, improve, and expand employer sponsored insurance as a pillar of our health care coverage, filling in the voids with a regulated market for private insurance and more Medicaid. The ACA seemed to enhance solidarity while preserving employment sponsored plans. The problem, as reviewed well recently, is that this experiment in health policy was a dismal failure in providing decent coverage for everyone, and thus a failure in the solidarity we seek. Tens of millions remain uninsured, and under-insurance exploded with the rapid growth of high deductible plans. If solidarity is building, it’s of the wrong variety: shared pain. Other nations provide us with ample highly successful examples of single payer. They are effective in providing affordable care for everyone and thus also fulfill the goal of solidarity. We really can have high performance universal health care, and save money in the process. A single payer system would guarantee better health care choices than in employer sponsored plans, for workers and for everyone. We have the opportunity to reject the current, fragmented, dysfunctional employer-sponsored system and adopt policies of social solidarity that would bring affordable, comprehensive high quality health care to everyone. Look around you. This really seems to be the year to fix the health care financing system in the United States. We can use our ingenuity to create a uniquely American system of social and economic justice. Let’s do it. In solidarity, single payer for all!

CMS Smothers Us with Inconsequential Regulations for Medicare Advantage

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December 22, 2022 No Commentson CMS Smothers Us with Inconsequential Regulations for Medicare Advantage Summary: The Center for Medicare and Medicaid Services (CMS) just released 957 pages of proposed regulations for Medicare Advantage (MA). Despite the massive verbiage, and purported reflection of public comments, they fail to remedy the fundamental dynamics that make MA so lucrative for private insurers and so inadequate for sick enrollees. U.S. Health Officials Seek New Curbs on Private Medicare Advantage Plans The New York Times December 17, 2022 By Reed Abelson and Margot Sanger-Katz Federal health officials are proposing an extensive set of tougher rules governing private Medicare Advantage health plans, in response to wide-scale complaints that too many patients’ medical claims have been wrongly denied and that marketing of the plans is deceptive. Despite their popularity, the plans have been the subject of considerable scrutiny and criticism lately. A recent report by the inspector general of the U.S. Department of Health and Human Services found that several plans might be inappropriately denying care to patients. And nearly every large insurance company in the program, including UnitedHealth Group, Elevance Health, Kaiser Permanente and Cigna, has been sued by the Justice Department for fraudulently overcharging the government. The period leading up to this year’s enrollment deadline, Dec. 7, amplified widespread criticism about the deceptive tactics some brokers and insurers had used to entice people to switch plans. In November, Senate Democrats issued a scathing report detailing some of the worst practices, including ads that appeared to represent federal agencies and ubiquitous television commercials featuring celebrities. Federal Medicare officials had said they would review television advertising before it aired, and the new rule targets some of the practices identified in the Senate report that caused some consumers to confuse the companies with the government Medicare program. A proposed regulation would ban the plans from using the Medicare logo and require that the company behind the ad be identified. Federal Medicare officials had said they would review television advertising before it aired, and the new rule targets some of the practices identified in the Senate report that caused some consumers to confuse the companies with the government Medicare program. A proposed regulation would ban the plans from using the Medicare logo and require that the company behind the ad be identified. The new proposal would require plans to disclose the medical basis for denials and rely more heavily on specialists familiar with a patient’s care to be involved in the decision-making. Dr. Meena Seshamani, the director of the Center for Medicare and a deputy administrator at the Center for Medicare and Medicaid Services, said the changes had been influenced by thousands of public comments solicited by the agency and by lawmakers. “The proposals in this rule we feel would really meaningfully improve people in Medicare’s timely access to the care they need,” she said. Hospitals, which have been pushing for changes that would address their concerns that insurers were abusing prior authorization, applauded the proposals. The proposed regulations are not yet final. Health officials are soliciting comments from the public and may make changes. Comment by: Don McCanne The Feds are finally listening to the uproar against the privatized Medicare Advantage plans and all of their abuses. Or are they? Let’s see. CMS proposed a 957 page set of rules which you can read and respond to by February 13, 2023. Actually reviewing the first 72 pages should be adequate since it contains the Executive Summary. Therein you will find that our bureaucrats are attacking issues such as warning insurers that if they use the Medicare logo we will tell on them, though using the term “Medicare” is still acceptable. Addressing evidently more significant problems, as an example Medicare will mandate that prior authorization reveal clinical justifications and incorporate expert review. But this is a micro-fix; the real issue is that insurers don’t want patients who need expensive health care and will continue to make getting care difficult so that patients switch to other coverage. The lawsuits they face for denying coverage are a drop in the bucket compared to the billions they rake in by avoiding expensive care. Most private Medicare Advantage patients are relatively healthy and thus not dissuaded by limited provider panels or lack of access to centers of excellence that they don’t need right now, if they can have their teeth cleaned or join an exercise club. It really isn’t their concern that extra taxpayer dollars are diverted to enrich these private plans. Sorry, burying us in 957 pages of rules is not going to cut it. The privatization of Medicare, as a wealth-creating business model, has significantly damaged the program and these rules are only camouflage for perpetuating it. Our traditional Medicare program has some real problems that need to be addressed, and that is where the effort should have been directed. As a public program the traditional program is designed to serve all of us well, whereas the private Medicare Advantage model is designed primarily to serve business interests. Sadly, our government is going to use this proposed rule to try to convince us that they are addressing the Medicare privatization issue. They clearly are not. They have been listening to us but not acting on what we say. We need to turn the volume up even higher. Let’s throw out the privatizers and enact a single payer Medicare for All system. Then we can have Health Justice for All!

A Rural Hospital’s Excruciating Choice: $3.2 Million a Year or Inpatient Care?

"...the “prohibition” on inpatient services was set by Congress ..." Congress is being controlled by big-money donors and their hired lobbyists. Too many of the big city hospitals have been taken over by for-profit corporations. Seems they want to force us small-town folks to be transferred at our cost and our risk to fill their pockets. Other than that quote this article seems to miss that point. https://www.nytimes.com/2022/12/09/health/rural-hospital-closures.html

In Health Care pay for performance does not work..Profit is not the goal

Study Calls Medicare Pay-for-Performance Program Results Into Question — MIPS doesn't consistently correlate with process, outcome measure performance in primary care by Crystal Phend, Contributing Editor, MedPage Today December 6, 2022 https://www.medpagetoday.com/practicemanagement/reimbursement/102090

Bill Kaplan: South Dakota expands Medicaid

"What is Wisconsin waiting for? Wisconsin is losing out on $ billions of federal funding and coverage for an additional 90,000 Wisconsinites, mostly low-income working adults." Full Article “South Dakota is one of the most Republican states in the nation. … In the 2020 presidential election, President Donald Trump won in a 26-point romp” (Almanac of American Politics). However, on November 8, South Dakota voted for a constitutional amendment to expand Medicaid by a vote of 56% to 44%. It joins 38 other expansion states, including many GOP-led and most Midwest states except Kansas and Wisconsin. Although the Kansas GOP-led legislature did pass Medicaid expansion, it was vetoed by Republican Governor Sam Brownback. Wisconsin remains an outlier. The South Dakota ballot measure was strongly supported by the South Dakota Chamber of Commerce and Industry, the State Medical Association (SDSMA) and the South Dakota Association of Healthcare Organizations (SDAHO). The business group said: “The South Dakota Chamber of Commerce and Industry believes that expanding Medicaid will have a positive impact on helping people in low wage jobs secure healthcare services and remain in the workforce as healthier people.” Doctors said: “The SDSMA advocates not just for adequate funding for the Medicaid program, but for Medicaid eligibility expansion … .” And, hospitals (SDAHO) said: “Its passage will provide the opportunity for more South Dakotans to have access to affordable healthcare coverage.” South Dakota, like Wisconsin, is rural and agricultural. The state Farmers Union praised the vote: “Medicaid expansion will be a crucial opportunity for farmers and ranchers across South Dakota to accept affordable healthcare coverage for the first time. … This will allow farmers and their families to keep tradition alive and keep taking advantage of the opportunities living in rural communities provides.” “In addition to the 90% federal matching funds available under the ACA (Affordable Care Act) for the (Medicaid) expansion population, states can also receive a 5 percentage point increase in their regular federal matching rate for 2 years after expansion takes effect. The additional incentive applies whenever a state newly expands Medicaid and does not expire” (Kaiser Family Foundation). What is Wisconsin waiting for? Wisconsin is losing out on $ billions of federal funding and coverage for an additional 90,000 Wisconsinites, mostly low-income working adults. Medicaid eligibility expansion will be needed to cover thousands of other Wisconsinites who will lose their eligibility when the COVID public health emergency is ended. Moreover, Joan Alker, Georgetown University’s Center for Children and Families, said: “We have over 400 studies showing why Medicaid expansion is a good thing. It has not busted the budgets of the states that have done it, it’s supported their budgets, it’s reduced mortality, it’s improved health outcomes, it’s supported hospitals – the evidence is piling up. And, so saying ‘no’ is getting harder and harder.” Time for Wisconsin to move forward. State doctors and healthcare executives must provide persistent leadership. Finally, I implore retired GOP state Senators Luther Olsen and Dale Schultz, both supporters of Medicaid expansion, to form an advocacy expansion lobby with business, civic, healthcare, labor and political leaders – “Wisconsinites for Common Sense on Healthcare Coverage.” We can do this and join the now 39 expansion states.

US Hospital Money Machine

Summary: US hospitals use aggressive business models (mergers, high prices, & marketing of lucrative services) to drive up revenues. For-profit hospitals benefit investors, but even not-for-profits act similarly, with huge financial rewards for participants. Single payer’s hospital global budgeting would remove these perverse incentives. Hospital Billing Is a Crime Against American Patients The American Prospect November 22, 2022 By Robert Kuttner Most hospitals in the U.S. are either for-profits, or nominal nonprofits like large teaching hospitals that behave just like for-profits. Their goal is to maximize market share, particularly for the most lucrative specialized procedures. That means they spend a great deal of capital, not just on acquisitions but on construction of new facilities (that may be redundant in many cities) and on new costly equipment. U.S. hospitals have triple the capital costs of Europe’s hospitals. Meanwhile, every major European nation not only spends far less on health care but has much better outcomes in terms of every major health indicator. Medicare could save taxpayers a lot of money. Why are they so timid? Because hospitals in many areas are the largest and most politically powerful local employers, even more so when they are teaching hospitals connected to universities. One of the many regulatory failures of antitrust in the U.S. is the nearly complete failure to challenge hospital mergers and acquisitions, which have created monopoly power and degraded services in city after city. Even worse, many of these merger binges are by hospital systems that are nominal nonprofits. There is no direct price regulation in the U.S., so hospitals are free to charge what they think the market will bear. Hospitals also overuse specialists, who can bill at higher rates. Executive pay is also exorbitant. A variety of market-friendly techniques were devised to contain costs. Hospitals proved expert at gaming all of them. Until recently, advocates of single-payer health care have focused on comprehensive coverage but less so on the abuses of profit-maximizing medicine. If we went to Medicare for All but did not reform these billing practices and did not end the system of profit-maximizing medicine entirely, these excess costs would simply be piled onto taxpayers. Rep. Pramila Jayapal’s current Medicare for All bill does best at addressing these abuses, and Bernie Sanders’s latest version is more attuned to them than his earlier bills. Under Jayapal’s bill, co-sponsored by about half of the House Democratic caucus, the system would keep some elements of fee-for-service medicine and diagnosis-related coding, but hospitals would operate under “global” budgets. That is, they would receive an annual flat sum from the government that would be adjusted regularly to reflect caseloads. Medical education—one of the ways that teaching hospitals pad bills—would be its own separate budget item. Capital outlays and staffing ratios would be regulated. Incentive compensation aimed at gaming the system would be prohibited. There would be much greater emphasis on primary care. This legislation, which merely reflects common practices in most European nations, is at the outer fringe of what is even debated in the U.S. It is a reminder of how inefficient as well as unjust is market-led medicine, and how incremental reforms can never repair our broken health system. Comment by: Don McCanne Although we have the most expensive health care system in the world, it performs very poorly by international standards. We have far too many who are uninsured or underinsured and thus suffer financial hardship, and our system has too many features designed to direct health care dollars to the wealthy rather than to the patients where the need is so great. This article by Robert Kuttner demonstrates that another defect is in one of the most basic elements of our health care system: our hospitals! Hospitals have not escaped much of the fragmented and dysfunctional design defects that characterize our health care system. As a glaring example, our nominally nonprofit hospitals, which should be dedicated to providing health care to the most needy, frequently engage in activities that make the rich (e.g., prodigiously paid CEOs and procedural specialists) richer as unmet community care needs should make us cry out for universal insurance. Yet where are our reform activities directed? Our current government, which is supposedly more progressive than the alternative, has been busy converting our public Medicare program into private insurance plans, via heavily marketed but optional Medicare Advantage and now involuntary Direct Contracting through the REACH program. Meantime, ownership of the actual health delivery system is passing to private investors through private equity and other innovative business constructs designed to siphon off the massive pool of health care dollars that we have but are not using in the high performance system that our nation deserves. What is wrong with us? For decades we have known that a well-designed single payer system, using an improved version of Medicare, would serve all of us well. As we have stalled and deferred, allowing inadequate, dysfunctional, incremental measures to substitute for reform, we have allowed our health care system to feed the injustice of wealth inequities such that we now have a much greater legislative problem than merely establishing a universal public health insurance program. That makes it all the more urgent to act now. The shift of wealth to the top is a rapidly accelerating process. We are not talking about some vague population in the future. We are talking about our grandchildren and even our children. Look around at the medical needs that our aging friends face. How can we be so callous as to not ensure that those needs will be met for all of us in the future. Now is when we have to act! Dammit, now!