Tuesday, October 13, 2015

Friday, October 9, 2015

U.S. Health Care from a Global Perspective: Spending, Use of Services, Prices, and Health in 13 Countries - The Commonwealth Fund

U.S. Health Care from a Global Perspective: Spending, Use of Services, Prices, and Health in 13 Countries - The Commonwealth Fund

Comment by Don McCanne

"This update, comparing us with 13 high-income countries, confirms that we
still spend far more than any other nation on health care, partly
because of our very high prices, even though we are not using more
health care.  Worse, in spite of our high levels of spending, our
population health remains relatively poor.

One exhibit in this report shows that our combined spending on health care
and on social care (retirement and disability benefits, employment
programs, and supportive housing) is about average (see Exhibit 8,
above). Considering that our health care spending is so high, it may be
that the comparatively low spending on social services is a significant
contributor to our poor population health.

We do need to improve the way we spend our health care dollars so that
everyone has affordable access to high quality care, and a single payer
system would do that. However, since we are a very wealthy nation, we
should be able to increase spending on social services as well. The
progressive taxes required to do that would also help to address our
crisis in income inequality."

Thursday, October 8, 2015

Risk Selection Threatens Quality Of Care For Certain Patients: Lessons From Europe’s Health Insurance Exchanges

Risk Selection Threatens Quality Of Care For Certain Patients: Lessons From Europe’s Health Insurance Exchanges

Comment by Don McCanne

"This report, supported by the Commonwealth Fund and published in Health
Affairs, looks at European nations that use variations of market
exchanges of private insurance plans (Belgium, Germany, Ireland,
Switzerland and, especially, the Netherlands) to see what lessons on
risk selection they may have for the United States. But are these the
right lessons for us?

Private insurers in the United States have long been masters at figuring out ways of insuring
the healthy, with their relatively low health care costs, while avoiding
insuring individuals with greater health care needs. Although the
Affordable Care Act prohibits insurers from refusing to cover
individuals anticipated to have higher health care costs, we are seeing
insurance innovations in gaming risk selection that substitute for
medical underwriting, which sometimes still prevents patients from
receiving the care that they should have.

The multi-payer system in the United States is infamous for the very high
costs of the wasteful administrative excesses in our health care
financing. In fact, some of these excesses are for the very purpose of
ensuring the business success of the private insurers. So what
efficiencies do the European systems that use marketplace exchanges of
private plans have that might help the United States avoid the
perversities of favorable risk selection on the part of the insurers?

The authors suggest the introduction of additional risk adjusters (more
administration), systems to collect yet more data (more administration),
introduction of risk-sharing strategies such as mandatory
community-rated reinsurance or risk sharing between the regulator and
the insurers (more administration), allowing insurers to charge their
enrollees, within a band or range of acceptable charges, risk-adjusted
health insurance premium rates (more administration), and balancing
trade-offs of quality-skimping selection, efficiency, and affordability
(more administration).

Not only would these “lessons” expand the administrative excesses of our system, but because
of the trade-offs involved, further compromises in quality and equity
would result. No matter what strategies are used, the private insurers
will always find a way around them. That is inherent in their
business-model DNA.

Instead of us looking for lessons in the European private insurance markets, it seems that these
European nations should be looking for lessons from our neighbor to the
North: Canada and its single payer model of health care financing. We
would do well to do the same."

How the debate over healthcare is changing - just in time for the 2016 election - LA Times

How the debate over healthcare is changing - just in time for the 2016 election - LA Times

Obamacare mandated better mental health-care coverage. It hasn’t happened. - The Washington Post

Obamacare mandated better mental health-care coverage. It hasn’t happened. - The Washington Post

"The Affordable Care Act has boosted the number of Americans with health insurance coverage but has not resolved the disparate way in which many insurers treat the costs of mental and physical health care, according to an April report released by the National Alliance on Mental Illness. "

Reimagining Health Care

Conversations on Health Care presents:

Reimagining Health Care

A panel of speakers from Canada, the UK, and Germany

will share their experience with universal health care. The

current state of the US health care system will be

presented for comparison. The presentation will be

followed by small and large group discussion.

Saturday, November 21, 2015

9 to 11 a.m.

St. Joan of Arc Catholic Community

Hospitality Hall

Join us - Be a part of the discussion

Be a part of the solution

Refreshments served

4537 Third Avenue South, Minneapolis, MN 55419

Sunday, October 4, 2015

More from Kip-Evidence DHS is peddling faith-based health policy

These comments by Kip are important nationwide as we see the corporations taking more and more control of the system at the expense of our health and our pocketbooks.
Oct. 4, 2015

I want to drive more stakes into the heart of DHS's belief that pushing Minnesotans into ACOs and "medical homes" will save money. I'll do that in this email by discussing two documents in the New England Journal of Medicine -- a paper in the current edition and a letter to the editor that I co-authored that I'm told will appear in the Oct 15 edition of NEJM.

The paper I'm referring to is by Jonathan Oberlander, an expert who teaches a the U of NC, and Miriam Laugeson, who teaches at Columbia. Oberlander is a prolific and highly respected writer. I don't know anything about Laugeson. The title of their paper is "Leap of faith -- Medicare's new physician payment system." http://www.nejm.org/doi/full/10.1056/NEJMp1509154 What the authors say about congressional and CMS infatuation with "value-based purchasing" and ACOs and other "alternative payment mechanisms" is directly relevant to DHS's obsession with those fads. "Value-based purchasing" and ACOs show up repeatedly in DHS's SIM application and in materials DHS hands out to members of the Health Care Financing Task Force. DHS is peddling the same theology for Medicaid and all of MN that Congress and CMS are peddling for Medicare.

Oberlander and Lauger essentially say two things: Other countries spend a lot less than we do on health care even though they rely on the fee-for-service method of payment and do not rely on ACOs etc; there is no evidence to support CMS's claims for ACOs, "medical homes," and similar entities designed to shift insurance risk onto clinics and hospitals. Congress and CMS have only faith in the rightness of their opinions.

The other document I want to call your attention to is a letter to the editor of NEJM that I co-authored with Ted Marmor, the professor at Yale who invited me to speak with him at the Yale conference on Medicare and Medicaid last November. The NEJM asst editor I'm dealing with told me recently this letter will appear in the Oct 15 edition of NEJM.

The letter is very short (you only get 175 words). It criticizes the authors of a paper published in the June 18, 2015 edition of NEJM by David Blumenthal, currently the head of the Commonwealth Fund and formerly a member of the Obama administration, and two colleagues. This paper appeared in the June 18 NEJM. It purported to assess the progress of the ACA five years after its enactment.http://www.nejm.org/doi/full/10.1056/NEJMhpr1503614 The authors did make an effort to avoid speaking as effusively about the ACA's cost containment nostrums (the major ones being ACOs and homes) as Obama, CMS and DHS do. Nevertheless, they couldn't resist screwing up royally.

They claimed that one of CMS's ACO programs (the Medicare Shared Savings Program (MSSP)) cut Medicare costs and one of CMS's three "home" programs cut Medicare costs. Neither statement was true. And here's the crazy thing: The two studies Blumenthal et al. cited proved them wrong. I don't know what to call the error Blumenthal et al made. How do you make a false statement and then cite a paper that demonstrates you made a false statement? Was it a lie? Was it laziness? Was it seeing the world through hallucinations induced by HMO Kool-Aid?

Here's what happened. The two papers Blumenthal et al relied on highlighted the reduced claims costs Medicare enjoyed as a result of the MSSP and "home" programs, but downplayed the cost of the bonuses CMS paid out to ACOs and "homes" that succeeded in cutting Medicare's claims costs. The latter costs were right there in the reports for anyone to see who didn't rely on CMS's press releases about the reports. Unfortunately for Blumenthal and all ACO and home buffs, the cost of the bonuses CMS paid out were HIGHER than the reductions in claims costs, for a net increase in costs to CMS of both programs.

What you should find especially troubling about Blumenthal et al's mistake is that they chose what they thought was the best research proving their point that ACOs and homes save money. They didn't have the space to do a literature review, so they cited what they thought were two of the most credible and up to date reports. But they got both reports wrong. The reports disproved their thesis.

So, if someone as smart as Blumenthal et al. couldn't find any literature to support their claims, what are the odds that DHS staff are going to find anything supporting their obsession with "value based purchasing" and ACOs?

Letters to NEJM rarely have replies. NEJM hasn't told me Blumenthal et al. were given a chance to reply and did or did not write a response. I don't know how you respond to our letter other than to say, "Thank you for catching our error."

I did give Blumenthal two chances to explain his behavior to me before I approached Ted about writing NEJM. I sent him and his Commonwealth Fund colleague Stu Guterman the email below. Guterman replied but dodged the question I directed at Blumenthal as to why he misrepresented the papers he cited. I replied to both men again and noted Guterman had dodged my question to Blumenthal. Neither man answered.

Ted and I then wrote the editor at NEJM who managed the article by Blumenthal et al. and politely demanded she print a correction, with or without Blumenthal's permission. She replied she would allow us to write a letter to the editor even though the three-week deadline for letters (they have to arrive at NEJM within three weeks of the publication of the article being criticized). So that's what we did.

So what is the probability that anyone at DHS can produce evidence for ACOs and "value based purchasing" that Blumenthal et al. couldn't think of? Answer: Zero.


From: kiprs [mailto:kiprs@usinternet.com]
Sent: Friday, June 26, 2015 8:04 AM
To: Stuart Guterman; David Blumenthal
Subject: Two questions about ACO research
Dear Mr. Guterman and Dr. Blumenthal,

I'm writing you to call your attention to a defect in the ACO model, and to an inexplicable tendency among health policy analysts to report the gross savings allegedly achieved by ACOs rather than the net savings. I urge you and other Commonwealth Fund officers and staff to use your influence to correct these problems.

I have pasted in below two comments I posted recently on the blog of Physicians for a National Health Program on these issues.
The first comment opens with a statement you made, Mr. Guterman, to Modern Healthcare about how difficult it is to make sense of the findings reported by L&M Policy Research, and by Nyweide et al. in their paper in JAMA based on the L&M report, on the first two years of the Medicare Pioneer ACO program. If Modern Healthcare had called and asked for a comment about the final evaluation of the five-year Physician Group Practice Demonstration (an earlier test of the ACO concept), you would have been forced to make the same comment -- it's hard to know who did what to whom to save the grand total of three-tenths of a percent that the PGP demo saved Medicare (net of CMS's bonus payments).

Can we agree that financing ACO experiments that tell us almost nothing about why ACOs saved or lost money is not a good use of taxpayer dollars? If so, I urge you to use your influence to induce ACO proponents (starting perhaps with your own board and Medpac) to demand that CMS and private promoters of ACOs define the mechanisms ACOs are supposed to use precisely enough to test them -- to operationalize them. That's not possible now given the extraordinarily vague, aspirational definition of "ACO."

The second comment I'm sending along addresses CMS's habit of reporting gross savings to Medicare and either ignoring the cost to CMS of its bonus payments to ACOs, the administrative costs associated with running the ACO programs, and the cost to ACOs of hiring the extra staff and buying equipment necessary to start and maintain an ACO, or burying them in a separate document. (The second comment also addresses another but less common problem -- simulating ACOs and reporting the results as if they were for a real program. If you care to comment on that issue, please do, but I'm more interested in the two issues I've described above.)

Dr. Blumenthal, your comment about the L&M/Nyweide et al. reports in your paper for NEJM, "The Affordable Care Act at 5 Years," illustrates the second problem -- the habit among analysts of repeating CMS's gross savings estimates and not calling readers' attention to the fact that the figures don't take account of CMS's costs, including the bonus payments they make to ACOs. In your NEJM paper, you cited CMS's claim that Pioneer ACOs have cut Medicare's costs by $385 million, but you neglected to tell readers that number was a gross number, not a net. According to a May report put out by CMS, the Pioneer program saved only two-tenths of a percent in 2012 and five-tenths in 2013 when CMS payments are taken into account (see page four here  http://www.cms.gov/Research-Statistics-Data-and-Systems/Research/ActuarialStudies/Downloads/Pioneer-Certification-2015-04-10.pdf. How do you justify citing the gross savings when the net savings are readily available and obviously the number we all care about?

Similarly, CMS says the MSSP ACOs have RAISED Medicare costs (see the same document above), but you claimed in your NEJM  paper savings of $700 million (with no citation).


I'd appreciate hearing any comments you have in response to this email, especially if you feel inclined to support the health policy community's current policy of defining ACOs so vaguely they can't be tested, and CMS's and the health policy community's emerging habit of pretending there are no costs to administering the ACO programs and, therefore, all savings are pure gravy.

Thank you.

Kip Sullivan

Long but important comments by an expert - Kip Sullivan

Oct 3, 2015
Yesterday DHS staff made a Powerpoint presentation to the Delivery Design and Sustainability work group (one of three work groups within the Health Care Financing task force). This presentation made it even clearer what DHS wants from the task force: They want the task force to recommend policies that expand ACOs to all Minnesotans.

True to form, DHS spoke in a language that sounds remarkably like English but actually isn't English when you ask yourself, What did I just hear? I will do my best to translate.

The presentation included 31 slides. It was entitled "Integrated Care Models and Value-based Purchasing in Minnesota." I know you understand what "in Minnesota" means. Let me translate the rest:

* "Integrated care" means medical care delivered by large corporations that own clinics, hospitals, pharmacies, and nursing homes. You see, providers can only communicate clearly with one another if they have the same corporate logo on their doors. Otherwise, communication is impossible. Email doesn't work, phones don't work, faxes don't work. If you don't have a corporate logo on your door, you provide "fragmented care" and, worse, "uncoordinated care."

"Value-based purchasing" is something insurers (public and private) do. "Value," as you know, is a combination of cost and quality. You might fear that letting DHS or BCBS define "value" is a recipe for disaster, but you'd be wrong, according to DHS. DHS knows we're on the brink of being able to measure not just cost per patient accurately, but the quality of care given to that patient as well. Moreover, DHS knows that some IT nerds somewhere are about to invent a computer program will that will combine an accurate score for cost with an accurate score for quality into a single "value" score. And then, DHS can rank all HMOs or all ACOs with a single value score, and award contracts on the basis of this score. Ditto for BCBS. It can rank all doctors and hospitals in the state and decide which ones to include in their ACO.

The first two-thirds of the Powerpoint slides are devoted to explaining ACOs that DHS has already set up within the Medicaid program. The first few slides use the phrase "integrated care model" (ICM) but gradually that label is displaced by the phrase "accountable care organization."

DHS warns us in slide 5 that we're never going to know what an ICM or an ACO actually does. Slide 5, entitled "MN approach to Medicaid ICM," says: "Define 'what' we want, rather than the 'how,'" and "Allow for local flexibility and innovation...." Slide 5 says what we "want" is "accountability for total cost of care," "robust quality measurement," and "models that drive rapidly toward increasing levels of integration."

See what I mean? The words are all words all have an obviously Anglo-Saxon origin, but when you stop and ask, What the hell did DHS just tell me, you realize you have no idea what they said.

The problem is that DHS won't state clearly what their end game is -- to identify the corporations they have in mind that will rule our system, and the tactics these corporations will use to control physician-patient decision-making. DHS's goal is to cram all Minnesotans into a few enormous insurance companies that will be nothing more than HMOs on steroids, but will be called ACOs. The Big Three insurers and a half-dozen dominant hospital-clinic chains (Allina, Mayo, Sanford, etc) will run these ACOs.

The Big Three and the hospital-clinic chains know precisely what DHS is up to. The rest of us don't. This is dog-whistle health policy. It's profoundly undemocratic.

Slides 24-28 describe DHS's attempt to determine how widespread ACOs are already in MN. This attempt was apparently conducted around the time MN received the SIM grant. I infer that from the title of slide 24, "SIM ACO baseline: What we hoped to learn." This note appears (after the name "Karen") at the bottom of the slide: "We wanted to learn about ACO and ACO-like practices in the health care delivery system and we wanted to know the strengths, weaknesses and barriers experienced by providers and payers, with the ultimate goal engaging our stakeholders in a broader discussion around statewide goals and SIM priorities."

The phrase "our stakeholders" appears to refer to insurance companies and hospitals. According to slide 26, DHS interviewed five insurance companies, five medical groups, and two community service workers for this "SIM ACO baseline" study.

Slide 27, entitled "ACOs are spreading," informs us that 40 percent of fully insured businesses (as opposed to self-insured) are "in ACOs," although there's no indication of whether the businesses know they're in an ACO. (I've never heard of an ACO definition which defines ACOs by the businesses that are "in" them. This is a definition peculiar to DHS.) We learn that about half of all providers (individual docs, clinics and hospitals) are in "organizations" that are in ACOs (note the convoluted progression from provider to organization to ACO).

Slide 28 informs us that, regrettably, the amount of insurance risk (presumably meaning risk borne by ACOs) is "low," defined as less than 10 percent of their revenues. But, and here's the good news, "many anticipate growth in % in next five years." You see, it won't be long before insurance companies have shifted all risk over to ACOs.

Not one of the slides in this presentation presents evidence that ACOs function as claimed -- that they reduce costs or improve quality. There is a good reason for that: Existing research shows ACOs either save no money or are raising costs, and that ACOs do improve their scores and the tiny handful of quality measures that are imposed on them, which of course tells us nothing about what happened to the patients whose care was not measured.

Not one of these slides discussed the evidence that "value based purchasing" harms poor people (because cost and quality cannot be measured accurately, that is, in a manner that measures only factors under physician or hospital control). This even though the entire task force has agreed they will examine every recommendation they make for its impact on health disparities.
Despite the evidence, and despite the threat that ACO mania will rapidly increase consolidation and worsen disparities and raise costs, the last slide, slide 31, recommends that we mash the ACO button even harder and spread ACOs across the land.

I have attached the slides that I have discussed here.

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