Category: Health Care Reform Debate

Shortage of Doctors Proves Obstacle to Obama Goals – NYTimes.com

Shortage of Doctors Proves Obstacle to Obama Goals – NYTimes.com:

“Senator Max Baucus, a Montana Democrat and chairman of the Finance Committee, said Medicare payments were skewed against primary care doctors — the very ones needed to coordinate the care of older people with chronic conditions like congestive heart failure, diabetes and Alzheimer’s disease.

““Primary care physicians are grossly underpaid compared with many specialists,” said Mr. Baucus, who vowed to increase primary care payments as part of legislation to overhaul the health care system.

“The Medicare Payment Advisory Commission, an independent federal panel, has recommended an increase of up to 10 percent in the payment for many primary care services, including office visits. To offset the cost, it said, Congress should reduce payments for other services, an idea that riles many specialists.

“Dr. Peter J. Mandell, a spokesman for the American Association of Orthopaedic Surgeons, said: “We have no problem with financial incentives for primary care. We do have a problem with doing it in a budget-neutral way.

““If there’s less money for hip and knee replacements, fewer of them will be done for people who need them.””

So, do we have the beginnings of class war in medicine? Our spending is unsutainable, we spend it in the wrong places quite often, and the specialties with something to lose ( high reimbursement rates) are not going to take this lying down.

The article also goes on to point out that as we bring more people into the ranks of the insured, waiting times will go up. Gee, where have I heard that before?

National Journal Online — Health Care Experts — Paying (Or Not) For Reform

National Journal Online — Health Care Experts — Paying (Or Not) For Reform – Uwe Reinhardt Response:

It didn’t take long before one of several howitzers got dug in to shoot at the idea of universal health insurance. The one out now is the familiar ‘we need to control health care costs in our bloated, inefficient health system first before we can bring yet other Americans under the umbrella of health insurance and into the system.’ That cannon has served us well for over three decades now. I can imagine its roar already, even before the cannon is fully cocked.

To shoot this cannon, you must have a license, and the requirement for that license is that you must be well insured and, indeed, be one of the folks who have helped bloat the system and made in inefficient. And because we, the well insured bloaters, have come to love that system so, we’ll do everything in our power not to change the status quo, won’t we?

The other cannon, still being readied, is the ‘crowd out’ or ‘crowd in’ cannon. It gets deployed whenever someone in Congress or in the White House identifies the year’s ‘objects of compassion’ (OCs). For example, the OC’s may be uninsured children, or unemployed adults over 50, or whatever. The compassionate originator of the idea to do something for the OCs may calculate that it will take, say, $2,700 per OC to practice compassion upon them. No sooner uttered than the computers at the AEI or NBER or RAND or wherever start to whirr, figuring out how many OC-look-alikes now privately insured will be crowded into the new public program intended mainly for the original OCs. And before you know it, the federal budget cost calculated as (federal cost per original OC plus federal cost per crowded in OC) divided per original OC is staggering. Bullet hits on the mark, OC plan is destroyed. Mission accomplished.

This is how America has always successfully warded off any impending threat of universal coverage. Maybe it’ll work again this time.

There’s more…

Support Growing for Major Changes to Health-Care System

Support Growing for Major Changes to Health-Care System:

Most notably, the group, known as the Health Reform Dialogue, calls for creating an ‘individual mandate’ that would require every American to have some type of health coverage. Anyone who cannot afford insurance would be eligible for subsidies or expanded government programs such as Medicaid.

‘We should seek to ensure coverage for all,’ the group concluded after six months of private, professionally facilitated negotiations.

The results are noteworthy because it is the first time that such a varied mix of special interests — ‘strange bedfellows,’ in the words of one participant — have coalesced around significant changes to the U.S. health system. The signers include the American Medical Association, the National Federation of Independent Business, two hospital groups, AARP and the liberal
consumer advocacy group Families USA.

‘We’re narrowing the range of disagreement,’ said Karen Davis, president of the Commonwealth Fund, a nonprofit private health-care foundation that was not involved in the effort. It is striking, she observed, that the Health Reform Dialogue and influential lawmakers have all but ruled out the prospect of a European-style single-payer system, opting instead to build on the existing employer-based insurance arrangements.

Equally striking, however, were the fundamental questions left unaddressed by the group of health-care heavyweights.

‘A day late and a dollar short,’ said one participant who spoke on the condition of anonymity so as not to jeopardize continuing participation.

The coalition’s report is silent on whether employers have a responsibility to contribute to the cost of care, and it does not address the idea of creating a government-sponsored insurance program that would be available for anyone having difficulty buying coverage.”

….

“A government-controlled plan available to every American will push 160 million Americans now in private plans into a one-size-fits-all bureaucratic plan,” said Nick Simpson, spokesman for Rep. Roy Blunt (R-Mo.).

I love that last bit by Rep. Blunt. If by push, he means that by being cheaper, more efficient and consumer friendly, public plans would be able to out compete the very inefficient private insurers, then yeah, they’ll be “pushed.”

Medical Professional Organizations’ Views on Legislative, Regulatory, and Other Issues: Health System Reform

ACS Views on Legislative, Regulatory, and Other Issues: Health System Reform:

Since November 1, 2004, representatives (one elected leader and one staff person) from 11 physician organizations have held three health reform summits, with the goal of developing consensus on approaches that might lead to health care coverage for all, control of exploding health care costs, and sensible adjustments to America’s medical justice system.

Participating organizations included:

  • American Academy of Family Physicians
  • American Academy of Orthopaedic Surgeons
  • American Academy of Pediatrics
  • American College of Cardiology
  • American College of Emergency Physicians
  • American College of Obstetricians and Gynecologists
  • American College of Osteopathic Family Physicians
  • American College of Physicians
  • American College of Surgeons
  • American Medical Associatio
  • American Osteopathic Association

    The Board of Directors of 10 of the 11 participating organizations approved the final set of “Principles for Reform of the U.S. Health Care System”; the AAP did not sign on.

    The goal when signing on to the principles was for each organization to be able to say: “These principles are consistent with our organization’s policy, and therefore we support them.”

Now is the time for the organizations to begin discussions about how we might wish to introduce these important principles to various external audiences — key decision makers, policy makers, the media — and to consider any other “next steps” that we might consider regarding this important issue.
…………….
1.Health care coverage for all is needed to ensure quality of care and to improve the health status of Americans.
2.The health care system in the U.S. must provide appropriate health care to all people within the U.S. borders, without unreasonable financial barriers to care.
3.Individuals and families must have catastrophic health coverage to provide protection from financial ruin.

………….

6. Access to and financing for appropriate health services must be a shared public/private cooperative effort, and a system which will allow individuals/employers to purchase additional services or insurance.

…
11.Comprehensive medical liability reform is essential to ensure access to quality health care.

This was news to me, and it is something to build on…

National Journal Online — Health Care Experts — The Public Plan: Time Bomb?

National Journal Online — Health Care Experts — The Public Plan: Time Bomb?:

“Can Congress fashion a public health plan option so that it does not blow up health care reform this year?”

I didn’t get invited to leave a response, so here’s mine:

Interesting discussion.

Dr. Nichols wonders if we have examples of regulated private insurers brhaving properly. At the risk of venturing beyond our shores, don’t we have examples in Switzerland, Germany and other Social Health Insurance Model countries? His examples of public plans already alive and well in the US seem like good models to consider.

Ms. Turner and Mr. Goodman seem to be arguing opposite sides of magical market place coin: One laments that privte insurers will never be able to compete with the public option, and the other that the private insurers will eat the public plans’ lunch. It is possible for them to co-exist, again, if one is willing to suspend the idea of American Exceptionalism and benefit from the experiences of other nations. I will venture to say that if Mr. Goodman is correct and the private insurers provide efficiency, quality and win-out, then “Hallelujah!”, and all of us skeptics of the efficiency and value of private insurers will have been proved wrong, will eat crow, and happily allow the private insurers to be our vehicles for value.

I don’t think this will happen, and it seems that Mr. Goodman may be conflating the role of private insurers in their function as Medicare Carriers and ther role as profit making (even when ostensibly “not for profit”) insurers, dominating their regional markets, and squeezing their policy holders and providers alike.

Dr. Reinhardt, of course, always nails things and does again here. I think he may have overlooked another latent demand among physicians and other providers. Depending upon where you practice medicine, Medicare may be your most reliable, hassle free and even, in some markets, your best payer. Private insurers, while paying significantly more in some regions, may cost providers more in time, hassle, staffing costs and the like that their reimbursement warrants.

Ms. Davis also frames the debate well by focusing in on the acknowledged truth that we must pay smarter, not just more and more and more.

Cheers,

AMNews: March 16, 2009. White House summit takes 1st step in health system reform discussion … American Medical News

AMNews: March 16, 2009. White House summit takes 1st step in health system reform discussion … American Medical News:

AMNews had a more complete list of physicians in attendance than I did in an earlier post about the Summit:

“President Obama invited more than 100 people to a White House summit on health system reform on March 5, including the following physicians.
Rep. Michael Burgess, MD (R, Texas)
Ted Epperly, MD, American Academy of Family Physicians president
Oliver Fein, MD, Physicians for a National Health Plan director
Jeffrey P. Harris, MD, American College of Physicians president
Risa Lavizzo-Mourey, MD, Robert Wood Johnson Foundation president and CEO
Nancy H. Nielsen, MD, PhD, American Medical Association president
Irwin E. Redlener, MD, Columbia University Mailman School of Public Health professor
Elena V. Rios, MD, MSPH, Hispanic Medical Assn. president
Michael Salem, MD, National Jewish Health hospital system president
Henry E. Simmons, MD, MPH, National Coalition on Health Care president
David T. Tayloe Jr., MD, American Academy of Pediatrics president
Ho Luong Tran, MD, MPH, Asian and Pacific Islander American Health Forum president and CEO
W. Douglas Weaver, MD, American College of Cardiology president”

For my own edification, I did some research on membership numbers:
First, total number of ohysicians in US about 800K.

American College of Physicians (Internists and Medical Specialists) 126,000 members
American Academy of Family Physicians 94,000 members
American Academy of Pediatrics 60,000 members

Amercian College of Cardiology 36,000 members

AMA 240,000 including students and residents (free membership) and retired.
— maybe 140,000 practicing physicians (Approximately 20 % or less of all physicians)

Hispanic Medical Association 36,000 members

Others:

American College of Surgeons 76,000 members

American College of Obstetricians and Gynecologists 52,000 members

American Society of Anesthesiology 43,000 members

American Psychiatric Association 38,000 members

American College of Radiology 32,000 members

American College of Emergency Physicians 27,000 members

American Academy of Dermatology 16,000 members

American Academy of Ophthalmology 7,000 members

American Orthopaedic Association (AOA) 1,500 members

These numbers are from the organizations own websites, except for the AMA data which is from Wikipedia – I actually have the actual data from the membership committee buried in my office somewhere, and if I can find it, I’ll post it.

In any case, some of the numbers include medical students, residents and fellows, and international members. But at least a rough guide, suggesting that there really is no single big gorilla, but I know some small groups put their money where their mouths are and have outsized political clout…

Some State Membership numbers, from their web sites:

California Medical Association 35,000

Texas Medical Society 43,000

Medical Society of New York 30,000

Florida Medical Association 19,000

Illinois State Medical Society _____

Pennsylvania Medical Society 20,000

The Concerns of “Harry and Louise” circa 1994

YouTube Link to videos here.

Because my daughter is working on her undergraduate thesis on comparing the health care reform policy environment in 1994 and now, we were looking at the old Harry and Louise videos.

It is funny, because there are two issues raised in the commercials. In the first, set “Sometime in the Future,”the concern is about having to choose among “insurance plans designed by government bureaucrats” and the lack of choice among doctors, hospitals, etc., should this happen. And the cute little line about, “Remember our old plan? That was a good one.”

Well, of course, those ships have all sailed. Our insurers now dictate our provider choices ever more restrictively. If you’ve ever changed your insurer, you probably have come to terms with looking through the provider book and figuring out which PCP practice to switch to, whether to go “out-of-network” to keep your old specialists, and whether to drive to a new hospital in your network. Unless, of course, you are in a federal plan, designed by bureaucrats, which generally will provide you with substantially more choice than your private plan.

It’s also worth saying that in most markets, insurance consolidation has resulted in ever dwindling choice in private insurers. So, the choice thing? Not so much.

The second commercial talks about the dangers of “community rating” to the premiums of the younger and healthier. This is exactly right, and Uwe Reinhardt has been warning about this lately. If not forced to buy insurance, those who are at lower risk of needing health insurance will opt out, driving up the premiums for those buying insurance, particularly small employers who can’t spread the risk out. A genuinely fair concern that is still in the mix of issues that need to be dealt with today.

So, how to deal with it? Everyone must be in. We must accept the societal bargain that when we are healthy, we subsidize those who are not. When our kids are healthy, we subsidize our neighbors’ kids with diabetes and autism and cancer. When our parents have chronic illnesses, we spread the risk amongst us all.

Eight principles of Health Care Reform – from Obama Budget

• Guarantee Choice. The plan should provide Americans a choice of health plans and physicians. People will be allowed to keep their own doctor and their employer-based health plan.

• Make Health Coverage Affordable. The plan must reduce waste and fraud, high administrative costs, unnecessary tests and services, and other inefficiencies that drive up costs with no added health benefits.

• Protect Families’ Financial Health. The plan must reduce the growing premiums and other costs American citizens and businesses pay for health care. People must be protected from bankruptcy due to catastrophic illness.

• Invest in Prevention and Wellness. The plan must invest in public health measures proven to reduce cost drivers in our system—such as obesity, sedentary lifestyles, and smoking—as well as guarantee access to proven preventive treatments.

• Provide Portability of Coverage. People should not be locked into their job just to secure health coverage, and no American should be denied coverage because of preexisting conditions.

• Aim for Universality. The plan must put the United States on a clear path to cover all Americans.

• Improve Patient Safety and Quality Care. The plan must ensure the implementation of proven patient safety measures and provide incentives for changes in the delivery system to reduce unnecessary variability in patient care. It must support the widespread use of health information technology with rigorous privacy protections and the development of data on the effectiveness of medical interventions to improve the quality of care delivered.

• Maintain Long-Term Fiscal Sustainability. The plan must pay for itself by reducing the level of cost growth, improving productivity, and dedicating additional sources of revenue.

Nothing over the top in here. The principles, I think, are not very assailable.

The Politico offers their “translation” and I think zeroes in on what may become the critical throw down issue: Will we have a public insurance option to compete with private insurers in a system where all are required to have insurance?

Henry Waxman told AMA members in DC that a public option was in his plans, and Obama and Sen. Baucus have also indicated support for a public option.

Here is a link to the AMA National Advocacy Council news site. I have to say, the list of speakers is impressive. No Cato, Fraser, Heritage to be found (at least on the fist day – Tuesday) speaker list. Mostly progressive speakers.

The White House – Press Office – White House Forum on Health Reform Attendees and Breakout Session Participants

The White House – Press Office – White House Forum on Health Reform Attendees and Breakout Session Participants

I was curious who was invited, so click on the link to see the complete list.

The physicians groups that I saw are below.

American College of Physicians, Jeff Harris, President
American Academy of Pediatrics, David Tayloe, President
American College of Cardiology, W. Douglas Weaver, President
American Academy of Family Physicians, Ted Epperly, President
American Medical Association, Nancy Nielsen, President
National Medical Association, Mohammad Akhter, Executive Director
Physicians for a National Health Plan, Dr. Oliver Fein, Director
University of Chicago Medical School, Eric Whitaker, Executive Vice President For Strategic Affiliations

And only one nurses group?

American Nurses Association, Rebecca Patton, President

Updated:Action Alert: Call The White House: Let Single Payer In | Physicians for a National Health Program

Action Alert: Call The White House: Let Single Payer In Physicians for a National Health Program:

***Update***

The White House has reversed itself and extended invitations for two single payer supporters to attend Thursday’s Healthcare Summit.
Congressman John Conyers, author of HR 676 single payer legislation in the House, and Dr. Oliver Fine, who currently heads Physicians for a National Health Program (PNHP), received invitations on Wednesday.

“On Thursday, March 5, 2009, the White House will host a summit on how to reform the healthcare system.

“The 120 invited guests include lobbyists for various interest groups including the private-for-profit insurance industry (AHIP), some members of Congress including Senate Finance Chairman Max Baucus who has already ruled single payer “off the table,” and various others concerned with healthcare.

“No single payer advocates have been invited to attend.”

A disappointing turn of events. My letter to the White House and Senator Casey (my Senator, who is now on the HELP Committee.)

RE: March 5th Health Care Summit

I am disappointed that Single-Payer Health Care advocates are not going to be represented at the Summitt. If this is because Single-Paye is “off the table,” then I suggest you disinvite all those representing the status quo, as I understand that that option is also off the table.

I personally favor transitioning to Universal Health Care via the Swiss or German Societal health Insurance model, but by not having Single Payer advocates at the table, a vast swath of serious intellectual and scientific thought is cut out of the discussion. This is NOT acceptable if we are to have a serious debate about the faith of Health Care in the US.

Thank you, etc.

To Senator Casey:

Dear Senator Casey,

I was very pleased to see that you have joined the HELP Committee. It represents a very important opportunity to do “to the least among us,” what we would want for ourselves and our children.

I hope you will push for a very strong intellectual debate on health care reform, in particular.

I was very disappointed in a recent decision by President Obama to exclude those who advocate for a Single Payer system in the US from his upcoming Health Care Summit.

If this is because Single-Payer is “off the table,” then I suggest disinviting all those representing the status quo, as I understand that that option is also off the table.

I personally favor transitioning to Universal Health Care via the Swiss or German Societal Health Insurance model, but by not having Single Payer advocates at the table, a vast swath of serious intellectual and scientific thought is cut out of the discussion. This is NOT acceptable if we are to have a serious debate about the faith of Health Care in the US.

Although I do not expect you to be able to change what will happen on March 5th, I hope you will use your position on the HELP Committee to ensure a robust, inclusive debate on health care reform.

Thank you etc.

You can get more details at the PNHP site, including that Rep. Conyers, the sponsor of HR 676 asked to be invited and was not at the PNHP site. And the WH phone numbers.