Sunday, August 12, 2018

Health Care Reform Articles - August 12, 2018

Editor's Note:

Here is a link to a very short video from Wendell Potter of Tarbell. It warns us about what is to come,  as the debate about single-payer (Improved Medicare For All) heats up over the the next few years - FUD!


Yes, Medicare for All is expensive. That’s not the point.
by Diane Archer - Washington Post - August 1, 2018
Something interesting is happening in the age of Trump: 63 percent of Americanssupport a national health insurance plan, or Medicare for All, in which the federal government would guarantee health insurance for everyone in the country.
Mounting support for Medicare for All has left conservatives hyperventilating. Commercial insurers and their Republican allies are working overtime to convince Congress and the electorate that we simply can’t “afford” Medicare for All. A reportby the Mercatus Center’s Charles Blahous, who spearheaded President George W. Bush’s attempt to privatize Social Security, is the latest entry in this fuzzy math sweepstakes.
Happily, for those of us who seek health-care security for all Americans, Blahous and his friends miss the point. Our commercial health insurance system is crazy and unsustainable, and Medicare for All is the only realistic path to reduce national health spending and improve the quality of our health-care system.
Sen. Bernie Sanders’s Medicare for All proposal improves and expands the current Medicare program, replacing commercial health insurance with federally administered coverage for all Americans. The proposal eliminates premiums, deductibles and co-pays, and includes new coverage for vision, hearing and dental care. It allows everyone to use the doctors and hospitals they know and trust, anywhere in the country, without the restrictive networks, arbitrary denials and high out-of-pocket costs that go hand in hand with commercial insurance.
Medicare for All, like Social Security, is social insurance, designed to pool and broadly distribute the costs of care across the entire population. At its core, Medicare for All gives doctors and hospitals the freedom to compete for patients without insurers getting in the way.
Blahous writes that Medicare for All is expensive. That’s correct, but it’s the wrong starting point. The current commercial health insurance system is much more expensive than Medicare for All and is unsustainable by any measure.
We spend more than $3.3 trillion a year on health care — about 18 percent of gross domestic product. That’s twice as much per capita on health care as the average of other high-income countries. In return, we get health-care outcomes that rank dead last among our peers. Health-care costs in this country are projected to increase by 5.5 percent a year over the next eight years. You do the math: The status quo doesn’t work. Period.
Medicare for All, by contrast, provides a compelling path to keeping health-care costs in check. To begin with, Medicare for All would eliminate the administrative waste and profit margins created by the commercial insurance system with hundreds of insurers negotiating different agreements with thousands of health-care providers. Total annual savings on administrative costs under Medicare for All are estimated as high as $500 billion a year (far more than Blahous estimates in his report).
Most important, Medicare for All would empower the federal government to use the collective bargaining power of 330 million Americans to reduce the cost of health care, something that commercial insurers have been unable to do. Blahous himself estimates that the extension of current Medicare rates to all health-care services coupled with lower prescription drug prices under Medicare for All would eliminate $445 billion in annual costs in 2022.
In all, Blahous concedes that Medicare for All would reduce national health spending by $2 trillion over 10 years, even after accounting for the cost of guaranteeing everyone coverage and offering better benefits. (And again, many health economists would say Medicare for All would drive far greater savings.)
Blahous’s concern is that Medicare for All will transfer the rest of the cost of health care from the private sector to the federal government. Okay. So how will we pay for Medicare for All? The same way we pay for the defense budget and everything else: through taxes. Does that mean that ordinary Americans will pay more under Medicare for All than they pay for health care today? No.
Think about it. Today, the typical family of four spends more than $28,000 on health care a year. Individuals pay that cost indirectly through lower wages (which fund the employer’s share of health insurance) and directly through out-of-pocket costs. Under Medicare for All, the typical family will see higher wages and lower expenses and spend much less on health care than it does today.
To be sure, the transition to Medicare for All will disrupt the health-care marketplace. Insurers will wind down. Pharmaceutical companies and medical device manufacturers likely will see their profits drop. Hospitals and doctors will need to work smarter and more efficiently; they will see an overall reduction in their rates, but they will save on administrative costs and their bills will all be paid.

There are always winners and losers in policy reform. Today, commercial insurers and other corporate interests in the health-care industry are the winners, and the American people are the losers. Medicare for All flips that paradigm. We can’t afford to live without it.

The Outsize Hold of the Word ‘Welfare’ on the Public Imagination

by Emily Badger - NTY - August 6, 2018

The federal program known as welfare delivers cash assistance to less than 1 percent of the United States population. This is far smaller than the share of those aided byfood stamps, or by other government support like disability benefits, unemployment insurance, college grants and medical benefits.
But none of those other social programs have captured the public imagination or pervaded American politics as thoroughly as welfare, a piece of the safety net that helps about 2.5 million people. Its outsize influence has remained — and could soon become larger — even as the program itself has shrunk to its smallest size
Unexpected evidence of this emerges in the research of Suzanne Mettler, a political scientist at Cornell University perplexed by the trends that Americans have come to dislike government more and more, even as they have increasingly relied on its assistance through programs other than welfare. Americans are far less likely today than 40 years ago to say in surveys that they trust the government to do what is right or to look out for people like them. At the same time, the share of Americans using nearly all of these other programs has risen.
In 1969, 7 percent of the average citizen’s income came from federal social transfers, and in 1979 it was 11 percent. By 2014, it was 17 percent, according to Ms. Mettler’s analysis of dozens of programs, including means-tested aid like food stamps, benefits tailored to narrow populations like veterans, and broad-based government programs like Social Security.
Her accounting totals most of the ways government assists people in their daily lives, regardless of whether programs are targeted at the poor, or require taxpayer contributions (the number would be higher still if we included benefits like the mortgage interest deduction that are channeled through the tax code). The growth in these programs, over a time when middle-class wages have stagnated, has lifted residents of some counties to count on government for as much as half of their income.
In her surveys, Ms. Mettler has found that people typically say the programs they’ve used have helped them. It seems reasonable to think that this sentiment might translate to appreciation for government — that the more programs people use, the more they might value the government that supplies them. But this is not what she found. Relying on government doesn’t make people more likely to value government, or make them feel more strongly that government is responsive to them.
Their feelings about government don’t appear connected to their own direct experience of it. But those feelings are shaped by opinions about other people’s reliance on government aid — specifically, on “welfare.” 
That was the “one factor that just kept showing up again and again,” Ms. Mettler said of the data she describes in a recent book, “The Government-Citizen Disconnect.”
People who strongly dislike welfare were significantly less likely to feel government had provided them with opportunities, or to feel government officials cared what they thought, regardless of how much they’d relied on government programs themselves.
“Their attitudes about welfare end up being a microcosm for them of government,” Ms. Mettler said. “They look at how they think welfare operates, and if they see that as unfair, they think: ‘This is basically what government is. Government does favors for undeserving people, and it doesn’t help people like me who are working hard and playing by the rules.’ ” 
Her surveys did not define the word “welfare.” So it’s unclear if people who say they strongly dislike the program were envisioning the cash transfers now called Temporary Assistance for Needy Families, or if they had in mind a broader collection of programs like the Supplemental Nutrition Assistance Program (or food stamps) that help the poor. 
The slippery definition of the word is part of what has made it so politically potent. Whatever programs people attached to it in their minds, Ms. Mettler’s data suggests that people who have used, say, Medicaid, unemployment insurance and veteran’s disability payments over the course of their lives may be more influenced by their dislike of something they haven’t used than by their experiences with the programs they have.
For perspective, in historical data Ms. Mettler has collected, this is how usage of welfare cash assistance actually compares in scale with some of these other programs:
So what accounts for welfare’s disproportionate hold on how Americans think of government? Other research points to the role of racial resentment: Controlling for other factors, states with larger African-American populations have imposed stricter rules and less generous benefits in their welfare programs. In Ms. Mettler’s data, whites were more likely than African-Americans to disapprove of welfare, as were middle-class people relative to poorer ones.
Some politicians opposed to welfare have implicitly linked the program to minorities, evoking “welfare queens,” recipients from the “inner city” or immigrants who come to America just to use welfare. It has both effectively tied minorities to welfare, and tied welfare to government writ large. 
The Trump administration has begun to take this connection one step further: It has proposed reorganizing the federal government to place many of these social programs under a new agency with the word “welfare” in its name
The president has repeatedly used “welfare” to refer expansively to all programs that aid the poor. And a recent Council of Economic Advisers report on expanding work requirements for Medicaid, food assistance and housing aid pointedly rebranded those programs as “noncash welfare.” 
“They certainly know that people hate welfare, and if you call something welfare, you get a large share of Americans who are against it,” Ms. Mettler said. The negative power of the word is so strong, she suggested, that programs that garner broad approval under another name could easily be tainted by it. “Call something welfare,” she said, “and forget it.”

Medicare for All Makes A Lot of Sense

The current system is an outrage, and Americans express less satisfaction with the health care system than do their counterparts abroad.
by Jeffrey Sachs - Common Dreams - August 7, 2018

The economics of Medicare for All championed by Sen. Bernie Sanders are actually quite straightforward. Under what advocates call "M4A," health care coverage would expand while total spending on health care—by companies, individuals and the government—would decline because of lower costs. More would be paid through the government and less through private insurers.
M4A would reduce health care costs for three reasons. First, Medicare pays hospital and doctors at lower rates than private insurers. Second, drug prices would be lower. And third, there would be administrative savings.
These conclusions are robust. Recently, the libertarian-leaning Mercatus Center published a study with data that bear out these conclusions. Indeed, these sensible conclusions jump out of any straightforward analysis.
M4A would seem to be an unbeatable approach. And indeed it is—almost. It's basically the solution adopted by Canada, the countries of Western Europe, Japan, Australia and New Zealand.
Yet one high-income country does it differently: the United States, which still relies heavily—far too heavily—on private health insurers.
A broken system
The main reason why the United States continues with a broken system is straightforward. The US private health care industry is enormously profitable and powerful. M4A would help the nation but hurt the owners, top managers and highest-paid health providers of the private health care industry.
Thus, the health care lobby blocks M4A—though it would greatly benefit the nation. (Free-market ideologues, including the Mercatus Center, oppose M4A because it would enlarge government, even though it would both expand health coverage and reduce costs. More government, in the free-market view, is bad even if it is more cost-effective.)
The challenge in adopting M4A is not really about whether it would be a better system. Yes it would be. It is about political muscle. The health care lobby is the biggest one in the country, with lobbying outlays of a whopping $557 million in 2017, including $280 million by pharmaceutical and health products companies, $103 million by hospitals and nursing homes, $92 million by health professionals and $82 million by health services and HMOs, according to the Center for Responsive Politics. Those princely sums add up to a lot of votes in Congress.
The lobbyists get a very good return on their political investments, to the detriment of almost all Americans. Americans spent an average of $10,300 per person on health care in 2017, about twice the average of comparable countries. Those excessive outlays pay for the ridiculously high earnings in the health care system. According to recently published data, 17 CEOs of not-for-profit hospitals, for example, were paid more than $5 million each in 2014. And that's just the not-for-profit sector.
Americans know well the dismaying case of a medicine like sofosbuvir (trade name Sovaldi), a cure for Hepatitis C, that cost about $1 to produce yet was originally sold for $1,000 per pill, with the monopoly power of patents and the protection of an absurd law that blocks the government from negotiating prices with the private pharmaceutical industry.
The current system is an outrage, and Americans express less satisfaction with the health care system than do their counterparts abroad. And yet it doesn't change. The health care lobby has been too strong, successfully playing on the public's fear of change and the fear of too many incumbent politicians of crossing a powerful lobby.
The missing facts
Vital facts are routinely obscured from the public. Consider the recent Mercatus study. On the one hand, it rightfully and straightforwardly concludes that M4A would provide more health care coverage at lower cost than the status quo, projecting a net reduction in national health expenditures of roughly $2 trillion over a 10-year period (2022-2031), while also enabling increased health care coverage.
Yet the study actually portrays this outcome in frightening terms, as simply a great expansion in the size of government and taxes: "Doubling all currently projected federal individual and corporate income tax collections would be insufficient to finance the added federal costs of the plan."
The simple retort, of course, is that the reduction of private-insurance premiums would more than offset the rise in the public sector costs (hence the overall net saving). Yet this fundamental point is buried in the report's rhetoric. It would not be hard to design the new taxes, perhaps as payroll taxes rather than income taxes, so that almost all workers would see a net reduction of their health care costs (with the elimination of private-insurance premiums more than offsetting the rise in taxes).
The Mercatus report fails to emphasize three crucial facts:
First, US health care is not a competitive marketplace. It is rife with monopoly power, enabling the extraordinary markups of drug prices, the extravagant salaries of the top-paid health care providers and the rampant price discrimination exercised by health providers, which charge different prices to different clients depending on the provider's market power vis-à-vis different clienteles. M4A would limit this monopoly power by putting a powerful government payer up against the monopolists.
Second, US health care prices are sky-high compared with the prices paid in other high-income countries, while US health outcomes are worse. Life expectancy in the United States is not only around five years lower than in the leading countries but has actually been declining in the past two years, in part because of epidemics of depression, suicide and substance abuse.
Third, M4A wouldn't require the United States to plunge into an unknown health care model. Medicare already ensures lower costs than private health care and is popular among the elderly. The health systems of every other high-income country offer other proven models. Par for the course, the Mercatus study doesn't even mention the overwhelming evidence from abroad
By looking more carefully abroad we would learn that M4A can save far more than $2 trillion over 10 years. The savings could actually approach $1 trillion per year, given that the United States would save even more than that amount per year were it to pay the same share of gross domestic product on health care as does Canada with its single-payer system (10.4% of GDP in Canada, compared with 17.1% in the United States, for 2017). Even with that lower rate of spending, Canada achieves a higher proportion of health care coverage and a longer life expectancy (81.9 years, compared with 78.6 years in the United States, for 2017).
Sanders nearly won the Democratic nomination in 2016 by taking M4A to the people despite the naysaying of the Democratic Party establishment and newspaper pundits. With health care premiums continuing to soar, and with Donald Trump and the Republican Congress aiming to cut back even further on health care coverage, the public backing for M4A is sure to surge by the presidential election in 2020.

Sorry about your Stage 3 cancer. Here's a bill for $21,000 in charges you thought were covered

by David Lazarus - LA Times - August 7, 2018

When Michele Brough was diagnosed with Stage 3 breast cancer in April, her oncologist wasted no time in reaching out to her insurer, Anthem Blue Cross and Blue Shield, to obtain pre-approval for a drug that would strengthen her immune system to better withstand chemotherapy.
The good news came shortly afterward. “We are pleased to authorize benefits for the service(s),” Anthem informed Brough, 56, by letter.
The chemo began in mid-May, with each session including an injection of the pre-approved drug Neulasta Onpro to stimulate production of white blood cells and help ward off infection.
It wasn’t until after the second round of treatment that Brough’s oncologist informed her Anthem wasn’t covering the injections, sticking her with the staggering cost of $7,000 for each shot.
As if that weren’t devastating enough, Anthem’s reasoning was downright absurd.
Yes, the drug had been pre-approved, but only if Brough bought it herself through the online pharmacy Express Scripts, and only if she gave herself the shots.
“It just made no sense,” Darrell Brough, Michele’s husband, told me. “They covered everything else, all the drugs, all the doctor’s visits. But not this?”
There was nothing in Anthem’s approval letter that said anything about buying it exclusively from Express Scripts or handling your own shots.
And even if Indianapolis resident Brough had bought the drug, her husband said the oncologist refused for legal and safety reasons to administer a drug she had acquired herself.
“They wouldn’t administer it because it wasn’t from their own pharmacy,” he said.
I’ve come across some strange insurance denials, often involving treatments that corporate bean counters say are experimental whereas actual medical professionals say otherwise. But Anthem took this up a level.
The company’s behavior seemed inconsiderate to the point of cruelty — at best an act of gross incompetence, at worst sheer meanness.
I mean, who does that, approving part of a cancer patient’s treatment but not the whole thing? And then sticking the patient mid-treatment with thousands of dollars in unexpected costs for some totally bogus reason?
To be sure, insurance companies are entitled to make money for managing people’s healthcare risk. But that doesn’t justify acts and decisions that demonstrate a near-total lack of empathy.
Michele Brough’s Stage 3 cancer is considered an advanced form of the disease, although the American Cancer Society places the five-year survival rate at 72% with appropriate treatment.
Her husband, who handled all the bills and the dealings with the insurer, said no reasonable person would anticipate a patient receiving chemotherapy treatments from doctors and nurses would be personally responsible for administering her own immune-system booster shots.
Moreover, once the chemo has begun, you’re committed. Even though Brough and his wife were $14,000 in the hole after the second session, they weren’t going to stop even when the oncologist made Michele sign a waiver before the third round promising that she’d be responsible for the cost.
Anthem denied that claim as well, placing the Broughs $21,000 in debt.
For the fourth and final round of chemo, the oncologist decided to skip the booster drug, hoping Michele’s immune system was by now strong enough to take the punishment.
I’m not second-guessing a doctor, but it seems to me that any time you forgo an established treatment solely for financial reasons, you’re placing yourself in danger. Happily, Brough said his wife has responded well to the chemo treatments.
But they weren’t in the clear. Brough said he was told by the oncologist that if Anthem wouldn’t cover the $14,000 for the first two shots, he and his wife would be held responsible and the case could be referred to debt collectors.
“It’s crazy,” he told me. “Any way you look at it, it makes no sense.”
Brough, 56, a project engineer for a computer consulting firm, appealed the charges to Anthem. Weeks later, he wasn’t getting anywhere. So he came to me.
Within days of my getting involved, Anthem acknowledged it had screwed up.
“When we were recently made aware of a concern pertaining to an oncology drug used by one of our consumers, our team began working to understand what happened and found the claims were processed incorrectly,” said Leslie Porras, a company spokeswoman.
I asked why it took a call from a reporter to figure that out. Why didn’t Anthem discover the mistake as soon as Brough lodged his appeal?
“Since the member first contacted us, we have been working with all parties involved to coordinate and resolve this matter,” Porras replied.
All appearances to the contrary notwithstanding.
Shortly afterward, Brough told me he’d heard from Anthem. “They are covering the three injections in full,” he said.
That’s great. It goes without saying, however, that no one should have to rely on the press to resolve an insurance matter — especially when the insurance company is at fault.
The Broughs did everything right. They sought pre-approval for coverage. They promptly appealed questionable charges. Yet they still got what they felt was the runaround.
The only other thing I’d advise in a situation like this is to bring in a professional patient advocate, a person who specializes in navigating the twists and turns of the healthcare system, including billing issues.
Many group insurance plans will cover the cost of a patient advocate — ask your employer. Otherwise, the advocate might charge on an hourly basis or receive up to a third of whatever savings can be secured.
You can search for a local advocate on the website of the National Assn. of Healthcare Advocacy Consultants or via the Alliance of Claims Assistance Professionals.
Another piece of advice: Don’t give up.
As the Broughs saw, insurers make mistakes.
They’re just not particularly good at admitting it.

Letters to the Editor - LA Times - August 9, 2018

To the editor: I read with interest and chagrin David Lazarus’ column on a cancer patient who was hit up for the full cost of a drug, for which she had been approved by her insurer, in the middle of her treatment. As a physician with more than 50 years of practice behind me, I have seen many similar instances of unconscionable acts by insurance companies.
I take issue with one of Lazarus’ statements: “To be sure, insurance companies are entitled to make money for managing people’s healthcare risk.”
The profit motive is at the core of what I believe to be the major problem with healthcare in the United States. Healthcare is not a commodity and it should not be the source of profit for insurance companies. It should be the right of all residents to receive care through a government-funded, single-payer system.
As more instances like these come to light, I believe the political will to enact a single-payer system will strengthen and change healthcare in this country.
Ronald F Young, MD, Laguna Beach

To the editor: My wife is also going through chemotherapy treatments for breast cancer. For us, this has been a very hard and lengthy process.
I’m a bit unclear as to why the insurer is to blame here. It agreed to cover a particular immunity-boosting drug purchased through the Express Scripts pharmacy, with the injections to be administered by a caregiver rather than the oncologist. This is an increasingly common cost-cutting practice among insurers.
My wife is on the same type of injected medication. She is being treated by Kaiser Permanente, which requires us to use its pharmacies and supplies us with the syringes. I administer one injection per day for five days after each round of chemotherapy. We have no problem with this.
To me, the real issue is the exorbitant cost of the injections for someone who has no choice but to pay for it themselves. Fortunately, insurance is covering the cost for us, but with the dismantling of the Patient Protection and Affordable Care Act by the Trump administration, people dealing with this life-threatening illness in the future may not be so fortunate.
Larry Levy, Winnetka
To the editor: I’m convinced Express Scripts created its subsidiary specialty pharmacy, Accredo, specifically to produce so many obstacles to obtaining prescribed medications that coverage is effectively denied.
If just a few percent of insured patients give up after repeated, lengthy phone calls and Accredo’s other rope-a-dope techniques, Express Scripts saves untold millions of dollars.
We earned our coverage. Why do we have to fight for it?
Thomas Bliss, Sherman Oaks

Why America Needs Medicare for All

By Meagan Day and Bhaskar Sundara - NYT - August 10, 2018

A growing majority of Americans agree: Health care shouldn’t be a business. They’re finally coming around to the idea that it can and should be a public good instead — something we can all turn to when the need arises. 
The favorite right-wing argument against Medicare for All — the most popular approach to universal, publicly financed heath care — is that it’s too expensive. More on those costs in a moment. But first, we should note that our current health care system is actually the most expensive in the world by a long shot, even though we have millions of uninsured and underinsured people and lackluster health outcomes. 
This is partly because a lot of that money doesn’t go directly toward keeping people healthy. Instead it goes to the overhead costs required to keep businesses running. These include exorbitant executive salaries, marketing to beat out the competition, the labor-intensive work of assessing and denying claims and so on. None of these would be a factor in a single-payer, Medicare for All system. Taiwan and Canada both have single-payer systems, and both spend less than 2 percent of total expenditures on administrative costs — and so does the United States’s current Medicare program. By contrast, private insurers in the United States spend as much as 25 percent on overheads.
But the most important way Medicare for All would save money isn’t by slashing administrative costs. It’s by using the power and size of the government, like other countries around the world currently do, to negotiate favorable terms with drug companies and service providers. There’s a reason a CT scan costs $896 in the United States, but only $97 in Canada.
And what about the sticker shock factor — the dramatic rise in government spending to accommodate such a program? Medicare for All would transfer all payment responsibility to one public agency (as opposed to a bunch of private companies), and that act of combination produces the big price tag that conservatives use as a cudgel. But while this would be more expensive for the government, it wouldn’t be for ordinary Americans. The money would be raised through progressive income and corporate taxes and end up costing most people less than their current health care. And coverage would be comprehensive and universal, meaning nobody would everbe unable to afford the care they need.
Pursuing Medicare for All would come with its own set of dilemmas: Eliminating an entire industry won’t be easy, and we’ll face plenty of political resistance and calls for half-measures. But if we want actual universal coverage, and we want it to be affordable and high-quality, Medicare for All is the only way forward.
This is our fifth and last newsletter; next week Quinta Jurecic of Lawfare will substitute for David Leonhardt. We’ll leave you with a few suggestions for further reading:
How Medicare Was Won by Natalie Shure, The Nation
Single-Payer or Bust by Adam Gaffney, Dissent
“It Was About the Insurance Fix” by Meagan Day, Jacobin

5 doctors and surgeons tell us what they really think about Medicare-for-all 

Some doctors support single-payer health care — even if that means a lower salary.

by Dylan Scott - VOX - August 10, 2018

The muscle of the health industry lobby — pharma, health plans, doctors, and hospitals — is gathering to stop single payer.
The Hill’s Peter Sullivan had the report on Friday morning. The industry’s influence can’t be underestimated: It stopped Clintoncare. And, for better or worse, it was a boon for passing Obamacare that the industry mostly supported the legislation.
The industry’s disparate interests fight over a lot of issues, but Medicare-for-all unites them. That is going to be a factor if we get to 2021 with a Democratic Congress and president, and they decide to pursue single-payer health care.
That moment really might come. A sign times are changing: A Republican health care lobbyist called me recently to ask whether all-payer rate setting would be a better alternative to single payer, by causing less disruption. (I quibbled that you would need some kind of coverage component, given the moral urgency that is animating the left on health care.)
Still, a Republican almost endorsing price controls. That is a pretty strong indicator of where our health care debate seems to be heading.
Payment cuts for health care providers, if we eliminate private insurance and move everybody to Medicare rates, are going to come up a lot in this debate.
Those cuts are an easy thing for industry lobbyists to target and for Republicans to run ads on. Cuts could be overstated, depending on how much legitimate waste single payer can actually eliminate by consolidating the administration of health care, but the projections for Medicare for All plans are going to anticipate big cuts.
That explains the industry’s lobbying position. But reality on the ground is more complicated than that. There are absolutely health care providers who support single payer. Quite a few of them sent me emails after I asked for their thoughts last week.
Here are some of the most interesting responses. From a registered Republican working at a next-gen gene sequencing company:
Medicare is, without question, the most reliable, most predictable payer that we deal with. And for somebody like me it would be a dream to only have to deal with them. Yes, they are pretty heavily regulated. And yes, they have pretty strict guidelines for who to cover. But unlike other payers, who make life virtually impossible for smaller providers because they’re in the for-profit game (the not paying for care game), Medicare at least adheres to a clear set of rules. Other payers put up an endless set of traps against reimbursement, contracting, and other parts of the revenue life cycle that add substantial cost to services and thus increase cost to the consumer. I can say with near certainty that parties in my industry would provide services at a materially lower price and with more predictable out of pocket costs if every payer was as reliable and consistent as Medicare.
As such, I’m now, despite growing up a conservative afraid of such government largesse as “Medicare for all,” convinced that a single public payer, either as rate setter or as a true single payer, is needed. In contrast, I remain a staunch defender of private medical care, where companies such as my own and our competition do battle to increase quality and lower patient cost.
So I guess you could count me as pro-Medicare for all, a sentence I never thought I’d write 15 years ago.
From a retired neurosurgeon, who had also thought of himself as a Republican:
I practiced neurosurgery in Texas and retired 20 years ago. I started out as a pretty solid, but non-thinking, Republican, opposing perceived intrusions of Medicare into my practice. I read Himmelstein and Woolhandler’s NEJM articlesand thought they were Harvard hippie Communists. Over time, I came to see that they were right, that we really need a universal health care system, as so many of my patients weren’t getting needed care. I was a bit embarrassed making as much money as I did, and would have done it for half of that.
From a radiation oncologist of more than 20 years, in Chicago and for the military:
I left full-time medicine a few years ago after getting fed up with continuously fighting insurance companies for pre-authorization and for the right to practice medicine the way I was trained within the standard published guidelines. I now work part-time seeing primarily uninsured and Medicaid patients.
A 2011 Health Affairs study found that the average US physician spends nearly $83,000 a year interacting with insurance plans. And a 2010 American Medical Association Study found the average doctor spent 20 hours a week on pre-authorization activities. This has only gotten more expensive and much worse. Under a single payer plan, this would be much easier and far less expensive.
In addition, we know that the major cost of malpractice coverage is for the continued medical care of the patient that was harmed. A single payer system would insure that any such patient would be covered for the rest of their lives and as a result, malpractice coverage would also be dramatically lower.
While reimbursement under a single payer plan most likely would be less, so would the headaches and administrative hassles and costs. And I would be able to see far more patients instead of being on the phone fighting with a case manager, while my office and malpractice coverage costs would be far less.
From a Texas oncologist still early in their career:
My general view of Medicare-for-all is that it would moderately contribute to remedying our health care spending problem, but by no means fix it.
My understanding is that the biggest savings would come from getting rid of the huge administrative dead weight in our private insurance system. However, that in and of itself would not fix the fact that billing rates are through the roof here in the US. Saving a few percent on overhead would be great, but MRIs and appendectomies are still going to cost 2x-4x here than in other OECD countries.
I am definitely heterodox among physicians in believing that our salaries (mainly among specialists such as myself) ought to be significantly lower. The greater bargaining power that a single, government payer might have could potentially rein in some of that.
On the other side, from an anesthesiologist intern in Chicago, fiscally liberal but socially conservative, who has some concerns about how single payer would handle Catholic hospitals:
The one part of a more single-payer system that worries me relates to the socially conservative opinions I have. I’m sure you have seen the series FiveThirtyEighthas had the past week on the effects of Catholic hospitals coming to predominate more rural areas and even some cities. (As someone who grew up in a small town, I can say the main health care provider in the area is a Catholic hospital.) I don’t fear a single-payer system would result in individual providers being required to provide services they individually oppose for religious beliefs.
However, I do worry about whether or not there would be requirements for Catholic hospitals to provide services contrary to Catholic teaching, generally surrounding abortion or end of life care, in order to be eligible for billing Medicare. I do presume a Medicare-for-All system would pass on a party-line vote with only Democrat support and could see them trying to expand abortion coverage--either directly in a law or through regulation like many abortion coverage issues have been changed--at the same time since that issue has also grown much more partisan in the past decade.

Staffers are fleeing as central Maine hospital system is roiled by turmoil

by Lindsay Tice - Lewiston Sun-Journal - August 11, 2018

LEWISTON — Central Maine Healthcare staff members say things have been bad within the hospital system for a while.
In recent months, the Sun Journal has spoken to or received emails from about a dozen people affiliated with the hospital system, most of them current or former members of the staff. Nearly all asked to remain anonymous, fearful of losing their jobs or being labeled troublemakers in the close-knit community that is Maine health care.
Their comments come amid public turmoil at Central Maine Healthcare, the corporate parent of Central Maine Medical Center, Bridgton and Rumford hospitals and a collection of medical practices in 15 communities. With about 4,000 workers, Central Maine Healthcare is one of the largest employers in the area.
Last month, medical staff at all three hospitals issued votes of no confidence in Central Maine Healthcare CEO Jeff Brickman. Last week, the hospital system’s board of directors voted to change its bylaws to give doctors more of a say in how things are run while affirming its support of Brickman, whom it had hired two years ago to lead the financially troubled system. The day after that board vote, the president of the Bridgton and Rumford hospitals resigned.
Each person who spoke to the Sun Journal had a different perspective, but a common theme quickly emerged: Doctors are fleeing Central Maine Healthcare.
“Every couple of days there are several more resignations,” said a provider within the hospital system.
Central Maine Healthcare officials acknowledged this past week that its most recent physician turnover rate stands at 27.1 percent. That means about 80 of its 300 doctors left this past fiscal year that ended in June.
Average turnover rates for doctors in hospital systems statewide or nationally are hard to come by, but health care data company SK&A says the annual turnover rate for office-based doctors in the U.S. is 8 percent.
It says the average turnover for all hospital employees – doctors, nurses, support staff and others – in the U.S. is 18.6 percent.
While people who spoke to the Sun Journal say Central Maine Healthcare’s doctor turnover is high and causing problems, particularly for patients, system officials say the turnover rate is actually lower than it was the previous two years.
Further, they say they’re working on boosting recruitment and retention and are taking to heart the medical staff’s concerns.
They say, however, at least some turnover is virtually guaranteed. Not every doctor will fit this new administration.
“Change is hard and they may decide that they aren’t up for the change,” said David Tupponce, executive vice president for the system and president of CMMC.
To be clear, current and former staff members say, the former Central Maine Healthcare administration wasn’t great, either.
When Peter Chalke retired in 2016 after 33 years with the system, 14 years as CEO, Central Maine Healthcare was running millions of dollars in the red.
Not long after he was hired to replace Chalke, Brickman spoke publicly about the system’s financial troubles and the need for a “transformational” plan.
He hired consultants from Kaufman Hall to look at Central Maine Healthcare’s performance, quality and finances. He declined at the time to say how much the consulting group would cost, except to say it would be “a lot of money” and “a very significant investment in resources.”
Brickman also soon began reshaping the administration. Outside hires dominated, including a new chief financial officer who had worked with Brickman at his last job in Colorado. Several key officials from the old administration left, including CMMC President Tina Legere and Chief Nursing Officer Sharron Chalke, wife of the former CEO.
In 2017, Brickman dropped Chalke’s plan to move sports medicine, outpatient physical and occupational therapy and weight management programs into Bates Mill No. 5. At the same time, Central Maine Healthcare laid off 28 workers and let the YMCA of Auburn-Lewiston take over operations of the CMMC Fitness and Wellness Center at 12 High St.
Also in 2017, Central Maine Healthcare closed its urgent care center in Auburn. Less than a year later, it decided to open one in Topsham.
Brickman’s mandate was clear: Things were going to change.
That was not unusual for him. In November 2016, just months after he took over at Central Maine Healthcare, Brickman wrote a piece for Harvard Business Review titled “How to Get Health Care Employees Onboard with Change.” In it he talked about his time as group president for Centura Health in Colorado – his last position before moving to Central Maine Healthcare – and his efforts to create a strong executive team in Colorado, fix financial and operational problems there and determine a clear, strategic path for the organization.
“Within a few years, we had dramatically turned around the organization’s finances, performance measures and market share,” he wrote. “Things were looking up on all fronts except one. Our employees weren’t along for the ride.”
Brickman outlined the ways he brought employees on board, including soliciting staff feedback, hiring an organizational change consultant he’d worked with at other hospital systems, and establishing teams of employees to identify problems and solve them.
It worked, Brickman wrote, and the experience changed him.
“The approach we put in place forced us to listen and learn how to support people rather than dictate or direct them,” he wrote.
A year and a half later, separate medical staffs at all three Central Maine Healthcare hospitals said his leadership here is so harmful that they have no confidence in him.
Brickman declined to comment for this story.
Those who spoke to the Sun Journal say Brickman’s management style is anything but the collaborative, cooperative approach he described in Harvard Business Review.
They paint a picture of a leader very concerned about the system’s financial future but less concerned about employees or patient care.
“From my perspective, it seems like the goal of health care has shifted from more of something that’s focused primarily on quality more toward the quality we can afford,” said one former Central Maine Healthcare provider. “Going from, ‘Let’s do this the best way we can,’ to, ‘As long as we can do it good enough, that seems to be OK.'”
He and others say they’ve seen staffing cuts, particularly among support staff. Employees who remain have to take up the responsibilities of those who left.
“Those people already had full-time jobs and now their work is being tripled or quadrupled,” the former provider said. “People then feel like they can’t do a good job because there just aren’t enough hours in the day to do a good job.”
Those who spoke to the Sun Journal say at least some doctors have been required to see patients faster – as quickly as every 15 minutes.
“Faster, so you could see more,” the former provider said.
One person said the new pace increased patient load in one office by about 50 percent.
That pace, those who spoke to the Sun Journal said, makes it impossible for doctors to spend much time with their patients or transcribe notes after each appointment. Doctors began waiting until the end of the day to add information to their patients’ files, a chore that took hours. It didn’t help that a new electronic medical records system added even more time, they said.
“It’s just unconscionable the way people have been treated,” the former provider said. “Treating providers like first-graders that needed to be scolded. Sometimes being brought to tears. And that’s no exaggeration.”
Some staff members said they got the sense their jobs were on the line if they continued to complain. John Berry, a volunteer chaplain, said he was fired.
Berry said he served CMMC for 13 years before being told not to come back last year. He said he was told he was fired because of a Facebook post in which he poked fun at a new Central Maine Healthcare plastic surgery effort, but his termination came a month after he publicly questioned Brickman at a staff meeting.
“I was marked because Brickman was very unhappy with me,” he said. “We had a subsequent conversation that was brief but during which he showed his displeasure. It was palpable.”
Berry wasn’t the only one told to leave. A number of people said they were fired or knew of people who were.
“Part of my trouble with the new administration is there just seems to be not very respectful interaction with the doctors,” said Gregory D’Augustine, a retired surgeon who worked at both CMMC and St. Mary’s Regional Medical Center and still speaks with former colleagues there.
As morale plummeted, people said, doctors started leaving on their own. Some moved up their retirement date by a few years. Others left to work somewhere else.
Earlier this year, the system hired Stacy Goldsholl to serve as chief physician executive.
“She was very much pro-physician. Extremely pro-physician,” a provider within the system said. “She wanted to improve our working conditions. She wanted to give us all the resources that have been taken away from us and just improve the ability to deliver care that has been jeopardized in the past two years.”
Goldsholl resigned two weeks ago, just before the board voted to keep Brickman.
Those who spoke to the Sun Journal say they worry about what the turmoil means for patients.
“My sense is that there is something very, very wrong going on at CMMC,” said Berry, the volunteer chaplain. “You have trained medical professionals – I’ve had brief conversations with a few, but I’ve had long conversations with five – and their impression, the thing I came away with, is the quality is suffering and will suffer more in the future because of the direction (the hospital system) is going in, and they want no part of it.”
Fewer support staff can mean longer waits on hold over the phone, a more difficult time getting appointments or medical information, a longer wait in the office.
High physician turnover can mean patients must find new doctors, and rely on doctors who haven’t met the patients and have little time to get to know their medical history, as well as deal with rescheduled and delayed appointments.
The Central Maine Healthcare board chairwoman also declined to comment for this story, but agreed to speak with the Sun Journal at a later date. Tupponce, the system’s executive vice president and president of CMMC, agreed to talk.
Tupponce and spokeswoman Kate Carlisle, both new within Brickman’s administration, made it clear that they disagree with many of the assertions made by the people who spoke to the Sun Journal.
“Significant change has been necessary to ensure the organization’s financial stability,” Carlisle said. “We recognize that change can be difficult and may create a sense of disruption or uncertainty. We encourage our staff to ask questions and raise concerns, and it is certainly not our practice to terminate employees for doing so.”
She said she could not comment on personnel matters, such as Berry’s removal as a volunteer chaplain.
Carlisle and Tupponce said physician firings have dropped over the past three years and doctor turnover, while at 27.1 percent, is lower than it was in either fiscal years 2017 or 2016, which includes the last year of the Chalke administration. Carlisle declined to say how much lower it is.
It is unclear how Central Maine Healthcare’s doctor turnover rate compares to similar hospital systems in Maine. Officials at MaineHealth in Portland, St. Mary’s Regional Health System in Lewiston, MaineGeneral Health in Augusta and Eastern Maine Healthcare in Brewer said they could not provide the information, either by deadline or at all.
Tupponce acknowledged that stresses have caused some Central Maine Healthcare doctors to leave. The new electronic medical records system, he said, was partly to blame.
“For some of the physicians it was just one more thing that they just didn’t want to go through, the pain of learning a new electronic medical record,” he said. “And so they said, ‘You know what, I’d rather retire,’ or, ‘I’m going to go find somewhere else.’ Honestly, that did drive some of the turmoil.”
Carlisle denied that any doctors have been told not to document so much or that their notes didn’t need to be so thorough.
“We would never suggest a provider compromise either patient care or documentation,” she said.
Tupponce said doctors did grow uncomfortable when leaders decided to standardize physician pay and employment contracts to make them more fair.
“That’s been kind of a long, hard process,” Tupponce said. “Any time you kind of start talking about how you’re going to compensate physicians, that’s personal. And so some physicians have been a little worried about that process and whether we would be responsive to the physicians’ needs, which I believe we have. But some of them decided, ‘You know what, this is making me nervous. I’m going to go look somewhere else.’ Some of them have chosen to leave the organization prior to us finalizing that.”
He said system leaders listened and responded when doctors raised concerns over the contracts.
“They’ve been at the table and we’ve really worked to a point where we presented some of the work that we’ve done at the last general medical meeting and it was very well-received,” he said. “I think because of that, that’s helped decrease some of the anxiety in the medical staff and prevent physicians from going and looking at other places.”
Tupponce said the system has struggled a bit to hire new doctors this year because some of its own recruiters left. Central Maine Healthcare hired outside recruiters to help solve the problem.
“That’s been what’s been such a good thing to see – all the great physicians, we’re getting more and more of them. But it feels harder because we lost some of those (internal) recruiters,” he said. “Now it’s starting to turn.”
Tupponce denied there have been cuts in support staff. He said, however, that the system has struggled to find people to fill positions. To address that, Central Maine Healthcare has contracted with recruiters to help fill jobs and more clearly laid a path for career advancement to help entice new hires.
“I will tell you, I’m not lying to you, that it has improved over the course of the year as far as our ability to recruit and retain those support staff,” he said.
He said the system has also shifted some responsibilities, freeing up people to “work at the top of their license.” That means, for example, nurses can focus more on patients rather than spending all day on the phone dealing with prior authorizations and referrals.
“That’s better for the practice, better for the patients and more fulfilling for the nurses,” Tupponce said.
As part of that, he said, Central Maine Healthcare this summer started an automated call, text and email system to confirm patient appointments.
“When we went live with that, we put 120,000 return phone calls into that system. Can you imagine how much time that gave back?” he said. “That’s just one example. There’s opportunities like this all over the place.”
Asked whether doctors are required to see patients faster, Carlisle didn’t say yes or no, but responded, “We would never request that our providers compromise patient care, or documentation.”
Tupponce acknowledged there have been other changes within Central Maine Healthcare and some of those affect staff and patients – like no longer automatically replacing doctors who leave with a new doctor in the same job.
“We’re taking that as the opportunity to strategically focus on, ‘OK, what does the community need?'” he said. “If we have a physician leave, it may not be one for one.”
An outgoing pediatrician, for example, might be replaced by a family medicine doctor or a pediatric nurse practitioner who can work with the doctors who remain.
He said Central Maine Healthcare is also structuring care differently, sometimes consolidating medical practices, sometimes partnering with outside medical groups – as with the new Topsham center – to provide health care.
He said the system has also strengthened its Massachusetts General Hospital partnership, which first formed under the previous administration. The Boston hospital now helps with recruitment and interviews potential Central Maine Healthcare doctors “to make sure that there’s a good fit in both places.”While that may raise some eyebrows – it’s unusual for an unrelated hospital to interview another hospital’s potential employees – Tupponce said this is not a sign that Central Maine Healthcare is looking to sell to Mass General.
“The basis of this relationship is really, ‘How do we use the best of what Mass General has to our advantage?'” he said.
Tupponce said Central Maine Healthcare leaders understand the anxiety of staff members, community members and patients — particularly when doctors, the most visible employees in any hospital system, leave.
“We do have a plan,” he said. “We’re going to make sure that we’re providing access to our communities.”