Medicare Part C For All -- A Proposed Hatch-Warren Bill
by Larry Koltikoff - Forbes - April 12, 2017
Whatever the Freedom Caucus thinks, there is a national consensus that everyone deserves a uniform, basic health insurance policy. Uniform means that everyone's kidneys are covered for the same problems regardless of whether their kidneys in great or terrible shape.
Unlike the market for wheat, where private markets work extremely well, insurance markets, particularly health insurance markets, break down because of differences in information of buyers and sellers. Buyers of health insurance know if they are sick. Sellers don't. To make a profit, sellers try to cherry pick the healthy and turn away the sick. Or they set premiums under the assumption that all their insureds will be sick. This makes health insurance too expensive for the healthy who opt to stay uninsured.
The solution to this well known adverse selection problem is to pool the sick and the healthy together. This is why we have ended with the population in one of four types of pools. These are the pools for workers in large firms (employer-provided healthcare), the pool for the disabled and elderly (Medicare), the pool for the indigent (Medicaid), and the pool for everyone else (Obamacare).
Unfortunately, each of these systems has failed or is failing. Insurers are deserting Obamacare. Medicaid traps participants into poverty by defining its pool based on income. Earn a dollar too much and "It's gone!" Medicare, at least traditional Medicare (Parts A, B, and D), has, over the years, exploded in costs. The same is true for Medicaid. The result has been price controls, which are leading more and more docs to turn away traditional Medicare and Medicaid participants. And employer-based healthcare is increasingly turning into catastrophic coverage, leaving participants with unaffordable out-of-pocket payments.
The answer is not replacing Obamacare with a far less generous Trumpcare system that sanctifies cherry picking. It's not handing Medicaid over to the states and looking the other way. It's not maintaining price controls for traditional Medicare. And it's not letting employers move to health insurance in name only.
Nor is the answer some other set of patchworks. It's time to fix the healthcare system from the ground up.
Remarkably, the path to such fundamental reform is staring us in the face. It's Medicare Part C For All.
Medicare Part C is the Republican part of a program established by Democrats. Hence, both parties can claim ownership of Medicare Part C For All. That's critical because no meaningful and lasting healthcare reform can arise without bipartisan support.
Medicare Part C For All entails eliminating Obamacare, employer-based healthcare, Medicaid, and traditional Medicare and enrolling the entire population in Medicare Part C.
Under Medicare Part C, participants annually choose their insurance company and the government pays the insurer for covering the participant for the year. The size of the payment, which includes a profit margin, is based on the participant's pre-existing conditions. This individual experience rating is designed to eliminate cherry picking by insurance companies. Yes, signing up healthy participants means lower expected costs, but it also means a lower premium payment from the government. This reduced payment fully offsets the incentive to cherry pick. In addition to having no profit incentive to cherry pick, insurers would be legally prohibited from turning away participants.
Under Medicare Part C For All, all insurers would need to provide an identical package of benefits, drug coverage, and assisted living/nursing home care.
Requiring all insurers to offer the identical basic health insurance plan will turn basic health insurance into a commodity like wheat. It will produce intense competition among insurance providers who will have one objective -- providing the best care at lowest cost.
With everyone enrolled in Medicare Part C, the government will finally have full control of its total healthcare spending. It can decide what to spend on basic healthcare for the population and then adjust what's covered under the basic plan such that the sum of the payments to insurers not exceed its budget -- say, 10% of GDP.
Moreover, since insurers will have to foot the bill for excessive usage of their healthcare systems, they will have the proper incentives to limit such usage. But if they under-provide coverage they will lose customers. In economics terms, insurers will internalize incentives to neither under nor over provide care.
The transition to Medicare Part C For All is easy. Traditional Medicare (Parts A, B, and D) participants can be grandfathered. Employers wishing to remain in the health insurance business could do so. But they would need to offer the same basic plan as any other Medicare Part C For All insurer and permit anyone, including non-employees, to sign up.
How would we pay for this new system? We'd replace the Medicare FICA tax with an income-based progressive insurance premium. Everyone with income would pay their fair share of the costs of Medicare For All Part C. And since it would cost nothing extra to sign up, everyone would do so.
Is this yet another entitlement program? Actually it's a reduction from 4 to 1 healthcare entitlement programs. It replaces the entitlement to Medicaid. It replaces the entitlement to traditional Medicare. It replaces the entitlement to Obamacare. And it replaces the entitlement to tax breaks on employer-paid health insurance premiums.
Anyone who knows anything about health insurance knows that getting the population insured requires the government to pool. That's the basic entitlement -- the entitlement to a government that pools us together and makes the health insurance market work. If the Freedom Caucus members don't like the word entitlement, I suggest they avoid using it. But their vision of U.S. healthcare -- healthy Joe's gall bladder is covered, sick Jane's gall bladder is not because she "chose" a policy that doesn't cover gall bladders -- is not carrying the day even among a majority of Republicans.
How do we achieve passage of Medicare Part C For All? My answer is for Senators Orrin Hatch and Elizabeth Warren to jointly sponsor the bill and get the President to sign on. There is precedent for such a bipartisan healthcare initiative. In 1996, Senators Hatch and Kennedy joined forces to sponsor the SCHIP program, which provides health insurance to children of the working poor.
If Senators Hatch and Warren aren't game, Senators John Thune and Tim Kaine could pick up the torch. They co-sponsored The Inform Act requiring proper government fiscal accounting, although their bill has yet to be passed.
Whether it is Hatch and Warren, Thune and Kaine, or some other bi-partisan pair of Senators, the first pair to move will reap the huge reward of finally properly solving our nation's never ending health insurance debacle.
Experts, anger, and the madness of crowds
Cetona - "Health Care Renewal Blog - March 5, 2017
Cetona - We find ourselves in a most peculiar historical moment. Among other things--many other things--problems of health care policy, research, and clinical practice more and more resemble those of society at large. There's a general sense everywhere that, whatever the outfit, the Wrong Guy is in charge of it. Then like a snake eating its tail, we argue endlessly about the details.
It's enough to give one a migraine, bigly. Whether we're talking DC, the Oscars, or (OMG) yet another health care reorg: if only we could get rid of the Gang That Couldn't Shoot Straight. But replace [fill in the blank] ... with what?
Let's look at a couple of recent Anglo-American pieces--here and here--and try to understand this odd moment in time.
In a recent number of The Guardian, an editorialist links the recent Oscars fiasco to what we here at HCRenewal, along with many others have come to call managerialism. The reliance on, indeed the cult of well paid and generic consultancy over real expertise seems now to have metastasized throughout our society. Why should we be surprised if this blight turns out to've insinuated itself into every nook and cranny of our medical organizations?
The hallmarks are the same everywhere. Bigness. The notion that generic managers know best. If you have a problem, do what you need to do. Bring in an outside hired-gun pseudo-expert and then keep your job. (Of course, occasionally the behavior is so laughably clumsy that some shmoe, like the accountant tweeting from the Academy Award wings, has to be thrown under the bus. So that their bosses can keep their jobs.)
The best bons mots in the Guardian piece: "[T]he kind of expertise worth paying for is almost always the least reassuring." So that, for example, in the case of Britain's National Health Service, "[i]t doesn’t take a consultant to understand, for example, that the NHS needs more money; but it takes a very special and expensive skill not to understand it."
And here we come to the meat of the matter. We all have to get through each and every day. So how do we offload the big decisions? Do we think (as so many AMA docs do) that decisions in health care should go back into the hands of Everyman Physician? (Our new HHS Secretary has been sounding a lot like that.)
Do we place our trust in the hands of the generic Experts? Our lead blogger at HCRenewal has, over many years, shown us how that usually works out.
Or do we place our trust in the hands of those with serious domain knowledge? Ah, but you see, these are the elites. And right now, if you're a knowledgeable person who gets that label, you're out of favor. They say the most non-reassuring things. Who're you gonna believe: me or your lying eyes? So much easier to trust the Big Man, Mr. Authority, or, if we're doing Group Think, generic Manager Man.
Why are we, both without and within Health Care, so gullible? Roger Cohen, in his Times piece, provides some guidance. Anger. Hard to believe that matters of culture and emotion can be so impactful. But Cohen makes the case. He notes that "the attempt to squeeze the last cent of profit out of any operation has also squeezed the last trace of sentiment out of what passes for human interaction. [Individuals] see that technology serves relentless efficiency, and somewhere in that efficiency life gets joyless and existence precarious."
"They note," he continues, "that good unions, retirement benefits, manufacturing jobs, overtime and health care get eliminated or curtailed in pursuit of that last cent. They observe how put-together types with attitude and little qualification can make a bundle buying and eviscerating solid companies that actually produce things or setting up consultancies that trade on connections at the money-influence margins of politics. They know that if something goes wrong with the rigged system the losses will get 'socialized.'"
EMR, anyone?
In any case what's interesting is that this kind of anger can lead to vesting faith equally in a Bernie or a Donald. Masses of people are tempted to go for simplistic solutions. Polarization is inevitable. The crowd supports autocrats, narcissists and charismatics of left and the right,
Fortunately, as a part-way solution, Englightenment thinkers--the authors of the Constitution--created a creaky but resilient system that usually leads to a regression to the mean. Pull people back to the sensible center. That may well happen in health care. What's a lot more questionable is: what's going to happen about our cult of managerialism? It really is a ball and chain. In the Guardian, a secondary header fails to reassure: "In troubled times, the appearance of authority is worth far more than the content of advice.
Cetona - "Health Care Renewal Blog - March 5, 2017
Cetona - We find ourselves in a most peculiar historical moment. Among other things--many other things--problems of health care policy, research, and clinical practice more and more resemble those of society at large. There's a general sense everywhere that, whatever the outfit, the Wrong Guy is in charge of it. Then like a snake eating its tail, we argue endlessly about the details.
It's enough to give one a migraine, bigly. Whether we're talking DC, the Oscars, or (OMG) yet another health care reorg: if only we could get rid of the Gang That Couldn't Shoot Straight. But replace [fill in the blank] ... with what?
Let's look at a couple of recent Anglo-American pieces--here and here--and try to understand this odd moment in time.
In a recent number of The Guardian, an editorialist links the recent Oscars fiasco to what we here at HCRenewal, along with many others have come to call managerialism. The reliance on, indeed the cult of well paid and generic consultancy over real expertise seems now to have metastasized throughout our society. Why should we be surprised if this blight turns out to've insinuated itself into every nook and cranny of our medical organizations?
The hallmarks are the same everywhere. Bigness. The notion that generic managers know best. If you have a problem, do what you need to do. Bring in an outside hired-gun pseudo-expert and then keep your job. (Of course, occasionally the behavior is so laughably clumsy that some shmoe, like the accountant tweeting from the Academy Award wings, has to be thrown under the bus. So that their bosses can keep their jobs.)
The best bons mots in the Guardian piece: "[T]he kind of expertise worth paying for is almost always the least reassuring." So that, for example, in the case of Britain's National Health Service, "[i]t doesn’t take a consultant to understand, for example, that the NHS needs more money; but it takes a very special and expensive skill not to understand it."
And here we come to the meat of the matter. We all have to get through each and every day. So how do we offload the big decisions? Do we think (as so many AMA docs do) that decisions in health care should go back into the hands of Everyman Physician? (Our new HHS Secretary has been sounding a lot like that.)
Do we place our trust in the hands of the generic Experts? Our lead blogger at HCRenewal has, over many years, shown us how that usually works out.
Or do we place our trust in the hands of those with serious domain knowledge? Ah, but you see, these are the elites. And right now, if you're a knowledgeable person who gets that label, you're out of favor. They say the most non-reassuring things. Who're you gonna believe: me or your lying eyes? So much easier to trust the Big Man, Mr. Authority, or, if we're doing Group Think, generic Manager Man.
Why are we, both without and within Health Care, so gullible? Roger Cohen, in his Times piece, provides some guidance. Anger. Hard to believe that matters of culture and emotion can be so impactful. But Cohen makes the case. He notes that "the attempt to squeeze the last cent of profit out of any operation has also squeezed the last trace of sentiment out of what passes for human interaction. [Individuals] see that technology serves relentless efficiency, and somewhere in that efficiency life gets joyless and existence precarious."
"They note," he continues, "that good unions, retirement benefits, manufacturing jobs, overtime and health care get eliminated or curtailed in pursuit of that last cent. They observe how put-together types with attitude and little qualification can make a bundle buying and eviscerating solid companies that actually produce things or setting up consultancies that trade on connections at the money-influence margins of politics. They know that if something goes wrong with the rigged system the losses will get 'socialized.'"
EMR, anyone?
In any case what's interesting is that this kind of anger can lead to vesting faith equally in a Bernie or a Donald. Masses of people are tempted to go for simplistic solutions. Polarization is inevitable. The crowd supports autocrats, narcissists and charismatics of left and the right,
Fortunately, as a part-way solution, Englightenment thinkers--the authors of the Constitution--created a creaky but resilient system that usually leads to a regression to the mean. Pull people back to the sensible center. That may well happen in health care. What's a lot more questionable is: what's going to happen about our cult of managerialism? It really is a ball and chain. In the Guardian, a secondary header fails to reassure: "In troubled times, the appearance of authority is worth far more than the content of advice.
A Beach Too Far - Ill-Informed, Conflicted Members of the "Beachhead Team" for the Department of Health and Human Services
Health Care Renewal Blog - March 15, 2017
ProPublica recently published an article describing the so-called "beachhead teams" sent by the Trump administration to various US federal departments and agencies. The article stated
Why these teams were described in terms of a military invasion is not clear. A beachhead more usually looks like:
While President Trump has not moved to fill many jobs that require Senate confirmation, he has quietly installed hundreds of officials to serve as his eyes and ears at every major federal agency, from the Pentagon to the Department of Interior.
Unlike appointees exposed to the scrutiny of the Senate, members of these so-called 'beachhead teams' have operated largely in the shadows, with the White House declining to publicly reveal their identities.
Why these teams were described in terms of a military invasion is not clear. A beachhead more usually looks like:
[Assault landing, one of the first waves at Omaha. The Coast Guard caption identifies the unit as Company E, 16th Infantry, 1st Infantry Division. Photo courtesy of Center of Military History. Look here.]
However, a Politico article suggested
The ProPublica article suggsted that some of the personnel on these teams might have conflicts of interest, including
The ProPublica article provided more detail about specific people, including a few on the Department of Health and Human Services (DHHS) "beachhead team." To supplement this information, I attempted to identify and characterize the background of all 32 members of this team contained in the ProPublica roster.
The full list of names, my characterizations, and its sources appear at the end of this post. There were 5 people I could not identfy, Of the 27 I could, I found they included...
Corporate Advocates/ Lobbyists
The ProPublica article profiled three people in detail, as "swamp denizens, including health care lobbyists hired by HHS Secretary Tom Price." These were:
In addition to these three, I found:
John Kalavritinos, who was a global lobbyist for Covidien, a pharmaceutical company, from 2008-2015, as we discussed here.
Lance Leggitt, who has become Secretary of DHHS Dr Tom Price's chief of staff, "oversaw health care lobbying for Baker Donelson for 11 years," according to StatNews.
Paula Stannard, formerly a lawyer for Alston and Bird, who "joined the health care practice of this law firm after serving in the last Republican administration as deputy general counsel to the Department of Health and Human Services. She was responsible for food and drug issues and other matters, including federal health insurance and public health preparedness,..." according to StatNews. But also, the "firm has earned more than $4.4 million lobbying so far this year for health care companies and trade groups including Novartis AG, Verax Biomedical, the American Hospital Association, St. Jude Children’s Research Hospital, and Aetna...."
Former Political Staffers
The largest group of people on the list were former staffers for US legislators, US congressional committees, and state officials. I counted 12. Apparently all the legislators they served were Republicans. Some worked in health policy.
Former Employees of Ideologically or Religously Oriented Non-Profit Organizations
I identified 7 people who worked for organizations I loosely characterized as ideologically or religiously oriented non-profits. The details are below, but the organizations included the National Council of Catholic Women, the Alliance Defending Freedom, the Committee for a Responsible Federal Budget, the Heritage Foundation, Concerned Women for America, and the American Media Institute.
[But No] Health Care Professionals, Biomedical Scientists, Public Health or Health Care Researchers
I could find no one who clearly was a health care professional, no one who clearly had worked in patient care, no one who was a biomedical scientist on the list.
The closest I came was Kamran Daravi, described in an article in Politico as someone who "graduated from St. John's University in New York City in 2014 and received his master's in public health from the school earlier this year. Most recently, Daravi was with the United Nations."
Discussion
The purpose of the "beachhead teams" dispatched to the DHHS is still obscure. It seems likely that the team is meant to have a major early influence on operations of the Department, which has very important health care regulatory responsibilities, sponsors major biomedical and health care research programs, and administers the major government health insurance programs. Given that, why the Trump administration chose thes particular team members is more obscure. None have apparent experience as health professionals or as medical or health care researchers, and many do not seem to have any knowledge of or affinity for health care, biomedical science, or public health.
Those who may have some knowledge of health care seem to all have significant conflicts of interest. They knew health care in that they had previous experience advancing the interests of large health care corporations, again without the benefit of any health care professional or scientific background. They all could be regarded as having transited the revolving door from industry to government. Recall that some experts believe that the revolving door goes beyond conflicts of interest and crosses the line over to true health care corruption.
As we have noted (here, here, here, here, and here) the people the Trump administration has chosen so far for health care leadership positions have had conflicts of interest remarkable for their prevalence and severity. While President Trump claimed famously that he would drain the Washington, DC "swamp," he seems to be rapidly repleting that swamp's health care subdivision.
True health care reform requires well-informed leaders who uphold health care professionals' values, put patient's and the public's health ahead of all other considerations, avoid self-interest and conflicts of interest, are honest and ethical, and surely are not corrupt. We seem to be getting farther and farther from that ideal.
Appendix: List of DHHS "Beachhead Team" Members
Anna K Abram
former Sen Richard Burr (R-NC) health policy director, look here
Alexander Aramanda
deputy legistlative director, Sen Ted Cruz (R-TX), look here
Juanita Balenger
administrator, National Council of Catholic Women, look here
Matthew Bowman
Senior Legal Counsel with Alliance Defending Freedom, look here
Brady Brookes
deputy legistlative director, Gov Michael Pence (R-IN), look here
John Brooks
department head of health policy at the MITRE Corp, previously an associate at Vinson & Elkins, look here
Alexandra Campeau
lobbyist, see Pro Publica
her husband is manager for major gifts from corporations and individuals at the Heritage Foundation; in laws own assisted living center,look here
Timothy Clark
lobbyist, se ProPublica
Kamran Daravi
adviser to the United Nations Economic and Social Council, look here
Carla DiBlasio
health care policy adviser, Rep Tom Price (R-GA), look here
Heather Flick
Senior Partner, Flick Law Group, former Director, Citizens Bancorp, look here
Darcie Johnston
former State Director (VT) for Donald Trump campaign, look here
John Kalavritinos
global lobbyist for Covidien through 2015, look here
Lance Leggitt
formerly led health care lobbying for Baker Donelson, look here and here
Keagan Lenihan
lobbyist, see ProPublica
Matthew Lloyd
former spokesman and deputy chief of staff for for former Gov Michael Pence (R-IN), look here and here
Tyler McGuffee
Unknown
Marie Meszaros
policy analyst at the Committee for a Responsible Federal Budget, former legislative staffer, Rep Mark Sanford (R-SC), look here
Dolly (Mari) Moorhead
unknown
Patrick Murphy
unknown
Brian Neale
former health policy director for Gov Michael Pence (R-IN), reported to be named as director of Medicaid and CHIP services, look here
Randolph Pate
formerly at Heritage Foundation, look here
Anna Pilato
executive, Concerned Women for America, look here
Mary Powers
Deputy Director of Development at the American Media Institute, look here
Nina Schaefer
Unknown
Paula Stannard
attorney, health care practice, Alston and Bird, former deputy general counsel, DHHS under Pres GW Bush, look here and here
Heidi A Stirrup
staffer, multiple R house members, formerly House Energy and Commerce Committee staff, look here
Amanda Street
House Budget Committee (recommended by Rep Tom Price [R-GA]), look here
Beth Tignor
Unknown
Laura Trueman
former Heritage Foundation director of strategic operations, then senior policy adviser, Rep Steve Scalise (R-LA), look here
Steven Valentine
staff, Rep Chris Smith (R-NJ), look here
Kyle Zebley
former legislative director, Rep Tom Price (R-GA), look here
However, a Politico article suggested
Trump’s team has long worried that career federal workers and President Barack Obama’s political appointees will seek to undermine the president-elect’s agenda. The transition sees the beachhead teams, named after the line of defense that the military constructs as it lands in enemy territory, as a check on existing agency officials.Who Are These People?
The ProPublica article suggsted that some of the personnel on these teams might have conflicts of interest, including
dozens of Washington insiders who could be reasonably characterized as part of the 'swamp' Trump pledged to drain.
The list is striking for how many former lobbyists it contains: We found at least 36, spanning industries from health insurance and pharmaceuticals to construction, energy and finance. Many of them lobbied in the same areas that are regulated by the agencies they have now joined.
The ProPublica article provided more detail about specific people, including a few on the Department of Health and Human Services (DHHS) "beachhead team." To supplement this information, I attempted to identify and characterize the background of all 32 members of this team contained in the ProPublica roster.
The full list of names, my characterizations, and its sources appear at the end of this post. There were 5 people I could not identfy, Of the 27 I could, I found they included...
Corporate Advocates/ Lobbyists
The ProPublica article profiled three people in detail, as "swamp denizens, including health care lobbyists hired by HHS Secretary Tom Price." These were:
Alexandra Campau, hired at the department of Health and Human Services, was formerly a lobbyist in Washington for the law firm Cozen O’Connor. According to disclosure records, her firm’s clients included a licensee of insurance giant Blue Cross Blue Shield, and Fresenius Medical Care, a German company that specializes in medical supplies for renal dialysis.
Timothy Clark, a senior adviser to HHS Secretary Tom Price, ran his own political consulting firm in California. His past clients included PhRMA, the powerful trade group that represents the pharmaceutical industry.
Keagan Lenihan, also a senior adviser to Price, was a director of government relations at McKesson Specialty Health, a firm that supports independent health providers. Disclosure records show Lenihan directly lobbied HHS. For Lenihan, the new post represents a return trip through the revolving door between government and the private sector, and a reunion with an old boss. Before registering as a lobbyist, she was a senior legislative assistant for Price, when the now-HHS secretary was in Congress.
Asked about the three HHS staffers, an agency spokeswoman said: ''e are not confirming or commenting on personnel at this time.'
In addition to these three, I found:
John Kalavritinos, who was a global lobbyist for Covidien, a pharmaceutical company, from 2008-2015, as we discussed here.
Lance Leggitt, who has become Secretary of DHHS Dr Tom Price's chief of staff, "oversaw health care lobbying for Baker Donelson for 11 years," according to StatNews.
Paula Stannard, formerly a lawyer for Alston and Bird, who "joined the health care practice of this law firm after serving in the last Republican administration as deputy general counsel to the Department of Health and Human Services. She was responsible for food and drug issues and other matters, including federal health insurance and public health preparedness,..." according to StatNews. But also, the "firm has earned more than $4.4 million lobbying so far this year for health care companies and trade groups including Novartis AG, Verax Biomedical, the American Hospital Association, St. Jude Children’s Research Hospital, and Aetna...."
Former Political Staffers
The largest group of people on the list were former staffers for US legislators, US congressional committees, and state officials. I counted 12. Apparently all the legislators they served were Republicans. Some worked in health policy.
Former Employees of Ideologically or Religously Oriented Non-Profit Organizations
I identified 7 people who worked for organizations I loosely characterized as ideologically or religiously oriented non-profits. The details are below, but the organizations included the National Council of Catholic Women, the Alliance Defending Freedom, the Committee for a Responsible Federal Budget, the Heritage Foundation, Concerned Women for America, and the American Media Institute.
[But No] Health Care Professionals, Biomedical Scientists, Public Health or Health Care Researchers
I could find no one who clearly was a health care professional, no one who clearly had worked in patient care, no one who was a biomedical scientist on the list.
The closest I came was Kamran Daravi, described in an article in Politico as someone who "graduated from St. John's University in New York City in 2014 and received his master's in public health from the school earlier this year. Most recently, Daravi was with the United Nations."
Discussion
The purpose of the "beachhead teams" dispatched to the DHHS is still obscure. It seems likely that the team is meant to have a major early influence on operations of the Department, which has very important health care regulatory responsibilities, sponsors major biomedical and health care research programs, and administers the major government health insurance programs. Given that, why the Trump administration chose thes particular team members is more obscure. None have apparent experience as health professionals or as medical or health care researchers, and many do not seem to have any knowledge of or affinity for health care, biomedical science, or public health.
Those who may have some knowledge of health care seem to all have significant conflicts of interest. They knew health care in that they had previous experience advancing the interests of large health care corporations, again without the benefit of any health care professional or scientific background. They all could be regarded as having transited the revolving door from industry to government. Recall that some experts believe that the revolving door goes beyond conflicts of interest and crosses the line over to true health care corruption.
As we have noted (here, here, here, here, and here) the people the Trump administration has chosen so far for health care leadership positions have had conflicts of interest remarkable for their prevalence and severity. While President Trump claimed famously that he would drain the Washington, DC "swamp," he seems to be rapidly repleting that swamp's health care subdivision.
True health care reform requires well-informed leaders who uphold health care professionals' values, put patient's and the public's health ahead of all other considerations, avoid self-interest and conflicts of interest, are honest and ethical, and surely are not corrupt. We seem to be getting farther and farther from that ideal.
Appendix: List of DHHS "Beachhead Team" Members
Anna K Abram
former Sen Richard Burr (R-NC) health policy director, look here
Alexander Aramanda
deputy legistlative director, Sen Ted Cruz (R-TX), look here
Juanita Balenger
administrator, National Council of Catholic Women, look here
Matthew Bowman
Senior Legal Counsel with Alliance Defending Freedom, look here
Brady Brookes
deputy legistlative director, Gov Michael Pence (R-IN), look here
John Brooks
department head of health policy at the MITRE Corp, previously an associate at Vinson & Elkins, look here
Alexandra Campeau
lobbyist, see Pro Publica
her husband is manager for major gifts from corporations and individuals at the Heritage Foundation; in laws own assisted living center,look here
Timothy Clark
lobbyist, se ProPublica
Kamran Daravi
adviser to the United Nations Economic and Social Council, look here
Carla DiBlasio
health care policy adviser, Rep Tom Price (R-GA), look here
Heather Flick
Senior Partner, Flick Law Group, former Director, Citizens Bancorp, look here
Darcie Johnston
former State Director (VT) for Donald Trump campaign, look here
John Kalavritinos
global lobbyist for Covidien through 2015, look here
Lance Leggitt
formerly led health care lobbying for Baker Donelson, look here and here
Keagan Lenihan
lobbyist, see ProPublica
Matthew Lloyd
former spokesman and deputy chief of staff for for former Gov Michael Pence (R-IN), look here and here
Tyler McGuffee
Unknown
Marie Meszaros
policy analyst at the Committee for a Responsible Federal Budget, former legislative staffer, Rep Mark Sanford (R-SC), look here
Dolly (Mari) Moorhead
unknown
Patrick Murphy
unknown
Brian Neale
former health policy director for Gov Michael Pence (R-IN), reported to be named as director of Medicaid and CHIP services, look here
Randolph Pate
formerly at Heritage Foundation, look here
Anna Pilato
executive, Concerned Women for America, look here
Mary Powers
Deputy Director of Development at the American Media Institute, look here
Nina Schaefer
Unknown
Paula Stannard
attorney, health care practice, Alston and Bird, former deputy general counsel, DHHS under Pres GW Bush, look here and here
Heidi A Stirrup
staffer, multiple R house members, formerly House Energy and Commerce Committee staff, look here
Amanda Street
House Budget Committee (recommended by Rep Tom Price [R-GA]), look here
Beth Tignor
Unknown
Laura Trueman
former Heritage Foundation director of strategic operations, then senior policy adviser, Rep Steve Scalise (R-LA), look here
Steven Valentine
staff, Rep Chris Smith (R-NJ), look here
Kyle Zebley
former legislative director, Rep Tom Price (R-GA), look here
Part of the Solution, or Part of the Problem? - Health Care Corporate CEOs on Physician Burnout
Health Care Renewal Blog - April 2, 2017
Physician burnout is in the news again. Late in 2015, an article by Shaneyfelt and colleagues in the Mayo Clinic Proceedings showed an increase in the proportion of physicians reporting at least one symptom of burnout to 54.4% in 2014(1), up from the 45.5% they reported in 2012(2). A March 28, 2017, post in the Health Affairs blog based on the latest article warning about burnout and suggesting how to address it got considerable attention.
Background - Physician Burnout
However, physician burnout is hardly new. As we wrote in 2012about the predecessor the 2012 Shaneyfelt article, this is just the latest in a long series of studies showing physicians' growing angst, dissatisfaction, burnout, or whatever one calls it. In 1987, in an AMA survey of physicians over 40, 44% replied that were they given chances to do it all over again, they would not go into medicine.(3) In a 2001 survey of Massachusetts physicians, 62.3% were dissatisfied with the practice environment.(4) In 2002, a national survey by the Kaiser Family Foundation showed that 45% of physicians would not recommend that a young person should go into medicine.(5) In a survey of primary care physicians in 2007, 38.7% were somewhat or very dissatisfied.(6) I have a 6 inch thick set of paper files containing articles on the subject, although it is remarkable how many research studies reported only average scores on instruments, and hence did not report proportions of physicians who were burned out or dissatisfied. Yet the 2017 Health Affairs post garnered headlines declaring physician burnout to now be a crisis.
Whether the current attention to burnout will lead to any real improvements is doubtful. In particular, I am concerned that the Health Affairs blog post that sparked all the attention was at best misdirected. It avoided discussing more than a few of the most immediate, proximate causes of burnout. It seemed more motivated more by concerns about money than about patients and the physicians that try to serve them. It read like a top down diktat uninfomed by the concerns of physicians or patients, maybe because all of its authors were CEOs of large health care organizations, all but one large hospital systems.
I will venture to go through the issues point by point in the hope of sparking a discussion more focused on the physicians subject to or at risk of burnout, and ultimately the effects of their burnout on their patients.
For the Love of Money
While the blog post began with a nod towards improving the quality of, lowering the cost of, and improving access to health care, there was a subtext. Consider some quotes, first, stating that one cause of burnout is,
Also,
Also,
Also,
Also,
To interpret these passages, note that the authors of the blog post were John Noseworthy, James Madara, Delos Cosgrove, Mitchell Edgeworth, Ed Ellison, Sarah Krevans, Paul Rothman, Kevin Sowers, Steven Strongwater, David Torchiana, and Dean Harrison(links are those supplied by the post.) All but Dr Madara are CEOs of large, nominally non-profit corporate hospital systems. Dr Madara is the CEO of the American Medical Association (AMA).
I would suggest that to a business CEO, efficiency refers to a state in which goods and services are produced with a minimum of costs. Furthermore, many business managers follow the business dogma first called the shareholder value theory, which seems mainly to be interpreted to mean managers should maximize short-term revenue as their first priority (look here). This is part of the larger financialization of all spheres of life, including hospital systems.
The focus on relentless revenue maximization may be reinforced by large incentives for top managers, particularly CEOs, based on revenue and other financial, not clinical outcomes. Such perverse incentives have resulted in huge increases in executive compensation for hospital CEOs. For example, as we recently discussed, author Dr John Noseworthy, CEO of the Mayo Clinic, received more than $2.3 million in total compensation in 2013, and was just reported to have received more than $2.5 million in 2015. Author Dr Delos (Toby) Cosgrove, CEO of the Cleveland Clinic, received more than $4.8 million in 2015 (look here).
Thus, too a hospital CEO, efficiency might mean the ability to provide services as cheaply as possible, and such efficiency is likely to be a top priority. The quotes above suggest that hospital CEOs mainly want to combat burnout to increase efficiency. One quote above refers directly to the monetary costs, again presumably to the hospital, of losing physicians to burnout. One quote refers to burnout as hampering physician productivity, which to a hospital CEO might mean the ability to produce maximum billing, that is revenue, in the minimum amount of time. Finally, one quote suggests that to the authors, burnout is a business problem, not a human problem, or a clinical problem.
Even stranger, two quotes suggest that the CEO authors believe inefficiency might cause burnout. That would appear very strange to employed physicians who may be increasingly pressured by top management to be more efficient, and thus to increase revenue. I would guess that many employed physicians would attribute their burnout to this relentless push for productivity and efficiency by top management.
So reading not between the lines, but the lines themselves suggests that the CEO authors might be more interested in reducing burnout to increase hospital revenues, and thus their total compensation, rather than to make physicians happier or more fulfilled, much to less improve patient care. Such a focus on revenue might not be reassuring to burned out physicians, especially those who feel forced to shortchange time spent with individual patients to fuel revenue. The repetitive discussion of efficiency and productivity in the Health Affairs blog post should worry any physician who feels his or her first responsbility is to take the best care of each individual patient.
Hear No Evil,...
Proximal Versus Organizational, Leadership and Governance Causes of Burnout
Here is what the blog post said about the causes of burnout:
The rest of the items seem more plausible. However absent from the post is consideration of why physicians lost control over work, have been subject to performance measurement (often without good evidence that it improves performance, and particularly patients' outcomes), and have been forced to use often badly designed, poorly implemented EHRs. Particularly absent was any consideration of whether the nature or actions of large organizations, such as those led by the authors of the blog post, could have had anything to do with physician burnout.
Contrast this discusion with how we on Health Care Renewal have discussed burnout in the past. In 2012, we noted the first report on burnout by Shanefelt et al(2). At that time we observed that the already voluminous literature on burnout often did not attend to the external forces and influences on physicians that are likely to be producing burnout. Instead, burnout etc has been addressed as if it were lack of resilience, or even some sort of psychiatric disease of physicians.
In fact, we began the project that led to the establishment of Health Care Renewal because of our general perception that physician angst was worsening (in the first few years of the 21st century), and that no one was seriously addressing its causes. Our first crude qualitative research(8) suggested hypotheses that physicians' angst was due to perceived threats to their core values, and that these threats arose from the issues this blog discusses: concentration and abuse of power, leadership that is ill-informed, uncaring about or hostile to the values of health care professionals, incompetent, deceptive or dishonest, self-interested, conflicted, or outright corrupt, and governance that lacks accountability, and transparency, . We have found hundreds of cases and anecdotes supporting this viewpoint.
We found some corroboration of these hypotheses from other research. Written comments from the 2001 Massachusetts survey made similar points about the causes of dissatisfaction, for example: "too much emphasis on the bottom line. Taken over by large corporations. Quality of care and interaction now subsumed by productivity and profit," and "the once most noble profession has become a factory job with a facade of ethics"(4) Pololi and colleagues' qualitative interviews of young medical faculty included anecdotes of angst due to academic leaders who put revenues ahead of patient care, teaching, and research; and who allegedly used deception for personal gain.(9) (Also, see our comments on this paper.)(10) Pololi and colleagues' large survey of US medical faculty showed that over half thought that managers were only interested in them because of the money they brought in.(11) We were able to show in a preliminary analysis of data from a physician survey that an instrument meant to measure physicians' perception of the integrity of the leadership of their organizations, which incorporated questions about whether leaders supported core values, put patient care ahead of revenue, supported transparency about quality issues, put patient care ahead of self-interest, and displayed honesty strongly correlated (negatively) with stress, intention to leave the practice, and burnout.(12)
Yet at best most studies of physicians' burnout, angst, or dissatisfaction only vaguely allude to "system factors" and not greedy, money-focused, preversely incentivized, self-interested, or corrupt leadership, etc as its causes. "System factors" such as bad EHRs and performance measures suggested by the Health Affairs bloggers were more likely to have been imposed on physicians by bad organizational leadership than by the physicians themselves. Of course, the CEO authors of the post likely would be made very uncomfortable with the notion that bad health care leadership, including of hospital systems like their own, might be a major cause of burnout.
Furthermore, there clearly have been leadership problems at many of the blog post authors' institutions that could have made them more uncomfortable. Cases involving some of the authors' institutions have appeared on Health Care Renewal.
Most recently we noted that Mayo Clinic CEO Dr Noseworthy had raised questions of mission-hostile management by suggesting that the Mayo Clinic should give some patients with commercial health care insurance priority over those with less well paying government health insurance (look here). Not long ago we noted the controversy generated by Cleveland Clinic CEO Dr Cosgrove's lukewarm approach to the Trump administration's "Muslim ban," even though that ban had affected one of the Clinic's own house-staff, while the Clinic was planning a fund raising event at Mr Trump's Mar a Lago resort, raising yet more conflict of interest questions (look here).
We have also disccused issues occurring at the American Medical Assocation, and particularly its RBRVS Update Committee (RUC)(CEO Dr Madara), Sutter Health (CEO Ms Krevans), Johns Hopkins(CEO Dr Rothman), Duke (CEO Mr Sowers), Partners (CEO Dr Torchiana), and Northwestern (CEO Mr Harrison).
Finally, several of the Health Affairs authors have "board level" conflicts of interest. In 2006, we first blogged about a "new species of conflict of interest" which involved health care organizational leaders who were simultaneously members of the boards of directors of for-profit health care corporations or other corporations which could strongly influence health care. We posited these conflicts would be particularly important because being on the board of directors entails not just a financial incentive, but also requires board members to "demonstrate unyielding loyalty to the company's shareholders" [Per Monks RAG, Minow N. Corporate Governance, 3rd edition. Malden, MA: Blackwell Publishing, 2004. P.200.]
Three Health Affairs blog authors have such conflicts. Dr Paul Rothman is on the boards of Merck and of Cancer Genetics, a biotechnology company specializing in DNA based testing. Dr David Torchiana is on the IKS Health Advisory Board, apparently a health care consulting firm. Dean M Harrison is on the board of Northern Trust, a wealth management firm. He was on the board of Ikaria Inc, a biotechnology company now part of Mallinckrodt, and is a special advisor to Merrick Ventures, a private equity firm (look here).
Thus, how can one regard as credible an article on physician burnout which ignores how large organizations' nature or actions might be the major cause of such burnout, and which was written by the top leaders of such organizations?
Corporate Employment as a Cause of Burnout
Finally, the Health Affairs post mention of "loss of control over work" deserves special attention. It could represent a catch-all of more "system factors" as noted above. However, the biggest cause of physicians' loss of control over work may be the rising power of large health care organizations, in particular the large hospital systems that now increasingly employ physicians, turning them into corporate physicians.
In the US, home of the most commercialized health care system among developed countries, physicians increasingly practice as employees of large organizations, usually hospitals and hospital systems, sometimes for-profit corporations. The leaders of such systems meanwhile are now often generic managers, people trained as managers without specific training or experience in medicine or health care, and "managerialists" who apply generic management theory and dogma to medicine and health care just as it might be applied to building widgets or selling soap.
We have also frequently posted about what we have called generic management, the manager's coup d'etat, and mission-hostile management. Managerialism wraps these concepts up into a single package. The idea is that all organizations, including health care organizations, ought to be run people with generic management training and background, not necessarily by people with specific backgrounds or training in the organizations' areas of operation. Thus, for example, hospitals ought to be run by MBAs, not doctors, nurses, or public health experts. Furthermore, all organizations ought to be run according to the same basic principles of business management. These principles in turn ought to be based on current neoliberal dogma, with the prime directive that short-term revenue is the primary goal.
Again, the authors of the Health Affaris post included some generic managers: Mr Edgeworth, whose highest degree was an MBA, and who had a long career as a hospital manager; Ms Krevans, and MBA with an MPH, who also had a long career as a hospital manager; and Mr Harrison, an MBA, who also had a career in hospital management. Doubtless all of the authors lead organizations whose upper management is frequently generic and managerialist. It is likely that the hospital systems they lead increasingly employ physicians, who thus have become corporate. So the Health Affairs blog authors might not be comfortable with the notion that a major cause of burnout may physicians' new status as hired employees sometimes of their own hospital systems, rather than autonomous practitioners.
To repeat, how can one regard as credible an article on physician burnout which ignores how large organizations' nature or actions might be the major cause of such burnout, and which was written by the top leaders of such organizations?
Summary
I am glad that physician burnout is getting less anechoic. However, in my humble opinion, the last thing physicians at risk of or suffering burnout need is a top down diktat from CEOs of large health care organizations. The CEOs who wrote the Health Affairs post not have any personal responsibility for any physicians' burnout. However, the transformation of medical practice by the influence of large health care organizations run by the authors' fellow CEOs, particularly huge hospital systems, often resulting in physicians practicing as hired employees of such corporations likely is a major cause of burnout. If the leaders of such large organizations really want to reduce burnout, they should first listen to their own physicians. But this might lead them to realize that reducing burnout might require them to divest themselves of considerable authority, power, and hence remuneration. True health care reform in this sphere will require the breakup of concentrations of power, and the transformation of leadership to make it well-informed, supportive of and willing to be accountable for the health care mission, honest and unconflicted.
Physicians need to join up with other health care professionals and concerned member of the public to push for such reform, which may seem radical in our current era. Such reform may be made more difficult because it clearly would threaten the financial status of some people who have gotten very rich from the status quo, and can use their wealth and power to resist reform.
Despite the fact that the current US president has stated he is for the "forgotten people" rather than the elites, do not expect such reform from him. He has sought advice on health care policy from the same people who wrote the Health Affairs post, as per the Washington Post, December 28, 2016:
We truly live in interesting times.
Background - Physician Burnout
However, physician burnout is hardly new. As we wrote in 2012about the predecessor the 2012 Shaneyfelt article, this is just the latest in a long series of studies showing physicians' growing angst, dissatisfaction, burnout, or whatever one calls it. In 1987, in an AMA survey of physicians over 40, 44% replied that were they given chances to do it all over again, they would not go into medicine.(3) In a 2001 survey of Massachusetts physicians, 62.3% were dissatisfied with the practice environment.(4) In 2002, a national survey by the Kaiser Family Foundation showed that 45% of physicians would not recommend that a young person should go into medicine.(5) In a survey of primary care physicians in 2007, 38.7% were somewhat or very dissatisfied.(6) I have a 6 inch thick set of paper files containing articles on the subject, although it is remarkable how many research studies reported only average scores on instruments, and hence did not report proportions of physicians who were burned out or dissatisfied. Yet the 2017 Health Affairs post garnered headlines declaring physician burnout to now be a crisis.
Whether the current attention to burnout will lead to any real improvements is doubtful. In particular, I am concerned that the Health Affairs blog post that sparked all the attention was at best misdirected. It avoided discussing more than a few of the most immediate, proximate causes of burnout. It seemed more motivated more by concerns about money than about patients and the physicians that try to serve them. It read like a top down diktat uninfomed by the concerns of physicians or patients, maybe because all of its authors were CEOs of large health care organizations, all but one large hospital systems.
I will venture to go through the issues point by point in the hope of sparking a discussion more focused on the physicians subject to or at risk of burnout, and ultimately the effects of their burnout on their patients.
For the Love of Money
While the blog post began with a nod towards improving the quality of, lowering the cost of, and improving access to health care, there was a subtext. Consider some quotes, first, stating that one cause of burnout is,
profound inefficiencies in the practice environment
Also,
The experience from Atrius Health suggests that replacing a physician who retires early or leaves to pursue other career opportunities can cost between $500,000 and $1 million due to recruitment, training, and lost revenue during this time.
Also,
Professional satisfaction for physicians is primarily driven by the ability to provide high-quality care to patients in an efficient manner.
Also,
As leaders, we must recognize burnout in physicians and other health care workers as a serious problem and respond vigorously. This is especially true if we want to maximize the effectiveness, productivity, and longevity of clinicians.
Also,
More than words are needed. Leaders of health care delivery organizations must embrace physician well-being as a critical factor in the long-term clinical and financial success of our organizations. We must make both the prevention of burnout and the restoration of the joy of a career in medicine core priorities, and address this issue with the same urgent methods we would use to solve any other important business problem: commit to measurement, develop strategy and tactics, and allocate the resources necessary to achieve success.
To interpret these passages, note that the authors of the blog post were John Noseworthy, James Madara, Delos Cosgrove, Mitchell Edgeworth, Ed Ellison, Sarah Krevans, Paul Rothman, Kevin Sowers, Steven Strongwater, David Torchiana, and Dean Harrison(links are those supplied by the post.) All but Dr Madara are CEOs of large, nominally non-profit corporate hospital systems. Dr Madara is the CEO of the American Medical Association (AMA).
I would suggest that to a business CEO, efficiency refers to a state in which goods and services are produced with a minimum of costs. Furthermore, many business managers follow the business dogma first called the shareholder value theory, which seems mainly to be interpreted to mean managers should maximize short-term revenue as their first priority (look here). This is part of the larger financialization of all spheres of life, including hospital systems.
The focus on relentless revenue maximization may be reinforced by large incentives for top managers, particularly CEOs, based on revenue and other financial, not clinical outcomes. Such perverse incentives have resulted in huge increases in executive compensation for hospital CEOs. For example, as we recently discussed, author Dr John Noseworthy, CEO of the Mayo Clinic, received more than $2.3 million in total compensation in 2013, and was just reported to have received more than $2.5 million in 2015. Author Dr Delos (Toby) Cosgrove, CEO of the Cleveland Clinic, received more than $4.8 million in 2015 (look here).
Thus, too a hospital CEO, efficiency might mean the ability to provide services as cheaply as possible, and such efficiency is likely to be a top priority. The quotes above suggest that hospital CEOs mainly want to combat burnout to increase efficiency. One quote above refers directly to the monetary costs, again presumably to the hospital, of losing physicians to burnout. One quote refers to burnout as hampering physician productivity, which to a hospital CEO might mean the ability to produce maximum billing, that is revenue, in the minimum amount of time. Finally, one quote suggests that to the authors, burnout is a business problem, not a human problem, or a clinical problem.
Even stranger, two quotes suggest that the CEO authors believe inefficiency might cause burnout. That would appear very strange to employed physicians who may be increasingly pressured by top management to be more efficient, and thus to increase revenue. I would guess that many employed physicians would attribute their burnout to this relentless push for productivity and efficiency by top management.
So reading not between the lines, but the lines themselves suggests that the CEO authors might be more interested in reducing burnout to increase hospital revenues, and thus their total compensation, rather than to make physicians happier or more fulfilled, much to less improve patient care. Such a focus on revenue might not be reassuring to burned out physicians, especially those who feel forced to shortchange time spent with individual patients to fuel revenue. The repetitive discussion of efficiency and productivity in the Health Affairs blog post should worry any physician who feels his or her first responsbility is to take the best care of each individual patient.
Hear No Evil,...
Proximal Versus Organizational, Leadership and Governance Causes of Burnout
Here is what the blog post said about the causes of burnout:
The spike in reported burnout is directly attributable to loss of control over work, increased performance measurement (quality, cost, patient experience), the increasing complexity of medical care, the implementation of electronic health records (EHRs), and profound inefficiencies in the practice environment, all of which have altered work flows and patient interactions.We dealt with the curious citation of inefficiencies as a cause of burnout above.
The rest of the items seem more plausible. However absent from the post is consideration of why physicians lost control over work, have been subject to performance measurement (often without good evidence that it improves performance, and particularly patients' outcomes), and have been forced to use often badly designed, poorly implemented EHRs. Particularly absent was any consideration of whether the nature or actions of large organizations, such as those led by the authors of the blog post, could have had anything to do with physician burnout.
Contrast this discusion with how we on Health Care Renewal have discussed burnout in the past. In 2012, we noted the first report on burnout by Shanefelt et al(2). At that time we observed that the already voluminous literature on burnout often did not attend to the external forces and influences on physicians that are likely to be producing burnout. Instead, burnout etc has been addressed as if it were lack of resilience, or even some sort of psychiatric disease of physicians.
In fact, we began the project that led to the establishment of Health Care Renewal because of our general perception that physician angst was worsening (in the first few years of the 21st century), and that no one was seriously addressing its causes. Our first crude qualitative research(8) suggested hypotheses that physicians' angst was due to perceived threats to their core values, and that these threats arose from the issues this blog discusses: concentration and abuse of power, leadership that is ill-informed, uncaring about or hostile to the values of health care professionals, incompetent, deceptive or dishonest, self-interested, conflicted, or outright corrupt, and governance that lacks accountability, and transparency, . We have found hundreds of cases and anecdotes supporting this viewpoint.
We found some corroboration of these hypotheses from other research. Written comments from the 2001 Massachusetts survey made similar points about the causes of dissatisfaction, for example: "too much emphasis on the bottom line. Taken over by large corporations. Quality of care and interaction now subsumed by productivity and profit," and "the once most noble profession has become a factory job with a facade of ethics"(4) Pololi and colleagues' qualitative interviews of young medical faculty included anecdotes of angst due to academic leaders who put revenues ahead of patient care, teaching, and research; and who allegedly used deception for personal gain.(9) (Also, see our comments on this paper.)(10) Pololi and colleagues' large survey of US medical faculty showed that over half thought that managers were only interested in them because of the money they brought in.(11) We were able to show in a preliminary analysis of data from a physician survey that an instrument meant to measure physicians' perception of the integrity of the leadership of their organizations, which incorporated questions about whether leaders supported core values, put patient care ahead of revenue, supported transparency about quality issues, put patient care ahead of self-interest, and displayed honesty strongly correlated (negatively) with stress, intention to leave the practice, and burnout.(12)
Yet at best most studies of physicians' burnout, angst, or dissatisfaction only vaguely allude to "system factors" and not greedy, money-focused, preversely incentivized, self-interested, or corrupt leadership, etc as its causes. "System factors" such as bad EHRs and performance measures suggested by the Health Affairs bloggers were more likely to have been imposed on physicians by bad organizational leadership than by the physicians themselves. Of course, the CEO authors of the post likely would be made very uncomfortable with the notion that bad health care leadership, including of hospital systems like their own, might be a major cause of burnout.
Furthermore, there clearly have been leadership problems at many of the blog post authors' institutions that could have made them more uncomfortable. Cases involving some of the authors' institutions have appeared on Health Care Renewal.
Most recently we noted that Mayo Clinic CEO Dr Noseworthy had raised questions of mission-hostile management by suggesting that the Mayo Clinic should give some patients with commercial health care insurance priority over those with less well paying government health insurance (look here). Not long ago we noted the controversy generated by Cleveland Clinic CEO Dr Cosgrove's lukewarm approach to the Trump administration's "Muslim ban," even though that ban had affected one of the Clinic's own house-staff, while the Clinic was planning a fund raising event at Mr Trump's Mar a Lago resort, raising yet more conflict of interest questions (look here).
We have also disccused issues occurring at the American Medical Assocation, and particularly its RBRVS Update Committee (RUC)(CEO Dr Madara), Sutter Health (CEO Ms Krevans), Johns Hopkins(CEO Dr Rothman), Duke (CEO Mr Sowers), Partners (CEO Dr Torchiana), and Northwestern (CEO Mr Harrison).
Finally, several of the Health Affairs authors have "board level" conflicts of interest. In 2006, we first blogged about a "new species of conflict of interest" which involved health care organizational leaders who were simultaneously members of the boards of directors of for-profit health care corporations or other corporations which could strongly influence health care. We posited these conflicts would be particularly important because being on the board of directors entails not just a financial incentive, but also requires board members to "demonstrate unyielding loyalty to the company's shareholders" [Per Monks RAG, Minow N. Corporate Governance, 3rd edition. Malden, MA: Blackwell Publishing, 2004. P.200.]
Three Health Affairs blog authors have such conflicts. Dr Paul Rothman is on the boards of Merck and of Cancer Genetics, a biotechnology company specializing in DNA based testing. Dr David Torchiana is on the IKS Health Advisory Board, apparently a health care consulting firm. Dean M Harrison is on the board of Northern Trust, a wealth management firm. He was on the board of Ikaria Inc, a biotechnology company now part of Mallinckrodt, and is a special advisor to Merrick Ventures, a private equity firm (look here).
Thus, how can one regard as credible an article on physician burnout which ignores how large organizations' nature or actions might be the major cause of such burnout, and which was written by the top leaders of such organizations?
Corporate Employment as a Cause of Burnout
Finally, the Health Affairs post mention of "loss of control over work" deserves special attention. It could represent a catch-all of more "system factors" as noted above. However, the biggest cause of physicians' loss of control over work may be the rising power of large health care organizations, in particular the large hospital systems that now increasingly employ physicians, turning them into corporate physicians.
In the US, home of the most commercialized health care system among developed countries, physicians increasingly practice as employees of large organizations, usually hospitals and hospital systems, sometimes for-profit corporations. The leaders of such systems meanwhile are now often generic managers, people trained as managers without specific training or experience in medicine or health care, and "managerialists" who apply generic management theory and dogma to medicine and health care just as it might be applied to building widgets or selling soap.
We have also frequently posted about what we have called generic management, the manager's coup d'etat, and mission-hostile management. Managerialism wraps these concepts up into a single package. The idea is that all organizations, including health care organizations, ought to be run people with generic management training and background, not necessarily by people with specific backgrounds or training in the organizations' areas of operation. Thus, for example, hospitals ought to be run by MBAs, not doctors, nurses, or public health experts. Furthermore, all organizations ought to be run according to the same basic principles of business management. These principles in turn ought to be based on current neoliberal dogma, with the prime directive that short-term revenue is the primary goal.
Again, the authors of the Health Affaris post included some generic managers: Mr Edgeworth, whose highest degree was an MBA, and who had a long career as a hospital manager; Ms Krevans, and MBA with an MPH, who also had a long career as a hospital manager; and Mr Harrison, an MBA, who also had a career in hospital management. Doubtless all of the authors lead organizations whose upper management is frequently generic and managerialist. It is likely that the hospital systems they lead increasingly employ physicians, who thus have become corporate. So the Health Affairs blog authors might not be comfortable with the notion that a major cause of burnout may physicians' new status as hired employees sometimes of their own hospital systems, rather than autonomous practitioners.
To repeat, how can one regard as credible an article on physician burnout which ignores how large organizations' nature or actions might be the major cause of such burnout, and which was written by the top leaders of such organizations?
Summary
I am glad that physician burnout is getting less anechoic. However, in my humble opinion, the last thing physicians at risk of or suffering burnout need is a top down diktat from CEOs of large health care organizations. The CEOs who wrote the Health Affairs post not have any personal responsibility for any physicians' burnout. However, the transformation of medical practice by the influence of large health care organizations run by the authors' fellow CEOs, particularly huge hospital systems, often resulting in physicians practicing as hired employees of such corporations likely is a major cause of burnout. If the leaders of such large organizations really want to reduce burnout, they should first listen to their own physicians. But this might lead them to realize that reducing burnout might require them to divest themselves of considerable authority, power, and hence remuneration. True health care reform in this sphere will require the breakup of concentrations of power, and the transformation of leadership to make it well-informed, supportive of and willing to be accountable for the health care mission, honest and unconflicted.
Physicians need to join up with other health care professionals and concerned member of the public to push for such reform, which may seem radical in our current era. Such reform may be made more difficult because it clearly would threaten the financial status of some people who have gotten very rich from the status quo, and can use their wealth and power to resist reform.
Despite the fact that the current US president has stated he is for the "forgotten people" rather than the elites, do not expect such reform from him. He has sought advice on health care policy from the same people who wrote the Health Affairs post, as per the Washington Post, December 28, 2016:
On Wednesday, his guests were health-care executives, many of whom represent companies or institutions that have a big stake in the outcome of Trump’s ambitions to dismantle the Affordable Care Act. According to a pool report, the group, all men, met with him at 11 a.m. at the Mar-a-Lago estate in Palm Beach, Fla. They included John Noseworthy of the Mayo Clinic, Paul Rothman of Johns Hopkins Medicine, David Torchiana of Partners HealthCare and Toby Cosgrove of the Cleveland Clinic.
We truly live in interesting times.
How to Stand Up to Trump and Win
by Nicholas Kristof - NYT - April 13, 2017
BOSTON — After President Trump’s election, a wave of furious opposition erupted. It was an emotional mix of denial and anger, the first two stages of grief, and it wasn’t very effective.
Yet increasingly that has matured into thoughtful efforts to channel the passion into a movement organized toward results. One example: the wave of phone calls to congressional offices that torpedoed the Republican “health care plan.”
Yes, Trump opponents lost the election and we have to recognize that elections have consequences. But if “resistance” has a lefty ring to it, it can also be framed as a patriotic campaign to protect America from someone who we think would damage it.
So what are the lessons from resistance movements around the world that have actually succeeded? I’ve been quizzing the experts, starting with Gene Sharp, a scholar here in Boston.
Sharp’s works — now in at least 45 languages and available free online — helped the Baltic countries win freedom from Russia, later guided students in bringing democracy to Serbia, and deeply influenced the strategy of Arab Spring protesters. Sharp is THE expert on challenging authoritarians, and orders for his writings have surged since Trump’s election.
Today Sharp is 89 and in fading health. But his longtime collaborator, Jamila Raqib, has been holding workshops for anti-Trump activists, and there have even been similar sessions for civil servants in Washington exploring how they should serve under a leader they distrust.
The main message Sharp and Raqib offered is that effectiveness does not come from pouring out into the street in symbolic protests. It requires meticulous research, networking and preparation.
“Think!” Sharp said. “Think before you do anything. You need a lot of knowledge first.” His work emphasizes grass-roots organizing, searching out weak spots in an administration — and patience before turning to 198 nonviolent methods he has put into a list, from strikes to consumer boycotts to mock awards.
Raqib recommended pragmatic efforts seeking a particular outcome, not just a vague yearning for the end of Trump. When pushed, she said that calls for a general strike in February were insufficiently organized, and that the Women’s March on Washington, which had its first protest the day after Inauguration Day, will ideally become anchored in a larger strategy for change. But she thinks the “Day Without Immigrants” protest was well crafted, and the same for the bodega strike by Yemeni immigrants.
Sam Daley-Harris, another maestro of effective protest, agrees on a focus on results, not just symbolic protest. He has overseen groups like Results and the Citizens Climate Lobby that have had outsize influence on policy, so I asked him what citizens upset at Trump should do.
“The overarching answer is to work with your member of Congress,” Daley-Harris told me. He suggested focusing on a particular issue that you can become deeply knowledgeable about. Then work with others to push for a meeting with a member of Congress, a state lawmaker or even a legislative staff member.
He recommended speaking courteously — anyone too hostile is dismissed and loses influence — and being very specific about which bill you want the person to support or oppose.
I’m encouraged by the increasing savvy of the resistance efforts, with excellent online resources cropping up and grass-roots groups like EmergeAmerica.org and RunforSomething.net developing to train people who want to run for political office. Students at Harvard’s Kennedy School of Government have organized “Resistance School,” a kind of online teach-in to sharpen the tools activists need. The first 90-minute webcast had more than 50,000 streams.
“We wanted to move away from a defensive response to an offensive response, not just marching but also thinking of longterm strategy,” one of the organizers, Shanoor Seervai, told me.
To students of resistance — patriotic resistance! — let me offer three lessons from my own experience reporting on pro-democracy movements over decades, from China to Egypt, Mongolia to Taiwan.
First, advocates are often university-educated elites who can come across as patronizing. So skip the lofty rhetoric and emphasize issues of pocketbooks and corruption. Centrist voters may not care whether Trump is riding roughshod over institutions, but they’ll care if he rips them off or costs them jobs.
Second, movements must always choose between purity and breadth — and usually they overdo the purity. It’s often possible to achieve more with a broader coalition, cooperating with people one partially disagrees with. I think it was a mistake, for example, for the Women’s March to disdain “pro-life” feminists.
Third, nothing deflates an authoritarian more than ridicule. When Serbian youths challenged the dictator Slobodan Milosevic, they put his picture on a barrel and rolled it down the street, allowing passers-by to whack it with a bat.
In recruiting for the Trump resistance, Stephen Colbert may be more successful than a handful of angry Democratic senators. Trump can survive denunciations, but I’m less sure that in the long run he can withstand mockery.
Universal healthcare supporters see their chance: 'There’s never been more support. su
It was a cold, misty, gray, early spring day in Albany, New York – the kind of bone-chilling, turn-up-the-heat weather that encourages residents to flee to Florida.
But 500 New Yorkers were still out on the sidewalk lobbying for healthcare reform that has long seemed like a pipe dream: government-provided universal health insurance.
“I wanna make sure my children get healthcare,” said Minerva Solla, a 66-year-old organizer with the New York State Nurses Association. “It’s a right, not a privilege.” Moments earlier she riled the crowd with call-backs: “If they don’t pass it? Vote them out!”
Americans might know the liberal dream as “Medicare for all”. If it ever passed, it could be as comprehensive as the UK’s National Health Service.
Universal healthcare is not a new idea, but one with fresh energy since Republicans’ disastrous attempt to reform the American health system. In Albany, a record number of people turned out to a rally for universal healthcare in New York, several activists and one lawmaker said.
“It’s an uphill battle, and the Republicans are in control of Congress, and there’s no signal they would be willing to let this pass right now,” said Clare Fauke, spokesperson for Physicians for a National Health Program, which advocates for universal healthcare. “But we’ve been thinking in terms of the long game, and there’s never been more support for it than there is right now.”
In a universal healthcare system, New York would pay for every resident not covered by an existing federal health insurance program, like Medicare for the old or Medicaid for the poor. For-profit health insurance companies would be all but eliminated.
That would mean New Yorkers would be freed from “co-pays”, “deductibles”, and “premiums”, all insurance industry jargon for one thing: medical bills.
“We’re unanimous that this is the most logical system going forward,” said Phil DeSalvo, a 29-year-old medical resident from New York City. He and three fellow health workers traveled three hours north on their only day off to protest. Was universal healthcare gaining momentum?
“Absolutely, particularly with the collapse of the plan advanced by the Republicans,” he said. “This is the best solution going forward.”
Despite campaigning for seven years to “repeal and replace” the Affordable Care Act, better known as Obamacare, Republicans’ first attempt at a reform bill sank like a stone.
Trump and the Republican leadership’s concessions to both hardline conservatives and moderate Republicans made the bill a mishmash. Tax credits would have helped Americans buy private insurance, but the gutting of insurance regulations would have made policies practically meaningless. It would have left 52 million peopleuninsured by the end of the decade, at last estimate.
It had an abysmal 17% public approval rating, and lasted two weeks before it was pulled. It is Trump’s single largest loss to date. In the vacuum of ideas, liberals have conjured hope.
“I think fear of the Republican bill, and fear that it will come back in even worse form, is sparking support,” said Richard Gottfried, a New York City Democrat who has sponsored a universal healthcare bill since 1992.
Advocates of universal healthcare are not missing an opportunity to make a fuss. Physicians for a National Health Program held their first day of national rallies to coincide with the Congressional recess on Saturday. Protests were planned from Florida to New Hampshire, Oregon to North Carolina.
Bernie Sanders plans to introduce a bill in the US Senate to support single-payer healthcare. In the House, there is already a single-payer bill with 93 co-sponsors.
In an issue of the British medical journal the Lancet devoted to the US healthcaresystem this week, Sanders wrote the opening letter.
“The goal of a healthcare system should be to keep people well, not to make stockholders rich,” wrote Sanders. “The USA has the most expensive, bureaucratic, wasteful, and ineffective healthcare system in the world.”
Sanders called single-payer healthcare “as American as apple pie” – an attempt to throw off single-payer reform’s negative reputation as “socialized medicine”.
Meanwhile, the American healthcare system may be worsening inequalities, the the Lancet found. A widening income gap, paired with insurance companies’ increasing tendency to push health costs on to consumers, has resulted in a “regressive” systemin which the richest 1% of Americans can now expect to live up to 15 years longer than the poorest 1%.
Even for those who have insurance, increasing monthly costs have eroded wage gains, the Lancet reported. Medical debt accounts for more than half (52.1%) of all unpaid personal debt.
“I could tell you this – I’ve been on the job for 25 years. When I first started, I paid nothing” for healthcare, said Chris Tague, who works in road construction. He is also a part-time town supervisor in Schoharie County, New York, which voted overwhelmingly for Donald Trump.
Tague’s health insurance costs grew to $20 per week, then to $50 per week, then $75, then to more than $200 per week, he said. Middle class Americans, he said, “work their asses off for nothing”.
The ACA insures more Americans than ever. Nevertheless, 9% of Americans, or 28 million people, remained uninsured in 2015, according to the Kaiser Family Foundation. Those people are predominantly in Republican-led southern states, which rejected an expansion of Medicaid, a federal program for the poor, even though the national government paid for it.
Even conservatives admit that government-run healthcare could save money.
“I mean look, you can save money with a single-payer system, don’t misunderstand me,” said Robert Moffit, a policy analyst at the conservative Heritage Foundation. “But the quality and supply of medical services is going to be determined by government officials.”
For this and other reasons, many argue single-payer reform simply is not viable.
“The history of healthcare reform in the US has dictated that it is politically untenable,” said Richard Boxer, a Los Angeles urologist who studies insurance reform. He pointed out that a public insurance option was proposed when the ACA was first under consideration in 2010. A Democratic Congress rejected the idea.
Grassroots efforts at the state level have also failed.
In Colorado, advocates tried to establish a state-funded universal health program through a ballot initiative last year. State residents would have paid a 10% payroll tax to fund the program.
Though the program would have insured all Coloradans, only 20% of voters favored the effort.
The insurance industry group Coloradans for Coloradans had a seven-to-onefundraising advantage at one point. The group raised more than $4m, its single-largest $1m donation coming from the insurance company Anthem. Comparatively, the pro-universal healthcare group ColoradoCareYES raised $902,000.
“The insurance companies, of course, were worried this would pass,” said Patricia Rice, a spokesperson for ColoradoCareYES. “Because it would signal a tidal wave. Once it passes in one state, I think it would just spread to other states and it would cut into profits.
“They were throwing everything they had at us, and we only had a few spots on television,” said Rice.
The economics of a public option
Most analyses of universal healthcare assume that money taxpayers once spent on private insurance would go to support a government program, and that the elimination of bureaucracy and profit would save money.
A 2015 analysis of single-payer health insurance in New York found the system would save $44.7bn in healthcare costs in the first year, assuming the state could negotiate with drug companies. Studies of single-payer healthcare at the federal level have also found savings. One 1998 study found that a single-payer health system would lead “to sizable savings in the future”.
Not all projections are rosy. The non-partisan Committee for a Responsible Federal Budget analyzed Sanders’ plan for universal health coverage in 2016, and found it would add $19tn to the federal debt.
New York’s latest battle to pass universal healthcare represents a theme in the long fight – so close to passage, but so far from enactment.
Gottfried’s bill is expected to pass the lower New York state assembly, but could run into trouble in the Republican-controlled senate.
The Republican senate majority leader may never let the legislation come to the floor, and it is an open question whether the moderate Democratic governor, Andrew Cuomo, would support the legislation.
If the bill did make it to the senate floor, just one Democrat stands in the way of a majority: Simcha Felder. He represents deeply conservative orthodox Jewish neighborhoods in Brooklyn, and often caucuses with Republicans.
“I do not have a position on the New York health act,” Felder said in an email. “This legislation would be a huge overhaul of the healthcare system in New York, and I would like to hear from experts and other senators on the committee.”
“Everybody’s calling about it,” said a worker in Felder’s office, as she folded a “Healthcare is a human right” sign in half and stuffed it into a wastebin.
Just an hour earlier, Dr Roona Ray was whipping up demonstrators, exclaiming, “We can have healthcare that covers everyone as a right and as a public good,” she said. “There will be no premiums, no co-pays, no co-insurance, no deductibles, no doughnut holes, no bills!”
“The other side has money,” she said, “but we have people.”
• This article was amended on 11 April 2017 to clarify the findings of the Committee for a Responsible Federal Budget’s analysis of Bernie Sanders’ healthcare plan.
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Trump Threatens Coverage Of Millions If Democrats Won’t Negotiate On ACA Repeal
by Jonathan Cohn - Huffington Post - April 12, 2017
President Donald Trump is contemplating a new strategy to get repeal of the Affordable Care Act through Congress: threatening to torpedo insurance for millions of Americans unless Democrats agree to negotiate with him.
In an interview with the Wall Street Journal that appeared on Wednesday, Trump made a warning. If Democrats won’t talk repeal, the president said, Republicans might decide to cut off some subsidies now flowing to health insurers offering coverage through Obamacare’s exchanges.
“I don’t want people to get hurt,” Trump said, sounding a bit like a mobster describing a protection racket. “What I think should happen — and will happen — is the Democrats will start calling me and negotiating.”
Those subsidies are a really big deal. Without them, insurers would have to jack up premiums ― by an average of 19 percent for typical policies, according to a Henry J. Kaiser Family Foundation study. That increase would be above and beyond any other increases in the works. Many insurers would probably exit the markets altogether.
The payments are called cost-sharing reductions, or CSRs. They reimburse insurers for the expense of providing special insurance plans, with lower out-of-pocket costs, to customers with incomes below 250 percent of the poverty line, or $61,500 for a family of four.
The health care law calls on the federal government to pay insurers the CSRs but it does not actually appropriate money for that purpose. The Obama administration had disbursed the money anyway, and devised a legal argument to justify the move. House Republicans sued, claiming the spending was unconstitutional, and last year a U.S. district court judge agreed with them.
The judge stayed the decision, allowing the Obama administration to file an appeal, and in the interim the federal government has continued to disburse the CSRs. But with the Obama administration gone, it’s up to the Trump administration and its allies to keep the money flowing.
The Trump administration could do so, at least temporarily, by pressing ahead with the appeal or simply seeking a delay in the case. Or it could work with Congress on a more permanent solution ― namely, passing legislation that would appropriate the money for a limited time or indefinitely.
Trump is spooking insurers ― and they were spooked already
Until Wednesday, the administration hadn’t said much, except that it would continue funding CSRs as long as it was required to do so by law. Several Republicans in Congress went a bit further, and said they thought the federal government should keep disbursing the funds as long as the law was in place ― although they stopped short of saying exactly how they intended to make that happen.
In the Journal interview, Trump for the first time shed light on his own thinking:
You know that if we follow that lawsuit, we’re not supposed to pay money toward Obamacare — you know, Obama just paid the money because he couldn’t get approved — the approval from Congress.Well, Congress hasn’t approved it, so if Congress doesn’t approve it, or if I don’t approve it, that would mean that Obamacare doesn’t have enough money so it dies immediately as opposed to over a period of time.So, Congress is going to have to approve it [the insurance payments]. Will they approve it? I don’t know, I’m not sure, 50-50. If they approve it, then I will have to approve it. Otherwise, those payments don’t get made and Obamacare is gone, just gone.
Politico subsequently quoted a senior official confirming that “POTUS wants to use [the subsidies] as leverage. When Obamacare fails on its own, the Dems will want to come to the table.”
That prediction may be a bit fanciful. House Minority Leader Nancy Pelosi (D-Calif.) called Trump’s statement “appalling” and accused him of trying to “manufacture a crisis.”
Her Senate counterpart, Minority Leader Chuck Schumer (D-N.Y.), said, “Our position remains unchanged: drop repeal, stop undermining our health care system, and we will certainly sit down and talk about ways to improve the Affordable Care Act.”
Nor is it clear whether Trump is prepared to carry out his threat. He ended up backing down from the last Obamacare-related ultimatum he made ― a demand, in March, that House Republicans vote on repeal legislation.
But simply making the threat is sure to unnerve the nation’s insurers, at a time when they are figuring out what premiums to charge for the coverage they sell through the Affordable Care Act’s exchanges ― and, in some cases, whether to withdraw from those exchanges altogether.
The law’s private insurance exchanges have been a fragile enterprise from the get-go, with insurers struggling to make money and premiums rising quickly in some states ― in part because many people have found the coverage too expensive to afford, and in part because Republicans at the state and federal level have done their best to undermine the program.
In 2014, for example, conservatives attacked the law’s “risk corridors,” a standard feature of public-private insurance programs designed to insulate carriers from huge losses. The conservatives prevailed, which meant the program paid out only a fraction of the money it owed ― saddling insurers with huge losses.
The difficulty of making money on Obamacare led some insurers, particularly the big national carriers, to pull back from the market, and today roughly one in five people buying through the exchanges can choose from just one carrier. Critics of the law, like Trump and House Speaker Paul Ryan (R-Wis.), have for years cited stories like these as proof the law was “exploding” and in need of repeal.
But the state of the program varies a lot from state to state, and in California, Florida and Maryland, just to name a few, the program is working well ― with multiple insurers and prices that are actually cheap relative to the cost of comparable employer plans. There is also strong evidence that last year’s price hikes ― the ones that Trump kept talking about during his presidential campaign ― were mostly a one-time correction of the premiums insurers initially set too low.
Just last week, a report from S&P Global Market Intelligence found that nonprofit Blue Cross plans, a staple of the exchanges, were seeing improved margins ― and on track for profitability within a few years.
But that report also made a warning that analysts and insurance officials had been making for months: Future success depended on steady management and nurturing. And that’s not what the Affordable Care Act has gotten since January, when the Trump administration took over.
Trump has already undermined the law in other ways
At various times, it looked like the Trump administration might be taking its stewardship of the law seriously ― and trying to keep insurance markets stable even as it sought to repeal the law. The Department of Health and Human Services issued new regulations, tweaking enrollment procedures in ways insurers had long recommended, and gave a green light to states trying to use special waivers from the law’s requirements in order to help struggling insurers.
But Trump’s very first act as president was to sign an executive order instructing agencies to ease the law’s regulatory burden ― an order that seemed to signal, among other things, that his administration would not aggressively enforce the law’s individual mandate penalty, which encourages healthy people to buy coverage before they get sick. Sure enough, within a few weeks the Internal Revenue Service announced it was canceling plans to tighten up mandate enforcement.
More ominously still, the Trump administration in January abruptly canceled some advertising that was supposed to run at the end of open enrollment. The advertising, which the Obama administration had planned, was supposed to nudge people waiting until the last minute to sign up for a plan. But without the ads ― and amid all the talk of repeal ― signups in the last two weeks fell well below last year’s levels, even though enrollment had been running slightly ahead of the 2016 pace through January.
The possibility that Trump might not implement the law aggressively ― to say nothing of the possibility that the law might be repealed altogether ― has been on the minds of insurers for weeks, as they try to figure out their plans for 2018 and beyond.
And they have made clear that one issue, in particular, would weigh heavily on their minds: the future of those reimbursements for offering plans with low out-of-pocket costs.
“You cannot understate how big a deal they are” to insurers, Sean Mullin, a senior director at the health care consulting firm Leavitt Partners, told The Huffington Post earlier this week.
On Wednesday, just hours before the Journal interview appeared, a group of eight influential trade groups ― including not just America’s Health Insurance Plans and the American Medical Association, but also the U.S. Chamber of Commerce ― wrote a letter to Trump saying “The most critical action to help stabilize the individual market for 2017 and 2018 is to remove uncertainty about continued funding for cost sharing reductions (CSRs).”
Following the publication of Trump’s comments, Kristine Grow, AHIP spokesperson, told HuffPost that “We must remember that when we talk about CSRs, we are talking about a subsidy that 7 million people rely on ― to get coverage, and to be able to see their doctor.”
In the Journal interview, Trump said he thought his threat would bring Democrats to the table because “they own Obamacare” ― but acknowledged that “the longer I’m behind this desk and you have Obamacare, the more I would own it.”
Recent polls suggest that transformation has already taken place. In a new Kaiser Foundation poll that appeared last week, 61 percent said they would blame Trump and the Republicans for problems with the health care law, while just 31 percent said they’d blame Obama and the Democrats.
4 ways states can prevent the Affordable Care Act from “exploding”
Tom Baker and Daniel Hemel = Vox - April The gravest danger facing Obamacare now is not legislative action — it’s executive inaction. Fortunately for the millions who rely on the Affordable Care Act, the states can save the health care law from “exploding.” But they need to move fast.
President Donald Trump’s latest bid to repeal the ACA looks as though it’s destined to meet the same fate as House Speaker Paul Ryan’s failed effort last month. Still, Trump has the ability — and quite likely the inclination — to undermine the health care law by deliberately failing to carry out important elements of it.
Obamacare faces four near-term threats from the president. First, the Trump administration could stop enforcing the individual mandate, which requires most individuals to have health insurance or else pay a penalty to the IRS. Trump can’t change the law without an act of Congress, but he might be able, through directives from the Oval Office, to stop the IRS from collecting the penalty.
The IRS has already said that for this tax season it will process so-called silent returns — returns filed by taxpayers who don’t indicate whether they had health coverage throughout the prior tax year. In other words, you can now go without health coverage, not pay a penalty, and still claim a tax refund when you file. (Under law, you still owe a penalty for failing to obtain insurance, but whether the IRS will ever come after you for the money is anyone’s guess.)
If young, healthy adults drop coverage because they don’t expect to pay a penalty, then the people in the risk pools on the exchanges will become older and sicker, on average, leading insurers to raise premiums for everyone. And if the healthy adults who drop coverage turn out not to be as healthy as they thought, then they will show up in emergency rooms without insurance. Hospitals will then have to provide them with uncompensated care, imposing costs borne by the rest of society.
The ACA is threatened by different kinds of malign neglect
A second and related threat is that the Trump administration will stop enforcing the employer mandate. Under the employer mandate, a firm with 50 or more full-time employees that fails to provide health insurance for its workforce faces a penalty of up to $2,260 per employee per year.
Trump signed an executive order on his first day in office telling his secretary of Health and Human Services, as well as other administration officials, to “waive, defer, grant exemptions from, or delay the implementation of” virtually all Obamacare provisions. We will soon see whether that leads HHS to carve out new exceptions to the employer mandate, in which case we can expect some firms to drop coverage and add their workers to the ranks of the uninsured.
A third threat is that the Trump administration will halt efforts to encourage people to buy insurance. Days before the January 31 enrollment deadline for 2017 coverage, the Trump administration pulled advertisements reminding consumers to sign up. We can expect the Trump administration to make even less of an effort to encourage sign-ups for 2018. Not only will that increase the ranks of the uninsured — a bad thing in itself — but the fewer consumers who buy coverage on the exchanges, the less likely it is that insurers will want to stay in the game.
A fourth threat, and probably the most pressing, is that the Trump administration will stop reimbursing insurers for costs the law requires them to take on. Under the Affordable Care Act, insurers must cover a portion of the costs that low-income households enrolled in individual-market plans would otherwise pay out of pocket; those “cost-sharing reductions” are then reimbursed by HHS.
So far, the Republican-controlled Congress has refused to appropriate funds for the reimbursements owed to insurers. The Obama administration paid the reimbursements anyway, but the House of Representatives responded by suing to stop those payments from continuing. That litigation continues, and while HHS is still making the payments for the time being, it’s not clear how much longer that will last.
What if HHS stops paying? A provision of the ACA requires insurers to make the cost-sharing reductions regardless of whether they are reimbursed by HHS. What’s more, the law also requires HHS to reimburse the insurers regardless of whether Congress appropriates funds. So if Congress doesn’t provide the money, then the insurers can sue the federal government in the Court of Federal Claims. The law is on the insurers’ side, and once the insurers have a court verdict in their favor, the reimbursements can be paid out of the federal government’s Judgment Fund.
But that process could take years, and it seems unlikely that insurers will be willing to shoulder more than $7 billion in annual costs while waiting for federal reimbursement. Many insurers may decide to pull out of the exchanges instead.
States don’t have to rely on Washington to enforce the individual or employer mandates
All this might make it sound like Obamacare is headed for a death spiral. It is not — at least, not yet. But it may be in need of some emergency treatment. And while Congress won’t come to the rescue, the states can.
First, the states can pick up the slack where the individual mandate is concerned. States should pass their own provisions that operate as fail-safes for the federal law. They should require individuals without insurance to pay the penalty to the state (allowing, of course, a full credit for amounts paid to the federal government). Anyone who complies with the federal mandate by obtaining insurance or paying the penalty to the IRS wouldn’t owe anything to the states, but people who ignore the federal law thinking that the IRS won’t come after them will face state tax collectors instead.
Second, states should pass similar fail-safes for the employer mandate. If the Trump administration tries to open up loopholes that allow employers to dump their employees onto the exchanges, then the states can close those loopholes on their own. They can require any firm with 50 or more full-time employees that doesn’t provide coverage and doesn’t pay the federal penalty to make that payment to the state instead.
Third, states should use the revenues they raise from the backup individual and employer mandates to fund their own enrollment campaigns — paying for advertising and in-person outreach. They could kick in additional funding as well, which would be a wise investment in the long run. Getting more of their residents insured through the exchanges will mean that more federal premium tax credit dollars will flow into the states. And with more individuals insured, the states will bear less of a burden for uncompensated care.
Fourth, if Trump stops paying reimbursements, the states should promise to reimburse insurers for making cost-sharing reductions until the federal government ultimately pays up. (This guarantee should come with full “subrogation” rights — meaning that if a state reimburses an insurer today and the federal government finally pays two years from now, the federal payment goes to the state, not the insurer.)
Yes, the states will bear a short-term cost while the issue is being litigated, but ultimately the courts will order the federal government to pay and the states’ treasuries will be replenished. In the meantime, the state guarantee will encourage insurers to remain on the exchanges rather than running for the exits.
These four steps — a backup individual mandate, a backup employer mandate, investments in state-level enrollment campaigns, and state guarantees for insurer reimbursements — will make it much more likely that Obamacare survives intact.
But the states will need to take these steps soon. June 21 is one important deadlinefor insurers to decide whether they will participate in the Healthcare.gov exchanges for 2018. Some states that run their own exchanges have earlier deadlines; California’s is May 1. By acting quickly, states can bolster insurance companies’ confidence that the marketplaces will remain functional regardless of what steps the Trump administration takes to undermine Obamacare.
Far from a “federal takeover” of health care, Obamacare actually gives the states considerable power to shape policy. They should use that power to preserve the health care law from a president bent on destroying it — and to protect the millions of Americans who depend on it.
Tom Baker is the William Maul Measey professor of law and health sciences at the University of Pennsylvania Law School and director of the Health Insurance Exchange Research Group at Penn’s Leonard Davis Institute for Health Economics. Daniel Hemel (@danieljhemel) is an assistant professor at the University of Chicago Law School.
The Big Idea is Vox’s home for smart discussion of the most important issues and ideas in politics, science, and culture — typically by outside contributors. If you have an idea for a piece, pitch us at thebigidea@vox.com.
http://www.vox.com/the-big-idea/2017/4/5/15189402/states-aca-ahca-insurance-markets-implode-explode
Get Set For Trump Revisions To Your Affordable Care Act Insurance
by Julie Appeby - NPR - April 13, 2017
Repeal and replace is on-again, off-again, but that doesn't mean the rules affecting your insurance will stay the same in the meantime.
The Trump administration's proposed rule aimed at stabilizing the existing health law's insurance marketplace could have rapid, dramatic effects — perhaps as soon as early summer — on people who do not get insurance through work, and buy it on the Affordable Care Act's exchanges instead.
If the changes the administration proposed in February hold up in the final draft, which is expected out soon, look for a shorter enrollment window, tighter vetting of people who sign up outside of those open periods and efforts to penalize consumers who don't maintain "continuous coverage."
The controversial proposal by the Department of Health and Human Services drew letters from nearly 4,000 organizations and individuals during an unusually short, 20-day public comment period that ended in early March. Consumer advocacy groups hate the proposal, saying it would wreak havoc by making it harder to get coverage.
But some specialists in the health law, including Christopher Condeluci of CC Law & Policy in Washington, D.C., see the HHS proposal as helpful for insurers, though he also thinks more adjustments are necessary.
"Does it meet all the carriers' asks when it comes to what changes are needed? No, I don't think it goes far enough," said Condeluci, a former staffer to the Senate Finance Committee who specialized in insurance issues.
Sabrina Corlette, an attorney who studies the individual marketplace for the Center on Health Insurance Reforms at Georgetown University, said the directive could result in fewer healthy enrollees — which insurers also would not like — and doesn't address some of the biggest concerns for the insurance industry, such as the fate of federal subsidies that help low-income consumers pay deductibles and other out-of-pocket costs.
The Trump administration's proposal, Corlette said, is "nibbling away at the margins."
Here are four ways the stabilization rule might change the individual health insurance market:
If you owe, you pay first
Under the proposed rule, consumers who want to sign up for an ACA plan with their same insurer for 2018 would have to repay past-due premiums from the previous 12 months before being granted new coverage. Because Obamacare has allowed a three-month grace period before people who haven't paid premiums are kicked out of coverage, a consumer's overdue premiums could tally hundreds of dollars — even more than $1,000.
Trump's proposed change aims to discourage people from gaming the system. Insurers say a person with a bad knee, for example, might enroll and pay just long enough to get an expensive knee replacement, then stop paying premiums.
But wait, consumer groups and the National Association of Insurance Commissioners warn. There might be legitimate reasons people stop paying premiums — billing errors that are not the fault of the consumer, for example, or the loss of a job. By making such a change, the groups argue, the Trump administration would violate a key part of the health law that requires insurers to offer coverage to just about everyone who applies.
Under Trump's proposed change, "only those who can rapidly come up with a possibly significant sum of money by a given deadline can be guaranteed access to coverage," wrote Families USA.
Some insurers have recommended broadening that proposal to include "unpaid premiums for any prior coverage year."
Better act quickly
Open enrollment this fall (for 2018 health insurance coverage) would shorten to six weeks, down from three months. While opening day would remain the same — Nov. 1 — the proposal would close the marketplace on Dec. 15 instead of at the end of January. That period "provides sufficient time for consumers to enroll," the administration has said, and would mean all who sign up would have a full year of coverage starting Jan. 1.
The shorter time period, the administration said, could also reduce the number of people who wait to enroll until after they find out they have a health problem. These late joiners are likely to use more health care than a healthy person their age, insurers and the Trump administration say, and can drive up the cost of insurance to everyone.
Consumer groups argue the Trump proposal could backfire, because those who tend to wait until the last minute to sign up are actually often the youngest and healthiest — and they may miss the enrollment window if it is shorter. Additionally, the proposed deadline falls around the holidays, when money and time are often tight, which could have a chilling effect on insurance sign-ups.
Prove you have a reason — and maybe prior coverage
The ACA allows people to sign up outside the open enrollment period for a variety of special reasons, such as moving, losing coverage, getting married or having a child. This provision has always been a sticking point with insurers, who have maintained that too many customers who made a change during the special enrollment period were sicker and costlier than average. In response, the Obama administration tightened some of these requirements last year and announced it would run a pilot program starting this summer to randomly select half of all special enrollment applicants for verification review, holding up the applicant's insurance coverage until they provide the proper documentation.
Under the Trump administration's proposal, 100 percent of those applications would be required to undergo preapproval verification — beginning in June 2017. Consumers would have to provide documentation proving they qualify for special enrollment before getting coverage. The administration also proposes that for marriage, at a minimum, one member of the couple would have to prove they had health coverage for at least one day in the two months before their nuptials.
Consumer groups are unhappy with the pre-verification idea — and the extra requirement for prior coverage of people who are getting married. Particularly hard hit would be couples who were uninsured previously because they could not afford health insurance as singles or could not get it under their state's Medicaid rules. Additionally, consumer advocates and some regulators say requiring newlyweds to prove prior coverage violates the health law.
Still, the Trump administration asked whether continuous coverage rules should be extended to all special-enrollment customers, not just those getting married. Perhaps people should prove they had coverage for the previous six to 12 months, the administration suggested, or else face a waiting period or financial penalty.
Flexibility — or higher deductibles?
The health law uses a complex formula to divide plans into metal tiers — bronze, silver, gold and platinum — based on an average percentage of a typical year's health care bills each level of plan covers. Bronze plans, for example, currently must cover an average of 60 percent of costs, while a silver one is 70 percent. Insurers are allowed wiggle room of plus or minus 2 percent around those averages.
The Trump proposal would tweak the formula, allowing insurers to create plans with larger variations around the average. (It exempts certain silver plans for low-income consumers from the change.) So, for example, a bronze plan might cover only 56 percent of costs and silver 66 percent. Insurers say this would allow them to create plans that appeal to more customers, particularly those looking for lower premiums. But critics say the move would increase the size of deductibles.
One big problem in boosting enrollment has been that many potential consumers — particularly younger, healthier ones — say premiums are too high. But adjusting the law in this way could raise deductibles and other cost-sharing requirements, which consumers may dislike even more. While the health law sets a maximum cap per year on such payments, for many people those deductibles are already thousands of dollars annually. Under the proposal, deductibles could increase by more than $1,000 a year, according to an analysis by the consumer advocacy group Families USA.
Please, may I have some more?
Topping insurers' wish list for other changes, which would require legislative action by Congress, would be permanent federal financial support for insurers that face high-dollar claims from some policyholders. Insurers have argued that change is important if they are to hold down premium costs across the board. Insurers also want a surcharge for people who let their coverage lapse, and the permission to charge older people five times more than younger ones, a practice known as "age rating." The current limit is 3:1. Widening that ratio could lower premiums for young people but cause big hikes for people older than 45.
Cigna said it would like to see an "appropriately funded system of state-designed high-risk pools," where people with costly illnesses could be sent. So, those with cancer, heart disease or other illnesses would be shunted into those pools, reducing spending — and perhaps premiums — for all remaining in the regular pool. High-risk pools historically, however, have been underfunded, often leading to expensive premiums for enrollees, long waitlists or annual limits on care.
Greg Kesich: Health care ‘free market’ sure has a lot of government involvement
The U.S. government was paying a big chunk of the medical bills long before Obamacare became a thing.
by Greg Kesich - Portland Press Herald - April 12, 2017
Let’s talk about the free market in health care. Oh, wait. It doesn’t exist.
It might look like one because health care is such a big business. Hospitals, insurance firms and pharmaceutical companies rake in billions, and our total health spending is more than $3 trillion a year, or one-sixth of the national economy.
But the transactions that produce all of that wealth are not made by people who have enough freedom of choice to make a market function.
If I get hit by a bus on my way home tonight, I’m not going to shop around for the healer with the best prices. I’m going where the ambulance takes me.
And if a doctor orders an X-ray, there’s no point in me asking her how much it’s going to cost because she won’t know. There are different prices negotiated by every insurance carrier, and billing is not the doctor’s job.
There is no free market in health care because there can’t be, which is why paying for health care is a government function throughout the developed world. What most people don’t realize is that’s true here, too.
The U.S. government was paying a big chunk of the health care bill long before Obamacare became a thing. It’s past time we take a hard look at what we are spending and ask if we are getting our money’s worth.
Everybody knows that about one-third of the American population gets health coverage through a government program, like Medicare for seniors, veterans programs, and Medicaid for the low-income and people with disabilities. But what’s usually forgotten is how the government is involved with the other two-thirds of us.
About half of all Americans get health insurance through their employer. Private employer, private insurance company, no government involvement there, right? Wrong.
The premiums for those policies are tax-exempt. Out-of-pocket costs are also deductible. That amounts to a few thousand dollars in subsidies every year for every family that gets insurance from work.
Another 10 percent buy insurance on the individual market, and many of them receive subsidies or tax credits under the Affordable Care Act. Any premiums they pay are also deductible.
The cost of “free” care for the remaining uninsured is distributed to all the other payers, which results in higher premiums and more tax deductions.
That’s hundreds of billions of dollars in government spending every year on top of the Medicaid-Medicare budgets, but it’s invisible.
People argue that a tax break is not a government expense, but they are wrong. If the Internal Revenue Service were not exempting health care spending, it would not have to tax other income as much. If not for the tax exemption, health insurance would be considerably more expensive and millions of us would not be able to afford it, but because of the policy, we can. Sorry, but that looks like government-supported health insurance to me.
The Obamacare replacement dust-up revealed some interesting attitudes that should shape how the health care debate moves forward. One surprise was how many people found that they liked the ACA after they realized that they were in danger of losing it. The other interesting discovery was what parts of the law they liked the most.
Almost universally, it was the market reforms in the ACA that had the most support. Under Obamacare, you can’t sell insurance unless you agree to let young adults stay on their parents’ plans until they turned 26. No insurer can cancel someone’s policy because they have a pre-existing condition or if they become so sick they hit a lifetime cap.
These regulations were even popular among Republicans like 2nd District Rep. Bruce Poliquin, who wouldn’t say how he planned to vote on the House bill, but did let everyone know how he supported maintaining some mandated coverage. And Republican governors in states that had expanded Medicaid were key voices in the House backing off plans to cut back that program, which brought coverage to millions of their constituents.
What’s interesting is that these are some of the least “free market” aspects of Obamacare. The part that was supposed to appeal to Republicans – the health care exchanges adapted from Mitt Romney’s universal insurance program in Massachusetts – is the part that has fewer fans, despite being the most market-based.
There’s a reason that House Republicans have had such a hard time describing a free-market health care system that doesn’t leave millions of people with no coverage. It’s because it can’t be done.
We’re already paying for a government-funded system, so we ought to demand one that works.
Letter to the editor: Personal experiences show Medicare-for-all is the way to go
Cathleen London (Maine Voices, April 5) makes a strong case, from a physician’s point of view, for adopting single-payer health insurance (Medicare for all). I would like to add a few personal observations.
Ever since I enrolled in Medicare five years ago, I have liked its simplicity and its benefits to the patient, including a much broader choice of providers than is available from private insurers, who restrict you to providers in their networks. I have wondered why there couldn’t be a similar plan for all of our citizens.
In discussions of this topic, the term “socialized medicine” is often used and referred to as something to be feared. It is incorrect to use this term in this context. We are only talking about socializing health insurance.
Nobody is proposing that the government run the hospitals or that the doctors become government employees. Single-payer would simply be a change in how the bills are paid, not in how medical services are delivered. (Whether there should be changes in the latter to reduce costs is a separate, though important, issue.)
From my experience with Medicare, I can say with confidence that the government does no harm to the doctor-patient relationship. Decisions about my care are made solely by me in consultation with my doctor. Medicare is patient-centered.
A study published in 2016 in The Lancet, a British medical journal, ranked the healthiest countries in the world. The U.S. ranks 28th. We should aspire to be first. Politicians who disagree should explain why.
Medicare-for-all would move us decisively toward the goal and would ensure that all of our citizens – whether lucky or unlucky, healthy or unhealthy, more successful or less successful in our highly competitive economy – are fully insured. It would be an accomplishment we could all be proud of. It would make America greater – and healthier.
Michael P. Bacon
Westbrook
How Many Pills Are Too Many?
by Austin Frakt - NYT - April 10, 2017
The point of prescription drugs is to help us get or feel well. Yet so many Americans take multiple medications that doctors are being encouraged to pause before prescribing and think about “deprescribing” as well.
The idea of dropping unnecessary medications started cropping up in the medical literature a decade ago. In recent years, evidence has mounted about the dangers of taking multiple, perhaps unnecessary, medications.
Deprescribing will work only if patients also get involved in the process. Only they can report adverse effects that they sense but that are not apparent to clinicians. And they need to be comfortable weaning from or dropping drugs that they are accustomed to and believe to be helpful.
Yet an increasing number of Americans — typically older ones with multiple chronic conditions — are taking drugs and supplements they don’t need, or so many of them that those substances are interacting with one another in harmful ways. Studies show that some patients can improve their health with fewer drugs.
Though many prescription drugs are highly valuable, taking them can also be dangerous, particularly taking a lot of them at once. The vast majority of higher-quality studies summarized in a systematic review on polypharmacy — the taking of multiple medications — found an association with a bad health event, like a fall, hospitalization or death.
One-third of hospitalizations include a drug-related harm, leading to longer hospital stays and greater expense. The Institute of Medicine estimated that there are 400,000 preventable adverse drug events in hospitals each year, costing $3.5 billion. One-fifth of patients discharged from the hospital have a drug-related complication after returning home, many of which are preventable.
Not every adverse drug event means a patient has been prescribed an unnecessary and harmful drug. But older patients are at greater risk because they tend to have more chronic conditions and take a multiplicity of medications for them. Two-thirdsof Medicare beneficiaries have two or more chronic conditions, and almost half take five or more medications. Over a year, almost 20 percent take 10 or more drugs or supplements.
Some are unnecessary. At least one in five older patients are on an inappropriate medication — one that they can do without or that can be switched to a different, safer drug. One study found that 44 percent of frail, older patients were prescribed at least one drug unnecessarily. A study of over 200,000 older veterans with diabetesfound that over half were candidates for dropping a blood pressure or blood sugar control medication. Some studies cite even higher numbers — 60 percent of older Americans may be on a drug they don’t need.
Though studies have found a correlation between the number of drugs a patient takes and the risk of an adverse event, the problem may not be the number of drugs, but the wrong ones. Some medications have been identified as more likely to contribute to adverse events, particularly for older patients.
For example, if you’re taking psychotropic agents, such as benzodiazepines or sleep-aid drugs, you may be at increased risk of falling and cognitive impairment. Diuretics and antihypertensives have also been identified as potentially problematic. (The Agency for Healthcare Research and Quality has published a longer list of drugs that are potentially inappropriate for older patients. Note that, even if they are problematic for some patients, they are appropriate for many.)
Relative to the mountain of evidence on the effects of taking prescription drugs, there are very few clinical trials on the effects of not taking them.
Among them is one randomized trial that found that careful evaluation and weekly management of medications taken by older patients reduced unnecessary or inappropriate drug use. Adverse drug reactions fell by 35 percent. Medication use was reduced, along with the risk of falls among a group of older, community-dwelling patients through a program that included a review of medications.
Several other studies also found that withdrawal of psychotropic medications reduced falls. A comprehensive review of deprescribing studies found that some approaches to it can reduce the risk of death. Another recent randomized trial found that frail and older people could drop an average of two drugs from a 10-drug regimen with no adverse effects.
So why isn’t deprescribing more widely considered? According to a systematic reviewof research on the question, some physicians are not aware that they’re prescribing inappropriately. Other doctors may have difficulty identifying which drugs are inappropriate, in part because of lack of evidence. In other cases, doctors believe that adverse effects of drug interactions are outweighed by benefits.
Physicians also report that some patients resist changing medications, fearing that alternatives — including lifestyle changes — will not be as effective. Other studies found that many doctors are concerned about liability if something should go wrong or worry they’ll fail to meet performance benchmarks — like the proportion of diabetic patients with adequate blood sugar control.
To reduce the chances of problems with medications, experts advocate that physicians more routinely review the medication regimens of their patients, particularly those with many prescriptions. At hospital discharge — when patients leave the hospital, often on more medications than when they entered it — is a particularly important time for such a review. Including nurses and pharmacists in the process can reduce the burden on physicians and the risks to patients.
Patients can play an important role as well. Walid Gellad, a physician in the Veterans Health Administration and at the University of Pittsburgh School of Medicine, advises that at every visit with a doctor, “patients should ask, ‘Are there any medications that I am on that I don’t need anymore, or that I could try going without?’ ”
Patients, of course, should not try weaning themselves off medication without consulting their doctors — but deprescribing is an idea for all parties to keep in mind.
Bill Limiting Doctor Gifts Receives Bipartisan Support
by Maine Public - AP - April 13, 2017
AUGUSTA, Maine - A bill limiting gifts from drug companies to doctors is receiving bipartisan support in Maine.
Rep. Scott Hamann, D-South Portland, says he wrote the bill after reading how some doctors who prescribed opioids received thousands of dollars from drug manufacturers. He says the bill received widespread support because many see the link between opioid prescribing and the heroin epidemic.
The Portland Press Herald reports that the bill prohibits gifts of more than $50 annually and limits doctor's speaking and consulting fees to research purposes.
Eastern Maine Healthcare Systems testified in support of the bill at a hearing Tuesday. It says the system's current ethics policy prohibits gifts that appear to be in a conflict of interest.
A representative of pharmaceutical manufacturers says the law would hinder the relationship between drug companies and doctors.
Rep. Scott Hamann, D-South Portland, says he wrote the bill after reading how some doctors who prescribed opioids received thousands of dollars from drug manufacturers. He says the bill received widespread support because many see the link between opioid prescribing and the heroin epidemic.
The Portland Press Herald reports that the bill prohibits gifts of more than $50 annually and limits doctor's speaking and consulting fees to research purposes.
Eastern Maine Healthcare Systems testified in support of the bill at a hearing Tuesday. It says the system's current ethics policy prohibits gifts that appear to be in a conflict of interest.
A representative of pharmaceutical manufacturers says the law would hinder the relationship between drug companies and doctors.
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