Seven reasons commercial insurance cannot meet our health care needs

by Diane Archer - JustCare - March 8, 2018

As policymakers, pundits and the public consider the path to universal health care coverage in the US, it is helpful to remind ourselves of the key reasons that commercial health insurance cannot and will never meet our health care needs.

Because, as a rule, commercial health insurers put profits before people:

Commercial health insurers are generally unwilling or unable to disclose their benefits or deliver value for people with costly and complex conditions; rather, they tend to deter people with complex and costly conditions from enrolling or, if they are enrolled, from seeking care and remaining in their health plans.
- To generate profits, they tend to market to people who are healthy and will not need a lot of health care services; and, they do not distinguish themselves from other health plans based on the care they cover for people with the greatest care needs, making it impossible for people with costly conditions to choose a health plan that meets their needs.
- They limit people’s choice of doctors and hospitals through inadequate networks that restrict access to care, including centers of excellence and top specialists in order to discourage people with costly conditions from enrolling.
- They generally do not disclose what treatments they will cover or people’s out-of-pocket costs for particular treatments before they decide whether to enroll in their plan or, if they are enrolled, before they receive treatments.
- They charge high copays and deductibles, which keep people from getting costly care. They ration care based on people’s ability and willingness to pay, penalizing people in the poorest health and with the lowest incomes.
Commercial health insurers cannot offer reliable coverage and they undermine continuity of care. They are constantly changing the doctors and hospitals you can use, and they cannot guarantee that they will offer you coverage from one year to the next.
- To generate profits, they change their networks all the time, placing little or no value on continuity of care. You cannot count on them to provide continuous coverage from doctors you know and trust or from doctors and hospitals outside your community. And, you can’t trust the health plan’s provider directory.
- From one year to the next, they can raise their premiums and deductibles significantly, forcing their members who cannot afford the increased costs to find new coverage.
- When they are not making money in a community, they pull out altogether, forcing their members to find new coverage. Humana and Anthem pulled out of state health exchanges. (Anthem in Maine, Virginia, Missouri, Ohio, Nevada ACA plans.)
Commercial health insurers may delay and deny care arbitrarily and keep their protocols and data proprietary, unwilling to be publicly accountable regarding their value to consumers.
- To generate profits, they treat data as proprietary that would allow researchers to report whether they deliver high value cancer, stroke or heart care. Outside researchers and rating agencies generally cannot access the needed data or, if they can, cannot report on what they learn with respect to a particular health plan or on the comparative value of these plans when it comes to costly services. Try googling “best health insurance for people with diabetes.”
- They may hire medical directors to oversee treatment decisions who do not understand the conditions or the treatments for which they are denying care, with little risk anyone will know.
- They may deny coverage for ER visits, based on patients’ diagnosis, expecting patients to know when they really need emergency care and deterring them from getting needed emergency care.
- They have a financial incentive to delay or deny care without fear of harming their brand image since consumers cannot compare their value in a meaningful way and they are unlikely to be held to account for these practices. Moreover, they have a financial disincentive to deliver high value cancer, stroke or heart care or to cover costly drugs to treat complex conditions or too many people with those conditions would enroll, jeopardizing their profits.
Commercial health insurers are unwilling or unable to drive system change that promotes overall value to our health care system.
- They are unwilling or unable to control high hospital rates. Rather, they shift costs to people who go to the ER unnecessarily by charging them the full cost of their visit rather than penalize hospitals for not having a cost-effective triage system for people who go to the ER. Medicare, in sharp contrast, penalizes hospitals with high readmission rates to incentivize them to discharge patients appropriately, rather than penalize patients who are readmitted.
- They are unwilling or unable to control rising drug costs. It can be financially rewarding for health insurers to make profits off of higher-priced drugs (formulary with brand-name drugs and not generic alternative) or to charge their members a higher copay than their actual cost for the drug.
- They are unwilling to share their knowledge and innovations that give them a competitive edge, be it on the value of a medical device, drug or treatment or any other care-related item. For example, it is hard to identify a health plan that alerts the general public to a particular treatment that causes their patients harm or provides unique benefits.
Commercial health insurers engage in fraudulent practices.
- To increase their revenues, they misrepresent the health status of their members, overcharging the government.
- The federal government has made tens of billions of overpayments to them. Here is one GAO report.
- They engage in enrollment fraud, enrolling people who do not want to be enrolled in their plans to generate more revenue.
Commercial health insurers are unwilling or unable to rein in ever-increasing health care costs. Rather, they drive up costs through the time, money and personnel they require for billing and other insurance-related activities.
- Commercial health plans have far higher administrative costs than Medicare and pay significantly higher provider rates. Hospitals in most communities have more power than commercial insurers, keeping commercial insurers in many markets from reining in provider rates.
- The cost of commercial health insurance is so high that it puts many smaller businesses at risk and eats deeply into employee wages.
- Medicare is more cost-effective than commercial health insurance.
Neither states nor the federal government have the resources to effectively oversee commercial health insurers and hold them accountable for their inappropriate or illegal activities.
- Unlike commercial firms that create products whose systemic defects are fixed and can be detected, if not immediately, over the long term, commercial health insurers create products that are constantly changing–doctors, hospitals, protocols for approving and denying care, costs, etc.–and make covert decisions that are constantly changing–medical necessity and billing, etc. As a result, arbitrary denials and delays of care can easily go undetected.
- All but a handful of states, if any, have the will, skill and resources to ensure that commercial health insurers are complying with their legal obligations and meeting the needs of consumers. And, the federal government does not oversee commercial health insurers outside of government programs.
- Even with the will, skill and resources needed, health plan data is proprietary, so even independent researchers are hard pressed to report on the failings of particular health plans.
- Except in the most egregious situations which come to public light, it is near impossible to develop measures to evaluate whether health plans are delivering on their obligations to consumers and not delaying or denying needed care, let alone delivering value or committing fraud.

Improving and expanding Medicare to everyone is the best way to ensure all Americans have access to good, affordable care. If you support Medicare for all, please let Congress know. Sign this petition.

http://justcareusa.org/seven-reasons-commercial-insurance-cannot-meet-our-health-care-needs/

Want to Be Happy? Try Moving to Finland

by Maggie Aston - NYT - March 14, 2018

Happy are the people of the Nordic nations — happier, in fact, than anyone else in the world. And the overall happiness of a country is almost identical to the happiness of its immigrants.

Those are the main conclusions of the World Happiness Report 2018, released Wednesday. Finland is the happiest country in the world, it found, followed by Norway, Denmark, Iceland, Switzerland, the Netherlands, Canada, New Zealand, Sweden and Australia. Though in a different order, this is the same top 10 as last year, when Norway was No. 1 and Finland was fifth.

Burundi and Central African Republic, both consumed by political violence, are the least happy countries for the second year in a row. This year, Central African Republic is slightly happier than Burundi; last year, their order was reversed.

As for the United States, it is 18th out of 156 countries surveyed — down four spots from last year’s report and five from 2016’s, and substantially below most comparably wealthy nations. Though the economy is generally strong and per capita income is high, it ranks poorly on social measures: Life expectancy has declined, suicide rates have risen, the opioid crisis has worsened, inequality has grown and confidence in government has fallen.

“I think there really is a deep and very unsettling signal coming through that U.S. society is in many ways under profound stress, even though the economy by traditional measures is doing fine,” Jeffrey D. Sachs, an editor of the report, said in an interview on Tuesday. “The trends are not good, and the comparative position of the U.S. relative to other high-income countries is nothing short of alarming.”

The report was produced by the United Nations Sustainable Development Solutions Network and edited by three economists: Dr. Sachs, the network’s director and a professor at Columbia University; John F. Helliwell, a senior fellow at the Canadian Institute for Advanced Research and professor emeritus at the University of British Columbia; and Richard Layard, a director of the Well-Being Program at the London School of Economics’ Center for Economic Performance. It is based on Gallup International surveys conducted from 2015 to 2017, in which thousands of respondents were asked to imagine a ladder with steps numbered 0 to 10 and to say which step they felt they stood on, a ranking known as the Cantril Scale.

The top 10 countries’ averages ranged from 7.632 for first-place Finland to 7.272 for 10th-place Australia; the United States’ average was 6.886, down from 6.993 last year. At the bottom of the scale, Burundi’s average was 2.905.

Compared with a 2008-10 base period, 58 countries became significantly happier, and 59 became significantly less happy. Of the 141 countries that had enough data from both 2008-10 and 2015-17 to measure how their happiness had changed, the United States ranked 107th, with a drop of 0.315 in its average happiness rating.

Explaining why one country is happier than another is a dicey business, but the report cites six significant factors: G.D.P. per capita, social support, life expectancy, freedom to make life choices, generosity and corruption levels.

Dr. Sachs noted that the happiest countries have very different political philosophies from the United States’. Most of the top 10 are social democracies, which “believe that what makes people happy is solid social support systems, good public services, and even paying a significant amount in taxes for that.”

This year’s report also focused heavily on how migration affects happiness. Most notably, it found that the happiness of a country’s immigrants is almost identical to that of its population at large — indicating, Dr. Helliwell said in an interview, that “people essentially adjust to the average happiness level of the country they’re moving to.”

“The closeness of the two rankings shows that the happiness of immigrants depends predominantly on the quality of life where they now live,” the report’s executive summary said. “Happiness can change, and does change, according to the quality of the society in which people live.”

This cuts both ways: A person who moves to a country high on the happiness list will probably become happier, and a person who moves to a lower-ranked country will probably become less happy.

The study did not examine how national immigration policies affect happiness. However, it did examine the findings of Gallup’s new “migrant acceptance index,” which measured public attitudes toward immigrants in various countries. These attitudes are not always correlated with national policies: The United States, for example, ranks highly on the migrant acceptance index, even though the Trump administration has pursued more restrictive immigration laws.

In countries with high migrant acceptance indexes — that is, countries where the populace is generally receptive to newcomers — immigrants “are happier than their other circumstances would indicate, and so were the people who were born there,” Dr. Helliwell said. “That sort of openness turns out to be good for both.”

https://www.nytimes.com/2018/03/14/world/europe/worlds-happiest-countries.html?

UnitedHealthcare Says It Will Pass On Rebates From Drug Companies to Consumers

by Reed Abelson - NYT - March 6, 2018

In response to growing consumer frustration over drug prices, UnitedHealthcare, one of the nation’s largest health insurers, said on Tuesday that it would stop keeping millions of dollars in discounts it gets from drug companies and share them with its customers.

Dan Schumacher, the president of UnitedHealthcare, said the new policy will apply to more than seven million people who are enrolled in the company’s fully insured plans, beginning next year.

“The benefit could range from a few dollars to hundreds of dollars to over a thousand,” Mr. Schumacher said.

Not all drugs come with rebates that are paid to the health plan. People in plans with high deductibles who buy drugs that carry large rebates will see the greatest savings, Mr. Schumacher said.

Insurers like UnitedHealthcare, whose parent company also owns a large pharmacy benefit manager, OptumRx, have come under increasing public pressure as drug prices — especially for brand-name drugs — continue to rise, angering consumers and lawmakers. The decision by UnitedHealthcare is the latest in a series of steps taken by drug makers and health plans to try to lessen public discontent over drug prices, even as the companies spar over who is to blame.

Aiming to deflect criticism, the pharmaceutical industry has increasingly pointed the finger at both insurers and pharmacy managers for not sharing the rebates with customers filling prescriptions. The Pharmaceutical Research and Manufacturers of America, the industry trade group, rolled out an advertising campaign, “Share the Savings,” last year to make the case that by passing on the discounts, plans could significantly lower patients’ out-of-pocket bills. The group called UnitedHealthcare’s decision “a step in the right direction.”

Insurers, including UnitedHealthcare, contend that they already use the money from discounts to lower premiums for all their customers, and argue the real issue is the high cost of so many drugs.

But UnitedHealthcare seems to have blinked, signaling what could be a coming shift away from the system of convoluted deals struck between the drug companies and these middlemen, said Adam J. Fein, president of Pembroke Consulting, a research firm. Although the new policy will only affect a fraction of the company’s customers, “it’s one more step on the path of creating a more transparent pharmacy supply chain,” Mr. Fein said.

The amount of rebates can vary widely, with some drugs, like Humira and Enbrel that treat rheumatoid arthritis, being deeply discounted. Others, like medicines for rare conditions where there is no significant competition, have little to no rebates. Patients, employers and the public have little information on what any one drug costs and whether the discounts ultimately flow back to customers.

“The industry is taking criticism from a lot of different people,” said Erik Gordon, a business professor at the University of Michigan. It is significant that UnitedHealthcare “felt compelled to do something,” he said.

The Trump administration recently floated the idea of requiring private drug plans under Medicare to pass on the savings to consumers at the pharmacy counter. On Tuesday, Alex M. Azar II, a former executive at Eli Lilly and the new secretary of health and human services, called UnitedHealthcare’s move “a prime example of the type of movement toward transparency and lower drug prices for millions of patients that the Trump administration is championing.”

But insurers have resisted the idea that they be forced to pass on the savings in Medicare drug plans, arguing that it would result in significantly higher premiums for everyone. Federal officials estimate that consumers buying the drugs would save, on average, from $45 to $132 a month under the proposal. But then premiums for all Medicare beneficiaries would increase anywhere from an estimated $14 to $44 a month.

UnitedHealth Group, UnitedHealthcare’s parent, opposes the Medicare proposal because it would raise premiums sharply for older people.

By contrast, the company’s plans offered through private employers would have a minimal effect on premiums, Mr. Schumacher said. “The benefit to the individual is meaningful.”

Employers who self-insure already have the option of passing the discounts onto customers, Mr. Schumacher said. CVS Health, a large pharmacy benefit manager, allows employers to share the discount with their workers and has offered rebates to its own employees since 2013. OptumRx also offers the option of sharing the discount directly with consumers.

But while some employers seem interested, it has not taken off, Mr. Schumacher said. “We have some customer interest,” he said. “It’s in the early innings.”

While some employers want to keep the savings, more are becoming concerned about how these large rebates affect people taking expensive medicines who are in high-deductible plans or pay a significant percentage of every prescription they fill, said Edward A. Kaplan, a senior vice president at Segal Consulting. The rebate “is such a big number,” he said.

The shift to choosing to share those savings with the employees filling these prescriptions “is beginning to happen slowly,” he said.

https://mobile.nytimes.com/2018/03/06/health/unitedhealth-drug-prices.html?referer=

The Health 202: UnitedHealthcare will hand some consumers more money for drug prices

by Paige Winfield Cunningham - The Washington Post - March 7, 2018

The cost rebates drugmakers give health plans are among the U.S. health-care system’s many strange features that inflate costs for consumers. Now the country’s largest private insurer is making a move to start fixing them.

Signaling that it hears the growing public frustration over drug prices, UnitedHealthcare announced yesterday it will pass on rebates on prescription drugs directly to the 7 million people enrolled in its fully insured employer plans.

These rebates — which have grown dramatically in recent years — are typically (and controversially) pocketed by employers or insurers instead of used to lower out-of-pocket costs for enrollees. Because the size of the rebates aren’t made public, customers often don’t know they’re paying far more for drugs than the price negotiated by their plan.

The move won swift applause from the Trump administration, which in its recent budget proposed making it mandatory for health plans to directly pass rebates to consumers. Health and Human Services Secretary Alex Azar called United’s move a “prime example of the type of movement toward transparency and lower drug prices” the administration is “championing.”

“Empowering patients and providers with the information and control to put them in the driver’s seat is a key part of our strategy at [HHS] to bring down the price of drugs and make healthcare more affordable,” Azar said in a statement.

Although UnitedHealthcare’s action will affect only a minority of its commercially insured population, what’s more significant is what the strategy symbolizes. It draws attention to a market distortion that has increasingly sparked the ire of the pharmaceutical industry and consumer advocates as the gap between the public list price of drugs and the private, negotiated price is growing ever wider.

“I think it’s more significant for what it signals about where we’re going,” Adam Fein, CEO of Drug Channels Institute, a website that provides analysis of the pharmaceutical industry, told me. “I think it’s creating a conversation on creating more transparency in the system.”

Rebates and discounts from drugmakers to insurance plans nearly doubled from 2013 to 2015, according to research commissioned by the Pharmaceutical Research and Manufacturers of America.

But those savings aren’t -- for the most part -- being passed on to consumers. So patients who rely on high-cost drugs such as insulin, for example, are shelling out for co-payments and deductibles based on the much higher list price. And more people than ever have moved into high-deductible health plans, requiring them to cough up more in co-pays and deductibles before their benefits kick in.

Remember the controversy a few years ago around Mylan’s EpiPen? Insured customers, despite their coverage, weren’t shielded from the company’s decision to dramatically hike prices. Patients’ out-of-pocket spending for EpiPens climbed 535 percent from 2007 to 2014, according to a University of Chicago study last year.

“You’ve got pretty sick people being exposed to pretty high bills,” Craig Garthwaite, an economist at Northwestern University who specializes in drug pricing, told me.

So it’s not surprising that there has been heightened scrutiny lately of the complicated mechanics of drug pricing. Drugmakers typically grant rebates to pharmacy benefit managers (PBMs), which secretly negotiate on behalf of insurers and employers. But are the savings then passed on to consumers? The PBMs say savings are produced while drug companies argue that rebates aren't trickling down to patients, my colleague Carolyn Y. Johnson explains.

Experts agree that UnitedHealthcare’s move is a good one, especially from a public relations perspective.

“I think they perceive it’s a good PR move, it will generate some good press,” Fein said. “It’s a way to signal that we’re going to try to bring down drug prices people pay.”

University of Chicago health economist Rena Conti told Carolyn it’s a “step in the right direction.” “I think patients — particularly those struggling with very high deductibles and costs associated with prescription drugs or high co-insurance rates associated with very high price drugs — stand to benefit significantly from this announcement."

https://www.washingtonpost.com/news/powerpost/paloma/the-health-202/2018/03/07/the-health-202-unitedhealthcare-will-hand-some-consumers-more-money-for-drug-prices/5a9ee55530fb047655a06b26/?

Ask Your Doctor. Until Then, Here’s a Word From Our Sitcom.

by Danny Hakim - NYTY - March 9, 2018

A reader recently wrote in about drug advertising.

“I used to work in production of TV commercials,” she emailed. “Unless I am mistaken, the U.S. is one of only 2 countries IN the WORLD that allow television advertising of pharmaceuticals. It is outrageous and it is clearly one of the reasons that our drugs are more expensive than any country in the world.”

I checked. It’s true that only the United States and New Zealand allow direct advertising of prescription drugs to consumers, while Brazil allows some advertising of nonprescription, over-the-counter medications.

This reminded me of a very special episode of the ABC sitcom “black-ish” a few months back. The father of the family, Dre, got a diagnosis of diabetes. He understandably freaked out a little bit. He couldn’t even bring himself to prick his finger with a drug applicator.

Then his troublemaking dad got involved. “You don’t need to be bothered with this mess,” he said, before showing his son a documentary on natural healing that was conveniently queued up. There were clearly some hard lessons coming. “Why didn’t my doctor tell me about this?” Dre asked.

Right after that scene, my television cut to a commercial for Victoza, a diabetes treatment from Novo Nordisk. There were scenes of a woman in a doctor’s office, an older couple gardening, women painting sunflowers. There were side effects: “nausea, diarrhea, vomiting, decreased appetite, indigestion and constipation.” At 90 seconds, it felt almost infomercial length, until the next commercial came on. For Victoria’s Secret.

My family are faithful “black-ish” viewers — funny show, great cast. But a season earlier we had endured what Vulture called “essentially a long commercial for Disney World,” the obligatory episode where a Disney sitcom goes to Disney World.

Now it was time for Diabetes World, brought to you by Novo Nordisk.

In the United States, when the Food and Drug Administration eased the advertising rules in 1997, it paved the way for an explosion of TV commercials pitching prescription drugs. Drug makers have had less success lobbying in other parts of the world.

I asked Novo Nordisk about this. Anthony Anderson, who plays Dre, has diabetes in real life and is the company’s paid spokesman. His story is compelling. Not only did he struggle coming to grips with the disease, but his father died of complications from diabetes a decade ago.

“One of the things we felt was important was it needed to be natural and it needed to tell his story, but it also needed to be medically accurate,” said David Moore, a senior vice president at Novo Nordisk. “We had individuals from our medical affairs really review the script, in the context of this is what a conversation would really sound like with a clinician.”

ABC declined to comment.

I don’t know how I feel about a drug company’s collaborating on a sitcom script, though it’s a little weird that the story and the commercials ran together. More important, it probably doesn’t help the soaring cost of prescription drugs. Companies spend more than $6 billion a year on this kind of advertising, according to Kantar Media.

Advertising budgets are by no means the biggest factor in drug costs. There is blame to go around.

Drug companies are stretching out their patent protections by seeking approvals for existing drugs to treat different diseases. There is also no nationwide body negotiating drug prices as you’ll find in other countries, and insurers are often looking out for themselves rather than patients. Sometimes buying a drug with insurance is even more expensive than without it, or insurers refuse to cover the cost of a generic drug.

This past week, UnitedHealthcare, one of the largest insurers, said it would stop keeping the rebates it got from drug companies, an issue that is of particular concern to the Type 1 Diabetes Defense Foundation, an advocacy group. “Any serious political conversation on economic incentives and prescription drug cost must begin from the market distortions created when insurers and other payers negotiate rebates” but don’t pass them through to patients, said Charles Fournier, the foundation’s vice president.

If nothing else, advertising brings us closer to how the drug business works, even if on a subliminal level.

“The conditions that are being promoted change over time in conjunction with the patent cycle,” Jon Swallen, chief research officer at Kantar, said. They also change with public health trends and research and development investments.

The closer a patent gets to expiring, the less enthusiastic companies can get about advertising. Hence the era of erectile dysfunction commercials for Viagra and Cialis yielded to omnipresent spots for Humira and Enbrel, used for rheumatoid arthritis and a range of other conditions.

Groups like the World Health Organization and Public Citizen have raised concerns. The drug industry, as you might imagine, wants to keep advertising.

Commercials “can benefit health care professionals, as well as patients,” said Holly Campbell, a spokeswoman for the Pharmaceutical Research and Manufacturers of America, an industry trade group, in an email. She cited a Harvard University/Massachusetts General Hospital survey from 2004 that found that “one-quarter of adult patients who visited their physician after seeing” a commercial “received a new diagnosis of a condition,” and “nearly half of the diagnoses were for ‘high priority’ conditions.”

Back to “black-ish.”

Hard lessons were indeed learned on the show. Dre’s venture into natural healing led him to pass out at a party, crushing a tower of champagne glasses. His wife, Rainbow, a doctor, explained to him that he had to take the medicine. “Look, Dre,” she said, “the important thing to know is that diabetes is not going to dia-beat us.”

“How long have you been holding on to that one?” Dre asked, rolling his eyes.

She had a lot more in her pocket: “It’s do or dia-beat-us!”

The show promptly cut to a commercial for a Novo Nordisk long-acting insulin called Tresiba, which had a snappy jingle refrain — “Tre-siba ready!”

I’m not going to stop watching “black-ish,” but could we stick to the show, people?

https://www.nytimes.com/2018/03/09/business/drug-commercials-product-placement-blackish.html?

Quebec Doctors Make a Pay Demand: Don’t Raise It

by Ian Austen - NYT - March 9, 2018

In a move that has drawn international interest, nearly 740 doctors, residents and medical students in Quebec are demanding that the province not follow through on promises to raise their pay.

Like many things related to Canada’s health care debate, the reasons behind the extraordinary request from the doctors are complex and, in some cases, political. But a petition detailing their concerns appeared online in late February after several nurses in the province set off a discussion about the medical system by describing their working conditions, including an unmanageable number of patients and marathon shifts extended by mandatory overtime.

The doctors want the province to take money that would have been used to increase their incomes and give it to nurses and other health care workers who are dealing with issues like pay cuts and crushing workloads.

“The system has to change — it will not survive much longer,” said Isabelle Leblanc, a family physician in Montreal who is one of the petition’s organizers and a professor at McGill University. “For a long time the system has revolved around physicians and hospitals.”

While Dr. Leblanc said she was gratified that 210 specialists were among the petitioners, the group looking to turn back raises remains a tiny minority within Quebec’s medical community. According to the Canadian Medical Association, the province has 20,254 doctors.

Dr. Leblanc’s group, Médecins Québécois Pour le Régime Public, first began demanding that its members’ raises be used elsewhere in 2015 after the government announced a series of budget cuts. Those early efforts, however, attracted relatively little notice.

She said that nurses who recently described seemingly impossible workloads to the news media and on social media raised the doctors’ current request to prominence and prompted a debate over compensation.

“It’s not money we’re lacking, it’s better allocating it,” Dr. Leblanc said.

Like most of their counterparts in Canada, Quebec’s doctors are not paid salaries but rather a fee for each service they perform. Because any individual doctor’s income depends on how much she or he works and the complexity of the task, it can be difficult to compare incomes between provinces. But Dr. Leblanc acknowledged that two decades ago, Quebec sat near the bottom in Canada.

A series of negotiations involving the separate groups that represent family doctors and specialists and several governments have led to a series of raises. By one estimate, the incomes of specialist physicians in Quebec increased by 160,000 Canadian dollars between 2009 and 2016. On average they now earn 403,537 Canadian dollars a year, or about $315,000 a year, according to the Canadian Institute for Health Information.

Current agreements with the government guarantee that raises for specialists continue until 2023.

Some critics suggest that conflicts of interest among politicians cloud the debate. Philippe Couillard, Quebec’s premier, is a neurosurgeon. Earlier in his career, as health minister, he negotiated some of the raises doctors are now enjoying. A radiologist, Gaétan Barrette, is the current health minister. He was the president of the specialist physicians’ group when it won raises for its members.

Dr. Leblanc, however, said that the health funding problems were systemic and not isolated to the current Liberal government or related to the backgrounds of its members.

Late last month, Dr. Barrette said that if doctors wanted to turn down pay raises, he would find other uses for the money. He acknowledged that improvements must be made for nurses, but he said he did not think that members of his previous profession were overpaid.

“We’re entering a new chapter regarding working conditions of nurses,” Mr. Barrette told reporters in Montreal. “To me, this is much more important than talking about doctors and money.”

https://www.nytimes.com/2018/03/09/world/canada/quebec-doctors-nurses-pay.html?hpw&rref=world&action=click&pgtype=Homepage&module=well-region&region=bottom-well&WT.nav=bottom-well

What Did Bernie Sanders Learn in His Weekend in Canada?

by Margot Sanger-Katz - NYT - November 17, 2018

TORONTO — As he tells it, Senator Bernie Sanders of Vermont fell in love with the Canadian health system 20 years ago when he brought a busload of his constituents across the border to buy cheaper prescription drugs. Now he wants to make Americans fall in love with his proposal to make the United States system a lot more like Canada’s.

That’s one reason he took the equivalent of a busload of staffers, American health care providers and journalists to Toronto last weekend, in a two-day trip that was part immersion, part publicity tour. Canadian government officials and hospital executives showed him high-tech care, compassionate providers and satisfied patients, all as videographers recorded.

He ended the trip with a speech at the University of Toronto titled, “What the U.S. Can Learn From Canadian Health Care.”

But our question is this: What did Bernie Sanders learn from his weekend in Canada?

Lesson 1: He’s a ‘rock star’

Mr. Sanders — after wedging himself into Row 21 and taking extensive notes on a legal pad during the flight — had barely gotten off the plane in Toronto when an airport security guard chased him down the hallway, telling him, “You’re like a hero to me.”

A team of cardiac nurses at Toronto General Hospital asked to take pictures after he toured their unit. At a full 1,600-seat university auditorium on Sunday, he received repeated and sustained standing ovations. College students waited for hours to get into the auditorium and see him speak.

Mr. Sanders, who drew huge crowds as a presidential candidate in the United States last year, learned firsthand that he is also a household name in Toronto. His policy vision, decidedly from the left in the United States, matches mainstream Canadian views.

“You received the welcome here that is normally reserved for celebrity rock stars,” said Greg Marchildon, the director of the North American Observatory on Health Systems and Policies at the University of Toronto.

Ed Broadbent, the chairman of the progressive Broadbent Institute, called Mr. Sanders the most important social democrat in North America — even though Mr. Sanders is not a Canadian social democrat, and is not even a particularly powerful member of the Senate.

Lesson 2: Doctors like the system as much as patients do

Many developed countries have achieved universal health coverage, but Canada is relatively distinct in its insistence that individuals should not have to pay any money at the point of care. When Canadians go to the doctor or hospital, they just show their Canadian “Medicare” card.

At Women’s College Hospital, executives showed Mr. Sanders an empty billing window. The hospital, they told him, has one employee who manages bills. “For the entire hospital?” Mr. Sanders said, in mock disbelief.

Several patients told him about the comfort that comes from not having to pay for their care directly. And doctors, too, said they felt more comfortable recommending their patients get an operation or see a specialist than they might if those treatments weren’t free.

“I didn’t have to fill out any forms; I didn’t have to worry about how I was going to pay for the simple job of staying alive,” said Lilac Chow, a kidney transplant patient at Toronto General Hospital, who had been brought in to share her experience with the senator.

Whenever Mr. Sanders was asked what he learned about the Canadian system, the value of free care came up.

“What I think stuck out to me was from both the patients and the physicians, the importance of not having to worry about money in terms of the doctor-patient relationship,” he said in an interview after his trip on Tuesday.

His Medicare-for-All bill includes free care as a central feature. If the legislation became law, no American would pay directly for a doctor, dentist or hospital visit, and co-payments for prescription drugs would be limited. (Taxpayers would, of course, finance the system.)

Lesson 3: Sometimes, you have to wait

At a round-table discussion at Women’s College Hospital, the chief of surgery noted that Canadian patients can’t always get all the care they want right away. “Wait times, you could argue are a problem for certain procedures,” said Dr. David Urbach, before discussing the ways the province and hospital were working to shorten the lines. Mr. Sanders quickly turned to the glass-half-full interpretation. “What you are arguing — correct me if I’m wrong — is that waiting times are not a problem, and it’s an issue you are dealing with,” he said.

In Canada, where government finances health insurance and the private sector delivers a lot of the care, patients with life-threatening emergencies are treated right away. But patients with cataracts or arthritis often have to wait for operations the Canadian system considers elective. A governmental review of the Ontario system recently found that wait times were getting worse in some cases, like knee replacements.

The Canadian system puts hospitals on a budget and limits the number of specialists it trains, both factors that can lead to lines for complex care that’s not life-threatening. The system also limits access to services, like M.R.I. scans, that are much more abundant south of the border.

On his weekend tour, Mr. Sanders didn’t see the places where patients might wait. Hospital executives instead showed him a refugee primary care clinic, a neonatal intensive care unit and a cardiac surgery unit.

But he points out that many Americans who are uninsured — or who have limited savings and insurance with high deductibles — may wait even longer than Canadians for elective, or even urgent, care.

“If you’re very, very rich, you’ll get the highest-quality care immediately in the United States,” Mr. Sanders said, in the interview. “If you’re working class, if you’re middle class, it is a very, very different story.”

The Commonwealth Fund, a health research group, ranked the United States health system at the bottom of its most recent 11-country rankings, published in July. But Canada did only a little better, at No. 9. Of all the measures in the study, Canada ranked the worst on the “timeliness” of care. (A team of Upshot experts eliminated Canada in the first round in an eight-country virtual bracket tournament of international health system performance.)

Any single-payer system will need to grapple with how much it should spend over all, and where it will save money. Mr. Sanders’s Medicare-for-All bill currently includes few details about how the government would set budgets and allocate resources once all Americans were brought into the government system.

Lesson 4: Even Canada’s system has holes

Mr. Sanders wants to bring big, sweeping change to the American health care system. Unlike the Affordable Care Act, which filled in holes in an existing system, his Medicare-for-All plan would take away the health coverage that most Americans hold now, replacing it with a single, very generous government system. It would do away with the premiums, deductibles and co-payments that individuals and businesses pay for health care, and instead impose large tax increases.

That is not the kind of change that would be politically trivial. In his speech, he noted that the creation of a single-payer system in Canada and Britain followed grass-roots movements, and political landslides by the parties that favored the change. “Real change always happens from the bottom up,” he said, to big applause. “You’ve got to struggle for it. You’ve got to fight for it. You’ve got to take it. And that is the history of all real change in this world.”

Yet even in Canada, he learned, changes to the health care system have been difficult. The Canadian system, with insurance run at the province level, covers doctors and hospitals. But decades after the 1984 Canada Health Act, many Canadians pay for supplemental private insurance through their jobs for prescription drugs, dentistry and optometry — despite a growing recognition that medications are essential to care.

“Any one of us around the table is just a job loss away from having access to prescription medications, and that’s a problem,” said Danielle Martin, a vice president at Women’s College Hospital and policy researcher, who helped organize the trip, at a round-table discussion.

“I’m on my own going to the dentist,” said Naomi Duguid, a patient, sitting across the table. “It’s the only time I get to experience what it must be like to be an uninsured American.”

Ontario has recently started a program that will provide coverage for medications to residents under 25. And there is a patchwork of drug coverage programs for older people, the poor and those who get insurance from work. But even in Canada, it’s tough to find the resources to expand coverage.

“We have to find the money to fund the program up front,” said Kathleen Wynne, the premier of Ontario, who helped establish the youth drug coverage program.

Lesson 5: Canadians seem to value fairness more than Americans do

Equity. Fairness. Throughout the weekend, Mr. Sanders kept asking Canadians what they thought about the higher taxes they’d paid to finance their system. Every one among the patients and doctors selected to meet him said the trade-off was worth it because it made the system fair.

“I think it’s a really fair way to do it,” said Frederick Brownridge, 67, of Etobicoke, Ontario, as he sat by the window in his Toronto General Hospital room, with IV lines in his arms. Mr. Brownridge had had two heart valves repaired and a double bypass three days earlier. “It also means if you’re in a lower economic status or higher economic status, you’ll get the treatment you need.”

On Tuesday, Mr. Sanders said the uniformity of this message really stuck out to him: “There really is, I think, a deep-seated belief in Canada that health care is a right, and whether you’re rich or whether you’re poor or whether you’re middle class, you are entitled to health care.”

In the United States, though, Republicans control the presidency and the Congress, and many candidates last year ran on a promise to roll back government support for health care coverage.

Several recent p ublic opinion surveys show majority support for a government guarantee of health coverage, but support declines substantially when pollsters mention that government coverage would mean higher taxes.

Mr. Sanders said he knows his bill isn’t going to become law anytime soon, but he thinks discussing the idea will help make its underlying values more broadly acceptable.

“When you talk about health care, you’re not just talking about health care,” he said in his Toronto speech. “You’re talking about values, because how a society deals with health care is more than medicine. It’s more than technology. It is about the values that those societies hold dear.”

https://www.nytimes.com/2017/11/02/upshot/bernie-sanders-went-to-canada-and-learned-a-few-things.html?

Health Officials Assail ‘Pricing Schemes’ That Gouge Patients

by Robert Pear - NYT - March 9, 2018

WASHINGTON — Alex M. Azar II, the secretary of health and human services, said Thursday that doctors and hospitals should tell patients how much their care would cost before patients received treatment. And if they do not do so voluntarily, he said, the government may use its leverage to force them to disclose the information.

Mr. Azar, speaking to a conference of health insurance executives, said that such information would give patients more control over their health care. And that, he said, would advance one of the Trump administration’s top priorities: “the value-based transformation of our entire health care system.”

“You ought to have the right to know what a health care service will cost — and what it will really cost — before you get that service,” Mr. Azar said.

His speech — and similar remarks this week by other federal health officials — amounts to an experiment in jawboning by an administration viscerally opposed to new regulations. It is unclear what President Trump will do if the exhortations fail to produce the desired results. Mr. Azar hinted, at a news briefing on Thursday, that the administration’s policy preferences could be included in Medicare regulations and perhaps, if necessary, in legislative proposals.

He told a personal story to illustrate what he called the powerlessness of many consumers. Several years ago, he said, when he was living in Indiana, his doctor ordered a routine echocardiographic stress test, which is meant to show how well the heart works during physical activity.

Instead of receiving “a simple test in the room next door,” he said, he was sent to a hospital clinic, and as a result, “the sticker price on the test just jumped dramatically.”

When he asked how much the test would cost, he was told that the information was unavailable. He persisted, and eventually the manager of the clinic told him that the list price was $5,500.

“I knew that wasn’t the right answer,” Mr. Azar said. “The key piece of information was what my insurer would pay as a negotiated rate, or what I’d pay with cash. That information didn’t come easily either, but eventually I was told it would be $3,500.”

Then, he said, he found on a website that a typical price for the procedure, performed in a doctor’s office, was $550. The price mattered to him because, like growing numbers of people, he had a health plan with a high deductible.

Mr. Azar said little about expanding insurance coverage, the overarching goal of health policy under President Barack Obama. But he made clear that the Trump administration was seeking big changes in other ways.

“Putting the health care consumer in charge, letting them determine value, is a radical reorientation from the way that American health care has worked for the past century,” Mr. Azar said. “In fact, it will require some degree of federal intervention, perhaps even an uncomfortable degree.”

Mr. Azar, a former top executive at Eli Lilly and Company, the drug maker, also complained that it was often impossible for consumers to know the true cost of prescription drugs.

“Your pharmacist typically cannot tell you the real price you’re going to pay for a drug, and therefore your out-of-pocket cost, until they actually create a claim,” Mr. Azar said.

“This administration is calling on not just doctors and hospitals, but also drug companies and pharmacies to become more transparent about pricing,” he said, and “if that doesn’t happen, we have plenty of levers to pull to push it along.”

Dr. Scott Gottlieb, the commissioner of the Food and Drug Administration, was even more pointed in remarks on Wednesday at the same conference, held by the America’s Health Insurance Plans, the health insurance industry lobby.

He said that drug manufacturers, health insurance companies and middlemen known as pharmacy benefit managers were profiting from “pricing schemes” that drove up costs to consumers and delayed access to copycat versions of expensive biotechnology drugs.

The “complexity and opacity of these schemes” — “these Kabuki drug-pricing constructs” — are creating an “insidious barrier” to the development and marketing of lower-cost copies of complex biologic medicines made from living organisms, Dr. Gottlieb said.

And he denounced insurers for charging high co-payments to cancer patients who needed these lifesaving treatments.

“What’s the point of a big co-pay on a costly cancer drug?” asked Dr. Gottlieb, himself a cancer survivor. “Is a patient really in a position to make an economically based decision? Is the co-pay going to discourage overutilization?”

Kara Kelber, a spokeswoman for Consumers Union, said: “It’s encouraging to hear administration officials address these issues head on with industry. But the proof is in the pudding. We hope this leads to actions that benefit consumers.”

Andrew M. Slavitt, a senior health official in the final years of the Obama administration, praised Dr. Gottlieb for highlighting what Mr. Slavitt called “the collusion to keep drug prices high.”

“I would argue it calls for more dramatic actions,” Mr. Slavitt wrote on Twitter. “But I give him great credit for laying bare the problem. Under Obama, I would have been proud to give this speech.”

https://www.nytimes.com/2018/03/08/us/politics/health-secretary-health-care-costs.html?

Why Is U.S. Health Care So Expensive? Some of the Reasons You’ve Heard Turn Out to Be Myths

by Margot Sanger-Katz - NYT - March 13, 2018

Maybe the United States health care system isn’t that bizarre after all.

Compared with peer nations, the United States sends people to the hospital less often, it has a smaller share of specialist physicians, and it gives people about the same number of hospitalizations and doctors’ visits, according to a new study. The quality of health care looks pretty good, it finds, while its spending on social services outside of health care, like housing and education, looked fairly typical.

If you’ve been listening to many of the common narratives that seek to explain the high costs of America’s health system and the nation’s relatively low life expectancy, those results might surprise you. Analysts are fond of describing the system as wasteful, with too many patients getting too many services, driven by too many specialist doctors and too few social supports.

But a large and comprehensive review in The Journal of the American Medical Association punctures a lot of those pat explanations. The paper, conducted by a research team led by Ashish Jha, compiled detailed data from the health care systems of the United States and 10 other rich developed nations, and tried to test those hypotheses. The group included nations with single-payer health care systems, like Britain and Canada, and countries with competitive private insurance markets, like Switzerland and the Netherlands.

Dr. Jha, the director of the Harvard Global Health Institute, said he came to the project with a sense of the conventional wisdom about how the United States differed from its peers. But, after assembling the data from the countries’ health ministries, he changed his mind about a number of key assumptions.

“We know we spend a lot more than everyone else, and we have looked for easy explanations — things like greed in the system, fee-for-service medicine, overutilization,” he said. But the research, he said, didn’t match his expectations. “I’ve been looking at other countries and seeing there’s a lot of fee-for-service in other countries, and other countries are struggling with overutilization.”

When it came to many of the measures of health system function, the United States was in the middle of the pack, not an outlier, as Dr. Jha had expected. Many analysts have called for the country to shift its physician training away from specialty care and toward more primary care medicine, for example. But the study found that 43 percent of U.S. doctors practice primary care medicine, about typical for the group.

It’s often argued that patients in the United States use too much medical care. But the country was below average on measures of how often patients went to the doctor or hospital. The nation did rank near the top in its use of certain medical services, including expensive imaging tests and specific surgical procedures, like knee replacements and C-sections.

The data are consistent with other evidence that health care systems are beginning to converge, as information and technologies spread around the world among doctors and administrators.

Bruce Landon, a professor of policy and medicine at Harvard Medical School, said that the complaints about rising health care costs are a worldwide issue. Even though other countries spend less than the United States, few believe they have found a way to tame spending forever.

“I don’t think there’s any of these countries where if you went and talked to them individually, they wouldn’t say they’re having a health care cost crisis,” he said. “They’re all struggling with paying for new technology and the cost of the system.”

The data did not suggest that any country had a plug-and-play policy template for devising a lower-cost, high-performing system. The systems tended to perform better than the United States on some measures and worse on others, with lots of idiosyncrasies.

Some experts who reviewed the results wondered about the accuracy of all the paper’s data points, which were numerous and drawn from an array of international sources. Dr. Jha acknowledged that the numbers may not be perfect but described the effort as careful and more comprehensive than previous comparisons.

There were two areas where the United States really was quite different: We pay substantially higher prices for medical services, including hospitalization, doctors’ visits and prescription drugs. And our complex payment system causes us to spend far more on administrative costs. The United States also has a higher rate of poverty and more obesity than any of the other countries, possible contributors to lower life expectancy that may not be explained by differences in health care delivery systems.

Just because other countries use the hospital more doesn’t mean that every hospitalization in the United States is appropriate. Jonathan Skinner, a professor at Dartmouth, who has studied patterns in health care use in the United States, noted that there probably is money to be saved by eliminating some of the extra scans and operations that are much more common in the United States than elsewhere.

“It’s not that we’re buying more pizzas, we’re just paying more for each pie,” Dr. Jha said. “But that doesn’t mean that you can’t still buy fewer pizzas.”

https://www.nytimes.com/2018/03/13/upshot/united-states-health-care-resembles-rest-of-world.html?

The messages that sanctify a culture of physician burnout

by Diane Shannon - KevinMD - March 11, 2018

I realize today that shame, and the stigma about needing help if you’re a care provider, profoundly affected my career path and even my sense of identity. When I was overwhelmed, exhausted, stressed, and scared, did I reach out for help? No, I kept going until I hit a wall, burned out, and left clinical practice. After leaving, did I talk publicly about the chaotic conditions and broken system that led to my burnout? No, I blamed myself and kept quiet for a decade and a half.

When invited to speak on clinician burnout at a recent conference, I decided to focus on the stigma that kept me from seeking help. Upon reflection, I saw that at its core was a mostly unspoken dictum that care providers cannot be fallible and cannot have human needs — as if the only way to help the vulnerable is to be completely invulnerable oneself. I wanted to see how clinicians in practice today view this stigma.

During the session I asked participants — who were physicians, nurse practitioners, psychologists, and students — to write out some of the messages they learned about self-care, being human, and being vulnerable during training or on the job. They submitted their entries on index cards, and volunteers shared their examples in real-time. Here’s what they had to say.

You do not have normal human needs.

“’Real’ ER doctors don’t need to eat or pee during and 8-hour shift. It’s a sign of weakness.”
“Direct quote from an attending: ‘Don’t be a pussy.’”
“Bad situations or outcomes should not have any lasting effect on you.”
“Sleep is for the weak. Sleep when you die.”
“When I was a medical student on urology, the resident was mocked in rounds for needing IV fluids after a bad stomach virus. The resident was only allowed time to get fluids and then had to get back to work.”
“Don’t call in sick. The ER is the best place for you. If you are sick enough, the attending will take care of you. If not, then you can pull your weight as scheduled.”
“Lie about your work hours (unspoken expectation for residents).”

Never display vulnerability.

“What! You hugged your patient?”
“When an unexpected tragedy occurs, BUCK UP. It’s never OK to cry in front of patients.”
“As for vulnerability — this seems to be something that remains shunned. You cannot be weak as a physician.”
“I saw staff manage several critical patients without any appearance of grief or emotional processing.”

It’s OK to humiliate you in front of others.

“In residency, the attending would question us until we were flustered or would cry.”
“A psychiatrist said in a group meeting, ‘Nurses should be seen, not heard.’”
“You should be reading and rereading Harrison’s every day, anticipate patients who will be seen that day, and read those sections ahead of time. (Said with a completely straight face).”

You are a machine.

“Even on days ‘off,’ it is expected that we will respond to emails and pages.”
“We would quiz each other on obscure facts rather than asking about the weekend, hobbies, family, etc.”
“Getting insulted, spit at, and threatened by patients and not seeing any consequences.”
“Patients in the ED can be incredibly rude, and we are expected to smile and appease. I’ve gone from holding a screaming mom after her 6-month old died to another room 5 minutes later to get yelled at for the wait to be seen for a sore throat. It’s soul-crushing.”
“Reverence is given to the physician who sees more patients, works longer hours, and spends more time with patients.”

We need more work out of you, and no complaining.

“I feel invisible, always afraid to ask questions because leadership does not appreciate those with strong views. My voice has been silenced.”
“Just try to double book 2 or 3 more patients per day to raise your RVUs for the clinic. That shouldn’t be hard.”
“You could have the resources you need to practice if you would see more patients.”
“When all the providers’ schedules are full, and a patient walks in expecting an appointment, we are expected to see that patient, which takes time away from our families, for no increased compensation or appreciation. That may happen several times a day.”
“Don’t ‘dump’ your work on others. Stay until the work is done.”

And this note from a participant, which sums up so much in so few words, “Why do physicians have the unshakeable belief that they are not like other people?”

Is it any wonder that physicians and other clinicians are burned out? These messages sanctify a culture where clinicians are expected to be superhuman, robots, and/or machines — and where broken systems, overwhelming clerical burden, and frustrating policies are tolerated.

https://www.kevinmd.com/blog/2018/03/messages-sanctify-culture-physician-burnout.html