In Historic Shift, Second Largest Physicians Group in US Has New Prescription: It's Medicare for All
"Major changes are needed," declares the 159,000-member American College of Physicians, "to a system that costs too much, leaves too many behind, and delivers too little."
The fight for Medicare for All received a two-handed boost from tens of thousands of doctors on Monday when the American College of Physicians—in a move described as a "seachange for the medical professions"—officially endorsed a single-payer system as among only one of two possible ways to improve the nation's healthcare woes.Representing 159,000 doctors of internal medicine nationwide, the ACP is the largest medical specialty society and second-largest physician group in the country overall after the American Medical Association (AMA)."All over this country, a growing number of doctors are sick and tired of the enormous waste and bureaucracy that exists in our cruel and dysfunctional healthcare system."
—Sen. Bernie Sanders (I-Vt.)The ACP delivered its case in a 43-page position paper—titled "Envisioning a Better U.S. Health Care System for All: Coverage and Cost of Care"—published in the Annals of Internal Medicine on Monday. According to the paper:Although the United States leads the world in health care spending, it fares far worse than its peers on coverage and most dimensions of value. Cost and coverage are intertwined. Many Americans cannot affford health insurance, and even those with insurance face substantial cost-related barriers to care. Employer-sponsored insurance is less prevalent and more expensive than in the past, and in response, deductibles have grown and benefits have been cut. The long-term solvency of U.S. public insurance programs is a perennial concern. The United States spends far more on healthcare administration than peer countries. Administrative barriers divert time from patient care and frustrate patients, clinicians, and policymakers. Major changes are needed to a system that costs too much, leaves too many behind, and delivers too little.Sen. Bernie Sanders (I-Vt.), a leading candidate for the 2020 Democratic presidential nomination and the author of the The Medical for All Act of 2019 now in the U.S. Senate, welcomed the development."I am delighted that the American College of Physicians has come out in support of a Medicare for All, single-payer healthcare system," Sanders said in a statement emailed to Common Dreams."All over this country, a growing number of doctors are sick and tired of the enormous waste and bureaucracy that exists in our cruel and dysfunctional healthcare system," Sanders added. "They are sick and tired of spending time filling out reams of paperwork and arguing with insurance companies. Medicare for All will give doctors the freedom to focus on making their patients healthy, not making health insurance executives wealthy.""Major changes are needed to a system that costs too much, leaves too many behind, and delivers too little."
—The American College of Physicians (ACP)The ACP's detailed review of the current for-profit system—even with some of the improvements resulting from the Affordable Care Act (ACA)—found that "too many Americans are uninsured or underinsured" and that current spending is "high and unsustainable"—especially as other developed nations show their ability to achieve better or similar outcomes for less while offering universal, government-guaranteed coverage to all.While it did not say that Medicare for All was the only way to achieve a more equitable, accessible, and sustainable healthcare system, the ACP laid out four key recommendations for achieving universal coverage in the United States. They are:1. The American College of Physicians recommends that the United States transition to a system that achieves universal coverage with essential benefits and lower administrative costs.2. Coverage should not be dependent on a person's place of residence, employment, health status, or income.3. Coverage should ensure sufficient access to clinicians, hospitals, and other sources of care.4. Two options could achieve these objectives: a single-payer financing approach, or a publicly financed coverage option to be offered along with regulated private insurance.While acknowledging that a transition to Medicare for All could be "highly disruptive" to the healthcare system, the ACP said "single-payer financing approach could achieve [its] vision of a system where everyone will have coverage for and access to the care they need, at a cost they and the country can afford. It also could achieve our vision of a system where spending will have been redirected from health care administration to funding coverage, research, public health, and interventions to address social determinants of health."Medicare for All, the paper continued, could also "achieve other key policy objectives, including portability, lower administrative costs and complexity, lower premiums and cost sharing, lower overall health care system costs, better access to care, and better health outcomes, depending on how it is designed and implemented.""As physicians, we see daily the harm that our fragmented, private-insurance based system does to our patients."
—Dr. Adam Gaffney, PNHPWhile the ACP in its backing of a single-payer approach also co-endorsed the more incremental step of creating a federally-administered "public option" as a pathway to universal coverage, Drs. Steffie Himmelstein and David Woolhandler, co-founders of Physician for a National Health Program (PNHP), argue the latter would be an inferior avenue if the aim is to cover everyone while reducing overall costs.According to an op-ed by Woolhandler and Himmelstein, also published in the Annalsalongside the ACP's new position paper, "Achieving universal coverage would be costlier under the "public choice" model the ACP co-endorses along with single payer."Unlike a public-private mix of coverage that the public option would represent, the pair write, a single-payer Medicare for All would allow hospitals and doctors to "save billions on billing-related costs" each year, and those savings could be re-purposed "to expand care" to millions for less cost than the status quo.In a separate but related move to the ACP's announcement, more than two thousand physicians on Monday announced an open letter to the American public, prescribing single-payer Medicare for All, in a full-page ad in The New York Times that will run in the print edition on Tuesday, January 21, 2020.Among the doctors "prescribing" Medicare for All as the only serious solution to the nation's healthcare crisis, said PNHP—which helped organize the effort—"are towering figures in American medicine" and include Dr. Marcia Angell, former editor-in-chief of the New England Journal of Medicine; Dr. Bernard Lown, developer of the defibrillator; Dr. Paul Farmer, infectious disease expert and founder of Partners in Health; and Dr. Mary Bassett, former New York City Health Commissioner.The full text of the open letter follows:We are doctors from across the spectrum of our profession. We serve patients rich and poor, in hospitals and clinics, private offices and public agencies.We witness daily the inhumanity and irrationality of the current health care system. America funds health care more generously than any other nation, and our hospitals and medical workforce are second to none. Yet despite an abundance of medical resources, care is too often meager.For the thirty million who remain uninsured and millions more whose insurance is inadequate to their needs, life-saving treatment is often out of reach, deepening health disparities. Oppressive costs and the fear of financial ruin amplify the suffering of illness. Meanwhile, doctors and nurses struggle to provide good care in a bad system. We waste countless hours complying with arcane billing requirements and, along with our patients, imploring insurers to fulfill their promises of coverage.It is time to transform the way we pay for care — to embrace improved Medicare for All.Medicare for All would curb soaring drug prices and dismantle the wasteful bureaucracy of private insurance companies, freeing up hundreds of billions of dollars to expand and improve care — while ensuring free choice of doctor and hospital.Vested interests who profit from the current broken system raise false alarms of dislocation and disruption to incite fear of change. They are wrong. Improved Medicare for All would bring welcome relief to patients, lower costs for families and communities, and allow doctors and nurses to focus on what matters most: caring for our patients."As physicians, we see daily the harm that our fragmented, private-insurance based system does to our patients," noted Dr. Adam Gaffney, president of PNHP and a pulmonary and critical care physician at Harvard Medical School and the Cambridge Health Alliance. "Patients go without the care they need, and physicians squander time and resources on wasteful billing and clerical tasks. Medicare for All would be a much better way — for patients and doctors both."
As physicians, the signatories of the letter said, the answer is obvious: "we prescribe Medicare for All."Our work is licensed under a Creative Commons Attribution-Share Alike 3.0 License. Feel free to republish and share widely.https://www.commondreams.org/news/2020/01/20/historic-shift-second-largest-physicians-group-us-has-new-prescription-its-medicare
Envisioning a Better U.S. Health Care System for All: A Call to Action by the American College of Physicians
Robert Doherty, BA; Thomas G. Cooney, MD; Ryan D. Mire, MD; Lee S.
Engel, MD; Jason M. Goldman, MD; for the Health and Public Policy
Committee and Medical Practice and Quality Committee of the American
College of Physicians *
What would a better health care system for all Americans be like?
This is the question that the
American College of Physicians (ACP) has been asking of its members
since July 2018, when the ACP Board of Regents asked ACP's Health and
Public Policy Committee and Medical Practice and Quality Committee to
“develop a new vision for the future of health care policy,” to exame
ways to achieve universal coverage with improved access to care, reduce
per capita health care costs and the rate of growth in spending, reform
clinician compensation, and reduce the complexity of our health care
system.
To develop this vision and recommend
ways to realize it, ACP considered evidence on the effectiveness of
health care in the United States and other countries; solicited input
from U.S-based members and ACP's policy committees; adopted draft
recommendations for review by ACP's regents, governors, committees, and
council members; finalized recommendations in response to this feedback;
and submitted the recommendations for approval by the ACP Board of
Regents. On 2 November 2019, the Board of Regents approved this call to
action and 3 companion papers on coverage and cost of care (1), health care delivery and payment system reforms (2), and reducing barriers to care and addressing social determinants of health (3).
Why Does the United States Need a Better Health Care System?
In developing its new vision for health care, ACP focused on 4 questions:
1. Why do so many Americans lack coverage for the care they need?
2. Why is U.S. health care so expensive and therefore unaffordable for many?
3. What barriers to health care, in addition to coverage and cost, do patients face?
4. How do delivery and physician payment systems affect costs, access, quality, and equity?
As detailed in the accompanying
position papers, there is a clear case that the U.S. health care system
requires systematic reform. Too many Americans lack health care
coverage. Despite historic gains in coverage with the Affordable Care
Act, the United States is the only high-income industrialized nation
without universal health coverage (4). Affordability is among the most commonly cited reasons for remaining uninsured (5, 6).
The United States spends far more per capita on health care than other
wealthy countries do, with nearly 17% of the nation's gross domestic
product in 2016 directed to health care (7).
Drivers of higher spending include higher prices for health care
services, devices, and medications in the United States than in other
wealthy countries (8). In addition, administrative costs account for 25% of total U.S. hospital spending (9).
Complex medical billing, documentation, and performance reporting
requirements for value-based payment initiatives have made the U.S.
health care system one of the most administratively burdensome in the
world. This burden takes time away from direct patient care, generates
billions of dollars of unnecessary administrative costs, and contributes
to unprecedented levels of burnout among physicians and other
clinicians.
Despite high health expenditure,
U.S. spending and prices generally do not correlate with better health
outcomes. The United States consistently ranks last or near-last in
access, administrative efficiency, equity, and health care outcomes (10).
Mortality rates are higher in the United States than in comparable
countries for most leading causes of death, although the United States
does better than its peer countries on deaths from cancer (11). Life expectancy has been decreasing in the United States since 2014 (12).
Environmental health hazards, poor nutrition, tobacco use, substance
use disorders, prescription drug misuse, suicide, injuries and deaths
from firearms, and maternal mortality are reversing progress made over
generations of increasing life expectancy. Contributing to suboptimal
health outcomes are the many systematic barriers to care that Americans
face, including discrimination because of personal characteristics, such
as race, ethnicity, religion, language, sex and sexual orientation,
gender and gender identity, and country of origin.
Underinvestment in primary care in
the United States also contributes to suboptimal outcomes. Evidence
shows that greater use of primary care is associated with decreased
health expenditures, higher patient satisfaction, fewer hospitalizations
and emergency department visits, and lower mortality. A Primary Care
Collaborative review found that primary care investment is associated
with a decrease in ambulatory-sensitive hospitalization and emergency
department visits, yet the national average for primary care investment
is approximately 5% to 10% of total health care spending, depending on
how primary care is defined; it also varies substantially across states.
The United States spends much less on primary care than other peer
countries. Organisation for Economic Co-operation and Development
countries spend an average of 14% on primary care (13).
Despite the value that internal medicine specialists and other primary
care physicians bring to the health system, the current U.S health care
system undervalues primary care and cognitive services (14, 15).
Much of the high spending and uneven
health outcomes in the United States have been attributed to a
fee-for-service payment system (16).
Policymakers have sought to move toward value-based payment, but there
is little agreement on how best to measure value across health care
settings and patients with diverse medical and socioeconomic conditions
and preferences. The clinical accuracy, ability of clinicians to act on
measures of their performance, and usefulness of quality criteria across
programs and payers have come under scrutiny.
Finally, health information
technology (IT) holds promise to facilitate improvements in care, reduce
administrative burdens of practice, and help both physicians and
patients communicate and navigate the complexities of the health care
system. However, ample evidence shows that health IT is not reaching
these goals, but rather adding administrative burden to clinical
practice (17, 18).
In summary, U.S. health care costs
too much; leaves too many behind without affordable coverage; creates
incentives that are misaligned with patients' interests; undervalues
primary care and public health; spends too much on administration at the
expense of patient care; fails to invest and support public health
approaches to reduce preventable injuries, deaths, diseases, and
suffering; and fosters barriers to care for and discrimination against
vulnerable individuals.
The ACP's Vision of a Better Health Care System for All
The ACP believes the United States
can, and must, do better and offers the following 10 vision statements
for a better health care system for all.
1. The American College of
Physicians envisions a health care system where everyone has coverage
for and access to the care they need, at a cost they and the country can
afford.
2. The American College of
Physicians envisions a health system that ameliorates social factors
that contribute to poor and inequitable health (social determinants);
overcomes barriers to care for vulnerable and underserved populations;
and ensures that no person is discriminated against based on
characteristics of personal identity, including but not limited to race,
ethnicity, religion, gender or gender identity, sex or sexual
orientation, or national origin.
3. The American College of
Physicians envisions a health care system where payment and delivery
systems put the interests of patients first, by supporting physicians
and their care teams in delivering high-value and patient-centered care.
4. The American College of
Physicians envisions a health care system where spending is redirected
from unnecessary administrative costs to funding health care coverage
and research, public health, and interventions to address social
determinants of health.
5. The American College of
Physicians envisions a health care system where clinicians and hospitals
deliver high-value and evidence-based care within available resources,
as determined through a process that prioritizes and allocates funding
and resources with the engagement of the public and physicians.
6. The American College of
Physicians envisions a health care system where primary care is
supported with a greater investment of resources; where payment levels
between complex cognitive care and procedural care are equitable; and
where payment systems support the value that internal medicine
specialists offer to patients in the diagnosis, treatment, and
management of team-based care, from preventive health to complex
illness.
7. The American College of
Physicians envisions a health care system where financial incentives are
aligned to achieve better patient outcomes, lower costs, and reduce
inequities in health care.
8. The American College of
Physicians envisions a health care system where patients and physicians
are freed of inefficient administrative and billing tasks, documentation
requirements are simplified, payments and charges are more transparent
and predictable, and delivery systems are redesigned to make it easier
for patients to navigate and receive needed care conveniently and
effectively.
9. The American College of
Physicians envisions a health care system where value-based payment
programs incentivize collaboration among clinical care team–based
members and use only appropriately attributed, evidence-based, and
patient-centered measures.
10. The American College of
Physicians envisions a health care system where health information
technologies enhance the patient–physician relationship, facilitate
communication across the care continuum, and support improvements in
patient care.
The accompanying policy papers (1–3)
offer specific recommendations, supporting rationales, and evidence on
ways the United States can move to achieve ACP's vision.
In “Envisioning a Better Health Care System for All: Coverage and Cost of Care” (1),
ACP recommends transitioning to a system of universal coverage through
either a single payer system, or a public choice to be offered along
with regulated private insurance. Although each approach has advantages
and disadvantages, either can achieve ACP's vision of a health care
system where everyone has coverage for and access to the care they need,
at a cost they and the country can afford. The evidence suggests that
publicly financed and administered plans have the potential to reduce
administrative spending and associated burdens on patients and
clinicians compared with private insurers. Other approaches were
considered by ACP, including market-based approaches, yet ACP found they
would fall short of achieving our vision of affordable coverage and
access to care for all. The ACP asserts that under a single payer or
public option model, payments to physicians and other health
professionals, hospitals, and others delivering health care services
must be sufficient to ensure access and not perpetuate existing
inequities, including the undervaluation of primary and cognitive care.
The ACP proposes that costs be
controlled by lowering excessive prices, increasing adoption of global
budgets and all-payer rate setting, prioritizing spending and resources,
increasing investment in primary care, reducing administrative costs,
promoting high-value care, and incorporating comparative effectiveness
and cost into clinical guidelines and coverage decisions.
In “Envisioning a Better Health Care System for All: Health Care Delivery and Payment Systems” (2),
ACP calls for increasing payments for primary and cognitive care
services, redefining the role of performance measures to focus on value
to patients, eliminating “check-the-box” reporting of measures, and
aligning payment incentives with better outcomes and lower costs. The
position paper calls for eliminating unnecessary or inefficient
administrative requirements, and redesigning health information
technology to better meet the needs of clinicians and patients. The ACP
concludes there is no one-size-fits-all approach to reforming delivery
and payment systems, and a variety of innovative payment and delivery
models should be considered, evaluated, and expanded.
In “Envisioning a Better Health Care System for All: Reducing Barriers to Care and Addressing Social Determinants of Health” (3),
ACP calls for ending discrimination and disparities in access and care
based on personal characteristics; correcting workforce shortages,
including the undersupply of primary care physicians; and understanding
and ameliorating social determinants of health. This position paper
calls for increased efforts to address urgent public health threats,
including injuries and deaths from firearms; environmental hazards;
climate change; maternal mortality; substance use disorders; and the
health risks associated with nicotine, tobacco use, and electronic
nicotine delivery systems.
These are just a partial summary of
the recommendations in the 3 position papers; considered together, they
offer a comprehensive and interconnected set of policies to guide the
way to a better a health care system for all. We urge readers of this
call to action to review the 3 papers for a complete understanding of
ACP's recommendations and the evidence in support of them.
Where Do We Go From Here?
The ACP believes that our
recommendations, if adopted, would address many shortcomings in U.S.
health care, but acknowledges that the recommendations do not address
every area of needed improvement. In some cases, more research is needed
for effective policy development. Because both are needed, the
recommendations aim to balance the imperative for transformational
changes with improvements in the current system.
The ACP is committed to ensuring
that the patient's voice is paramount in creating a health care system
that better meets their needs. The ACP also believes that physicians are
uniquely trusted and qualified to offer solutions to the problems in
U.S. health care.
We hope that those who challenge
ACP's recommendations will offer their own thoughtful alternative
solutions rather than just opposing ours.
The ACP rejects the view that the
status quo is acceptable, or that it is too politically difficult to
achieve needed change. Dr. Atul Gawande wrote, “Better is possible. It
does not take genius. It takes diligence. It takes moral clarity. It
takes ingenuity. And above all, it takes a willingness to try” (19).
By articulating a new vision for health care, ACP is showing a
willingness to try to achieve a better U.S. health care system for all.
We urge others to join us.
https://annals.org/aim/fullarticle/2759528/envisioning-better-u-s-health-care-system-all-call-action
Supplement: Vision for U.S. Health Care |21 January 2020
The American College of Physicians' Endorsement of Single-Payer Reform: A Sea Change for the Medical Profession Free
Steffie Woolhandler, MD - David U. Himmelstein, MD - Annals of Internal Medicine - January 21, 2020
Like their U.S. counterparts in an
earlier era, many Canadian physicians feared, and fiercely opposed,
single-payer reform. “We were afraid it would destroy the
profession . . . that our integrity would be destroyed . . . that the
government would intrude on the private doctor–patient relationship,”
said E.W. Barootes, who as President of Saskatchewan's medical
association led a 3-week doctors' strike in 1962 against that province's
new single-payer program (3).
Yet despite a rocky start, most
Canadians now embrace their single-payer system. Everyone is covered,
and all doctors and hospitals are “in-network.” Health costs, almost
identical to U.S. levels in the 1960s, are now about 40% lower, with
savings on administration accounting for half the difference (4).
Although funding for some aspects of care has, in our view, been
squeezed too tightly in Canada, physicians' incomes have not; Canadian
internists' take-home pay averages about CAD$300 000. Canada's health
outcomes surpass those of the United States, including for such
conditions as cystic fibrosis, end-stage renal disease, and type 1
diabetes, whose outcomes reflect quality of care (5–7).
Canada's generally positive
experience is among the strands of evidence underpinning the ACP's
endorsement. A single-payer reform that reduced insurance overhead to 2%
(the level for Canada and traditional Medicare) could save more than
$200 billion annually. In addition, our multipayer system imposes
complexity and expense on providers; the Cleveland Clinic has
210 000 000 different prices (8).
Single-source payment could streamline reimbursement—for example, by
replacing per patient hospital payment with global budgets and
establishing uniform billing and documentation requirements. Hospitals
and doctors could save billions on billing-related costs and repurpose
those savings to expand care, making universal, first-dollar coverage
affordable.
Achieving universal coverage would
be costlier under the “public choice” model the ACP co-endorses along
with single payer. Multipayer systems incorporating for-profit insurers
have not gleaned large administrative savings. For-profit insurers'
overhead is high everywhere (9), and the persistence of multiple payers would hinder efforts to streamline providers' billing-related work.
Moreover, real-world experience with
2 public choice models—Medicare's Advantage program and the Consumer
Oriented and Operated Plans (CO-OPs) under the Patient Protection and
Affordable Care Act (ACA)—warns that in health insurance competition,
public option good guys finish last.
Twenty-three CO-OPs offering plans
on the ACA exchanges received $2.4 billion in federal start-up loans.
Only 4, covering 150 000 enrollees, survive. New York's defunct CO-OP,
like many others, attracted many expensively ill patients, in part
because its network—unlike that of other exchange plans—included
Memorial Sloan Kettering Cancer Center. Iowa's CO-OP, which offered
lower cost sharing for antiretrovirals than its competitors, reportedly
enrolled 98% of all patients with HIV covered by Iowa's exchange plans.
Although the ACA included special funding to compensate CO-OPs for
high-risk enrollees, the losses far exceeded what Congress was willing
to appropriate.
Small start-ups, such as the CO-OPs,
often succumb to deep-pocketed competitors. However, the traditional
Medicare program—a large, well-established public option—also is losing
out in competition with private (Medicare Advantage) plans, despite
their 6-fold higher overhead and 6% higher total costs (after accounting
for “cherry picking” and upcoding) (10).
Medicare Advantage plans have
flourished, because chicanery trumps efficiency. The Centers for
Medicare & Medicaid Services uses patients' diagnoses to risk adjust
its payments to Medicare Advantage plans and minimize incentives for
cherry picking. However, insurers game the risk-adjustment formulas by
labeling enrollees with new (often clinically insignificant) diagnoses
and recruiting lower-cost patients within a diagnostic category, such as
minimally symptomatic patients carrying such diagnoses as
osteoarthritis, asthma, or congestive heart failure.
Plans also profit by “lemon
dropping”—pushing out unprofitably ill enrollees. Imposing high
copayments for chemotherapy agents and excluding specialized cancer
providers from networks encourages oncology patients to disenroll.
Seniors requiring nursing home stays or treatment for new-onset
end-stage renal disease have transferred in droves from Medicare
Advantage to traditional Medicare (11, 12).
Moreover, Medicare Advantage plans that accumulate unprofitably ill
seniors can, and do, pull out of entire counties, an option unavailable
to their public option competitor.
Private insurers have turned
traditional Medicare (like the ACA's CO-OPs) into a de facto high-risk
pool, despite regulations banning cherry picking and lemon dropping.
Enforcement of those regulations, already overmatched by insurers'
stratagems, will surely become harder. Google, part owner of Oscar, an
insurance start-up, knows who's playing tennis and who's buying
plus-size dresses and can micro-target marketing accordingly. As some
suggest, insurers, like casinos, are profitable because they know the
odds of every bet they place and can eject people who are beating the
house (13).
Despite drawbacks, public choice
reform offers 2 apparent advantages: It avoids confrontation with
private insurers and allows individuals to retain their current
coverage.
Unfortunately, achieving universal,
affordable coverage through public choice would, like single payer,
impose painful sacrifices on private insurers. In Germany, an oft-cited
example of a universal multipayer system, insurers offering the
mandatory coverage are nothing like ours. By law, Germany's “statutory”
insurers must be nonprofit, pay the same fees, charge the same premiums,
and contract with every hospital and every doctor. Insurers with
low-risk patients must cross-subsidize others, effectively creating a
single risk pool. In sum, Germany's statutory insurers (like
Switzerland's and Holland's) “are not as a matter of public policy
conceived of . . . [or] allowed to function as private businesses” (14);
they are more akin to the fiscal intermediaries that process
traditional Medicare claims. U.S. insurers would surely fight tooth and
nail against such transformation.
Public choice's second purported
advantage may also be illusory. Although surveys indicate that voters
value choice, it's choice of doctor and hospital—not insurer—that they
care about.
Although no reform achieves
perfection, evidence indicates that a well-structured single-payer
reform might resolve our nation's coverage and affordability problems,
preserve the choices patients value, and allow doctors to focus on what
matters most: caring for our patients.
Three decades after leading the
Saskatchewan strike, Dr. Barootes had changed his view: “Today I support
the universal healthcare program . . . . There has been no interference
in the decision making between a doctor and his [sic] patient . . . . A
politician is more likely to get away with canceling Christmas than he
is with canceling Canada's health insurance program” (15).
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