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Would a Single-Payer System Require Painful Sacrifices From Doctors?
by Robert H. Frank - NYT - June 8, 2018
Single-payer health care systems deliver better outcomes at much lower cost than those that rely primarily on private insurance, as we do in the United States.
Considerable evidence supports this claim. And because of these cost savings, I said in a recent column, the United States could switch to a single-payer system without requiring painful sacrifices from anyone.
Several readers pointed out an apparent flaw in my argument. Since the biggest savings result from lower payments to service providers, wouldn’t the transition be painful for physicians and other health care professionals?
The answer is less obvious than may appear. It is true that there clearly would be constraints on the income of doctors and other service providers in a single-payer system, and many of them would surely feel aggrieved by any attempt to reduce their salaries.
But cutting their pay directly probably wouldn’t happen, nor would it make sense.
To be politically feasible, any cuts in the purchasing power of doctors and other service providers would have to be gradual and take the form of lower rates of salary growth, not outright salary reductions. People are far less sensitive to reductions in rates of growth than to simple pay cuts, as behavioral scientists have long known.
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So the real question is: Would such a gradual shift constitute a painful sacrifice?
For some doctors, it might. But research on the determinants of human well-being suggests that the answer to this question is also somewhat surprising. That’s partly because the long-run link between money and happiness is complex, but also because salary is only one determinant of the satisfaction people derive from their jobs.
Most people believe that having more money would make them happier, but studies of happiness suggest that the truth is more complicated. As the authors of the 2017 World Happiness Report wrote: “People are constantly amazed that aggregate happiness has not risen in the U.S.A. and many other countries, when incomes and educational levels have risen so much and when income and education are associated with greater individual happiness.”
As expected, being poor — often defined as having less than 60 percent of a country’s median income — does indeed make people less satisfied. But once a certain absolute income standard is achieved, satisfaction depends more heavily on how one’s earnings compare with the earnings of others.
This should not seem surprising since, as Charles Darwin recognized, life is graded on a curve. How smart, strong or rich you are matters less than how those attributes compare with those of your closest rivals.
One implication is that the comparisons that matter most are highly local. Even billionaires can feel poor if they spend most of their time with people who earn more than they do.
For doctors to be satisfied with their pay, then, their earnings must be on par with those of their close colleagues. That helps explain why American doctors who work for nonprofit clinics like Mayo, Cleveland, and Kaiser Permanente — and earn less than their fee-for-service counterparts — generally seem content with their terms of employment.
We know, too, that highly qualified people pursue careers as health care professionals even in countries that pay providers substantially less than the salaries we see here.
Non-monetary working conditions are also important determinants of job satisfaction. Switching to a single-payer system promises significant reductions in many of the everyday hassles confronting doctors under private insurance systems.
One difficulty is having to wrangle with insurance companies that deny payment for tests and procedures that their policies seem to cover. If you complain often and loudly enough, you may eventually get paid, but the process takes a toll — not just on consumers but on doctors, too.
Such disputes are a direct consequence of the economic incentives confronting private insurers. Because most consumers lack the detailed knowledge necessary to compare competing coverage options, they focus heavily on price when choosing a provider. Insurers have an incentive to compete for market share by offering the lower prices made possible when they adopt hard-to-detect reductions in the quality of their coverage.
Billing disputes are far less common under single-payer systems. Canadian doctors, for example, are less than one third as likely as their American counterparts to report that they “spend an excessive amount of time on paperwork or disputes related to medical bills.”
In sum, although the switch to a single-payer system would entail lower payments to service providers like doctors, it would also affect their frames of reference and conditions of employment in offsetting ways. International happiness studies offer no reason to conclude that, once it has been fully implemented and absorbed, the switch would require truly significant sacrifices by most American health care providers.
There would of course be exceptions.
As Atul Gawande described in a much-cited New Yorker article, current reimbursement arrangements have encouraged some physicians to view their practices less as centers for healing than as revenue streams. Some have invested in image centers and clinics to which they refer patients for scans and treatment, capturing insurance reimbursements for themselves directly.
Others demand kickbacks for referring patients to home-health agencies. And because most insurers don’t reimburse for phone calls, patients who call with questions that could easily be answered by phone are often told to schedule reimbursable office visits. Physicians who adopt these practices may earn seven- or even eight-figure annual incomes.
Because meaningful health reform would eliminate the incentives for these abuses, we can be sure that at a small number of doctors would suffer steep income declines. These few might scream bloody murder. And, as many Californians may discover, moving immediately to single-payer health care will require a host of trade-offs, some of them painful over the short-term.
So, on reflection, I’d say that the switch to a single-payer system wouldn’t require unreasonable sacrifices from anyone.
On More Generous Terms, Obamacare Proves Newly Popular
Sign-ups, which have set a record, have been especially strong in states that had resisted expanding coverage under the Affordable Care Act.
A record number of Americans — 13.6 million — have signed up for health plans through the Affordable Care Act’s marketplaces for 2022. The major reasons for the rise appear to be: Congress lowered the cost of Obamacare insurance; the Biden administration increased advertising for the program; and the pandemic disrupted many Americans’ employer-provided coverage.
The Covid-19 public health emergency helped usher in an era of greater generosity and expanded outreach to the uninsured that many of Obamacare’s original authors had long called for.
The increased enrollment, covering at least two million more Americans than in any previous year, was particularly pronounced in states like Georgia and Texas that have high rates of uninsurance and declined to expand Medicaid to cover their poorest adults.
“What a great day it is to really see how the programs are working as they are intended,” Chiquita Brooks-LaSure, the administrator for the Centers for Medicare and Medicaid Services, told reporters on a conference call.
The Biden administration has invested heavily in promoting the availability of insurance subsidies under the Affordable Care Act. It also quadrupled the network of professionals available to help people enroll. But Ms. Brooks-LaSure said she thought the main driver of the enrollment increase was the lower prices most Americans would pay.
A stimulus bill passed by Congress in March made many more Americans eligible for financial assistance in buying Obamacare plans. For most people with low incomes, comprehensive coverage is currently available for no premium. Some middle-class people earning higher incomes became eligible for subsidies for the first time.
Taken together, the policies have represented an expansion and a reimagining of the Affordable Care Act, what some policy experts have called Obamacare 2.0. The enrollment numbers suggest that these changes have substantially increased enrollment in the program, counteracting coverage declines from falling employment during the pandemic.
But those gains may be fragile. The enhanced subsidies are scheduled to expire at the end of 2022. Democrats in Congress hope to extend them through 2025 as part of their large social spending and climate bill, but that legislation is currently stalled in the Senate.
“The only cloud on the horizon is the current uncertainty with the Build Back Better Act now being in limbo,” said Peter Lee, the executive director of California’s marketplace, Covered California. “Because if the subsidies that are expanded under the American Rescue Plan aren’t continued, the sad truth is hundreds of thousands of Californians will drop coverage after next year, and millions of Americans will drop coverage across the country.”
Federal health officials said enrollment gains were most pronounced in states that had not expanded their Medicaid programs. Enrollment in Georgia grew by a third from last year, and enrollment in Texas increased by more than a quarter. The Build Back Better package would also create new insurance options for poorer residents of those states.
Laura Colbert, the executive director of Georgians for a Healthy Future, a consumer advocacy group that also helps sign Georgians up for coverage, said the big enrollment boost this year came thanks to increased subsidies and advertising — but also a new state reinsurance program that helped lower premiums and attract more insurers into the state’s marketplace. She, too, worries about what will happen if the subsidies expire.
“If nothing else, consumers are price-sensitive, and an expiration of the enhanced subsidies will definitely lead to fewer enrollments,” she said. “When extra help is in place, people really appreciate it. But when it goes away, they are often more frustrated by it than they appreciated the help in the first place.”
The economic disruptions of the pandemic mean that some Americans who lost job-based coverage may be purchasing their own plans now. And the increased investment in advertising probably attracted many customers who had always had access to good deals but had been unaware that financial help was available. Research on the uninsured has found that more than half would qualify for free or subsidized health care.
“The messaging angle here is also really important to even get people to the door,” said Cynthia Cox, a vice president at the Kaiser Family Foundation who conducts research on the A.C.A.’s effects. “And the subsidies make it more appealing to walk through the door to actually sign up.”
The administration also established a long “special enrollment period” related to the pandemic through the spring and summer. Millions of new customers signed up for insurance then and are renewing now.
Enrollment remains open until Jan. 15 in most states for those who want coverage that would begin in February. A handful of states that operate their own marketplaces will continue to allow sign-ups later in January.
Overall health spending in the U.S. reached record levels in 2020.
by Margot Sanger-Katz - December 15, 2021
The Covid-19 pandemic brought unprecedented trends in health spending last year — with overall health spending reaching its largest share of the U.S. economy ever at 19.7 percent, or $12,530 per person. But direct spending on medical care was lower than it was in 2019.
A new report from the actuaries at the Centers for Medicare and Medicaid Services, published Wednesday in the journal Health Affairs, found that total health spending in the economy grew to $4.1 trillion in 2020, a leap that represented the highest rate of increase since 2002. But nearly all of that growth came from emergency government spending on the pandemic — the effort to rapidly develop Covid vaccinations, infusions of dollars into public health, and economic stimulus spending to states, hospitals and medical providers, meant to insulate them from the shock of shutdowns in the early days of the pandemic.
“Obviously, 2020 was like no other year we’ve estimated in the history of the accounts,” said Aaron Catlin, a deputy director in the Medicare actuary’s national health statistics group.
Spending in most normal categories of health care actually went down. Health spending by businesses, individuals and state and local governments all fell. Direct spending by individuals and health insurers on medical services at hospitals, doctors and dentists also declined.
But federal programs authorized by Congress pumped unusual amounts of money into the health care system, by offering hospitals and medical practices forgivable loans, increasing the federal share of Medicaid spending, and investing billions in public health and vaccine development programs.
Federal spending on health care grew by 36 percent overall. Overall spending on health care that did not include public health spending or special pandemic programs grew by 1.2 percent.
https://www.nytimes.com/2021/12/15/upshot/overall-health-spending-record-2020.html?
Big Hospital Chains Drop Vaccine Mandates for Health Workers
With the federal requirement in limbo because of legal challenges, some major multistate hospital systems have stopped enforcing their own policies.
by Reed Abelson - NYT - December 14, 2021
The legal uncertainty over a federal requirement that the nation’s 17 million health care workers be vaccinated against the coronavirus has led some well-known hospital chains to drop their own mandates — at least temporarily.
The Cleveland Clinic, HCA Healthcare and Intermountain Healthcare, among others, have said they are no longer requiring employees to be vaccinated until the courts sort out whether the federal mandate can go into effect. The hospitals’ decisions were first reported by The Wall Street Journal.
The moves are likely to slow down efforts to quell the latest surge in infections, potentially worsened by holiday traveling, large gatherings indoors and the introduction of the Omicron variant. Public health officials are renewing their pleas for more people to get vaccinations and booster shots as this latest wave of Covid cases threatens to again overwhelm hospitals. Some 66,000 Americans are now hospitalized with Covid.
Suspending the localized requirements will also make it harder for hospitals to meet the federal government’s deadline of early January for vaccinating all eligible staff if the courts uphold the mandate. Federal officials are appealing a Louisiana judge’s decision to halt the rule, and the case is likely to go to the Supreme Court. The court on Monday allowed New York State’s vaccine requirement for health care workers to continue, and the justices have previously rejected challenges to other vaccine requirements.
Exactly how many hospitals are abandoning the policy is unclear. Many states, like California and New York, and local governments, like Philadelphia’s, adopted their own edicts. HCA specified that it would continue the requirement at hospitals in places where there is a state mandate.
Several large hospital groups imposed their own requirements earlier this year after experiencing a sharp rise in cases from the Delta variant. About 40 percent of the nation’s hospitals mandated vaccinations for staff members, and the Centers for Medicaid and Medicare Services, which issued the new rule, says many facilities have already succeeded in getting workers protected.
Decisions on enforcement “have varied across the board,” said Erin J. McLaughlin, a labor and employment lawyer for Buchanan, Ingersoll & Rooney. She said an equal number of her health care clients had scrapped the requirement as had continued it.
“We do not think most hospitals are changing their mandates,” the American Hospital Association, a trade group, said in a statement. “While the current C.M.S. vaccine requirement may be delayed, hospitals and health systems are not delaying their efforts to vaccinate staff,” the group said.
But the legal landscape is confusing at best, with states and local governments often running counter to the federal efforts. In Florida, where AdventHealth, HCA and UF Health Jacksonville have all paused their requirements, Gov. Ron DeSantis prohibited vaccine mandates by private employers shortly after the federal government issued its rule for health care workers.
Exactly how many health care workers still need to get vaccinated is also unclear. While a study by federal researchers found that 30 percent of hospital workers were not fully vaccinated as of mid-September, overall immunization rates have climbed in the last few months. HCA, which employs about 275,000 workers and operates in 20 states, said most of its workers were fully vaccinated, but it would not provide specifics. Neither AdventHealth nor UF Health Jacksonville would say how many of its employees were vaccinated. Unlike nursing homes, hospitals are not required to publicly report their vaccination rates.
But many hospitals insist they are continuing efforts to persuade workers. “Based on scientific evidence and what we see in our hospitals every day, Covid-19 vaccines are safe and effective at reducing both the risk of becoming infected and the level of harm in the case of a breakthrough infection,” AdventHealth said in a statement.
Hospitals “are totally committed to having their work force vaxxed,” said Chip Kahn, the chief executive of the Federation of American Hospitals, which represents for-profit chains like HCA.
Much of the opposition to the requirements is over concerns that workers who object to the vaccine will leave. Many hospital chains said departures had not been numerous, but Mr. Kahn emphasized that even a small number of resignations can be disruptive. “Those small numbers can really be a problem,” he said.
Some hospital companies said they would pursue alternatives to keep patients and employees safe. The Cleveland Clinic, which estimated that nearly 85 percent of its employees were fully vaccinated, said it was adding more measures, “including periodic testing for those providing direct clinical care.”
Hospitals that do not want to insist on immunizations are focusing on testing their employees, said Ann Marie Pettis, the president of the Association for Professionals in Infection Control and Epidemiology, which supports a mandate for health care workers. “It’s not like they are just throwing up their hands and saying it is a free-for-all,” she said.
Other hospitals already have high numbers of vaccinated workers. Intermountain, along with other Utah hospitals, is pausing its requirement and said 98 percent of its staff had complied with the requirement.
https://www.nytimes.com/2021/12/14/health/hospitals-vaccine-mandate.html?
Docs Sue Envision Over Violation of Bans on Corporate Practice of Medicine
Amanda D'Ambrosio - MedPage - December 26, 2021
Group says the corporation should be barred from running EDs in California
An emergency medicine physician group sued private equity-owned Envision
Healthcare, alleging it violated laws that ban corporations from practicing
medicine in California, according to the lawsuit complaint
The American Academy of Emergency Medicine Physician Group (AAEM-PG), a
unit of the AAEM that supports independent physician practices, claimed
that Envision Healthcare violated laws banning the corporate practice of
medicine when it took over an emergency department contract at
Placentia-Linda Hospital, a facility owned by Tenet.
"Envision through itself and by the direct control of its controlled
medical groups, kickbacks, restrictive covenants, and other practices
alleged, violated California's ban on the practice of medicine in
violation," AAEM-PG stated in the lawsuit.
The suit does not seek monetary damages. Instead, it is asking the court to
stop Envision from operating the emergency department at Placentia-Linda
Hospital and other facilities in California. Envision currently operates at
least a dozen emergency departments in the state, according to the
complaint.
Several states have corporate practice of medicine laws that aim to keep
commercial interests out of the doctor-patient relationship. California law
bans corporations or any other non-licensed individuals or entities from
practicing medicine, assisting in the unlicensed practice of medicine,
employing physicians, or owning physician practices.
AAEM-PG alleged that Envision, which is owned by private-equity giant KKR,
interfered with clinical practice, offered remuneration to hospitals in
exchange for emergency department contracts, and used restrictive covenants
to limit physicians' ability to practice their profession.
In response to an inquiry from *MedPage Today*, a spokesperson for Envision
Healthcare stated that the company does not comment on pending litigation.
"This is the bottom line interfering with medical decision-making," Robert
McNamara, MD, chair of emergency medicine at Temple University and former
president of AAEM, said in an interview. "There's all kinds of implications
associated with corporations making decisions for the bottom line that may
not be in the best interest of patients. Those are the greatest concerns."
Last August, a subsidiary of Envision Healthcare was awarded an exclusive
emergency department contract by Placentia-Linda Hospital, which guaranteed
its employees exclusive rights to treat patients at that location. Prior to
the takeover, the hospital's emergency department was run by an independent
physician group, which contracted AAEM-PG to take care of administrative
services.
The complaint states that Envision allocated remuneration to hospitals in
exchange for exclusive emergency department contracts. In this case, the
AAEM-PG alleged that Envision provided anesthesia services to a Tenet
hospital without the hospital having to pay a subsidy for those services in
exchange for the Placentia-Linda ED contract, adding that the organization
believes this kickback scheme is one of Envision's "standard methods of
acquiring new contracts and maintaining existing ones."
Additionally, the AAEM-PG claimed that Envision "exercises profound and
pervasive" control over physicians' practice of medicine. The corporation
not only decides which and how many physicians will be hired, their work
schedules, and their compensation -- it also determines how many patients a
provider takes on, medical charges, and clinical decisions, the AAEM-PG
stated.
"Envision establishes and promulgates physician 'best practices,' 'red
rules,' and 'evidence-based pathways' protocols which enumerate standards
for treating patients and are a form of clinical oversight," the group
noted.
The AAEM-PG also alleged that Envision requires its physicians to sign
restrictive covenants -- agreements that prohibit the clinicians from
forming a group to compete with Envision or from helping any other groups
acquire the emergency room contracts that the company currently holds.
Physicians' mobility is also restrained for a 1-year period after their
departure from Envision, barring them from working with groups who compete
with Envision for contracts, the complaint noted.
"The provision has the effect of reducing competition in the business and
trade of emergency department physician services, reducing the number of
competitors for Emergency Services Contracts, limiting the supply of
emergency physicians available to patients seeking emergency services, and
causing increases in the price of such patient services by limiting the
facilities where emergency physicians can practice," AAEM-PG stated.
McNamara said the organization hopes the courts "take a hard look" at how
this business is set up, and examine how the alleged violations impact
patients.
"The essence of the corporate practice of medicine law is rooted in
protecting the physician-patient relationship," McNamara said. "That's what
we're looking to get upheld here.
https://www.medpagetoday.com/special-reports/exclusives/96364?
A New Ban on Surprise Medical Bills Starts This Week
If you have a medical emergency, you will no longer need to worry about a large bill from a doctor you did not choose.
by Margot Sanger-Katz - NYT - December 30, 2021
For years, millions of Americans with medical emergencies could receive another nasty surprise: a bill from a doctor they did not choose and who did not accept their insurance. A law that goes into effect Saturday will make many such bills illegal.
The change is the result of bipartisan legislation passed during the Trump administration and fine-tuned by the Biden administration. It is a major new consumer protection, covering nearly all emergency medical services, and most routine care.
“I think this is so pro-consumer, it’s so pro-patient — and its effect will eventually be felt by literally everybody who interacts with a health care system,” said Senator Bill Cassidy, a Republican from Louisiana, who was part of a bipartisan group of lawmakers who wrote the bill. He said he counted the bill as among his top achievements as a lawmaker.
Even with insurance, emergency medical care can still be expensive, and patients with high deductible plans could still face large medical bills. But the law will eliminate the risk that an out-of-network doctor or hospital will send an extra bill. Currently, those bills add up to billions in costs for consumers each year.
“This is such an important consumer victory because it is going to protect consumers from an egregious and pervasive billing practice that has just grown over the years,” said Patricia Kelmar, the health care campaigns director at the consumer group U.S. PIRG.
Behind the scenes, medical providers are still fighting with regulators over how they will be paid when they provide out-of-network care. But those disputes will not interfere with the law’s key consumer protections.
What does the law mean if I go to the emergency room?
If you are having a medical emergency and go to an urgent care center or emergency room, you can’t be charged more than the cost sharing you are accustomed to for in-network services. This is where the law’s protections are the simplest and the most clear for people with health insurance.
You will still be responsible for things like a deductible or a co-payment. But once patients make that normal payment, they should expect no more bills.
“We shouldn’t have to depend on people knowing minutia about insurance regulation in order for them to get care or not be unfairly billed,” said Anthony Wright, the executive director of Health Access California, a patient group that supported the federal law and that fought for a law that banned surprise bills in California starting in 2017.
Several studies found that around 20 percent of U.S. patients who had emergency care were treated by someone outside of their insurance network, including emergency room doctors, radiologists or laboratories. Any of those providers could send patients an extra bill after the fact, and some medical groups did so routinely. Such bills are now illegal.
There is one important exception.
What does the law mean if I need an ambulance?
The new law does not prevent ambulance companies from billing you directly for their services if they travel on roads. It does offer protections against surprise bills from air ambulances.
Ground ambulances were left out of the recent legislation because legislators determined they would need a different regulatory approach. Congress established a commission to study the issue and may consider reforms.
Eleven states prevent ambulances from sending out-of-network medical bills. Patients who live in the other states are quite likely to get a bill in the mail if they require an ambulance. Research shows as many as half of people who need an ambulance receive such a bill, though the amount is not always large.
What does the law mean for routine hospital procedures?
For scheduled services, like knee operations, C-sections or colonoscopies, it’s important you choose a facility and a main doctor that is in your insurance plan’s network. If you do that, the law bars anyone else who treats you from sending you a surprise bill. This also addresses a large problem. Surprise bills from anesthesiologists, radiologists, pathologists, assistant surgeons and laboratories were common before.
If, for some reason, you are having such a service and you really want an out-of-network doctor to be part of your care, that doctor typically needs to notify you at least three days before your procedure, and offer a “good faith estimate” of how much you will be charged. If you sign a form agreeing to pay extra, you could get additional bills. But the hospital or clinic can’t force you to sign such a form as a condition of your care, and the form should include other choices of doctors who will accept your insurance.
“People should really, really think carefully before they sign that form, because they will waive all of their protections,” Ms. Kelmar said. She recommended that patients skip right to the part of the form that lists covered alternatives.
Does this mean I will never be surprised by a medical bill?
No. When health policy experts discuss “surprise bills,” they are talking about a specific thing: extra charges from a medical provider whom patients didn’t choose. But there are still many parts of the U.S. health care system that remain perplexing.
If you have an insurance plan with a high deductible, or have a kind of cost-sharing known as “coinsurance” in which you have to pay a percentage of your medical charges, you could still get a big bill in the mail after any medical care. The government is taking steps to make the costs of medical care more transparent. But it is still not always obvious what medical care will cost in advance, and what insurance plans will cover. It is always worth understanding how your insurance benefit works so that you have a general sense of how much you could be asked to pay beyond your premium.
If you are going to a doctor for something that’s not an emergency, it is also still important to confirm that the doctor is part of your health insurer’s network. Visits to doctors who are out of network could result in extra bills. Mr. Wright recommends asking doctors whether they are “in network” and not whether they simply “accept my insurance.” That’s because some doctors who are out of network will accept insurance payments but still bill patients for additional fees.
What about lawsuits over the law?
Doctor and hospital groups have brought lawsuits challenging a part of the surprise billing law. But even if those lawsuits are successful, there will be little immediate impact on bills. (It is possible they will eventually cause insurance premiums to rise.)
The lawsuits relate to what happens after an out-of-network doctor treats a patient. The new law sets up an arbitration system for the provider and the health insurer to determine a fair payment. In the lawsuits, the medical providers say the regulations for that process are not consistent with the wording of the law and may cause their payments to fall. If they win, they want some of the instructions for the arbiter to be deleted, but they do not seek the ability to send surprise bills.
https://www.nytimes.com/2021/12/30/upshot/medical-bill-ban-biden.html
This is an outstanding posting that will hopefully be read by many supporters of universal, publicly funded healthcare; and importantly, will be shared thousands of times. Thank you Phil.
ReplyDeleteOne aspect of reducing the cost of heath care and increasing the accessibility is training more generalists who can cover a much wider population of patients. This requires a rethinking of turf issues, the certifying boards, and medical school and residency training. William Babson Jr. MD
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