Maine Voices: Emphasis on revenue sabotages medical practices and hospitals
At some point, most of us who entered medicine for altruistic reasons find ourselves providing a declining quality of care.
By Deborah Patten - Special to the Press Herald - April 9, 2023
Recent medical news has focused on the need to recruit more health care workers because of the departure of many from the field. Although the COVID-19 pandemic certainly added stress to the work, there were difficulties that preceded the pandemic.
When I began practicing pediatrics about 40 years ago, the ratio of
help needed to support me was 3:1 – or essentially nursing, secretarial
and billing positions. Now the ratio is 16:1. That’s a lot of salaries
for one provider to support, despite some being new and essential, such
as an IT person. However, the offloading of some tasks of past smaller
practices has been replaced by other burdens.
Primary care has historically been the most poorly reimbursed of
medical fields. Now these are often the empty positions. I found it
shameful that insurance would reimburse more for procedures as minor as
freezing warts than for an hour spent resuscitating a newborn or
counseling a suicidal teen.
My eight years of college and medical school, which cost $30,000 in
the 1970s, now costs $600,000 for tuition only. This pushes young
doctors away from primary care in order to pay back school loans using
the higher salaries that come with subspecialty and surgical care.
There are many well described challenges for those currently
providing health care. Insurance companies routinely challenge charges,
limit reimbursement and also change coverage rules. Drug companies
frequently deny prescriptions, something that necessitates time to
respond and negotiate – and often re-prescribe.
The electronic medical record may offer clarity of notes but also
requires mastery of every program change, a shameful lack of eye contact
with the patient, and the skill for rapid data entry, primarily for the
purpose of billing. Our patients’ mental health needs have soared, and
can now rarely be addressed in compressed office visits.
We need to acknowledge that health care has become a business.
As medical practices and hospitals have been taken over by the
corporate world, decisions are made by non-health care individuals and
are based on economics. The emphasis is on revenue, and that means
seeing more patients faster, despite the complexity of or lack of
familiarity with their problems. It means closing and consolidating
hospitals and practices. It also means hiring less expensive and
therefore less qualified people to answer phones, screen patients and
even provide care. Less overhead, more visits, more procedures, more
“billable moments.”
At some point, most of us who entered medicine for altruistic reasons
find ourselves providing a declining quality of care. We find that we
have become a high-speed data entry person for the various corporations
that decide how we practice medicine – the insurance companies, the
drugmakers, even the corporations that run the practices and hospitals.
Some of these corporations can use the label nonprofit because they pour
the revenue into administrative salaries. In response to our feedback
and calls for change, we are told that we must be more “resilient.”
Until we turn some of health care management back to those who are
providing the care, we will continue to see a loss of qualified nurses
and doctors. The problem is not only burnout with multiple demands and
clerical work, but also what has aptly been labeled “moral injury.” We
cannot provide the level of care that we know to be best and that we
aspired to provide.
Letter to the editor: A system of publicly funded health care is the answer
In her April 9 column, Dr. Deborah Patten painted a disturbing
picture of doctors suffering from burnout and “moral injury” – tension
between business and professional responsibilities (“Maine Voices: Emphasis on revenue sabotages medical practices and hospitals”). This matters because our health depends on those doctors.
Implementation of a publicly funded health care system covering everyone (such as described in the Medicare for All Act of 2021, quoted below) would help address five of the problems she mentioned:
• Increasing need for administrative staff. Consolidation of all
payers into one public payer would reduce the expense of medical billing
departments (“a uniform national system for electronic billing for
purposes of making payments”).
• Lower reimbursement for primary care. Reimbursement of these providers
would likely be increased to “promote policies that expand the number
of primary health care practitioners.” “[R]eview board … assure … fair
reimbursements for physician-delivered … services.”
• Time-consuming pre-authorizations. “Benefits provided … without any need for any prior authorization determination.”
• Distraction of the electronic medical record. Coding would be
simplified through a “national fee schedule” and documentation could be
minimized (“documentation as may be reasonably required”).
• Productivity demands. Self-imposed productivity goals would continue
for independent physicians, but negotiated institutional global budgets
would limit productivity demands on employed physicians (who “may elect
to be paid through such institutional provider’s global budget”).
There are, no doubt, other solutions for burnout and moral injury.
The public needs to hear what other physicians have to say on the
subject and then advocate for the best solutions – before it’s too late.
Epidemiologists have long noted that people who earn less money live shorter lives and suffer more ill-health than people with more money. Onerecent studydocumenting this phenomenon found that “higher income was associated with greater longevity throughout the income distribution.”
That 2016 study, led by Stanford economist Raj Chetty, found the greatest difference in longevity was between people in the bottom and top 1% of the income distribution, where the gap was about 15 years for men and 10 years for women. To put that spread in perspective, the richest 1% lived longer than people in Japan, which is ranked first in longevity, while the poorest 1% lived about as long as the average person in Russia or North Korea, which are tied for 113th.
Just a few months before that study appeared, Anne Case and Angus Deaton, who had just won the Nobel Prize for economics,documenteda rapidly falling longevity rate for white Americans. The main causes were “drug and alcohol poisonings, suicide, and chronic liver diseases and cirrhosis,” which they dubbed “deaths of despair.”
Those studies appeared around the time the U.S. entered what has become an unprecedented long-term slide in life expectancy, which was only exacerbated by the COVID pandemic. The latest data show U.S. average life expectancy fell to 76.1 years in 2021 after peaking at 78.9 years in 2014.
In other words, stagnant incomes in the lower half of the income distribution and our bungled response to the pandemic managed to chop nearly three years of life off the average American over the past decade. The average masks hugeinequities. Black Americans lost four years over that span; indigenous people more than six years. Both groups include a disproportionate share of the nation’s poor.
Updating the definition of poverty
I was prompted to revisit that literature this week after seeing a briefresearch notein JAMA Internal Medicine that tried to address some of the criticism leveled at the original JAMA study. This new study also viewed its findings through a health care lens: What would our response to poverty and inequality be if we treated stagnant real income and growing income inequality like a disease?
Before addressing that second question, the authors corrected for what is the most frequent conservative critique of studies that tie deteriorating health for people in the bottom 20-30% of the income distribution to enduring poverty: the impact of safety net programs like child tax credits, the earned income tax credit and food stamps on income.
Conservatives claim poverty is grossly overestimated because the Census Bureau’s calculations do not include the value of transfer payments. For instance, former Sen. Phil Gramm, now at the conservative American Enterprise Institute, estimated in aWall Street Journal commentarylast November that anti-poverty programs funnel a staggering $1.9 trillion a year into the households of the poor (I’d like to know how he arrived at that number given that the entire federal budget for non-defense discretionary spending was only $800 billion in 2022).
David Brady, who’s at the University of California, Riverside, and colleagues took that critique into account by wrapping all tax credits and “near cash” transfers like food stamps into their definition of income. Moreover, they expanded their definition of poverty to go up to half the median income. Whileprogressive economistssupport that expanded definition of poverty, its use in the study meant more better-off but still lower-income Americans would be in the group being evaluated for the ill health effects of poverty.
And here’s what they found: People living in poverty have a 42% greater chance of premature mortality than people in higher income brackets. If they remained mired in poverty for the ten-year period of the study, premature mortality rose by 71%.
Translated into annual death rates, poverty kills just under 200,000 people per year, making it the third leading cause of death. (If one includes smoking as a cause of death, it falls to fourth. The vast majority of smoking-related deaths are counted as either cancer or heart disease deaths in statistics compiled by the Centers for Disease Control and Prevention.)
President Biden has launched a “moonshot” to cure cancer. The nation’s media, whether aimed at a mass audience or the specialized health care press, run articles and segments almost daily about the untreated high blood pressure, obesity, substance abuse and mental illness that is leading to early mortality and driving down longevity.
Yet we rarely see stories that directly address the fact that poverty and economic stress on low-wage workers is triggering a disproportionate share of those illnesses. Nor do we hear many politicians articulating a program to address what may well be the number one cause of ill-health in our society: the impact of poverty and growing income inequality.
In acommentaryon the Chetty study published seven years ago, Nobel laureate Deaton expressed no surprise that the medical mainstream “emphasizes biology, genetic factors, specific diseases, individual behavior, health care, and health insurance” in its approach to improving the overall health of the population and putting America back on the path toward increasing longevity.
“Even if it is true that the fundamental causes of health are social and economic, there is every reason to focus on treatment and health behaviors in a country, even one as rich as the United States, where poverty is intractable and there is little immediate prospect of making the distribution of income more equitable,” he wrote.
Should your credit score suffer, setting you up for higher-priced loans, because of medical debt for an accidental injury?
The
cost of health care in the United States is highly expensive,
unpredictable and often based on factors out of people’s control. Being
billed for a medical condition or emergency isn’t the same as deciding
to get a mortgage, in which you are choosing to take on the debt
obligation.
If you need emergency care, you’re not likely to tellthe physician, “No, I don’t think I can handle the expense of fixing my broken leg. Let me just limp home and comparison shop.”
Medical
billing practices can put a strain on people’s budgets and, for many,
propel them toward bankruptcy. A survey conducted by the American Journal of Public Health of bankruptcy filers found that the majority said medical expenses contributed to their seeking relief.
On
Tuesday, the three major credit bureaus — Equifax, Experian, and
TransUnion — announced that medical collections with balances of $500 or
less would no longer appear on consumer credit reports.
This
is a significant step in helping millions of people — particularly
those who are young and on the lower end of the wage scale — who rely on
having a good credit score to get an apartment or an affordable loan.
“We
understand that medical debt is generally not taken on voluntarily, and
we are committed to continuously evolving credit reporting to support
greater and responsible access to credit and mainstream financial
services,” the chief executives of the credit bureaus said in a joint statement.
With
this change, nearly 70 percent of all medical debt sent to collections
is no longer part of consumer credit files, the executives said.
The Biden-Harris administration also announced plans
for medical debt reforms. It includes directing the Department of
Health and Human Services to look at providers’ billing practices and
helping veterans get their medical debt forgiven.
The point of credit scoring is to predict who is likely to default on their debts. In a report last
year, the Consumer Financial Protection Bureau questioned whether this
type of debt should be reported to the credit bureaus and thus factoredinto credit scores.
“Unlike
many other consumer debts, people rarely plan to take on medical debt,”
the CFPB report said. “Two-thirds of medical debts are the result of a
one-time or short-term medical expense arising from an acute medical
need. Medical debt is also unique in that people have less ability to
shop around for medical services.”
Even
the most cost-conscious consumers can find themselves saddled with
bills for medical services. Prices vary tremendously and are usually
higher fortheuninsured or for people with health coverage butusing out-of-network providers. Even in-network costs can vary widelybetween different facilities or departments.
And we know many people avoid getting the care they need because they rightly fear the financial consequences.
To
grasp why this removal is so important, you have to understand the
gravity of these small-dollar debts. It’s not just one bill under $500.
People are often receiving multiple bills from different health-care
providers. According to the CFPB, $88 billion of outstanding medical
bills are in collections — affecting 1 in 5Americans.
Here
are other disturbing statistics from the CFPB about the most common
collection tradeline reported on consumer credit records.
As of the second quarter of 2021, 58 percent of bills that are in collections and on people’s credit records are medical bills.
Medical
debts constituted 68.9 percent of accounts reported by debt collection
companies that base their fee on how much they collect.
Credit scores are lower in the South largely because of medical debt.
People
with low incomes, veterans and older adults are significantly impacted
by medical debt. Black and Hispanic consumers are disproportionately
more likely to have medical debt. “Due to racial inequities in health
and wealth, the medical debt crisis has impacted Black families more
acutely than White families,” according to a 2022 report from the National Consumer Law Center.”
The
action by the credit bureaus is the latest move to get rid of
health-care debt plaguing Americans and contributing to lower credit
scores. Even folks with good health insurance can find themselves in
medical debt.
Last
year, the credit bureaus removed all medical collection debt that had
been paid by the consumer in full. Additionally, the time period before
unpaid medical collection debt appears on a consumer’s credit report was
increased from six months to one year, giving consumers more time to
address suchdebt before it appears in their credit files. Often
these debts are reported to the credit bureaus because of payment delays
by people’s insurance companies. Or there are billing errors.
Despite
recent steps forward, we still should be exploring whether all medical
debt should be removed from people’s credit files.
“Approximately
half of all people with medical collections on their credit reports
will still have medical collections on their credit reports, and the
majority of the bills, by dollar amount, will remain,” according to an
emailed statement from CFPB spokeswoman Tia Elbaum.
Elbaum
said people who live in the southern and western parts of the country,
as well as those who live in lower-income neighborhoods, are least
likely to benefit from the change and are most likely to continue to
have medical items reported on their credit reports.
Newer
credit scoring models don’t weigh medical collections as heavily as
other forms of credit. And when such data is removed, people’s scores
can jump significantly, as much as 25 points, according to the CFPB.
Here’s what one consumer wrote to the CFPB in a complaint
about an emergency room visit: “I called and asked for an itemized
invoice, trying to understand how five minutes with a doctor who
essentially told me not to worry, that my daughter was fine, could cost
$1,500. The response I received was that that was the flat rate the
hospital charges my insurance company.”
I’m all about personal responsibility, but tell me how this kind of excessive pricing predicts someone is creditworthy.
Speaker Talbot Ross: ‘Health care for all’ must not rule out immigrants
It's time to close a small but unjust gap in MaineCare and return our state to its longstanding practice of greater inclusion.
By Rachel Talbot Ross - Portland Press Herald - April 12, 2023
All means all. It sounds simple, but when it comes to accessing healthcare in Maine, it isn’t.
L.D. 199,
my bill to provide MaineCare to all Mainers with qualifying low income,
regardless of immigration status, would provide much needed fairness,
equity and simplicity to our Medicaid program. And based on the
heartfelt testimony I recently heard in support of the bill from
parents, workers, health care providers and advocates from across the
state, it is abundantly clear that the time for this legislation is now.
Immigrants who testified at a long and
often emotional public hearing shared their love of living and working
in Maine, how much they care about the health and safety of their
communities, and how deeply they want to be included and respected as
part of our state. They desire what every
generation of immigrants to Maine has – a chance to live in peace and
safety, to build a life, and to give their children a strong start in
this beautiful place.
Crystal Cron, founding director of Presente! Maine said,
“Immigrants have been contributing to the strength and vitality of
Maine for centuries. They have resettled here with hopes and dreams of
building a new life for themselves, and of investing in the communities
they now call home. And they have
invested. If you’ve worked thousands of hours in a lobster plant, or in
the blueberry fields, or in potato packing, aren’t you a Mainer? The
health of one is the health of us all, and we all reap the benefits when our communities are cared for.”
Others testified to the tragic loss of
life and livelihood that immigrants they know have experienced. A loving
and involved father of two elementary students in Falmouth died of
treatable cancer, orphaning them. Two young members of the Congolese
community who could not afford basic health screenings died suddenly
last year in Lewiston.
L.D. 199 is a straightforward bill
that would help close a small but unjust gap in our MaineCare system
and return Maine to its longstanding practice of greater inclusion. It
was only in 2011, under the LePage administration, that this access was
restricted. This initiative would continue building on Maine’s health
care progress that began with Medicaid expansion, and repair a
two-tiered health care system that is divided along complex and
ever-evolving immigration lines. And it would help prevent untold
tragedies through affordable medicine or regular preventative medical
care.
Just as we have seen with Medicaid
expansion, helping more people afford health care will also have
beneficial ripple effects for our workforce and economy.
In 2018, immigrants in Maine contributed at least $193.9 million in state and local taxes.
That number is certainly higher today. Yet they pay into a healthcare
system that they are not allowed to access. This is unfair and
tragically short-sighted. The overall costs of missed workdays, lower
production, and disability far outweigh the direct costs of medical
care. As we wait for Congress to make the necessary federal reforms to
our broken immigration system, providing healthcare to our essential
workers is something we can do now.
Access to affordable healthcare saves
lives and reduces costs in overall healthcare spending. Currently, the
people who would gain coverage from my bill are only eligible for
Emergency MaineCare to stabilize a life-threatening emergency. Patients
who lack full health coverage often delay or go without care until a
condition worsens and becomes an emergency, resulting in more costly and
resource-intensive services that place unnecessary burdens on our
hospitals and the entire health care system.
Mainers voted overwhelmingly to expand
Medicaid and the Maine Legislature has honored the will of the voters.
It is time to finish what we started and make sure all Maine residents
have the healthcare they need and deserve.
My fellow lawmakers have a choice to make.
Will we put our values into policy and practice and ensure that
everyone in our state can access necessary care? Or will we continue to
disregard the needs of people who keep our state running? Let’s choose
equity, prosperity and a health care system that works better – no
exceptions, no exclusions – for all.
Bill would mandate nurse-to-patient ratios in Maine hospitals
Supporters say nurses are spread thin and overworked, but the Maine
Hospital Association says the mandate would restrict patient care.
by Joe Lawlor - Portland Press Herald - April 12, 2023
A nurses union is supporting a bill that would establish minimum nurse-to-patient staffing ratios at Maine hospitals.
Supporters say it would provide relief for nurses who are spread too
thin because of a hospital workforce shortage, while hospital officials
oppose the bill and say such a mandate would reduce patients’ access to
care.
The bill, sponsored by state Sen. Stacy Brenner, D-Scarborough, was
released Wednesday and contains a lengthy list of nurse-to-patient
ratios depending on conditions of patients. Averaged out, it would
require roughly one nurse for every two patients.
If it is approved, Maine would become the second state, after California, to have a law mandating nurse-to-patient ratios.
There are about 26,000 licensed nurses in Maine, according to state data.
Cokie Giles, president of the Maine State Nurses’ Association and a
nurse at Northern Light Eastern Maine Medical Center in Bangor, said the
problem is not an overall nursing shortage, but a shortage of those
willing to work in hospitals under difficult conditions caused by high
patient loads. The nurses are instead choosing primary care, outpatient
clinics or other non-hospital jobs.
“Plenty of nurses are getting hired at hospitals. What’s happening is they’re not staying. We have a leaky bucket,” Giles said.
But Jeff Austin, vice president of governmental affairs for the Maine
Hospital Association, disputed that characterization, arguing there’s
an overall shortage of nurses, and that hospitals would be hampered by
such an inflexible mandate. Austin said hospitals value nurses and want
to hire more, but this bill is not the way to do it.
“This bill is the most significant threat to access to care and
threat to hospitals that I’ve ever seen,” Austin said. “It will cost
hospitals over $100 million, because we would have to hire 1,000 nurses.
That assumes we first are able to fill all of the 1,500 positions we
are currently trying to fill.”
A 2022 analysis prepared for the hospital association and the Maine
Nursing Action Coalition says there was a shortage 2,250 registered
nurses in 2021 and projects a shortage of 1,450 to 2,250 registered
nurses by 2025. Because there has been an increase in nursing graduates
in recent years, that projection is better than an earlier forecast,
which predicted a shortage of 3,200 registered nurses over that time.
Giles said colleges are focusing on graduating more nurses, which will
help even more in the coming years.
Austin said hospitals have already blown through their personnel
budgets because they have been forced to hire traveling nurses, who have
been in higher demand since the pandemic but cost exponentially more.
The difficult working conditions during the pandemic strained hospitals
and led many nurses to leave, including many who were near retirement
age.
Positions filled by traveling doctors, nurses and other medical staff
have more than quadrupled because of the pandemic, from 535 traveling
positions in 2019 to 5,138 in 2022, according to data from the Maine
Hospital Association. The MHA did not have a breakdown of how many of
those positions were nurses.
Brenner said if hospital nursing jobs become more attractive, hospitals won’t need to hire as many traveling nurses.
Austin said with hospital budgets already strained, a staffing-ratio
mandate will lead to more waiting and reduced access to care for
patients.
“If you don’t meet the rigid statute, you can’t see the patient,” Austin said.
Sharon Baughman, chief nursing officer for MaineHealth, the parent
organization of Maine Medical Center and seven other Maine hospitals,
said nurse-to-patient ratios can be good guidelines, but an inflexible
mandate would reduce efficiency.
“If we have a patient ready to go home and just waiting for a few
hours for family to come pick them up, that patient would still be part
of the ratio,” Baughman said. “But now, a nurse might make a judgment
call and could facilitate bringing in another patient. With the ratios,
we would not be able to make that same level of independent
decision-making.”
But Brenner said the bill is much more flexible than opponents are
portraying. If a patient’s condition improves, for instance, the
staffing ratio would be eased, she said.
And Giles said that if nurses know a state law requires adequate
staffing for patent care, hospital jobs will be more attractive, also
leading to better patient care.
“How many times have we heard patients say, ‘the nurses are so busy
they can’t get to me,’ ” Giles said. “The patients’ needs are not being
met. Nurses often don’t have time to break for lunch and we have nurses
going home every night crying because they can’t help patients the way
that they should be able to.”
Research on California’s ratio law is mixed. According to a 2010
study for Health Services Research, “hospital nurse staffing ratios
mandated in California are associated with lower mortality and nurse
outcomes predictive of better nurse retention in California.”
But another 2013 study found “mixed effects” on quality and a 2014
analysis by the Health Economics journal found that “in spite of years
of work to establish statewide staffing regulations, there is little
evidence that the (California) law was effective in attracting more
nurses to the hospital workforce or improving patient outcomes.”
The bill will go before the Legislature’s Joint Standing Committee on Labor and Housing in the coming weeks.
Commentary: Health care for vulnerable populations makes spiritual and economic sense
An unconditional commitment to caring for the sick, however you arrive
at it, represents a fundamental quality of a decent world.
By Peter Pressman - Maine SundayTelegram - April 16, 2023
House Speaker Talbot Ross’ column of April 12 was a powerful and timely essay (“‘Health care for all’ must not rule out immigrants,”
April 12). However, I was struck as much by the readers’ responses to
the column online as by the speaker’s eloquent plea for healthcare
access regardless of immigration or low-income status.
The eminently understandable and justified frustrations resulting
from the breathtaking costs of healthcare and delays in receiving timely
medical interventions were comingled and contaminated with the anger
and myriad xenophobias that have polarized our country and our state.
As a physician, as a teacher, and as a health care consumer, I want
to address both the readers’ frustrations and fears about access to
quality care in this era of unprecedented social and public health
challenges.
First, let’s revisit the essence of what is arguably Martin Luther
King Jr’s most important and overlooked speech, “The World House,” from
the Nobel Prize Lecture at the University of Oslo in 1964. King
suggested that in the world house, what affects one can affect all
indirectly eventually.
COVID-19 certainly demonstrated this prophecy. Under one roof, in the
world house, if someone is sick, then you may become ill as well. If
someone is poor, they can be hidden away, banished into the basement
with little light or access to that which helps sustain life, but they
are still there. Our housemates, “essential workers” as they are often
called, grow the food, harvest the food, serve the coffee and tend to
the sick, often with catastrophic consequences to their own health.
Is this the sort of world we want to live in? Is this the uniquely
American way, the Maine way, the Judeo-Christian way? The duty to heal
the sick and provide for the poor are deep moral imperatives in the
Judeo-Christian tradition. Combined with the biblical command to treat
the stranger as yourself because you were once a stranger in a strange
land, this duty transforms our obligations beyond the worthy interest in
promoting the health and well-being of our own community.
Providing care and support to the needy are at the core of Islamic
philosophy and accordingly, the Prophet Muhammad reflected the same
through his services to the poor and to patients.
My point here is that every major global religious philosophy has at
its core an unconditional commitment to caring for the sick. Despite
sociocultural and political differences, we revere this spiritual
mandate; it represents a fundamental quality of a decent world.
How do we provide the material and instrumental structure of that
decent world? In the most general and modern terms, the path to
universal health care is incredibly complex and no single policy
solution exists. It involves political will and commitment by
governments to meet the health needs of us all (to uphold our right to
health); it involves putting the resources in place (financing and
health services) to ensure that services are accessible to all; and it
involves ensuring that the right steps are in place to protect people
from financial ruin.
Again, in the broadest sense, public health interventions for
vulnerable populations not only make spiritual sense, they make economic
sense by reducing the burden of illness and preventing eventual and
inevitable higher costs to the mainstream community.
Care must be based upon a patient’s medical need and not upon
medically unrelated and irrelevant factors such as race, creed, color or
nationality. Contrary to some views, undocumented immigrants are not
the cause of crowding in our emergency departments. Today, most
emergency rooms are crowded with patients seeking primary care treatment
because they do not have access to an ongoing or real-time source of
care.
And yet again, despite claims to the contrary, undocumented workers
do pay taxes. They pay sales taxes on purchases, ad valorem taxes
through rent or home ownership, and many pay Social Security, Medicare
and worker’s compensation via payroll deductions.
Consider also that we can reduce infant mortality and days of
neonatal care – all while saving thousands of dollars per child – simply
by providing meaningful access to prenatal care.
If we take care to educate our underserved and vulnerable groups, and
collaborate with them toward optimizing their health, we will all
benefit. It cannot be over-emphasized.
We have made great progress in Maine in terms of pragmatically
achieving genuinely adequate and accessible health care. The expansion
of Medicaid and Emergency MaineCare are vital elements. L.D. 199, the bill proposed by Talbot Ross, is the next critical piece.
To ultimately and fully operationalize this legislation, we need to
closely consider the entire northern half of our state, which is without
adequate primary and specialty care, and without a school of medicine
or a university hospital focused on educating, training and retaining
our own most valuable health care resource: our young people, who will
become the physicians, surgeons, and medical scientists of the future.
Hospitals face new wave of competition from infusion centers
It's the latest example of insurance companies partnering with independent centers to offer lower-cost outpatient services.
By Joe Lawlor - Portland Press Herald - April 17, 2023
The recently opened Novella Infusion center in Portland offers some
of the latest perks in outpatient health care: private rooms where
patients can sit back in recliners and watch online streaming services
while receiving IV infusions to treat chronic conditions from rheumatoid
arthritis to multiple sclerosis.
Novella has similar centers in Lewiston and Augusta. A second
infusion company, Local Infusion, has launched a treatment center in
Augusta and is opening one in South Portland this month.
The infusion centers are the latest example of insurance companies
partnering with independent centers to compete directly with hospitals
by providing lower-cost out-patient services such as screenings,
infusions, X-rays, laboratory work, MRIs and CT scans in less clinical
settings designed to appeal to patients. In this case, Anthem – Maine’s
largest insurance company – and other insurers have signed agreements to
provide in-network coverage for treatments at Novella Infusion and
Local Infusion.
It’s a national trend that has been building for years as insurance
carriers seek to contain their costs and patients become more
consumer-oriented when seeking care that was once the exclusive domain
of hospitals.
“I think this is perhaps a good thing,” said Ann Woloson, executive
director of Consumers for Affordable Health Care, a Maine-based advocacy
group. “We definitely welcome any new pathways to increase competition.
This does have a chance to bring down costs. Consumers who have access
to quality, less expensive care, that in theory should help with the
cost of insurance premiums.”
Hospitals, however, say the competition isn’t exactly fair and
creating redundant services doesn’t improve the overall efficiency of
the health care system.
“The cost structure of hospitals is simply different than it is for a
provider of a single service, be that an infusion center, or an imaging
center or a dermatologist or anything else,” said Jeff Austin, vice
president of government affairs for the Maine Hospital Association.
For Trilby Burgess, 35, of Vassalboro, who has rheumatoid arthritis,
she estimates that going to Local Infusion in Augusta will save her
$600-$800 out-of-pocket per visit compared to when she used to go to Pen
Bay Medical Center in Rockport.
“Saving that money will be huge,” said Burgess, who gets infusions
every six weeks. “Being a single mom, it wasn’t easy to come up with the
money every time.” Burgess said she’s not sure exactly how much she
will have to pay out-of-pocket at Local Infusion, but she believes it
will be a few hundred dollars per session.
Peter Hayes, president and CEO of the Healthcare Purchaser Alliance
of Maine – a nonprofit that advocates for improved health care quality,
lower costs and consumer choice – said that for certain patients, the
presence of infusion centers and other services will drive prices down.
But for the overall picture of health care spending in Maine, the
impacts of services like independent infusion centers are more murky.
From the patient’s perspective, more competition, more sites of care,
more choice – that’s a good thing,” Hayes said. “These places can be
more convenient than hospitals, patients can get a better care
experience. But it’s unclear what impact it will have overall on the
cost of care in Maine.”
Denise McDonough, president of Anthem Blue Cross and Blue Shield of
Maine, said that these services up until a few years ago were almost
entirely conducted in hospitals, and patients had no choice but to go to
hospitals and oftentimes get overcharged.
“There’s this huge disparity in costs,” McDonough said. “Our view is
the same service that can be offered in an independent facility down the
street should not be hundreds of percents more expensive at a
hospital.”
Anthem is offering incentives of up to hundreds of dollars in cash,
depending on the service, for patients who choose the independent
facilities over hospital-owned care. The insurance company is increasing
awareness of the incentives to try to spur more patients to choose
independent health care services.
Up until recently, there were very few independent labs,
independently owned urgent cares, and very few independent imaging
centers,” McDonough said. “These services were conducted almost entirely
in hospital-owned facilities.”
Anthem provided some cost breakdowns of services provided at
independent health centers compared to hospitals, and showed the Press
Herald that a CT scan cost $436 at an independent facility, while
hospital prices in Maine for the same service ranged from $802 to
$1,721.
For infusions, Remicade, a treatment for Crohn’s, ulcerative colitis
and rheumatoid arthritis, infusion clinic costs were $4,800, compared to
a range of $14,900 to $60,000 at Maine hospitals, according to the
Anthem data provided to the Press Herald. A smaller dose of the same
Remicade treatment on the comparemaine.org website shows that costs at
hospitals were twice as expensive when compared to clinics.
But Austin of the Maine Hospital Association, said hospitals perform
many services that lose money, and so hospitals have to make up the
funds by charging more for other services.
“Hospitals form the backbone of the health care system for the
state,” he said. “There are parts of the health care system that lose
money. We operate many of those parts. There are other parts of the
system that finance the money-losing parts of the system.”
Austin said independent, for-profit centers “don’t run emergency
rooms that are open and equipped and staffed to treat everything from a
stroke to a heart attack on Christmas day. Hospitals do. It doesn’t make
financial sense to stay open on Christmas day. For-profit primary care
doctors don’t. For-profit urgent care centers don’t. We do.”
Austin also said that patients with more complex cases who need infusions likely need hospital-level care.
“Hospitals can’t close their clinics,” Austin said. “They have to
exist for the difficult patients that other centers can’t or won’t take.
Is it efficient to have a redundant for-profit clinic or would it be
better to use the essential infusion clinic that must exist?”
But Hayes, of the purchaser’s alliance, said that competition by the
independent health services puts pressure on hospitals to charge closer
to what it actually costs to provide the service. It could also
potentially reduce the market clout of hospital systems like MaineHealth
and Northern Light.
“There doesn’t seem to be a logical basis to how hospitals decide what to charge for their services,” Hayes said.
But one obstacle for insurance companies is that for many patients,
the cost of the service, even at an infusion center, is high enough that
patients are meeting their deductible and so the cost savings is not
seen by the patients. That’s where the cash incentives – called
SmartShopper by Anthem – will play a role, said Anthem spokeswoman
Stephanie DuBois. Some patients will save money, DuBois said, such as
those who need a one-time infusion or a lower-cost infusion.
But it’s not only cost savings that’s driving the changes, but the
overall patient experience, said Woody Baum, CEO and founder of Local
Infusion.
“When you are introducing change, that change needs to be attractive
to the patients,” Baum said. “You can’t just throw chairs in a room. You
need to make it a nice experience, have private rooms, night and
weekend scheduling. You need to make it a good experience if the
patients are in there for hours at a time.”
For instance, Baum said initial attempts to locate infusion
treatments at urgent care centers flopped because patients didn’t like
the atmosphere and the immune-compromised patients needing the infusions
didn’t want to be around others who could be contagious.
Burgess, the Vassalboro resident, said that the hospital experience
was not pleasant, and that she felt overwhelmed sitting in a large room
with numerous other patients, including some cancer patients, receiving
treatment at the same time as her. Burgess said she will like the
privacy of Local Infusion.
At Novella in Portland, Rebecca Greenbaum, vice president of
operations, said that they can provide good services at a cost savings
for patients. Novella is not only partnering with Anthem, but also all
the other major insurance carriers in Maine.
“It’s a personal, comfortable space where patients can receive
therapy from highly skilled clinicians,” Greenbaum said. “Patients can
get in and out quick, and you are always seeing the same personnel
providing the service. They are going to get to know you, where you
might see different people every time you go to the hospital.”
There is a great deal of apprehension among many physicians and physician groups (assuming corporate "persons" can be apprehensive) about what a "universal" or "single payer" health care plan would mean for their own incomes.
The following paper authored by Maine AllCare volunteer Dan Bryant raises real questions suggesting that these fears are over-blown, or just plain wrong.
Single-payer Health Care: Financial Implications for a Physician
Daniel C. Bryant
25–32 minutes
Abstract
When
considering proposed reforms of the U.S. health care system, some
physicians dismiss the single-payer model (Medicare for All or
state-based universal health care proposals) out of concern that their
reimbursement and thus their income would be reduced. This study is an
effort to quantitate that concern in the case of state-based plans and,
in so doing, to suggest a template for evaluating the financial
consequences for physicians of single-payer health care reform in
general. To put the data into concrete, practical terms, I envision a
hypothetical primary care physician's practice and develop its plausible
financial components in the present multi-payer system and in five
proposed state-based, single-payer systems. The calculations reveal that
in all five single-payer plans evaluated, the hypothetical physician's
Total Net Income (take-home pay) would exceed that in the current
multi-payer system. Whether these results apply to actual practices or
not, they suggest that, when considering the financial impact of
single-payer reform on their practices, physicians should consider all
the financial consequences of such reform, not just the proposed
reimbursement level. More quantitative analyses of these important
financial variables in different practice settings must be pursued.
The
single-payer health care model (publicly funded, privately provided
universal health care), both national and state-based, has been much
discussed in the United States since the early 1980s,1 and polls2,3 have shown increasing public support for the concept. Physician support has also been growing,4 manifested by Physicians for a National Health Program advocacy, the American College of Physicians’ recent announcement5 of openness to a single-payer system, endorsement by the Society of General Internal Medicine,6 and the Vermont Medical Association's 2020 resolution7
in support of a “single-payer national health program.” Not all
physicians support such reform, however, as indicated by the American
Medical Association's vote at its annual meeting in Chicago in 2019 to
reaffirm its opposition to a single-payer health care system, and by the
membership of medical organizations such as the Association of
Neurological Surgeons and the Congress of Neurological Surgeons in the
(anti-Medicare for All) Partnership for America's Health Care Future.
Reasons for physician suspicion of single-payer plans are many,
including concerns over rationing, unaffordability (presumably for both
physicians and patients), patient privacy, unconstitutionality, and so
forth.8
A recurring concern is potential loss of income due to reduction of
provider reimbursement, perhaps to Medicare levels. A 2019 Medscape poll
of attitudes toward Medicare for All found that “[m]ore than half of
providers across all four categories said they were concerned or
somewhat concerned that Medicare for All could reduce physician
compensation. The breakdown for this worry was 59% for physicians….”.9
Physicians may find it unseemly to complain publicly about
reimbursement concerns, but in my private conversations with colleagues,
those concerns come up often.
Advocates for single-payer reform
counter this focus on reimbursement by pointing to the potential for
practice savings in a single-payer system: simplified billing, relief
from responsibility for a health benefit for themselves and their
employes, and reduced malpractice and other costs. However, despite
national studies10,11
of excessive billing and insurance-related (BIR) expenses for
physicians in the current system, a study of the effect of Canada's
single-payer Medicare system on physician income,12 and a study of the effect of the Medicare for All model on physician income in general,13
to date, there have not been quantitative studies of the degree to
which these savings might—or might not—compensate for reduced
compensation in an individual practice. The current study is an effort
to develop a format for addressing that deficiency.
Methods
To
examine the financial implications for physicians of implementation of a
single-payer plan, I studied state-based plans because they provide
more funding detail than national plans do, and for reasons of space, I
limited the number to five recent or widely discussed plans. (No
calculations were made prior to selection, which was thus unbiased.) I
then developed a simple, plausible practice scenario—a hypothetical solo
primary care practitioner's LLC practice supported by a staff of three:
one full-time equivalent (FTE) each for nurse, receptionist, and
bookkeeper (BIR department). (According to a 2014 study,14
the ratio of clinical and administrative staff to physician in one- or
two-person practices is 5:32. If this ratio, rather than 3:0, were used
in this analysis, the physician's Total Health Insurance-Related
Expenses would be greater in the systems studied.) This model is not
meant to capture the experience of an actual current practice, or to
apply to practices in general, but rather to suggest how medical
practices, specialist as well as primary care, could compare their
finances in the current multi-payer system with what they might be in
single-payer systems. In Column 1 of the Table 1,
relevant Financial Elements of the hypothetical practice are listed,
while the subsequent columns contain corresponding estimates for the
practice in the Current System (multi-payer) and in five proposed
Single-Payer Plans. Initial Net Income is the difference between the
Gross Practice Income (set arbitrarily at Medicare rates) and Total
Expenses in the various systems, while Total Net Income takes into
account New Potential Net Income from freed-up administrative time.
Table 1. Physician Finances Under Six Different Funding Schemes.
No
one figure can represent all practices, so the starting figures used in
the table for the Current System are gross roundings of findings from a
2020 primary care study indicating average income for primary care
providers of $241 728 (all dollar amounts in U.S. Dollars) and average
gross revenue of $542 19015:
Gross Practice Income, $500 000; Physician Personal Income, $250 000;
and resulting Total Expenses, $250 000. The revenues are approximated as
a mix16
of Medicare, Medicaid, and commercial insurance payments averaging 22%
from Medicare (0.22 × $500 000 = $110 000), 17% from Medicaid
(0.17 × $500 000 = $85 000), and 61% from commercial insurance and
“other” (0.61 × $500 000 = $305 000). Other pertinent financial elements
for the Current System and the Single-Payer Plans are developed as
follows and displayed in the remainder of the Table 1.
In
the Current System, the physician/owner's expenses relating to health
insurance coverage (Total Health Insurance-Related Expenses) consist of
three elements: Staff Health Insurance Cost, Physician Health Insurance
Cost, and BIR Expense (bookkeeper).
Staff Health Insurance Cost is taken from Kaiser Family Foundation data17
showing that in 2020, an employer's share of family coverage for an
employee was $15 754 and for individual coverage was $6227. If two of
the staff had family coverage and one had individual coverage, that
employer cost for the health benefit would total $37 735. Physician
Health Insurance Cost is assumed to be that of a family plan, the
average cost of which, according to the Kaiser Family Foundation, was
$21 342 in 2020. Total health insurance cost is thus $59 077.
BIR Expense is considered that of the bookkeeper, whose salary, according to Salary.com,18
would have been $44 686 on average in 2021, or a BIR cost that in this
simple scenario is 9% of revenues ($44 686/$500 000). Additional costs
of billing software, consultations, and physician time spent on
negotiating contracts, prior authorizations, appeals of payment denials,
etc, are not included and would increase BIR costs to closer to the 13%19 to 14%20 of revenues reported in the literature.
Given
total expenses of $250 000 and Total Health Insurance-Related Expenses
of $103 763, the remaining Non-Health Insurance-Related Expenses (labor
costs, rent, utilities, etc) is calculated to be $146 237 ($250 000
minus $103 763).
Initial Net Income is calculated as Gross
Practice Income minus the sum of Total Health Insurance-Related Expenses
and Non-Health Insurance-Related Expenses.
Five proposed
state-based Single-Payer Plans, selected, without an eye to results but
merely from among those that include enough specifics to make the needed
calculations, and limited to five because of space limitations, are
then considered: ColoradoCare,21 Massachusetts Health Care Trust,22 Ohio Health Care Plan,23 Pennsylvania Health Care Plan,24 and Green Mountain Care (Vermont).25
In
all five of these systems, to address the concern about reduced
reimbursement, I assume the physician would be paid at Medicare rates,
resulting in a reduction in Gross Practice Income from the original
$500 000 to $458 000. This figure is arrived at by combining the payer
mix noted above with the estimate26 that private insurers pay 143% of Medicare rates for physicians and data27
showing that Medicaid pays 63% of Medicare rates for physicians in my
state of Maine specifically. Thus, this physician's reimbursement for
Medicare patients would stay at $110 000, for patients previously on
Medicaid would increase from $85 000 to $135 000, and for previously
commercially-insured patients would decrease from $305 000 to $213 000;
and the $500 000 total would, as a result, decrease to $458 000—a
decrease in reimbursement of $42 000, or 8%.
BIR Expense in the
single-payer plans is assigned a value half that of the Current System
expense ($22 343). This conservative reduction is a rough average of
published estimates of BIR savings of 75%,28 of “on the order of one-third to one-half of current spending”,29 and of “between 33% and 53%”30 due to simplification of billing.
Given
BIR Expense of $22 343 in the single-payer scenarios, and Non-Health
Insurance-Related Expenses of $146 237, the Physician Personal Income
Prior to Taxes in those scenarios is $289 420 ($458 000 minus $146 237
minus $22 343); that is the income to which the Physician Single-Payer
Income Tax rates specified in the various plans are applied.
The Single-Payer Payroll Taxes1 and the Single-Payer Gross Receipts Tax2 are also those resulting from the rates specified in the various plans. According to Salary.com,31
the average salary of an office nurse is $53 343 and of a physician
office receptionist is $36 890. Total payroll for the three staff (0.5
FTE bookkeeper) is thus $112 576. It is assumed the physician/owner will
pay their employes’ share of payroll taxes in the various plans (but
not in the Current System). For purposes of this study, other payroll
expenses (FICA, workers’ compensation, etc) are disregarded. Because the
practice is set as an LLC, the physician/owner's income is assumed to
“pass through” to their personal Form 1040 and thus be subject to income
but not payroll tax.
Single-Payer Income Taxes imposed by most of
the plans examined are those calculated from the rates specified in the
respective plans3.
Only one of the plans (Pennsylvania) imposes an income tax on workers,
which, at a rate of 3%, comes to $3377 for the three employes. It is
assumed that the physician would pay that tax.
New Potential Net
Income is income from billable hours freed up by reduced
insurance-related administrative time. According to Woolhandler and
Himmelstein,10
writing in 2014, “The average doctor spent 8.7 h per week (16.6% of
working hours) on administration.” If just two of these hours per week
were freed from insurance responsibilities, they could be spent seeing
patients instead, adding approximately 100 newly billable hours per
year. At $230 per hour (Gross Income of $458 000 per year equates to
$230 per hour for a physician working 40 h a week), that would produce
additional gross income of $23 000. Given that these new patient
encounters would generate new expenses, New Potential Net Income is
reduced to the product of this amount and the ratio of Initial Net
Income to Gross Practice Income.
Results
As shown in the Gross Practice Income row of the Table 1,
as a consequence of setting remuneration at Medicare rates, Gross
Practice Income is lower in the Single-Payer Plans than in the Current
System, while the Physician Personal Income Prior to Taxes row income is
higher due to the savings listed in the Staff Health Insurance Cost,
Physician Health Insurance Cost, and BIR Expense (bookkeeper) rows.
Those Total Health Insurance-Related Expenses, together with the
Non-Health Insurance-Related Expenses, are then subtracted from Gross
Practice Income to produce the Initial Net Income. It is evident that in
four of the state-based single-payer schemes, Initial Net Income would
be greater than the $250 000 designated in the Current System, while in
one (ColoradoCare) it would fall $780 short. In addition, if some of the
time estimated to be freed up from health insurance-related duties in
the single-payer plans were spent on seeing additional patients, Total
Net Income would be higher in all.
Discussion
If
a single-payer plan at the national level or, as discussed in this
study, state level were brought before the voters, physician support
would be essential to its passage and long-term success. In order to win
that support, single-payer plan advocates would have to address
physician concerns about single-payer, such as those mentioned in the
introduction to this article. This article focuses on one of the major
concerns, potentially reduced provider reimbursement, and in the
analysis sets reimbursement rates to Medicare's to examine that concern.
As noted in the Methods section, on average, private insurers pay 143%
of Medicare rates, meaning that a single-payer plan would pay about 70%
of commercial rates. But the physician in this study, like most
physicians, sees a mix of Medicare, Medicaid, and commercially insured
patients and would experience only an 8% decrease in reimbursement. (In
contrast, a Rand analysis32
found that “the all-payer average rate under the Medicare for All plan
in 2019 would be 107% of current Medicare rates for physician payment,” a
rate that, if applied in this study, would produce an even larger Total
Net Income than that found.) What is more important than reimbursement,
though, is how much of that reimbursement is left for the physician
after they have paid all the expenses, including Total Health
Insurance-Related Expenses, of the particular system in which they are
working.
As shown in the table, in the present multi-payer system,
the hypothetical physician/employer has three main health
insurance-related costs: Staff Health Insurance Cost, Physician Health
Insurance Cost, and BIR Expense (the cost of a full-time bookkeeper to
handle billing for services covered under multiple payers’ various
plans). In the single-payer plans, the first two costs are eliminated
and replaced by various taxes, while the BIR costs are halved,
representing a savings of 5% of revenues ($22 343/$458 000). This is
actually a more modest administrative savings than the median
single-payer administrative savings of 8.8% found by Cai and colleagues
in their systematic review33 of projected costs of single-payer health care financing.
The
funding taxes proposed by single-payer plans are the basis for one of
single-payer opponents’ major arguments. In the proposed state plans
reviewed for this study, the combined taxes for which the physician
would be responsible run from $14 410 (Vermont) to $40 200 (Colorado).
As draconian as those sound when quoted out of context, the highest
total taxes approximate what this physician pays now just to insure
staff, and they are far less than their current Total Health
Insurance-Related Expenses ($103 763).
Estimation of payroll tax
is especially difficult in analyses such as this because few plans
define the phrase, and application of the tax would vary with the
business structure of the physician's practice. For this study, the LLC
model was chosen because of its relative simplicity and because,
according to the American Medical Association,34
the LLC or S Corporation model is the business structure for more than
half of private practices. In the C Corporation model, the
physician/owner's pay would be included in payroll.
The time
saving referenced in the New Potential Income row is of interest not
only because it could allow the physician to increase their income
further, but because it could help address the issue of physician
burnout, found to be largely related to the administrative complexity of
our present system.35
This time saving would also help to address the potential physician
shortage problem discussed by the Congressional Budget Office in its
2019 report on single-payer health care systems.36
As
seen in the Initial Net Income row of the table, when Total Health
Insurance-Related and Non-Health Insurance-Related Expenses are
subtracted from physician Gross Income, the physician's Initial Net
Income in four of the five single-payer plans examined would match or
exceed Initial Net Income in the current health care system; Total Net
Income would do so in all. Some could argue that the physician should
shift all their commercial premium savings to staff in the form of
increased wages, but, in the face of decreased reimbursement, the
physician does pay the staff's health care tax expenses that replace
previous premiums; and in general, when other practice expenses are
reduced, physicians don't automatically increase staff wages. Of course,
given the favorable physician finances found in this analysis, the
physician would have the option of sharing additional savings with
staff.
It should be noted that in this study, I have used
conservative figures for BIR costs as a percentage of revenue (9% in the
Current System: $44 686/$500 000) and for percentage decrease in BIR
costs (50%) due to single-payer efficiencies. However, the most
sophisticated empirical research suggests that total BIR costs currently
represent 13 to 14% of revenue (see Jiwani and Kahn references) and
that the percentage of BIR savings in a single-payer system could be as
much as 75% (see Morra reference). If those higher BIR costs and savings
turn out to apply, this hypothetical physician's Total Net Income could
be significantly higher than that found. In addition, with this kind of
reform, demand for primary care is likely to increase modestly (due to
supply-side constraints37)
and doctors are likely to prioritize sicker patients. Both are likely
to increase revenue, and, as many primary care physicians are women and
members of minorities, this would help to address gender and racial pay
gaps in medicine. Gaffney, Himmelstein, and Woolhandler, in their
critique of the Congressional Budget Office estimate of physician
finances in a national single-payer system, conclude that
“payments to clinicians would rise in all five scenarios…. We estimate
this translates into an additional $39 816–$157 412 in revenue per
practicing physician”.38
Indeed, HR 1976, the Medicare for All Act of 2021 (Section 612),
specifies that a “physician practice review board” will assure “fair
reimbursements for physician-delivered items and services.” The
specifics of how physicians in general, including salaried employes,
will be affected is up to legislative specifics and individual
corporations, yet it is possible to design a system in which average
physician pay increases under single-payer.
This study could be followed up with two further projects to make the conclusions more relevant to actual practice situations: (a) companion studies of physicians in other practice settings, such as partnerships and hospital employment, and (b)
development of an interactive spreadsheet allowing physicians to enter
their own financial numbers (expenses, gross and net income, payer mix,
etc) and see what their automatically calculated incomes might be in
various single-payer plans.
Limitations
1.
The results of this analysis, although not its form, depend to a large extent on the assumptions made.
2.
The plans studied did not include specific costs, meaning that actual funding needs could not be verified.
3.
To
simplify this analysis, a primary care setting was chosen. Results
could be different for specialty practices, in which procedures play a
large role, but the process used here should be applicable. Also, a
number of potentially significant variables were ignored: additional
savings for the physician in a single-payer plan, such as reduced
malpractice, disability, homeowner's, auto, property, and workers’
compensation insurance, and elimination of un-reimbursed care; other
taxes (excise, inheritance, etc) mentioned in some of the plans; and
other physician income (eg, investments, side businesses, rents) that
could be subject to health care taxes.
4.
The results of this study may not be generalizable to other practice models for two reasons: (a)
as pointed out in the introductory section and the Discussion section,
the solo practitioner LLC model chosen for the study is unique, and
results could be different for physicians practicing in partnership,
corporation, hospital employment, salary or capitation arrangement,
group or specialty practice, or other settings or for physicians with a
different payer mix; and (b) almost half of the health
insurance-related savings found result from elimination of the health
benefit for staff, a benefit that some practices may not offer or may
not offer to the same degree.
Declaration of Conflicting Interests
The
author(s) declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
ORCID iD
Footnotes
1.
Colorado:
“With premium tax rates of 3.33% for employees, 6.67% for employers…”;
Massachusetts: “[1] An employer payroll tax of 7.5% will be assessed,
exempting the first $20 000 of payroll per establishment… [2] An
employee payroll tax of 2.5% will be assessed, exempting the first
$20 000 of income…”; Ohio: “Receipts from taxes levied on employers’
payrolls to be paid by employers. The tax rate in the first year shall
not exceed three and eighty-five hundredths percent of the payroll”;
Pennsylvania: “… a tax of 10% is imposed on payroll amounts generated as
a result of an employer conducting business activity within this
Commonwealth”; Vermont: Option 1B Standard Plan: 9.6% Employer, 3.2%
Employee [total 12.8%]
2.
Ohio:
“Receipts from additional taxes levied on businesses’ gross receipts.
The tax rate in the first year shall not exceed three per cent of the
gross receipts.”
3.
Colorado:
“10% for non-payroll income”; Massachusetts: “A payroll tax on the
self-employed of 10% will be assessed, exempting the first $20 000 of
payroll per self-employed resident” [Interpreted as equivalent of income
tax]; Ohio: “Receipts from additional income taxes, equal to five per
cent of all of an individual's Ohio adjusted gross income, less the
exemptions allowed under section 5747.025 of the Revised Code, in excess
of two hundred thousand dollars”; Pennsylvania: “Personal income tax….
Rate.-- the tax imposed by subsection (a) shall be at the rate of 3%”;
Vermont: none.
References
10.
Woolhandler S, Himmelstein DU. Administrative work consumes one-sixth
of U.S. physicians’ working hours and lowers their career satisfaction. Int J Health Serv. 2014;44(4):635–642.
11.
Tseng P, Kaplan RS, Richman BD, Shah MA, Schulman KA. Administrative
costs associated with physician billing and insurance-related activities
at an academic health care system. JAMA. 2018;319(7):691–697.
12. Duffin J. The impact of single-payer health care on physician income in Canada, 1850-2005. Am J Public Health. 2011;101(7):1198–1208.
14. Peikes DN, Reid RJ, Day TJ, et al. Staffing Patterns of Primary Care Practices in the Comprehensive Primary Care Initiative. Ann Fam Med. 2014;12(2):142–149.
15.
Basu S, Phillips RS, Phillips R, Peterson LD, Landon BE. Primary Care
Practice Finances in the United States amid the COVID-19 Pandemic. Health Aff. 2020;39(9):1605–1614.
19.
Jiwani A, Himmelstein D, Woolhandler S, Kahn J. Billing and
insurance-related administrative costs in United States’ health care:
synthesis of micro-costing evidence. BMC Health Serv Res. 2014;14(1):556. https://doi.org/10.1186/s12913-014-0556-7
20.
Kahn J, Kronick R, Kreger M, Gans D. The cost of health insurance
administration in California: estimates for insurers, physicians, and
hospitals. Health Aff (Millwood). 2005;24(6):1629–1639.
27. Zuckerman S, Skopec L, Aarons J. Medicaid physician fees remained substantially below fees paid by Medicare in 2019. Health Aff. 2021;40(2):343–348.
28.
Morra D, Nicholson S, Levinson W, Gans DN, Hammons T, Casalino LP. US
physician practices versus canadians: spending nearly four times as much
money interacting with payers. Health Aff. 2011;30(8):1443–1450.
30.
Scheinker D, Richman BD, Milstein A, Schulman KA. Reducing
administrative costs in US health care: assessing single-payer and its
alternatives. Health Serv Res. 2021;56(4):615–625.
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Biographies
Daniel C. Bryant,
MD, graduated from Columbia University College of Physicians and
Surgeons (now Vagelos College of Physicians and Surgeons) in 1965. After
residency in internal medicine at Barnes Hospital in St. Louis,
Missouri, and the Maine Medical Center in Portland, Maine, he practiced
office and hospital medicine in Portland, initially in a partnership and
then with InterMed, the largest physician-owned primary care practice
in Maine. Since retiring, he has pursued an interest in health care
policy.
Organized medicine in the USA is shifting
its position toward single-payer reform, one version of which,
“Medicare for All,” has gained substantial support in Congress. The
American Medical Association recently left the Partnership for America’s
Healthcare Future, a lobbying group that spent more than one hundred
million dollars annually opposing both a public option and Medicare for
All in federal election campaigns. In 2020, the American College of
Physicians and the Society of General Internal Medicine went a step
further, endorsing both public option and single-payer reforms.
Yet,
physician opinion on Medicare for All remains split, with most doctors
concerned that such reform might decrease their income. While physicians
are highly paid, these concerns are understandable given the burden of
student debt, the length of medical training, and Medicare’s lower fees
relative to private insurers’.
Are such concerns supported by
evidence? The nonpartisan Congressional Budget Office (CBO) recently
estimated payments to physicians in 2030 under current policies and five
options for Medicare for All. It projects that without reform the
weighted average of public and private payments to physicians will
increase to 116% of the 2019 weighted average, versus between 108% and
117% under the various Medicare for All options analyzed.1
But because the CBO expects Medicare for All to increase society-wide
utilization of care, it also predicts that providers’ total revenues
would increase, even if fee levels were to decline.
More
specifically, the CBO projects that in 2030 providers’ total outpatient
revenues would be between 5 and 9% higher under Medicare for All than
without reform; physician services currently account for 78% of such
revenue.1,2
These estimates assume that Medicare for All would not significantly
alter the supply of physicians, which is currently limited by the supply
of residency and medical school spots.1
Some
scholars project even larger boosts to physicians’ take-home pay
because the CBO estimates may understate practices’ savings from
streamlined billing. If, as studies suggest, Medicare for All would free
up roughly 5% of doctors’ work hours currently spent on billing,
allowing them to increase patient care, per-physician revenue could rise
by between $39,816 and $157,412 annually.2
While those figures may be an overestimate, since some providers might
choose to spend the freed-up time on leisure activities rather than
increased patient care, they may underestimate revenue changes, as
fee-for-service providers have, in the past, responded to decreased
Medicare reimbursement rates by increasing volume of services.1
The latter won’t apply to salaried providers, such as those working in
capitated healthcare systems, but these providers are still likely to
feel the benefits of administrative streamlining.
Other prominent
economic analyses of Medicare for All have also projected net increases
in physicians’ revenue, even if current Medicare payment rates do not
increase.3
Yet despite projecting increases in physicians’ revenues, almost all
estimates of the overall costs of single-payer reform project savings,
due to savings from administrative simplification.3
Hence, it appears possible to design a single-payer reform that would
offer universal coverage without cost sharing, while increasing net
revenue to providers and decreasing national health expenditures. 3
History
offers hopeful messages about the likely effect of single-payer reform
on doctors’ incomes. When Canada transitioned to single-payer in the
mid-20th century, physician income increased, and physicians remained
the highest paid professionals in the nation.4
Since then, physician income in Canada has grown faster than the
incomes of other workers. Yet, caution is warranted in interpreting
these trends, which may not be duplicated in a reform initiated five
decades or more after Canada’s system was fully implemented in 1971.
Medicare’s history offers mixed lessons. Limitation on increases in
Medicare’s payments to physicians (known as the sustainable growth rate
or SGR) included in the 1997 Balanced Budget Act threatened sharp cuts
in Medicare’s fee schedule. Yet Congress annually overrode the
threatened cuts, and eventually repealed the SGR formula.
How
would increases in revenue projected by the CBO be distributed among
various physician specialties? Since both Congressional Medicare for All
bills provide comprehensive benefits with little or no cost sharing
(copayments or deductibles), individuals who currently cannot get
medical care because of cost would increase their utilization of care.
As a result, doctors who serve patients who are undertreated at present
may experience the greatest increases in demand for their services, and
in their revenues. Primary care providers are likely to fall into this
category, given the degree to which hypertension, diabetes,
hyperlipidemia, and other chronic conditions are currently undertreated.
Anticipating this, the Congressional legislation would set aside
funding to establish an Office of Primary Care, charged with developing
policies to increase the number of primary care practitioners.
Although
primary care doctors might get the biggest income boosts under single
payer, specialists would continue to be high earners. The 1966
implementation of Medicaid/Medicare resulted in an increase in
per-capita surgical procedures among the elderly. 5
In Canada, the specialist:primary care income ratio has remained quite
high; in 2019, gross clinical payments to thoracic surgeons averaged
$588,000 (Canadian dollars) compared to $280,000 for family medicine
physicians. Malpractice insurance costs, currently the highest for
proceduralists, would likely fall as they did in Canada, since patients
would no longer have to sue to cover future medical costs. And in many
doctors’ practices, the case mix is likely to change for the better. As
patients with unmet medical needs increase their utilization, the
limited supply of hospital beds and physicians would likely cause a
modest decrease in the delivery of low-value services.5
In essence, doctors could shift their efforts to address the greatest
needs, without fear of losing income. To prevent waitlists, an increase
in residency training programs may be necessary.
Medicare for All
may also decrease inequities in physician pay. Increased demand and
federal funding for primary care may modestly mitigate the racial and
gender pay gaps in medicine, as nonwhite and non-male physicians are
more likely to specialize in primary care fields.6
In addition, using a funding scheme called “global budgeting,” Medicare
for All would likely increase revenue for underfunded safety net
hospitals and clinics, which disproportionately employ physicians of
color. 7
However, the root causes of such pay disparities are racism and sexism,
and thus, even with Medicare for All, additional anti-racist and
anti-sexist reforms will be needed in the workplace.
Proposals for
a Medicare “public option” or “Medicare Advantage for All” would
sacrifice most of the administrative savings that Medicare for All could
garner, making universal first dollar coverage unaffordable, minimizing
increases in the utilization of care, and hence physicians’ practice
revenues. Additionally, current fee schedules would likely persist under
a public option reform, preserving the status quo that offers outsized
rewards for performing procedures and caring for privately insured
patients.
In sum, the available evidence—including the CBO’s
authoritative estimate—suggests that physicians would prosper under
single-payer reform. By supporting Medicare for All, physicians—and
organized medicine—can get a twofer: acting in physicians’ self-interest
while advancing legislation that would be enormously beneficial to
patients.
References
How
CBO Analyzes the Costs of Proposals for Single-Payer Health Care
Systems That Are Based on Medicare’s Fee-for-Service Program: Working
Paper 2020-08 [Internet]. Congressional Budget Office; [cited 2021 Jan
30]. Available from: https://www.cbo.gov/publication/56898
Cai
C, Runte J, Ostrer I, Berry K, Ponce N, Rodriguez M, et al. Projected
costs of single-payer healthcare financing in the United States: a
systematic review of economic analyses. PLoS Med 2020;17(1):e1003013.
Gaffney
A, McCormick D, Bor D, Woolhandler S, Himmelstein D. Coverage Expansions
and utilization of physician care: evidence from the 2014 Affordable
Care Act and 1966 Medicare/Medicaid Expansions. Am J Public Health
2019;109(12):1694–701.
Why Is Finland the Happiest Country on Earth? The Answer Is Complicated.
Penelope Colston, Jake Michaels - NYT - April 8, 2023
On March 20, the United Nations Sustainable Development Solutions Network released its annual World Happiness Report, which rates well-being in countries around the world. For the sixth year in a row, Finland was ranked at the very top.
But Finns themselves say the ranking points to a more complex reality.
“I
wouldn’t say that I consider us very happy,” said Nina Hansen, 58, a
high school English teacher from Kokkola, a midsize city on Finland’s
west coast. “I’m a little suspicious of that word, actually.”
Ms.
Hansen was one of more than a dozen Finns we spoke to — including a
Zimbabwean immigrant, a folk metal violinist, a former Olympian and a
retired dairy farmer — about what, supposedly, makes Finland so happy.
Our subjects ranged in age from 13 to 88 and represented a variety of
genders, sexual orientations, ethnic backgrounds and professions. They
came from Kokkola as well as the capital, Helsinki; Turku, a city on the
southwestern coast; and three villages in southern, eastern and western
Finland.
While people praised Finland’s strong social safety net
and spoke glowingly of the psychological benefits of nature and the
personal joys of sports or music, they also talked about guilt, anxiety
and loneliness. Rather than “happy,” they were more likely to
characterize Finns as “quite gloomy,” “a little moody” or not given to
unnecessary smiling.
Many also shared concerns about threats to their way of life, including possible gains by a far-right party in the country’s elections, the war in Ukraine and a tense relationship with Russia, which could worsen now that Finland is set to join NATO.
It turns out even the happiest people in the world aren’t that happy. But they are something more like content.
Finns
derive satisfaction from leading sustainable lives and perceive
financial success as being able to identify and meet basic needs, Arto
O. Salonen, a professor at the University of Eastern Finland who has
researched well-being in Finnish society, explained. “In other words,”
he wrote in an email, “when you know what is enough, you are happy.”
The Art Couple Grateful for a Safety Net
“‘Happiness,’ sometimes it’s a light word and used like it’s
only a smile on a face,” Teemu Kiiski, the chief executive of Finnish
Design Shop, said. “But I think that this Nordic happiness is something
more foundational.”
The high quality of life in Finland
is deeply rooted in the nation’s welfare system, Mr. Kiiski, 47, who
lives in Turku, said. “It makes people feel safe and secure, to not be
left out of society.”
Public funding for education and the arts,
including individual artist grants, gives people like his wife, Hertta, a
mixed-media artist, the freedom to pursue their creative passions. “It
also affects the kind of work that we make, because we don’t have to
think of the commercial value of art,” Ms. Kiiski, 49, said. “So what a
lot of the artists here make is very experimental.”
The Advocate Fighting to Be Heard
As a Black person in Finland — which is more than 90 percent
white — Jani Toivola, 45, spent much of his life feeling isolated. “Too
often, I think, you still feel, as a Black gay man in Finland, that you
are the only person in the room,” Mr. Toivola said. His father, who was
Kenyan, was absent for much of his life, and Mr. Toivola, whose mother
is white, struggled to find Black role models he could relate to.
After serving two terms, Mr. Toivola left politics to pursue
acting, dancing and writing. He now lives in Helsinki with his husband
and daughter and continues to advocate L.G.B.T.Q. rights in Finland. “As
a gay man, I still think it is a miracle that I get to watch my
daughter grow,” he said.
The Teenagers Raised to Be Content
The conventional wisdom is that it’s easier to be happy in a
country like Finland where the government ensures a secure foundation on
which to build a fulfilling life and a promising future. But that
expectation can also create pressure to live up to the national
reputation.
“We are very privileged and we know our privilege,”
said Clara Paasimaki, 19, one of Ms. Hansen’s students in Kokkola, “so
we are also scared to say that we are discontent with anything, because
we know that we have it so much better than other people,” especially in
non-Nordic countries.
Being sad or being not content with our life would be seen as ungrateful.
Clara Paasimaki
Frank
Martela, a psychology researcher at Aalto University, agreed with Ms.
Paasimaki’s assessment. “The fact that Finland has been ‘the happiest
country on earth’ for six years in a row could start building pressure
on people,” he wrote in an email. “If we Finns are all so happy, why am I
not happy?”
He continued, “In that sense, dropping to be the second-happiest country could be good for the long-term happiness of Finland.”
The Finnish way of life is summed up in “sisu,” a trait said to be part of the national character.
The word roughly translates to “grim determination in the face of
hardships,” such as the country’s long winters: Even in adversity, a
Finn is expected to persevere, without complaining.
“Back in the
day when it wasn’t that easy to survive the winter, people had to
struggle, and then it’s kind of been passed along the generations,” said
Ms. Paasimaki’s classmate Matias From, 18. “Our parents were this way.
Our grandparents were this way. Tough and not worrying about everything.
Just living life.”
The Entrepreneur Who Misses the Joy of Her Homeland
Since immigrating from Zimbabwe in 1992, Julia Wilson-Hangasmaa,
59, has come to appreciate the freedom Finland affords people to pursue
their dreams without worrying about meeting basic needs. A retired
teacher, she now runs her own recruitment and consulting agency in
Vaaksy, a village northeast of Helsinki.
But she has also watched the rise of anti-immigration sentiment, exacerbated by the 2015 migrant crisis,
and worries about the sustainability of the high quality of life in
Finland. “If we have attitudes that are ‘Finland is for Finns,’ who will
take care of us when we are elderly?” she said, referring to a common
right-wing slogan. “Who will drive the truck that delivers the food to
the supermarket so that you can go and shop?”
When she returns to
her home country, she is struck by the “good energy” that comes not from
the satisfaction of sisu but from exuberant joy.
“What I miss the
most, I realize when I enter Zimbabwe, are the smiles,” she said, among
“those people who don’t have much, compared to Western standards, but
who are rich in spirit.”
The Farmer and His Cellist Daughter
Tuomo Puutio, 74, started working at 15 and supported his family
for decades as a cattle and dairy farmer. Thanks to Finland’s school
system, which includes music education for all children, his daughter
Marjukka, 47, was able to pursue her dream of a music career beyond
their village. “You get the chance to be a cello player, even if you are
a farmer’s daughter,” she said.
Music is a source of well-being
for many Finns, many of whom sing in choirs, learn instruments or attend
regular concerts, especially during the country’s long, dark winters.
But Ms. Puutio worries that these opportunities may not be available to
future generations: Finland will hold parliamentary elections on April
2, and the far-right Finns Party, which won the second-highest number of
seats in 2019, has promised to cut funding for the arts if it secures a
majority coalition this year.
“Music, which I am passionate about, it creates a mind-set where
you can face your inner feelings and fears,” Ms. Puutio, who now
manages an orchestra, said. “It touches parts of our soul we could
otherwise not reach. And that will have a long-term effect on people’s
lives, if these experiences are taken away from us.”
The Former Olympian and the Therapist
Many of our subjects cited the abundance of nature as crucial to
Finnish happiness: Nearly 75 percent of Finland is covered by forest,
and all of it is open to everyone thanks to a law known as “jokamiehen
oikeudet,” or “everyman’s right,” that entitles people to roam freely throughout any natural areas, on public or privately owned land.
“I
enjoy the peace and movement in nature,” said Helina Marjamaa, 66, a
former track athlete who represented the country at the 1980 and 1984
Olympic Games. “That’s where I get strength. Birds are singing, snow is
melting, and nature is coming to life. It’s just incredibly beautiful.”
Her daughter Mimmi, a dance teacher and certified sex therapist,
recently got engaged to her girlfriend. Mimmi, 36, said she is
encouraged by the openness and deeper understanding of gender and
sexuality she sees in the next generation.
“A lot of teenagers already show themselves as they are,” she said. As adults, “we need to encourage that.”
The Violinist Who Fears a Warming Planet
Finland’s natural treasures, about one-third of which lie above the Arctic Circle, are particularly vulnerable
to the effects of the climate crisis. Like Ms. Puutio, Tuomas
Rounakari, 46, a composer best known in Finland as a former member of
the folk metal band Korpiklaani, is concerned about the rising popularity of groups like the Finns Party and the anti-climate policies they’ve championed.
Global capitalism is still leading the game. To me, all of this is alarming.
Tuomas Rounakari
“I
am worried with this level of ignorance we have toward our own
environment,” he said, citing endangered species and climate change. The
threat, he said, “still doesn’t seem to shift the political thinking.”
The Badminton Dad and His Children
Reasons for optimism can be personal. For the Hukari family, that reason is badminton.
A
sports facility in the rural community of Toholampi has enabled Henna,
16, and Niklas, 13, to compete at a European level, exposing them to new
places and players from around the continent. The game has given the
teens a fulfilling hobby in a remote area and their parents, Lasse and
Marika, optimism about their children’s futures.
Mr. Hukari, 49, hopes that, in time, the children will come to
fully grasp the opportunities they have gained from badminton. “Now,
maybe they don’t understand what they have, but when they are my age,
then I know they will understand,” he said.
The Matriarch and Her Granddaughter
Born 17 years after Finland won independence from Russia, Eeva
Valtonen has watched her homeland transform: from the devastation of
World War II through years of rebuilding to a nation held up as an
exemplar to the world.
“My mother used to say, ‘Remember, the
blessing in life is in work, and every work you do, do it well,’” Ms.
Valtonen, 88, said. “I think Finnish people have been very much the same
way. Everybody did everything together and helped each other.”
Her
granddaughter Ruut Eerikainen, 29, was surprised to see Finland now
ranked as the happiest place on earth. “To be honest, Finns don’t seem
that happy,” she said. “It’s really dark outside, and we can be quite
gloomy.”
Maybe it isn’t that Finns are so much happier than
everyone else. Maybe it’s that their expectations for contentment are
more reasonable, and if they aren’t met, in the spirit of sisu, they
persevere.
“We don’t whine,” Ms. Eerikainen said. “We just do.”
Assisted-living homes are rejecting Medicaid and evicting seniors
Some
residents who drained their nest eggs to cover private-pay rates have
been evicted after turning to Medicaid to pay their bills.
by Christopher Rowland - Washington Post - April 8, 2023
Shirley
Holtz, 91, used a walker to get around. She had dementia and was
enrolled in hospice care. Despite her age and infirmity, Holtz was
evicted from the assisted-living facility she called home for four years
because she relied on government health insurance for low-income
seniors.
Holtz
was one of 15 residents told to vacate Emerald Bay Retirement Community
near Green Bay, Wis., after the facility stopped accepting payment from
a state-sponsored Medicaid program. And Emerald Bay is not alone. A
recent spate of evictions has ousted dozens of assisted-living residents
in Wisconsin who depended on Medicaid to pay their bills — an
increasingly common practice, according to industry representatives.
The evictions highlight the pitfalls of the U.S. long-term care system,
which is showing fractures from the pandemic just as a wave of 73
million baby boomers is hitting an age where they are likely to need
more day-to-day care. About 4.4 million Americans have some form of
long-term care paid for by Medicaid, the state-federal health system for the poor, a patchy safety net that industry representatives say pays facilities too little.
Residents
of assisted-living facilities — promoted as a homier, more appealing
alternative to nursing homes — face an especially precarious situation.
While federal law protects Medicaid beneficiaries in nursing homes from
eviction, the law does not protect residents of assisted-living
facilities, leaving them with few options when turned out. In Wisconsin,
residents who entered facilities on Medicaid, as well as those who
drained their private savings after moving in and subsequently enrolled
in Medicaid, have been affected.
“It’s
a good illustration of how Medicaid assisted-living public policy is
still in its Wild West phase, with providers doing what they choose in
many cases, even though it’s unfair to consumers,” said Eric Carlson, a
lawyer and director of long-term services and support advocacy at the
nonprofit group Justice in Aging. “You can’t just flip in and out of
these relationships and treat the people as incidental damage.”
The
U.S. government does not monitor or regulate assisted-living
facilities, and no federal data is available on the frequency of
evictions. In Wisconsin, The Washington Post counted at least 50
Medicaid-related evictions since the fall based on statements by
operators, as well as nonprofit and government Medicaid agencies.
But
evictions have become so common that some states, including New Jersey,
have enacted policies to curb them. Nationally, state ombudsman
programs for long-term care received 3,265 complaints related to
evictions from assisted-living facilities in 2020, the latest data
available. That data does not detail the reason for evictions, though
ombudsmen said most complaints arose after operators declared that a
resident’s needs had become too great to be handled at the facility.
Emerald
Bay did not explain why it stopped participating in Medicaid. But
advocates, family members and the nonprofit that managed the facility’s
Medicaid contract contend the motivation was financial: Medicaid
reimbursement is lower than full private pay rates.
Family
members said they were upset and angry. Holtz spent her entire savings
paying out of pocket with the understanding that she would be permitted
to stay once she qualified for low-income insurance, her relatives said.
Ann Marra, Holtz’s daughter, said her mother — who worked much of her
life as a professional secretary and raised her family in Algoma, a
small town on Lake Michigan — deserved better treatment.
Marra feared the eviction would affect her mother’s mental health.
“It’s cruel, heartless and sad,” she said.
After
a stressful search, Holtz’s family moved her on March 13 to an
assisted-living facility that still honors state Medicaid. Emerald Bay’s
operator, Baka Enterprises, did not respond to requests for comment.
Advocates
for assisted-living residents worry that pandemic-induced economic
conditions are contributing to the problem in pockets of the country.
Profits in assisted-living facilities are threatened by a shortage of
staff and big spikes in labor costs, inflation that is jacking up the
costs of goods, and higher interest rates. Meanwhile, occupancy rates
continue to lag behind pre-pandemic peaks.
The industry blames evictions oninsufficient
Medicaid funding. Reimbursements, made under federal waivers that allow
states to spend Medicaid dollars for elderly care outside of nursing
homes, are not keeping up with rising costs, industry representatives
said.
“Chronic
Medicaid underfunding is not sustainable and is limiting participation
as well as driving many providers out of the waiver program, reducing
access to care options,” said LaShuan Bethea, executive director of the
National Center for Assisted Living trade group.
The gap in pay rates between Medicaid and the full amount charged to families paying out of pocketvaries
among states. While private pay rates are often $5,000 a month or more,
Medicaid in many states pays only about $3,000 a month, said Paul
Williams, vice president of government relations at Argentum, a trade
association representing assisted-living facilities.
Operators
“have tried to hold off [canceling Medicaid contracts] as long as they
can, hoping the reimbursement will be increased to help them afford
inflation factors,” Williams said. “Hope has diminished in some states
of that happening, and they’re saying, ‘I cannot do this anymore.’”
In
2020, about 18 percent of 818,000 residents in U.S. assisted-living
facilities were supported by Medicaid payments, according to federal data, a ratio that has remained stable for at least a decade.
In
Wisconsin, at least four facilities have canceled Medicaid managed-care
contracts in recent months. In addition to Emerald Bay’s 15 residents,Cedarhurst
of Madison had 28 residents who were Medicaid beneficiaries when it
terminated its contract last year. Residents found out they were being
evicted after being called to a group meeting in late fall, said one of
those told to leave, Elizabeth Burnette.
“Residents
were in tears to hear they had to find another place to live,”
Burnette, 80, said. “Most of us are incapacitated in some way, with
walkers and in wheelchairs or mobile beds.”
Cedarhurst
operates the facility, which is owned by a Massachusetts-based real
estate investment trust, Diversified Healthcare Trust. Going to 100
percent private pay at the Madison site was a “tough decision” made in
conjunction with Diversified Healthcare, Cedarhurst spokeswoman Christie
Schrader said.
Cedarhurst became the facility’s operator in November 2021.
“When
we took over management, we inherited Medicaid residents with special
cases who required advanced care that we do not offer at our
communities,” Schrader said. “Therefore, we believed it was in the
residents’ best interest to aid them in finding alternative placement
which could care for them in the way they deserve.”
The
lobbying and trade group in Wisconsin that represents the long-term
care industry said assisted-living operators recognize evictions are
highly stressful for residents and their families.
“Not
only is it traumatic for the resident and the family, it’s also
traumatic for the facility. It really is,” said Rick Abrams, president
and CEO of the Wisconsin Health Care Association/Wisconsin Center for
Assisted Living. “This is the residents’ home. Everyone understands
that.”
He
said evictions usually occur when an assisted-living facility and one of
the state’s nonprofit Medicaid managed-care organizations cannot agree
on the monthly rates for care of an elderly person. Written notices
given to residents in the recent evictions stated little about the
rationale.
HarborChase
of Shorewood, outside Milwaukee, had six Medicaid residents when it
said it was ending its Medicaid contracts in January, according to
managers of the state’s nonprofit Medicaid managed-care organizations.
“With
the new year comes necessary changes,” Karin Bateman, chief operating
officer of Vero Beach, Fla.-based Harbor Retirement Associates,
HarborChase of Shorewood’s parent company, wrote in a three-paragraph
letter to residents on Jan. 6
that informed them that the facility would no longer accept Medicaid.
“Our 60-day notice of Medicaid termination gives you time to plan
accordingly.”
Harbor Retirement Associates did not respond to requests for comment.
The
evictions carry an especially harsh sting for residents who enter
assisted-living facilities paying full rates out of pocket with the
understanding that, once their nest egg has been spent down, they can
remain in the facility under Medicaid. Such arrangements are common
across the country and are discussed with families by marketing staff,
according to elder-law attorneys and industry experts.
But
facilities may have strict limits on the number of beds they designate
as Medicaid-eligible, or they can back out of state Medicaid contracts
completely. Such caveats may be buried in the fine print of resident
agreements or are not addressed at all in the contracts, according to
contract provisions in the Wisconsin cases reviewed by The Post.
Families often sign such contracts in a time of stress, as they are
seeking a safe place for a parent who can no longer remain in their own
home.
“This
is how people are getting screwed, by promises that the place will take
[Wisconsin Medicaid] if they stay for two years. Then they either sell
to another company, or change their minds and opt out of the program
entirely, which you really can’t stop them from doing. At that point,
the family has used up their funds,” said Carol Wessels, an attorney
specializing in elder law in Mequon, Wis.
Family members are often left feeling betrayed.
“It’s
appalling to say the least,” said Megan Brillault, whose mother, Nancy
Brillault, was evicted from HarborChase of Shorewood after spending most
of her $120,000 savings. “They said, ‘Here, let us take your money, all
your life savings, and you can live here forever,’ and 10 months later
they’re saying, ‘We miscalculated, and we are no longer taking Medicaid
beds.’”
Megan
Brillault provided an email to The Post in which a HarborChase
representative said Nancy could transition to Medicaid after paying
private-pay rates for one year. The residency contract did not address
the issue, said Brillault, a lawyer.
Medicaid
pays for nursing home care directly. It’s an entitlement — if a
low-income person qualifies, the state must fund a nursing home bed.
Medicaid pays all costs in nursing homes, including room and board, as
well as care.
Assisted
living is different. At those facilities, Medicaid money can be used to
reimburse only the cost of care, such as bathing and dressing, and not
room and board, although some states offer supplemental payments to help
with rent and food.
With
the overwhelming majority of residents paying privately, the median
operating profit for U.S. assisted-living facilities in 2019 was 29
percent before deductions for interest and rent payments, according to
the National Investment Center for Seniors Housing & Care.
Kate
McEvoy, executive director of the National Association of Medicaid
Directors, said states want to give elderly people options outside of
nursing homes but are squeezed between restrictions on how Medicaid
money can be used and the high costs of assisted living.
“This has been a challenge in what has primarily been a proprietary, market-driven model,” she said.
In the eviction notice emailed to Holtz’s family in Wisconsin, Baka Enterprises,Emerald
Bay’s operator, said it had decided to terminate its contracts with the
state’s Medicaid program that covers services for the elderly. It did
not provide a reason, but cited a provision of its contract with
residents that allowed it to discharge them if they could not afford
private-pay rates and the facility did not have designated Medicaid
beds.
Kris Holtz, Shirley Holtz’s son, said he was not aware of the provision when he moved his mother into Emerald Bay.Shirley
Holtz paid private rates for 26 months before qualifying for Medicaid.
She lived at Emerald Bay for another two years at the Medicaid rate
before receiving the eviction notice, he said.
The
Emerald Bay Medicaid contract was managed by a nonprofit called
Lakeland Care. “In the end, Emerald Bay asked us to pay the full
private-pay rate for these members, which we are unable to do as a
Medicaid-funded agency,” Lakeland Care’s chief executive officer, Sara
Muhlbauer, said in a written statement to The Post.
Experts say moving elderly people out of familiar surroundings can induce a condition called “transfer trauma” that
accelerates decline. Shirley Holtz’s relatives detected rapid changes
after the eviction, said Marra, her daughter. Her mother lost 15
pounds, she said, and quickly stopped using her walker.
On Monday, three weeks after moving out of Emerald Bay and into the new facility, Shirley Holtz died. “The move was a huge factor in her decline,” Marra said in a text.
Even
as she mourned, Marra texted an expletive to describe the U.S.
long-term care system, punctuated by a red-faced frown emoji. “Kinda
angry right now,” she said.
The preceding clipping about the eviction of seniors from long-term facilities in the USA is a nice counterpoint to the the preceding clipping about life in Finland.
- SPC
Doctors are drowning in paperwork. Some companies claim AI can help
by Geoff Brumfiel - NPR - April 5, 2023
When Dereck Paul was training as a doctor at the University of
California San Francisco, he couldn't believe how outdated the
hospital's records-keeping was. The computer systems looked like they'd
time-traveled from the 1990s, and many of the medical records were still
kept on paper.
"I was just totally shocked by how analog things were," Paul recalls.
The experience inspired Paul to found a small San Francisco-based startup called Glass Health.
Glass Health is now among a handful of companies who are hoping to use
artificial intelligence chatbots to offer services to doctors. These
firms maintain that their programs could dramatically reduce the
paperwork burden physicians face in their daily lives, and dramatically
improve the patient-doctor relationship.
"We need these folks not in burnt-out states, trying to complete
documentation," Paul says. "Patients need more than 10 minutes with
their doctors."
But some independent researchers fear a rush to incorporate the
latest AI technology into medicine could lead to errors and biased
outcomes that might harm patients.
"I think it's very exciting, but I'm also super skeptical and super cautious," says Pearse Keane,
a professor of artificial medical intelligence at University College
London in the United Kingdom. "Anything that involves decision-making
about a patient's care is something that has to be treated with extreme
caution for the time being."
A powerful engine for medicine
Paul co-founded Glass Health in 2021 with Graham Ramsey, an
entrepreneur who had previously started several healthcare tech
companies. The company began by offering an electronic system for
keeping medical notes. When ChatGPT appeared on the scene last year,
Paul says, he didn't pay much attention to it.
"I looked at it and I thought, 'Man, this is going to write some bad blog posts. Who cares?'" herecalls.
But Paul kept getting pinged from younger doctors and medical
students. They were using ChatGPT, and saying it was pretty good at
answering clinical questions. Then the users of his software started
asking about it.
In general, doctors should not be using ChatGPT by itself to practice medicine, warns Marc Succi, a doctor at Massachusetts General Hospital who has conducted evaluations
of how the chatbot performs at diagnosing patients. When presented with
hypothetical cases, he says, ChatGPT could produce a correct diagnosis
accurately at close to the level of a third- or fourth-year medical
student. Still, he adds, the program can also hallucinate findings and
fabricate sources.
"I would express considerable caution using this in a clinical scenario for any reason, at the current stage," he says.
But Paul believed the underlying technology can be turned into a
powerful engine for medicine. Paul and his colleagues have created a
program called "Glass AI" based off of ChatGPT. A doctor tells the Glass
AI chatbot about a patient, and it can suggest a list of possible
diagnoses and a treatment plan. Rather than working from the raw ChatGPT
information base, the Glass AI system uses a virtual medical textbook
written by humans as its main source of facts – something Paul says
makes the system safer and more reliable.
"We're working on doctors being able to put in a one-liner, a patient
summary, and for us to be able to generate the first draft of a
clinical plan for that doctor," he says. "So what tests they would order
and what treatments they would order."
Paul believes Glass AI helps with a huge need for efficiency in
medicine. Doctors are stretched everywhere, and he says paperwork is
slowing them down.
"The physician quality of life is really, really rough. The
documentation burden is massive," he says. "Patients don't feel like
their doctors have enough time to spend with them."
Bots at the bedside
In truth, AI has already arrived in medicine, according to Keane.
Keane also works as an ophthalmologist at Moorfields Eye Hospital in
London and says that his field was among the first to see AI algorithms
put to work. In 2018, the Food and Drug Administration (FDA) approved an AI system that could read a scan of a patient's eyes to screen for diabetic retinopathy, a condition that can lead to blindness.
That technology is based on an AI precursor to the current chatbot
systems. If it identifies a possible case of retinopathy, it then refers
the patient to a specialist. Keane says the technology could
potentially streamline work at his hospital, where patients are lining
up out the door to see experts.
"If we can have an AI system that is in that pathway somewhere that
flags the people with the sight-threatening disease and gets them in
front of a retina specialist, then that's likely to lead to much better
outcomes for our patients," he says.
Other similar AI programs have been approved for specialties like
radiology and cardiology. But these new chatbots can potentially be used
by all kinds of doctors treating a wide variety of patients.
Alexandre Lebrun is CEO of a French startup called Nabla. He says the goal of his company's program is to cut down on the hours doctors spend writing up their notes.
"We are trying to completely automate all this wasted time with AI," he says.
Lebrun is open about the fact that chatbots have some problems. They
can make up sources, get things wrong and behave erratically. In fact,
his team's early experiments with ChatGPT produced some weird results.
For example, when a fake patient told the chatbot it was depressed, the AI suggested "recycling electronics" as a way to cheer up.
Despite this dismal consultation, Lebrun thinks there are narrow,
limited tasks where a chatbot can make a real difference. Nabla, which
he co-founded, is now testing a system that can, in real time, listen to
a conversation between a doctor and a patient and provide a summary of
what the two said to one another. Doctors inform their patients that the
system is being used in advance, and as a privacy measure, it doesn't
actually record the conversation.
"It shows a report, and then the doctor will validate with one click, and 99% of the time it's right and it works," he says.
The summary can be uploaded to a hospital records system, saving the doctor valuable time.
Other companies are pursuing a similar approach. In late March,
Nuance Communications, a subsidiary of Microsoft, announced that it
would be rolling out its own AI service
designed to streamline note-taking using the latest version of ChatGPT,
GPT-4. The company says it will showcase its software later this month.
AI reflects human biases
But even if AI can get it right, that doesn't mean it will work for every patient, says Marzyeh Ghassemi, a computer scientist studying AI in healthcare at MIT. Her research shows that AI can be biased.
"When you take state-of-the-art machine learning methods and systems
and then evaluate them on different patient groups, they do not perform
equally," she says.
That's because these systems are trained on vast amounts of data made
by humans. And whether that data is from the Internet, or a medical
study, it contains all the human biases that already exist in our
society.
The problem, she says, is often these programs will reflect those biases back tothe doctor using them. For example, her team asked an AI chatbot trained on scientific papers and medical notes to complete a sentence from a patient's medical record.
"When we said 'White or Caucasian patient was belligerent or
violent,' the model filled in the blank [with] 'Patient was sent to
hospital,'" she says. "If we said 'Black, African American, or African
patient was belligerent or violent,' the model completed the note [with]
'Patient was sent to prison.'"
Ghassemi says many other studies have turned up similar results. She
worries that medical chatbots will parrot biases and bad decisions back
to doctors, and they'll just go along with it.
"It has the sheen of objectivity: 'ChatGPT says you shouldn't have
this medication. It's not me – a model, an algorithm made this choice,'"
she says.
"I don't know whether the tools that are being developed are being
developed to reduce the burden on the doctor, or to really increase the
throughput in the system," she says. The intent will have a huge effect
on how the new technology affects patients.
Regulators are racing to keep up with a flood of applications for new
AI programs. The FDA, which oversees such systems as "medical devices,"
said in a statement to NPR that it was working to ensure that any new
AI software meets its standards.
"The agency is working closely with stakeholders and following the
science to make sure that Americans will benefit from new technologies
as they further develop, while ensuring the safety and effectiveness of
medical devices," spokesperson Jim McKinney said in an email.
But it is not entirely clear where chatbots specifically fall in the
FDA's rubric, since, strictly speaking, their job is to synthesize
information from elsewhere. Lebrun of Nabla says his company will seek
FDA certification for their software, though he says in its simplest
form, the Nabla note-taking system doesn't require it. Dereck Paul says
Glass Health is not currently planning on seeking FDA certification for
Glass AI.
Doctors give chatbots a chance
Both Lebrun and Paul say they are well aware of the problems of bias.
And both know that chatbots can sometimes fabricate answers out of thin
air. Paul says doctors who use his company's AI system need to check
it.
"You have to supervise it, the way we supervise medical students and
residents, which means that you can't be lazy about it," he says.
Both companies also say they are working to reduce the risk of errors
and bias. Glass Health's human-curated textbook is written by a team of
30 clinicians and clinicians in training. The AI relies on it to write
diagnoses and treatment plans, which Paul claims should make it safe and
reliable.
At Nabla, Lebrun says he's training the software to simply condense
and summarize the conversation, without providing any additional
interpretation. He believes that strict rule will help reduce the chance
of errors. The team is also working with a diverse set of doctors
located around the world to weed out bias from their software.
Regardless of the possible risks, doctors seem interested. Paul says
in December, his company had around 500 users. But after they introduced
their chatbot, those numbers jumped.
"We finished January with 2,000 monthly active users, and in
February we had 4,800," Paul says. Thousands more signed up in March, as
overworked doctors line up to give AI a try.
ChatGPT can answer many medical questions correctly, but experts warn against using it on its own for medical advice.
Alexandre Lebrun of Nabla says AI can "automate all this wasted time" doctors spend completing medical notes and paperwork.
