Even Doctors Like Me Are Falling Into This Medical Bill Trap
by Danielle Ofri - NYT - June 17, 2024
Thank goodness for urgent care centers. Last July, my daughter was still limping a week after a bike injury and we needed a quick X-ray to rule out a fracture. As a doctor, I knew we didn’t need an expensive emergency room for something this straightforward. We found an urgent care at the end of a strip mall in Chicago, and 20 minutes later we received the good news that there was only a sprain.
As the three employees closed up shop for the day, I reflected on how urgent-care centers filled a perfect niche between the overkill of an emergency room and the near-impossibility of snagging an immediate orthopedic appointment.
But this is health care in America, and nothing ever closes up tidily. Two weeks later a bill arrived: The radiology charge from NorthShore University HealthSystem for the ankle and wrist X-rays was $1,168, a price that seemed way out of range for something that usually costs around $100 for each X-ray. When I examined the bill more closely, I saw that the radiology portion came not from the urgent care center but from a hospital, so we were billed for hospital-based X-rays. When I inquired about the bill, I was told that the center was hospital-affiliated and as such, is allowed to charge hospital prices.
It turns out that I’d stumbled into a lucrative corner of the health care market called hospital outpatient departments, or HOPDs. They do some of the same outpatient care — colonoscopies, X-rays, medication injections — just as doctors’ offices and clinics do. But because they are considered part of a hospital, they get to charge hospital-level prices for these outpatient procedures, even though the patients aren’t as sick as inpatients. Since these facilities don’t necessarily look like hospitals, patients can be easily deceived and end up with hefty financial surprises. I’m a doctor who works in a hospital every day, and I was fooled.
As of 2022, federal law protects patients from surprise bills if they are unknowingly treated by out-of-network doctors. But there is no federal protection for patients who are unknowingly treated in higher-priced hospital affiliates that look like normal doctors’ offices or urgent care clinics. Federal regulations are needed, at the very least, to require facilities to be upfront with their pricing scheme — and more ideally, to eliminate this price differential entirely. Otherwise patients will continue to face unexpected high bills that most can ill afford.
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One study of pricing revealed that HOPDs charged an average of $1,383 for a colonoscopy, compared with the $625 average price at a doctor’s office or other non-HOPD settings. A knee M.R.I. averaged $900, compared with $600. Chemotherapy and other medications cost twice as much. Echocardiograms command up to three times as much. Much of these costs comes from tacked-on “facility fees,” which are rising far faster than other medical costs.
The American Hospital Association justifies these costs by arguing that patients seen in HOPDs are sicker than other outpatients. But that doesn’t typically make the procedures performed at these facilities any more complicated — an outpatient echocardiogram, for instance, is basically the same no matter who it’s for. If a patient’s illness does render a procedure more complicated, there are legitimate ways to account and bill for that.
Last December, the health insurer Blue Cross Blue Shield released findings that HOPDs charged far more than doctors’ offices for certain procedures (prostate biopsies, for example, cost over six times more). HOPDs turn out to be an attractive business plan for hospitals that are aggressively acquiring doctors’ practices. When these acquisitions occur, prices often rise as patients are now seen in “hospital facilities.”
It’s difficult to quantify how many patients find themselves unknowingly getting higher-price care at HOPDs as we did. But news outlets have reported frustrations suffered by some patients receiving hospital-cost charges after a visit to walk-in care centers. There are also stories on Reddit and other platforms about new — and steep — facility fees at doctors’ offices appearing on medical bills and often not covered by insurance. One patient’s bill went up 10-fold for the same procedure after her doctor’s practice changed its classification of her appointment to a hospital-based designation. Another study of outpatient surgical procedures found an increase of more than 50 percent in facility fees over the course of six years, resulting in much higher out-of-pocket expenses for patients. Most patients find out only weeks later when the bill arrives.
There’s a movement afoot to make so-called site-neutral payments the law, meaning that Medicare would pay doctors the same price for an outpatient procedure like an endoscopy no matter what type of outpatient setting it’s performed in. Though at least 16 states have passed laws requiring transparency about facility fees, headwinds are still stiff. Congress inserted a site-neutral payment rule into the Bipartisan Budget Act of 2015, but ferocious lobbying from the hospital industry exempted nearly all existing HOPDs. The American Hospital Association vehemently opposes any legislation that equalizes HOPD payments or eliminates facility fees.
The House recently passed the Lower Costs, More Transparency Act, which would enforce site-neutral payments for one narrow slice of health care — physician-administered medications. The Senate has yet to take up any such legislation.
I was so livid about being charged hospital rates for two simple X-rays that I filed a formal complaint with the Illinois attorney general’s office, which concluded that the billing was legal under federal law. When I asked for on-the-record comments about my contention that the charges seemed excessive and that the system felt deceptive, a representative for NorthShore University HealthSystem (now Endeavor Health) offered only a general statement that read, in part: “We understand that navigating the health care landscape, including billing, can be complex.”
It’s time for Congress to protect patients from both unfair pricing schemes and health care deception. MedPAC, the nonpartisan Medicare Payment Advisory Commission, recently recommended to Congress a basic set of site-neutral policies. It would apply site-neutral payments to a handful of low-risk procedures — some imaging, medication injections, simple office procedures — and this would apply to all HOPDs.
After six months of fighting the cost, the hospital quietly canceled our bill. I’m sure it calculated that this was the simplest way to get rid of a pesky patient — but that wasn’t what I was after. I wanted to untangle this loophole that catches patients unaware and saddled with exorbitant bills. Congress should tune out hospital lobbying and enact these common-sense measures to protect patients.
Danielle Ofri, a primary care doctor at Bellevue Hospital, is the author of “When We Do Harm: A Doctor Confronts Medical Error.
”https://www.nytimes.com/2024/06/17/opinion/medical-bill-trap.html
'They All Laughed When I Spoke of Greedy Doctors'
by George Lundberg - medscape.com - March 20, 2023
"They all laughed when I spoke of greedy doctors."
Spoken by Dr Ralph Crawshaw at the Oregon Medical Association, as documented in the Western Journal of Medicine.
Crawshaw continued:
...the central clinical problem we physicians face in clinical practice is appetite control. Patients seem insatiably hungry for cigarettes, food, sex, money, love and pills. Are we so different from our patients?
My good friend Ralph was a leader in the development of the Oregon Health Plan. He also proposed that the Impaired Physician Program of the Oregon Medical Association look into physicians who were "impaired by money."
George D. Lundberg, MD
Let's face it: The American sickness care industry, with all of its disorganized elements and multiple protected revenue streams, has become a financial behemoth, and at the town, city, county, state, and federal levels, an untouchable political juggernaut. And, unlike anything seen since the US ramped up to fight the Second World War, it is a recession-proof engine for job creation. Who would not be impressed by those achievements?
Any questions? Did I hear the word "outcomes"? Uhhhh. A healthy population? Ooooh. Average lifespan of Americans? Efficiency and effectiveness? Quality of living and dying? National happiness? No need for psychoactive chemicals to escape reality? A happy workforce?
It's all about greed, but not only greedy doctors. Since Ralph's 1985 declaration, no one has said it better than Don Berwick, MD.
Can the American medical-industrial complex be tamed? Let's follow the money.
Wind up a capitalist doll and aim it at a large pile of money, and pretty soon the capitalist person or company will own a substantial portion of that pot, no matter what the entity or field may be. It is the nature of the for-profit beast.
Wind up a non-profit organization (NPO) doll in the same field as the capitalist doll and it may well assume the same characteristics as the capitalist doll to compete. And compete it will, often quite successfully. For practical purposes, little differentiates an NPO from the "capitalist beast."
A key difference is ownership: One has stock, which can compensate employed individuals with shares and options. NPOs do not have stock but must (and do) find other methods of compensation for their leaders to be able to compete for talent in the marketplace. The governing bodies of both organizational approaches are typically boards of directors. The "killer app" for successful NPOs is to populate their boards with the same kinds of people that comprise the for-profit boards, so the two approaches blend.
Of course, for-profit entities are subject to taxes in ways that NPOs are not. The laws that established such tax exemptions placed requirements to provide community goods and services on the NPOs. It is one of the worst-kept secrets in the medical industry that many (maybe most) of those tax-exempt organizations do not so contribute, or at least not enough. Enforcement ranges from none to limited and is essentially complaint driven. Everyone knows this but no one seems to care, as long as the money rolls in.
Did the United States (writ large) deliberately decide around 1980 (or was it the 1960s?) that it would build a "sickness" rather than a "health" system"? Or did the powerful motivators of human and organizational behavior simply evolve into a sickness system to the detriment of the public's health?
W. Edwards Deming (and others) observed and deduced that every system is perfectly designed to perform exactly as it does. A country cannot have money-driven medicine without a lot of money. It comes from health insurance, public (Medicare-Medicaid), private, for-profit companies, and individuals. The ability of an industry to generate goods and services to "find and treat sickness" is endless supply-driven demand. Voilà: "The New Medical-Industrial Complex" of Arnold Relman in 1980.
Greed Is Good, Right?
Just ask Gordon Gekko or F. Scott Fitzgerald's Gatsby, or in the medical domain, former governor and current senator Rick Scott. After Scott resigned from his post as CEO of Columbia/HCA in the 1990s, his lawyers kept him out of the slammer for billions of dollars in Medicare fraud that took place under his watch and led to the corporation pleading guilty to multiple felonies.
Greed certainly can motivate a lot of ambitious work.
On the other hand, according to Pope Gregory I in the 6th century, and many theological scholars since then, the seven deadly sins are pride, greed, lust, envy, gluttony, wrath, and sloth. Look at your everyday practices, docs. How many of your patients' illnesses are the result of lust, wrath, gluttony, and sloth? Yeah, a lot.
The most recent global report on health once again ranks the United States at the top of the list of developed countries for money expended on healthcare and at the bottom for health outcomes. And it isn't even close.
Many studies indicate that only 20% of healthcare comprises medical (sickness) care, while 80% results from social determinants such as education, housing, income, and environment.
Because we currently spend some 18.3% of our GDP ($4.3 trillion a year or $12,900 per capita) and have so little to show for it, maybe we should just take, let's say, 40% of that $4.3 trillion away from sickness care and invest it in healthy food, housing, crime reduction, education, clean air and water, public health, disease prevention, vaccinations, exercise, tobacco elimination, alcohol control, suicide prevention, and other drug-control and harm-reduction programs.
What?
Millions of people could lose their jobs. I get it — the American medical-industrial complex is, at its essence, a jobs program.
I wrote about waste in the US healthcare system in 2009 and warned about an impending burst of the multitrillion-dollar healthcare "bubble," during which roughly 40% of the total expenditures (the parts that do not contribute to health) would/could/even should disappear or be transferred into something of value for the country and its people.
Of course, that did not happen. We would need an enormous retraining program for those hundreds of thousands of workers who are busily doing work that does not need to be done, especially those whose main function is following the money. I refer to the health insurance industry — be gone with you.
All you do is take as much money as possible, spend as little as possible on sickness care, consume as much as possible for unneeded processing, and pay your executives and shareholders as much as possible. We don't need you.
While we are at it, how about investing to save our planet for future generations of humans, other animals, and plants?
To illustrate the capacity of the system to resist downward economic pressure, one need look no further than the mostly well-intentioned people who believed that price transparency would shame hospitals into posting actual fair prices and empower consumers to make smart choices. Think again.
Among the fatal flaws of this plan is not recognizing that the leaders of healthcare institutions are far beyond feeling any shame for their gouging behavior, and the patient-consumers are far too naive to understand what a fair price would be, not understanding how competition and other factors enter into pricing decisions. Most hospitals simply ignored the directive and awaited compliance actions. CMS, in charge of implementing this rule, now seems overjoyed that compliance with hospital price transparency is coming along. But what about the effects of this initiative? It's too soon to tell.
Solutions, Please
I'm happy to report that physicians and other professionals across the United States are appalled by the current situation and are offering paths to reform.
In 2023, Don Berwick attempted to demonize "salve lucrum" (the glorification of profit), and called upon caring professionals of all stripes and their organizations to rise up and use all tools available to reverse this long-standing trend.
Chicago-based Eric Reinhart, MD, PhD, writing in 2023, opined that we need to shrink healthcare to build health, an ideologic change that benefits the population and could reassert professionalism.
In 2023 Tatiane Santos, PhD, MPH, of Tulane, has written about how to end the US health disadvantage by focusing on prevention and social policy rather than sick care. However, she notes that "the reallocation of resources from hospitals towards primary care, prevention, and the social determinants of health is complex." Oh yeah.
Political science professor Peter Swenson, of Yale, writing in his great 2022 book Disorder, proposed that the AMA revert to its earlier public health roots by increasing the number of members. Membership dues would become the main source of revenue (replacing corporate ventures and reliance on industry) and then lobbying transparently toward progressive ends.
In 2022, San Francisco–based controversial critic Vinay Prasad, MD, MPH, detailed how this mess has played out in oncology, and states that government regulation is the only avenue to reform.
It would help if more NPOs in medicine and health that generate enormous revenue would behave more like the charitable institutions that their charters (plus society and the law) expect, and less like their for-profit competitors.
Of course, we must always remember that one person's waste is another person's income.
What other field could so consistently convert sickness, pain, suffering, and dying into revenue centers, profit margins, shareholder value, and ultimately mega-mansions, yachts, islands, endowed professorships, eponymous educational palaces, hospitals, and art galleries?
It seems pretty obvious that profit-taking as a prime motive should have absolutely no place in what is historically the premier service profession.
Let's get real. Money is power. Huge money is huge power. If anything like this ideologic transition happens, it will have to be political and incremental. Recent CMS guidance authorized Medicaid to address such social determinants of health as housing and food insecurity, on a state-by-state basis.
Johnson and Berwick proposed redesigning Medicare. They envision a "Medicare 2.0" that would shift dollars away from fee-for-service medical care to meeting population-based social needs that improve health.
Sensible help may indeed be on the way.
That's my opinion. I'm Dr George Lundberg, at large for Medscape.
George Lundberg, MD, is contributing editor at Cancer Commons, president of the Lundberg Institute, executive advisor at Cureus, and a clinical professor of pathology at Northwestern University. Previously, he served as editor-in-chief of JAMA (including 10 specialty journals), American Medical News, and Medscape.
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Medscape Internal Medicine © 2023 WebMD, LLC
Any views expressed above are the author's own and do not necessarily reflect the views of WebMD or Medscape.
Cite this: 'They All Laughed When I Spoke of Greedy Doctors' - Medscape - Mar 20, 2023.
Last year, Maine made assaulting an emergency medical worker a felony. The problem of patient violence remains
by Alexa Foust - Maine Monitor - July 15, 2024
A year-old law seems to have done little to curb a surge in violence against health care workers that began during the pandemic, despite increasing charges for assaults on nonmedical staff – such as custodial, security or administrative workers – who are providing emergency medical care.
According to Maine’s Judicial Branch, there have been 12 charges of “assault on an emergency medical care provider” in 2024 – on track to meet similar numbers as the last five years. There were 27 charges in 2023 and 25 in 2022, for example.
Joe Bragg, a registered nurse and nursing supervisor at Down East Community Hospital in Machias, said the expanded definition doesn’t seem to be changing the behavior of patients, many in a state of crisis when they arrive in the emergency department.
“I don’t think anybody is going into the hospital going, ‘Well, I better not act out today because L.D. 1119 is in effect,” said Bragg. “It doesn’t change anything. If violence is going to happen, it’s going to happen.”
The law – L.D. 1119 – which passed in July 2023, increased charges for an assault occurring in an emergency department setting, regardless of whether the victim is a health care worker, from a Class D crime – punishable by up to 364 days in jail and a $2,000 fine – to a Class C crime, punishable by up to five years in prison and a $5,000 fine.
(Felonies are typically crimes punishable by more than a year in prison, while misdemeanors are typically considered less serious crimes punishable by less than a year in jail. Maine no longer uses these categories.)
Between 2017 and 2021, Maine health care workers filed 1,000 claims for lost time due to intentional injury, most related to interactions with patients.
Prior to the new law, health care workers filed 167 intentional injury lost time claims in the first seven months of 2023; 114 were filed in the first four months after the law took effect.
Advocates for the expanded law, including Maine’s two largest health care conglomerates, MaineHealth and Northern Light Health, say the changes were intended to help law enforcement and prosecutors hold people accountable for their behavior and to protect those not previously included, such as security officers.
“L.D. 1119 really doesn’t impact the number of assaults, it simply clarifies the ability to prosecute,” said Jeff Austin, principal lobbyist for the Maine Hospital Association.
Austin said MHA is seeing around 200 incidents per month at its member hospitals, similar to years prior.
To further help combat workplace violence, hospitals have put out campaigns. The Northern Light Hospital system is working to get the ‘Safety from Violence for Healthcare Employees’ Act passed in Congress. At DECH in Machias, administrators have hung signage encouraging a safer environment and reminding visitors to “be kind to our staff.”
While violence in emergency departments predates the pandemic, its ongoing effects have added to the frequency of assaults.
In testimony last year, a registered nurse within the MaineHealth system described a patient throwing a chair at a sliding door, shattering the glass before grabbing her arm.
In another instance, Nancijean Goudey, the director of emergency services at Maine Medical Center, described a patient who lunged, grabbed her around the neck, threw her on a bed and attempted to climb on top of her.
In testimony, emergency providers described attacks that ranged from spitting to verbal abuse to physical violence. The Maine Medical Center emergency department reported 277 incidents of workplace violence in a three-month period in early 2023.
Nurses and hospital staff pushed for the passage of the law, arguing that something needed to be done to help with the violence and protect nonmedical staff.
Defense attorney Walt McKee believes classifying assault on emergency health care personnel as a felony can be a slippery slope – the person’s job should not be part of the consideration, he said.
“A felony level crime should be dealt with when there is significant bodily harm, not because it was on a nurse and not a teacher,” said McKee.
CRIMINALIZING MENTAL HEALTH
Others argue the expanded law hasn’t helped deter violence in the year since it was passed and that it adversely affects those with mental health issues, who may be more likely to act violently in emergency settings.
Advocates on both sides agree that violence against hospital staff should not be tolerated. But with mental health treatment resources across the state increasingly strained, those in crisis have few places to turn beyond an emergency room.
There are only 10 inpatient psychiatric treatment facilities across Maine, with roughly 500 beds. The long waitlist of people seeking mental health treatment only continues to grow, with wait periods stretching for months.
Facing a lack of resources and appropriate treatment, people turn to their hospitals, said state Rep. Nina Milliken, D-Blue Hill.
“The message is if you have a medical issue, just go to the emergency department,” said Milliken. “These systems are operating as our only response currently to a long list of human suffering. It isn’t fair to the criminal legal system, it isn’t fair to ER staff, and it isn’t fair to anyone else.”
The new law punishes people – some of whom may be in a state of psychosis and unaware of their actions – “for something that is essentially a treatment failure,” said Emily Mott, staff attorney for Disability Rights Maine.
People in crisis brought to an emergency department against their will because they are deemed a danger to themselves or others are often more at risk of lashing out, although they may not be fully in control – or even aware of – their actions.
That was the case for Julie Potter, who brought herself to the emergency room for a dissociative episode while studying for her master’s in social work at the University of New England.
Potter said after explaining her situation to hospital staff that she was led by police officers to a sterile room. Potter said she tried to leave, and remembers only waking up to bruises on her body with officers saying she had assaulted them.
Potter was eventually charged with assault on a police officer – a charge that carries similar punishments to those under L.D. 1119.
While the charges were eventually dropped, after what she said was a lengthy court proceeding and a year of psychiatric supervision, the incident upended her life and ultimately resulted in Potter leaving her master’s program.
“What it’s going to do is criminalize people’s trauma in mental health,” Potter said of the expanded law. “We are going to have more people in prison, in jails, in the court system that are just hurting and more hopeless, and do not believe in a system that cares about them. … You are ruining people’s lives.”
People convicted of a felony may have trouble getting jobs or housing, said Mott, of Disability Rights Maine, which can further delay treatment.
“In a world of collateral damages, it’s important.”
Health care workers shouldn’t have to tolerate assault, said Frayla Tarpinian, district defender at the new Capital Region Defender’s Office, but expanding the law will not effectively deter violence if the behavior is driven by mental illness and the punishment doesn’t include treatment.
“There is just something manifestly unfair about somebody who does not want to be touched to be forcibly medicated, then charging them because they don’t comply.”
WHO BENEFITS?
“It’s a tough situation all around. Who does it help the most? The irony is, it probably helps prosecutors, judges and defense attorneys,” said Brendan Trainor, district attorney for Penobscot County. “It does give us more options to charge somebody.”
Despite this, many district attorney offices and police departments across the state say they have not seen an increase in the number of charges since the law was passed.
The Portland Police Department has only seen four charges since the law was enacted, despite Maine Medical Center reporting large numbers of assaults.
Other departments, including in Augusta, Lewiston and Machias, said they had seen little change in the number of charges since the law’s passage.
In Penobscot County, there have been eight charges for assault on emergency medical service personnel since July 2022. The Lewiston Police Department reported six charges between July 2023, when the law was enacted, and this June, and the Augusta Police Department reported four – on par with the 10 and seven charges, respectively, reported in the year prior.
On the other side, McKee, the defense attorney, felt prosecutors already had enough “tools in the toolbox” to charge someone with assault. Unless judges said they were seeing serious offenses that require more serious charges, he said, there was no reason to increase the penalty.
Health care providers emphasized they do not file charges against a person in a mental health crisis, unable to distinguish right from wrong. Once charges are brought, whether a person is competent to stand trial is decided by the state’s forensic evaluators and a judge.
Austin, of the Maine Hospital Association, and hospital staff recognize that violence can be unintentional, especially if it stems from someone with a mental illness.
But that’s not true for all, said Austin.
“And we believe [they] should be held accountable for their decisions.”
https://www.pressherald.com/2024/07/14/last-year-maine-made-assaulting-an-emergency-medical-worker-a-felony-the-problem-of-patient-violence-remains/
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A Better Path to Universal Health Care
The United States should look to Germany, not Canada, for the best model.
by Jamie Daws - NYT - February 20, 2019
Dr. Daw teaches health policy and management at Columbia University.
As a Canadian living and studying health policy in the United States, I’ve watched with interest as a growing list of Democratic presidential candidates — Senators Bernie Sanders, Kamala Harris, Elizabeth Warren, Kirsten Gillibrand and Cory Booker — have indicated support for a Canadian-style single-payer plan with little or no role for private insurance. Approval of such a system has become almost a litmus test for the party’s progressive base.
But rather than looking north for inspiration, American health care reformers would be better served looking east, across the Atlantic.
Germany offers a health insurance model that, like Canada’s, results in far less spending than in the United States, while achieving universal, comprehensive coverage. The difference is that Germany’s is a multipayer model, which builds more naturally on the American health insurance system.
Although it receives little attention in the United States, this model, pioneered by Chancellor Otto von Bismarck in 1883, was the first social health insurance system in the world. It has since been copied across Europe and Asia, becoming far more common than the Canadian single-payer model. This model ensures that all citizens have access to affordable health care, but it also incorporates age-old American values of choice and private competition in health insurance.
Germans are required to have health insurance, but they can choose between more than 100 private nonprofit insurers called “sickness funds.” Workers and employers share the cost of insurance through payroll taxes, while the government finances coverage for children and the unemployed. Insurance plans are not tied to employers. Services are funded through progressive taxation, so access is based on need, not ability to pay, and financial contributions are based on wealth, not health. Contributions to sickness funds are centrally pooled and then allocated to individual insurers using a per-beneficiary formula that factors in differences in health risks.
The United States has the foundation for this kind of system. Its Social Security and Medicare systems use taxation to pay for social insurance policies, and the health care exchanges created by the Affordable Care Act provide marketplaces for insurance policies.
In an American version of this system, private insurers would have to be heavily regulated to ensure that coverage was affordable and to prevent the sort of rapid increases in premiums, deductibles and cost-sharing that have occurred over the past decade. Similar to regulations for Medicare and Medicaid, insurers would be required to provide a comprehensive set of benefits with limits on patient cost-sharing, which could be means-tested or tied to other criteria, such as having a chronic disease.
In Germany, for example, insurers can charge only small out-of-pocket fees limited to 2 percent or less of household income annually. Compared with the mostly fee-for-service, single-payer arrangements in Canada or the Medicare system, enrolling Americans in managed care plans paid on a per-patient basis would offer greater incentives to increase efficiency, improve quality of care and promote coordination of care.
Under a German-style plan, states could still be given flexibility in regulating nonprofit insurers to reflect regional priorities, similar to the flexibility offered to states in managing Medicaid and the A.C.A. exchanges.
Germany, Austria, the Netherlands and other countries with similar systems vastly underspend the United States. Americans may be concerned that lower spending reflects rationing of care, but research has consistently found that not to be the case. Other high-income countries spend less on health care than the United States because they have lower prices, not because they receive less care. In Germany, sickness funds leverage market power to secure lower prices, coming together regionally to negotiate contracts with doctors and hospitals, and nationally to negotiate drug prices.
Administrative and governance costs in multipayer systems are higher than in single-payer systems — 5 percent of health spending in Germany compared with 3 percent in Canada. But there is much room to cut prices. If, for example, insurers were able, on average, to achieve hospital and physician prices at the level of Medicare, and prescription drug prices at the level of the Department of Veterans Affairs, the savings would be significant.
While recent polls indicate that a majority of Americans support so-called Medicare for all, approval diminishes when the plan is explained or clarified. The former Starbucks chief executive, Howard Schultz, who is considering running for president, called the proposal to eliminate private health insurance “not American.” A German-style multipayer road to universal coverage might receive a much warmer reception.
Americans have long valued choice and competition in their health care. The German model offers both: Patients choose private insurers that compete for enrollees, in the process driving innovation and improving quality. If the United States adopted this model, insurance companies would be more tightly regulated and required to become nonprofits, and some job losses would be likely. But they would not need to be eliminated, an idea suggested, and then retracted, by Ms. Harris in her call for Medicare for all.
The diversity of health financing arrangements globally demonstrates that there are many possible paths to achieving universal health care at an affordable cost — as Ms. Harris’s advisers acknowledged after walking back her call for the elimination of private insurance.
Advocates and policymakers should pick carefully among these paths, choosing one that strikes a balance between what is possible and what is ideal for the United States health system. While the single-payer model serves Canada well, transitioning the United States to a multipayer model like Germany’s would require a far smaller leap. And that might encourage Americans to finally make the jump.
Jamie Daw is assistant professor of health policy and management at Columbia University’s Mailman School of Public Health.
https://www.nytimes.com/2019/02/20/opinion/health-care-germany.html
Opinion Medicare needs reform. Start with Medicare Advantage.
The GOP has gone from trying to cut entitlements to proposals that would make them financially unsustainable.
Repudiating the Republican Party’s traditional support for trimming entitlement programs, former president Donald Trump has promised repeatedly not to “touch” Social Security or Medicare since declaring his first candidacy in 2015. This simplistic but popular position helped Mr. Trump compete with Democrats for working-class votes. But it foreclosed any realistic plan for long-term federal debt control. In the 2024 campaign, however, Mr. Trump has taken his pandering to new and truly reckless heights, with proposals that would go beyond merely tolerating an unsustainable status quo to making it even worse.
“SENIORS SHOULD NOT PAY TAX ON SOCIAL SECURITY!” Mr. Trump declared in a July 31 Truth Social post. This appears to mean that he would eliminate the partial income taxation of Social Security benefits, which first went into effect 40 years ago as part of a bipartisan deal to shore up the Social Security and Medicare Hospital Insurance trust funds. Proceeds from the measure help to replenish both. Mr. Trump’s suggestion would amount to a tax cut of between $1.6 trillion and $1.8 trillion over 10 years, according to the Committee for a Responsible Federal Budget. Benefits would disproportionately accrue toward relatively prosperous households, according to the Tax Policy Center.
Because of the lost revenue, Social Security’s trust fund would become insolvent one year sooner than otherwise; Medicare’s insolvency date would arrive six years ahead of current projections. And the sooner the trust funds run out of money, the sooner seniors face the prospect of mandatory benefit cuts. Mr. Trump says such a crisis might be worth precipitating: “One of the things good about that is that’s when people will make a deal,” he told Fox Business’s Maria Bartiromo. We’d feel better about that particular stratagem if he had actually backed it up with some specifics about how to make up the shortfall, but all he offered Ms. Bartiromo was “there is so much waste in our government.”
In short, Mr. Trump’s outburst about Social Security taxation will make it harder for him to keep the 2024 Republican platform’s promise to “protect Social Security and Medicare with no cuts, including no changes to the retirement age.” In fact, even before that Trump-approved document had appeared, the party had gravitated toward a position that would make it more difficult to control a key source of cost growth in the government’s health programs for seniors: Medicare Advantage.
An alternative to the “original” fee-for-service Medicare, Medicare Advantage contracts with private insurers to offer retirees a health package and manage their outpatient care, in return for an annually determined set fee. That fee is “risk-adjusted” according to the health of the insured patient population. In 2023, Medicare Advantage covered more than half of all Medicare participants for the first time in its 20-year history — 30.8 million seniors. In theory, the program taps the private-profit motive to save Medicare money and raise quality of care. In practice, insurers game the system. A recent Wall Street Journal investigation revealed that between 2018 and 2021 insurers engaged in $50 billion worth of dubious “upcoding,” tacking on extra, sometimes false, diagnoses to their enrollees’ files to inflate the risk-adjusted rates the government pays. Medicare Advantage, now a $450 billion-per-year item in the federal budget, costs more per-person than traditional Medicare.
To its credit, the Biden administration has tried to rein in Medicare Advantage, squeezing reimbursement levels and reforming risk adjustment formulas. To be clear: We’re talking about reductions in how much spending grows, not “cuts.” The administration’s most recent payment plans, announced in April, still raised Medicare Advantage by $16 billion. Nevertheless, lobbied by the insurance industry, GOP lawmakers branded these tweaks an attack on seniors. A GOP campaign ad accused Mr. Biden of “ripping health-care benefits away.” The Heritage Foundation’s Project 2025 advocated making Medicare Advantage the default option for Medicare-eligible seniors, while ending regulations that supposedly “micromanage” the program. Mr. Trump and his campaign have disavowed the Heritage policy blueprint in the face of Democratic attacks on it as a plan for extremism. But on the Medicare Advantage issue the document was hardly inconsistent with Republican thinking.
Small wonder that investors bid up stock in Medicare Advantage providers after President Joe Biden’s disastrous June 27 debate performance made a Trump victory seem more likely. The companies’ stock prices have settled back down as new developments — including Vice President Kamala Harris’s replacement of Mr. Biden at the top of the Democratic ticket and a broad market retreat — superseded the debate. The Trump-dominated GOP’s cavalier approach to entitlements looks like it’s here to stay, though. You might call it “Political Advantage.”
https://www.washingtonpost.com/opinions/2024/08/09/medicare-advantage-reform/
Tim Walz pick excites hopes of taking US healthcare beyond Obamacare era
When Kamala Harris picked the Minnesota governor, Tim Walz, as veep for the Democratic presidential ticket, advocates for healthcare reform felt a jolt of electricity.
Here, they saw a man who proclaimed healthcare a “basic human right”, reformed medical debt collections, and who laid the groundwork for expanded government insurance and denied corporate health insurers contracts with Medicaid, a state-run health insurance program for the poor. Walz even once joined Harris at an abortion clinic in support of abortion rights.
It was a sense of possibility some had not felt since the Obama era, and hard for some to contain their excitement.
“We’re celebrating here at the cabin,” said the Democratic Minnesota state representative Liz Reyer, who helped Walz pass a medical debt collection reform bill in 2023. She was on vacation in northern Wisconsin, sipping coffee next to her sleeping dog – a quiet, midwestern kind of celebration. Reyer felt compelled to stress “how absolutely strongly I was pulling for Governor Walz to be the VP pick”.
“It feels really important and like a huge opportunity,” said Reyer, about the possibility of making such reforms nationally. “I share with Governor Walz the bedrock belief that healthcare is a human right. So, to me – yeah, let’s go.”
Since the Obama era, health reformers have had a tough run. After the passage of the Affordable Care Act (ACA) better known as “Obamacare”, in 2010, the Democratic party suffered heavy midterm losses to what would become known as the conservative Tea Party movement.
Perhaps worse, the ACA became a focal point of Republican rage well into the Trump administration. Republicans only abandoned calls to “repeal and replace” the ACA in 2017, after the now-deceased Republican senator John McCain stunned party leaders by casting the decisive vote against Trump’s plan, returning to Washington amid a brain cancer diagnosis.
Although Republicans were not able to repeal Obamacare, they were successful in another way: years of attacks left little room to expand coverage or rein in healthcare prices, essentially the unfinished work of Obamacare.
Republicans policy wonks have since retreated to time-worn proposals for a second Trump term, primarily fleshed out in the Project 2025 document. Among the early 2000s hits now on a nostalgia tour: Make healthcare shoppable! More privatization! Less regulation! Tax-free savings accounts!
The former president has disavowed Project 2025, though the official Republican platform does not look dissimilar. Notably, Trump’s current campaign and former administration has close ties to authors of the project.
The 2024 Republican platform focuses on “transparency”, “choice” and “competition” (read: shoppable prices and fewer regulations). It also promises “no cuts” to Medicare, a government program for the elderly, though Project 2025 promotes further privatizing the program.
Today, about 92% of Americans have health insurance. That still leaves about 26 million people out of the system – potentially vulnerable to the full force of market prices in the world’s most expensive health system. A catastrophic illness or ailment can easily lead to financial ruin.
What’s more, even for people who have health insurance, medical debt remains a persistent problem. Forty-one per cent of Americans owe money to a medical provider, credit card or family member for healthcare. Often, when people have or fear medical debt, they cut back on food, clothing and other household items, according to a widely cited Peterson-KFF Health System Tracker poll. People with medical debt tend to be sicker and die sooner.
At the same time, the cost of healthcare now eats up 17% of America’s gross domestic product, nearly double that of peer nations. That is in spite of the fact that Americans see the doctor less than peers in other wealthy nations and have worse health outcomes.
While not all of America’s health problems can be pegged to problems with the insurance industry, anecdotal reports show at least some can be – such as adults waiting until they reach Medicare eligibility age to get cataract surgery or Americans feeling reticent to smile for fear of revealing a mouth full of decay.
Exactly what Harris and Walz’s healthcare platform will be remains to be seen. The 2020 Democratic platform included a call for a public option, reining in pharmaceutical spending and strengthening Obamacare. The administration accomplished some of this.
Notably, the Biden administration just finished its first Medicare prescription drug price negotiation – a process common in peer nations but which was prohibited when Biden took office. The most recently released Democratic party platform came in July, before Biden dropped out of the race.
What is clear is the similarities in Harris’s and Walz’s records. The Biden administration capped insulin prices at $35 a month for Medicare beneficiaries. So did Walz for Minnesotans not on Medicare – an act he named after resident Alec Smith, a 26-year-old who died from rationing his $1,300-a-month insulin supply.
Walz worked closely with Reyer to pass a comprehensive package of reforms for medical debt collection, which included a prohibition on hospitals from denying care to patients with outstanding balances, and which stopped the automatic transfer of debt liability to spouses. Similarly, the Biden administration has sought medical debt restrictions through rule-making with the Consumer Financial Protection Bureau.
Walz said in his inaugural address as governor that he believed healthcare was a “human right”. That’s widely accepted wisdom outside the US, and all but the unofficial tagline for single-payer healthcare advocates – the kind of government-run universal healthcare that is a source of pride for the UK’s National Health Service.
Similarly, Harris co-sponsored 2019 legislation introduced by Senator Bernie Sanders that would have established single-payer healthcare nationally. The revolutionary proposal stood no chance of passing, and she has since sought to moderate from that moment. Her campaign has said she would “not push” single-payer as president. Still, it has got advocates excited.
“From our standpoint, this is fantastic,” said Dr Philip A Verhoef, a critical care doctor in Hawaii and president of Physicians for a National Health Program, the nation’s largest single-payer advocacy organization.
“Ten years ago, single-payer burst on to the scene,” with Sanders’s presidential run, said Verhoef. “Prior to that, nobody ever talked about this.” Similarly, single-payer advocates were “shut out” of Obamacare discussions, Verhoef added.
Walz also laid the groundwork for a “public option” health insurance plan in Minnesota, where the government would allow people to buy into Medicaid, and banned private health insurance companies, such as behemoth UnitedHealth, from contracting with Minnesota’s Medicaid plan.
How the Harris-Walz ticket will translate the excitement of reformers into action – and what exactly their proposals will be – remains to be seen. For the time being, activists are enjoying a sense of possibility, knowing difficult discussions lie ahead.
“So often, we see people in positions of political power are thinking, ‘Well, what can we get done without blowing up the system,’” said Verhoef. “I appreciate that attitude – in a way that’s what the ACA was. It helped a lot of people. But it still left 30 million people uninsured in this country and it hasn’t stopped people from going bankrupt from healthcare bills.”
https://www.blogger.com/blog/post/edit/3936036848977011940/6772813047445060851
Biden policy will make 10 popular medicines less expensive for those with Medicare
First of its kind US policy will mean discounts on 2023 prices ranging from 38% to 79%
Joe Biden’s administration announced a landmark healthcare negotiation on Thursday in which 10 popular medications will now be available at lower prices for Medicare beneficiaries.
The discounts on the 2023 prices ranged from 38% to 79%, according to the figures released by the Centers for Medicare & Medicaid (CMS).
The 10 drugs are Januvia (diabetes), Fiasp (diabetes), Farxiga (diabetes, heart failure, kidney disease), Enbrel (arthritis and psoriasis), Jardiance (diabetes, heart and kidney disease), Stelara (arthritis, psoriasis and colitis), Xarelto (blood clots), Eliquis (blood clots), Entresto (heart failure) and Imbruvica (blood cancers).
The new policy, which is the first of its kind in the US, was part of the Inflation Reduction Act, which Democrats passed in 2022. It gives people on Medicare, a government insurance plan for seniors above 65, financial relief amid increasing health costs.
“For years, millions of Americans were forced to choose between paying for medications or putting food on the table, while Big Pharma blocked Medicare from being able to negotiate prices on behalf of seniors and people with disabilities,” Biden said in a statement. “But we fought back – and won.”
Biden’s statement also pointed out that no Republicans voted for the bill, which also includes climate legislation. The announcement also comes toward the end of a fraught election cycle, in which the Biden administration and Democrats are hoping to double down on their messaging around economic growth and so-called kitchen table issues.
Healthcare is a key issue for voters in this election, and Biden held a slight lead over Trump for his platform throughout the year before he dropped out of the race.
“As someone who’s worked on these issues for a really long time, it is a historic moment that is finally happening,” said Neera Tanden, director of the White House Domestic Policy Council.
“As we like to say, on landmark healthcare achievements, this is a big … deal,” she added, making reference to Biden’s infamous remark at the signing of the Affordable Care Act by inserting a pause where Biden used an expletive.
According to the administration, the negotiations will save Medicare $6bn when they take effect in 2026, while saving seniors an estimated $1.5bn.
Xavier Becerra, the Health and Human services secretary, said on a call with reporters that the negotiations were “comprehensive” and “intense”.
“It took both sides to reach a good deal,” he said.
Bringing down the cost of prescription drugs was a cornerstone of Biden’s economic agenda and part of his re-election pitch to Americans.
Kamala Harris, the vice-president and Democratic nominee for president, also weighed in on the Medicare negotiations, focusing on her tie-breaking vote for the IRA, her work with Biden and her past record.
“As attorney general, I held Big Pharma accountable for their deceptive and illegal practices. The record-breaking settlements that I won – for the people – amounted to more than $7bn against pharmaceutical companies for their unsafe and unfair tactics,” she said. “President Biden and I will never stop fighting for the health, wellbeing, and financial stability of the American people.”
Becerra emphasized that Harris played a critical role by casting the tie-breaking vote in her capacity as president of the Senate to pass the IRA.
“Without her vote, we wouldn’t be talking about having negotiated drug prices,” Becerra told reporters. “President Biden and Vice-President Harris delivered on their promise to bring down the price of essential prescription medications, and now we’re going to see the benefits of it with that.”
https://www.theguardian.com/us-news/article/2024/aug/15/biden-policy-medicines-less-expensive
