Author: davidgimlett

Retired Family Physician and advocate of healthcare reform

Post-Election: Health Care Reform or Health Care Deform?

November 11, 2016

It’s difficult to verbalize all the feelings after the  election results. We can only fear what is to come. Yes, medical reform will be on the agenda and we will speak to that.
We will continue to advocate for health care reform but it’s obvious that we have to broaden our concern  to include reminders of our social contract, the role of ethics (doing what is right) and the dangers of relying on the profit-motive free market to care for our social needs.
Obamacare was flawed from the start. Dr.  John Geyman highlighted this in 2010 with his book, “Hijacked :The Road to Single Payer in the Aftermath of Stolen Health Care Reform.” The main problem was that the bill was essentially written by industry lobbyists. They did everything they could to make sure that corporate profits were maximized. Now that the Republican party is in control of the federal government those same health care industries, their lobbyists and their dark money supported politicians are preparing to replace Obamacare with something. We know it won’t be with single payer medicine. That will come only when our medical care is totally broken. First we are going to have to witness the failure of medical savings accounts, insurance companies freed from oversight by state insurance commissioners, and some sort of supplements to help pay the insurance companies inflated premiums for low value coverage. The sudden post-election jump in the value of drug company stocks tell us how likely it is that drug prices are going to be brought under control. And of course policies will be based on the false assumption that people will make smarter (cheaper) choices about going to the doctor if they have to pay out of pocket. This assumes, of course, that many people go to the doctor when they don’t need to and that nobody will avoid needed care because of the expense. Strange, after 50 years of family practice I found neither of these concepts to be true.  But what do I know? In the past we have theoretically discussed the fallibility of the various alternatives to single payer medicine.  Now we are going to have to actually live with another (even worse than Obamacare) option. Watch for an astronomical jump in our medical induced bankruptcy rate and a big increase in the 45,000/year unnecessary death rate.

Can new FDA Commissioner transcend industry ties?

The announcement that Dr. Robert Califf has been nominated to become the next head of the FDA offers no encouragement that the failures and corruption of the FDA will be addressed in the foreseeable future. As Sabrina Tavernise writes in the New York Times, “…he has deeper ties to the pharmaceutical industry than any F.D.A. commissioner in recent memory, and some public health advocates question whether his background could tilt him in the direction of an industry he would be in charge of supervising.” As previously noted the FDA is a failed public agency with unanswered criticisms of regulatory approval of worthless and harmful drugs, flawed criteria for drug approval, lack of investigation of unpublished results of drug research products, and absence of oversight of the conclusions, methods, and conflicts-of-interest in published research studies. The agency’s uncritical use of R & D figures supplied by the industry makes the agency an unwitting apologist for outlandish U.S. drug prices. Hopefully Dr. Califf will be able to transcend his relationship with the pharmaceutical industry and use his knowledge and clinical sympathies to create a more honest, transparent, and effective agency.

Vouchers Are Not a Plan

Opponents of a single payer health care system in the United States like to say it would cost too much, even throwing in the inappropriate complaint that the CBO has not scored any plan.  Of course that won’t happen until congress puts bills such as H.R. 676 through the committee system. As an alternative a voucher plan is often offered up. The only thing that the voucher system offers is a cost-shifting lid on government spending. No control over total health care costs. No access to medical care for those who cannot afford the ever-increasing costs not covered by the vouchers. No system. An improved, expanded Medicare would require hard, thoughtful work and discipline, but it can succeed. We can pick and choose figures to argue over but  there is no ethical and rational alternative.

The financing of Medicare for All is a well explored issue. As far back as 1991 the GAO reported that, “If the universal coverage and single-payer features of the Canadian system were applied in the United States, the savings in administrative costs alone would be more than enough to finance insurance coverage for the millions of Americans who are currently uninsured. There would be enough left over to permit a reduction, or possibly even the elimination, of copayments and deductibles, if that were deemed appropriate.”   Later the same year the CBO reported, “If the nation adopted…[a] single-payer system that paid providers at Medicare’s rates, the population that is currently uninsured could be covered without dramatically increasing national spending on health. In fact, all US residents might be covered by health insurance for roughly the current level of spending or even somewhat less, because of savings in administrative costs and lower payment rates for services used by the privately insured. The prospects for controlling health care expenditure in future years would also be improved.” (“Universal Health Insurance Coverage Using Medicare’s Payment Rates”) .  Fourteen years later the lack of true (not just for the government) cost controls make improved Medicare for All an even more imperative goal.

For a good, up-to-date discussion (2013 figures) of H.R. 676 see the article by Gerald Friedman, professor of economics at the University of Massachusetts, Amherst. Friedman extrapolates on (1) the savings on provider administrative overhead and  pharmaceutical costs, (2) the regressive and obsolete funding sources to be replaced by progressive taxation (in billions of dollars), (3) the savings on administrative costs of insurers, Medicaid, and employers (in billions of dollars) and (4) the savings on federal tax expenditures.

As Professor Friedman states, “On top of the enormous administrative savings of single payer, the savings from effective cost-control would make it possible to provide universal coverage and comprehensive benefits to future generations at a sustainable cost.”


…and study Friedman’s charts

Funding with progressive taxationFunding with Tobin Tax

Reference Pricing: Another Fad


There have been a number of good discussions of reference pricing. This concept is mainly applicable only to large employer sponsored plans. As Ricardo Alonso-Zaldivar from the Associated Press observed, “However, the strategy appears to be suitable only for a subset of medical care: procedures and tests that are frequently performed, where the prices charged vary widely but the quality of results generally does not. In addition to knee and hip replacements, that could include such procedures as MRIs and other imaging tests, cataract surgery and colonoscopies.” The idea is essentially incompatible with the insurance exchanges and narrow networks. And, is there any reason to trust the insurance companies to use a fair, patient-centered set of standards in establishing any given price? Or is it possible that they will game any such system to their own advantage? For instance, they have already found a way to make sure any additional expenses incurred by the patient will not be allowed to apply to the out-of pocket caps required by the ACA.  Sarah Lazare in Common Dreams discusses some of the pitfalls in this latest experiment by CMS. In June, 2014, FamiliesUSA published an excellent brief by Lydia Mitts, “How To Make Reference Pricing Work For Consumers.” Ms. Mitts points out the potential financial risks of cost shifting to consumers if the insurance companies set their pricing too low making it difficult for patients to find providers who will accept the payments. She also mentions that those who do accept the prices might raise prices for other services. She concludes with an excellent list of key elements that would be necessary in order to make such a system work for patients. Unfortunately, the health insurance industry has shown little interest or ability to do such things as providing adequate networks or prioritizing (or even, measuring) quality. Don McCanne provided a good commentary back in 2013, which he summarized by saying, that CMS is saying “we should shift risk to the patients – exposing them to financial penalties should they not make perfect decisions in their health care purchasing, even as the private insurers create yet more barriers to perfectly priced health care!”

The goal to bring down prices of medical care is admirable but one more payment system just adds to the incomprehensible world of multiple payers, multiple (often conflicting) rules and regulations, confused eligibilities, unintended consequences, profit-making, rent-seeking and cost-shifting to the “consumer.”

The Narrative in the Dead Files

Dr. Edwin Leap’s blog in KevinMD is so right on. But I think the murder he describes is more heinous than the picture he paints. In addition to the loss of story from the medical records we also see three additional faults in the trial records. The first is one immediately experienced when, as a patient, you are confronted with a check list that someone is going to enter into the computer. The choices you are given don’t include any answer that approximates your real experience. And you have been instructed to choose an answer closest to your experience. The second (not so obvious) is that these codified answers will end up in an insurance company’s computer as a diagnosis that will follow you for the rest of your life. And thirdly, most importantly, the story that is lost is not just what unfolded from the doctor-patient encounter but what was the true meaning of the patient’s request for help. Dr. Leap mentions the sore throat or sprained ankle as straight forward problems which he says “I can figure out.” But missing from this dismissal is the story of why the patient came for help in the first place. Is it because they have no job sick leave and they are anxious about missing work? Or they had a neighbor who was told he had just a sprained ankle and ended up in surgery because of a missed diagnosis? Or one of their children was diagnosed with a “strep throat” two weeks ago and didn’t get better until they were put on antibiotics. If they have had a flare up of back pain is there any clue to why they come in now? Is it a different pain? In what way? What has changed that makes this more upsetting in their life? Does the change make them worry about something else going on? What have they been doing on their own to try to manage the pain. What used to work and doesn’t any longer? These all important discussions don’t end up in any computerized record. And, contrary to other comments, improved software will not solve this problem unless…unless…the software includes an accurate rendering of a dictated narrative. And, of course, the narrative doesn’t generate ICD-10 codes and can’t be used to measure “value” under the latest pay-for-value scheme. As personal medical care is disappearing we may be witnessing, not murder, but genocide.

Improve-Don’t Destroy-Medicare

The recently passed House of Representatives “doc fix” is a warning and should serve as an inspiration to forge ahead in improving and expanding Medicare for all.  Instead of sticking with the necessary goal of repealing the Sustainable Growth Rate (SGR) the Republican lead House has started on its quest to privatize (cost-shift back to out-of-pocket expensing) Medicare and cut back on Medigap benefits. Those of us who are concerned about the health care of everyone in our country need to get serious about the job of improving Medicare even before we move into universal coverage. We could start with proposals for quickly eliminating the donut hole in drug coverage. That, combined with eliminating the proscription against negotiating prices with the pharmaceutical industry, would offer affordable availability of even the specialty drugs for cancer, hepatitis C, multiple sclerosis, rheumatoid diseases, etc.  A quick fix should be made to the physician payment system until workable substitutes for our present volume based system can be developed under a single payer plan. That fix could be a simple up-adjustment of evaluation and management codes and down-adjustment of procedural codes with a budget neutral end point. And we could stop wasting time, money and other resources on the present catch-word pay-for-performance and pay-for-value experiments. Attention could be focused on mental health and long term care needs. Expandable systems could be developed for these areas even before Medicare moves to universal coverage. We should also be making the necessary changes to eliminate the need for Medigap policies, Part D coverage, and Medicare Advantage Plans. Not solely related to Medicare but open to immediate action would be improvement in the recruitment and financing of the primary care pipeline from first year medical students through residency training programs. We could also take a few steps back to re-think the present electronic medical records push and its Meaningful Use regulations. This has been a poorly thought out, expensive, provider exhausting  effort with a huge disconnect between the stated goals and the existing technology and financing resources.

We should be improving Medicare, not destroying it. We should all be putting pressure on our Congressmen and administration to eschew any actions that disregard the above goals.

FDA Exit

News that Dr. Hamburg is stepping down as FDA Commissioner is just a reminder of how ineffective the FDA is as a regulatory agency.  As Jack Lewin, M.D. states, “She has understood that we need industry as a partner.” Unfortunately that seems to have been her perspective, too. However, the FDA can not be a “partner” with half its budget paid for by the pharmaceutical industry and still fulfill the regulatory function it is charged with. Approval of worthless and harmful drugs, lack of investigation of unpublished results of drug research products, absence of oversight of the conclusions, methods, and conflicts-of-interest of published studies all add up to a failed public agency that needs more than a new commissioner.  A new agency with a new mandate, infused with scientific integrity and immune from political grandstanding and industry corruption is vital for the health of our nation. For further reading…Where is the FDA?…

All the Way to the Bank

There has been a lot of discussion about excessive CMS payments to the privatized Medicare Advantage plans.  One area of special concern is the risk management adjustments that provide additional payments for the care of high risk patients. This leaves open a huge area for gaming the system by the insurance companies. Upcoding and adding new diagnoses (not those supplied by the attending physicians) seems to be on the increase. A recent article by Bob Herman in Modern Healthcare discusses this problem. Besides this chicanery of the insurance industry one of the most sordid aspects of the current debate is the overt buying of government by the same industry and the obvious bribery in the U.S. Senate. 53 Senators have sent a letter to CMS pressuring the agency to continue the overpayments. According to Open the two senators leading the pack have received more than $727,000 in campaign funds from the health insurance companies in the last 8 years; Mike Crapo $234,000, Charles Schumer $493,000. In the mind of Everyman this is unethical. But, then, we already know that our politicians are not answerable to Everyman.

Obamacare Unsustainable

Geyman's Books

Dr. John Geyman has published his latest book on the state and future of American health care.* He has written a series of books on this subject over the last 13 years.** His latest, “How Obamacare is Unsustainable” should be must reading for every congressmen, CMS employee and medical reporter and blogger as well as President Obama and his staff. It should be recommended reading for everyone else concerned about health care in the United States.

Dr. Geyman discusses the failure of the Affordable Care Act (ACA) to effectively address the four biggest challenges of health care reform: restricted access, increasing costs, increasing unaffordability even for people with insurance, and poor quality of care compared to the rest of the industrial world. He first reviews the history of the corporation led charade that created the byzantine ACA. Political corruption, lobby money, and media entanglements with corporate stakeholders (especially the pharmaceutical and insurance industries) disfigured the initial goals beyond recognition.

In Chapter 10, after reviewing where we stand now, 5 years into the ACA, he elaborates on the ten lessons we should have learned (and were predictable):

1) Health care “reform’ through the ACA was framed and hijacked by corporate stakeholders, themselves in large part responsible for system problems of health care and dedicated to perpetuating their self-interests in an unfettered health care marketplace.

2) You can’t contain health care costs by leaving for-profit health care industries to pursue their business “ethic” in a deregulated marketplace.

3) You can’t reform the delivery system without reforming the financing system.

4) The private insurance industry does not offer enough value to be bailed out by government.

5) It is futile to embark on unproven and disproven incremental tweaks to our present system while ignoring health policy and experience around the world.

6) In order to gain the most efficiency of insurance coverage we need the largest possible risk pool to spread the risk and avoid adverse selection.

7) The ACA is a massive bailout of private interests profiting on the backs of sick or injured Americans.

8) The single-payer alternative was considered “politically unfeasible” by being “too disruptive” to the existing system; instead, look at how disruptive the ACA has been compared to the simplified single-payer alternative.

9) The ACA is unaffordable for many patients and their families, is byzantine in its complexity, and is unsustainable in the long run.

10) We cannot trust many states to assure an adequate safety net for the insured and underinsured.

Dr. Geyman goes on to define the need for, and the barriers to the development of a single-payer system in the United States. He describes what a single-payer system would look like and what the political prospects are for developing such a system.

This evidence-based analysis of our health care non-system offers the most comprehensive, accurate, and functional map of the road to universal health care in the United States.

* Geyman, JP. How Obamacare is Unsustainable: Why We Need a Single-Payer Solution for All Americans. Friday Harbor, WA. Copernicus Healthcare, 2015.

**A list of books by Dr. John Geyman

  •  Health Care in America                                                 2002
  • The Corporate Transformation of Health Care               2004
  • Falling Through the Safety Net                                       2005
  • Shredding the Social Contract                                        2006
  • The Corrosion of Medicine                                              2008
  • Do Not Resuscitate                                                          2008
  • Hijacked                                                                           2010
  • Breaking Point                                                                  2011
  • The Cancer Generation                                                    2012
  • Health Care Wars                                                             2012
  • How Obamacare is Unsustainable                                   2015

To see Dr. Geyman’s biography and web site visit….… &

Congressional Committe Eyes Medicare

Again, a congressional committee is studying a fix to the Medicare Sustainable Growth Rate (SGR) problem. Last year’s attempt led to a three committee compromise plan that never came before congress for a vote. The plan was an over-reaching attempt to change the entire physician compensation system. This produced a minefield that incorporated concepts that, so far, have proven to be ineffective and/or expensive, viz., using controversial guidelines to guide the already failed pay-for-performance mantra and tying payments to physician participation in alternate payment models (APMs) such as patient centered medical homes (PCMHs). So far this latter entity has been ill-defined and unsuccessful even though, in the future, thoughtful development may make this a viable optional medical care delivery system. Rather than attempt to re-write all of Medicare it would be wiser for the committees to focus on two rather simple things that they have been unable to accomplish: repeal of SGR and revision of the flawed RBRVS payment system. This latter contributes to the present inappropriate physician payments and to the demise of primary care. For a discussion of a quick fix for both of these problems read…