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.
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 single payer movement in the U.S. is built around the concept of an “improved Medicare for all”. The “improved” part of that message recognizes that our present Medicare system needs some revisions to make it a valid vehicle to provide universal health care. Some of the major areas of concern are the control over fraud and abuse, the contrary incentives of the fee for service system, the disappearance of the primary care workforce, and the uncontrolled costs of prescription medications and durable goods. Solution to many other aberrations in our delivery of health care will have to wait for single payer.
Tackling some of these problems now can help ready us for producing a winner out of the starting gate. This includes working to improve quality of medical care. But trying to move forward illuminates the same problem that prevented the Affordable Care Act from achieving quality and cost-saving while providing comprehensive insurance coverage, viz., the political power of the various stakeholders and lack of any immunity from micromanagement by congress and the administration.
We need to get our voices heard as we work on the triple goals to:
- Improve Medicare
- Improve the quality of medical care
- Create Single Payer Medicine
These goals provide a set of action points for realizing the “Triple Aim” of improving the individual experience of care; improving the health of populations; and reducing the per capita costs of care for populations. (http://content.healthaffairs.org/content/27/3/759.full)