Jim Flower has written an excellent article in Hospitals & Health Networks stating, ”It’s time to Rebuild Health Care’s Business Model”. He nicely portrays the unworkable elements of our present system and concludes that there is no way of tweaking the model to make it work. As he says, “The health care system, payers and providers playing the Default Model Game, are delivering an unreliable, unguaranteed, financially and medically dangerous product to their real customers — the large purchasers and the consumers of health care. This is not stable.” Unfortunately he runs out of steam when it comes to the solution. Admittedly, he is speaking to hospitals and health networks and not to individual patients, policy makers, CMS, legislators, etc. His recommendations to get out of the fee-for-service business as much as possible, drive down internal costs and bid actual prices are, again, just different ways of playing the same old game. They don’t alter the present underlying attitudes of treating health care as a commercial, for-profit business rather than as a humane service. We have to grasp the knowledge that health insurance is a no-value-added business, that the patent protected pharmaceutical industry is avaricious, hospital systems are bounced between profit-making and forced service and physicians are losing their sense of their profession as a “calling”. Reforming business models is not going to change these fundamental dynamics. If we want affordable, accessible and universal health care we need to improve Medicare and expand it to cover everybody from the day they are born and finance it through a single payer, multiple provider system dedicated to health care reform.
Dr. James Binder recently wrote an article on one of the manipulations that health insurance companies use to circumvent the new insurance regulation that makes it illegal to deny insurance coverage on the basis of pre-existing illness. So what do they do? They create multiple tiered drug benefits which generate high out of pocket expenses for people under treatment for serious illness such as cancer, rheumatoid arthritis and multiple sclerosis. This drives these patients away to find a different source of insurance, which means more expensive. The industry has found a way to discriminate on the basis of pre-existing illness.
It should be mentioned that the insurance companies have a similar ruse in developing narrow networks. This creates an automatic screening of patients with chronic illnesses. First, by excluding major referral centers (like Children’s Hospital in Seattle) they drive patients to other insurance or it forces them to pay large amounts out of pocket to continue to see their specialists who have been taking care of them. They also make their insurance policies unpalatable by excluding large percentages of all of the physicians practicing in the area. For those individuals who are basically healthy it does not present too big of a problem to choose a physician from the approved list. But for those patients who have multiple chronic illnesses and multiple specialists it becomes almost impossible to find all of their usual physicians on any one narrow plan. And, of course, the plans change providers every year. So, again, they look for more expensive broader networked plans, and they are back to the old problem of paying higher premiums because of pre-existing illnesses.
As Dr. Binder says, “It is well past the time to rid the health care system of these middlemen.” How? Improved, expanded (to everyone) Medicare. For more see…http://wp.me/p4MwV3-11
Gov.Shumlin of Vermont has announced that he has given up trying to create a single payer medical system in Vermont. This is not surprising. There is no way that single states can obtain the authority to pool the present health care funding of our present system. This amounts to over 65% of today’s costs mostly paid by Federal programs, V.A., military, Medicare, Fed Employees and Fed share of Medicaid and ACA along with Fed prison expenses. Employers, many of whom are national or international, pick up most of the remainder of the bills. And single states do not have the power to control pharmaceutical prices and provider payments. As Don McCanne wrote of Gov.Shumlin, “He has shown us that it is imperative that we continue with our efforts toward a goal of enactment of federal single payer legislation.”. The only affordable way to do this and offer comprehensive coverage for everybody is on a national level
Accountable Care Failure
Recent releases from CMS verify that 13 of the original 32 Pioneer ACO’s have quit even though year 3 isn’t even over yet. Keep in mind that all 32 of these organizations are sophisticated EHR driven medical care systems. The reason for quitting is that they could not qualify for earned shared savings and many reported losses. Interestingly enough there are still no reports of what the start-up costs were for all these entities and, of course, we have no estimates of what the national start-up costs would be if ACO’s dominated Medicare reimbursement across the country. Many facilities lack sufficient EHR systems and staffing to comply with all of the regulations in the Pioneer ACO experiment. And what is it costing CMS to administer the program? Even worse, none of this applies to private and exchange insurance policies.
All of this nonsense could be stopped with the creation of a single payer system.
U.S. hospitals spend 25.3% of income for administrative expenses-the highest of 8 industrialized nations studied in this report. If we had the same percentages as Scotland or Canada we would have saved $140 billion in 2011 and even more per year since then. We could do that by having a simpler single payer system. Health Aff September 2014 vol. 33 no. 9 1586-1594
We Need an Improved Medicare
We should all be looking at ways we can increase the quality of our medical care and decrease the costs at least to equal the accomplishments of the rest of the industrialized world. It makes sense to work on improving Medicare so that when we finally exhaust all of the other alternatives (the American way) and adopt a single payer system, “Improved Medicare for All” we will already have accomplished a lot of the improvement. But Centers for Medicare and Medicaid Services (CMS), while administering Medicare and the Affordable Care Act, seems determined to spend a lot of money on “experiments” that don’t even make sense much less have any evidence to suggest that they are viable. And they seem to spend no effort on predicting unintentional consequences. The effect of these diversions is going to be a further degradation of the medical care available not only to the Medicare eligible but to the entire population. The latest example is the new twist on Chronic Care Management (CCM) services. This was recently discussed in the New York Times in an article by Robert Pear, published August 16, 2014. This is a plan to pay doctors a separate fee of $41.92 a month for managing the chronic care of some Medicare patients after January 1, 2015. This is for non face-to-face development and revision of care plans, communication with other care providers, prescription drug management, etc. see ADDENDUM. It will be classified as a G code with the description,” Chronic care management services furnished to patients with multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient, that place the patient at significant risk of death, acute exacerbation/ decompensation, or functional decline; 20 minutes or more; per 30 days.”
There is no question that care coordination is an increasing problem as patient care has transitioned to specialists and hospitals. Medical care of patients with chronic conditions is especially disjointed and plagued with discontinuities. This breakdown in care over the last 20 years has occurred as primary care, basically family practice, has been driven back to an office based medicine with little communication with hospitals, specialists, urgent care centers and other health care providers.
The creators of this program have done an excellent job of incorporating many of the concepts that are being developed for complex ambulatory medical care, including the Leap Project.
Unfortunately the Chronic Care Management formula presents a number of consequences (which should be foreseen);The number of patients who will fall within the eligible parameters will probably be less than half of the Medicare population. And, in turn, the Medicare population represents 16.5% of the total population in the United States.
This creates two major problems: The small, age defined group of beneficiaries will not provide ample sampling size or randomness to derive useful data for improving chronic care over-all. The additional fixed costs to medical providers for participation will be very high considering the small percentage of their practices affected and the reimbursement limited to the Medicare panel.
The matter of cost to the practitioners will limit participation to large groups and corporations. Rural and underserved areas will again be excluded from some of the benefits of Medicare. Keep in mind that as of 2010 almost half of primary care physicians saw their patients in offices of one or two physicians. Since then, of course, many have left practice.
- Certified Electronic health records are required in this new plan but practice size is a major determinant of physicians’ use of EMRs and HIT capacity, including exchanging patient information electronically and providing electronic access to their patients. Half of physicians in solo practices report using EMRs, compared to 90 percent of those in practices with 20 or more physicians; likewise, there is a 4-fold difference between solo and large practices in achieving multifunctional HIT capacity (11 vs. 45 percent).
- Participant practices will have to have a supervised staff person on call, after-hours, 24/7, to address the “urgent chronic care needs” of the patients.
- Tremendous amounts of paperwork, manpower and teamwork will be required to monitor, coordinate, and document all of the requirements of this plan. For a recent CMS list of these requirements see the ADDENDUM below.
- Deborah N. Peikes discovered in her analysis of the similar team-based Comprehensive Primary Care Initiative that “At baseline, most CPC initiative practices used traditional staffing models and did not report having dedicated staff who may be integral to new primary care models, such as care coordinators, health educators, behavioral health specialists, and pharmacists. Without such staff and payment for their services, practices are unlikely to deliver comprehensive, coordinated, and accessible care to patients at a sustainable cost.”
It is understood that from the perspective of Medicare the high costs of the top 20% of the chronic care patients create the greatest expenditure. But our medical cost and care problems are much bigger than this small corner of the landscape. And all we have to help us is CMS with Medicare, Medicaid, and the Affordable Care Act. Of course if we had everyone in and nobody out we could tackle the bigger problems.
This program is serving as a diversion from solving the problem of adequate compensation for primary care in general. Meanwhile, our family practice workforce continues to decline while Nero fiddles. If as much energy had been put into solving the RVU and physician income disparities we could be on our way to re-establishing a primary care base. Unfortunately the new proposal only aggravates these problems. Two of the major factors that are driving medical students away from primary care is the low future income combined with the high student debt. The third problem is the large burden of office practice administration. The cost of compliance and documentation with all of the existing programs is already overwhelming . This leaves the primary care profession with no time left over to worry about coordination but with a big desire to abandon this field of medicine. CMS has no solution to this and yet they want to add one more program that requires more continuous documentation, appeals of denial to file, cost of extra personnel, etc. CMS states that as part of the new service, doctors will assess patients’ medical, psychological and social needs; check whether they are taking medications as prescribed; monitor the care provided by other doctors; and make arrangements to ensure a smooth transition when patients move from a hospital to their home or to a nursing home. This workload is multiplied by the fact that the target patients are the sickest and oldest. They have a high mortality rate so the paperwork starts all over for the next replacement on the panel. For $42/month.
Who in primary care is left to carry out the program? Basically, it will be members of large group practices and hospital and other institutional employers in urban centers. The growing supply/demand incongruence of available primary care physicians will make that option even more profitable for the physicians. That leaves out the rest of America. And the uninsured and underinsured will continue to be left out in the cold. We need a broader vision. We need an Improved Medicare for All.
“To assist stakeholders in commenting, we remind you of the elements of the current scope of service for CCM services that are required in order for a practitioner to bill Medicare for CCM services as finalized in the CY 2014 final rule with comment period. We would note that additional explanation of these elements can be found at 78 FR 74414 through 74428. The CCM service includes:
- Access to care management services 24-hours-a-day, 7-days-a-week, which means providing beneficiaries with a means to make timely contact with health care providers in the practice to address the patient’s urgent chronic care needs regardless of the time of day or day of the week.
- Continuity of care with a designated practitioner or member of the care team with whom the patient is able to get successive routine appointments.
- Care management for chronic conditions including systematic assessment of patient’s medical, functional, and psychosocial needs; system-based approaches to ensure timely receipt of all recommended preventive care services; medication reconciliation with review of adherence and potential interactions; and oversight of patient self-management of medications.
- Creation of a patient-centered care plan document to assure that care is provided in a way that is congruent with patient choices and values. A plan of care is based on a physical, mental, cognitive, psychosocial, functional and environmental (re)assessment and an inventory of resources and supports. It is a comprehensive plan of care for all health issues.
- Management of care transitions between and among health care providers and settings, including referrals to other clinicians, follow-up after a beneficiary visit to an emergency department, and follow-up after discharges from hospitals, skilled nursing facilities, or other health care facilities.
- Coordination with home and community based clinical service providers as appropriate to support a beneficiary’s ’s psychosocial needs and functional deficits.
- Enhanced opportunities for a beneficiary and any relevant caregiver to communicate with the practitioner regarding the beneficiary’s care through, not only telephone access, but also through the use of secure messaging, internet or other asynchronous non face-to-face consultation methods.Similarly, we remind stakeholders that in the CY 2014 final rule, we established particular billing requirements for CCM services that require the practitioner to:
- Inform the beneficiary about the availability of the CCM services from the practitioner and obtain his or her written agreement to have the services provided, including the beneficiary’s authorization for the electronic communication of the patient’s medical information with other treating providers as part of care coordination.
- Document in the patient’s medical record that all of the CCM services were explained and offered to the patient, and note the beneficiary’s decision to accept or decline these services.
- Provide the beneficiary a written or electronic copy of the care plan and document in the electronic medical record that the care plan was provided to the beneficiary.
- Inform the beneficiary of the right to stop the CCM services at any time (effective at the end of a 30-day period) and the effect of a revocation of the agreement on CCM services.
- Inform the beneficiary that only one practitioner can furnish and be paid for these services during the 30-day period. With the addition of the electronic health record element that we are proposing, we believe that these elements of the scope of service for CCM services, when combined with other important federal health and safety regulations, provide sufficient assurance that Medicare beneficiaries receiving CCM services will receive appropriate services. However, we remain interested in receiving public feedback regarding any meaningful elements of the CCM service or beneficiary protections that may be missing from these scope of service elements and billing requirements. We encourage commenters, in recommending additional possible elements or safeguards, to provide as much specific detail as possible regarding their recommendations and how they can be applied to the broad complement of practitioners who may furnish CCM services under the PFS.”
Federal Register Vol 79 No. 133 July 11, 2014
Darn it. Let’s get this right. Health Care for All is not just a need that we all have (like I need to go to the bathroom). Health Care is not just a right that we can march in the street for and demand because it’s implied in our Declaration of Independence and Constitution. It’s not something that just the neglected should fight for (as their right). It’s a moral mandate that covers all of us and should be embraced by all of us.
Peter Bach has stirred the pot with his recent article, “Cancer: Unpronounceable Drugs, Incomprehensible Prices”. Apologists for the drug industry like to argue that new anti-cancer drug, Zykadia (generic=ceritinib) is far superior to the current $11,000/month drug, Xalcori (crizotinib) and is therefore worth $13,000/month. At present the main argument for this superiority refers back to The New England Journal of Medicine article whose lead author has been an advisor and consultant to the company that makes the drug. If further evidence verifies the superiority it doesn’t argue that our medical system can afford the ever-growing list of multi-thousand dollar drugs. See the Hepatitis C treatment, Sovaldi, at $30,000/month for a total of $84,000 a treatment.
Bach rightly concludes that, “Regardless of the estimate, the pricing of new drugs for cancer and now other common diseases has come unglued from the rationale the industry has long espoused. Instead, pricing is explained by a phenomenon of increasing boldness by the industry against a backdrop of regulators and insurers who have no legal authority to dictate or even propose alternative pricing models.”. At present the model is that the companies charge what they do “because they can”. That won’t work. This free market cliché is unsustainable. The best (?only) solution lies in a medical payment system that gives universal coverage and the power of negotiated pricing with the drug companies. At another time we’ll discuss the lack of transparency of that industry when discussing the true cost of new drug research.
This last January two cancer specialists published an article explaining “Why Oncologists Should Support Single-Payer National Health Insurance”. In his Huffington Post Blog, Dr. John Geyman discusses this problem and points out that not only is the ACA is powerless to control drug prices but it is also unable to control the cost-shifting that is exposing all of us to unsupportable medical costs. Every person concerned with the future of health care and the economy in the United States should read these critiques. The future is now.
The American Academy of Family Physicians in a recent article has complained about the “Arbitrary Elimination’ of Physicians From Insurers’ Networks.” http://www.aafp.org/news/practice-professional-issues/20140729narrownets.html#embeddedforumform
Narrow networks are just the latest insurance subterfuge. No matter what CMS does the insurance companies will always be ahead of them in the gaming of the system. When will the AAFP get wise and endorse single payer medicine?
Dr.George Barron Replied:
To see this problem as an insurance subterfuge and in the same breath ask the AAFP to endorse a single payer system betrays a thorough misunderstanding of the current problem as well as the proposed solution. I think every physician who believes in the utopian notion of a single payer system either spend a year working in the VA system or a week as a patient in the VA system
Thanks, Dr. Barron, for responding to my comment on the AAFP denouncing the “Arbitrary Elimination of Physicians from Insurers’ Networks.” I am sorry that you have had such poor experiences as a physician and patient with the Veteran Administration. Obviously you were not in the Rand Corporation study of the VA medical system which stated that “Based on 294 health indicators in 15 categories of care, they found that overall, VA patients were more likely than patients in the national sample to receive recommended care. In particular, the VA patients received significantly better care for depression, diabetes, hyperlipidemia, and hypertension. The VA also performed consistently better across the spectrum of care, including screening, diagnosis, treatment, and follow-up. The only exception to the pattern of better care in VA facilities was care for acute conditions, for which the two samples were similar.” http://www.rand.org/pubs/research_briefs/RB9100/index1.html
I think we can both agree that government run programs (like the Air Force, the CIA, the Federal Reserve System, Medicare, etc.) all leave room for improvement. And I assume that your dislike for these agencies will tempt you to forego any Medicare limitations and rely on your own personal finances and private insurance for your future health care. However, some of us are not satisfied that, with our insurance-based medical system, the U.S. pays almost twice as much as any other industrialized country and yet ranks 11th in health care quality. And the first 10 countries have some form of single payer medicine. And, like the AAFP, we are not satisfied that health insurance companies are eliminating primary care physicians from plan networks across the country.
We describe single-payer medicine as improved Medicare for all. The ‘improved” part of this is important. No one believes it will not take a lot of work. In addition to system changes we need to insure that the program is appropriately funded and relative immune from political micro-management. And we should start now. I assume you would not be interested in joining me and the 19,000 other members of Physicians for a National Health Program.
The recent article by Alicia Caramenico in Fierce Health Payer, http://www.fiercehealthpayer.com/story/narrow-networks-striking-right-balance/2014-07-21, expresses a few of the problems with narrow networks. The three main problems went unmentioned however.
- The main value of the narrow networks goes to the insurance companies who use them to cherry-pick policy holders and providers on the basis of what’s good for the bottom line of the insurance company.
- The panel highlighted in the report consisted of “featured leaders representing a nonprofit health system, health insurers, insurance commissioners and a healthcare economist.” There was no mention of the opinions of physicians and patients.
- The whole issue is nothing but an insurance underwriting problem that would not exist if we had single payer medicine.
Please see http://wp.me/p4MwV3-11 for more on Narrow Networks