11 thoughts on “Money-Driven Medicine on Bill Moyers Journal, PBS, Friday, August 28 —”

1. I can’t wait to view it!!! I have blocked the time on my calendar! I will also be sending update to my groups and contacts. That is great news.
   Thanks for your insight and help on what we share as a common mission with common goals.

2. I too endorse this film based on Maggie’s book. I attended the NYC premiere.
   Obama is correct -This really boils down again to FEAR VSERSES HOPE
   The film “Money Driven Medicine”, because it is factual and features highly credible leaders should reduce unwarranted fear of necessary change.
   Dr. Rick Lippin
   Southampton,Pa

3. I hope the documentary stems the tide that seems to be flowing in the wrong direction.
   Money Driven Medicine should be mandatory reading for every US legislator. 650 or so copies sent one to each and every legislator would be an excellent idea. Maybe just send each of them a DVD of the program because I’m not certain if they can all read. 😉

4. Maggie, I’d appreciate it if you and your blog readers would discuss this article by Richard Thaler in the Sunday New York Times – http://www.nytimes.com/2009/08/16/business/economy/16view.html
   I am confused. I like the idea of a public option for it’s ability to gather information and create effective outcome based delivery systems and to create more primary care options. I don’t understand why the government will be better able to negotiate discounts accept by forcing rate reductions on providers which I thought resulted in doctors refusing to take medicare and medicaid patients and leaving hospitals with deficits that require cost shifting. Thayers suggestion that the government has never shown the ability to outperform the private sector seems suspect to me. Your thoughts would be appreciated

5. Ed, Dr. Rick, Gail and Pat–
   Ed., Dr. Rick & Gail–
   Thank you!
   Pat–
   First a public sector plan would have clout because it would be so large.
   This would allow it to negotiate for lower drug prices –something that the VA (a government plan) does very successfully.
   Private insurers make “deals” with drug-makers that serve their bottom line, but don’t get great discounts and don’t look closely at risks.
   The Bush administration forced legislation through
   Congress that specifically forbid Medicare from negotiating for discounts becuase the administratoin and drug-lobbyists knew that Medicare could get much lower prices.
   The House bill would let Medicare and a public plan negotiate lower prices with drug makers.
   As for paying providers, the House Bill specifically says that the public plan won’t just adopt Medicare rates–it will have to negotiate with provdiers.
   Some will accept the public plan’s rates; some won’t.
   The truth is that half of all hospitals make a profit on Medicare’s reimbursements. Many of those that don’t are simply inefficient.
   Finally, Medicare is an example of a public sector program that is more successful than the private sector equivalent–private insurance.
   Medicare has done a much better job of holding down health care inflation during past 10 years (5% a year vs. 8.5% a year under
   private insurance) and customer satisfaction with Medicare is much, much higher than customer satisfaciton under private insurers.
   Some docs also prefer Medicare– paperwork is much simpler, less hassle, and Medicare pays on time.
   Finally, see my post on how only a public sector plan has the political moral standing to elminate waste without cutting valuable care here http://www.alternet.org/healthwellness/141040/only_a_public_option_can_make_decisions_in_patient's_best_interest/

6. Ed, Dr. Rick, Gail and Pat–
   Ed., Dr. Rick & Gail–
   Thank you!
   Pat–
   First a public sector plan would have clout because it would be so large.
   This would allow it to negotiate for lower drug prices –something that the VA (a government plan) does very successfully.
   Private insurers make “deals” with drug-makers that serve their bottom line, but don’t get great discounts and don’t look closely at risks.
   The Bush administration forced legislation through
   Congress that specifically forbid Medicare from negotiating for discounts becuase the administratoin and drug-lobbyists knew that Medicare could get much lower prices.
   The House bill would let Medicare and a public plan negotiate lower prices with drug makers.
   As for paying providers, the House Bill specifically says that the public plan won’t just adopt Medicare rates–it will have to negotiate with provdiers.
   Some will accept the public plan’s rates; some won’t.
   The truth is that half of all hospitals make a profit on Medicare’s reimbursements. Many of those that don’t are simply inefficient.
   Finally, Medicare is an example of a public sector program that is more successful than the private sector equivalent–private insurance.
   Medicare has done a much better job of holding down health care inflation during past 10 years (5% a year vs. 8.5% a year under
   private insurance) and customer satisfaction with Medicare is much, much higher than customer satisfaciton under private insurers.
   Some docs also prefer Medicare– paperwork is much simpler, less hassle, and Medicare pays on time.
   Finally, see my post on how only a public sector plan has the political moral standing to elminate waste without cutting valuable care here http://www.alternet.org/healthwellness/141040/only_a_public_option_can_make_decisions_in_patient's_best_interest/

7. Maggie, I applaud your efforts and would like your thoughts on one solution that’s been entirely overlooked amidst the healthcare reform debate: Employers eliminating the managed care middleman and contracting directly with doctors and hospitals.
   For the past 15 years, I’ve been working with major self-insured employers, negotiating direct agreements between those employers and medical providers as an alternative to conventional PPO networks. One of my largest clients, a company with over 50,000 covered lives, was with Cigna when they opted to develop their own direct networks instead of using Cigna’s PPO networks.
   With direct networks now across 14 states, my client’s medical trend has been essentially flat for the past 8 years, while companies their size suffered increases of 10% or more each and every year. This company’s employer-owned networks, built upon fair “win-win” agreements, are stable and well-liked by providers. Compare that to the openly contentious and adversarial relationships you and I know exist in virtually every commercial PPO network.
   The huge savings this particular employer has achieved by having its own direct networks for the past 8 years has allowed it to maintain a relatively rich medical benefits plan, with low deductibles and without shifting costs onto employees.
   Incidentally, this employer uses a third party administrator (TPA) to process its claims according to the reimbursement and contractual terms of the direct agreements, as well as the UR, pre-cert, and case-management components. In this case, the TPA works for the client, and has no middleman loss-ratio to protect, so the admin costs are a fraction of what they run with Cigna or any other carrier.
   I invite you to peruse the articles about the success of this approach that appeared in the WSJ, Business Insurance, Employee Benefits Review, and the Kiplinger Letter. Many of these are available at my website, AJLester.com.com, in the Resource Center-Newsroom.
   For years, managed care companies have disdained my efforts to help employers bypass PPO networks by contracting directly with providers. Unfortunately, they’ve done such a bullet-proof job as middlemen, that most doctors and employers believe there is no other way for them to do business with each other than through a managed care company.
   Ironically, the very first people that my prospective clients consult with about the idea of direct contracting is….you guessed it, their insurance company. You can imagine how quickly employers are talked out of that idea.
   What are your thoughts about employers cutting out the middleman and contracting directly with doctors and hospitals? Shouldn’t it be promoted as an alternative to commercial PPO networks? It’s still a “private-payer” approach, which should appease opponents of the “public option”. But the private part of it really is private. That is, between the employer as buyer and the medical provider as seller, without need of a middleman.
   Lastly, is anyone else you know talking about this approach? If not, why not? If it’s because no one thinks it’ll work, where is that message coming from? There are companies out there, albeit not a huge number, who can tell a compelling story about the success of this approach. Is it possible to get people to listen?
   Many thanks in advance for whatever insights you can lend

8. A.J.
   What you describe sounds interesting, but while you tell me that this system reduces costs and providers like it–you don’t tell me the 3rd thing that I most want to know:
   Are outcomes better for patients? Are they recieving more evidence-based medicine? Over the long run, are patients exposed to fewer risks and errors?
   Over the long run, is their health better?
   I agree that removing the for-profit insurer as middle-man could be a good thing.
   But the for-profit employer has his own priorities, which don’t always square with better patient care.
   The employer–quite undertandably–wants to keep costs down. His costs have been spiralling. Providing care for employees is becoming prohibitively expensive.
   But the employer also knows that in today’s labor market, most of his employees won’t be with him 15 or 20 years from now. So does he really want to spend extra money on managing chronic diseases like diabetes?
   By the time his diabetic employee is in danger of needing amputations, he will be working for someone else.
   I’m not suggesting that most employers are cold enough to consciously think of things this way–
   But they are also not in a postion to judge the long-term quality of care. By and large, neither they, nor their human resource directors are health care experts, public heatlh experts, or doctors. . .
   Even if they want to, it is very hard for them to evaluate the quality of care.
   There are exceptions. When I wrote my book, Pitney Bowes had an excellent director of healthcare benefits who was a very experienced MD (Had been Gerry Ford’s doctor in the White House)
   He had greatly reduced all co-pays for prentive care and chronic disease management. He was committed to designing benefits to improve empoloyee’s health long term, whether or not they would still be working for the company. . .
   But he was unusual.
   Bottom line: rather than seeing employers contract with providers directly (through a for-profit consultant) I would like to see them choose a public sector insurance plan, overseen by a panel of physicans and healthare experts who have absolutely no financial interest in the gudelines (not rules) that they set up.
   This is what the administraion and Senaotr Jay Rockefeller have proposed. The panel would set fees and co-pays they are designed to steer both docs and patients toward treatments that will provide the greatest benefits for patients, whatever the cost.
   That said, it sounds as if you truly are trying to improve health care–
   I would urge you to try to connect employers to more of the non-profit insurers running accountable care organizations.
   In contrast to the for-profit insurers, I think that many of these non-profits are truly adding value to the system.
   And they possess knowledge and experience that employers in other industries just don’t have.

9. In the debate about cost no one seems to mention the fact that the pubic is already paying for the health care of a substantial portion of the population – including many who we don’t think of as publicly funded. The obvious ones are all federal employees, military personnel and recipients of MediCare. Medi-Caid and SCHIP and the VA. But we – JQ Taxpayers – also pay directly for people like, 1) federal, state and local prisoners, 2) state, county and local government employees, 3) school district employees, 4) public college and university employees,5) all Massachusetts residents to name a few.
   BUT – IN ADDITION – we also already pay for the millions whose health care is paid for indirectly by federal, state and local governments? The most obvious example being those in aerospace or any other industry that provides goods and services to public agencies under government contracts, including their subcontractors. My husband has worked for Northrup, Boeing, ITT, Raytheon and other defense contractors for many years. All the defense contracts have the cost of labor (wages and benefits i.e health insurance) built into contract price whether it is cost plus or a fixed amount. The employees buy their health insurance on the open market but they pay for it with their taxpayer funded paychecks. Ditto for all who consult with public entities, and/or supply them with office supplies, construction work, foodstuffs, vehicles, student loans, uniforms, electronics, landscaping, etc. etc. Many large businesses have whole divisions that do business exclusively with public sector clients. I don’t know how much of the GDP comes from individuals and companies who provide goods and services to the pubic sector at all levels, but it must be substantial. Unfortunately in the current system, we, the taxpayers, are paying retail including add-ons for the middlemen and the shareholders for Well Point, HCA, Aetna, Blue Cross etc every time we pay for a government contract. If all these people could buy their health care directly from the [public sector, we would all save on both direct health care costs and on the costs of government funded contracts. Our taxes could be going directly into health care, public health and coordination of the two, at lower prices, instead of into the profit margins of the private sector.

10. I was v. impressed by the documentary, and among my health care working friends, unanimous agreement. My question is:
    1 What can be done to correct our system,
    2.Are solutions in any of the current bills?
    seems like rhetoric on both sides miss the bigger picture portrayed in this documentary. Great job, Maggie!

11. Bill D,
    Bill D.–Yes, the House bill addresses many of the problems illustrated in Money-Driven Medicine.
    First, it calls for Medicare reform that would change the way we pay providers (paying for quality of care, not quantity). It also would change what Medicare pays for (allowing Medicare to pay more for effective treatment, less for poor outcomes, like preventable readmissions). Finally it would have Medicare provide financial incentives to change the way care is delivered–paying bonuses to doctors and hopsitals who collaborate with each other.
    In addition, under the House bill there would be no co-pays for primary care (even private insurers would not be allowed to charge co-pays for primary care) and both Medicare and the public plan woudl raise fees for primary care docs, pedicatiricans and geriatricisin by 5% to 10% (10% if there is a shortage in the area where the doctor works.)
    There would also be bonsues for primary care docs who provide medical homes and do a good job of managing patients with chronic diseases.
    Finally, there would be greatly expanded scholarships and loan forgiveness programs for med students who go into primary care, particularly those willing to serve in areas where there are shortages.
    We know that in countries where there is more primary care, there is better preventive care–and patients are healthier. (This is also true in regions of the US where there are more primary care docs and fewer specialists.)
    Specialists’ care is expensive and often could be avoided–if the patient got the care he wanted in the first place.
    All in all the House bill encourages doctors to talk to and listen to patients.
    That’s why it would pay providers for “end-of-life counseling.” No patient would be required to do the counseling; it would simply be an option. (See Naomi’s recent post on advanced directives.)
    But if you wanted it, the provider woudl be paid for the time it takes to do it. (Today, he is not–or at best, paid very poorly.)
    Finally, the House bill calls for Medicare reform that would lift the quality of Medicare while reducing spending (by discouraging ineffective and unnecessary treatments and rewarding the most effective treatments. In this way, the bill paves the way for a public sector health plan which would incorporate Medicare reforms.
    Finally, the House bill gives Medicare the right to negotiate for discounts on drugs. This means Medicare would look at comparative effectiveness research and refuse to pay exorbitant prices for new drugs that are no better than drugs they are trying to replace–and not fully tested so perhaps riskier. . .
    Basically, the House bill is patient centered: it focuses on protecting patients and making sure they get the best treatment.
    The bi-partisan bill that Sen. Baucus Senate Finance committee are working on is much more focused on pleasing the lobbyists and the corporate interests they represent.

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