At the moment, the Senate health-care compromise would replace the public option with a menu of private sector non-profit insurance plans overseen by the Office of Personnel Managment (OPM), the goup that oversees Federal Employees’ Health Benefit Plan (FEHBP).
I say “at the moment” because I’m not at all certain that this compromise will hold. As one pundit observed over the week-end: “It’s bad enough to witness how the legislative sausage is made; it’s worse to see it being made on the fly.”
But let’s assume for a moment that the Gang of Ten Solution holds. What will it mean for unemployed and self-employed Americans under the age of 55? Those who support this proposal talk about how much federal employees like FEHBP, and how successful it has been, as if it were a single plan, like Medicare, that offers the same benefits to everyone.
The truth is the FEHBP is make up of a menu of private plans—some pretty good, some not so good. Many carry very high deductibles. Senators and postmen typically have very different plans.
Over at Kaiser Health News, Gail Wilensky, an economist and a senior fellow at Project HOPE, an international health education foundation, and a former administrator of the Health Care Financing Administration (now the Center For Medicare & Medicaid Services) asks a key question about the private sector plans OPM would oversee:
“One of the real questions . . . . how much variation in the benefit structure will actually be allowed? When you look at FEHBP, you've got the $5,000 a year Mail Handler plan, and you have standard Blue Cross Blue Shield, which is $12,000 – $13,000 a year. Those are pretty big differences. The issue is what are you going to set up: a skinnied down plan with a tight network that would allow it to be low cost, or whether you insist on a very expansive plan in terms of benefits with few exclusions. The question is going to be the nature of what these plans are supposed to look like.” http://www.kaiserhealthnews.org/Stories/2009/December/14/FEHBP-health-insurance-public-option-OPM.aspx
Today, some observers have been aruging that we must pass some form of health care reform because if we don’t, tens of thousands of Americans will die prematuely 00 because they don’t have health insurance.
But having health insurance doesn’t necesssary mean access to the health care that might save lives: good chronic disease management; smoking cessation clinics with no co-pay; Pap smears with no co-pay; pre-natal care and nutrititional counseling; mental health care; primary care with no co-pay; chemotheray that can acually give a cancer patient extra years; very expensive drugs that can slow down MS; access to specialists (who may or may not agree to join the network of a less expensive plan that pays lower fees. )
Finally, experience shows that if the insurance carries a high deductible, patients are just as likely to defer needed care as they are to put off less vital care.
The alternative is to require that all of the plans that the OPM oversees provide a full package of comprehensive benefits. This means that they will be more likely to cost $12,000 to $13,000. Like any private sector plan, they will have high administrative costs to cover lobbying, marketing, advertising and executive salaries. Unlike the public option , they will have no vested interest in reducing costs and lifting the quality of care.
Probablly we’ll wind up with a mixed bag: pretty-good plans for those who can afford the highest premium;s and poor plans for the middle-class and the poor. Supporerts will call this “giving Americans choices” and ignore the fact that we are still rationing care by ability to pay.
Will the least expensive plans save tens of thousands of lives? Probably not. They should save some lives, but as Marilyn Moon, vice president and director of the health program at the American Institutes for Research points out on Kaiser Health News:
“These private plans aren't necessarily [going to be] doing what is best for the population. They're doing what they think is best for their own competitive environment and other criteria. So the question is, how are you holding the plans accountable?”
OPM doesn’t hold the federal employee plans accountable. It’s not a regulatory agency and it doesn’t have the size or the clout to insist that insurers meet certain standards in terms of providing value for health care dollars. Without a public plan in the marketplace, no one will be setting a benchmark that puts patients first.
It is sounding more and more like real health reform that will provide AFFORDABLE EFFECTIVE care eventually to all American citizens will fail! Too bad. I guess we will need to let the current private for profit system totally die under its own unsustainable waste and weight before we try again.
Maggie, thank you again for continuing to point out the reality of various interests in this discussion–and the importance of a public option in re-forming health care along the lines of chronic disease management, mental health care and evidence-based prevention and early intervention. I would only add the need for addiction treatment–Columbia University’s excellent report, “Shoveling Up II” this year pointed out this stark statistic: “For every dollar the federal and state governments spent on prevention and treatment, they spent $59.83 shoveling up the consequences, despite a growing body of scientific evidence confirming the efficacy and cost savings of science-based interventions.” The public option has an opportunity to respond in a coherent way by covering early intervention and treatment for substance use problems in addition to mental health care.
All this discussion is now moot. Lieberman, aided and abetted by a White House anxious to get a bill, any bill, no matter how bad, passed has put the Medicare buy-in on the chopping block this evening.
Of course, that means that any notion of public option is dead too.
One Senator hold the key to health care non-reform; only in America!
I’m sure by now most have heard or seen this Politico piece. If the stakes for society have become this high at least in the minds of progressives, then isn’t there a budget reconciliation avenue that only requires 51 votes to pass. If so, maybe it is time to go down that road before giving up all realistic reforms to the status quo or worse.
http://www.politico.com/news/stories/1209/30601.html
Harry Reid prepares to Declare Victory and Go Home. Hope and Change, anyone?
Sometimes change has to occur in increments. I will take the garantees against preexisting conditions and the subsidies for people unable to afford current levels of insurance if it means sacrificing the public option idea. Besides, as a primary care doc I am less than enthused about the notion of expanding Medicare to others unless something is clearly done to fix the payment disparities within the program.
Keith Sarpolis:
Besides, as a primary care doc I am less than enthused about the notion of expanding Medicare to others unless something is clearly done to fix the payment disparities within the program.
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When I get a Medicare/Tricare EOB lately, the amount allowed by Medicare/Tricare is 80% on average less than what the provider is actually billing full fee. I find this immoral that uninsured or those with low leveraged payers behind them are billed potentially 80% higher than those with highly leveraged payers backing them. That to me is one of the most ringing endorsements for a single payer system, namely the high leverage of this monopsonic payer for all to rein in charges.
So with that thought in mind and also the idea that Medicare is going broke as now structured, do you want this Medicare disparity to be fixed by lowering the fee to those providers who now get more or raising the fee for those providers who now get less.
NG,Bob,Dr. Frankie,Doc 99,
NG–Some people who I respect do think that things are going to have to get much, much worse before we have reform.
In other words, we’ll have to get to the point where upper-middle class Americans earning, say $85,000 to $175,000 a year, joint income, cannot afford insurance.
Of course, by then it may be too late– and I mean this.
If health care spending continues to spiral, Medicare and other govt programs will cause the deficit to balloon.
Other nations will lose faith in the dollar; the dollar will decline; oil will be priced in another currency (which means that the cost of energy to us will climb) and the standard of living in the U.S. will fall.
At that point, it’s not clear how we will be able to afford universal coverage except through a serious redistribution of income (both the wealthiest and the upper-middle class paying much higher taxes.)
Bob–
Thank you.
I think of treatment for substance abuse as part of mental health care.
People tend to self-medicate with drugs because they are seriously anxious, depressed, or angry (often all three.)
I totally agree–we need to put much more effort into early prevention for substance abuse.
Dr. Frankie–
I have come to realize that Lieberman’s extraordinary power is all tied up with the rules of our Senate–and the fact that in the face of filibuster, the 60th vote is all powerful.
We should change Senate rules. This will be very difficult. But if we don’t , it will continueto be extraordinarily difficult to pass any progressive change.
NG– This morning I was thinking what you’re thinking.
But the danger is that in reconciliation we would lose the good chunks of the legislation that are left.
(In part 2 of the post that I began today, I’ll talk about the good things
that remain in the legislation ,and that we don’t want ot lose.
Doc 99–
There is hope for change.
See the two-part post that I just wrote about Berwick and Gawande.
There is change that has been happening on the groun–and that will continue– that will be in the vanguard of what we need.
There are actually a fair number of doctors, nurses, woman doctors, and enlightened hopsital admiistrators out there who understand what needs to be done.
They will continue to do what they are already doing.
Doc 99, Keith
Doc 99–
Good to hear from you.
This is the first game, not the match.
Neither the House nor the Senate bill plans to roll out reform before 2013 (or 2014).
Over the next three years, Congress will revisit the public plan. And Conservaites will try to repeal the stripped-down bill that we have now.
The battle is just beginning.
Keith–
I agree.
I was not happy with the Medicare buy-in because it could stand in the way of Medicare reform.
With more people in the plan, it woudl be even harder to reform Medicare–i.e. to lift the quality of care and reduce costs by paying more for care that offers the greatest benefit to patients–and paying less for care that provides little benefit to the patient.
In part 2 of the post that I put up today I’ll elaborate on how important the Independent Medicare Advisory Panel could be.
NG,
A single payer system can certainly leverage a better price for health care services. However, it can also create the imperfections that currently exist in medical reimbursement with overpayment for some services (probably accounting for why we get so many more surgical procedures and imaging than the rest of the industrialized world)and underpayment for others (psychiatric, primary care, etc.). Actually Medicare has done more to make this situation worse over the past 2 decades through so called payment reforms and the fact that most commercial carriers follow the lead of Medicare when it comes to determining physician payment. Distortions by the insurance market are what make it difficult to determine the true worth of individual physician services since insurers, not patients, get to decide what payment will be. Consequently we get pocket shortages in certain physician specialties (psychiatry, primary care, general surgery) and oversupply in others. The oversupply in the well compensated fields drives demand since it is clear that excessive numbers of specialists tend to result in more of the procedures that they perform. Consequently you get the now emerging rrealization that oversupply of specialists in certain areas can actually result in more unnecessary procedures and even result in a negative effect on community health and increase the costs at the same time!
I abhor the fact that the uninsured can get soaked by providers with astonomically high bills if they do not have insurance to protect them. It is our practice to discount these rates (basically we allow 50% discount off full charge for payment at time of service) since we do not have to play the insurance collection game with these patients that adds so much to medical office overhead. But since some have simply elected not to carry insurance, we do not feel they deserve the same break that those who are paying monthly premiums deserve. This, after all, is why people carry insurance; to cover a loss that they might not otherwise be able to afford. If someone fails to insure their house and it gets destroyed by a hurricaine, do you think that the general contractor should discount his fees to replace his house since the homeowner does not have home insurance? Those who choose not to carry insurance should not gain access to the same discounts as those who pay monthly to cover potential risks that they may get sick!
I do realize that the entire system is designed to cater to insured patients and that high usual and customary charges are universal in health care. They discourage uninsured patients from knocking on your door and they are set high to capture all insurance payments from the mix of carriers a provider services. Many carriers pay you their negotiated charge or your usual fee, whichever is less, so you would be foolish to charge less than what an insurer pays. Simple distorted economics under our current health insurance system leads to this perverse system, since there is absolutely no reason for providers to keep their prices low. When was the last time you knew what you were being charged for a medical test or procedure before you actually had said test or procedure? If patients actually asked such things instead of passively letting their insurers handle the negotiation, we might not have such egregiously excessive charges.
In answer to your question, I would certainly cut the costs for many tests and procedures since their costs are premised on false data as to what the overhead expenses are in delivering these services. Most outpatient costs are undervalued and need to be increased. Medicare attempted to reanalyze this several years back, but enough well paid specialists societies squacked that they gave up and continued the current payment disparities that have now almost destroyed primary care. That is why expansion of such a program does not seem to be in our interest since it has succumbed so easily in the past to the whims of special interests and has not been able to control overall health care costs. And that is why many have opposed expansion of Medicare since to do so without further reform would increase these existing disparities and quite possibly increase costs in the long run.
As an “overpaid specialist” (Radiology) I would like to echo much of what Dr. Sarpolis says.
There are significant discrepancies in the income of various specialties that are not related to the difficulty of the work, the length of training or any other relevant variable. These discrepancies favor certain groups (cardiology, many surgical subspecialties, radiology and others) and discriminate against primary care (general internal medicine, family practice and pediatrics) In a perfect world, these discrepancies would be eliminated – and I believe the government is working to do so.
There is a whole lot of unnecessary/poorly indicated diagnostic imaging out there. In my estimation, the number of imaging exams could be cut by almost 50% without any harm to the population.
But I will go on to say some things that Dr. Sarpolis has not said. Each one of these “unnecessary” imaging tests has been ordered by someone other than a Radiologist. And much of the increase in high cost, high tech imaging is due to self referral.
In addition to greed, I believe that fear plays a large part in the over ordering of diagnostic tests. Despite what Maggie and the plaintiff attorneys on this forum say, I have never seen anyone sued for ordering too many tests, but I can’t count the number of malpractice cases I have reviewed where one of the allegations is “why didn’t your order ____” Doctors are not stupid and learn to “CYA” with additional tests.
And despite what Maggie has said, I believe that many patients do want the “latest and greatest” test. They want to be taken seriously, not dismissed. They want a doctor who is thorough and leaves no stone unturned. What better way to demonstrate this than to order a fancy test?
Legacy Flyer posted:
And despite what Maggie has said, I believe that many patients do want the “latest and greatest” test. They want to be taken seriously, not dismissed. They want a doctor who is thorough and leaves no stone unturned. What better way to demonstrate this than to order a fancy test?
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I can only see two ways to prevent this abuse of test expenses, as well as other treatment excesses:
–Give the providers cover through clear standards for all to follow.
–Make the patients pay
Good points from Legacy Flyer,
But I will add that many of the tests I order often come with recommendations from the radiologist for additional radiologic studies. I realize this is self protection for the radiologists, since lawsuits for failure to diagnose that speck on the CT scan which a year later turns out to be a carcinoma are what drives this interpretation and reccomendation, totally ignoring the potential harm done by repeated exposure to scads of radiation (its just not as easy for the lawyers to connect the cause and effect here, but I would watch out for the possibility of lawsuits in the future if it does turn out that repeated CT scans induce significant risks of causing cancer).
The main problem is that the combination of fear of litigation plus the economic incentive to do alot of worthless radiologic studies drives utilization, and I would agree that patients feel they have gotten better medical care when they are subjected to dozens of tests. My early experience in internal medicine out of residency was having patients tell me I was not thorough when I did not order all the laboratory testing they had done by the physician I took over for, despite no proof that these tests do anything to improve health. And trying to talk patients out of tests they have already determined from their internet research they should have, is often a waste of time. I would agree that patients need to bear a larger burden of these costs that they demand, but are largely worthless, but I have no idea how to get there without negative ramifications.
Keith–
Virtually everything you say in your long Dec. 15 commment is spot-on.
I would add only Medicare won’t be able to reduce waste and bring down costs unless it is protected from Congress–and lobbyists.
This is why the Independent Medicare Advisory Commission is so important. It woudl be protected the way the panel on closing military bases was insulated from Congress. Legislators could only vote yes or no on a package of the panel’s recommendatoins. It couldn’t edit them. And it had a limited amount fo time for that up or down vote or the recommendations automically went into effect.
Legacy,
I agree that some patients will try to insist on more tests.
But I also think that it’s up to the doctor to refuse to be bullied.
Particuarly if you’re a primary care doc, there are plenty of patients out there waiting for an appointment. Let the patient who thinks that you’re not “thorough” if you don’t order more tests find another doctor.
Most specialists also are pretty busy.
I do think that, at this point, physicians have a responsiblity to try to educate patients that “more care is not better care.”
Patient-centered medicine is fine– but “consumer-driven medicine”–with the patient telling the doctor what he wants, when he wants it seems to me a very poor idea.
Finally, as far as I know, there are no “plaintiff’s attorneys” commenting on this blog. (Though if there are, they, like everyone else, are welcome as long as they are civil and attempt to make rational arguments, buttressed, when possible, with evidence.)
As I’ve said before,of course fear of malpractice suits exists, but it’s impossible to untangle it from the many other motives that can drive over-treatment.
We know that, in states like Texas, where malpracice awards have been capped, over-treatment has not dropped.
So we need to find another answer to the malpractice problem.
“I agree that some patients will try to insist on more tests. But I also think that it’s up to the doctor to refuse to be bullied.”
I learned something a long time ago when I was young and idealistic – trying to hold the line on diagnostic imaging tests is a fool’s errand in our society with its current legal system and patient expectations.
In the “old days” (80s and early 90s) CT techs and Radiologists had to drive in to the hospital in the middle of the night for emergency CTs. The typical protocol was that the physician that wanted to have the test done (frequently an ER doc) would call the Radiologist, the Radiologist would discuss the study with the requesting doc and then the Radiologist would “approve” (or not approve) the study and call the tech in. This process resulted in substantially lower utilization of CT than what occurs today.
I soon learned that you can be right 90+ percent of the time in NOT approving a test, but the one time you are wrong, you will get your a** handed to you. Hospital executives, Q/A Committees, fellow physicians and patients will write you nasty letters if you ever deny something that subsequently turns out to have been indicated, but nobody will give you a thank you (except the tech) when you are right. And of course I must admit that saving insurance companies money was not our sole reason for not wanting to come in during the middle of the night.
Consequently, in the mid to late 90s, when I was the Chief of Radiology at a local hospital, I did two things; I instituted a “no approval” policy – we did every test the ER docs wanted and we put a CT tech in the hospital all night. In essence we “opened the flood gates” and volumes increased by leaps and bounds. 300 – 400 bed hospitals that used to order 3 or 4 CTs a night in the 80s now order as many as 30 to 40 a night. (In truth, it is not just the way that “approvals” are handled or CT scanner are staffed that have made the difference, it is also that improved scanners and more research have lead to a greater number of legitimate indications for CTs.)
If I was to use my best judgement as to what studies were indicated and which ones were not and I was to be correct 90+ % of the time, I can just hear some of the “experts” on Health Beat criticize me for my errors. Until someone takes a realistic look at what can and cannot be predicted and who should bear the consequences for the inevitable errors that will be made, the “flood gates” will remain open.
NG, I think you are to negative on the situation. I still believe the health reform will bring positive results and be better than the previous