McCanne Health Justice Monitor

Summary: With the acquisition of One Medical, Amazon becomes a primary care middleman. It wants to access your medical records and sell the data, sacrificing your privacy.

To become an Amazon Clinic patient, first you sign away some privacy
Washington Post
May 1, 2023
By Geoffrey A. Fowler

This Amazon form is asking for something more extraordinary: “use and disclosure of protected health information.” It authorizes Amazon to have your “complete patient file” and notes that the information “may be re-disclosed,” after which it “will no longer be protected by HIPAA.”

Wait, you agreed to what? Amazon is essentially pushing people to waive some of their federal privacy protections, say the lawyers at the Electronic Privacy Information Center whom I asked to inspect the jargon. Amazon is required by law to say doing so is voluntary — but in practice you must agree to become a patient at its Clinic. There’s only one button to click: “Continue.”

What could go wrong? There are lots of icky ways Amazon could use your health information: to upsell you on other services, to target marketing for its giant advertising business, or to build out artificial intelligence or patient-risk models.

What you really give away when you sign up for Amazon Clinic
Komando.com
May 2, 2023
By Albert Khoury

Though Amazon declares it’s “compliant with HIPAA and all other applicable laws and regulations,” there’s more to the fine print. 

When you sign up for treatment through Amazon Clinic, you “authorize” all entities involved. This includes doctors, pharmacies and labs to share your Protected Health Information (PHI) with Amazon.

Here’s what constitutes PHI:

• Contact Information (for example, email address).
• Demographic Information (for example, date of birth).
• Account and Payment Information (for example, insurance information).
• Your complete patient file, including medical and billing records related to the services that any HCP supplies to you through Amazon Clinic.

Amazon has the right to “retain, use and disclose this information” for two purposes: If an HCP you used through Amazon Clinic no longer provides service there, Amazon will “coordinate healthcare services” on your behalf. How nice of them. 

Here’s the kicker: Amazon can use your PHI “in relation to any Amazon services” to “facilitate services from other providers.” Who exactly are these providers? Doctors? Other businesses? 

Amazon Clinic is not actually a clinic. It’s a service that connects you with third parties such as HealthTap, HelloAlpha and SteadyMD, delivering telehealth services with clinicians.

Amazon Clinic Chief Sees Intersection of Retail and Healthcare
PYMTS
April 6, 2023

The future of healthcare will look a lot more like retail with customer experience coming first and artificial intelligence (AI) playing a larger role in that transformation.

These were among the takeaways from a series of discussions during the CNBC Healthy Returns 2023 Summit last week, as leaders from healthcare, Big Tech and the investment world discussed how the consumerization of healthcare and applications of AI will transform healthcare as we know it, in some cases on a time horizon of as little as three years.

Amazon Clinic Chief Medical Officer and General Manager Dr. Nworah Ayogu said during his segment that one reason many people are not receiving needed care is access, which Amazon is addressing with acquisitions like One Medical and its expanding network of retail clinics.

“I would think of Amazon Clinic as a marketplace, similar to what Amazon does well on its retail site, connecting buyers and sellers to the products they need,” Ayogu said. “I think we’re doing the same thing with Amazon Clinic. I would think of it more as a marketplace where you can find providers and provider groups for your issue.”

… As for broader implications for Big Tech bringing AI into the healthcare space, (Breyer Capital CEO, Jim) Breyer said, “My personal view over the last 12 months is that our mega-cap companies … are not just doubling or tripling down on healthcare and medicine. It’s 10x 50x over the next couple of years.”

Comment by: Steve Auerbach MD

Those of us who read JAMA or NEJM, or even Health Affairs, are clearly reading the wrong journals to keep up with healthcare practice in the United States. Unfortunately to find out who and what is controlling healthcare one needs to read business and finance articles like the above. You will learn that Amazon, the online retail conglomerate and data-mining company, which has been expanding into healthcare for years, has been marketing their so-called Amazon “Clinic” in anticipation of their purchase of OneMedical. I received an unsolicited email to sign up.

Amazon Clinic is both more and less than meets the eye. It is less because it is not a clinic, but just a virtual message-based service that connects consumers with third-party telehealth providers. It is more because, in return for connecting you to third party partner telehealth companies (such as HealthTap, Hello Alpha, and SteadyMD … which you could sign up for directly), Amazon requires you to you to “authorize” data sharing. That is, all entities involved can share all your protected health information (contact info, demographics, financial and medical records) with any service they connect you with and  “retain, use and disclose this information to ‘coordinate healthcare services’ on your behalf and to ‘facilitate services from other providers.’” This applies for Amazon itself and any other company with which they do business. 

And this being Amazon, they can then link your healthcare data with all of your other Amazon purchase, search, and financial and credit data. Amazon’s power comes from their combination of self-interest and self-dealing: The same company sells drugs, medical supplies, medical equipment, and data. So no doubt your medical and other personal data will be linked back to all the other data they and their business partners have collected on you.

What could possibly go wrong? And since the Supreme Court’s decision in the Sorrell v IMS Health and similar decisions, “corporate free speech” overrides privacy and protection concerns.

We need, and could have, guaranteed access to universal healthcare, paid for through progressive taxation affordable for all and without point of service financial or administrative barriers. The overall system would be publicly accountable while leaving the doctor-patient relationship between just the doctor and patient.  We don’t want to turn our entire lives over to corporate overlords. We need to support national M4A and local single payer movements, while also working with anti-privatization and anti-monopoly allies to fight the hyper-financialization of our health care and lives.

Summary: Mr. Barkan, a resolute and articulate advocate for single payer / Medicare for All, warns us about privatization of Medicare via Medicare Advantage. We must unite to battle the corporate takeover of our premier public insurance program.

How Medicare Advantage Could Kill Medicare
The Nation
May 17, 2023
By Ady Barkan

Today, Senator Bernie Sanders, Representative Pramila Jayapal, and Representative Debbie Dinged introduced the Medicare for All Act in the Senate and House.

In 2019, The House of Representatives announced that it would hold its first-ever hearing on the Medicare for All Act. I was the first witness in the overflowing Rules Committee room. I spoke through my computer; paralyzed by ALS at age 35, I embodied the reality that we all will need health care, no matter how lucky and privileged we feel.

I had become a prominent champion for universal health care, particularly for strengthening and expanding Medicare. But I am now embarrassed to admit that I actually didn’t understand the massive changes that had been happening to the Medicare system. For more than two decades, health insurance companies have been privatizing our cherished Medicare program. Now, I’m worried that once they have it we may never get it back.

The Medicare Advantage program was created with the promise that the private sector could reduce costs by better managing care. But, as The New York Times reported in October – which is when I finally understood the scale and gravity of this problem – the hunger of health insurance corporations for profits that these plans supply has been insatiable. The program is more costly than traditional Medicare, not more efficient.

Health insurance companies and private-equity firms are buying up primary care as fast as they can and extracting profit however they can.

As more people enroll in Medicare Advantage, and fewer in traditional Medicare, there may be less political will to improve traditional Medicare. The future of health care in this country might in fact be Medicare Advantage for All.

There is a better way. American voters from across the political spectrum support Medicare and Medicare for All. Generations of activists and leaders have pursued this same vision. But to get there, we will need to stop the corporate takeover of Medicare.

Comment by Don McCanne

The opportunity to enact and implement a universal, comprehensive, affordable, high quality, equitable health care program – an Improved Medicare for All – is rapidly slipping away from us, and Ady Barkan explains why. You should read his full article in the Nation and share it with others.

Then we should act on it. New legislation for Medicare for All has been introduced this week in both the House and the Senate. Clearly the time calls for political activism. That doesn’t mean that we leave it to the politicians. It has to be the work of the people. We all have to join together to make it happen. The alternative is exposure to suffering, misery, bankruptcy, and even death.

Summary: Senator Bernie Sanders & Representative Pramila Jayapal re-introduced their Medicare-for-All bills on May 17th. Although prospects for passage are low this Congress, enthusiasm for organizing is high. By including everyone in health care, we save money. If only the Right and Left could unite on this eminently practical solution to our health care mess.

Sen. Bernie Sanders renews push for Medicare for All to end ‘totally broken’ health-care system
CNBC
May 17, 2023
By Lorie Konish

For many Americans, a medical emergency can lead to a financial crisis due to the high cost of health care in the U.S.

This week, Sen. Bernie Sanders, I-Vt., is renewing his push for a new approach — Medicare for All — that he touted as a presidential candidate.

“The current health-care system in the United States is totally broken,” Sanders said Tuesday at a Capitol Hill event.

“It is totally dysfunctional, and it is extremely cruel,” he said.

With the support of Democratic Reps. Pramila Jayapal of Washington and Debbie Dingell of Michigan, the lawmakers plan to reintroduce a bill, titled Medicare for All Act of 2023, in both the House and the Senate on Wednesday.

In the House, the proposal will have 112 co-sponsors, more than they have ever had at the introduction of the bill, Jayapal noted, despite having fewer Democratic seats than in the previous Congress.

Medicare for All would create a single-payer program, which would allow one source to collect all health-care fees and pay all health-care costs.

“It is long overdue for us to end the international embarrassment of the United States being the only major country on earth that does not guarantee health care to all of its people,” Sanders said. “Now is the time for a Medicare for All single-payer program.”

The Evidence Is Clear: Medicare for All Will Save Money and Lives
Common Dreams
May 18, 2023
By James G. Kahn & Alison Galvani

Will Medicare for All raise or lower healthcare costs in the United States? Is it affordable?

We led two academic teams that published scientific papers to address this, the only peer-reviewed medical articles on this topic in the last 30 years. We worked separately, at Yale University and the University of California.

We think it’s time to retire doubts about the net cost of single payer or Medicare for All. The evidence for big savings is real.

We came to the same conclusion: Yes, Medicare for All will save money, by removing unnecessary paperwork and insurance company profits, lowering drug costs, and other factors. These savings will more than offset the cost of improving coverage and expanding it to everyone.
…

What’s the difference between these studies, which conclude that single payer would save money, and other studies that conclude it would not?

First, the Yale and University of California, San Francisco (UCSF) studies are peer-reviewed, which means that the reports were closely examined by experts in the field for validity, and refinements implemented to satisfy the reviewers and editor. Other studies were not subject to this rigorous scrutiny.

Second, the Yale and UCSF studies are based on a strict definition of what makes a healthcare financing system “single-payer.” Some studies purporting to be about single-payer include private insurers and their added costs in their calculations.

Third, the Yale and UCSF researchers do not stand to profit from the outcome. They are academics, not consultants paid by clients with strong political and policy priorities.

Comment by: Jim Kahn

Senator Sanders has long battled for Medicare for All, and Representative Jayapal, Chair of the Congressional Progressive Caucus, now spearheads the House effort.

These inspiring leaders re-introduced their legislative proposals, with many co-sponsors. Sad to say, this Congress (and this political moment) bodes poorly for passage. But it bodes well for organizing. Single payer discussion, education, and coalition-building continues, at the federal level and in the states.

The Common Dreams piece (full disclosure: I’m an author) reviews the powerful economic argument that savings (from administrative simplification and drug price reductions) means lowered costs despite increased access to and use of care, averting tens of thousands of deaths per year.

Single payer, Medicare-for-All is the right thing to do – efficient and effective. If we could only convince the GOP that it’s the Right thing to do! They certainly won’t be Left out when the US implements high quality universal health insurance. (Seriously, right and left are united on this issue in dozens of other countries, so it’s not such a crazy idea.)

Summary: Two news items this week lay bare US drug cost problems. The underlying cause is prices several-fold higher than elsewhere. Exacerbating that is convoluted gaming – moving money around to boost and retain profits. Who wins? Pharma and Pharmacy Benefit Managers (partnered with insurers). And loses? The rest of us.

Senators Call Out PBMs, Drugmakers for High Prescription Drug Costs
MedPage Today
May 11, 2023
By Shannon Firth

Drugmakers and pharmacy benefit managers (PBMs) traded the blame over high drug prices during a hearing of the Senate Health, Education, Labor and Pensions Committee on Wednesday.

Each side argued the other was trying to fleece patients and the government, but Sen. Bernie Sanders (I-Vt.), chairman of the committee, argued there was plenty of blame to go around.

“Let’s be clear, while Americans pay outrageously high prices for prescription drugs, the pharmaceutical companies and the PBMs make enormous profits every year,” he said.

In 2021, the 10 major drug companies made $100 billion in profits, and in 2022, the three largest PBMs made over $27 billion, Sanders noted. Moreover, the three pharmaceutical companies that produce insulin — Eli Lilly, Novo Nordisk, and Sanofi — have hiked the price of the drug dozens of times over the last two decades for “the same exact product,” he added.

Meanwhile, 1.3 million Americans have been forced to ration their insulin because of its high cost, and some, including 23-year-old Alec Raeshawn Smith, have died.
…

Several lawmakers argued that PBMs benefit from higher list prices because higher prices mean higher rebates, and PBMs keep a portion of rebates. …

In their testimony, the PBM witnesses all stated that they pass about 98% of their rebate onto their customers, which include employers, health plans, and unions. …

Notably, however, because of vertical integration, the three largest PBMs, CVS Health, Express Scripts, and OptumRx … are all owned by or partnered with health plans. UnitedHealth Group owns OptumRx, Cigna owns Express Scripts, and CVS Health and Aetna merged in 2018.

Sen. Markwayne Mullin (R-Okla.) likened this setup to “the fox guarding the henhouse.” He pointed out that when PBMs say 98% of rebates go to customers, health plans are included among their customers.

“So you’re rebating yourselves. That is just — wow — [a] great business model,” he said.

Wonking Out: Attack of the Pharma Phantoms
New York Times
May 12, 2023
By Paul Krugman

The U.S. health care system, unlike health systems in other countries, isn’t set up to bargain with drug companies for lower prices. In fact, until the Biden administration passed the Inflation Reduction Act, even Medicare was specifically prohibited from negotiating over drug prices. As a result, the U.S. market has long been pharma’s cash cow: On average, prescription drugs cost 2.56 times — 2.56 times — as much here as they do in other countries.

Strange to say, however, pharmaceutical companies report earning hardly any profits on their U.S. sales. … a striking chart comparing 2022 revenue and profit for six major pharma companies:

… 2022 was an exceptionally profitable year for these companies, but the pattern — large revenue in the U.S. market, with very low reported profits — has been consistent over time.

How do the pharma giants do that? Mainly by assigning patents and other forms of intellectual property to overseas subsidiaries located in low-tax jurisdictions. Their U.S. operations then pay large fees to these overseas subsidiaries for the use of this intellectual property, magically causing profits to disappear here and reappear someplace else, where they go largely untaxed.

Comment by: Jim Kahn

These two pieces, a news report on a Senate hearing and an op-ed by a prominent economist, succinctly characterize the massive cost problems we face with prescription drugs.

First, prices are more than 2.5 times as high in the US as in comparison wealthy countries.

Second, drug companies avoid paying US taxes on those profits by setting up intellectual property havens in other countries with low tax rates. They pay themselves (their foreign entities) inflated amounts for patent use, thereby shifting profits to where they can keep them.

Third, PBMs – an invented intermediary structure — manipulate prices and rebate schemes to grab another huge slice of income and profits. The “rebates” are largely to the insurance companies with which they share corporate structure.

Single payer would replace this convoluted profit-maximizing drug marketing maze with a straightforward, proven and transparent system of drug price negotiation and payment. This shift would save enough money, along with administrative simplification, to make single payer the economic unicorn: a “free lunch” — a cost–saving expansion to universal high-quality insurance.

Summary: The large-scale corporate appropriation of primary care reflects and enables the profiteering that now dominates US health care. The doctor-patient relationship suffers. Single payer financing may falter if corporations own the vast majority of providers. What are our reform options?

Corporate Giants Buy Up Primary Care Practices at Rapid Pace
The New York Times
May 8, 2023
By Reed Abelson

Why are multibillion-dollar corporations, particularly giant health insurers, gobbling up primary care practices? 

The appeal is simple: Despite their lowly status, primary care doctors oversee vast numbers of patients, who bring business and profits to a hospital system, a health insurer or a pharmacy outfit eyeing expansion.

And there’s an added lure: The growing privatization of Medicare means that more than half its 60 million beneficiaries have signed up for policies with private insurers under the Medicare Advantage program. The federal government is now paying those insurers $400 billion a year.

The absorption of doctor practices is part of a vast, accelerating consolidation of medical care, leaving patients in the hands of a shrinking number of giant companies or hospital groups. Nearly seven of 10 of all doctors are either employed by a hospital or a corporation. Experts warn these major acquisitions threaten the personal nature of the doctor-patient relationship, especially if the parent company has the authority to dictate limits on services from the first office visit to extended hospital stays. [The article provides examples of how corporate control of primary care leads to abusive practices to increase revenue.]

“We’re dealing with incredible levels of burnout within the profession,” said Dr.Max Cohen, who practices near Portland, Ore.

Comment by: Don McCanne & Jim Kahn

There is not much new here in this report of the corporate takeover of our health care system except maybe for the rapidity and boundlessness with which it is taking place.

Recently single payer financing gained in popularity as people recognized how it could transform our defective insurance system to bring truly affordable, accessible, equitable care with free choices for all. But with corporations now controlling medical delivery including linchpin primary care providers, care has become less affordable and thus less accessible for many, certainly less equitable, and our choices are limited to the dictates of the corporate entity. 

The complexity that this has produced was explained by Steffie Woolhandler and David Himmelstein, the founders of Physicians for a National Health Program, in a recent Jacobin interview and HJM post. Just a few years back, all we needed was a public financing program that displaced private ownership of health insurers (single payer).

But now with Wall Street’s takeover of the health care delivery system, reform of ownership of provider resources is needed. Community rather than corporate control of care seems to be what we need, but imagine the hurdle in transferring ownership of our entire health care system from the titans of Wall Street to the inhabitants of Main Street. Difficult times lie ahead, but what can we do? One thing for sure, we cannot leave control of our health care in the hands of the billionaires.

Are there any ideas out there that would actually work, short of socialized medicine (which, of course, would)? We’re contemplating this, and welcome ideas healthjusticemonitor@gmail.com.

Summary: The May 2023 issue of Health Affairs, the leading health policy journal, has 20 articles. In our assessment, 9 of them would be unnecessary and another 7 simplified if the US had truly universal and standard health insurance. These health policy resources could be redirected to critical non-insurance issues in access, equity and disparities, and outcomes.

Health Affairs Table of Contents May 2023

(Parenthetical assessments by HJM.)

Availability Versus Accessibility: Identifying COVID-19 Testing Deserts Across Massachusetts (Largely a coverage issue; simplified.)

The Role of Financial Incentives in Biosimilar Uptake in Medicare: Evidence from the 340B Program (Drug pricing issue; simplified.)

Benchmarking Changes and Selective Participation in The Medicare Shared Savings Program (ACO issue; likely moot.)

Trend Toward Older Maternal Age Contributed to Growing Racial Inequity in Very-Low-Birthweight Infants in the US (Partially an insurance issue; simplified)

Federal Funding for Discovery and Development of Costly HIV Drugs Was Far More Than Previously Estimated (Informs drug pricing; still needed.)

Medicaid Payment For Postpartum Long-Acting Reversible Contraception Prompts More Equitable Use (Coverage issue; moot.)

Insurer Market Power and Hospital Prices in the US (Insurer patterns; moot.)

Hospital-Physician Integration Is Associated with Greater Use of Cardiac Catheterization and Angioplasty (Provider ownership & practice issues; likely still relevant.)

The Costs of Disparities in Preventable Heart Failure Hospitalizations in The US South, 2015–17 (Partially insurance issue; simplified.)

Enrollment and Characteristics of Dual-Eligible Medicare and Medicaid Beneficiaries in Integrated Care Programs (Insurance issue; moot.)

The Neighborhood Atlas Area Deprivation Index for Measuring Socioeconomic Status: An Overemphasis on Home Value (Equity; still relevant)

Changes In Health Coverage During The COVID-19 Pandemic (Insurance issue; moot.)

Buprenorphine Treatment for Opioid Use Disorder: Comparison of Insurance Restrictions, 2017–21 (Insurance issue; moot.)

‘We’ll Decide for You’: A Patient Is Rushed at Hospital Discharge (Partially insurance issue; simplified.)

Inequities In the Use of High-Quality Home Health (Largely insurance issue; simplified.)

Risk Adjustment and Health Equity (Insurance issue; probably moot.)

The Neighborhood Atlas Area Deprivation Index and Recommendations for Area-Based Deprivation Measures (Equity issue; still relevant.)

The Health Plan Price Transparency Data Files Are a Mess- States Can Help Make Them Better (Insurance complexity issue; moot.)

Identifying Scalable Strategies to Maintain Coverage as Medicaid Continuous Enrollment Ends (Insurance issue; moot.)

Why International Recruitment Won’t Solve the US Nursing Staffing Crisis (Largely financial issue; simplified.)

Comment by: Jim Kahn

Much health policy research examines the harms of and potential fixes for un- and underinsurance – problems created by our chaotically fragmented health insurance.

Our review of the table of contents of the premier US health policy journal suggests that the government and academic health policy community focuses on issues that would disappear with universal high quality health insurance, including drug price regulation – under single payer.

The considerable collective skills of health policy researchers should, could, and would be re-directed to the issues that are not fully resolved with single payer, such as disparities in access, care, and outcomes related to economic status and race.

Health policy researchers would also be called upon to study and refine the performance of single payer. For example, how should drug prices be set? How do provider reimbursement levels affect care patterns and outcomes? What is the impact of covering long-term care? How do clinical outcomes in the real world vary by choice of medical strategies? In another post, I’ll more fully describe a single payer health policy research agenda.

The contributions of health policy research must be unleashed by removing from the research portfolio the highly frustrating and largely futile research focused on trying to fix our irremediably broken insurance system. Policy band-aids, no matter how cleverly designed, won’t fix major pathology.

Liberate and empower health policy research!

Summary: PNHP founders Woolhandler and Himmelstein propose that progressive health reform needs updating to respond to the widespread takeover of providers by for-profit corporations. The original vision of insurance reform should be expanded to include ownership of provider organizations.

We Don’t Just Need Medicare for All — We Need a National Health System
An Interview with Steffie Woolhandler and David U. Himmelstein
Jacobin
May 2, 2023

The founders of Physicians for a National Health Program put single-payer health care on the map. Now, discussing the next phase of the movement, they say even single-payer won’t be enough to fix the problems caused by continued privatization. …

Steffie Woolhandler

There’s two countervailing things going on. One is that giant for-profit corporations have a much stronger hold on the health care system than they did when we started PNHP. So when we started, we were mostly up against the insurance industry and pharmaceutical industry. But now there’s all sorts of involvement by banks and for-profit ownership of health providers, so that makes things harder.

The other thing is that the health care system continues to be so dysfunctional. People with or without insurance face massive medical bills, the complete inability to afford lifesaving treatments like insulin and sometimes cancer treatments. The growing dissatisfaction among doctors is now often called burnout or sometimes moral injury. Whatever you call it, physicians recognize that the system’s not functioning very well. So the system’s own problems and dysfunctions continually create an interest in and constituency for fundamental health reform.

Giant for-profit corporations have a much stronger hold on the health care system than they did when we started PNHP.

David U. Himmelstein

We need to have a deep understanding of what the problems in the current system are, and the shifts in the organization of the current system need to guide both our program and our political work. So I think we need to update what the vision of single-payer health care is from when we first conceived of it.

We thought we could control the health care system by replacing insurance companies with a single public financing system. And I think that was true as long as health care was essentially carried out by small-scale practices, mostly individual hospitals, that were not parts of large chains, not controlled by giant corporations. But at this point, we have the vertical and horizontal integration of ownership of the health care system. So for instance UnitedHealthcare employs seventy thousand doctors. Just taking away the insurance business isn’t going to be an adequate reform of the health care system.

We need to reconsider our reforms to think about how we seize ownership of health care assets from the corporations that have come to dominate them, and how patients and people doing health care work can really take ownership of this system. I don’t think it’s possible any more by just taking control of insurance. I don’t see a lot of advocacy for radical reform of the health care system, and that I think is the next phase that either PNHP or some new form will need to take up.

Comment by: David Himmelstein and Steffie Woolhandler

Looking forward rather than backward, progressives need to update the vision of health reform that we and others articulated in the 1980s. Back then, a public financing program that displaced private ownership of health insurers would have had the leverage needed to broadly transform health care. But Wall Street’s subsequent takeover of health care delivery – hospitals and nursing homes, doctors’ practices, and even hospices – necessitates reform of who owns provider resources. Communities, not corporations should control care.

We hope that by speaking out on this issue, we can encourage the health reform movement to take on the critical ownership issues.

A few comments on the mostly accurate PNHP history presented in the article. It was founded 37, not 35 years ago. We note that Ron Sable, and subsequently Quentin Young, and then Claudia Fegan took over day-to-day oversight when PNHP moved from Cambridge to Chicago. Former Executive Directors Ida Hellander and Matt Petty made important contributions to PNHP. We are currently members, but not leaders, of the organization.

Summary: Aggressive collection tactics by a large bariatric surgery practice exemplify widespread problems with our health insurance: complex payment arrangements, confusing and misleading financial contracts, widely variable prices, medical debt, expensive litigation, and rising private equity.

Lose Weight, Gain Huge Debt: NY Provider Has Sued More Than 300 Patients Who Had Bariatric Surgery
KFF Health News
April 20, 2023
By Fred Schulte

Seven months after Lahavah Wallace’s weight loss operation, a New York bariatric surgery practice sued her, accusing her of “intentionally” failing to pay nearly $18,000 of her bill. …

Wallace denies the allegations, which the bariatric practice has leveled against patients in hundreds of debt-collection lawsuits filed over the past four years, court records in New York state show.

In about 60 cases, the lawsuits demanded $100,000 or more from patients. Some patients were found liable for tens of thousands of dollars in interest charges or wound up shackled with debt that could take a decade or more to shake. Others are facing the likely prospect of six-figure financial penalties, court records show. …

[Wallace] said she turned over checks from her insurer to the bariatric group and was stunned when the medical practice hauled her into court citing an “out-of-network payment agreement” she had signed before her surgery.

“I really didn’t know what I was signing,” Wallace told KFF Health News. “I didn’t pay enough attention.” …

The bariatric group has cited these out-of-network payment agreements in at least 300 lawsuits filed against patients from January 2019 through 2022 demanding nearly $19 million to cover medical bills, interest charges, and attorney’s fees, a KFF Health News review of New York state court records found. …

In most cases, the medical practice had agreed to accept an insurance company’s out-of-network rate as full payment for its services — with caveats, according to court filings.

In the agreements they signed, patients promised to pay any coinsurance, meeting any deductible, and pass on to the medical practice any reimbursement checks they received from their health plans within seven days.

Patients who fail to do so “will be held responsible for the full amount charged for your surgery, plus the cost of legal fees,” the agreement states.

That “full amount” can be thousands of dollars higher than what insurers would likely pay, KFF Health News found — while legal fees and other costs can layer on thousands more.
…

Wallace, the Brooklyn legal assistant, was billed $60,500 for her lap sleeve gastrectomy, though how much her insurance actually paid remains to be hashed out in court.

Michael Arrigo, a California medical billing expert at No World Borders, called the prices “outrageous” and “unreasonable and, in fact, likely unconscionable.” …

Private Equity Arrives
…

In August 2019, the private equity firm Sentinel Capital Partners bought 65% of the MSO for $156.5 million, according to Garber’s affidavit. The management company is now known as New You Bariatric Group. The private equity firm did not respond to requests for comment.

Comment by: Jim Kahn

This exposé of one firm exposes problems that plague all of health care. The aggressive legal tactics employed by this surgery practice drew press attention because they’re so egregious and extensive. But the fundamental issues permeate our insurance system.

1) Complex payment arrangements: Scores of public insurance programs (Traditional Medicare with and without direct contracting, Medi-gap policies, Medicare Advantage and Medicaid plans in profusion) and thousands of private insurance plans from work and ACA exchanges. Out-of-network payments regulated by ambiguous laws. All of this contributes hugely to more than $600 billion per year in excess administrative costs.

2) Confusing and misleading financial contracts with patients: The patients of this bariatric surgery practice were told that it would accept out-of-network payments offered by insurers … except if … here’s the fine print … they failed to take care of all tasks within 7 days, in which case their obligation would shift to “the full amount charged for your surgery, plus the cost of legal fees”. And, it seems, the practice charged very high prices.

3) Widely variable prices: Which brings us to prices. It turns out that prices listed by different practices for these standard surgeries vary widely in nearby areas. This is generally true of medical prices: the amount “charged” (aka “billed”, aka “chargemaster”) is entirely discretionary, and varies hugely across providers. Insurers typically negotiate much lower “allowed” charges. Discerning a truly fair local price is impossible. This surgical practice aims high, which means the sued patients are on the hook for amounts far in excess of actual costs.

4) Medical debt: Which leads to medical debt. As detailed in the article, this is the result for many sued patients. And, as covered in HJM, estimates of the current prevalence of medical debt are in the range of 40-50%, with a median debt of $2,500 or more.

5) Expensive litigation: Collections lawyers are happy to line up when liabilities of tens of thousands of dollars are in the offing from poorly-represented patients who didn’t read the fine print in their contracts, and the lawyers will keep 1/3 of the yield. That adds to administrative costs. And the litigation clogs the courts and traumatizes patients.

6) Rising private equity: As the last excerpted paragraph notes, the surgery practice payment lawsuits accelerated once private equity entered the scene. Private equity is rapidly expanding its role in provider ownership, as reported in HJM. Pursuit of income and profit as their guiding light.

Single payer would solve problems 1, 2, 3, 4, and 5. And greatly mitigate 6.

Summary: Oracle Health, acquired by Cerner, is pursuing a global cloud-based health records repository. Except that they can’t even succeed in five Veteran’s Administration hospitals. And their grand vision fails to address core healthcare financing challenges. When will we turn our attention from profit-seeking business models to health coverage basics?

Oracle’s plan to build national health records database ‘going great,’ Feinberg says
Healthcare Dive
April 21, 2023
By Rebecca Pifer

(David Feinberg was CEO of Cerner and then became chairman of Oracle Health when it acquired Cerner.)

Healthcare Dive: When the deal closed, Oracle said it planned to focus the unit on medical software usability and voice-enabled user interfaces, and would expand Cerner’s business to more countries. Can you give me an update on these priorities?

Feinberg: I remember those three things being listed. It’s more now. Our vision is to create a cloud-enabled health platform that brings all kinds of information together to make individuals and communities healthier around the world. That includes the electronic health record, and Oracle’s human capital management, enterprise resource planning, supply chain management, claims processing, clinical trials – so we have a platform that normalizes data and then tees it up for whoever needs it, a mom taking care of kids at home, or a government looking at public health issues.

Healthcare Dive: Larry Ellison announced Oracle has plans to build a health records database to link the thousands of separate hospital databases. How is this going?

Feinberg: It’s going great. We have a new product we just launched called Seamless Exchange. A clinician gets a new patient, and this patient has records from multiple places. With one click, we take all of that information and we make a longitudinal story of that patient.

Healthcare Dive: What are the next steps?

Feinberg: I want all information that’s applicable to my health. That includes social determinants, that includes claims processing, so many other pieces of information.

Healthcare Dive: How will Oracle pull that additional data?

Feinberg: Oracle Financial Services processes 80% or 90% of the world’s credit card transactions… So we have the clinical data. Oracle Financial Services also does claims data. We think we can be the trusted intermediary between clinical care and the payment of clinical care that dramatically decreases the cost.

VA Halts Future Launches of its Oracle Cerner Health Record System
Military.com
April 21, 2023
By Patricia Kime

The Department of Veterans Affairs has abandoned plans to introduce its new electronic health records system at more facilities, announcing Friday that it has halted all future deployments as if moves to fix the system at the five places where it is currently used.

Comment by: Don McCanne

So it looks like Oracle wants to take over the entire health care information technology system. In whose interest is this?

In these days when the medical-industrial complex dominates, it seems that Oracle’s designs are on enhancing shareholder value, probably not just for individual shareholders and for the corporate executives, but especially for the dominant shareholders representing the shift of wealth from the masses to the billionaire element in our society.

Is this in the interest of the health care professionals and the health care industry at large? It does provide a framework for an overlay of their health information technology, but for the purpose of enhancing income produced by the IT system. Any income for the actual health care delivery system would be to keep them satisfied so they would continue to use Oracle products.

But shouldn’t the health care delivery system be designed to, above all, meet the needs of patients? What does this IT system do for those individuals who could qualify for Medicaid but are left out because of political decisions in their states? What about for those who are left un- or under-insured because of employer-labor disputes? What about those who are medically underserved due to well-documented problems such as racial inequities? Why would we ignore all our health policy lessons about how to provide optimal care for everyone?

Creating more wealth-generators in health care without fixing the profound deficiencies in our health care system is obviously continuing down the wrong path, blatantly disregarding real needs. At least they understand this at the VA. They’ve halted the launch of the Oracle Cerner Health Record System because it is not working for the patients, and the patients are what health care is all about. Oracle can’t manage data for five health facilities, but they’re eager to take on health data around the world.

Shouldn’t we get serious about health system improvement? Clear goals on how to optimize access to care for everyone (not maximize profits), using proven methods (not shoddy IT).

Summary: In Part 1, we discussed how primary care is being acquired and distorted by huge corporations pursuing massive profits. Today, we present a competing vision: a broad social movement to reclaim primary care as a “common good” focused on public benefit.

Forging a Social Movement to Dismantle Entrenched Power and Liberate Primary Care as a Common Good
Annals Of Family Medicine
March/April 2023
By Kevin Grumbach

ABSTRACT: The state of family medicine and primary care in the United States is precarious, afflicted by chronic underinvestment. Family physicians and their allies should not expect different policy outcomes without adopting a different theory of change and tactical approach to reform. I argue: (1) high-quality primary care is a common good, as asserted by the National Academies of Sciences, Engineering, and Medicine; (2) a market-based health system captured by extractive capitalism is inimical to primary care as a common good; (3) professionalism has both aided and constrained family physicians as agents of change for primary care as a common good; and, (4) to actualize primary care as a common good, family physicians must embrace “counterculture professionalism” to join with patients, primary care workers, and other allies in a social movement demanding fundamental restructuring of the health system and democratization of health that takes power back from interests profiting from the status quo and reorients the system to one grounded in healing relationships in primary care. This restructuring should take the form of a publicly financed system of universal coverage for direct primary care, with a minimum of 10% of total US health spending allocated to Primary Care for All.

Over past decades, several waves of health reform and advocacy efforts offered hope of revitalizing the specialty of family medicine and the primary care sector: the rise of managed care in the 1990s; the Joint Principles of the Patient- Centered Medical Home in 2007; enactment of the Patient Protection and Affordable Care Act in 2010; the launching of Family Medicine for America’s Health in 2013. Yet the reality on the ground has not fundamentally improved for family physicians and others working in primary care, or for patients struggling to obtain high-quality primary care. Between 2005-2015, the number of primary care physicians per capita in the United States declined, primary care visits per capita decreased, and waiting times for new primary care appointments lengthened. The earnings gap between primary care physicians and physicians in other specialties widened and burnout remains high. Most tellingly, only about 5% of national health expenditures in the United States are spent on primary care—one-half or less than the proportion spent in Canada and Europe.
…

A Social Movement for Primary Care as a Common Good

To actualize primary care as a common good, family physicians must embrace what I call “counterculture professionalism” to join with patients, community members, primary care workers, and other allies to build a broad-based social movement demanding a fundamental restructuring of the health system and democratization of health that takes power back from interests profiting from the status quo and reorients the system to one grounded in healing relationships in primary care. A social movement must have clarity about what it wants to achieve, and how to achieve it.
…

By social movement, I mean a coming together of people and organizations united by a sense of common purpose counter to the dominant power. The consequential issues of our times—climate change, systemic racism, inequality of wealth, gun violence, reproductive rights, among others—are all contests for the common good. Progress requires an activated citizenry working in solidarity to challenge profits, power, and privilege that harm collective well-being. High quality primary care for all is not simply a parochial interest for family medicine. In the US context, it is a radical proposition that calls for family physicians to find common cause with others who share this goal.

Comment by: Jim Kahn

Kevin Grumbach (a colleague at UCSF) is a long-time leader in the single payer movement and in family medicine. He is thoroughly frustrated by the failure of typical policy tools – laws and high-profile reports – to mitigate the declining role of primary care in US health care. Our population suffers as a result.

Addressing family medicine doctors, Kevin proposes a broad-based social movement to reclaim primary care. His call to action is stirring. Kevin is realistic about the challenges facing social change, given powerful entrenched opponents. Yet he sees a movement as the only chance to revive primary care, given the futility of traditional policy levers.

Should the single payer movement endorse “primary care for all”, leaving specialist and hospital care for the time being in the hands of existing insurers and providers? Kevin proposes that a “successful PC4All program might prompt the nation to consider not only primary care, but all health care, to be a common good, and to join other countries with advanced capitalist economies in implementing a comprehensive, tax-financed universal health care program.”

Is “primary care for all” a stepping-stone for “health care for all”?

Maybe the more circumscribed revolution has a greater chance of success, demonstrating the value of a public approach to health care financing, and building the large and strong coalition needed for comprehensive health system transformation.

Lots to contemplate here.