Expensive Drugs are Becoming Ultra-Expensive

Health Affairs, June 2021, Ultra-Expensive Drugs And Medicare Part D: Spending And Beneficiary Use Up Sharply, By So-Yeon Kang, Daniel Polsky, Jodi B. Segal, and Gerard F. Anderson

Drugs with exceptionally high prices have sparked debate on their sustainability and affordability. We refer to these as “ultra-expensive” drugs, defined as drugs with average annual per beneficiary total spending in excess of the annual US per capita gross domestic product ($62,996 in 2018). In the context of Medicare, this includes both Medicare’s and the beneficiary’s responsibilities. Our findings show a rapid increase in the share of Medicare Part D spending on these drugs compared with other drugs.

It is a limitation of our study that we analyzed only Medicare Part D data and thus could not draw any conclusions regarding Medicaid or private insurance.

Medicare Part D spending for ultra-expensive brand-name drugs, 2018:

  • 122 – Total number of drugs
  •  278,000 – Total number of beneficiaries
  •  $24,550,000,000 – Total spending
  •  $175,513 – Average spending per beneficiary per drug

(The table also includes a section for drugs that are only expensive, defined as those that were not ultra-expensive but whose annual per beneficiary total spending was more than the yearly average Social Security benefits of retired workers [$16,848 in 2018]. These expensive drugs were consumed by 651,000 beneficiaries at an average of $34,451 per drug for total Medicare Part D spending of $21,552,000,000.)

The number of ultra-expensive drugs covered by Medicare Part D increased from 23 in 2012 to 122 in 2018.

We note that sixty-one drugs (50 percent of ultra-expensive drugs in 2018) entered the market as ultra-expensive drugs between 2012 and 2018; 31 percent were on the market but not ultra-expensive in 2012 and became ultra-expensive by 2018.

One challenge for policy makers is that half of these ultra-expensive drugs are new, and their sustained therapeutic and economic benefit for the price has not yet been demonstrated.

The concentration of Part D spending on the growing number of beneficiaries using ultra-expensive drugs suggests that policy makers should pay attention to this drug category.

Comment by Don McCanne

Drug spending is out of control and getting much worse. By the standards in the article, the newly released, likely-ineffective Alzheimer’s drug, aducanumab, at $56,000 per year, is considered onl expensive and not ultra-expensive.

Imagine, single drug pricing per beneficiary in excess of the per capita GDP. Wasn’t the equivalent of taking a full year’s Social Security retiree benefits for a single drug enough?

Perhaps the most important statement in this article, which is decidedly an understatement, is that “policy makers should pay attention to this drug category.”

Perhaps we should approach Sen. Joe Manchin, as a moderate conservative, and explain the situation to him so he can lead a unified Congress to do something about it. But, wait a minute, wasn’t it his daughter, Heather Bresch, as CEO of Mylan, who purchased the company, Abbott, that sold the EpiPen brand of epinephrine, and then increased its price by 461 percent?

Sadly, this Congress has already shown its lack of concern by its inaction; this price gouging is taking place under its very nose. No, we need to elect a Congress that will not only pay attention, but one that will actually do something about it. We certainly can no longer leave it up to the pharmaceutical industry to come up with fair pricing for its products.


Medicine Must Meet the Moment on Racial Justice

AMA Doctors Meet Amid Vocal Backlash Over Racial Equity Plan
U.S. News
June 12, 2021
By Lindsey Tanner

The nation’s largest, most influential doctors’ group is holding its annual policymaking meeting amid backlash over its most ambitious plan ever — to help dismantle centuries-old racism and bias in all realms of the medical establishment.

The dissenters are a vocal minority of physicians, including some white Southern delegates who accuse the American Medical Association of reverse discrimination.

Dr. Gerald Harmon, the group’s incoming president, is a 69-year-old white native of rural South Carolina who knows he isn’t the most obvious choice to lead the AMA at this pivotal time. But he seems intent on breaking down stereotypes and said pointedly in a phone interview, “This plan is not up for debate.”’’

The six-day meeting that began Friday is being held virtually because of the pandemic. It offers a chance for doctors to adopt policies that spell out how the AMA should implement its health equity plan. But some white doctors say the plan goes too far.

Announced last month, the plan is unusually bold for the historically cautious AMA, acknowledging that racism and white privilege exist in the medical establishment and have contributed to health disparities laid bare during the coronavirus pandemic.

Portions of the plan include the language of critical race theory, referencing the theft of native lands and centuries-old white supremacy. The dissenters took offense and attacked the plan in documents recently leaked online. One leaked draft of a letter intended for AMA executives called portions of the plan “divisive, accusatory and insulting.”

“White males are repeatedly characterized as repressive and to some degree responsible for the inequities. This … implies reverse discrimination,’’ the letter said. It was signed by Dr. Claudette Dalton, a member of the AMA’s Southeastern delegation, four other physicians and five state delegations representing 68 AMA delegates.

Medical Journals Blind to Racism as Health Crisis, Critics Say
NY Times
June 2, 2021 
By Apoorva Mandavilli

The top editor of JAMA, the influential medical journal, stepped down on Tuesday amid a controversy over comments about racism made by a colleague on a journal podcast. But critics saw in the incident something more pernicious than a single misstep: a blindness to structural racism and the ways in which discrimination became embedded in medicine over generations.

“The biomedical literature just has not embraced racism as more than a topic of conversation, and hasn’t seen it as a construct that should help guide analytic work,” said Dr. Mary Bassett, professor of the practice of health and human rights at Harvard University. “But it’s not just JAMA — it’s all of them.”

Following an outcry over the incident, editors at JAMA on Thursday released a plan to improve diversity among its staff, as well as in research published by the journal. 

Comment by Eagan Kemp

In a country that has consistently refused to come to terms with its racist history, it should come as no surprise that the medical profession is also in need of a reckoning. 

Almost no aspect of American life is untouched by decisions and institutions that empowered white men over everyone else, even in matters of life and death. And there are few places where the consequences are more deadly than in the practice of medicine. The disturbing  examples are numerous, whether the Tuskegee Syphilis Experiment; exposure of Black, Japanese-American, and Puerto Rican soldiers to mustard gas and other chemicals during World War II; or the complicity of numerous doctors in the torture regime of the Bush Administration. The list goes on and on. The practice of medicine in the services of evil remains a stain on the profession and on the country. 

But racism in medicine is not just a list of egregious episodes. Every day, insurance coverage, access to care, and health outcomes are often far worse for Black, Indigenous, and other people of color than for white Americans. Structural racism pervades our health care system, just as it pervades the rest of American society.

Indeed, public policy issues in the U.S. are typically debated through the lens of race — often implicitly — and health care is no different. Opposition to universal health care has often reflected an unwillingness to extend benefits to Black, Indigenous, and other communities of color. 

As Jeneen Interlandi highlighted in her crucial piece, which is part of the 1619 Project:

One hundred and fifty years after the freed people of the South first petitioned the government for basic medical care, the United States remains the only high-income country in the world where such care is not guaranteed to every citizen. In the United States, racial health disparities have proved as foundational as democracy itself. “There has never been any period in American history where the health of blacks was equal to that of whites,” Evelynn Hammonds, a historian of science at Harvard University, says. “Disparity is built into the system.”

It is crucial to remember that the American Medical Association was initially a whites-only organization, necessitating the creation of the National Medical Association in 1895 by twelve black doctors in Atlanta, GA. In 2008, the AMA formally apologized “for its past history of racial inequality toward African-American physicians.”  

The opposition of the AMA to universal coverage has often come from its unwillingness to see Black and Brown Americans as worthy of the same quality of care experienced by white Americans. We only have to look back at their attempts to block Medicare and other health reforms. The AMA’s opposition to universal health care continues today, though many doctors and medical students are undertaking heroic efforts to push the AMA away from its opposition to universal health care and toward supporting health care justice generally and Medicare for All specifically. But let’s be clear, Medicare for All wouldn’t immediately solve issues of racism in medicine, but it would finally end the coverage gap and improve access to care for millions. It would also allow the collection of better disaggregated data, improving our ability to address health disparities. 

The time has come for change, and doctors must meet the moment and lead on directly addressing racism in health care. Doctors should not take this racial justice reckoning as a negative thing or feel disempowered in their work. Doctors — and all Americans — must individually and collectively engage with their own complicity with institutions that undermine progress on racial justice and make changes personally, professionally, and societally starting where they can. In few other places is that task as crucial as it is in medicine.

Health Care Reform

Colorado’s Pseudo-Public Option

By Adam Gaffney

Last week, lawmakers in Colorado passed a bill that would establish what some might call a “state public option” plan, although that’s not what it is. The bill would require, as the Colorado Sun and Denver Post describe, private insurance companies to offer a health plan on the individual and small-marketplaces with premiums that are 15% lower in 2025 than they are today after adjustment for medical inflation; if that goal was not met, the state could potentially regulate payment rates under these plans.  

The bill was heavily opposed by state Republicans and, variably, by healthcare industry players. Its advocates tried to achieve more. But unfortunately, the impact of the law is likely to be paltry, potentially even difficult to perceive. If that pans out, it could be used to discredit the notion of true public health insurance.    

For one thing, as the Colorado Sun describes, the source of the 15% savings is not entirely unclear. It quotes one of the bills’ chief sponsors: “The spirit of this bill is to ask everyone to come to the table to work on decreasing cost and increasing access.”  But these plans would still be run by private insurers, so there is no reason to expect any savings on insurer administration — the primary source of savings under Medicare for All according to the Congressional Budget Office. On the other hand, government rate-regulation (or the threat of it) might give insurers more leverage to reduce reimbursements to providers. Whether this process will succeed, however, is uncertain. After all, Colorado is following in the footsteps of Washington state, which passed a quasi-public option in 2019. Premiums for these “public option” plans (which are actually private insurance plans sold on the marketplaces that pay rates tethered at a percentage above Medicare) were actually 5% higher in 2021 relative to 2020 ACA marketplace plans, per Bloomberg Law.

But the reach of these plans, even if they achieved modestly lower premiums, will also be highly limited. They are available only to those buying insurance on the individual and small-business market. They would hence provide no benefits for those with employer-sponsored coverage and high premiums or deductibles, or for those with holes and gaps in their public insurance plans. Moreover, although they have been advocated as a tool to expand coverage, they are unlikely to be more affordable for the vast majority of uninsured individuals even if they achieve lower premiums. That is because, under the ACA, premium contributions for marketplace plans are set as a proportion of income for all those earning under 400% of the federal poverty level, which is now also the case for those of any income under Bidens’ America Rescue Plan (at least through 2022). Hence, there is no real popular constituency for these programs: at best, if totally successful, they would mostly serve to bring about a modest reduction in government expenditures on ACA subsidies, with little gain in coverage, access, or affordability of care for patients. 

And that is not just a policy problem, but a political one. To bring about meaningful change in healthcare, you need a powerful popular constituency behind you, because invariably you encounter opposition from powerful interests. This sort of reform, however, fails to generate such a constituency; its weakness is, in this sense, a feature and not a bug of its design. In contrast, although single-payer reform poses far larger political obstacles for passage, it is unique in that it could benefit nearly every segment of society, and hence potentially help generate the constituency needed to achieve it.


Uninsured Adults Nearing Medicare Age More Likely to Die from Cancer

Cancer Outcomes Among Medicare Beneficiaries And Their Younger Uninsured Counterparts, Health Affairs, May 2021, Gerard Silvestri, Ahmedin Jemal, K. Robin Yabroff, Stacey Fedewa, and Helmneh Sineshaw

Abstract: Proposals for expanding Medicare insurance coverage to uninsured Americans approaching the Medicare eligibility age of sixty-five has been the subject of intense debate. We undertook this study to assess cancer survival differences between uninsured patients younger than age sixty-five and older Medicare beneficiaries by using data from the National Cancer Database from the period 2004–16… We found that uninsured patients ages 60–64 were nearly twice as likely to present with late-stage disease and were significantly less likely to receive surgery, chemotherapy, or radiotherapy than Medicare beneficiaries ages 66–69, despite lower comorbidity among younger patients. Compared with older Medicare patients, younger uninsured patients had strikingly lower five-year survival across cancer types. For instance, five-year survival in younger uninsured patients with late-stage breast or prostate cancer was 5–17 percent lower than that among older Medicare patients. We conclude that… expanding comprehensive health insurance coverage to people approaching Medicare age eligibility may improve cancer outcomes in the US.


Comment by Isabel Ostrer

Cancer is a leading cause of death in the United States. However, there are stark disparities in cancer outcomes among different populations. Lack of insurance is an unfortunate and unnecessary contributor to these disparities. 

In this Health Affairs paper, we learn that uninsured patients ages 60-64 with a new cancer diagnosis had significantly worse one-, two-, and five-year survival rates compared to their Medicare-insured counterparts — who were also older (66-69) and more likely to have comorbidities. The reasons for these discrepancies are varied but certainly include lack of access to care. Patients who are uninsured are less likely to have a usual source of primary care and to participate in cancer screening programs leading them to present with later-stage disease that is not easily curable. Of note, patients in the younger age group who had insurance coverage had better survival rates than their older counterparts, as would be expected due to age differences. 

Disparities in cancer outcomes also vary by race, with Black patients faring worse than white patients. When adjusting for insurance coverage these disparities decrease, although they are not eliminated. 

The authors posit that lowering the Medicare eligibility age to 60 could improve cancer outcomes and reduce disparities. Why stop at 60? Patients across their lifespan are at risk of developing not just cancer, but other conditions that respond to early treatment and intervention. Nearly 20% of adults in the 45-64 age group have diabetes. Furthemore, nearly one in five deaths among adults 25-64 is due to cardiovascular disease

We know that insurance coverage both improves survival and reduces racial disparities in outcomes, not only for cancer but also for other medical conditions – chronic and acute. It’s time to assure that all Americans have high-quality insurance. The only way to achieve this is thorough Medicare for All.

Health Care Reform Medicare For All

The Buffett-Bezos-Dimon-Gawande insurance fail? A powerful policy lesson!

How Amazon, JPMorgan, and Berkshire Hathaway took on America’s health care system—and lost, Fortune, June 1, 2021, By Erika Fry

Was it a press release, or a declaration of war?

How else to explain the media and market frenzy that followed the announcement, issued on Jan. 30, 2018, that Amazon, Berkshire Hathaway, and JPMorgan Chase — three of the nation’s largest, most high-profile, and best-run companies, then with some $534 billion in revenues between them — were teaming up to take on the ever-more-expensive, ever-more-complex problem that is American health care.

To those who had toiled in the world of employer-sponsored health care for decades, trying but never really succeeding to come up with new ways to control costs and improve outcomes … the statement, from three powerful CEOs, was cause for celebration.

Five months in, the team announced another star would lead the venture: Atul Gawande, the surgeon and influential New Yorker writer whose clear-eyed analysis of America’s dysfunctional health care system had earned him the admiration of Barack Obama and Buffett. In March 2019, the venture finally got a name, Haven.

The project officially sputtered to an end earlier this year. Even with its star power, Haven couldn’t break the black box that is U.S. health care.

So, did Haven make a difference? Some argue the effort undermined progress by raising the obvious question: If they couldn’t do it, who can? In a recent Kaiser Family Foundation survey of very large employers, 85% of top executives think government support will be necessary to control costs and provide coverage.

Gawande goes further and has recently argued that the employer-sponsored system can’t be fixed. Noting how many Americans lost their health insurance in a global pandemic, he said, “A job-based system is a broken system.”


Comment by Don McCanne

I contend that the Haven health reform effort of Warren Buffett, Jeff Bezos and Jamie Dimon, along with Atul Gawande, was a spectacular success, as an experiment in health policy. They proved beyond any reasonable doubt that the private sector is incapable of fixing our highly dysfunctional health care financing system. The only model that has shown promise is a single payer Medicare for All system. But you cannot set that up as an employer-sponsored system; it will have to be a public system for all the people.

Health Care Financing

Insurers That Squeeze Care are Killing Thousands of Enrollees Each Year

Mortality Effects and Choice Across Private Health Insurance Plans, The Quarterly Journal of Economics, May 6, 2021, Jason Abaluck, Mauricio Caceres Bravo, Peter Hull, and Amanda Starc. 

*The abstract is available at  While the full text is behind a paywall, an earlier version of the full paper is available here

From the Abstract: “We develop and apply a novel instrumental variables framework to quantify the variation in causal mortality effects across plans and how much consumers attend to this variation. We first document large differences in the observed mortality rates of Medicare Advantage plans within local markets. We then show that when plans with high (low) mortality rates exit these markets, enrollees tend to switch to more typical plans and subsequently experience lower (higher) mortality. . . . 

We then extend our framework to study other predictors of plan mortality effects and estimate consumer willingness to pay. Higher-spending plans tend to reduce enrollee mortality, but existing quality ratings are uncorrelated with plan mortality effects. Consumers place little weight on mortality effects when choosing plans. Good insurance plans dramatically reduce mortality, and redirecting consumers to such plans could improve beneficiary health.”

From the text:  “We find that the most widely used measure of plan quality, CMS star ratings, is uncorrelated with plan mortality effects. Higher premium plans have better mortality effects, as do plans with more generous prescription drug coverage and higher medical-loss ratios. Thus, in every way we measure, plans that spend more tend to reduce enrollee mortality.”


Comment by David Himmelstein and Steffie Woolhandler

A simple message emerges from this complex econometric analysis: insurers that skimp on paying for care (as measured by a low medical-loss ratio – the share of premiums devoted to patient care) or provide highly restrictive drug coverage, are killing their enrollees.

The study examined the mortality rates of patients covered by different Medicare Advantage (MA) plans. Not surprisingly, mortality varied among plans. That could just reflect differences in how sick the enrollees were to begin with, not anything the insurers did.

The compelling finding is that when plans with high mortality rates stopped offering coverage in a particular county – forcing their enrollees to switch to a different plan – the mortality rate for those forced to switch went down. (Similarly, when low-mortality plans shut down, the mortality rate of the enrollees forced to look elsewhere for coverage went up.) In sum, the study provides quite convincing, quasi-experimental evidence that MA plans’ quality influences the mortality of their enrollees. Indeed, the effect is so large that shifting MA enrollees from the worst 5% of plans to the average (not even the best) plan would save about 12,000 lives each year.

The researchers then looked at what differed between high and low mortality MA plans.  They found no correlation with the CMS star rating – a one star-rated plan was just as likely to do well by its enrollees as a five star plan. And, not surprisingly, seniors, who often look to these ratings were bad at choosing a plan with low mortality.

What made a difference – and a big one – was how much a plan spent on its enrollees. Plans that had a higher medical loss ratio (i.e. they spent more of their premiums on care, and less on overhead and profit) had lower mortality rates. (The medical loss ratio of  MA plans averaged 83% in 2020 vs. traditional Medicare’s 97.7%). Additionally morality was lower in plans with better drug coverage and those with higher premiums. 

As is often true of economists, these researchers drew the wrong conclusions from their important findings, clinging to the pro-market notion that additional tweaks could finally make commercially-driven health insurance work to patients’ advantage. They recommend that CMS improve its rating system to take account of MA plans’ mortality performance. As the authors note, however, private insurers would game any mortality-based rating system, just as they have successfully gamed CMS’ star system. The authors further suggest that health and life insurance be merged so that MA plans that kill people by squeezing care would have to pay out more in life insurance benefits.  

They ignore the obvious better choice: a single payer system that would have a loss ratio of 97.7%, as well as better drug coverage than the best MA plan. The data indicate that would save tens of thousands of seniors’ lives annually.

Health Care Reform

Let’s Not Mourn the Death of the Public Option

The health insurance public option might be fizzling. The left is OK with that., NBC News, June 5, 2021, By Benjy Sarlin and Sahil Kapur

“A decade later, Joe Biden campaigned on making the public option a reality, but so far, he’s done little to get Congress to enact one. Instead of outrage, influential progressives seem to be OK watching the promise go unfilled, preferring to pursue universal health care through other means, like expanding Medicare eligibility.

Elected officials, health care activists and experts who spoke to NBC News said the issue has fallen off the national radar and will be difficult to revive without a major push by the White House.

Responding to the pandemic has consumed much of Biden’s attention in his first months in office. And beyond that, he has a long list of agenda items to get to first, including many that are popular with progressives.

“I don’t think there’s a dynamic where we see it at the center of a political fight again,” said Alex Lawson, the executive director of the left-leaning group Social Security Works.”


Comment by Eagan Kemp

No one should mourn the end of a push for a public option in health care. It was never the solution the country needed for health reform. 

The risks inherent in a public option completely overwhelm any potential gains. Given the rapid rise in for-profit companies gaming Medicare through Medicare Advantage, there is no reason to believe that a public option would be any different when it comes to insurers dumping patients with high health needs, while retaining patients that are profitable. If the for-profit insurers can cherry-pick healthier Americans through seemingly more favorable plans (while they are healthy), then the public option could become overly burdened and unsustainable. 

In addition, a public option would have just been one more area of added complexity in our already fragmented health care system, which already struggled to respond to the COVID-19 crisis

A public option would also further entrench the power of for-profit insurers. And the massive administrative waste of private insurance companies would continue under a public option, whereas under Medicare for All the reduction in administrative savings would be more than $500 billion a year

In terms of political feasibility, there is the perception that less comprehensive reforms could have an easier chance of passing. However, the companies that profit off our healthcare system have shown they are just as opposed to the most basic public option proposal as they are to Medicare for All. Both the Partnership for America’s Health Care Future and Coalition Against Socialized Medicine—which strongly oppose Medicare for All as well as a public option —have shown they will not compromise on behalf of their corporate backers. 

While proponents of a public option may try to make their proposal sound “reasonable,” it wouldn’t come close to matching Medicare for All. Whether it is savings for families, savings for the country or ensuring that everyone in the country has guaranteed access to medically necessary care, only Medicare for All would create the health care system we need.

Medicare For All

Public Insurers Provide Better Access, Financial Protection, & Satisfaction Than Private Insurers

Access to Care, Cost of Care, and Satisfaction With Care Among Adults With Private and Public Health Insurance in the US, JAMA Network Open, June 1, 2021, By Charlie M. Wray, Meena Khare, Salomeh Keyhani

Introduction: In the past decade, health insurance expansion has been a major aspect of health care reform in the US, with the Patient Protection and Affordable Care Act (ACA) increasing coverage to more than 20 million US adults.

We used the Behavioral Risk Factor Surveillance System (BRFSS) to compare experiences related to access to care, costs of care, and satisfaction with care among the 5 major forms of health insurance coverage (private employer–sponsored insurance, private individually purchased insurance, Medicare, Medicaid, and Veterans Health Administration [VHA] or military coverage) after accounting for respondents’ underlying health.

Results: …Compared with those covered by Medicare, individuals with employer-sponsored insurance were less likely to report having a personal physician (odds ratio [OR], 0.52; 95% CI, 0.48-0.57) and were more likely to report instability in insurance coverage (OR, 1.54; 95% CI, 1.30-1.83), difficulty seeing a physician because of costs (OR, 2.00; 95% CI, 1.77-2.27), not taking medication because of costs (OR, 1.44; 95% CI, 1.27-1.62), and having medical debt (OR, 2.92; 95% CI, 2.69-3.17). Compared with those covered by Medicare, individuals with employer-sponsored insurance were less satisfied with their care (OR, 0.60; 95% CI, 0.56-0.64)…

Conclusions and Relevance: In this survey study, individuals with private insurance were more likely to report poor access to care, higher costs of care, and less satisfaction with care compared with individuals covered by publicly sponsored insurance programs. These findings suggest that public health insurance options may provide more cost-effective care than private options.


Comment by Don McCanne

How many times do we have to say it? Public health insurance is designed to make health care accessible and affordable for the people. Private health insurance is designed to make a profit for the insurers. The policies used in the design of the various insurance products are selected on the basis of the desired results. Access to care, cost of care, and satisfaction with care are very important in the design of public insurance. In contrast, profits are of utmost importance in private insurance.

This study confirms that the private insurers will sacrifice access, cost, and satisfaction in order to increase profits. Patients have much higher access to care, financial protection, and satisfaction with public insurance. Shouldn’t we be demanding single payer Medicare for All so that we can all have what we want in health care, and so that we can free up the private insurers to engage in productive occupations that would be a greater benefit to society?

Health Care Financing

Time to Abandon Pay For Performance

Time and Financial Costs for Physician Practices to Participate in the Medicare Merit-based Incentive Payment System: A Qualitative Study, JAMA Health Forum, May 14, 2021, By Dhruv Khullar, Amelia M. Bond, Eloise May O’Donnell, Yuting Qian, David N. Gans, and Lawrence P. Casalino

“Participating in the MIPS program results in substantial financial and time costs for physician practices. We found that, on average, it cost practices $12 811 per physician to participate in MIPS in 2019. We found that physicians themselves spent a considerable amount of time to participate in MIPS. In 2019, physicians spent more than 53 hours per year on MIPS-related activities, which translates to nearly $7000 per physician. If physicians see an average of 4 patients per hour, then these 53 hours could be used to provide care for an additional 212 patients a year—equal to more than a full week’s work for a physician.”


Comment by Adam Gaffney

Pay-for-performance (P4P) is an increasingly central part of the American healthcare landscape. The Affordable Care Act added a multitude of new P4P programs to Medicare, including the Hospital Readmissions Reductions Program (HRRP) and the Hospital Value-Based Purchasing Program (HVBP). Then, the Medicare Access and CHIP Reauthorization of 2015 gave us the Merit-based Incentive Payment System (MIPS), a new P4P program that imposes financial sticks and carrots on individual clinicians across the country based on a slew of complicated performance metrics.

Much research suggests that these programs have little effect on patient outcomes. The HRRP was much lauded for apparently reducing readmissions, but later research attributed much (or all) of this apparent reduction to changes in diagnostic coding. There is also some evidence HRRP may have harmed some cardiac patients. Meanwhile, studies of the HVBP have found virtually no impact. Fewer studies, however, have examined the costs of such programs.

That’s what makes this study, led by Dr. Dhruv Khullar at the Weill Cornell Medical College, so valuable. The researchers interviewed the leaders of 30 physician practices across the nation who participated in the MIPS, and quantified the costs of participation in the program. Overall, they found that we spend more than $12,000 per physician annually to cover the administrative costs of participation in MIPS. Additionally, “MIPS-related activities” suck up over 200 hours of labor per year from practice staff, including 53.6 hours from frontline clinicians. And this is merely for a single P4P program.

There is little evidence, in other words, that P4P programs substantively improve care — and growing evidence that they further inflate our already enormous administrative costs while sapping the time and energy of practicing doctors. For these reasons, P4P should not be included in a Medicare for All reform. Notably, the House Medicare for All Bill excludes this payment mechanism. The underlying political idea of P4P is a fundamentally neoliberal one: the idea that we are all motivated only by pursuit of the dollar. Instead, doctors want to provide the best care they can. That it is not to say that there isn’t room for quality improvement in our healthcare system — far from it — but a paucity of profit incentives is not the culprit. Further, an increasing number of studies show that P4P is redistributive — shifting funds from providers that care for poorer patients (who tend to have worse outcomes) to the providers of the wealthy.

Long Term Care

Single Payer Must Include Rational & Compassionate Long Term Care

Health Care Use and Out-of-pocket Spending by Persons With Dementia Differ Between Europe and the United States, Medicare Care, June 2021, By Sabrina Lenzen, Pieter Bakx, Judith Bom, Eddy van Doorslaer

Background: Persons with dementia need much care, but what care is used and how the burden of financing is divided between persons with dementia, caregivers, and public programs may differ between countries.

Objective: The objective of this study was to compare how health care use and out-of-pocket (OOP) spending associated with dementia differ between the United States and Europe, with and without controlling for background characteristics.

Research Design: We use prospectively collected survey data from the United States-based Health and Retirement Study (n=48,877) and the Survey of Health, Ageing, and Retirement in Europe (n=98,971) including all adults over the age of 70 years. Dementia status is imputed using a validated algorithm…

Results: Persons with dementia in the United States use 50% less formal home care per year than persons living with dementia in Europe [mean (SD)=236.8 h (1047.4) vs. 463.3 h (1371.2)], but use more nursing home care [75.1 d (131.4) vs. 45.5 d (119.4)). Dementia is associated with higher OOP spending in the United States than Europe [$4406 (95% confidence interval, 3914-4899) vs. $246 (73-418).

Conclusions: The far greater reliance on nursing home care in the United States likely causes much higher expenditures for people with dementia and insurance programs alike.


Comment by Steffie Woolhandler and David Himmelstein

When individuals require extensive assistance with daily living, most patients and families prefer home care to care in a nursing home. The COVID-19 pandemic has highlighted the sorry state of long term care – particularly nursing home care – in the US. This study documents the far greater reliance in the US as compared to Europe on nursing homes (67% more nursing home days per year on average) for the care of dementia patients, a corollary of the US deficit for home care (49% fewer hours). And the out-of-pocket costs to patients are also strikingly different: more than $4000 higher per patient in the US in 2017.

Single payer reform must include a rational and compassionate long term care program. Although not detailed in this article, the programs in several European nations include key elements that should be adopted in the US – e.g. salaries for family members who forego other paid employment to care for a disabled loved one, and the provisions of full time (or respite) live-in caretakers.