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Texas Bans Nearly All Abortions

Summary: Texas passed a ban on all abortions after 6 weeks, enlisting citizens to enforce it. This week, the U.S. Supreme Court let the law stand without hearing arguments. Roe v. Wade took a huge hit. So did health care justice.

Supreme Court, Breaking Silence, Won’t Block Texas Abortion Law
New York Times
September 1, 2021
August 23, 2021
By Adam Liptak, J. David Goodman and Sabrina Tavernise

The Supreme Court refused just before midnight on Wednesday to block a Texas law prohibiting most abortions, less than a day after it took effect and became the most restrictive abortion measure in the nation.

[…]

In the emergency application urging the justices to intervene, abortion providers in the state said the new law “would immediately and catastrophically reduce abortion access in Texas,” and most likely force “many abortion clinics ultimately to close.”

Comment by Isabel Ostrer and Jim Kahn

On Wednesday, the U.S. Supreme Court let stand Texas’ near-total ban on abortion (SB8). The law prohibits abortion once fetal cardiac activity can be detected — typically at six weeks of gestation, when most women don’t even know they’re pregnant — in effect banning 85-90% of abortions. Rape and incest are not excepted. The law evades Roe v. Wade’s restrictions on state action by empowering citizens (not the police, not the government) to enforce the ban using civil litigation, with the rules stacked against anyone who facilitates an abortion. There is no precedent for this bizarre enforcement design.

SB8 is the perfect storm of abusing law-making to take away the right to control one’s own body. It strikes at the nexus of health, human rights, and democracy. It will harm health both physically and mentally, predominantly for poor people of color. 

Representative Cori Bush wrote, “I’m thinking about the Black, brown, low-income, queer, and young folks in Texas. The folks this abortion health care ban will disproportionately harm. Wealthy white folks will have the means to access abortion care. Our communities won’t.”

Prior to SB8 taking effect, Texan’s seeking abortions had to travel an average of 24 miles round trip to access care. Now they will have to travel nearly 500 miles to access this same care out of state, putting safe abortions out of reach for many. 

When abortion bans go into effect, women don’t stop seeking abortions, rather abortions become less safe. Abortions performed by a trained health-care provider are incredibly safe — much safer than child birth. When the U.S. legalized abortion in 1973, the number of abortion-related deaths dropped drastically, mainly due to a decline in the absolute number of deaths from illegal abortion. Total abortions have also dropped to below 1973 levels. With the new law, women’s lives are being sacrificed.

We must ensure access to health care for all — including the full-spectrum of reproductive care, which encompasses abortion care.

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Reminder from Med Students & Residents: Academic Medical Centers are Mostly AWOL in the Fight Against Racism

Summary: This extensive report card about 26 medical schools found widespread deficiencies in the pursuit of racial justice in training, clinical care, policing, worker relations, and research. Despite increasing recognition of these problems, attempts to address them remain far short of vigorous. 

Racial Justice Report Card, 2020-2021.
September 1, 2021.
White Coats for Black Lives

The Report Card consists of metrics that evaluate institutions’ curriculum and climate, student and faculty diversity, policing, racial integration of clinical care sites, treatment of workers, and research protocols. Ultimately, WC4BL hopes that the Racial Justice Report Card will highlight best practices and encourage academic medical centers to direct their considerable power and resources toward addressing the needs of our patients and colleagues of color.

Recruitment and Admissions: URM (Under-Represented Minority) physicians are so sparse in the United States that medical schools would have to admit only URM students for almost ten years for physician racial demographics to match that of the general population. For this reason, the RJRC requires each school to have an overrepresentation of URM students with relation to the current demographics to start to correct intentionally produced inequities. None of the 26 medical schools graded met the metric set for this year’s report card with regards to student representation.

Anti-Racist Curriculum Development: While the majority of schools evaluated had some form of education on social determinants of health, schools did not uniformly provide instruction on the sociopolitical (non-biological) nature of race. Only ten of the twenty-five medical schools evaluated were reported to teach race as a social construct.

Clinical Education and Patient Protection: Twenty out of the twenty-five medical schools assessed allowed preclinical (first- and second-year) medical students to provide patient care in the setting of student-run clinics for uninsured patients. This is not the standard of care in academic medical centers, where preclinical students are generally restricted to observation and shadowing. Students at several institutions reported being provided more autonomy when caring for marginalized patients in public hospitals or student-run free clinics than they were afforded when caring for patients in the primary teaching hospital.

Equal Access for All Patients: The majority of medical schools evaluated had some system of segregated care based on insurance status. Because of the link between racism and capitalism in the United States, segregation based on insurance status generates de facto racial segregation.

Medical School and Hospital Relationship to the Carceral State: Most of the hospitals reported that patients who are experiencing incarceration were not interviewed or examined apart from an officer and that there were no clear policies that protect the privacy or information of  these patients.

Treatment of Workers: Nearly all of the evaluated academic medical centers paid at least some of their workers less than the living wage for the local area. 

Research: Some medical centers’ institutional review boards (IRBs) listed racial and ethnic minorities as “vulnerable subjects.” However, few schools required researchers to define race or how researchers planned to use race in their research prior to approval.

Comment by: David Himmelstein and Steffie Woolhandler

These excerpts offer a glimpse of White Coats for Black Lives’ extensive findings documenting the racism that continues to permeate our nation’s leading medical institutions. The carefully researched 411 page report was produced by medical students and house officers at each of the institutions evaluated (disclosure: one of our daughters participated in this effort). All of the schools received mostly failing grades.

While the medical establishment has, in recent years, begun to pay lip service to anti-racism, actions would speak much louder. 

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Sutter Medicare Advantage Pays $90 million Due to False Data

Summary: Sutter Health (California) is paying $90 million to settle allegations that it submitted false diagnoses to increase payments to its Medicare Advantage plans. This type of gaming and fraud permeates the private insurance-run Medicare Advantage program. Let’s return to a social insurance model – traditional Medicare, without the privates. Then extend it to everyone.

Sutter Health and Affiliates to Pay $90 Million to Settle False Claims Act Allegations of Mischarging the Medicare Advantage Program
August 30, 2021
The United States Department of Justice

Sutter Health, a California-based health care services provider, and several affiliated entities including Sutter Bay Medical Foundation (dba Palo Alto Medical Foundation, Sutter East Bay Medical Foundation, and Sutter Pacific Medical Foundation) and Sutter Valley Medical Foundation (dba Sutter Gould Medical Foundation and Sutter Medical Foundation) … have agreed to pay $90 million to resolve allegations that Sutter Health violated the False Claims Act by knowingly submitting inaccurate information about the health status of beneficiaries enrolled in Medicare Advantage Plans.

Under Medicare Advantage, also known as the Medicare Part C program, Medicare beneficiaries have the option of enrolling in managed health care insurance plans called Medicare Advantage Plans. The plans are paid a capitated, or per-person, amount to provide Medicare-covered benefits to beneficiaries who enroll in one of their plans. Payments to plans are based on demographic information and the health status of each plan beneficiary. In general, plans receive larger payments for beneficiaries with more severe diagnoses.

The government alleged that Sutter Health knowingly submitted unsupported diagnosis codes for certain patient encounters for beneficiaries under its care. These unsupported diagnosis codes caused inflated payments to be made to the plans and to Sutter Health. The lawsuit further alleged that, once Sutter Health became aware of these unsupported diagnosis codes, it failed to take sufficient corrective action to identify and delete additional unsupported diagnosis codes.

The claims resolved by the settlement are allegations only and there has been no determination of liability.

Comment by: Don McCanne

Sutter Health does not have a reputation of being a crooked organization. But here they have agreed to pay a penalty for knowingly submitting inaccurate information about the health status of beneficiaries enrolled in Medicare Advantage Plans. So what happened?

The primary culprits are Congress and the prior administrations. We had a publicly administered program, Medicare, that required updating so that it would function better for the beneficiaries and provide better value to the taxpayers. Instead of making the appropriate adjustments in this social program, they decided to turn it over to the private sector in the form of private Medicare Advantage plans. Thus, rather than being operated as a social insurance program primarily serving the interests of the patients, it was operated as a private business model serving the interests of the investing entity, whether nominally for profit or non-profit.

Should we have been relying on Sutter, or any other sector in the health care delivery system, to override the business model presented to them and provide their services based on a public social insurance model? That’s not the way it works.

You know, we don’t have to continue to cater to the private insurers at a cost to the beneficiary-taxpayers. We can eliminate the private insurance business model and proceed with efforts to improve the Medicare public social insurance program. The vision we have had would be such a beneficial program that it would be appropriate to extend it to everyone and thus eliminate many of the injustices in our health care system. Health justice for all. Although it took the efforts of our Department of Justice to publicize that conclusion, that is also our message here at Health Justice Monitor.

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More market fiddling, that’s the answer!

Summary: In a JAMA opinion piece, two physicians with homes in the business world propose payment innovations for our multi-payer health care system. Are these proven strategies? Of course not. Do they betray a blind faith in the magic of the marketplace? Sure do.

Setting the Stage for the Next 10 Years of Health Care Payment Innovation
JAMA
August 16, 2021
By Bob Kocher and Rahul Rajkumar

This Viewpoint describes 4 health policy strategies.

Broaden Participation in Alternative Payment Models, Particularly Among Specialists

Alternative APMs [e.g., Accountable Care Organizations] include higher levels of risk and therefore reward clinicians with more money for more cost savings and ensure that the Medicare program saves money by transferring risk to physicians.

A better approach would be to broaden the value-based payment portfolio by creating APMs for specialists …

Ensure That Payment Systems Reward Multiyear Investments in Health

A major shortcoming of the current system is that investments in health have very short payback periods. These time frames make it challenging to invest in interventions that have longer-term benefits, even when these investments may produce substantial improvements in health.

A new funding mechanism for breakthrough preventive care, such as health-related bonds, which are held by investors, and which increase in value along with a person’s long-term health, could create a strong incentive to address social determinants of health and healthier lifestyle interventions.

Align Payment Models Across Payers

One model could be moving to a capitated payment model for hospital services so hospitals receive monthly payments for the availability of their services rather than be paid on a fee-for-service basis.

Reduce the Administrative Burden of Risk Adjustment and Quality Measure Reporting

Commercial, Medicare Advantage, and Medicaid payers should adopt the same patient attribution, quality metrics, and risk adjustment (when appropriate) methods as Medicare.

Comment by: Don McCanne & Jim Kahn

This Viewpoint proposes a set of innovations based on shoddy, non-existent, or discouraging data. One example is shared savings programs. like accountable care organizations. As we recently wrote, Medicare’s experiment with ACOs failed. Why continue it? And why shift to hospital capitation when the primary problem is prices, not utilization? And, if you’re looking for the big pot of gold, why not eliminate $800 billion in annual excess billing-related administrative costs that derives from the morass of insurance products and rules?

The language used by the authors highlights the business orientation. Besides investors gambling on health-related bonds, they also mention bundling for specialists who agree to provide “parsimonious” care, making APMs more “attractive economically” for specialists, and, of course, the great overlooked potential of producing financial savings merely by “reversing” diabetes. Rather than basing the system on the opportunity to improve patient and population health, we should be developing systems catering to physician greed, they seem to suggest.

One innovation they don’t advocate: proven unified health insurance systems that lower costs and lengthen lives. Like single payer. Why not? Because, as the authors’ affiliations indicate, their interest is in making money.

Ah, marketplace innovations, they’ve worked so well for healthcare up to now, as we can all see. Clearly the best medicine is more of the same!

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Learning from Costa Rica

Summary: Atul Gawande writes a compelling New Yorker report of how Costa Rica melded medicine and public health to greatly reduce disease and lengthen life. If the U.S. is to learn from this inspiring example, we’ll need universal coverage with no cost barriers, robust health data, and strong primary care. Single payer will help pave the way.

Costa Ricans Live Longer Than Us. What’s the Secret?
The New Yorker
August 23, 2021
By Atul Gawande

“People who have studied Costa Rica, including colleagues of mine at the research and innovation center Ariadne Labs, have identified what seems to be a key factor in its success: the country has made public health—measures to improve the health of the population as a whole—central to the delivery of medical care. Even in countries with robust universal health care, public health is usually an add-on; the vast majority of spending goes to treat the ailments of individuals.

[…]

As the pandemic ebbs, countries will be assessing what went wrong with their public-health systems. A fundamental failure has been the separation of public health from health-care delivery. Getting that right, across the globe, could present our greatest opportunity to secure longer and better lives.”

***

Comment by: Isabel Ostrer

Atul Gawande’s captivating article about Costa Rica’s robust public health system describes a framework for how to improve health outcomes — one that a single payer healthcare system can facilitate. In fact, I contend that a unified health system is a prerequisite for implementing this type of comprehensive delivery.

Gawande recounts the three principal elements of Costa Rica’s universal approach to care: 1) merge public health services with hospital- and clinic-based care, 2) collect and integrate household-level demographic data with medical records to drive national health priorities, and 3) emphasize local primary care delivery.

Single payer provides the prerequisites for this transformation by:

1) Facilitating marginalized communities’ access to care: For the Costa Rican model to work, everyone needs excellent access to care. In the U.S, 33 million Americans are uninsured and nearly ⅓ of insured adults are inadequately insured. Single payer would eliminate barriers to care by ensuring every American has health insurance, with no point of care costs (premiums, co-pays, and deductibles) which discourage care seeking.

2) Creating a unified electronic health record: Electronic health records (EHR) are clunky and disparate, and don’t communicate with each other. A 2018 report revealed that fewer than half of office-based physicians were able to exchange health information with providers outside their organization electronically. A single payer system would prioritize a single EHR that allows easy exchange of information among medical providers. This foundation could be expanded to include public health data, mirroring the Costa Rican system Gawande describes.

3) Prioritizing a primary health workforce: Greater primary care is associated with lower mortality, lower costs, and higher quality of care. But the number of primary care physicians (PCPs) decreased from 46.6 to 41.4 per 100,000 people between 2005 and 2015. This is unsurprising given that the median PCPs’ income is just 60% of specialists’. The Medicare for All Act of 2019 establishes an Office of Primary Health Care to expand the primary care workforce and ensure greater access to care, particularly in underserved areas. Moreover, primary care compensation would increase through two mechanisms. First, a single payer system would compensate previously unreimbursed care. Second, it would free up time previously spent on administrative work for reimburseable direct patient care.

Gawande writes that as countries assess how they could have better responded to the Covid-19 pandemic there will be more focus on public health infrastructure. Indeed, this moment of reflection is an opportunity to fundamentally rethink how we deliver care with emphasis on universal coverage as a foundation to “braid together public health and individual health.”

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HJM Reader Feedback Survey

Dear HJM Reader:

We want your feedback!

Health Justice Monitor started in late May as the successor to Don McCanne’s quote of the day. It’s time to see how we’re doing. Please complete this quick (9 questions, 5 minutes) survey to help us improve HJM.

Many thanks,

Jim Kahn and the HJM team

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PHARMA Distorts Public Opinion on Drug Price Negotiation

Summary: The pharmaceuticals trade association ran a big ad claiming that Americans oppose negotiations on drug prices. It is dishonest: only after hearing pharma’s scare tactics do most Americans become opposed. It’s time for drug price negotiations in Medicare.

Axios Vitals
August 24, 2021

MESSAGE FROM PHARMA


KFF Health Tracking Poll – May 2021: Prescription Drug Prices Top Public’s Health Care Priorities
June 3, 2021

From the Key Findings

Overall, nearly nine in ten (88%) favor allowing the federal government to negotiate for lower prices on medications, including three-fourths (77%) of Republicans, nine in ten independents (89%) and 96% of Democrats. And while majorities of the public continue favoring this proposal after hearing that people and the federal government could save money on their prescription drugs if this policy were implemented, majorities oppose this policy proposal [after hearing the] argument made by pharmaceutical companies that it could lead to less research and development for new drugs, or that access to newer prescriptions could be limited.

https://www.kff.org/health-costs/poll-finding/kff-health-tracking-poll-may-2021/


Comment by: Don McCanne

The KFF Health Tracking Poll was the reference provided by PHARMA to support their claim that Americans reject government negotiation in Medicare. Yet the tracking poll indicates that 88% do support allowing federal negotiation for lower prices on medications. What they report as a myth is actually a fact. What they report as a fact is actually a myth. Only when told specifically that negotiations could cause less drug research or less access to newer prescriptions (dubious claims meant to scare us) do 65% become opposed.

The fact is that PHARMA is being dishonest in presenting an ad that can only be interpreted as representing American opposition to drug price negotiation, when the opposite is true. They certainly do not deserve to have their price gouging protected, especially when based on deception. It’s long past time to enact government drug price negotiation for Medicare.

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Price Chaos at US Hospitals

Summary: The New York Times found huge price variations reported by hospitals across private insurers, generally far above Medicare prices. This causes inefficiencies, inequities, and financial distress for patients. These problems would be eliminated with a single set of negotiated prices.

Hospitals and Insurers Didn’t Want You to See These Prices. Here’s Why.
New York Times
Aug 23, 2021
By Sarah Kliff and Josh Katz

This year, the federal government ordered hospitals to begin publishing a prized secret: a complete list of the prices they negotiate with private insurers.

… [M]any hospitals are simply ignoring the requirement and posting nothing.


But data from the hospitals that have complied hints at why the powerful industries wanted this information to remain hidden.

It shows hospitals are charging patients wildly different amounts for the same basic services: procedures as simple as an X-ray or a pregnancy test.

And it provides numerous examples of major health insurers — some of the world’s largest companies, with billions in annual profits — negotiating surprisingly unfavorable rates for their customers. In many cases, insured patients are getting prices that are higher than they would if they pretended to have no coverage at all.

Comment by: Jim Kahn

Excellent analyses and reporting by the New York Times highlight three very important facts about the now mandatory reporting by hospital of prices by payer:

  1. Most hospitals are ignoring the reporting requirements, either failing to report altogether or providing mostly empty or unnavigable data sets.
  2. For the limited price data available, variations are astoundingly wide across insurers, and self-pay patients may do much better than insurer cost-shares.
  3. The insurer prices are far above prices paid by Medicare – which are based on actual costs.

So what we have is price chaos. A profound morass of prices determined by myriad individual negotiations.

Why do we care? Because this chaos has severe consequences. It causes inequity – vast differences across individuals. It causes financial distress – for the unfortunate individual whose cost share is thousands of dollars. It causes inefficiency – setting those prices and implementing them takes a significant portion of the hospital and insurer operating budgets. It’s profligate for the system – prices far above actual (Medicare) costs. There is a huge financial conflict of interest that harms patients – hospitals and insurers jockey to gain profit, and patients lose out.

It also confirms, yet again, that the free market doesn’t work for health care. The price is hidden, so how can the consumer be price sensitive? Indeed, there is no unitary price for a specific product – a fundamental principle of market theory. Kenneth Arrow is turning in his grave.

There is another way, as other countries demonstrate.

A single payer, with a single set of negotiated prices.

No inequity, distress, inefficiency, profligacy, or excess profits.

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The Financialization of “Non-Profit” Health Systems

Health Systems With Largest Private Equity Investments.
Modern Healthcare
May 3, 2021


Largest Health System Investors in Hedge Funds
Modern Healthcare
May 3, 2021


Both charts are behind a paywall. From the Charts:

Health SystemPrivate Equity InvestmentsHedge Fund Investments
Kaiser Health Plan$10.180 bil.$2.820 bil.
Mayo Clinic$3.869 bil.$3.421 bil.
Cleveland Clinic$2.061 bil.$3.335 bil.
Mass General Brigham$1.140 bil.NA
Indiana U. Health$0.802 bil.$1.218 bil.
Sutter$0.414 bil.$1.132 bil.

Comment by: David Himmelstein and Steffie Woolhandler

We and others have noted the worrisome commercialization of health care, and particularly private equity firm purchases of physician practices, hospitals, and nursing homes. 

But commercialization is also reflected in “non profit” health systems’ increasing focus on financial gain. Profits on patient care undoubtedly account for the vast majority of the surpluses they invest, as well as their executives’ multimillion dollar pay packages. This thirst for profit distorts priorities: mental health, primary care, and care for the poor are money losers, while delivering high tech cardiac and orthopedic procedures to affluent patients is the road to riches.

All payments for patients’ care should go for care, not to augmenting institutional wealth and power.  

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ACOs Fail to Save Medicare Money, Even With Do Overs

Promise vs. Practice: the Actual Financial Performance of Accountable Care Organizations
Journal of General Internal Medicine
August 13, 2021
By James G. Kahn and Kip Sullivan

We collect and compare financial performance data from all four CMS ACO programs from 2005 to 2018, examining net CMS cost.

We found that overall, ACO programs roughly broke even from the CMS perspective. That is, when bonuses CMS paid to ACOs are subtracted from gross savings, the programs lost money or saved no more than a few tenths of a percent.

[I]t is time to draw the ACO experiment to a close. We now have a decade of impressive empirical evidence demonstrating minimal if any benefit from ACOs of several designs. This model arose from laudable goals, drawing on theories of human and organizational behavior. However, reality as measured in formal evaluations failed to align with theory. ACOs have not worked for Medicare and will not work for the broader health care system. Indeed, CMS recently ended the Next Generation ACO program. However, CMS is launching another unproven program, direct contracting, to replace the open structure of traditional Medicare.

We propose instead turning to empirically proven tools used by other high-income nations to control health care costs. These include uniform benefits, simplified financing that dramatically reduces payer and provider overhead, removal of profit for primary insurance, regulation of pharmaceutical prices, and public control of capital investments.

Comment by: Jim Kahn

This article (full disclosure: I’m an author) settles once and for all the results of this CMS foray into financially incentivizing physician behavior. It didn’t work. This could have been predicted, and indeed was by HJM contributors Steffie Woolhandler and David Himmelstein in 2012, as cited in the article. But CMS wasn’t listening.

Now CMS is pursuing another unproven and misguided idea about how to manipulate health systems using managed care: direct contracting in traditional Medicare. I wrote about it in this space. It won’t save money, and it will shift health care dollars to managers and shareholders. Do we really need to wait another 15 years for the failure of another misguided experiment?

Let’s follow the advice of the authors: “uniform benefits, simplified financing…, removal of profit for primary insurance, regulation of pharmaceutical prices, and public control of capital investments”.

How do we get there? Single payer.