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How Financial Incentives for Quality Metrics Hurt Us

Summary: An excellent commentary describes how two decades of paying to improve quality metrics has failed. Quality hasn’t improved, and we’ve spent billions of dollars and hours on quality indicators of dubious validity. We’ve compromised the practice of medicine, and increased disparities. Universal insurance is the foundation for improving quality.

Reassessing Quality Assessment – The Flawed System for Fixing a Flawed System
New England Journal of Medicine
April 13, 2022
Lisa Rosenbaum, M.D.

[R]ecently, there has been growing recognition of the QI movement’s shortcomings. One study, for instance, showed that only 37% of MIPS measures for ambulatory internal medicine were valid, and even CMS and the Government Accountability Office have acknowledged the need to improve the quality of measuring quality.

[O]nce a measure is implemented and tied to a financial incentive, an entire industry arises to boost organizations’ scores on that measure. Consultants get hired. Electronic health records (EHRs) are changed. And the measures become a source of intense organizational focus. Not only does it become difficult to modify measures that aren’t clearly working, but a tremendous amount of resources are directed toward the appearance of quality rather than its substance.

[V]alue-based payment initiatives can also worsen inequities, even though addressing them ought to be at the forefront of our QI efforts. Indeed, after implementation of CMS’s value-based purchasing programs, safety-net hospitals disproportionately bore the brunt of financial penalties. In 2019, hospitals caring for a high percentage of Black patients were disproportionately likely to incur financial penalties. And hospitals serving the highest-risk patients incurred the largest penalties under the HRRP, independent of quality of care. Billions of dollars are thus being transferred from poorly resourced hospitals or those serving the sickest patients to well-resourced hospitals, worsening the disparities we claim to be trying to fix.

Punishing the hospitals and patients most in need of support makes “zero sense,” says Wadhera. He notes the broader irony of attempting to reduce spending with programs that create untold administrative costs and possibly greater net costs to the system long term. For instance, smaller practices that are unable to afford these administrative costs are increasingly being bought by larger health systems that sometimes charge higher prices. And though such consequences create hard-to-quantify indirect costs, truly unquantifiable is the loss to society as consummate community physicians become a dying breed. “Community doctors want to practice medicine,” said Wadhera. “They don’t want to practice quality measurement.”

Some early QI leaders recognized the risk of demoralizing the workforce.

Comment by: Jim Kahn

This thoughtful perspective highlights critical points about our efforts to improve quality with financial incentives, often under the rubric of “value-based care”.

First, financial incentives largely failed to improve quality. There have been a few focal benefits, but rare.

Second, they harm the practice of medicine, by distracting physicians from a focus on clinical care to documentation of quality metrics.

Third, and related, the imperative to increase revenue with quality scores makes coding even more onerous. Unwelcome added time in the EHR is the result.

Fourth, medicine “plays to the code” – any modest gains in measured tasks result in less attention to important quality activities that aren’t in the metric set.

Fifth, the onerous requirements for all this coding, too much for small physician offices, instigated a shift to corporate ownership of providers. That increases costs. (And makes medicine more corporate, which many of us dislike.)

Finally, disparities – inferior resources for the poor and sick – are exacerbated. Exactly the opposite of what we want.

The poor theoretical basis of financial incentives in medicine was pointed out long ago, by among others two HJM bloggers and a behavioral economist. Financial incentives diminish the intrinsic motivation that is so widespread and valuable in medicine.

Recently, several leaders in quality improvement described well the failings of numerical quality scores and proposed a new “criterion” approach. The details need working out, but the move away from competitive scoring linked to reimbursement is very welcome indeed.

The other critical element of improving quality is to remove the distraction of missing, inadequate, and inconsistent insurance. Just cover everybody, with exactly the same benefits and same payments. (Single payer!) Let physicians focus on their clinical mission, provide resources to help them keep improving, and measure success with non-punitive outcome tracking and by talking with patients.

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Congenital Syphilis Deaths Should Be a Wake-Up Call

Summary: More fetuses and babies are dying from syphilis, a completely preventable outcome with adequate access to quality prenatal care. This is a another marker of failure of our systems for health care financing and public health.

Babies Die as Congenital Syphilis Continues a Decade-Long Surge Across the US
California Healthline
April 12, 2022
By Anna Maria Barry-Jester

For a decade, the number of babies born with syphilis in the U.S. has surged, undeterred. Data released Tuesday by the Centers for Disease Control and Prevention shows just how dire the outbreak has become.

In 2012, 332 babies were born infected with the disease. In 2021, that number had climbed nearly sevenfold, to at least 2,268, according to preliminary estimates. And 166 of those babies died.

About 7% of babies diagnosed with syphilis in recent years have died; thousands of others born with the disease have faced problems that include brain and bone malformations, blindness, and organ damage.

“The really depressing thing about it is we had this thing virtually eradicated back in the year 2000,” said William Andrews, a public information officer for Oklahoma’s sexual health and harm reduction service.

From 2011 through 2020, congenital syphilis resulted in 633 documented stillbirths and infant deaths, according to the new CDC data.

Comment by: Don McCanne

Though we spend far more per capita on health care than any other nation, we have a flawed health care financing system that leaves millions who are insured in financial hardship and millions more with no insurance coverage at all. We finance our health care delivery system in a manner designed to create personal wealth for a few while failing to ensure health care access for all.

At least in the past we could be proud of some of the basics of our health care system such as the provision of prenatal and other public health services that reduced afflictions such as congenital syphilis. But public health capacity has decreased, and recent statistics demonstrate that we are moving backwards even in basic disease control that we previously took for granted. Shockingly, maternal mortality is also rising.

So where are we? Our partly public health care financing system is becoming more privatized, and our health care delivery system is experiencing increasing dominance by private equity firms and other corporate middlemen. And now our public health delivery is becoming more reliant on the private sector. On all three levels – our system of financing health care, ownership of health care delivery, and our support of our public health services – we are failing. We spend enough money (the public’s money either directly or indirectly) but fall short on much-needed public oversight.

One little niche in which we are beginning to fulfill the American entrepreneurial dream – the manufacture and marketing of infant caskets. (Excuse me while I attempt to wipe the tears from my eyes.)

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Medicare Advantage Costly Diagnostic Upcoding

Summary: Investigative reporting by Bloomberg highlights the work of whistleblowers and the federal government to combat fraudulent upcoding by Medicare Advantage plans. But Medicare itself greatly worsens the problem, by failing to properly regulate aggressive (largely legal) upcoding.

Major Insurers Are Scamming Billions from Medicare, Whistle-Blowers Say
Bloomberg
April 12, 2022
By John Tozzi

Each year, [Medicare Advantage] plans submit giant data files to Medicare with diagnostic codes meant to reflect their members’ illnesses. Those codes determine how much they get paid. A federal watchdog warned in March that coding differences brought Medicare Advantage plans $12 billion in excess payments in 2020, compared to what traditional Medicare would have paid to cover the same population. The cumulative extra payments since 2007 will soon top $100 billion, according to the Medicare Payment Advisory Commission, or MedPAC.

The Department of Justice called policing Medicare Advantage an important priority on its anti-fraud agenda. The agency said in February that it pursued health plans that gamed the system “by submitting unsupported diagnosis codes to make their patients appear sicker than they actually were,” …

Health-care companies developed increasingly sophisticated methods to maximize payments. A cottage industry of vendors emerged to help them. They mine data from patient charts, send staff to do health-risk assessments in patients’ homes and prod doctors to review potentially missed diagnoses.

By 2011, Group Health’s finances deteriorated, and it was facing downgrades from credit raters. That fall, Group Health’s chief executive officer met a counterpart from a Buffalo plan called Independent Health, which had just formed a new subsidiary focused on risk adjustment called DxID.

[Whistleblower] Ross recalls her managers lit up when they realized how much money it might bring in. Reviewing two years of data, DxID added thousands of potential diagnoses that increased Group Health’s revenue by $32 million, the U.S. alleged. But when Ross checked DxID’s work, she found that three-quarters of the diagnostic codes it submitted for payment lacked proper documentation and didn’t stand up to scrutiny, according to her complaint.

The plan got paid for one patient’s depression diagnosis even though a physician said it had resolved and the patient now had “an amazingly sunny disposition,” according to Ross’s complaint. It claimed another patient had kidney complications from diabetes even after a doctor had explicitly ruled that diagnosis out.

Comment by: Jim Kahn

This article highlights how even the most respected HMOs, like Group Health and Kaiser, fall prey to the temptations of increased revenue from highly suspect diagnostic upcoding practices. It’s terrific that whistleblowers and the federal government team up to catch and punish offenders, and perhaps discourage others.

However, the real money isn’t in the fraud, it’s in the legal upcoding that Medicare Advantage plans do and Medicare (CMS) fails to properly regulate. It’s well understood that MA plans have a much greater incentive than traditional Medicare to find and document diagnoses, because these added codes raise the capitation payments to MA whereas they don’t affect traditional Medicare reimbursements. CMS knows about this bias, and is permitted to adjust the payment levels to counteract it. But they put a cap on the size of the adjustment, even as upcoding grows rapidly in magnitude. The difference between upcoding and the allowable adjustment represents pure profit for MA plans.

The amounts at risk are staggering. CMS estimates $100 billion so far. Rick Kronick, a prominent health policy researcher, looks at trends and estimates a far greater toll in years to come. In a Nov 2021 article on the impact of sharply rising Medicare Advantage coding intensity he estimated that “total Medicare payments to MA will be $600 billion higher over the 2023-2031 period than … if the coding intensity adjustment were set [accurately] … $85 billion will be paid by beneficiaries in higher Part B premiums, and $515 billion in higher net Medicare spending.”

That’s highway robbery (by the MA plans) and dereliction of duty (by CMS).

Risk adjustment is being massively gamed by private insurers. Time to change the game, to single payer.

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US Physician EHR Burden = Less Clinical Focus, More Burnout

Summary: The electronic health record is now ubiquitous. Doctors complain about its time demands and its emphasis on billing. This review quantifies that burden – more than 4 hours per day, far higher than in countries with simpler insurance.

How much time do physicians spend in the EHR?
KevinMD
April 10, 2022
By Thrisha Gogineni, James G. Kahn, Sigal Maya

Doctors often find the Electronic Health Record (EHR) time-consuming and annoying. … We assembled evidence on hours dedicated to the EHR each day by physicians. The result is impressive – 4.5 hours.

Ninety percent of office-based physicians in the US use an EHR system. However, many report negative experiences. Two recent studies found that physician EHR effort lowers clinical focus and contributes to burnout. EHRs are often described as having poor usability and being unintuitive and inefficient, detracting from clinical focus and sometimes even leading to patient harm.  These systems also decrease collaboration and communication between doctors and nurses.

… To estimate the magnitude of EHR burden in the U.S. and potential savings with streamlined EHR function, we collated existing published evidence.

The figure summarizes what we found. Median daily physician EHR time ranged from 3.5 to six hours with the observation, log file, and web tracking methods. … The time burden of the EHR in US was significantly higher than in other countries where reported daily EHR time was one hour.

This is a striking amount of time.

Greater demands in the U.S. for billing and regulation related documentation contribute to the excess time burden of EHR systems compared with other countries.

Only half of a doctor’s day remains for direct clinical interactions with patients.

The essential lesson from this EHR evidence is that the time burden it imposes on physicians is substantial in the US, occupying hours that could otherwise be spent building truly meaningful relationships with patients (not “meaningful use” metrics!) and providing quality care.

Comment by: Jim Kahn

Doctors are forced to use the electronic health record, including entry of large amounts of clinically-irrelevant data, especially billing-related details about procedures and overly precise diagnostic codes. This degrades the clinical experience for doctor and patient alike.

This study (full disclosure: I’m an author) assembles evidence on the time burden. It is indeed large.

Although the EHR can improve access to medical information, it is a data-hungry beast that exacts a huge toll as measured in hours, clinical focus, communication quality, and quite likely clinical outcomes.

Single payer would permit us to streamline the EHR to focus on clinically relevant information, as in other wealthy countries.

(ps a podcast on this is coming, I’ll let you know)

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US Women of Reproductive Age Hurt by Insurance Barriers

Summary: “Among women of reproductive age in high-income countries, rates of death from avoidable causes, including pregnancy-related complications, are highest in the United States. U.S. women of reproductive age are significantly more likely to have problems paying their medical bills or to skip or delay needed care because of costs.” This says it all.

Health and Health Care for Women of Reproductive Age
The Commonwealth Fund
April 6, 2022
By Munira Z. Gunja et al

The maternal mortality crisis in the United States has been well documented: U.S. women have the highest rate of maternal deaths among high-income countries, while Black women are nearly three times more likely to die from pregnancy-related complications than white women are. But maternal deaths and complications may be a bellwether for the U.S.’s wider failures with respect to women’s health and health care.

Among women of reproductive age in high-income countries, rates of death from avoidable causes, including pregnancy-related complications, are highest in the United States.

U.S. women of reproductive age are significantly more likely to have problems paying their medical bills or to skip or delay needed care because of costs.

U.S. women of reproductive age have among the highest rates of multiple chronic conditions and the highest rate of mental health needs.

High health care costs are significant burdens for many U.S. households, even those covered by health insurance. Over one-quarter of women of reproductive age in the U.S. and Switzerland spend USD 2,000 or more in out-of-pocket medical costs, as compared with less than 5 percent of women in the U.K., France, and Netherlands.

Half of women of reproductive age in the U.S. reported skipping or delaying needed care because of costs. U.S. survey respondents were significantly more likely to report skipping care than respondents in all other countries. In the Netherlands, only 12 percent of women said they had forgone care for cost reasons. America’s outlier status on this measure likely stems from the large number of women who lack health insurance — 10 million — as well as the high copayments, coinsurance, and deductibles that many U.S. women enrolled in commercial health plans face when seeking care.

Compared to their counterparts in the other 10 countries, women of reproductive age in the U.S. were significantly more likely to report one or more medical bill problems, with over half saying they had experienced one or more. Only one in 10 women in the U.K., which provides free care to all residents through the country’s National Health Service, reported a medical bill problem.

When looking at all women, we found that those in the U.S. have the highest rate of avoidable deaths: nearly 200 in 100,000 deaths could have been prevented or treated with the right care provided at the right time.

Research shows that investing in women’s health results in a healthier overall population, healthier future generations, and greater social and economic benefits. Yet the U.S. remains the only wealthy country without universal health care, leaving about 10 million women without insurance.

Comment by: Don McCanne

How is the United States doing in providing adequate health care for its residents? Let’s just look at women of reproductive age – a group that plays such an important role in family and community life and should not be afflicted by medical risks more characteristic of older age.

Compared to other wealthy nations that spend less on health care than us, our record is miserable. Not only do our insurance programs leave many unacceptable gaps in coverage, we leave ten million women with no insurance coverage at all, thus potentially unnecessarily exposed to physical and financial suffering and even death. We are already spending the funds that could prevent this, but we are spending them on the wrong health care financing system – a highly dysfunctional, fragmented system designed to benefit venture capitalists and private equity investors, with insurance and much patient care being primarily a tool to enable wealth accumulation.

We are spending enough money to do it right, but it appears that our health care infrastructure is now so distorted by capital interests that even single payer Medicare for All may not be enough to ensure adequate health care for all. Maybe all of us, as communities, need to play a greater role. For those who missed it, several HJM contributors last week published an article in The Nation how communities, not corporations, should own our most vital health care assets.

With public financing and community control, women of reproductive age would no longer have to worry about their own health care access and affordability, and also would no longer have to worry about health care for their loved ones, or for everyone else.

Maybe women are best positioned to lead the march toward health care justice for all.

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Big Insurer Explosive Growth & Profits Since ACA Passage

Summary: An excellent review of 12-year financial trends for the largest six insurers reveals: a) skyrocketing revenue and profits, b) based mainly on growth in the public insurance sector, and c) acquisition of pharmacy benefit plans. Half of Americans are in their plans.

A decade-long look at how Big Insurance profiteers American taxpayers and the sick
Wendell Potter NOW
April 4, 2022

Those six companies–Anthem, Centene, Cigna, CVS/Aetna, Humana, and UnitedHealth–are massively bigger today than they were 12 years ago [when the ACA was passed] as a result of numerous mergers and acquisitions and a new love interest: the government. In 2010, the companies took in a combined total of $245.2 billion dollars in revenue. Last year, that number had more than quadrupled to $1.1 trillion.

Two of those companies–United and CVS/Aetna–have grown so fast they have leapfrogged into the top five of the Fortune 500 of America’s biggest companies. Only Walmart, Amazon and Apple took in more money last year than those two companies. (Cigna, the third largest in terms of revenue and my former employer, is now the 13th largest on the Fortune list.)

The big six insurers’ profits have soared along with their revenues. Last year they made $60.7 billion in profits collectively, compared to $16.9 billion in 2010.

Relatively little of the six companies’ growth in health plan revenues and profits has come from private paying customers. By far most of the money they now collect to administer health plans comes from us as taxpayers. That’s because all of the companies have shifted their focus away from the private sector and toward various government-funded programs: Medicare, Medicaid, federal employees and the military.

In 2010, 16.9 million Americans were enrolled in the Medicare Advantage, Medicare supplement and Medicaid plans operated by the big six. In 2021, that number had increased by 46 million–373%–to 63 million.

Thanks to the many mergers and acquisitions since then, one of every two of us are now enrolled in one of their health plans. (And 31.1 million of us remain uninsured.)

AND THEN THERE IS …

The Big Three of the Big Six make more money “managing” Americans’ prescription medications than by administering our health insurance plans. Aetna supersized itself when it merged with CVS, which operates the country’s largest pharmacy benefit management [PBM] company, Caremark, in 2017. Cigna bulked up the next year when it merged with Express Scripts, the second largest PBM. And United’s fastest growing and most profitable division is Optum, which encompasses the country’s third largest PBM. Together, CVS, Cigna, and United control nearly 80% of the national PBM market. At all three companies, the PBMs now generate more profits than their health plan businesses.

Those three companies are also far bigger than the biggest company that actually makes prescription medications. Johnson & Johnson, the biggest U.S. drug company, ranks a distant 36 on the Fortune 500. To put that in perspective, J&J was #33 on the Fortune list in 2010. Cigna, which is now #13 was #129 in 2010.

Comment by: Jim Kahn

The Affordable Care Act will strengthen the hand of private insurers, single payer advocates said in 2010. Oh how I wish we’d been wrong.

Wendell Potter’s review highlights just how right we were. Half of us are enrolled in plans (both private and public) run by the top six insurers, with $1.1 trillion in annual revenues and $61 billion in profits. (Lest you think, oh, that’s not such a big profit margin, consider that the rate of return on real investment is 6 to 9 times higher.)

Most of the gains are for publicly funded programs, primarily Medicare Advantage and Medicaid Managed Care.

They’ve even taken over pharmacy benefit management companies (PBMs), which specialize in extracting more profits from health care.

All in all, a dismal state of affairs. Profits grow exponentially, while access to care and health outcomes plummet. Shareholders gain and beneficiaries lose.

Time for disintermediation. Seriously.

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Nurse Conviction for Fatal Error vs System Harm

Summary: A nurse mistakenly gives an incorrect drug that kills a patient, and is convicted of homicide. Our system kills up to 100,000 a year due to un- and under-insurance, and nobody is indicted. Where is the justice and sense of proportion? Our inaction is outrageous.

Why Nurses Are Raging and Quitting After the RaDonda Vaught Verdict
KHN (Kaiser Health News)
April 5, 2022
By Brett Kelman and Hannah Norman

Vaught, who worked at Vanderbilt University Medical Center in Nashville, was convicted in the death of Charlene Murphey, a 75-year-old patient who died from a drug mix-up in 2017. Murphey was prescribed a dose of a sedative, Versed, but Vaught accidentally withdrew a powerful paralyzer, vecuronium, from an automated medication-dispensing cabinet and administered it to the patient.

Vaught was acquitted of reckless homicide but convicted of a lesser charge, criminally negligent homicide, and gross neglect of an impaired adult. 

Comment by: Jim Kahn

A nurse in a university hospital was convicted of unintentionally killing a patient due to a medication error. She’ll likely get 8 years in prison.

Yet those who defend our dysfunctional health insurance system and extract tens of billions in profits by restricting access to care are causing 100,000 excess deaths per year. Do they know of these horrendous effects? They must; it’s plain to see in the stories and research (eg, here and here).

Where is justice? Proportionality? Common sense? Humanity?

I’m sick about our indifference to large-scale systematic harm. We punish one nurse for her inadvertent, if tragic, error. We protect and enable those who cause deaths on a massive scale.

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Health Insurers to Disintermediate

Summary: A very surprising and hugely important announcement: US health insurers have decided to “disintermediate” – step back from their traditional position between purchasers of health care (e.g., policyholders) and providers of health care (e.g., doctors and hospitals). The implications of this change are far-reaching.

Health Insurer Trade Association Announces Disintermediation
USA Wire Service
April 1, 2022
By Ziua Pācālelilor

Today the trade group America’s Health Insurance Plans, known as AHIP, announced that its members – scores of health insurers – voted to “disintermediate”. In a press release, AHIP explained that “disintermediation” means removing themselves from playing an intermediary role between insurance purchasers and healthcare providers, and between patients and clinical care.

The insurance companies represented by AHIP voted unanimously at the annual conference to make this drastic change in their business model. During the meeting, which was off limits to the press, one insurance CEO reportedly said, “It’s about time that we place efficiency and medical care over bureaucracy and profits. I for one am quite set financially, and would like to make this socially responsible action my swan song.”

The decision was completely unexpected. Health policy analysts expressed shock and confusion. One asked, stuttering, “But then what’s their purpose for existence, if not intermediation?”

A representative of the federal Center for Medicare and Medicaid Services, or CMS, said, “Well, that’s quite a course change. Seems like we’ll need to reinstate traditional Medicare and Medicaid, paying doctors and hospitals directly.”

Former insurance company executive and whistleblower, now a leading advocate for single payer universal health care, Wendell Potter said, “What? Holy shit! Really? This is transformative. Kudos to AHIP and their members. Finally, they’ve seen the light.” Mr. Potter popularized the term “disintermediation” in 2011, soon after leaving Cigna Insurance Company. At the time, he said it was the greatest fear of health insurers.

Today AHIP’s membership vigorously embraced that fear, and apparently conquered it.

Comment by: Jim Kahn

Whoa? For real? Health insurers voluntarily throwing in the towel on their half-century role in financing – and influencing – US health care.

The motivations of AHIP and its members are pure speculation. By adopting this position, they are abandoning their highly lucrative business model. Perhaps they have decided that the profit-taking cannot continue indefinitely, and this is a good time to get out. Perhaps, if we believe the quoted CEO, some had a change of heart regarding the purpose of health care financing – to pay for care and improve health, rather than bring giant financial returns to shareholders.

We can now look forward to settling on the details of the successor financing system – efficient, equitable, and health-maximizing single payer.

Let’s also remove corporate intermediaries on the provider side.

Alas, were it so. Today is, I remind our dear HJM readers, April Fool’s Day.

Keep working to make it real. With single payer, and community control.

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Health Care Reform Must Return Ownership to the Community

Summary: In a landmark article in The Nation, long-time single payer leaders (including four HJM bloggers) review the pervasive and damaging ownership of providers by corporations. They propose that real reform must transfer ownership and control of providers to communities.

Medicare for All Is Not Enough
The Nation
March 31, 2022
By David U. Himmelstein, Steffie Woolhandler, Adam Gaffney, Don McCanne, John Geyman

We have long advocated for single-payer national health insurance. By eliminating private insurers and simplifying how providers are paid, single-payer would free up hundreds of billions of dollars now squandered annually on insurance-related bureaucracy. The savings would make it feasible to cover the uninsured and to eliminate the cost barriers that keep even insured patients from getting the care they need. And it would free patients and doctors from the narrow provider networks and other bureaucratic constraints imposed by insurance middlemen. We still urgently need this reform.

However, the accelerating corporate transformation of US health care delivery complicates this vision. In the past, most doctors were self-employed, free-standing hospitals were the norm, and for-profit ownership of facilities was the exception. Single-payer proposals hence envisioned payment flowing from a universal, tax-funded insurer (like traditional Medicare) to independent clinicians, individual hospitals, and other locally controlled, nonprofit providers. This was usually the state of play when national health insurance (NHI) was achieved in other nations, such as Canada in the 1960s and ’70s—the model for single-payer reform in the United States.

But insurers are now being joined by a new set of corporate middlemen asserting control over American care. Amazon plans to expand Amazon Care from Seattle to 20 other cities this year, and then to all 50 states. Wall Street is buying up doctors, hospitals, and other health care institutions, distorting care to generate profit. Today, most doctors are employees of large organizations, and most hospitals have become subsidiaries of corporate enterprises encompassing many facilities and firms with tenuous ties to the communities they serve. Meanwhile, for-profit control of health care providers—including by private equity firms—has burgeoned, despite strong evidence that profit-seeking siphons off resources and undermines quality.

These sweeping changes require an expansion of the traditional single-payer vision. Reform needs to go beyond changing the way we pay for care: It also needs to change whom we pay for care. Communities, not corporations, should own our nation’s vital health care assets.

Responding to the evidence of for-profits’ misconduct, most Medicare for All bills and proposals have prudently called for either the exclusion or public buy-out of for-profit providers. However, the first option, excluding them, is not a viable solution, because their facilities—like the 5,300 dialysis clinics owned by Fresenius and Davita, the two dialysis giants—are needed for patient care. And while a public buy-out is economically feasible, who would then own and operate such providers? And what of the nonprofits whose boards often run them as private fiefdoms and increasingly behave like for-profit wannabes?

In both instances, a transition to public, community-based ownership—a reform model generally labeled National Health Service (NHS), in contrast to NHI—seems the most appropriate solution, especially since taxpayers have directly or indirectly bankrolled the construction of most hospitals and other health facilities.

Such an NHS should have federal funding and oversight, similar to the Veterans Health Administration—a publicly owned and operated health system that delivers higher quality of care at lower cost than the private sector. However, as Democratic Representative Ron Dellums proposed in the 1970s, the NHS should delegate day-to-day governance to local communities. The system should direct new investments to currently underserved communities, develop the primary care infrastructure that is the bedrock of effective and efficient care, and build the linkages between public health and medical care whose lack has hobbled the US’s pandemic response—and in so doing, turn the tide of faltering health in America.

Comment by: David Himmelstein & Steffie Woolhandler

Medicare for All would cover the 31 million who are uninsured, relieve the cost burdens faced by the tens of millions more who are under-insured, rein in administrative costs, and ameliorate inequality because providers would receive the same reimbursements for the care of rich and poor patients.

But Medicare for All would not, by itself, address the ill effects of the corporate ownership of physicians’ practices, hospitals, and other health care institutions. Avaricious firms — both for-profit and non-profit – are gobbling up the vital resources needed for care, gaming even traditional Medicare’s payment incentives, and prioritizing profitability over patients’ and communities’ needs. Physicians, like other health care personnel employed by these organizations, must either comply with executives’ profit-seeking directives or be shown the exit.

Hence, health care reform must address who owns health care, not only who pays the bill. Taxpayers’ and patients’ dollars have paid to build the US health care system; the public must reclaim ownership of it. Following Scotland’s National Health Service, we should recast patients (in partnership with health care personnel) as owners of the health care system, not its customers.

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Protect Medicare, Promote Medicare for All

Summary: This week, two major efforts are working in parallel to advance health care justice — fighting against the private corporate takeover of traditional Medicare, and promoting legislation to create an improved Medicare for All. Please check out both!

Protect Medicare (new website from PNHP)
The Medicare REACH program puts middlemen between patients and the care they need. This threatens the future of Traditional Medicare as an effective, efficient, and truly public health care
program.

Medicare for All Congressional Caucus Briefing (NNU)
** TODAY ** 2 pm Eastern / 11 am Pacific
(plus available for later viewing)
The briefing will explore the multiple mechanisms through which private entities are profiteering in our current health system and how Medicare for All would stop it. Our featured speaker, NNU President Zenei Triunfo-Cortez, RN, will also discuss how health care executives make immense profits from patient sickness and more.

Examining Pathways to Universal Health Coverage (House Oversight Committee)
From yesterday. Extensive hearings, many witnesses (4 h)

Congressional Progressive Caucus Celebrates Medicare for All Hearing

Today, on the occasion of the first hearing on universal health care coverage in the 117th Congress, the Congressional Progressive Caucus celebrated this historic moment for the Medicare For All movement.

The Congressional Progressive Caucus has long championed health care as a right, not a privilege, with a history of members introducing single-payer legislation. Today’s Medicare For All Act, introduced by CPC chair Representative Pramila Jayapal (WA-07) and Representative Debbie Dingell (MI-12) in both the 116th and 117th Congress, is the most comprehensive Medicare for All bill yet, providing a clear roadmap to achieving single-payer healthcare. It is co-sponsored by 120 members of Congress in the House; similar legislation was introduced in the Senate last Congress by CPC co-founder Senator Bernie Sanders (I-VT).

Comment by: Jim Kahn

We must pursue a two-pronged strategy for justice in health care financing.

Most immediately, fight the corporate transformation of traditional Medicare. Read about it in HJM here. PNHP has been spearheading a huge and growing effort, and just launched a new website. Go to it (link above) and contribute to this cause however you can.

Of course, we must also keep proposing Medicare for All, and our progressive leaders in Congress just submitted a bill. Although with 120 co-sponsors, we don’t yet have enough for passage, the number is growing over time. Stay informed and involved.