These cost-related problems are: the prevalence over one year of trouble getting health care due to cost, or problems with / non-payment of medical bills. Detailed wording here.
The Kaiser Family Foundation has a new report that underscores the likelihood of significant access to care issues in Medicare Advantage for people with modest incomes and people in fair or poor health.
Comment by Jim Kahn
These findings from KFF, based on a national survey, are startling. They call out brightly the hazards of relying on private insurers to protect enrollees in our huge publicly financed Medicare program for the elderly and disabled.
The lesson is: If you’re at risk of fair or poor health, don’t choose Medicare Advantage. Especially if you’re Black.
Private insurance is not the way to deliver publicly funded services. Not if our goal is to provide affordable medical care for the sick.
There’s a second take-away: With financial problems for enrollees even in traditional Medicare (especially those with no Medigap coverage), we need to place a cap on individual annual out-of-pocket spending. That critical Medicare improvement should rank high on the Congressional agenda.
We need a government fund to directly compensate providers. No private intermediaries siphoning off profits and shifting costs to enrollees. And no cost-sharing. Single payer.
We conducted a literature search for … papers including the word “racism” that were published between January 1, 1990 and December 31, 2020 by four leading medical journals (all with impact factors for 2019 exceeding 30). These journals were: the New England Journal of Medicine (NEJM), The Lancet, JAMA, and the British Medical Journal (BMJ). We focused deliberately on the term “racism” because naming racism is a critical step in addressing its impacts. And given evidence of some journals censoring its use, this focus allowed us to assess the extent to which use of this term has been permitted.
For comparative purposes, we also searched publications in one of the longstanding and leading global public health journals, the American Journal of Public Health (AJPH), and we additionally examined the Annual Review series for four disciplines (medicine, public health, sociology, and psychology) as a gauge of the extant evidence base. . . .
The four medical journals published markedly lower numbers of papers including the word “racism” compared to AJPH, despite their publishing many more papers between 1990-2020 (14,192 for AJPH, vs. 40,411 for JAMA, 43,378 for NEJM, 63,971 for The Lancet, and 78,545 for BMJ). Although we did not include Health Affairs in this analysis, Rhea Boyd (one of the authors of this post) and colleagues noted in an earlier Health Affairs Blog post, “A quick search of the Health Affairs website reveals only 114 pieces include the word racism in the 39-year history of the journal.” . . .
Exhibit 2: Analysis of article type for journal articles that included the word ‘racism.’
For the four leading medical journals, upwards of 90 percent of publications including the word “racism”… were commentaries, viewpoints, or letters. The percentage that were either original empirical investigations or review articles with a significant data component ranged from 4 percent (BMJ and NEJM) to at most 10 percent (The Lancet) (exhibit 2). By contrast, for AJPH, 60 percent of identified articles were empirical studies or review articles with significant data, and only 40 percent were commentaries, viewpoints, or letters. . . .
Non-publication of this research conveys the message that racism and its impact on people’s health are not important and not topics that warrant scientific study or publication, thereby minimizing concerns about these harms among scientists, funding agencies, and the broader public.
Second, non-publication of scientific research on racism and health by leading journals, especially in this era of evidence-based clinical medicine, fosters ignorance about these issues among health professionals, who as trusted sources of information then transmit this ignorance to their patients, clients, and the broader public.
Third, this non-publication of evidence undercuts and limits the important kinds of evidence needed by policy makers, health agencies, funders, lawyers, and advocates for their complementary work to prevent racism and rectify how it harms health.
Fourth, non-publication of this work effectively excludes scholars who study racism and health from high-impact journals, harming not only knowledge dissemination but also potentially the career pathways of these scholars.
Comment by David Himmelstein and Steffie Woolhandler
In recent months younger colleagues and others we know have had several studies documenting stark racial inequities in health care rejected by major journals based on: (1) minor quibbles about methods that have not been raised about closely similar analyses of age-, insurance or income-based disparities; or (2) claims that race-based disparities may simply reflect overuse of care by White people, and hence are not indicative of racism.
Our experience is apparently not unique. This meticulous survey documents major medical journals’ refusal to publish data on racism. While the journals have accepted commentaries and letters on racism, they continue to boycott studies documenting the patterns of care and outcomes indicative of structural racism. So while we’re now allowed to say that racism in the health care system exists, we’re not allowed to provide the data that’s key to addressing it.
Medicare offers enrollees a choice of “traditional” Medicare (government-administered coverage for virtually all physicians and hospitals in the US) or Medicare Advantage (private insurance plans with restricted provider panels). Nearly 60% of enrollees select traditional Medicare, and financial analyses by CMS, MedPAC, and others consistently show that traditional Medicare is less costly than Medicare Advantage.
However, in 2020, the Trump Administration launched a new CMS experiment, the Global Professional Direct Contracting (GPDC) model, that is designed to privatize traditional Medicare. That’s right, end the public part of Medicare as we know it.
GPDC transfers cost and care management to private for-profit insurer and investor contracting entities. Under this model, CMS could auto-assign more than 30 million beneficiaries who have chosen traditional Medicareinto entities managed by private for-profit companies, without their understanding or consent. These entities are similar to Medicare Advantage plans even though the enrollees explicitly rejected this type of coverage. Although not technically permissible, contracting entities could shift enrollees to Medicare Advantage.
The direct contracting experiment, as designed, has four profound flaws:
Violates the spirit and public insurance essence of traditional Medicare.
Undoes the fundamental choice made by Medicare enrollees.
Will increase costs.
Likely will not improve quality or allow for objective quality assessment, based on the Medicare Advantage experience.
You’ll notice that this post includes no document link at the top. That’s because this program is happening behind closed doors, on the sly. No public discussion of a massive transformation of traditional Medicare. I know about it because of the excellent sleuthing of colleagues, who have assembled a compelling analysis and report. This will be public soon, but we agreed that there is great urgency to let people know about this threat, so they can speak against it.
Here’s the solution:
Immediately suspend GPDC, pending full review and revision, including participation by relevant stakeholders and external experts.
Restrict direct contracting to entities that are >75% owned by providers, not investors or insurers.
Limit GPDC to < 500,000 participants.
Traditional Medicare enrollees must be:
assured full understanding of the program;
enrolled only if they actively “opt in;” and,
properly informed of their ongoing right to see out-of-network providers and to opt out of GPDC.
Participating providers must submit all medical claims to CMS to permit effective evaluation of cost (to CMS and enrollees), access to care, and health outcomes.
CMS must end GPDC if, overall, it fails to lower costs and improve the care experience within three years.
Objective To assess whether the health outcomes of White US citizens living in the 1% and 5% richest counties (hereafter referred to as privileged White US citizens) are better than the health outcomes of average residents in other developed countries. . .
Conclusions and Relevance: This study suggests that privileged White US citizens have better health outcomes than average US citizens for 6 health outcomes but often fare worse than the mean measure of health outcomes of 12 other developed countries. These findings imply that even if all US citizens experienced the same health outcomes enjoyed by privileged White US citizens, US health indicators would still lag behind those in many other countries.
Comment by David Himmelstein and Steffie Woolhandler
US society and medical care are bad for almost everyone’s health. While Black and Native Americans, and the poor, suffer the most, even white residents of the wealthiest 1% of counties have worse health outcomes on many measures than the average of other wealthy nations.
This terrible indictment of our society indicates the need for fundamental changes in medical care and beyond. A society that values corporations’ drive for profit above all else is bad for everyone’s health.
Modern Healthcare June 25, 2021 San Diego sues Molina, HealthNet, Kaiser By Nona Tepper
The city of San Diego sued three health insurers on Friday, alleging Kaiser Permanente, HealthNet and Molina Healthcare all advertised false networks of providers in an attempt to get consumers to sign up for their plans.
“Consumers should be able to trust their health insurers when seeking medical attention,” San Diego City Attorney Mara Elliot said in a statement. “Error-filled directories create dangerous barriers to healthcare services, with patients struggling to find a directory-listed doctor who will accept their insurance.” California law requires health insurers to update their printed provider directories quarterly and online listings weekly, the complaint said. These payers knew they were advertising false networks.
The complaints allege that up to 35% of the providers in Kaiser Permanente and HealthNet’s directories were listed inaccurately, and 80% of clinicians in Molina Healthcare’s directory were falsely listed as in-network.
Insurers’ error-riddled provider directories allowed them to attract more prospective enrollees and command higher prices, according to the suit. Falsely inflating their network size also made it harder for competitors to compete in the marketplace, the complaint said.
Each complaint said that insurers’ inaccurate listings disproportionately impacted low-income enrollees — who were more likely to be Black or Hispanic, according to the lawsuit — individuals with disabilities, people seeking mental healthcare, seniors lacking digital literacy, and women.
Each complaint noted that this was not the first warning insurers received.
Comment by Don McCanne
The dishonesty of these insurers in maintaining deceptive provider directories not only represents an unfair business practice, but it is also a violation of law that results in financial harm to patients, the very population that they should be serving.
If we had a single payer Medicare for All program, there would be no need for provider lists because all legal health care professionals and institutions would be automatically covered under one system. Further, we would not need to pay hundreds of billions of dollars to these superfluous intermediaries. (But think of a future for integrated systems such as Kaiser Permanente strictly as health care delivery systems and not as risk-bearing insurers.)
For those who say that we have a moral obligation to support the insurers, think again. Our moral obligation is to the patients, and we need to terminate the burden that the insurers are placing on them, and, incidentally, the burden that they are placing on the health care delivery system itself.
Background: In the Medicare Advantage (MA) program, private plans receive capitated payments that are adjusted based on their enrollees’ number and type of clinical conditions. Plans have the ability to review charts to identify additional conditions that are not present in claims data, thereby increasing risk-adjusted payments.. . .
Results: Chart reviews were associated with a $2.3 billion increase in payments to plans, a 3.7% increase in Medicare spending to MA plans. Just 10% of plans accounted for 42% of the $2.3 billion in additional spending attributed to chart review. Among these plans, the relative increase in risk score from chart review was 17.2%. For-profit plans engaged in chart reviews substantially more frequently than nonprofit plans.
Comment by David Himmelstein and Steffie Woolhandler
It’s long been known that Medicare Advantage (MA) plans selectively recruit low-cost Medicare enrollees and evict the expensively-ill, such as those who require nursing home care. As a result, Medicare pays MA plans 4% more than it would cost to care for their patients in the traditional Medicare program.
In response, CMS has tried to risk adjust MA plan premiums based on patients’ diagnoses. MA plans have counter-attacked by pressing clinicians to more assiduously code every diagnosis that might raise the risk score. That’s entirely legal. But this study shows that they’ve gone even further than that, combing through patients’ medical records for possible indicators of diagnoses that physicians never entered as actual diagnoses. So if, for instance, a doctor never mentioned renal failure, but noted a slightly high creatinine level on one blood test (which might have come down on a subsequent test), that might trigger an MA plan to claim the extra payment for renal failure.
After 40 years of unsuccessful attempts to rein-in MA plans’ profit-driven efforts to cheat the taxpayers, it’s time to end the MA program and return to fully public Medicare.
On the 4th of July, my thoughts turn to our system of governance, as it relates to health reform.
Our democracy is under siege. First, the President who lost his re-election bid tried to retain power by claiming he won and fomenting a coup. Crisis averted, barely. The vast majority of GOP officials still support this “big lie” about the election. Then, in June, a Democratic Senator – Joe Manchin of W. Virginia – published an op-ed declaring his fealty to the filibuster (anti-majority) and bipartisanship (a myth) over voting rights. This would allow GOP-controlled swing states to selectively disenfranchise Democrats, especially poor people of color living in big cities. Subsequently, Manchin expressed support for a scaled-back but still strong voting rights bill. Encouraging. Last week, the U.S. Supreme Court upheld state laws that manipulate voting rules in ways that will likely selectively disenfranchise blacks, relying on a 6-3 conservative majority enabled by Mitch McConnel’s abandonment of long-standing norms regarding Supreme Court appointments. Worrisome. The future of voting bills and rights – with implications for 2022 Congressional midterms and Biden’s ability to govern – will play out later this month. These events are thoroughly and thoughtfully chronicled by Heather Cox Richardson in Letters from an American. I also recommend Paul Krugman’s forceful take-down of the GOP’s thorough abandonment of reality in favor of ideology and self-interest. Dire challenges loom for democracy.
So what does this have to do with single payer financing of health care?
A lot, actually. The parallels are numerous. For today’s blog, I offer a list. If you care to suggest others, please reply to the email or add comments on the website. In future posts, I’ll delve into specific issues.
Democracy and single payer …
Both honor human rights, highlighting human dignity – the ability to participate in collective decisions, and the right to healthcare and health.
Both foster equality – everyone is treated the same. No preferential voice, no preferential care. Nobody excluded.
Both reflect and strengthen community values – society working collectively to address important decisions and solutions.
Both honor majority rule – fair voting to maximize the right and ability to cast ballots, and adoption of a health care financing approach favored by most Americans.
Both use simplicity to achieve performance & efficiency – one straightforward, unconvoluted set of rules for everyone, simplifying and maximizing access.
Both reduce manipulation of the system for gain by those in control – by requiring neutral voting rules and eliminating exorbitant profits from the provision of health.
Both recognize that some societal functions are most efficiently and effectively accomplished by government agencies –e.g., fairly designed and enforced voting, and financing for essential services like health care.
I think I always knew intuitively that single payer is profoundly democratic. Now I’m beginning to understand the details.
Finally, the day-to-day struggles for both causes are linked:
Empowering the maximum number of people with the vote will bolster the prospects for single payer. Because voters – especially those the GOP is trying to exclude – support single payer. And achieving single payer will build commitment to progressive, democratic values, and showcase the advantages of a benevolent government. Linking the battles may prove synergistically enabling, helping achieve both worthy causes.
Enjoy the holiday weekend, and next week let’s all dig in again to fight for justice in democracy and health care.
Methods: Using a commercial and Medicare Advantage claims database, we identified members 19 to 63 years old whose employers exclusively offered low-deductible (≤$500) plans in 1 year, then, at an index date, mandated enrollment in HDHPs (≥$1000) for a subsequent year. We matched them with contemporaneous members whose employers only offered low- deductible plans. Primary outcomes included population rates of index ED visits with a principal diagnosis of nonspecific chest pain, admission during index ED visits, and index ED visits followed by noninvasive cardiac testing within 3 and 30 days, coronary revascularization, and acute myocardial infarction hospitalization within 30 days. Members from higher-poverty neighborhoods were a subgroup of interest.
From Discussion: The contrasting findings between members from neighborhoods of different poverty levels merit particular attention. After HDHP switches, members from lower-poverty neighborhoods reduced invasive procedures after nonspecific chest pain ED visits without changes in ED visits for nonspecific chest pain, hospitalizations, non-invasive testing, or AMI admissions. However, members living in higher-poverty neighborhoods reduced non-specific chest pain ED visits, disproportionately reduced hospitalizations from index ED visits, and significantly increased AMI hospitalization in 30 days after index ED visits. Our findings support that, although HDHPs can reduce potentially low-value acute care among those with higher socioeconomic status, the disproportionate financial pressure from high out-of-pocket costs on lower-income populations appears to lead to unintended consequences with potentially negative health implications.
There is growing evidence that exposing low socioeconomic status populations to high cost-sharing leads to the deferral of appropriate care.
What Is New?
High deductible health plan enrollment was associated with increased 30-day acute myocardial infarction rate after emergency department visits for nonspecific chest pain among patients living in neighborhoods with higher poverty rates.
Comment by Don McCanne
Keep in mind that high deductibles are a tool used by private insurers to discourage patients from obtaining health care that the insurer might have to pay for. It is a profit-motivated business tool and not a tool to provide assistance to a patient in obtaining beneficial health care. It especially negatively impacts those with greater financial needs. Of note, this study evaluated private commercial and Medicare Advantage plans and not patients in the public Medicare program which avoids high deductibles (though even modest deductibles may be a hardship for those of limited financial means).
In this study of emergency department patients presenting with chest pain, it was found that those with low socioeconomic status who had high deductibles “reduced non-specific chest pain ED visits” and “significantly increased acute myocardial infarction hospitalization in 30 days after index ED visits.” They conclude, “the disproportionate financial pressure from high out-of-pocket costs on lower-income populations appears to lead to unintended consequences with potentially negative health implications.”
We can conclude that “potentially negative health implications” from deferred diagnosis of acute myocardial infarctions includes the potential for death. Since the delays were due to high deductibles, we can further conclude that high deductibles used by private health plans kill people.
We don’t need high deductibles, and we certainly don’t need expensive private insurers who use them to create more wealth for themselves at a cost of providing optimal patient service. After many decades, their profit-maximizing behavior only grows worse. Time to replace them with a single payer improved Medicare for All – no profits, just patient service.
“It’s disappointing but not surprising” that people living below the poverty line have spent large sums of money for unproven treatments for Covid-19, said Rais Vohra, the interim head of Fresno County’s health department. “People are desperate and bombarded with misinformation and may not have the skills, time or context to interpret medical evidence.” …
During the pandemic, many immigrants shut out of mainstream health care have turned to such markets for Covid-19 treatments. About 20 percent of Hispanic people in the United States lack health insurance, and the proportion is far higher among undocumented immigrants.
What’s more, some immigrants mistrust doctors who don’t speak their language or who treat them curtly — and those concerns have been amplified by harsh political rhetoric directed at Mexicans and Central Americans. …
“My community fears that the government might be trying to get rid of us,” said Oralia Maceda Méndez, an advocate at a Fresno-based community group for Indigenous people from Oaxaca, Mexico. She has heard many stories from immigrants in her community who treat themselves for Covid-19 with penicillin, other antibiotics or a mix of vitamins and herbal therapies bought from shops or travelers selling medications bought in Mexico.
“I am not surprised that people are taken advantage of,” she said. “We don’t have the care we need.”
Comment by Eagan Kemp
Barring undocumented immigrants and workers from getting health care is cruel and inhumane. As the cited NYT article notes, the COVID-19 crisis has further exacerbated the costs and dangers of lacking health insurance in America. This is particularly severe for undocumented workers in frontline industries where they are unable to social distance. Even before the pandemic, almost half of undocument immigrants were uninsured, placing them at risk for financial ruin if they got sick.
It may also be suicidal — lack of regular medical care will prevent many from getting the COVID-19 vaccine. We must protect everyone from even more dangerous COVID-19 variants through inoculating a sufficient percentage of people in the U.S. and around the world.
And while undocumented immigrants make up only around 3 percent of the U.S. population and 4.4 percent of the workforce, they are make up a large share in certain industries, including some deemed essential during the COVID-19 crisis.
For example, more than half of all agricultural workers are undocumented, many of whom were deemed essential during the COVID-19 crisis, placing them at increased risk for the virus. Similarly, around 40 percent of workers in meatpacking plants in the U.S. are reported to be undocumented, with many unable to effectively social distance or fight for better worker protections.
Of the policy reforms under consideration by Congress, only Medicare for All would guarantee all necessary health care to all undocumented immigrants, by finally treating health care as a human right instead of as a means for profit.
No one in the U.S. should be forced to go without health care, especially the COVID-19 vaccine. And leaving immigrants to fend off the medical vultures seeking to exploit them and take their money is no solution at all. We need reform now.
Design, Setting, and Participants: This cross-sectional study analyzed the deidentified metadata of ambulatory care health systems in the US, Canada, Northern Europe, Western Europe, the Middle East, and Oceania from January 1, 2019, to August 31, 2019. All of these organizations used the EHR software from Epic Systems and represented most of Epic Systems’s ambulatory customer base.
Results: US clinicians spent more time per day actively using the EHR compared with non-US clinicians (mean time, 90.2 minutes vs 59.1 minutes; P < .001). In addition, US clinicians vs non-US clinicians spent significantly more time performing 4 clinical activities: notes (40.7 minutes vs 30.7 minutes; P < .001), orders (19.5 minutes vs 8.75 minutes; P < .001), in-basket messages (12.5 minutes vs 4.80 minutes; P < .001), and clinical review (17.6 minutes vs 14.8 minutes; P = .01). Clinicians in the US composed more automated note text than their non-US counterparts (77.5% vs 60.8% of note text; P < .001) . . . . The median US clinician spent as much time actively using the EHR per day (90.1 minutes) as a non-US clinician in the 99th percentile of active EHR use time per day (90.7 minutes) in the sample. These results persisted after controlling for organizational characteristics, including structure, type, size, and daily patient volume.
Comment by David Himmelstein and Steffie Woolhandler
US clinicians complain bitterly about their documentation burden and unwieldy EHRs that sap the joy of patient care, and these burdens are a main cause of the widespread and growing burnout problem. This study makes clear that the US payment system inflicts much of this burden. In other nations, clinicians using EPIC – the most widely used EHR in the US – spend far less of their time staring at computer screens and checking the endless boxes needed to assure payment. A single payer reform that simplifies payment would greatly improve clinicians’ work lives.
