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Tag: Health policy

Your Face is Not Your Own

By KIM BELLARD

I swear I’d been thinking about writing about facial recognition long before I discovered that John Oliver devoted his show last night to it.  Last week I wrote about how “Defund Police” should be expanded to “Defund Health Care,” and included a link to Mr. Oliver’s related episode, only to have a critic comment that I should have just given the link and left it at that.  

Now, I can’t blame anyone for preferring Mr. Oliver’s insights to mine, so I’ll link to his observations straightaway…but if you’re interested in some thoughts about facial recognition and healthcare, I hope you’ll keep reading.

Facial recognition is, indeed, in the news lately, and not in a good way.  Its use, particularly by law enforcement agencies, has become more widely known, as have some of its shortcomings.  At best, it is still weak at accurately identifying minority faces (or women), and at worst it poses significant privacy concerns for, well, everyone.  The fact that someone using such software could identify you in a crowd using publicly available photographs, and then track your past and subsequent movements, is the essence of Big Brother.  

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A Missed Opportunity for Universal Healthcare

Connie Chan
Phuoc Le

By PHUOC LE, MD and CONNIE CHAN

The United States is known for healthcare spending accounting for a large portion of its Gross Domestic Product (GDP) without yielding the corresponding health returns. According to the Center for Medicare and Medicaid Services (CMS), healthcare spending made up 17.7% ($3.6 trillion) of the GDP in the U.S. in 2018 – yet, poor health outcomes, including overall mortality, remain higher compared to other Organization for Economic Cooperation and Development (OECD) countries. According to The Lancet, enacting a single-payer UHC system would likely result in $450 billion in savings in national healthcare and save more than 68,000 lives.

Figure 1. Mortality rate in the US versus other OECD countries.

The expansion of Medicaid under the Patient Protection and Affordable Care Act (ACA or Obamacare) was not the first attempt the United States government made to increase the number of people with health insurance. In 1945, the Truman administration introduced a Universal Health Care (UHC) plan. Many Americans with insurance insecurity, most notably Black Americans and poor white Americans, would benefit from this healthcare plan. During this time, health insurance was only guaranteed for those with certain jobs, many of which Blacks and poor white Americans were unable to secure at the time, which resulted in them having to pay out-of-pocket for any wanted healthcare services. This reality pushed Truman to propose UHC within the United States because it would allow “all people and communities [to] use the promotive, preventative, curative, rehabilitative and palliative health services they need of sufficient quality…, while also ensuring that the use of these services does not expose the user to financial hardship.”

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Defund Health Care!

By KIM BELLARD

In the wake of the protests related to George Floyd’s death, there have been many calls to “defund police.”  Those words come as a shock to many people, some of whom can’t imagine even reducing police budgets, much less abolishing entire police departments, as a few advocates do indeed call for.

If we’re talking about institutions that are supposed to protect us but too often cause us harm, maybe we should be talking about defunding health care as well.  

America loves the police.  They’re like mom and apple pie; not supporting them is essentially seen as being unpatriotic.  Until recent events, it’s been political suicide to try to attack police budgets.  It’s much easier for politicians to urge more police, with more hardware, even military grade, while searching for budget cuts that will attract less attention.  

It remains to be seen whether the current climate will actually lead to action, but there are faint signs of change.  The mayor of Los Angeles has promised to cut $150 million from its police budget, the New York City mayor vowed to cut some of its $6b police budget, and the Minneapolis City Council voted to “begin the process of ending the Minneapolis Police Department,” perhaps spurred by seeing the mayor do a “walk of shame” of jeers from protesters when he would not agree to even defunding it.  

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A Healthcare System, If We Can Keep It

By KIM BELLARD

We are in strange days, and they are only going to get stranger as COVID-19 works its way further through our society.  It makes me think of Benjamin Franklin’s response when asked what kind of nation the U.S. was going to be:  “A Republic, if you can keep it.” 

SAUL LOEB / AFP VIA GETTY IMAGES

The versions of that response that COVID-19 have me wondering about are: “A federal system, if we can keep it,” and, more specifically, “a healthcare system, if we can keep it.”  I’ll talk about each of those in the context of the pandemic.

In times of national emergencies — think 9/11, think World Wars — we usually look to the federal government to lead.  The COVID-19 pandemic has been declared a national emergency, but we’re still looking for strong federal leadership.  We have the Centers for Disease Control, infectious disease experts like Dr. Anthony Fauci, and a White House coronavirus task force.  But real national leadership is lacking. 

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The Primary Cares Initiative: How Value-Based Payment Models Aim to Strengthen Primary Care

By CHRIS JAEGER MD, MBA

In April 2019, the Centers for Medicare & Medicaid Services (CMS) announced the Primary Cares Initiative, which is expected to reduce administrative burdens and improve patient care while decreasing health care costs. Learn more about the Primary Cares Initiative and its proposed value-based payment models in part one of this two-part blog series. 

Introduction

While the health care landscape has never been static, rarely has it seen such radical changes as it has within recent decades. The population of the United States continues to age, and the prevalence of chronic conditions such as obesity, diabetes, heart disease, and anxiety or depression contribute to a substantially increased demand for care. These factors are pushing a shift from a provider-centric model toward more efficient outcome-based models that put the patient at the center and heavily rely on primary care as the steward of patient care.

Primary care is a vital resource in dealing with the many factors altering the health care landscape. A 2019 study published in JAMA Internal Medicine found that for every 10 additional primary care physicians (PCPs) per 100,000 people, patients saw a 51.5-day increased life expectancy.

To promote further adoption of primary care-based models, the U.S. Department of Health and Human Services (HHS) and the Centers for Medicare & Medicaid Services (CMS) recently announced a set of payment models meant to further transform primary care through value-based options under the new Primary Cares Initiative. This voluntary initiative will test financial risk and payment arrangements for primary care physicians (PCPs) based on performance and efficiency, including five new payment models under two paths: Primary Care First (PCF) and Direct Contracting (DC). These models, slated to hit 20 states in 2020, seek to address the many difficulties in paying for, and incentivizing, valuable primary care within current payment models.

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Patient Worries as a Central Feature of their Health Care Experiences

By JOHN JAMES, ROBERT R. SCULLY, CASEY QUINLAN, BILL ADAMS, HELEN HASKELL, and POPPY ARFORD

Political forces trying to shape and reshape American healthcare without hearing the voice of patients provided the rationale for this work. Our experiences as patients, caregivers, and users of media sources cause us to worry. The Patient Council of the Right Care Alliance developed 6 questions to form a national survey of Americans to guide policy makers. The questions and our rationale were as follows:

1) Finding a doctor I can trust. Trust in our doctors is not as high as it once was. There are stories of serious patient abuse that appear in the media; two of the more notorious examples include a neurosurgeon harming many patients before being stopped and an oncologist who was deliberately misdiagnosing cancer to sell chemotherapy. Patients perceive this as the reluctance of the physician community to effectively ‘police their own.’

2) I will be misdiagnosed. Misdiagnosis happens far too often at all levels of healthcare. The problem is so common that the National Academy of Medicine turned its attention to the problem and published Improving Diagnosis in Health Care in 2015. The solution to the misdiagnosis problem is complex and has yet to arrive at the clinician-patient interface.

3) I will get an infection while receiving treatment. Healthcare-associated infections have dropped somewhat in the past decade, yet there are still about 720,000 infections and 75,000 deaths per year from healthcare-associated infections. Many of these are becoming nearly impossible to effectively treat. The improper use of ordinary antibiotics continues to be a problem in clinical settings.

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To Improve Patient Care, Think Both “Zebras” and Golf

By MICHAEL MILLENSON

Super Bowl Week ended with the San Francisco 49ers and 161 U.S. hospitals having something in common.

Both were publicly penalized, both lost money as a result and both passionately believed the process was unfair. Unfortunately, it’s not easy to decide whether their objections were sensible or sour grapes and, in the case of hospitals, the real-life consequences are not a game.

The penalty that pained the 49ers occurred shortly before halftime of Super Bowl LIV, when offensive pass interference was called on tight end George Kittle. The call negated a big gain that might have enabled the 49ers to take the lead.

Replays showed that the referees – nicknamed “zebras” for their black-and-white striped shirts – were technically correct in their decision. Nonetheless, controversy erupted over whether given other possible penalties called or overlooked, this one deserved a yellow flag.

Hospitals call that kind of context “risk adjustment.” A few days before the Super Bowl, the Medicare program blew the whistle on a group of hospitals having high rates of infection and other patient injuries. The hospitals who are outliers in what are blandly labeled “hospital-acquired conditions” (HACs) suffer a cut of one percent in their Medicare payments over next fiscal year.

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Charting The Economic History of US Health Reform

By MIKE MAGEE, MD

Adam Gaffney’s recent Boston Review article, What the Health Care Debate Still Gets Wrong”, a landmark piece that deserves careful reading by all, reaches near perfection in diagnosing our health system malady.

Dr. Gaffney is president of Physicians for a National Health Program, and a co-chair of the Working Group on Single-Payer Program Design, which developed the Physicians’ Proposal for Single-Payer Health Care Reform.

A seasoned health policy expert, his article cross-references the opinions and work of a range of health commentators including Atul Gawande, Steven Brill, Sarah Kliff, Elizabeth Rosenthal, Zack Cooper, and Canadian health economist Robert Evans. But his major companion is Princeton health economist, Uwe Reinhardt, whose posthumous book, Priced Out: The Economic and Ethical Costs of American Health Care, was recently published by Princeton University Press.

Gaffney’s affection for Reinhardt is evident as he recounts his desperate upbringing in post-war Germany, challenged by poor living conditions, but made whole by access to health care.  Quoting a 1992 JAMA interview, Reinhardt states, “When we needed medical care, we got it at the local hospital, no questions asked. When you were sick, society was there for you.”

That acknowledgment is not only personal but historically significant, as I outline in my recent book, Code Blue: Inside the Medical Industrial Complex. The services Reinhardt received were part of a new national health care system funded fully by American taxpayers as part of the Marshall Plan. At the very same time, American citizens were denied a national health plan of their own as Truman was effectively branded a supporter of “socialized medicine” by the AMA and a cabal of corporate partners.

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$2 Trillion+ in New Taxes for Single Payer, or $50 Billion to Strengthen ObamaCare? Next Question, Please

By BOB HERTZ

It is not wise for Democrats to spend all their energy debating Single Payer health care solutions.

None of their single player  plans has much chance to pass in 2020, especially under the limited reconciliation process. In the words of Ezra Klein, “If Democrats don’t have a plan for the filibuster, they don’t really have a plan for ambitious health care reform.”

Yet while we debate Single Payer – or, even if it somehow passed, wait for it to be installed — millions of persons are still hurting under our current system.

We can help these people now!

Here are six practical programs to create a better ACA.

Taken all together they should not cost more than $50 billion a year. This is a tiny fraction of the new taxes that would be needed for full single payer. This is at least negotiable, especially if Democrats can take the White House and the Senate.

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Improving the Affordable Care Act Markets (Part 1)

By JONATHAN HALVORSON, PhD

With each passing year, the Affordable Care Act becomes further entrenched in the American health care system. There are dreams on both the far left and far right to repeal and replace it with something they see as better, but the reality is that the ACA is a remarkable achievement which will likely outlast the political lifetimes of those opposing it. Future improvements are more likely to tweak the ACA than to start over from scratch.

A critical part of making the ACA work is for it to support healthy, competitive and fair health insurance markets, since it relies on them to provide health care benefits and improve access to care. This is particularly true for insurance purchased by individuals and small employers, where the ACA’s mandates on benefits, premiums and market structure have the most impact. One policy affecting this dynamic that deserves closer attention is risk adjustment, which made real improvements in the fairness of these markets, but has come in for accusations that it has undermined competition.

Risk adjustment in the ACA works by compensating plans with sicker than average members using payments from plans with healthier members. The goal is to remove an insurer’s ability to gain an unfair advantage by simply enrolling healthier people (who cost less). Risk adjustment leads insurers to focus on managing their members’ health and appropriate services, rather than on avoiding the unhealthy. The program has succeeded enormously in bringing insurers to embrace enrolling and retaining those with serious health conditions.

This is something to celebrate, and we should not go back to the old days in which individuals or small groups would be turned down for health insurance or charged much higher prices because they had a history of health issues. However, the program has also had an undesired effect in many states: it further tilted the playing field in favor of market dominant incumbents.

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