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Single-Payer is the American Way

Jul 31, 2017• 107

By MARGALIT GUR-ARIE

As is customary for every administration in recent history, the Trump administration chose to impale itself on the national spear known as health care in America. The consequences so far are precisely as I expected, but one intriguing phenomenon is surprisingly beginning to emerge. People are starting to talk about single-payer. People who are not avowed socialists, people who benefit handsomely from the health care status quo seem to feel a need to address this four hundred pound gorilla, sitting patiently in a corner of our health care situation room. Why?

The all too public spectacle of a Republican party at war with itself over repealing and replacing Obamacare is teaching us one certain thing. There are no good solutions to health care within the acceptable realm of incremental, compromise driven, modern American solutions to everything, solutions that have been crippling the country and its people since the mid-seventies, which is when America lost its mojo. To fix health care, we have to go back to times when America was truly great, times when the wealthy Roosevelts of New York lived in the White House, times when graduating from Harvard or Yale were not cookie cutter prerequisites to becoming President, times when the President of the United States conducted meetings while sitting on the toilet with the door open and nobody cared. Rings a bell?

Single-payer health care is one such bold solution. Listening to the back and forth banter on social media, one may be tempted to disagree. We don’t have enough money for single-payer. Both Vermont and California tried and quit because of astronomic costs. Hundreds of thousands of people working for insurance companies will become unemployed. Hospitals will close. Entire towns will be wiped out. Doctors will become lazy inefficient government employees and you’ll have to wait months before seeing a doctor. And of course, there will be formal and informal death panels. Did I miss anything? I’m pretty sure I did, so let’s enumerate.

Doctors Do Know Best.
Exhibit A: The Charlie Gard Case.

Jul 31, 2017• 4

By SAURABH JHA, MD

For American conservatives, Britain’s NHS is an antiquated Orwellian dystopia. For Brits, even those who don’t love the NHS, American conservatives are better suited to spaghetti westerns, such as Fistful of Dollars, than reality.

The twain is unlikely to meet after the recent press surrounding Charlie Gard the infant, now deceased, with a rare, fatal mitochondrial disorder in which mitochondrial DNA is depleted – mitochondrial depletion disorder (MDD). In this condition, the cells lose their power supply and tissues, notably in the brain, die progressively and rapidly.

The courts forbade Charlie’s parents from taking him for a last dash of hope to the United States. This confirmed for many conservatives the perils of a government-run healthcare system, where the state decides who lives and who dies through Death Panels.

Ted and Mike, whose healthcare reform might affect many curable little Charlies, were moved by the plight of an incurable Charlie. No European will understand the science behind their sentiment – if you care so much about a sick incurable baby, why don’t you care about sick, curable babies, they’d ask.

Brits will never get the importance conservatives place on individual choice, even if that choice is forlorn, and of the lure of medical heroism. Conservatives seldom acknowledge that modern medicine reaches its limitations too quickly for Death Panels to be effective. Charlie was given a grim prognosis by doctors at the Great Ormond Street Hospital (GOSH), arguably the finest hospital for sick children in the world.

The Pri(n)ce of Healthcare

Jul 28, 2017• 21

By DANIEL STONE, MD

Tom Price, President Trump’s new Secretary of Health and Human Services (HHS) strode to the podium to the sound of applause. The two thousand medical administrators and physicians at the annual meeting of CAPG, a trade organization representing physician groups, heard him described as the most influential person affecting the 300+ participating groups that provide care for millions. Only the third physician to lead HHS, many hoped that the orthopedist and six term GOP congressman would bring new sophistication to the federal government’s healthcare programs.

The perfectly coiffed Secretary looked every bit the new man in charge of healthcare. Sadly, his resonant voice soon dashed any hope for substance. He might have commented on the essential U.S. healthcare quandary: A country with average household income of $56,000 can’t afford the $15,000 annual cost of health insurance for a family of four. Neither Republicans nor Democrats can conjure up inexpensive insurance that covers unaffordable healthcare services. What does the Secretary think? He sidestepped the issue, twice patting his audience on the back by touting the American health system as “the finest in the world.” Seriously? If Price had attended the morning session he would have heard that the U.S. spends about 6% more of its GDP on healthcare than average developed country. That extra $1.2 trillion amounts to more than twice the defense budget. Yet U.S. health outcomes for crucial measures like infant mortality and lifespan rank average or even worse. Yes, U.S. medical technology leads the world and foreign dignitaries still travel here for world class, high tech care. But shouldn’t the secretary of HHS understand that the measure of a healthcare system is the quality and accessibility of care provided to average citizens? Continue reading…

Why California Should Try Single Payer. Yes, We Said That.

Jul 28, 2017• 19

By JIM PURCELL

This Spring, California SB (Senate Bill) 562 proposed a single-payer healthcare financing system for California. Governor Jerry Brown was immediately skeptical, stating, “This is called ignotum per ignotius….In other words, you take a problem and say, ‘I’m going to solve it by something that’s even a bigger problem,’ which makes no sense.” And in early July, California Assembly Speaker Anthony Rendon tabled the bill calling it “woefully incomplete.” While true, that incurred the predictable wrath of single payor advocates.

Understandably, it’s difficult for supporters not to be enthusiastic about SB 562 given the conclusions reached by the Political Economy Research Institute (PERI) based out of the University of Massachusetts, Amherst. PERI has released a Study commissioned by the California Nurses Association (which has always favored single payor universal coverage) that projects reductions in healthcare spending by $37.5 billion a year! No small change there.

The Study reports that the proposed single payor system could provide “decent health care for all California Residents…” and while providing full universal coverage would increase overall system costs by about 10%, it “could” produce savings of about 18%. The savings supposedly will be realized through reduced administrative costs, reducing pharmaceutical reimbursement charges, and “a more rational fee structure for providers.” “More rational” usually means “reduced,” and that usually means primary care and mental health are the first in line to take it in the neck, given their limited negotiating leverage.

And it gets even better. There would be no premiums, copays, or deductibles. According to the Study, people could get treated whenever and wherever they want. And money will be saved. This is like heaven.

Repair and Reboot

Jul 27, 2017• 3

NIRAN AL-AGBA, MD

I told you so. I also told the POTUS in my open letter, but he did not read it.

Who could honestly believe the nation would support dumping coverage for 22 million people? As David Leonhard wrote recently op-ed in the New York Times: “They [Republicans and President Trump] had only one big weakness, in fact: They weren’t dealing in reality.” When faced with reality, it is interesting what a few good Senators with a conscience will refuse to do.

Success is never attained by taking shortcuts. We do not need reform of health care; we need to reboot the entire system. Special interests do not belong in the picture. They are incompatible with developing innovative solutions that place profits on the back burner. Congress is making this too difficult. They need to roll up their sleeves, go back to the drawing board, and start again. My suggestions:

Step 1: Every member of Congress should participate in a mock hospital admission as a patient, starting with presentation to the ER, being poked and prodded, having surgery if necessary, and staying overnight to recuperate. After your experience, you should be provided a “bill” on your way out the door and pay the balance by cash or check.

Step 2: Go see your own primary care physician for two reasons. The first is to have an annual exam and to connect with your constituents in the waiting room, solicit their comments, thoughts, or suggestions, and converse with office staff to understand their perspective. The second reason is to elicit feedback directly from your primary care physician. Listen for groundbreaking solutions to the perplexing boondoggle of caring for greater numbers at a lower cost.

Extra credit: Follow a primary care physician in a Health Professional Shortage Area (HPSA) for three days. Listen, engage, clarify, empathize, and most importantly absorb how monumental this undertaking of reforming health care will be.

This EHR Mess We’re In

Jul 27, 2017• 5

MICHAEL CHEN, MD

Dr. Matthew Hahn blogs about the current state of today’s EHR’s and rightly points out many of the same reasons that I have identified in my previous posts:

The negative impact of Meaningful Use (MU) since 2009
Poor usability of EHR’s

There are several other important concerns that have been left unanswered by our current Health IT offerings.

Patient privacy and control of their health records
Interoperability

Government Pipedream?

The solution Dr. Hahn proposed is one that hinges on the hope that government will abandon MU (unlikely given this political climate), and create a whole new EHR development program based on a national competition and then for the government to subsidize the cost of that winner EHR for physicians to use.

Subsequently, this national competition will engage physicians so that they have control over their destinies in designing the EHR of their dreams. But is it realistic to hope that government will support such an endeavor? Although I’m a believer that government should and ought to play a role in setting fair rules and be accountable to the public (for the many and not the few) and not to be overrun by lobbyists and those with the most money and influence who can rig the system, I doubt this solution will see the light of day with our currently polarized politics and the continued, large influence of big money interests in government today.

Movements as Inspiration

Here is my proposal that leverages existing platforms and technologies (but that most physicians may not be aware of) without hoping for the government to intervene today (or yesterday). Only until a community of patients, physicians, and developers that have a common goal of creating an EHR that works for both physicians and patients, that we ultimately compel the government to support (financially) the further development and adoption of this type of system. Those who have studied previous movements (such as the LGBT social movement, thee Civil Rights movement, and the women’s suffrage movement) took a group of like-minded individuals from different walks of life who struggle together, make their voices heard, participate, and ultimately control the cultural narrative to the point that government had no choice but to abide to the sea change that has already taken place. This is where physicians and patients have to start. And we have the tools to start the change as we see fit.

Digital Health Marketplace: Facilitating Rapid Technology Adoption and Spurring Growth in New York City.

Jul 27, 2017

By ALYX STERNLICHT

$200,000 in Awards to Health Tech Companies and Pilot Partners for the 4th Class of Digital Health Marketplace

Six winners were awarded of a total of $200,000 in grant funding through Digital Health Marketplace.

Digital Health Marketplace, a New York City Economic Development Corporation (NYCEDC) program, powered by Health 2.0, connects health technology buyers with market-ready sellers through biannual matchmaking and by providing grants to offset the cost of piloting their technologies in healthcare institutions. The program has provided over $2,500,000 in grant funding over the course of 3 classes. This year, the fourth class of Digital Health Marketplace winning pilots are anticipated to impact over 6,000 patients in New York City throughout the next year. The technologies span from care coordination platforms to patient engagement systems to devices.

How Much Is That CAT Scan in the Window?

Jul 26, 2017• 10

ANISH KOKA, MD

Who knew healthcare could be so complex? The GOP proposal for health care reform rests on health savings accounts and high deductible health plans. The basic premise is that price opacity, and deep pocketed third party payers drive up the cost of health care. Giving patients dollars in health savings accounts they control should make them price sensitive, and thus help reduce the cost of healthcare. A recent analysis by Drs. Chandra and others provides an interesting perspective on the matter.

The researchers took a large self insured firm that required all of its employees to switch from an insurance plan that provided free healthcare to a nonlinear, high deductible plan. The switch worked. Health care spending was significantly reduced, but the concern was the mechanism by which spending was reduced. One would like to believe spending reductions related to price shopping, so patients were getting the same services just for cheaper. Unfortunately, it appeared that consumers reduced all spending regardless of whether it was worthwhile or not. Deciding what is worthwhile in healthcare is a complicated business that I will leave for another day but I agree with the general contention of the paper – giving a patient control over health care dollars does not make for a smart price shopper.

How Insane Could This Get?

Jul 25, 2017• 13

STEVEN FINDLAY

At long last, the Senate is poised to begin voting today on a measure to repeal and/or alter portions of the Affordable Care Act.

Much remains in flux regarding process and the substance of what will be voted on. According to multiple media sources today, Senate leaders latest strategy is to hold a vote on a narrower piece of legislation than those circulated in recent weeks.

The substance of such a measure—if indeed, it exists and is submitted for a vote—is unclear as of this posting. But it reportedly could contain just a repeal of the ACA’s individual and employer mandates and a few of the law’s taxes, such as the one on medical device companies.

This narrow, or “skinny,” bill would not have any provisions pertaining to Medicaid.

The idea, apparently, is to pass this initial piece of the puzzle—to get things going—and then to take up the larger and more controversial issues that have so deeply divided the Republican caucus.Continue reading…

ONC Interoperability Meeting Raises More Questions Than Answers

Jul 25, 2017• 2

By ADRIAN GROPPER, MD

ONC’s first public event under the new administration was very well organized and run. Eight leading health information exchange incumbents were able to describe their current approaches and plans, the patient advocate position was clearly stated, and a nice synthesis of the issues raised by the trusted framework approach to interoperability was prepared by a consulting organization. Much to ONC’s credit, they went out of their way to provide access and public comment to an extent that is unprecedented in my experience. Slides and recordings will be posted soon and a 30-day comment period runs through August 24. Kudos to ONC.

The proceedings raised a lot more questions than answers and, from my perspective, call into question the whole approach to interoperability that we’ve inherited from the HITECH-era ONC.

Algorithmic (and coercive) patient identity matching has no solution in sight
Interoperability between HIPAA and non-HIPAA entities has no solution in sight
Different frameworks with different governance principles can only interoperate at a lowest common denominator, frustrating both clinicians and families
Identity proofing of patients confuses pretty much everyone
All agree that accountability is important but nobody proposed how patients can hold anyone accountable for anything
Incumbent systems are built around clunky document exchange instead of modern APIs and API Task Force principles
There is no consensus on who will pay the rent the health data brokers are seeking
Patient access is an afterthought for most of the data brokers and no solution seems to be in sight
The 21st Century Cures goal of a Longitudinal Health Record was not mentioned by anyone at all

By contrast, in the patient perspective presentation by Cynthia Fisher, we heard a call to turn the interoperability problem on it’s head: to start with the patient and caregiver not the provider and EHR vendor. “We paid for it already…we own it and should have it”, she said.