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Llewellyn King: Start all over again with healthcare reform

The process now underway in Congress to repeal and replace the Affordable Care Act (Obamacare) reminds me of what would happen if you tried to thread a small darning needle with a strand of bulky yarn: It won’t go through the eye. The more you try to pull the strand through the eye, the less useful the yarn coming through it will be.

Therefore, isn’t it time to reconsider the whole proposition as though there were no Obamacare, no House version of its replacement, and no preconceived objective beyond affordable care for all?

Also, there should be no pre-established conditions, such as single-payer and multiple-payer; no pre-established goals, such as preserving particular insurance practices and expectations that employers will always be part of the deal; and no expectation that the health-care bill should also be a tax bill or a welfare bill.

Its simple goal should be to free people from fear of medical catastrophe and enable physicians and hospitals to care for the sick without commercial pressure.

I’ve come to the belief that big, new ideas are needed from my own experience as an employer-provider. For more than 30 years, as a small Washington publisher, I provided health insurance for my staff of 25. It was a nightmare that got worse as medicine got more expensive.

Of many strange situations, none was worse than the employee who developed nasopharyngeal cancer, a rare type of head and neck cancer. The insurance paid for chemotherapy and radiation, but refused to pay for expensive painkillers. These had to be brought in from France by a family member.

Maybe the most discouraging was a printing-press operator who wanted the premiums given to him, as he refused to see the point of insurance, although he was married with three small children. “We don’t use insurance,” he declared. “When the kids are sick we go to the emergency room and tell them we have no money.” When pressed, he said they did this because they didn’t want the bother of filling out forms.

If you think, as I do, that the system we have is less than perfect, one is immediately thought to be a believer in British-type national health insurance. Not necessarily so.

As a former British subject,  I know something about Britain’s National Health Service and I think it is better than what is happening in the United States. I’ve received treatment in Britain under the system and members of my family in England are devoted to it. There is good treatment for major procedures. However for lesser ailments, there are long waiting lists. Bureaucracy is everywhere.

Worse, can you imagine a health-care system dependent on the budget cycle in Congress?

In Switzerland there is a totally private system, which looks like improved Obamacare. Everyone is obliged to buy insurance, just as everyone has to pay taxes. There are no limits on troublesome things like preexisting conditions. The government regulates the insurers. In a referendum, the Swiss rejected a switch to a single-payer system by 60-40 percent.

There also are mixed systems in Germany and Holland. The commonality is that everyone is covered and the governments regulate. That way, insurance pools are large and have the correct mix of old and young — otherwise the old will overwhelm any system.

Unless we devise a structure that caters to all, we will continue with overburdened emergency rooms, preposterous hospital charges and doctors who will pick and choose their patients.

No one on a gurney being wheeled down a hospital corridor should be thinking, “How will I pay for this?”

The chances are that when Congress has finished trying to thread the unthreadable needle, there will be a groundswell on the left for single-payer — better, possibly, but not a fit in the United States.

Meanwhile, there are too many pre-existing conditions in congressional thinking. We need a new prescription, a bigger needle and a finer thread.
Llewellyn King (llewellynking1@gmail,com) is host and executive producer of White House Chronicle, on PBS, and a veteran publisher, editor, columnist and international business consultant. He is based in Rhode Island and Washington. This piece first ran in Inside Sources.

Massive ransomware seen as more proof of perilous over-reliance on IT


The Web site of Roy Poses, M.D., sees the worldwide ransomware attack underway, including against hospitals and other healthcare institutions, as yet another ominous sign of our extreme over-reliance on computer systems.

Dr. Poses writes:

“InformaticsMD reviewed the recent global ransomware attack in the health care context, focused on the hacking of British NHS  {National Health Service} hospitals.  As seems usual in health care information technology debacles, hospital managers were quick to soft-pedal what aspects of it they could (the NHS was not the ‘target’ of the attack?  There was no evidence that “patient data was accessed”?)  Preliminary reports indicated that the NHS was using an outdated version of Windows which had not been updated.  Once again, advocates for commercial health information technology have been exaggerating (if not fabricating) its benefits, while pooh-pooling its harms for a long time.  The use of technologies whose benefits and harms have never been properly assessed by clinical research studies continues to pose dangers for patients.  Insiders in the health IT industry seem to be collaborating with government bureaucrats to promote this unproven technology.  True health care reform would require rigorous assessment of all new medical/ health care technology, regardless of who might be offended if such assessments provide negative results.”

To read more, please hit this link.

English make progress toward more value-based payment system



Scenes from Milton Keynes, in  England.

The National Health Service in England  may have some  big lessons for the U.S. in adopting a value-based healthcare payment system, reports this HealthAffairs piece. Among the authors’ remarks:

“The first attempts at incentive change were relatively small scale. In 2011, payers in Milton Keynes… sought to improve substance misuse and sexual health services. They devised and developed a new form of contract to align financial incentives with system goals.

“The key elements of the new payment mechanism were that the contracts:

  • “Were multi-year as opposed to annual.
  • “Were based on capitation payments rather than fee for service.
  • “Included outcome indicators that attracted annual additional payments of up to 20 percent for improved performance. Significantly the incentivized outcomes were identified through dialogue with people who used services.

“These capitated outcome-based and incentivized contracts (also known as COBIC) quickly resulted in better coordinated services, delivered at lower cost, and produced better outcomes.

“Since 2011, this initiative has been built upon and extended elsewhere. The next wave of outcomes-based COBICs addressed problems with services for single groups of disorders, most commonly musculoskeletal services  …. As in the U.S., although not every initiative was successful, it was found that these contracts could quickly lead to better coordinated, more patient-centered care, with improved patient choice, good patient experience, and reduced costs.

“The concept is now being extended still further in both geography and ambition, with multi-year capitated outcomes-based COBICs being prepared and implemented for mental health care …, older people’s services …, and for people with long-term conditions…. One area, Somerset, has even begun to develop long-term per capita funded and outcomes-incentivized contracts for all the healthcare it buys for its whole population.

“The changes being catalyzed by these innovative approaches to payment are profound. They operationalize a value-based approach to healthcare, in which responsibility for population health is shared with providers. By placing more emphasis on achieving patient-defined outcomes, they make the whole system more patient-centric, shifting power from the providers to the people that use the system in terms not just of where and when services are provided, but what treatments and care an individual chooses to have in the first place.”

“The introduction of multi-year capitated outcome-incentivized contracts is a practical approach to operationalizing a value-based approach to care that can catalyze major change across a health economy at relative pace and scale (compared with the pace and scale of attempts at widespread transformation in the NHS’s recent past).”

New IHI head talks about his Scottish experience



The “Old Course” at St. Andrews. Mr. Feeley, like many Scots, is an enthusiastic golfer.

Derek Feeley is the new  chief executive of the Institute for Healthcare Improvement. Mr.  Feeley is  from Scotland, where he was head of the national healthcare system before becoming executive vice president of the IHI in 2013.

In this Hospitals & Health Networks interview he talks his experience in Scotland. Among his remarks:

“{The Scottish system is}a single-payer system. It’s almost exclusively tax funded. There’s very little competition. The National Health Service is more or less a monopoly provider of health care, but part of my responsibilities in Scotland was extended to the health of the population, as well as to delivering effective health care, and I had to do that within a cash-limited financial allocation…. So what I had to do in leading that healthcare system is what we call the Triple Aim at IHI:”

  • “Improving the patient experience of care (including quality and satisfaction).
  • “Improving the health of populations.
  • “Reducing the per capita cost of healthcare.”

“I had to make sure that the quality of the healthcare experience we were delivering was as high as it could possibly be, and I had to make sure that we were delivering improvements in the health of the population. I had to make sure that we were getting maximum value for every dollar that we were spending.”

“The challenges that leaders are facing in healthcare are pretty similar right across the developed world, actually — economic factors, political change, demographic pressures, the growth of co-morbidities, shifting customer expectations, and the accelerating pace of change. The challenges that leaders are facing are actually very similar across the Developed World. There never has been such a challenging time to be a leader in healthcare, but the good news is, because we are all tackling the same kind of issues, the opportunities for us to collaborate and learn from each other are significant.”

But what does ‘single payer’ really mean?


For Kaiser Health News

Healthcare has emerged as one of the flash points in the Democratic presidential race.

Vermont Sen. Bernie Sanders has been a longtime supporter of a concept he calls “Medicare for All,” a health system that falls under the heading of “single-payer.”

Sanders released more details about his proposal shortly before the Democratic debate in South Carolina Sunday night. “What a Medicare-for-All program does is finally provide in this country health care for every man, woman and child as a right,” he said in Charleston.

Sanders’s main rival for the nomination, former Secretary of State Hillary Clinton, has criticized the plan for raising taxes on the middle class and said it is politically unattainable.  “I don’t want to see us start over again with a contentious debate” about health care, she said Sunday night.

Some of the details of Sanders’s plan are still to be released. But his proposal has renewed questions about what a single-payer health care system is and how it works. Here are some quick answers.

What Is Single-Payer?

Single-payer refers to a system in which one entity (usually the government) pays all the medical bills for a specific population. And usually (though again, not always) that entity sets the prices for medical procedures.

Single-payer is not the same thing as socialized medicine. In a truly socialized medicine system, the government not only pays the bills but owns the health care facilities and employs the professionals who work there.

The Veterans Health Administration (VA) is an example of a socialized health system run by the government. It owns the hospitals and clinics and pays the doctors, nurses and other health providers.

Medicare, on the other hand, is a single-payer system in which the federal government pays the bills for those who qualify, but hospitals and other providers remain private.

Which Countries Have Single-Payer Health Systems?

Fewer than many people think. Most European countries either never had or no longer have single-payer systems. “Most are basically what we call social-insurance systems,” said Gerard Anderson, a professor at Johns Hopkins Bloomberg School of Public Health, who has studied international health systems. Social insurance programs ensure that almost everyone is covered. They are taxpayer-funded but are not necessarily run by the government.

Germany, for example, has 135 “sickness funds,” which are essentially private, nonprofit insurance plans that negotiate prices with healthcare providers. “So you have 135 funds to choose from,” Anderson said.

Nearby, Switzerland and the Netherlands require their residents to have private insurance (just like the Affordable Care Act does), with subsidies to help those who cannot otherwise afford coverage.

And while conservatives in the United States often use Britain’s National Health Service as the poster child for a socialized system, there are many private insurance options available to residents there, too.

Among the countries that have true single-payer systems, Anderson lists only two — Canada and Taiwan.

Are Single-Payer Plans Less Expensive Than Other Health Coverage Systems?

Not necessarily. True, eliminating the profits and duplicative administrative costs associated with hundreds of different private insurance plans would reduce spending, perhaps as much as 10 percent of the nation’s $3 trillion annual health care bill, Anderson said. But, he noted, once that savings is achieved, there won’t be further reductions in following years.

More important, as many analysts have noted, is how much health services cost and how those prices are determined. In most other developed countries, even those with private insurance, writes Princeton Health Economist Uwe Reinhardt, prices “either are set by government or negotiated between associations of insurers and providers of care on a regional, state or national basis.” By contrast, in the U.S., “the payment side of the health care market in the private sector is fragmented, weakening the bargaining power of individual insurers.”

Would Medicare For All Be Just Like The Existing Medicare Program?

No, at least not as Sanders envisions it. Medicare is not nearly as generous as many people think. Between premiums (for doctor and drug coverage), cost-sharing (deductibles and coinsurance) and items Medicare does not cover at all (most dental, hearing and eye care), the average Medicare beneficiary still devotes an estimated 14 percent of all household spending to health care.

Sanders’s plan would be far more generous, including dental, vision, hearing, mental health and long-term care, all without copays or deductibles (which has given rise to a lively debate about how to pay for it and whether middle-class families will save money or pay more).

Would Private Insurance Companies Really Disappear Under Sanders’s Plan?

Probably not. Private insurers are fully integrated into Medicare, handling most of the claims processing and providing supplemental coverage through “Medigap” plans. In addition, nearly a third of Medicare beneficiaries are enrolled in private managed care plans as part of the Medicare Advantage program.

Creating an entirely new federal claims processing structure would in all likelihood be more expensive than continuing to contract with private insurance companies. However, Sanders makes it clear  that insurers in the future would no longer be the risk-bearing entities they are today, but more like regulated utilities.

General hospital wards particularly perilous for heart patients


The Guardian reports that patients with heart failure “are twice as likely to die if they are admitted to a general hospital ward rather than one specializing in cardiology, (British} research suggests.”

“Research published in the journal Heart has found that patients admitted to general NHS {National Health Service} wards are 2.5 times more likely to die than those admitted to cardiology wards.”

We wonder if there would be similar figures for the U.S. We suspect so.


Britain’s experience with cutting procedure use


Read how British National Health Service savings plan might have cut the use of three ”low-value” procedures.

The authors of this HealthAffairs piece conclude:

”Our findings highlight some of the challenges of making major budget cuts in healthcare. Reducing ineffective spending remains a significant opportunity for the US healthcare system, and the English experience may hold valuable lessons.”

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