This month’s poll probes Democrats’ views about the general approaches to expanding health coverage and lowering costs put forward by the candidates; the public’s health care prio…
This month’s poll probes Democrats’ views about the general approaches to expanding health coverage and lowering costs put forward by the candidates; the public’s health care prio…
Thank to Dr. McCanne, I am re-posting the following article from the Annals of Internal Medicine that was published Tuesday. I have written before about MSSPs, so I thought it would be a respite from talking about single payer.
Here is the article in its entirety:
Annals of Internal Medicine
June 18, 2019
Performance in the Medicare Shared Savings Program After Accounting for Nonrandom Exit: An Instrumental Variable Analysis
By Adam A. Markovitz, BS; John M. Hollingsworth, MD, MS; John Z. Ayanian, MD, MPP; Edward C. Norton, PhD; Phyllis L. Yan, MS; Andrew M. Ryan, PhD
Accountable care organizations (ACOs) in the Medicare Shared Savings Program (MSSP) are associated with modest savings. However, prior research may overstate this effect if high-cost clinicians exit ACOs.
To evaluate the effect of the MSSP on spending and quality while accounting for clinicians’ nonrandom exit.
Similar to prior MSSP analyses, this study compared MSSP ACO participants versus control beneficiaries using adjusted longitudinal models that accounted for secular trends, market factors, and beneficiary characteristics. To further account for selection effects, the share of nearby clinicians in the MSSP was used as an instrumental variable. Hip fracture served as a falsification outcome. The authors also tested for compositional changes among MSSP participants.
Fee-for-service Medicare, 2008 through 2014.
A 20% sample (97 204 192 beneficiary-quarters).
Total spending, 4 quality indicators, and hospitalization for hip fracture.
In adjusted longitudinal models, the MSSP was associated with spending reductions (change, −$118 [95% CI, −$151 to −$85] per beneficiary-quarter) and improvements in all 4 quality indicators. In instrumental variable models, the MSSP was not associated with spending (change, $5 [CI, −$51 to $62] per beneficiary-quarter) or quality. In falsification tests, the MSSP was associated with hip fracture in the adjusted model (−0.24 hospitalizations for hip fracture [CI, −0.32 to −0.16 hospitalizations] per 1000 beneficiary-quarters) but not in the instrumental variable model (0.05 hospitalizations [CI, −0.10 to 0.20 hospitalizations] per 1000 beneficiary-quarters). Compositional changes were driven by high-cost clinicians exiting ACOs: High-cost clinicians (99th percentile) had a 30.4% chance of exiting the MSSP, compared with a 13.8% chance among median-cost clinicians (50th percentile).
The study used an observational design and administrative data.
After adjustment for clinicians’ nonrandom exit, the MSSP was not associated with improvements in spending or quality. Selection effects — including exit of high-cost clinicians — may drive estimates of savings in the MSSP.
Primary Funding Source:
Horowitz Foundation for Social Policy, Agency for Healthcare Research and Quality, and National Institute on Aging.
In addition, here is an article from The Incidental Economist of June 17th on the same subject:
The Incidental Economist
June 17, 2019
Spending Reductions in the Medicare Shared Savings Program: Selection or Savings?
By J. Michael McWilliams, MD, PhD, Alan M. Zaslavsky, PhD, Bruce E. Landon, MD, MBA, and Michael E. Chernew, PhD.
Prior studies suggest that accountable care organizations (ACOs) in the MSSP have achieved modest, growing savings. In a recent study in Annals of Internal Medicine, Markovitz et al. conclude that savings from the MSSP are illusory, an artifact of risk selection behaviors by ACOs such as “pruning” primary care physicians (PCPs) with high-cost patients. Their conclusions appear to contradict previous findings that characteristics of ACO patients changed minimally over time relative to local control groups.
Monitoring ACOs will be essential, particularly as incentives for selection are strengthened as regional spending rates become increasingly important in determining benchmarks. Although there has likely been some gaming, the evidence to date — including the study by Markovitz et al. — provides no clear evidence of a costly problem and suggests that ACOs have achieved very small, but real, savings. Causal inference is hard but necessary to inform policy. When conclusions differ, opportunities arise to understand methodological differences and to clarify their implications for policy.
And finally, Don McCanne’s comment:
This important study in the highly reputable Annals of Internal Medicine concludes that accountable care organizations (ACOs) participating in the Medicare Shared Savings Program (MSSP) did not show any improvement in spending or quality when adjustments were made for selection effects, especially the non-random exit of high-cost clinicians (“I’m worth the extra money, and if you’re gonna cut my fees, I’m outta here.”)
The conclusions were immediately challenged by others in the policy community who have previously published studies indicating that “ACOs have achieved very small, but real, savings,” albeit admitting that “there has likely been some gaming.” And the savings were, indeed, very small. Others have suggested that the very small savings did not take into consideration the significant increase in provider administrative costs for technological equipment and personnel to run the ACOs, and certainly did not consider other unintended consequences such as the tragic increase in physician burnout.
Another problem with the infatuation for ACOs is that politicians and the policy community are insisting that we continue with this experiment in spite of the disappointing results to date. That simply postpones the adoption of truly effective policies, such as those in a single payer Medicare for All program, that would actually improve quality while greatly reducing administrative waste. The tragedy is that this also perpetuates uninsurance, underinsurance, and personal financial hardship from medical bills.
People are suffering and dying while the policy community continues to diddle with ACOs and other injudicious policy inventions. Enough! It’s long past time to reduce suffering and save lives! Single Payer Medicare for All!
(Yes, I’m angry, but even more I’m terribly anguished over the health care injustices that we continue to tolerate through our collective inaction.)
See, we can’t get away from Medicare for All after all.
Whenever the subject of what to do about the cost of health care arises on the social media site, LinkedIn, invariably there is someone who attempts to deflect the discussion away from the logical solution of Medicare for All/Single Payer, to what I am calling the Free Market Utopian Fantasy.
Those of you who read my post, “Health Care Is Not a Market”, will understand that when it comes to health care, the rules of the market do not apply. That is why I have called the attitude and comments made by these individuals, the Free Market Utopian Fantasy. Because the free market in health care is a fantasy. It is usually the expression of economic libertarianism coming from the right-wing propaganda machine.
Simply put, the Free Market Utopian Fantasy states that if we only had a truly free market health care system, costs would regulate themselves through competition, as in other areas of the free market.
In fact, one observer recently said the following in a thread on LI: “This would not be the case IF there were created and implemented an ORDERLY market for health care services based upon free market enterprise principles whereby ALL costs are transparent to ALL parties.”
An orderly market? Are you serious? More of the same BS from the Free Market Utopians.
Then there is the idea that consumers, read that as patients, must educate themselves as to the best choice. Choice? When you are dying of a heart attack? Choice, when you only have a short time to live due to a serious illness like Cancer or Diabetes?
Folks, we are not talking about choosing between buying steak or chicken. This is not choosing to go to Italy next summer or to the Caribbean. We are talking about life and death. And the only choice is to do what will save your life, not choose between colors on a swatch.
This Free Market Utopian Fantasy has infected so many people in the health care industry, and they are trying to prevent the American people from receiving the same quality of care at lower cost than all the other Western and other nations already do for their people.
They claim that we can’t afford to do it. I ask, can we afford not to?
They cite statistics about Medicare like some cite similar statistics about Social Security, but they are wrong then, and they are wrong about Medicare for All, because it will be expanded to cover everyone and everything, not requiring separate insurance for things like vision and dental care, mental health, and long-term care.
Here is what one person said in the same thread cited above:
“We can barely afford Medicare for the 60 million current Medicare recipients. Adding another 270 million recipients would bankrupt the nation in short order. Latest data (2017) on Medicare shows an annual cost of $700 billion, and projections show the Medicare Trust Fund will be insolvent in 2026 – and by the way, Medicare actually only covers about half of the real cost because the rest is covered by supplementary insurances that have to be bought by the patient. If you assume that Medicare expansion was at the same cost rate as current Medicare, Medicare for all would cost at least $3.15 trillion in 2017 dollars. Total 2019 federal government revenue is estimated at $6.5 trillion, and estimated Medicare for all costs for 2019 would be $3.5 trillion. It is simply not feasible.”
Boy, they really know how to BS their way to keeping us the only Western nation that does not have universal health care. What they don’t realize is, there won’t be any private insurance, because it is private insurance that drives up the cost of health care with administrative costs and waste,
Well, it is high time we call BS on all of them, and their Free Market Utopian Fantasy. Until we stop listening to these folks who are protecting their careers and profits, no American will never have to worry if they or a loved one gets sick and cannot afford the needed medical care without going bankrupt or dying without ever receiving the care they so desperately need. I said as much in my other post, “By What Right”, where I took these folks to task for preventing the enactment of MFA/Single Payer.
These Free Market Utopians are not doing anyone any favors. They are only hurting millions of Americans, born or not-yet-born who will someday need a truly comprehensive, universal health care system, and it won’t be there thanks to them and their associates.
Today’s New York Times Opinion piece on universal health care is a timely one, given the attempts by the medical-industrial complex and their allies to derail any move towards health care for all. It is even more important now that the 2020 Democratic primary campaign is gaining momentum.
Yesterday, Sen. Bernie Sanders introduced the Medicare for All Act for 2019, along with 19 co-sponsors in the Senate.
This bill mostly follows the previous bill he introduced in 2017, yet it has one notable addition. The new bill is summarized as follows:
* Eligibility: Covers everyone residing in the U.S.* Benefits: Covers medically-necessary services including primary and preventive care, mental health care, reproductive care (bans the Hyde Amendment), vision and dental care, and prescription drugs. This bill also provides home- and community-based long-term services and supports, which were not covered in the 2017 Medicare for All Act.* Patient Choice: Provides full choice of any participating doctor or hospital. Providers may not dual-practice within and outside the Medicare system.* Patient Costs: Provides first-dollar coverage without premiums, deductibles or co-pays for medical services, and prohibits balance billing. Co-pays for some brand-name prescription drugs.* Cost Controls: Prohibits duplicate coverage. Drug prices negotiated with manufacturers.* Timeline: Provides for a four-year transition. In year one, improves Medicare by adding dental, vision and hearing benefits and lowering out-of-pocket costs for Parts A & B; also lowers eligibility age to 55 and allows anyone to buy into the Medicare program. In year two, lowers eligibility to 45, and to 35 in year three.
* Funding hospitals through global budgets, with separate funding for capital projects: A “global budget” is a lump sum paid to hospitals and similar institutions to cover operating expenses, eliminating wasteful per-patient billing. Global budgets could not be used for capital projects like expansion or modernization (which would be funded separately), advertising, profit, or bonuses. Global budgeting minimizes hospitals’ incentives to avoid (or seek out) particular patients or services, inflate volumes, or up-code. Funding capital projects separately, in turn, allows us to ensure that new hospitals and facilities are built where they are needed, not simply where profits are highest. They also allow us to control long term cost growth.* Ending “value-based” payment systems and other pay-for-performance schemes: This bill continues current flawed Medicare payment methods, including alternative payment models (including Accountable Care Organizations) established under the ACA, and the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). Studies show these payment programs fail to improve quality or reduce costs, while penalizing hospitals and doctors that care for the poorest and sickest patients.* Establishing a national long-term care program: This bill includes home- and community-based long-term services and supports, a laudable improvement from the 2017 bill. However, institutional long-term care coverage for seniors and people with disabilities will continue to be covered under state-based Medicaid plans, complete with a maintenance of effort provision. PNHP recommends that Sen. Sanders include institutional long-term care in the national Medicare program, as it is in Rep. Pramila Jayapal’s single-payer bill, H.R. 1384.* Banning investor-owned health facilities: For-profit health care facilities and agencies provide lower-quality care at higher costs than nonprofits, resulting in worse outcomes and higher costs compared to not-for-profit providers. Medicare for All should provide a path for the orderly conversion of investor-owned, for-profit health-care providers to not-for-profit status.* Fully covering all medications, without co-payment: Sen. Sanders’ bill excludes cost-sharing for health care services. However, it does require small patient co-pays (up to $200 annually) on certain non-preventive prescription drugs. Research shows that co-pays of any kind discourage patients from seeking needed medical care, increasing sickness and long-term costs. Experience in other nations prove that they are not needed for cost control.
Richard’s Note: A shout-out to Don McCanne for posting this today from the Annals of Internal Medicine, which is providing the full article for free. The authors, Steffie Woolhandler and David Himmelstein, both MDs, should be familiar to readers as two of the authors I covered in my review of the Waitzkin, et al. book, Health Care Under the Knife: Moving Beyond Capitalism for Our Health. In the spirit of the AIM, I am posting the entire article below with link to the original. It is that important.
In the annals of Western history, two courageous men stood up and challenged the establishment of their nations to act to change history or to right a grievous wrong done to an innocent man.
The first individual was Patrick Henry when he gave his “Give me liberty, or give me death” speech, and the second was Émile Zola, who wrote “J’Accuse…!,” which he wrote in defense of Alfred Dreyfus, imprisoned falsely on Devil’s Island for treason.
These, of course were not the only instances where men of good intention, rallied people to a just and rightful cause; but it was the two instances that came to mind after reading another health care expert poo-poo Medicare for All on social media.
The individual commented on an article in Healthcare Dive.com that I had discussed some days ago. The article was about how kidney care in the US was being revamped, and the individual claimed that Medicare for All would damage the care dialysis patients are currently receiving.
What this person is doing is trying to scare people with propaganda that is akin to saying Medicare for All is “Socialism.” We know that none of the countries that have such a system are Socialist. They are Capitalist. The scare tactic being used here is rationing of care. It so happens that my clinic company is a European company, and I don’t believe people in their home country are rationed dialysis care. And they have a single payer system.
In the past few days, I have seen several comments made by men and women in occupations related to, or in the health care industry. These comments generally have attacked the very idea of Medicare for All for a variety of reasons. Many of these individuals are either a part of the medical-industrial complex, or they are lawyers, employee benefits consultants, or other types of consultants to specific areas of health care. They are defending a turf.
These individuals believe they can supersede the right of all Americans to have decent, affordable health care that does not force them into bankruptcy, or to go without because they cannot afford treatment for serious illnesses or diseases, or expensive medications.
Those of you who have been reading my blog of late, know that I have been very passionate about enacting Medicare for All, either because a fellow blogger has written so eloquently about it, or for personal reasons.
So, I have decided, like M. Zola did, to declare openly: By What Right?
By what right do you have to deny millions of Americans health care? By what right do you have to even suggest that Medicare for All is too expensive, would do more harm than good, or any of the other remarks made on social media to attack the very notion of health care for all?
By what right do you have to consign others to a broken, complex, complicated, bloated, and out of control health care system, whose true aim is to line the pockets of insurance companies, pharmaceutical companies, device manufacturers, hospitals, Wall Street investors, or the shareholders of these and other companies?
I don’t mind constructive criticism of this plan or that plan put forth by any number of Congressmen or Senators, but to outright state that it won’t work, or should not work, is to deny the rest of the nation the same kind of health care that the members of Congress receive.
By what right do you have to tell the millions of uninsured and under-insured, “sorry, we don’t believe in Medicare for All, so you will just have to suffer, so that we can keep our jobs, and collect our fat paychecks.”
I have yet to hear a logical answer to why the US should be the only Western nation to not provide its citizens with universal health care. Some say it is too expensive. Do you mean, it is more expensive than spending taxpayer money on weapons of war? Or on a wall on our Southern border? Or a space force?
Do you mean that it would raise taxes, first on the wealthy and corporations, and later everyone else? Well, maybe the rich and the corporations should pay more in taxes. Polls seem to indicate that as much lately.
Another line of attack says that providers would be hurt. Do you mean that certain very wealthy physicians, surgeons and specialists, would see their incomes cut in half? Do you mean that hospitals could not buy each other up and become larger conglomerations that raises health care costs, instead of lowering them?
I thought medicine was a calling, not a get-rich quick scheme.
Oh, and what about the pharmaceutical industry that uses Americans as a cash cow while the same drugs, manufactured overseas, by the same companies, cost a fraction of what they do here, and have made men like current Federal pen occupant, Martin Shkreli, a wealthy man. Why not allow Americans to import those very same drugs from Canada, the UK, Israel, Mexico, etc. so that they can have their insulin and other life-saving medications without having to cut the dosages in half or go without altogether.
By what right do you have to defend the status quo? To make huge and obscene profits? As I wrote in Health Care Is Not a Market:
“…they are deciding that they have the right to tell the rest of us that we must continue to experience this broken, complex and complicated system just so that they can make money. And that they have a right to prevent us from getting lower cost health care that provides better outcomes and does not leave millions under-insured or uninsured.”
“…not all these individuals are doing this because of their jobs. Some are doing so because they are wedded to an economic and political ideology based on the free market as the answer to every social issue, including health care. They argue that if we only had a true free market, competitive health care system, the costs would come down.”
“…the free market companies have jacked up the prices simply because they can, and because lobbyists for the pharmaceutical industry have forced Congress to pass a law forbidding the government from negotiating prices, as other nation’s governments do.”
Instead of trying to tear down Medicare for All, why not offer your expertise and knowledge to improving the Medicare for All bills introduced to Congress, as well as other plans, especially the proposal by the Physicians for a National Health Program (PNHP)?
Those of you who are not familiar with the legislative process, something that at times has been compared to the production of sausages, it isn’t pretty. There is a lot of negotiating and horse-trading that occurs before a bill is passed and signed into law. Unfortunately, given a Republican President, and his lapdog, Republican Senate, none of the introduced pieces of legislation will pass the Senate, even if the House passes it.
So, consider this, by what right do you have to step in the way of progress for all Americans to get health care? By what right do you have to put your economic interests ahead of the health needs of others? By what right do you have to be cruel and inhumane, to let people die, get sick, and suffer needlessly, just so that you can sleep at night?
I hope that once you do consider this, you won’t sleep at night, because it would mean that you are not just greedy little cogs in the medical-industrial complex, but rather, kind and compassionate human beings who are motivated more out of love, than out of what’s in it for you if things don’t change.
By what right do you have to tear down something that has not even been passed and implemented? Why don’t we enact Medicare for All, and see if all the criticisms you have will come true or not? Could it be because you know deep in your heart it will, but are afraid to say so for fear of what your colleagues would say?
And finally, by what right do you have to play God with other people’s lives? You have already predicted that Medicare for All will fail, so why even bother? You are basing your opinions on what you have been told by free market ideologues, academics, business leaders, Conservative media, and politicians.
So, who cares if the poor die, if the elderly die, if children born with crippling illnesses and diseases die, if young people stricken down in the prime of life die, etc., as long as someone can make a hefty profit off of adverse selection, and the outrageous cost of desperately needed medications that they cannot afford?
I know what you are going to say to yourselves, and to me. That I don’t know what I am talking about, that I am wrong on so many levels, that I don’t have the experience in health care that you do. Well, I really don’t care what you will say. Do you have compassion and concern for your fellow citizens, or are you minions of a heartless, soulless Capitalist system that grinds people down for profits and wealth?
Patrick Henry stirred a people to revolution against a tyrant, Émile Zola rallied a nation to free a man unjustly accused and sentenced to hard labor in the most horrible prison ever constructed by Western man.
You can do what is right. You can defend Medicare for All, and even improve on what has already been proposed, but don’t attack it. Doing so will only cause more pain and suffering to millions of Americans, and will make investors, stockholders and providers and industry leaders wealthier, and the rest of us, poorer. Both spiritually and materially.
You are better than this.