More Docs Reject Privately Insured Patients!

A study expecting to find even fewer doctors willing to accept new Medicare patients found, sure enough, a modest drop in that percentage. But the shocker was a far steeper decline for doctors willing to accept privately insured patients.
The study shows 93.3 percent of doctors accepting insurance for payment in 2005, and 87.8 accepting insurance in 2008.

The drop for those accepting Medicare coverage during the same time was 95.5 percent down to 92.9 percent. Not the huge difference the right-wing media has been harping about - and they seem to have missed completely the fact that some doctors turn away patients wanting to pay with private insurance.

I first heard of this a few years ago with a doctor in Fort Collins, Colo., who wouldn't accept private insurance. He said he did so so he could practice medicine instead of argue with bureaucrats whose primary concern was profit, not patients. The insurance companies also didn't pay him enough - and he's a family doctor, not a country-club suburban specialist.

Dr. Tara Bishop's study was in the 27 June 2011 Archives of Internal Medicine. She's assistant professor of public health at Weill Cornell Medical College and practices at New York-Presbyterian Hospital/Weill Cornell Medical Center. Dr. Bishop is concerned that the growing numbers of physicians saying no thanks to insurance companies could bollocks up President Obama's reform - which depends on everyone buying private health insurance from this deadly industry.

It's one more reason to simply expand Medicare to cover everyone.

There are economic sectors where the free market delivers most effectively, no doubt. Manufacturing computers and running casinos come to mind. Other tasks - like covering the cost of health care, fighting fires, policing our communities, educating all the children - societies that tax themselves to provide those services for all come out ahead.

Pretty simple. You want the Pakistan model or Paris?

Medicare Meets Mephistopheles

That's the title of a 2006 Cato Institute rip on Medicare. Here's the spin, via Amazon: "Let's say you're the devil, and you want to corrupt the American republic. How would you go about it? According to David Hyman, you might create something like Medicare, the federal health care program for the elderly. Hyman submits that Medicare may be the greatest trick the devil ever played. Medicare feeds on the avarice of doctors and other providers, turns seniors into health care gluttons, and makes regions of the United States green with envy over the dollars showered on other regions... With epic political battles over Medicare and the future of limited government looming just over the horizon, Hyman uses satire to cast a critical eye on this mediocre government program."

You can pick upMedicare Meets Mephistopheles, for $1.40 from Amazon or $14.95 from Cato. Your choice as a consumer in a market that actually works - unlike the free-market healthcare biz. The New England Journal of Medicine had a January 2007 review:

Hyman is surely correct that current financial trends in Medicare funding are unsustainable and will eventually erode public support. But in focusing on Medicare's inadequacies and mocking the system as an intergenerational scam (my word, not his), Hyman overlooks the reason why Medicare was enacted in the first place and why it retains considerable public support. At its inception, Medicare addressed the palpable medical needs of the elderly and the failure of the private insurance market to meet those needs. The program reflected a set of values and social commitments that included universalism, government responsibility for social welfare, and public accountability.

More important, Hyman ignores the reality that many of Medicare's flaws are at least rivaled, and perhaps exceeded, in the private sector. It is doubtful that the private sector would match Medicare's considerable strengths in providing access to health care that was unavailable before the program was introduced. Whatever its failures, there is evidence that the program has clearly improved the lives of its intended beneficiaries. As J. Lubitz and colleagues wrote in Health Affairs ("Three Decades of Health Care Use by the Elderly, 1965–1998") in 2001, "Our findings are consistent with the idea that Medicare-funded services have improved the health of the elderly." Is there any legitimate nonideological reason to believe that consumer-driven health care will better serve the elderly than Medicare? I am dubious.

Still, Hyman's bracing critique reflects the fact that neither Medicare's problems nor the ascendancy of market-based approaches to solving them can be ignored any longer. In an era of rampant individualism, the attempt to defend Medicare's collective ethos has the aura of a reactionary battle waged to save an old order in the midst of its last throes. Those who support the social obligations underlying Medicare must demonstrate anew why market-based solutions are unappealing and why governmental investment in health care is morally justified.

Here's hoping that Obama means new hope for social obligations.

Cost doesn't equal quality

The renowned education author Jonathan Kozol tells a story about money and education.

The inner boroughs of New York City spent $8,000 or so per student (more now). The outer boroughs about $12,000. The really tony enclaves spent $24,000 per student. At Andover, where Bush went to school, it's $40,000.

When Kozol's conservative friends told him that the answer to our education crisis wasn't to simply throw money at the problem, he liked to reply, "Why not? It works for your kids..."

(I think we can all imagine where Bush might be today - also a federal facility - if he'd gone to an underfunded school in New Orleans or D.C.)

The impact of cost on health care outcomes is different. The rigorous Dartmouth Atlas of Health Care has shown that spending doesn't necessarily correlate with outcome. Now a survey of Medicare beneficiaries released this week in JAMA "suggests that more regional spending on medical care does not improve patients' perception of the medical care they receive..."

The researchers found that per capita expenditures were highly related to receiving more medical care, such as average number of ambulatory visits to physicians in the past year and more cardiac tests (respondents reporting receiving tests in past year, 40.1 percent [lowest average expenditures quintile] to 63.5 percent [highest average expenditures quintile]). However, 7 of the 10 measures of perceived quality, including perceived unmet needs for tests and treatment (respondents reporting unmet needs, 3.9 percent to 5.0 percent) and spending enough time with physicians (respondents reporting adequate time, 88.7 percent to 87.0 percent), were unrelated to expenditures, while the overall rating of perceived quality of care was higher in the lower-expenditure areas (respondents reporting overall care rating of 9 or 10, 63.3 percent to 55.4 percent).

What's wrong with Medicare

Dennis Kucinich explains: "Medicare, essentially, is built to be efficient. And it has worked for many people... (But) the Bush administration's philosophy has been to move increasingly toward the privatization of Medicare. They don't want Medicare to work ... the (federal government) is trying to drive up the costs, (and) they're limiting reimbursements to physicians to discourage them from participating in the system."

Maine paper pushes single-payer

This isn't quite an endorsement of single-payer, but it's pretty close. The Bangor Daily News evidently has a readership close enough to Canada that they're not fooled by the propaganda slurring Canada's system. The editorial reads:

Much of American health care is already run quite satisfactorily on a single payer basis: Medicare, Medicaid and the veterans’ health system.

Government run health plans, usually single payer plans, are good enough for Canada, Britain, France, Denmark, Sweden, Germany, Australia, New Zealand and most other developed countries. Why can’t they even be considered and debated by candidates for the U.S. presidency?

An issue crying out for leadership

Kevin Drum offers insight into the LA Times poll on healthcare, which found that 29 percent thought that healthcare is the responsibility of the government, but 53 percent thought the healthcare solution is extending Medicare to cover everyone.

So 29% think government should be responsible for providing healthcare, but 53% approve of extending Medicare to cover everyone. Uh huh. And then this Blendon fellow suggests that maybe this contradiction is the result of people not realizing that Medicare is paid for with taxes. That's completely crazy, of course, but it's also quite possibly true.

So what to think? Two things: (a) Support for national healthcare really isn't as strong as a lot of liberals would like to believe. (b) People really are confused on this subject, and their opinions are shallow and malleable. Genuine leadership could change a lot of minds.

Hillary says it right

For all those who hate Hillary, take a look at this. In "Hillary Lashes Out at Health Care Critic," she answers someone accusing her of being for "socialized" medicine, like they have in Canada.

"Do you think Medicare is socialized medicine? Clinton asked, turning the tables on her inquisitor, who did not identify himself.

"To a degree," he responded.

"Well, then you are in a small minority in America," Clinton said to applause, before explaining that Medicare allows patients to choose their doctors even though the federal government foots the bill with money deducted from workers' paychecks.

Clinton then asserted that "on balance" countries with uniform national systems of health care, including Japan, Australia and Canada, offer their citizens better health care than the U.S. The answer left her questioner shaking his head in disagreement.

"I can give you the statistics and you can shake your head," Clinton said sharply. "You come and introduce yourself to the staff. And we'll try to give you some information if you're interested in being educated instead of being rhetorical."

Walking the talk

An angry woman not long ago demanded to know if Health Care for All Colorado's president, Dr. Elinor Christiansen, was a Medicare recipient, since Dr. Christiansen believes in a government solution to the U.S. healthcare crisis — as in so many other industrialized countries.

Of course, said Dr. Christiansen.

The exchange struck me as odd -- that this woman thought she was likely to score a point here, that she thought a 70-something retired physician wouldn't be signed up with Medicare.

Are there really a lot of seniors who decline Medicare? Even well-off seniors?

The other side of this coin comes in a letter to the editor today to Seacoast Online. Responding to someone who is against single-payer, Rich DiPentima writes, "Lastly, I assume since Mr. Brighton is so scared about putting his health care choices in the hands of a federal bureaucrat, that when he turns 65 he will decline Medicare and keep his ability to make his own choices with his private insurance overseer. Good luck and most importantly, good health."

Now that is a good question.

TPMCafe with more single-payer

Maggie Mahar's post at TPMCafe kept me up until 1 in the morning last night, reading it and all its links.

I decided to buy her book on the spot — Money-Driven Medicine is a great deal for $8 at Amazon. Here's how she begins the TPM piece:

I understand why some believe that radical reform is politically impossible. But they remind me of those who said that we could never pass Medicare. Eventually, the pain became too great. Too many seniors could not afford care, and popular support trumped the then-powerful AMA. In 1962, Gallup polls showed public support at 69% and President Kennedy called for Medicare in front of crowd of 20,000 in Madison Square Garden.

Still, it wasn’t easy.

After Kennedy’s speech, the Medicare bill was defeated 52-48. This did not stop the Democrats—they understood what was at stake. They knew that the opposition would be fierce, but they also understood that this was like civil rights. It was not a time for caution. It was a time for politicians who cared about issues....

Great stuff.

Mahar seems to say, however, that even if we did institute a single-payer system that costs could still be out of control unless we fixed provider reimbursement: "The most honest physicians admit that in our system, over-treatment is driving healthcare inflation."

This sounds like the conservative argument that overuse is the problem, but in fact overtreatment and overuse are different creatures — although they're both created by the perverse incentives of our current system's for-profit market structure. Both would be most easily rectified via a single-payer system.

She criticizes fee-for-service — which seems to be a sacrosanct part of the single-payer deal for many physicians who support reform.

To support her position, Mahar links to a wonderful piece she did for Dartmouth Medicine Online about their research on costs.

In study after study, the Dartmouth team has shown that Medicare spends twice as much, per patient, in some regions of the country than in others--for reasons that have absolutely nothing to do with medical science, the severity of the patient’s illness, or even his or her preferences.

What’s driving the higher costs? Supply.

“Build the beds and they will come.”

Based on their research, the Dartmouth team estimates that one out of three of our health care dollars are squandered on redundant tests, unnecessary hospitalizations, unproven bleeding-edge procedures and over-priced new drugs and devices that are no better than the products that they have replaced.

Some hospitals spend two-and-a-half times what others do, without better outcomes. In fact, outcomes are worse.

Both pieces are thought-provoking. Single-payer will only be part of reining in costs. If we have single-payer and continue pharmaceutical advertising, or single-payer Plan D, shackling government's ability to negotiate for better costs, or single-payer with physicians still over-utilizing questionable pharmaceuticals, lab tests, technology, etc. — we'll still have problems. Other countries are so far ahead of us on all of this.

Medicare cuts

The NYT reports that "President Bush will ask Congress in his budget next week to squeeze more than $70 billion of savings from Medicare and Medicaid over the next five years, administration officials and health care lobbyists said Thursday."

Mr. Bush is also expected to propose changes in the Children’s Health Insurance Program to sharpen its focus on low-income families. The changes could reduce federal payments to states that cover children with family incomes exceeding twice the poverty level. Under federal guidelines, a family of four is considered poor if its annual income is less than $20,650.

What should our response be?

Marilyn Clement, national coordinator of Healthcare-now writes, "if we allow the debate to go on in the beltway this year around trying to keep Bush from cutting $70 billion dollars from Medicare or other incremental cuts or $35 billion or a few bucks less and focus all of our time on trying to keep him from cutting dollars from Medicare and the CHIPS program for children rather than getting to the central debate, then the current (new) Congress will have lost its momentum and be subject to rebuke and likely defeat by the voters in 2008 who voted for real comprehensive change in 2006, not incremental reforms."

Just say no, congress.

Clements urges everyone to call or write Pelosi and other congressional leaders, as well as our own congresspeople, to urge support for HR 676, the improved Medicare for All bill — and to call our senators to ask them to create a complementary bill in the Senate.

Connecticut looks at reform

It looks like Connecticut’s Democrats will unveil a plan in a couple weeks that would expand health insurance programs, covering Connecticut’s 400,000 uninsured and also raise Medicare and Medicaid rates for doctors and dentists. The plan would cost $450 million but could bring new federal funds to the state to cover about half of that. The plan would do this by first expanding eligibility to an existing program that provides coverage to low-income children and adults. That could cover an additional 140,000.
But the Ds also want to assemble a “panel to come up with ways to cover the remaining 260,000 uninsured - typically younger adults with no children who don't qualify for state assistance programs and don't receive insurance coverage from their employers.”
They would “consider ideas ranging from mandated health coverage by employers to a statewide single-payer system.”
Really?

Medicare Tales

The American Prospect offers Robert Reich's view on the D’s new bill on the Medicare Drug benefit. He says it has no teeth. Democrats have been burned so many times by the Republicans false populism that they’re scared to design sustainable, realistic programs.

Republicans have promoted an entitlement culture in which we think we shouldn’t pay taxes but we should get good stuff from the government. This corporate welfare has gone on for a long time, but seniors also indulge in feeling entitled, as do farmers, politicized churches and plenty of others. Pick your favorite group to rail against.

The Dem’s bill would require Medicare to negotiate for the best price from pharmaceuticals. However, it doesn’t give Medicare authority to drop drugs from their formulary, or approved list of drugs.

“This is like Wal-Mart telling its suppliers ‘we’re going to use our bargaining clout to get from you the lowest prices for our customers -- but regardless of what price you offer we'll still carry your product in our stores,’” Reich writes.

He points out that Medicare could easily do this without eliminating any particular drug from a senior’s choice of options by simply allowing private insurers to compete with its plan. Seniors could buy their heavily marketed and overpriced drug of choice from the private insurers.

Paul Krugman gets borderline TOO wonky for my brain with his column on the history of HMOs and Medicare at Smirking Chimp. He begins in the 1990s, when Medicare began allowing recipients to replace traditional Medicare with private managed-care plans, where the government pays a fee to the HMO.

So instead of paying doctors and hospitals, the government pays the HMO, which was supposed to save the government money. Except that the HMOs started gate-keeping, and only accepting healthy patients. Medicare caught on, and began adjusting its payments. And HMOs began dropping out.

“That should have been the end of the story,” writes Krugman. “But for the Bush administration and its Congressional allies, privatization isn’t a way to deliver better government services — it’s an end in itself.”

And now the plans are heavily subsidized. The rest of the piece minces the concept of the magic of the free market bringing down costs.

I think that works with cell phones, though.