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Donna SiCKO's Blog

News about the U.S. health care system and its dysfunction from a leader of the health reform movement in America. Donna "American SiCKO" Smith was a subject in Michael Moore's 2007 film, "SiCKO," and has been in 43 U.S. states, Canada, and D.C. talking about improving and expanding Medicare for all for life in America.

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High Health Plan Deductibles Weigh Down More Employees

By Tara Siegel Bernard
The New York Times, September 1, 2014

Anita Maina was working on an arts and crafts project she found on Pinterest — creating a table out of wood and cork — when she ripped off a fingernail while removing staples from a piece of wood.

“It is one of those things that really hurt, and I thought I should go to urgent care,” said Ms. Maina, 27.

But she ultimately skipped the visit since she had not met the $6,000 deductible on her health plan, and she knew she probably did not have much left in her health savings account, a type of tax-advantaged savings vehicle that is often used with high-deductible plans to help defray out-of-pocket costs.

Ms. Maina, an associate in a health and human services consulting agency, said her employer added the high-deductible plan earlier this year; though her monthly premiums are only $34, these plans require employees to pay for a greater share of their medical expenses upfront, before the plan starts making payments.

Next year, even more corporate workers are likely to be offered high-deductible plans — sometimes known more benignly as consumer-directed plans — and at a rising share of large companies, it will be the only option remaining.

“You can’t sugarcoat this,” said Paul B. Ginsburg, a professor of the practice of health policy and management at the University of Southern California’s Sol Price School of Public Policy. “This is a more challenging situation for consumers and it’s a reflection of how difficult it is to afford health care.”

Just as employers replaced pensions with retirement savings plans, more large companies appear to be in a similar cost-sharing shift with health plans. Besides making workers responsible for more of their care, employers hope these plans will motivate employees to comparison-shop for medical services — an admirable goal but one that some say is hard to achieve.

Several big companies started offering consumer-driven plans as their only option in the last couple of years, including JPMorgan, Wells Fargo, General Electric and Honeywell, among others; it is the only choice for Bank of America employees earning more than $100,000.

Next year, nearly a third of large employers will offer only high-deductible plans — up from 22 percent in 2014 and 10 percent in 2010, according to a study by the National Business Group on Health, which included 136 large companies that collectively employ 7.5 million workers. And 81 percent of those large employers will have added one of these plans to their lineup of choices, up from 53 percent in 2010.

With high-deductible health plans, consumers pay for all their medical services — at the insurer’s negotiated rate — until they meet their deductible. After that, consumers typically pay coinsurance, which is a percentage of each service — say 10 to 35 percent — until they reach the out-of-pocket maximum.

That is scheduled to be generally capped at $6,450 for singles and $12,900 for families in 2015, according to the Kaiser Family Foundation, and includes items like deductibles, coinsurance and co-payments, but not premiums, which tend to be lower in these plans.

So it is easy to see how shopping for an M.R.I. of the lower back — which canrange from roughly $415 to $4,530 — would suddenly pay off for both the employee and the employer.

“There are different approaches to cost containment,” said Professor Ginsburg. “One is having a lot of skin in the game, or just having to pay for a lot of your health care.”

Insurers and independent providers, including Castlight and Healthcare Bluebook, offer tools that help consumers estimate their costs and the quality of the providers. But shopping around can still be challenging.

“Castlight and others like it make a valiant effort to provide price and quality information,” said Uwe E. Reinhardt, a health policy expert and professor at Princeton.

“But the question is whether the prices they give you are binding. To really shop around effectively, prospective patients need binding prices.”

Castlight — working with more than 130 large employers — provides consumers with tools that offer personalized pricing and quality information for services within their insurer’s network. But even the most diligent shoppers can run into problems.

“They may have done everything right,” said Dr. Dena Bravata, Castlight’s chief medical officer. “They may have picked an in-network gastroenterologist for a colonoscopy. But then you don’t know if you need to have a biopsy, which then goes to a lab or pathologist who is out of network.”

And using the tools can simply be impractical in certain circumstances. “Most health care costs are incurred by very sick patients, such as those with heart attacks, strokes, cancer, mental illness, injuries — often under emergency conditions,” said Sara Collins, vice president for health care coverage and access at the Commonwealth Fund.

Another concern is that some people will be ill prepared to handle large bills, and will forgo care as a result. “If you go to the pharmacy and there is a $1,000 deductible on your drug benefit, they aren’t going to write you a five-year loan,” said Karen Pollitz, a senior fellow at Kaiser.

High-deductible plans are often used with health savings accounts. As long as the plan deductibles in 2015 exceed $1,300 for single people or $2,600 for families, and meet other criteria, employers and workers can deposit money into the H.S.A.; in 2015, individuals will be allowed to contribute up to$3,350 in pretax dollars (or $6,650 for family coverage). The money grows tax-free and can be used to pay for out-of-pocket health care expenses. (Health reimbursement accounts can also be used, but those are largely controlled by employers, and workers cannot keep the money if they leave.)

The National Business Group on Health’s study found that the vast majority of large employers make deposits. But Kaiser’s 2013 survey, which covers both small and large employers, found that about half of employers do not fund these accounts. Of those that do, Kaiser found they deposit $950 for singles with health savings accounts, on average, and $1,680 for families.

Kaiser also found that the average deductible for single people in a high-deductible plan paired with a health savings account was $2,098 in 2013, while it was about $4,037, in aggregate, for families.

Employers can insulate their workers by depositing more generous amounts into their H.S.A.s, which employees keep even if they leave the company. “Once it becomes their money, they treat it like their money, and there is that desire to shop,” said Brian Marcotte, president of the National Business Group on Health. “And that is what employers are trying to do.”

That was one of the attributes that was most attractive to Matt Van Horn, a 46-year-old senior software engineer who lives in Lafayette, Calif., with his wife and 13-year-old son. His employer, an online apparel company, contributes $1,500 into an H.S.A., or half of his family’s $3,000 deductible. “I like having the H.S.A., and the fact that it will survive the insurance policy,” he said, adding that the policy feels more like catastrophic coverage, although preventive care is fully covered (as it is with all high-deductible plans).

Given the increased adoption of the plans — Kaiser estimates about 20 percent of workers covered by plans were enrolled in a high-deductible plan with a savings account option in 2013, up from 8 percent in 2009 — consumers will need to weigh their options more closely during open-enrollment season.

“Understanding the mechanics of these plans is really important,” Mr. Marcotte said. “When you walk into the pharmacy and all of a sudden it costs $200 as opposed to $20, there is sticker shock.”

When evaluating these plans, consumers need to ask themselves several questions: Do you have the money to pay for all medical expenses until the deductible is met? What is the out-of-pocket maximum — can you afford that? And are you the type of person who will skip needed care if you need to pay out of pocket?

Many workers may not have a choice — a high-deductible plan may be their only option. “If the deductible is very high, all of a sudden the financial protection part of insurance, you are losing that,” Professor Ginsburg said. “You still have protection against very high claims, but you have people who may have to pay $5,000 during one year toward the cost of their care or more. And a lot of people don’t have that kind of savings.”

http://www.nytimes.com/2014/09/02/business/increasingly-high-deductible-health-plans-weigh-down-employees.html

Bureaucracy consumes 1/4 of US hospitals’ budgets...

Authors say single-payer reform could save $150 billion annually on hospital overhead

Sept. 8, 2014
Contact:
Mark Almberg, mark@pnhp.org, (312) 782-6006

A study of hospital administrative costs in eight nations published today in the September issue of Health Affairs finds that hospital bureaucracy consumed 25.3 percent of hospital budgets in the U.S. in 2011, far more than in other nations.

Administrative costs were lowest (about 12 percent) in Scotland and Canada, whose single-payer systems fund hospitals through global, lump-sum budgets, much as a fire department is funded in the U.S.

The study is the first analysis of administrative costs across multiple nations with widely varying health systems. It was carried out by an international team from the U.S., the U.K., France, Germany and the Netherlands, and was coordinated by researchers at the City University of New York (CUNY) and the London School of Economics.

The researchers analyzed detailed accounting data that hospitals reported to each nation’s government. The data covered virtually all hospitals in each nation. The research was funded by a grant from The Commonwealth Fund, which played no role in the study.

Hospital administrative spending totaled $667 per capita in the U.S., vs. $158 in Canada, $164 in Scotland, $211 in Wales, $225 in England and $325 in the Netherlands. Comparable dollar estimates could not be calculated for French and German hospitals because of accounting differences. However, their hospital administration costs were about 20 percent higher than in Canada and Scotland, but still 40 percent below the U.S. levels.

The study found no evidence that the high U.S. administrative costs translated into better care or yielded any other benefits.

The study also found that U.S. hospital administrative costs rose from 23.5 percent of hospital budgets ($97.8 billion – 0.98 percent of GDP) in 2000 to 25.3 percent ($215.4 billion – 1.43 percent of GDP) in 2011.

In contrast, the proportion spent on administration by Canadian hospitals fell slightly from 12.9 percent in 1999 to 12.4 percent in 2011. The article attributes the high administrative costs in the U.S. to two factors: (1) the complexity of billing a multiplicity of insurers with varying payment rates, rules and documentation requirements; and (2) the entrepreneurial imperative for hospitals to amass profits (or, for nonprofit hospitals, surpluses) in order to fund the modernization and upgrades essential to survival.

Paradoxically, this entrepreneurial imperative has reduced hospitals’ efficiency, driving them to divert personnel and dollars to marketing, to cherry-picking profitable patients and services (and avoiding unprofitable ones), and to expensive computer systems and consultants to game the payment system.

The researchers found that within the U.S., administrative costs were highest (27.2 percent of spending) at for-profit hospitals.

The relatively high hospital administrative costs in the Netherlands, and rising costs in England – both of which are transitioning to market-oriented hospital systems – were also cited as evidence that increasing reliance on market mechanisms raises administrative costs.

“We’re squandering $150 billion each year on hospital bureaucracy,” said lead author Dr. David Himmelstein, a professor at the CUNY/Hunter College School of Public Health and lecturer at Harvard Medical School. “And $300 billion more is wasted each year on insurance companies’ overhead and the paperwork they inflict on doctors.”

He added: “Only a single-payer reform can squeeze out the bureaucratic waste and use the money to give patients the care they need. Instead, we’re layering on more bureaucracy in insurance exchanges and ‘accountable care organizations.’”

Dr. Steffie Woolhandler, senior author of the study, said: “For three decades our policy makers have pushed market-oriented strategies that have turned health care into a business. As a result, Americans now have the world’s costliest health care, and our life expectancy is years shorter than in most other wealthy nations. It’s time to admit that, when it comes to caring for sick people, markets don’t work.”

Woolhandler is a professor at CUNY/Hunter College who also holds appointments at Harvard and the Albert Einstein College of Medicine. She co-founded Physicians for a National Health Program with Dr. Himmelstein.

**** “A Comparison Of Hospital Administrative Costs In Eight Nations: US Costs Exceed All Others By Far,” David U. Himmelstein, Miraya Jun, Reinhard Busse, Karine Chevreul, Alexander Geissler, Patrick Jeurissen, Sarah Thomson, Marie-Amelie Vinet, and Steffie Woolhandler. Health Affairs, September 2014.

A link to the abstract of the study is available here: http://content.healthaffairs.org/content/33/9/1586.abstract

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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Keep Medicaid expansion plan in Ohio: editorial

 By The Plain Dealer Editorial Board on April 09, 2013 at 7:15 PM, updated April 09, 2013 at 7:24 PM

Ohio House Republicans are acting with gross irresponsibility in rejecting Republican Gov. John Kasich's bid to expand Medicaid coverage for poor Ohioans. Even more perplexing is the lack of vocal opposition from some Cleveland-area GOP lawmakers for a decision that -- if it stands -- will gravely damage Greater Cleveland.

Anti-expansion Republicans portray their position as a matter of principle. But their stance is the poisoned fruit of childish partisanship and craven self-interest: They fear primary-election challenges from other Republicans who think that expanding Medicaid in Ohio represents a form of collusion with President Barack Obama, whom they loathe.

For that seamy reason, the Ohio House's GOP caucus, led by Medina's William Batchelder, would deny adequate medical care to hundreds of thousands of Ohioans (many in Greater Cleveland) and reject billions of dollars from the U.S. Treasury. It's mindless and it's pathetic.

Rejecting Medicaid expansion will damage Ohio from Lake Erie to the Ohio River. It will further imperil community hospitals already squeezed by the cost of caring for uninsured patients. It will especially damage Greater Cleveland, which has some of Ohio's greatest concentrations of poverty -- and a nexus of high-tech biomedical companies, including world-renowned hospitals that help shoulder the costs of caring for the uninsured, a burden Medicaid expansion would lighten.

Medicaid expansion also is a smart economic strategy that will underwrite jobs, keep Ohioans' tax dollars in Ohio, improve the health and productivity of our citizens and reduce state outlays for prison health care.

Among those who would benefit are working Ohioans without health insurance who live at or below 138 percent of the poverty level. These men and women, who play by the rules, are the very Ohioans Republicans claim to respect.

What Ohio House Republicans have really decided is that unpaid emergency room charges -- and all other such unpaid medical costs -- will be paid not with help from taxpayers in all 50 states but instead by jacking up the health-insurance premiums or employer-sponsored health plan costs of Ohioans who do have coverage. If that's fair to Ohio employers, the word "fair" has no meaning at the Statehouse.

The House Finance-Appropriations Committee now will affirm or reject House Republicans' refusal of Medicaid expansion. Among the committee's members are Reps. Marlene Anielski of Independence and Mike Dovilla of Berea, both Republicans. Also with a key voice within the House GOP caucus, although she's not on the committee, is Westlake's Nan Baker.

Baker, Anielski and Dovilla have a clear choice. They can stand with the blind partisanship of some of their GOP colleagues. Or they can stand with Greater Clevelanders by fighting for Medicaid expansion.

Medicaid expansion adds up for Ohio

Medicaid expansion adds up for Ohio families, taxpayers: Evelyn Lundberg Stratton

By Plain Dealer guest columnist on March 16, 2013

As a former Ohio Supreme Court justice busily and happily transitioning into my new work on mental health and veterans' issues, I wasn't paying much attention to the discussion about Medicaid expansion. Like Gov. John Kasich and many others, I had issues with Obamacare. Then a friend asked me to "look at the facts" of Medicaid expansion. That triggered 23 years of judicial training, learning how to put aside personal biases and feeling and judge a matter on evidence alone.

This is what I learned:

Medicaid is health insurance for Ohio's most vulnerable citizens -- those earning up to 138 percent of the federal poverty level, or about $15,856 for an individual and $32,499 for a family of four. About 366,000 Ohioans will be covered by the Medicaid expansion for an estimated total cost of $2.6 billion over the biennium.

That cost will be paid entirely by the federal government through 2016, ratcheting down to 90 percent afterward. Ohio can opt out of the expansion if the rules change later.

Rejecting the federal expansion money would send federal money back to Washington and to other states to pay for their Medicaid expansions. Yet Ohio receives billions of dollars every year from the federal government for roads and bridges, education and research grants, and we don't for one minute consider sending that money back to the federal government. After all, we pay good money to the federal government in the form of taxes, and we deserve to get some of it back. How is Medicaid expansion any different?

Besides, state and local governments, employers and taxpayers already pay for the health care of uninsured Ohioans. Our Department of Rehabilitation and Corrections will save $27 million over the biennium on inpatient hospital costs to prisoners under the expansion. In addition, the community behavioral health system will save approximately $105 million over the biennium on services that shift to Medicaid. For example, of the 8,000 individuals in Lucas County now requiring behavioral health services, 7,000 -- or 88 percent -- would be covered by Medicaid, saving $4.6 million and freeing up much-needed local funding for other county needs.

Today, health care for 1.5 million uninsured Ohioans is borne by Ohio's hospitals, employers and 10 million other taxpayers. Hospitals are required to provide medically necessary care, at no cost, to low-income and uninsured individuals. Hospitals make up their losses by charging others more or eliminating services or programs. As a result, the average privately insured individual pays approximately $1,000 per year for costs incurred by uninsured individuals.

Preventive health care for uninsured individuals is virtually nonexistent. They often wait to seek medical treatment -- hoping the condition resolves itself -- until their situation worsens, requiring care in the emergency department. This is a costly scenario for both the individual and the hospital. In 2010, Ohio hospitals provided $1.1 billion in total charity care and incurred $645 million in bad debt.

The Affordable Care Act reduced reimbursement to hospitals that provide a high volume of care to low-income and uninsured individuals with the expectation that the additional Medicaid funds associated with the expansion would offset the loss. The U.S. Supreme Court ruled that the Medicaid expansion is optional for states, but if a state rejects it, its hospitals will still feel the impact of the reimbursement cuts.

My analysis: Why would we turn down these federal funds and instead use local dollars to pay for needs that already exist? Our federal income-tax dollars will go to other states and we still have to come up with the local dollars.

I have used my health insurance many times, including for surgery that I otherwise would never have been able to afford. But so many people have no such insurance. I am particularly concerned about those with serious mental illnesses. I saw many of them in my courtroom, and I know firsthand the ill effects of a lack of insurance and a poorly funded community behavioral health system.

Individuals who do not get needed physical and behavioral health treatment and their families struggle. Extending Medicaid to Ohio's lowest-income uninsured is the right thing to do for them and for all Ohioans.

Evelyn Lundberg Stratton, a former Ohio Supreme Court justice, is a health care adviser and attorney with Vorys, Sater, Seymour and Pease LLP.

Medicine's Sticker Shock

October 2, 2005
New York Times

In the aftermath of Hurricane Katrina, we have an opportunity to construct something far more important than higher levees - a national health care system that looks less like a tightrope and more like a safety net.
A dozen years after Bill Clinton's health reform efforts were destroyed by the insurance industry's duplicity, it's worth trying again. The health care system is steadily becoming more gummed up in ways that are impossible to hide.

 

One of the bumper stickers attacking the Clinton plan read: "If You Like the Post Office, You'll Love National Health Insurance." That wouldn't work today: the Postal Service runs a system that is manifestly more rational and efficient than our health care system. For starters, imagine a postal system that refused to deliver letters to or from 45 million Americans - except on rare occasions, by ambulance.

 

"This is one of those fleeting opportunities where a catastrophe creates an opportunity to rebuild something better than before," says Dr. Irwin Redlener, president of the Children's Health Fund and associate dean of the Mailman School of Public Health at Columbia University.

 

In a sign of the growing disenchantment with our health system, 13,000 doctors have joined Physicians for a National Health Program, which lobbies for a single-payer government-financed health program.

 

There are four main problems with the existing system. First, it leaves out 45 million uninsured Americans, and their number is rising. Second, it is by far the most expensive in the world, costing 15 percent of our national income, yet our outcomes are awful - U.S. life expectancy is worse than Costa Rica's. Third, our business competitiveness is undermined when, for example, medical expenses add $1,500 to the sticker of each General Motors car. Fourth, our system is catastrophically inefficient: according to a study in The New England Journal of Medicine, health administrative costs are $1,059 per capita in the U.S., and just $307 in Canada.

 

A single-payer system would be most efficient but probably is not politically feasible at the moment. The smart new book "The Health Care Mess" suggests a variety of more gradual approaches that would face less opposition.

 

Whatever the mechanism, all children should be covered. It's a disgrace that we use public funds to save the lives of nonagenarians but not those of 9-year-olds. And kids are a bargain: per capita medical spending is $1,525 for children less than 5, and $9,000 per person aged 65 to 74.

 

A second principle is that we should put less emphasis on curative medicine and more on public health and prevention - everything from preparing for avian flu to encouraging exercise. Sure, we can buy more "left ventricular assist devices," which cost $210,000 per patient installed, or buy Erbitux for colon cancer, at $17,000 per month of treatment. But as a wise new book, "Prescription for a Healthy Nation," argues, you get more bang for the buck when you promote healthier lifestyles - fighting obesity, cigarette smoking and the like.

 

Raising cigarette taxes saved far more American lives, for example, than an army of neurologists ever could. In the same spirit, I'd like to see a French-fry tax. And imagine the health gains if we banned potato chips and soda from schools.

 

Reforming the health system won't be easy. In the real world, poor kids don't see doctors not only because they're uninsured, but also because Mom doesn't have a car, can't easily get time off from work, or doesn't speak English. Those are hard nuts to crack - but one reason to think that we can do better is that much of the world does better.

 

I've been thinking of health care partly because of something that happened when I was on vacation in August. My kids and I were stacking firewood for my parents on the Yamhill, Ore., farm where I grew up, when suddenly the seven-foot stack collapsed - on top of my youngest. She was knocked down and pinned, her face bleeding, under a pile of logs.

 

I had insurance, and a car to get to the emergency room - and in the end the logs (stained with blood) turned out to be in worse shape than my daughter. She's just fine. But that instant was heart-stopping in its terror - and the system routinely does fail such children in need. Isn't it worth fighting one more time for reforms, so that we Americans can get health care every bit as good as Canada's?



Medicine's Sticker Shock

October 2, 2005
New York Times

In the aftermath of Hurricane Katrina, we have an opportunity to construct something far more important than higher levees - a national health care system that looks less like a tightrope and more like a safety net.
A dozen years after Bill Clinton's health reform efforts were destroyed by the insurance industry's duplicity, it's worth trying again. The health care system is steadily becoming more gummed up in ways that are impossible to hide.

 

One of the bumper stickers attacking the Clinton plan read: "If You Like the Post Office, You'll Love National Health Insurance." That wouldn't work today: the Postal Service runs a system that is manifestly more rational and efficient than our health care system. For starters, imagine a postal system that refused to deliver letters to or from 45 million Americans - except on rare occasions, by ambulance.

 

"This is one of those fleeting opportunities where a catastrophe creates an opportunity to rebuild something better than before," says Dr. Irwin Redlener, president of the Children's Health Fund and associate dean of the Mailman School of Public Health at Columbia University.

 

In a sign of the growing disenchantment with our health system, 13,000 doctors have joined Physicians for a National Health Program, which lobbies for a single-payer government-financed health program.

 

There are four main problems with the existing system. First, it leaves out 45 million uninsured Americans, and their number is rising. Second, it is by far the most expensive in the world, costing 15 percent of our national income, yet our outcomes are awful - U.S. life expectancy is worse than Costa Rica's. Third, our business competitiveness is undermined when, for example, medical expenses add $1,500 to the sticker of each General Motors car. Fourth, our system is catastrophically inefficient: according to a study in The New England Journal of Medicine, health administrative costs are $1,059 per capita in the U.S., and just $307 in Canada.

 

A single-payer system would be most efficient but probably is not politically feasible at the moment. The smart new book "The Health Care Mess" suggests a variety of more gradual approaches that would face less opposition.

 

Whatever the mechanism, all children should be covered. It's a disgrace that we use public funds to save the lives of nonagenarians but not those of 9-year-olds. And kids are a bargain: per capita medical spending is $1,525 for children less than 5, and $9,000 per person aged 65 to 74.

 

A second principle is that we should put less emphasis on curative medicine and more on public health and prevention - everything from preparing for avian flu to encouraging exercise. Sure, we can buy more "left ventricular assist devices," which cost $210,000 per patient installed, or buy Erbitux for colon cancer, at $17,000 per month of treatment. But as a wise new book, "Prescription for a Healthy Nation," argues, you get more bang for the buck when you promote healthier lifestyles - fighting obesity, cigarette smoking and the like.

 

Raising cigarette taxes saved far more American lives, for example, than an army of neurologists ever could. In the same spirit, I'd like to see a French-fry tax. And imagine the health gains if we banned potato chips and soda from schools.

 

Reforming the health system won't be easy. In the real world, poor kids don't see doctors not only because they're uninsured, but also because Mom doesn't have a car, can't easily get time off from work, or doesn't speak English. Those are hard nuts to crack - but one reason to think that we can do better is that much of the world does better.

 

I've been thinking of health care partly because of something that happened when I was on vacation in August. My kids and I were stacking firewood for my parents on the Yamhill, Ore., farm where I grew up, when suddenly the seven-foot stack collapsed - on top of my youngest. She was knocked down and pinned, her face bleeding, under a pile of logs.

 

I had insurance, and a car to get to the emergency room - and in the end the logs (stained with blood) turned out to be in worse shape than my daughter. She's just fine. But that instant was heart-stopping in its terror - and the system routinely does fail such children in need. Isn't it worth fighting one more time for reforms, so that we Americans can get health care every bit as good as Canada's?



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