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Why This Private Health Insurance CEO Is Against A Public Plan

It’s not because of what you think.

The common thought is that health insurers will quiver at the sight of a government plan, with the public option offering lower premiums to patients due to leaner administrative burdens.

But Charlie Baker, CEO of Massachusetts’ Harvard Pilgrim Health Care, isn’t so worried about that. Instead, he first wonders about the government’s competence in handling another large bureaucratic program:

I worry less about the impact of having the federal government writing the rules and competing directly with plans like Harvard Pilgrim for business, and more about the federal government’s ability to do this at all, much less do it well. Merely coordinating basic demographic information between Social Security, Medicare and Medicaid – three big federal programs that millions of Americans belong to – can be a chore for beneficiaries, their children, and their health plans. It’s not unusual for our members to spend six months or so trying to get this stuff corrected before they call us and ask us to step in on their behalf.

And next, he has zero confidence that the government will be fiscally disciplined administering such a plan. With how it handled the General Motors fiasco as an example, Mr. Baker wonders how any proposed public plan “will negotiate with providers for a mutually agreeable fee . . . will balance its books every year . . . will have to cover its costs of doing business – just like the private plans do – [but] won’t add to the federal deficit.”

Is that even possible?

*This blog post was originally published at*

Desperate Hospitals And Healthcare Reform

I was in the “audience” of the phone conference today organized by Dr. Bob Goldberg, President, Center for Medicine in the Public Interest (CMPI).  In addition to him, Dr. Val Jones (Founder and CEO of Better Health) and Dr Gary Puckrein (President, National Minority Quality Forum) were on the panel of speakers.  The focus was to be on the risks of government-run healthcare.

It seemed to me that many good points were made, but the main one was that the focus of the healthcare discussion needs to be refocused on the patient and the care given rather than simply on the high cost of care/insurance and any cost savings to be gained short-term.  As Dr Wes pointed out in his recent post (The $400 Billion Dollar Question), patients aren’t at the “table” of many of the discussions of healthcare reform that are taking place.

Should America understand precisely what is being cut when we see $400 billion suddenly disappear from the health care reform budget?

I would argue we must know.

After all, it’s we the patients who are not at the policy table, and you can bet that it’s the patients who will ultimately be paying the tab, be it directly through health care premiums, or indirectly by taxation or deficit spending.

There were two links given by the CMPI as sources for factual information on the healthcare discussion: and

I went to both, but in an effort to keep this post at a reasonable length will highlight only a few from the first link.  First this one —

  • Public plan proponents are advocating a $1.25 per hour per employee tax to pay for the public plan. The Commonwealth Fund, “The Path to a High Performance U.S. Health System”, p. 29, February 2009.

I won’t comment on that one, but will this next one:

  • Under the public plan, doctors and hospitals would see their reimbursements for providing medical care cut by as much as 30%. The Commonwealth Fund , “The Path to a High Performance U.S. Health System”, p.33, February 2009.

This decrease in reimbursement troubles me as I have watched the struggles many hospitals have experienced over the past several years with the current reimbursements.  I think this trend will only get worse.  Check out Barbara Duck’s series at Medical Quack on desperate hospitals.  Here’s an excerpt from the May 24, 2009 post:

In Chicago, Illinois

The Loyola University Health System in west suburban Maywood on Tuesday said it will eliminate more than 440 jobs, or about 8 percent of its workforce, amid the recession and an economic downturn causing an influx of patients who cannot pay their bills.

The cost of patients who cannot pay has increased 73 percent, to $31.3 million from $18.1 million, from a year earlier for the nine months ended March 31.

“We have been hit by a number of things,” Dr. Paul Whelton, chief executive of Loyola University Health System, said in an interview. “We are having more trouble with charity care, and the money we are getting [from patients] is more slow to come in. But we have a mission to provide care in our communities and we are going to stick to it.”

In all this talk on healthcare reform, it seems to me and others at the phone conference that the quality of patient care rather than simply cost containment needs to be put back at the front of the discussion.   Healthcare should provide care without being hampered by more and more rules and regulations in an effort to contain costs.  We don’t need more rules like the Medicare’s 75% rule.

Saving money by providing an inferior “product” isn’t what any of us want.  Is it?

*This blog post was originally published at Suture for a Living*

Hot Topics In Healthcare Reform: A Primer

For those of who believe there is a pill for every ill, the recent flurry of legislation and ensuing debates on health care reform may be just too big a pill to swallow.

You’ll need a very large glass of water for sure.

“There’s a lot to consider and not everyone is going to like everything about this legislation,” Rep. Lois Capps (D-CA) told participants at Avalere Health’s conference on Raising the Bar:  Payment Reform and CV Disease on Friday, June 12 in Washington.  Capps, a 20 year veteran school nurse, co-chair of the Democratic Heart and Stroke Caucus and member of the House Energy & Commerce Health Subcommittee describes the pending legislation in terms of “choice” and “a balance” but readily admits that finding a way to pay for it will be difficult.

For those who might not feel up to speed on the latest buzz on health care reform, here’s a quick primer:

Public Option. To cover the 47 million uninsured or underinsured Americans, the President is asking for a public plan that would compete within the insurance market place either directly on cost, or indirectly with clout.  Supposedly, this plan (yet to be included in the Senate HELP health reform legislation introduced last week but rumored to be coming in the markup) will be subject to the same rules and regulations of the private health insurance market.  It could be an extension of Medicare, Medicaid or a hybrid of approaches involving capitation and integrated systems for physicians and hospitals.

The debate about whether or not to introduce a new public option to the current health insurance system involves more than a sense of fairness or simply closing the gap.  The private insurance business is strongly tied to state regulations and competitive forces that will remain as long as 15% of Americans purchase their insurance out of pocket and another 40% have insurance through employment .  Designing the right form of public assistance that can compete with private insurance but not control the market place is surely to reflect the strong differences between political parties.

Centralists in Congress, namely Sen. Kent Conrad (D-ND), have proposed co-ops as a third approach between a public option and the status quo.  Co-ops are membership-owned and operated non-profit organizations that adhere to state laws for health care coverage and provide health insurance for individuals and small businesses.  Reaction has been mixed but some believe co-ops will hit the right balance of competition and public assistance needed for passage in the Senate.

Comparative Effectiveness. Comparative effectiveness research seeks to compare the clinical effectiveness of two alternative therapies for the same condition.  It’s rooted in the idea that our system of paying for the volume (e.g., “fee-for-service”) should be replaced with payment for effectiveness and value that is based on the best science possible.  Recent examples of comparative effectiveness research include trials comparing bare metal coronary stents to drug-eluting stents and comparing older versus newer drugs for treatment of schizophrenia.   All this can be extremely valuable to clinicians and patients trying to decide between alternative courses of treatment.  And to the extent that comparative effectiveness research improves the quality of care, it can also reduce costs.

But clinical data alone cannot reflect patient preferences or whether a treatment course for the overall population is the best one for an individual.   The hot button here is how to encourage clinical research that can help physicians and patients make the best treatment choices yet safeguard it from being used by insurance companies and the government to deny coverage or set payment.  What, exactly, will be compared needs close scrutiny.

Accountable Care Organizations (ACOs). An ACO is a combination of one or more hospitals, primary care physicians and possibly specialists, who are accountable for the total Medicare spending and quality of care for a group of Medicare patients.   Various carrots and sticks are being discussed, but the idea is to control Medicare spending and improved quality of care.  While most physicians recognize the need to move away from Medicare’s fee-for-service approach, the incentives and infrastructure needed to coordinate among providers isn’t apparent.  What about rural areas where coordination of care is a misnomer?  This may be a hot topic for systems change, but practitioners are skeptical.

Patient-Centered Care. It’s hard to imagine that the American College of Cardiology felt the need to launch a new initiative, the “Year of the Patient” or the British Medical Journal depicted tango dancers on its cover story, “Partnering with the Patient” but re-infusing the health care debate from the patient’s perspective is long overdue.   Look for it in every piece of legislation, new commission and advisory group.  Raising the voice of a few on a plum commission or panel discussion  is a laudable start, but we’re all, at one time or another, patients.  We’re all consumers of health care and drawing upon our own experiences to improve our professional stance will be necessary.

Gateways. The Senate HELP Committee’s legislation introduces the concept of “gateways” or “exchanges”, a clearinghouse of sorts on a state level to help consumers parse through insurance plans and public services.  The program would be optional for states for the first six years then federal compliance would prevail.  Organizations such as Kaiser Family Foundation have already established online “gateways” ( to inform consumers wanting to know more.

Health reform is coming fast and furious.  On Monday, June, 15, the Congressional Budget Office is expected to release their projections on what it will take to pay for such massive reforms.  Hospitals and physician groups are deeply concerned about cuts in Medicare payments – estimated by the President on his weekend radio chat as an additional $313M on top of the $309M included in the Administration’s FY2010 budget.

Further legislation will be released this week; keep an eye on the Senate HELP Committee, Senate Finance Committee, House Energy & Commerce, House Ways & Means, and House Education and Labor.

There’s much more to health reform than covered here.  I encourage you to find a passion point of entry and share your insights.

And get ready to swallow a very big pill.

Here’s a quick list of what’s hot in health care reform:

  • Public Option
  • Electronic Medical Records
  • Elimination of pre-existing exclusion
  • Patient-Centered Care
  • Accountable Care Organizations
  • Payment based on value not volume
  • Integrated health delivery systems
  • Federal Health Board
  • Transparency in data, costs and outcomes
  • Personalized health care/personalized information
  • Chronic care models/Transitional Care Models
  • Prevention and wellness programs
  • Comparative Effectiveness
  • Payment reform/Medicare cuts
  • Shared decision making

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