"Medicare now pays the same amount regardless of quality .... even rewards poor quality,paying doctors to treat complications caused by their own mistakes."
Senators Charles E. Grassley, Republican of Iowa, the outgoing chairman of the Senate Finance Committee
“I am very skeptical of pay-for-performance. I’m not sure we can measure quality and performance that well."
Representative Henry A. Waxman, Democrat from California
Dear Friends and Colleagues:
Attached two recent articles from the New York Times highlighting two important issues: 1) last minute insertion of earmarks or special provisions into bills that favor pet projects for certain constituencies , 2) Pay-For-Quality measures in Medicare bill.
1) Earmarks or special provisions are increasing in an exponential fashion.Whereas Congress spent $10 billion on 1,439 such projects in 1995, it ran ran up $27.3 billion for a record 13,997 such projects last year, according to the nonpartisan Citizens Against Government Waste.
That means that our tax money is being used to satisfy the insatiable appetite of congress to funnel money away from budgeted projects to please local constituents. Medicares budget serves just as one example how precious resources are being squandered by politicians.Unfortunately, payment to doctors are being cut year by ear, if one takes inflation and increased practice expenditures into consideration. What can we do? Ally with our patients to point out those abuse by politicians and their financial backers and target them in the media. Lets not forget that doctors are also have their lobby in Washington, but we need to align our interests with the public to promote public health and not only our financial well being.
2) After averting a major pay cut, doctors have to prepare themselves for the next challenge: Pay-for-Quality. Now, doctors can qualify for a 1.5 percent bonus in the second half of 2007 if they report data on the quality of their care, using measures specified by the government. For example, doctors could be asked to report how often they prescribe a particular drug after a heart attack or how well they control blood pressure in patients with diabetes.Beyond broader questions about whether the government can accurately measure the quality of care, many are concerned about the feasibility of developing standards for hundreds of thousands of doctors within six months. The quality reporting system begins on July 1.
In a recent speech to the American Medical Association, Dr. Scott Gottlieb, deputy commissioner of the Food and Drug Administration, said he worried about intrusions into the practice of medicine by federal agencies, including his own.
We have several choices left: boycott Medicare and opt-out of the system or insist that we ONLY participate in such quality assessment program if they criteria are being developed with our significant input.
In my opinion, we cannot objectively measure quality in the ambulatory setting, unless we have tools i.e. medical information technology available and successfully implemented in the clinical practice. Then we should start with pilot projects to validate the feasibility of those assessments including outcome measures.
At this moment I think our elected politicians FROM BOTH PARTIES are shoveling those P4P measures down our throat.
My tip: don't swallow.
=======================================================================================
December 15, 2006
Last-Minute Inserts Offer Benefits in Medicare Bill
By ROBERT PEAR
WASHINGTON, Dec. 14 — By slipping four sentences into a big bill passed last week, Speaker J. Dennis Hastert secured a major change in Medicare policy avidly sought by a few health insurers, in particular a multinational company with headquarters in his home state, Illinois.
In the final hours of the 109th Congress, the Senate Democratic leader, Harry Reid of Nevada, also got special treatment for a hospice in his state. The bill did not name the hospice, but specified the Medicare provider number for the intended beneficiary, the Nathan Adelson Hospice in rural Pahrump, Nev.
Representative Bill Thomas, Republican of California, inserted a provision earmarking $40 million for a valley fever vaccine sought by his constituents, while the Senate Republican leader, Bill Frist of Tennessee, obtained tens of millions of dollars for hospitals in his state.
These examples illustrate how power is exercised in the final, chaotic hours before Congress adjourns. Obscure provisions of interest to just a few lawmakers were quietly stuffed into a grab bag of legislation, with no indication of their parentage or purpose.
The White House has indicated that President Bush will sign the bill, which deals not only with health care but also with a variety of tax and trade issues. The bill, for example, creates a special tax depreciation allowance for property used to produce ethanol from corn stalks, regulates the use of wine names like Champagne and Chablis, and suspends the tariff on imported rayon fibers used in making certain tampons.
Mr. Hastert’s provision showed up mysteriously after House and Senate negotiators had finished writing the bill. The provision was added by the House Rules Committee, just a few hours before the bill went to the House floor last week.
Congressional aides, Medicare officials and insurance lobbyists said the main proponent of the measure was the Aon Corporation and its subsidiary, Sterling Life Insurance Company. Aon, a Fortune 500 company, is based in Chicago and does business in more than 120 countries.
Under current law, Medicare beneficiaries can sign up for a prescription drug plan or a private Medicare Advantage plan from Nov. 15 to Dec. 31 each year. They have a limited ability to make changes through March 31 and are generally locked in for the remainder of the year.
Mr. Hastert’s amendment permits certain Medicare Advantage plans, like Aon’s, to enroll people throughout the year. Ron Bonjean, a spokesman for Mr. Hastert, said the purpose was “to get more people enrolled in Medicare Advantage plans.” Al Orendorff, a spokesman for Aon, said, “We are not going to comment.”
The provision could benefit several other insurers, but Larry Oday, a lawyer and lobbyist for Aon, said the company was “actively involved in consideration of this piece of legislation” and had led opposition to the lock-in requirement.
The addition of the provision infuriated Senate negotiators from both parties.
Senator Charles E. Grassley, the Iowa Republican who is chairman of the Senate Finance Committee, said the provision did not go through the regular legislative process.
“It disturbs me that this major policy change — one that treats some plans unfairly — was included at the last minute by the House Rules Committee,” Mr. Grassley said.
The senior Democrat on the Finance Committee, Senator Max Baucus of Montana, said: “I soundly rejected this proposal during negotiations with our House colleagues. They were clearly informed of my position. Our final agreement did not include this provision.”
Mr. Reid’s amendment provided $3.8 million in relief to the Nathan Adelson Hospice. Medicare officials said they had overpaid the hospice and were trying to recover that amount.
Mr. Reid said the legislation would overturn “a flawed administrative ruling” by the federal Centers for Medicare and Medicaid Services. The legislation retroactively designates the Adelson hospice in Pahrump as a branch of one in Las Vegas, making more money available.
Hospice trustees used their influence with the state’s Congressional delegation, and the hospice retained a Washington law firm, Hogan & Hartson. But Carole A. Fisher, president of the hospice, said Mr. Reid and Nevada’s Republican senator, John Ensign, “were the real champions of our cause, who ensured that we got relief from our Medicare debt.”
In Tennessee, hospitals estimate that they will get at least $131 million because of the provision added by Mr. Frist, who is retiring from the Senate next month. The money will go to about 90 hospitals serving disproportionate numbers of low-income Medicaid patients and people without insurance.
Craig A. Becker, president of the Tennessee Hospital Association, said his organization had received help from an influential Washington lobbyist: Thomas A. Scully, former administrator of the Centers for Medicare and Medicaid Services, who is now a lawyer at Alston & Bird.
The same section of the bill provides $10 million for hospitals in Hawaii. That state’s senators, Daniel K. Akaka and Daniel K. Inouye, both Democrats, have been trying to get such an allotment for years.
Hawaii, like Tennessee, is exempted from many requirements of the federal Medicaid law because of a waiver granted by federal officials. The waivers give the states a great deal of freedom in setting eligibility and benefits, but do not provide the extra money available to other states for hospitals serving large numbers of poor people.
In seeking money for a vaccine against valley fever, Mr. Thomas said he was addressing a serious health problem caused by inhalation of a soil-borne fungus in southwestern states.
“The disease is especially prevalent in Kern County, Calif., which I represent,” Mr. Thomas said. “Unfortunately, there is no vaccine for valley fever, and there is no private industry interest in making the investment, estimated at $40 million, needed for development of the vaccine.”
Among those seeking the legislation was Sandra P. Larson, executive director of the Valley Fever Americas Foundation in Bakersfield, Calif. “Thomas is the guy who got this done for us,” Ms. Larson said. “We are so appreciative.”
========================================================================================
December 12, 2006
Medicare Links Doctors’ Pay to Practices
By ROBERT PEAR
WASHINGTON, Dec. 11 — After years of trying to rein in the runaway cost of the Medicare program, Congress has decided to use a carrot instead of a stick to change doctors’ behavior.
Doctors had been fearing a pay cut under Medicare, the health care program for 43 million elderly and disabled, but Congress instead has offered doctors a small bonus with big strings attached. To get the money, doctors will have to report how often they provide quality care, as defined by the government.
Lawmakers approved the change as one of their final acts before adjourning early Saturday morning, and proponents said it would improve the quality of medical care.
But the plan immediately raised concerns among some doctors and lawmakers who specialize in health issues. They said they worried that it could be a step toward cookbook medicine and could erode the professional autonomy of doctors.
Doctors had been facing a 5 percent cut in Medicare payments in 2007. Congress deferred the cut, freezing doctors’ payment rates instead.
Now, doctors can qualify for a 1.5 percent bonus in the second half of 2007 if they report data on the quality of their care, using measures specified by the government. For example, doctors could be asked to report how often they prescribe a particular drug after a heart attack or how well they control blood pressure in patients with diabetes.
With these statistics, Medicare officials say, they will , in the near future, be able to reward doctors who follow clinical guidelines and perhaps penalize those who flout such standards without justification.
For several years, Medicare officials have advocated a pay-for-performance system, noting wide regional variations in the practices of hospitals and medical specialists. The idea was supported by the Bush administration and by Senators Charles E. Grassley, Republican of Iowa, the chairman of the Finance Committee, and Max Baucus, the Montana Democrat who will be chairman next year.
“Medicare now pays the same amount regardless of quality,” Mr. Grassley said. Indeed, he said, Medicare “rewards poor quality,” paying doctors to treat complications caused by their own mistakes.
But some influential Democrats, and even some administration officials and Republicans who support the general idea of pay-for-performance, expressed concern with federal agencies setting benchmarks for care.
“This is a very significant step,” Catherine G. Cohen, vice president of the American Academy of Ophthalmology, said Monday. “It’s the first time Medicare has ever paid individual doctors a differential for reporting quality measures. It could impose a significant new burden on doctors’ offices.”
The legislation has created strange bedfellows.
Some doctors, health policy experts and politicians, including liberals like Representative Henry A. Waxman and conservatives like Robert E. Moffit, director of health policy studies at the Heritage Foundation, are apprehensive. Beyond broader questions about whether the government can accurately measure the quality of care, they are concerned about the feasibility of developing standards for hundreds of thousands of doctors within six months. The quality reporting system begins on July 1.
In an interview, Mr. Waxman, a California Democrat who has been working on health policy for more than three decades, said: “I am very skeptical of pay-for-performance. I’m not sure we can measure quality and performance that well.”
Representative Pete Stark of California, who will become chairman of the Ways and Means Subcommittee on Health in January, said, “The entire concept of pay-for-performance is offensive.” Doctors, Mr. Stark said, are supposed to provide “quality care” and should not be paid extra for doing so.
Moreover, he said, federal officials “do not have the capability, the understanding, the knowledge or the training” to set standards for the quality of care.
Representative Charlie Norwood, Republican of Georgia, led efforts to enact a “patients’ bill of rights,” saying insurance companies should not tell doctors how to practice medicine. He objects just as much to government efforts to define quality.
“When government bureaucrats determine what good medicine is, instead of patients and doctors, I get very suspicious,” said Mr. Norwood, a dentist.
The administration says Medicare should not simply pay for more services, but should reward doctors for efficiency and high-quality care.
Representative Nancy L. Johnson, Republican of Connecticut, also championed the idea of pay-for-performance. But in an interview, Mrs. Johnson said she was disappointed that Congress had not gone further to ensure that doctors would develop the criteria for measuring quality. “Bureaucrats must never be allowed to dictate medical practice,” she said.
This concern is shared by some administration officials. In a recent speech to the American Medical Association, Dr. Scott Gottlieb, deputy commissioner of the Food and Drug Administration, said he worried about intrusions into the practice of medicine by federal agencies, including his own.
The original Medicare law, passed in 1965, said, “Nothing in this title shall be construed to authorize any federal officer or employee to exercise any supervision or control over the practice of medicine.”
Mr. Moffit of the Heritage Foundation said the new initiative was “a backdoor attempt to repeal” this guarantee.
“It’s pay for compliance, not pay for performance,” Mr. Moffit said. “Doctors will be financially pressured to comply with government guidelines and standards. The integrity and independence of the medical profession could be compromised.”
Dr. Stephen C. Albrecht, a family doctor in Olympia, Wash., said Monday: “Medicare has a good idea here, but has not put much money behind it. The 1.5 percent bonus does not justify the extra effort required to do the quality reporting that the government wants.”
Some doctors, like anesthesiologists and thoracic surgeons, have been eager to develop their own quality measures.
Over the last 17 years, the Society of Thoracic Surgeons has collected demographic and clinical data on three million patients. Doctors say they have used the data to improve the quality of care.
Dr. Frederick L. Grover, president of the Society of Thoracic Surgeons, said, “We have provided feedback to doctors, comparing their performance with state and national benchmarks, and in this way we have significantly reduced mortality and complications.”
When possible, Medicare officials are supposed to use “quality measures” that have been endorsed by the private sector.
Despite the move toward pay-for-performance, Medicare payments to doctors are unlikely to keep pace with inflation. Congress postponed for one year a cut in fees but did not change the Medicare law’s formula for computing payments to doctors. They face an even bigger cut next year, in the range of 5 percent to 10 percent, ensuring that Congress will have to revisit the issue.
Representative Stark said, “Doctors and others who like pay-for-performance have to remember that it’s a zero-sum game.” As a result, he said, most doctors will have to accept lower fees if Medicare is to pay bonuses to the best performers.
Dr. Frank G. Opelka, a surgeon at the Louisiana State University School of Medicine in New Orleans, said: “We fully support the goal of enhancing the quality of care, but this is a new program. It will take some time to get broad acceptance by physicia
Sunday, December 17, 2006
Helath Care Costs and Quality of Care
TOPIC: Healthcare Costs and Quality of Care
“The biggest failure of the American health care system is not that we overuse stuff but that we underuse stuff,”
(David Cutler, Economist,Harvard)
Dear Friends and Colleagues:
Attached two articles from the Miami herald and New York Times discussing the paradox of increasing health car costs and decreasing quality of care.
John Dorscher, the renowned Miami Herald health care reporter, reviews the costs, quality and outcome of medical care in South Florida.
Unfortunately, we have the highest per capita healthcare expenditures, but our performance is the lowest in the country.
In plain simple English: our patients (including your employees and families) or their insurance spent the most, but get the short end of the stick.
Among others the following factors contribute to this problem: fragmented health care system, uncoordinated health care delivery, poor or non-existing information sharing resulting in unnecessary duplication of diagnostic testing and absence of quality measures in ambulatory care setting.
Unfortunately, doctors are still resisting to conduct performance and outcome measure assessments.
These measures are not meant to be punitive, but to provide guidance for physicians to assess and compare their performance.
For that purpose I am using for more than seven years an electronic health records and routinely check if the treatment of my patients with certain chronic disease (Diabetes, Hypertension, Asthma) meets the standards of care and complies with national guidelines.
I learn a lot from those routine reviews and adjust my care accordingly.
If I can do it, why do we have to wait for the government to prescribe how we should practice medicine?
Lets take the initiative and implement modern business management principles in our practices including medical information technology.
Looking forward to your comments.
Happy Chanukah and Merry Christmas.
Yours
Bernd
Posted on Sun, Dec. 17, 2006
HEALTHCARE | FIFTH OF AN OCCASIONAL SERIES
High prices don't translate into better healthcare in South Florida
In the still murky world of healthcare information, high costs of healthcare are not at all linked to high quality care in South Florida.
BY JOHN DORSCHNER
jdorschner@MiamiHerald.com
With studies showing that South Florida has among the highest healthcare costs in the country, consumers might assume local hospitals' performance on quality standards would be among the tops in the country.
Think again.
After a thorough examination of quality data made public by Medicare, Harvard researchers have discovered South Florida's performance is among the worst in the country in two out of three key categories.
Their findings reveal what many experts now see as a growing amount of health information becomes available: The relationships among costs, the quality of treatment and ultimate outcome is murky at best. That means measuring proper treatments may not have much to do with costs at the moment -- or even whether the patient lives longer.
Insurers and the federal government want the consumers to have more health information to make better choices and to pay providers according to their performances. In theory, it's great. In reality, providers fear it it may be something else.
''Though I am supporting transparency in healthcare pricing and the patients (sic) right to receive high-quality care, I am concerned that insurers may just focus on cheaper and not necessarily better,'' wrote North Miami Beach doctor Bernd Wollschlaeger in a letter to colleagues after a recent Miami Herald report on healthcare pricing.
In fact, Wollschlaeger believes one problem may be that there is not enough information. One major example: South Florida doctors usually don't know whether the patient received the proper test at the hospital, meaning they frequently order the same test again.
Unnecessary repetition of services and tests, frequently caused by excessive trips to specialists, is one reason why researchers of the Dartmouth Medical School have found that per capita healthcare costs in Miami are almost twice what they are in Minneapolis, another similar-size city they studied.
Contrast that with the findings of four researchers from Harvard's School of Public Health who studied the 40 largest hospital markets in the United States for the basic Medicare quality measures, such as giving aspirin to a patient after a heart attack.
BOTTOM FIVE
In two of the three main categories -- treatment for heart attack and for pneumonia -- the Miami region ranked in the bottom five, the researchers wrote in their article, published in the New England Journal of Medicine. For the third category, congestive heart failure, it didn't do much better, finishing 29th out of 40.
''These are very simple but really important things to perform,'' says Ashish K. Jha, the lead Harvard researcher. ``Aspirins, beta-blockers -- things that can cost pennies but can be crucial.''
Meanwhile, Florida's healthcare dollars are being spent much more frequently, according to a Dartmouth study released in May. During the last six months of life, the average Medicare recipient spends twice as many days in intensive care and has twice as many doctor visits as his counterpart in Utah.
Within Florida, a patient in Miami spends twice as much time in intensive care and sees twice as many specialists in those last six months than does a patient in Fort Myers.
Alan Sager, a Boston University health professor, thinks these big-picture spending contrasts are what the industry should be looking at, not insurers revealing provider prices.
After The Miami Herald ran a report about insurers making public health cost and pricing information as a prelude to steering consumers toward more efficient providers, Sager sent an e-mail to The Miami Herald: ``Shopping by price won't save serious money because it addresses the wrong question. The big question is not, where's the cheapest place to get the operation, MRI or primary care visit? The big question is, do I need the operation, MRI or visit?''
UNNECESSARY EXPENSES
Sager, like many other experts, believes about half of all healthcare expenses are unnecessary, and if needless work could be curtailed, then America could provide healthcare for everyone.
The nonprofit National Committee for Quality Assurance, which has been measuring health plan performance on various measures for a decade, is now starting to look into these broader ''efficiency'' questions.
NCQA is starting a pilot that will go beyond measuring health plans' quality -- making sure diabetics get blood-sugar tests -- to look at cost, and not just for specific measures.
''We're going to focus on the total cost of healthcare,'' says NCQA Vice President Joachim Roski. ``It could mean you spend money in some areas, but not in others. You might spend more on preventive visits or more on pharmacy but spend less on hospitalizations.''
Adjusting for risk factors such as age and health condition, NCQA plans to release its first efficiency data in September 2007. ''The ultimate question is, do organizations in Miami get the same level of quality with the same level of cost?'' says Roski. ``And if not, why not?''
Brian Klepper, head of the Center for Practical Health Reform, agrees that many healthcare dollars are spent on unnecessary care. He thinks a primary cause may be the present fee-for-service model, in which the more doctors do, the more they get paid. He points out that some years ago, when the state lowered provider payments for workers' compensation treatment, the doctors responded by finding more treatments to do on each patient.
Klepper thinks that payment model has to be changed -- so that doctors get sums for a total treatment of an illness, not for each incremental step -- but he also believes that there must be greater transparency in the system.
Klepper and Wollschlaeger, the doctor who is a delegate to the American Medical Association, believe one good way to provide transparency and cut unnecessary costs is to form regional health information systems.
That way, doctors can see online what other providers have already done for a patient, particularly important in South Florida, which has 40 percent more specialists than does Minneapolis -- a fact that Dartmouth researchers believe causes many duplicative services here.
With providers sharing patient information online, that means someone like Wollschlaeger can see that a patient just released from the hospital ''has already had the pneumonia vaccination shot, so I don't have to order another one for $85,'' says Wollschlaeger.
Discussions about forming a network in South Florida, however, are just getting under way. In the meantime, many are still struggling to comprehend the meaning of the data now available.
A study published Wednesday in the Journal of the American Medical Association found that performance measures reported by Medicare for 3,657 hospitals ''are not tightly linked to patient outcomes,'' meaning that hospitals that are doing a good job of giving, say, the beta-blocker at the right moment are not necessarily showing a good job in lowering mortality rates.
''These findings should not undermine current efforts to improve healthcare quality through measurement and reporting,'' wrote the researchers, headed by Rachel M. Werner. ``However, attention should be focused on finding measures of healthcare quality that are more tightly linked to patient outcomes. Only then will performance measurement live up to expectations for improving healthcare quality.''
================================================================================
December 17, 2006
Economic View
The More You Pay, the Better the Care? Think Twice
By EDUARDO PORTER
EXPERTS have long been puzzled by the existence of large regional disparities in medical care in the United States. Even for diseases for which the appropriate treatment is widely accepted, doctors across the country take vastly different approaches, often leading to enormous expense without making any appreciable improvement in their patients’ health.
Consider heart attacks. Prescribing beta blockers immediately after a heart attack is a well-established, cheap and efficient treatment. In Iowa, nearly 80 percent of victims in 2000 received the drugs within 24 hours of a heart attack. In Alabama or Georgia, by contrast, fewer than 6 out of 10 patients received the drugs.
“What makes the lag in beta-blocker adoption puzzling is that the clinical benefits have been understood for years,” wrote Jonathan S. Skinner and Douglas O. Staiger, economists at Dartmouth, in a recent study about these regional patterns.
Congress has decided that some treatment decisions may be best taken out of doctors’ hands. In one of their last acts this year before adjourning, lawmakers passed a bill entitling doctors to a bonus from Medicare if they report data on the quality of their care, using criteria like whether they prescribe aspirin or beta blockers to heart attack victims. In the future, this data would permit Medicare to reward doctors who followed government guidelines.
Many doctors criticized the decision, saying it would impose a form of medicine by cookbook that could endanger patients. Still, some experts contend that this form of accountability is a necessary step to deal with inefficiencies that riddle the health care system and fuel much unnecessary spending on care.
Several new studies suggest that there is no relationship between the amount spent on treating a patient and the quality and outcome of the care.
Consider chronically ill elderly patients in the last two years of their lives. According to a comparison of hospitals across the country done by researchers at Dartmouth, if the patients die in a hospital in New York State, the average cost of those two years would be $38,369. In Florida, by contrast, it would be $29,604, while in Iowa it would be only $23,746.
To be sure, much spending on health care provides enormous benefits. A study published this year by Mr. Skinner, Mr. Staiger and Dr. Elliott S. Fisher of Dartmouth Medical School found that Medicare spending on hospital care for heart attack victims surged two-thirds from 1986 to 1996, after accounting for inflation. But the percentage of victims who were alive a year after their attacks also increased, though by just 10 percentage points, to roughly 68 percent.
The relationship — rising costs bringing increased benefits — has broken down recently. From 1996 to 2002, Medicare spending on treatments for heart attack victims increased about 14 percent, after inflation. But there was virtually no improvement in survival rates.
There is mounting evidence that the zeal to treat and spend may actually hurt patients. The study by Mr. Skinner, Mr. Staiger and Dr. Fisher found that hospitals in regions where spending grew fastest from 1986 to 2002 had some of the worst practices, in terms of providing tried-and-true therapies, and recorded the smallest gains in survival rates.
Treatment of heart disease underscores the deeply idiosyncratic nature of many choices made by America’s doctors and hospitals. Coupled with a fee-for-service system that encourages aggressive treatment, these choices stimulate health spending that provides little benefit to patients. “A lot of the innovation and spending growth are going into gray areas that are not helping people that much,” Mr. Skinner said.
But perhaps the most puzzling inefficiency in how doctors treat heart disease is not the spending on fancy yet ineffective therapies. It’s the lack of spending on treatments that have been known to work for years, like beta blockers.
“The biggest failure of the American health care system is not that we overuse stuff but that we underuse stuff,” said David Cutler, an economist at Harvard. Consider aspirin. It helps prevent formation of blood clots, and its widespread use has probably been the cheapest breakthrough in the history of heart disease treatment.
A study five years ago by Dr. Mark McClellan, who was to become the commissioner of the Food and Drug Administration, and Dr. Paul A. Heidenreich of the Veterans Affairs Palo Alto Health Care System in California, estimated that growing aspirin use explained more than a third of the decrease in the death rates of heart attack victims from 1975 to 1995.
Still, a Duke University study of about 32,000 patients with coronary artery disease who were treated from 1995 to 2002 found that only 83 percent took aspirin. And only 71 percent did so consistently.
The financial incentives in the health care system are part of the problem, experts say. These incentives encourage hospitals and clinics to provide more services, hire more specialists and install more devices. They shuttle patients from one specialist to the other — providing more-scattered care. All too often, when the patient leaves the hospital, nobody among the crowd of doctors takes responsibility for prescribing the beta-blockers. “The system rewards throughput and higher-margin services,” Dr. Fisher said. “This leads us inadvertently to waste and inadvertently to harm.”
He argued that hospitals and doctors must gather into bigger units that coordinate care smoothly — sharing medical records and responsibility for a patient’s overall health. They should provide information about treatments and outcomes. And, he said, Medicare must start paying for results, measured in terms of lives improved and extended and of value for the money.
Congress has taken a step in this direction. But changing entrenched practices is not easy.
MR. SKINNER and Mr. Staiger found an odd pattern in the regional propensities of doctors to prescribe beta blockers: it closely matched the propensities of farmers to embrace hybrid corn early in the 20th century.
Hybridization spread through Iowa’s cornfields as early as the mid-1930s. By contrast, in Alabama and Georgia it didn’t take hold until the late 1940s. In other words, the lag in the prescription of beta blockers is not simply a problem of the health care system. It also reflects regional attitudes about the adoption of new technologies, the study concluded. That problem could take generations to solve.
“The biggest failure of the American health care system is not that we overuse stuff but that we underuse stuff,”
(David Cutler, Economist,Harvard)
Dear Friends and Colleagues:
Attached two articles from the Miami herald and New York Times discussing the paradox of increasing health car costs and decreasing quality of care.
John Dorscher, the renowned Miami Herald health care reporter, reviews the costs, quality and outcome of medical care in South Florida.
Unfortunately, we have the highest per capita healthcare expenditures, but our performance is the lowest in the country.
In plain simple English: our patients (including your employees and families) or their insurance spent the most, but get the short end of the stick.
Among others the following factors contribute to this problem: fragmented health care system, uncoordinated health care delivery, poor or non-existing information sharing resulting in unnecessary duplication of diagnostic testing and absence of quality measures in ambulatory care setting.
Unfortunately, doctors are still resisting to conduct performance and outcome measure assessments.
These measures are not meant to be punitive, but to provide guidance for physicians to assess and compare their performance.
For that purpose I am using for more than seven years an electronic health records and routinely check if the treatment of my patients with certain chronic disease (Diabetes, Hypertension, Asthma) meets the standards of care and complies with national guidelines.
I learn a lot from those routine reviews and adjust my care accordingly.
If I can do it, why do we have to wait for the government to prescribe how we should practice medicine?
Lets take the initiative and implement modern business management principles in our practices including medical information technology.
Looking forward to your comments.
Happy Chanukah and Merry Christmas.
Yours
Bernd
Posted on Sun, Dec. 17, 2006
HEALTHCARE | FIFTH OF AN OCCASIONAL SERIES
High prices don't translate into better healthcare in South Florida
In the still murky world of healthcare information, high costs of healthcare are not at all linked to high quality care in South Florida.
BY JOHN DORSCHNER
jdorschner@MiamiHerald.com
With studies showing that South Florida has among the highest healthcare costs in the country, consumers might assume local hospitals' performance on quality standards would be among the tops in the country.
Think again.
After a thorough examination of quality data made public by Medicare, Harvard researchers have discovered South Florida's performance is among the worst in the country in two out of three key categories.
Their findings reveal what many experts now see as a growing amount of health information becomes available: The relationships among costs, the quality of treatment and ultimate outcome is murky at best. That means measuring proper treatments may not have much to do with costs at the moment -- or even whether the patient lives longer.
Insurers and the federal government want the consumers to have more health information to make better choices and to pay providers according to their performances. In theory, it's great. In reality, providers fear it it may be something else.
''Though I am supporting transparency in healthcare pricing and the patients (sic) right to receive high-quality care, I am concerned that insurers may just focus on cheaper and not necessarily better,'' wrote North Miami Beach doctor Bernd Wollschlaeger in a letter to colleagues after a recent Miami Herald report on healthcare pricing.
In fact, Wollschlaeger believes one problem may be that there is not enough information. One major example: South Florida doctors usually don't know whether the patient received the proper test at the hospital, meaning they frequently order the same test again.
Unnecessary repetition of services and tests, frequently caused by excessive trips to specialists, is one reason why researchers of the Dartmouth Medical School have found that per capita healthcare costs in Miami are almost twice what they are in Minneapolis, another similar-size city they studied.
Contrast that with the findings of four researchers from Harvard's School of Public Health who studied the 40 largest hospital markets in the United States for the basic Medicare quality measures, such as giving aspirin to a patient after a heart attack.
BOTTOM FIVE
In two of the three main categories -- treatment for heart attack and for pneumonia -- the Miami region ranked in the bottom five, the researchers wrote in their article, published in the New England Journal of Medicine. For the third category, congestive heart failure, it didn't do much better, finishing 29th out of 40.
''These are very simple but really important things to perform,'' says Ashish K. Jha, the lead Harvard researcher. ``Aspirins, beta-blockers -- things that can cost pennies but can be crucial.''
Meanwhile, Florida's healthcare dollars are being spent much more frequently, according to a Dartmouth study released in May. During the last six months of life, the average Medicare recipient spends twice as many days in intensive care and has twice as many doctor visits as his counterpart in Utah.
Within Florida, a patient in Miami spends twice as much time in intensive care and sees twice as many specialists in those last six months than does a patient in Fort Myers.
Alan Sager, a Boston University health professor, thinks these big-picture spending contrasts are what the industry should be looking at, not insurers revealing provider prices.
After The Miami Herald ran a report about insurers making public health cost and pricing information as a prelude to steering consumers toward more efficient providers, Sager sent an e-mail to The Miami Herald: ``Shopping by price won't save serious money because it addresses the wrong question. The big question is not, where's the cheapest place to get the operation, MRI or primary care visit? The big question is, do I need the operation, MRI or visit?''
UNNECESSARY EXPENSES
Sager, like many other experts, believes about half of all healthcare expenses are unnecessary, and if needless work could be curtailed, then America could provide healthcare for everyone.
The nonprofit National Committee for Quality Assurance, which has been measuring health plan performance on various measures for a decade, is now starting to look into these broader ''efficiency'' questions.
NCQA is starting a pilot that will go beyond measuring health plans' quality -- making sure diabetics get blood-sugar tests -- to look at cost, and not just for specific measures.
''We're going to focus on the total cost of healthcare,'' says NCQA Vice President Joachim Roski. ``It could mean you spend money in some areas, but not in others. You might spend more on preventive visits or more on pharmacy but spend less on hospitalizations.''
Adjusting for risk factors such as age and health condition, NCQA plans to release its first efficiency data in September 2007. ''The ultimate question is, do organizations in Miami get the same level of quality with the same level of cost?'' says Roski. ``And if not, why not?''
Brian Klepper, head of the Center for Practical Health Reform, agrees that many healthcare dollars are spent on unnecessary care. He thinks a primary cause may be the present fee-for-service model, in which the more doctors do, the more they get paid. He points out that some years ago, when the state lowered provider payments for workers' compensation treatment, the doctors responded by finding more treatments to do on each patient.
Klepper thinks that payment model has to be changed -- so that doctors get sums for a total treatment of an illness, not for each incremental step -- but he also believes that there must be greater transparency in the system.
Klepper and Wollschlaeger, the doctor who is a delegate to the American Medical Association, believe one good way to provide transparency and cut unnecessary costs is to form regional health information systems.
That way, doctors can see online what other providers have already done for a patient, particularly important in South Florida, which has 40 percent more specialists than does Minneapolis -- a fact that Dartmouth researchers believe causes many duplicative services here.
With providers sharing patient information online, that means someone like Wollschlaeger can see that a patient just released from the hospital ''has already had the pneumonia vaccination shot, so I don't have to order another one for $85,'' says Wollschlaeger.
Discussions about forming a network in South Florida, however, are just getting under way. In the meantime, many are still struggling to comprehend the meaning of the data now available.
A study published Wednesday in the Journal of the American Medical Association found that performance measures reported by Medicare for 3,657 hospitals ''are not tightly linked to patient outcomes,'' meaning that hospitals that are doing a good job of giving, say, the beta-blocker at the right moment are not necessarily showing a good job in lowering mortality rates.
''These findings should not undermine current efforts to improve healthcare quality through measurement and reporting,'' wrote the researchers, headed by Rachel M. Werner. ``However, attention should be focused on finding measures of healthcare quality that are more tightly linked to patient outcomes. Only then will performance measurement live up to expectations for improving healthcare quality.''
================================================================================
December 17, 2006
Economic View
The More You Pay, the Better the Care? Think Twice
By EDUARDO PORTER
EXPERTS have long been puzzled by the existence of large regional disparities in medical care in the United States. Even for diseases for which the appropriate treatment is widely accepted, doctors across the country take vastly different approaches, often leading to enormous expense without making any appreciable improvement in their patients’ health.
Consider heart attacks. Prescribing beta blockers immediately after a heart attack is a well-established, cheap and efficient treatment. In Iowa, nearly 80 percent of victims in 2000 received the drugs within 24 hours of a heart attack. In Alabama or Georgia, by contrast, fewer than 6 out of 10 patients received the drugs.
“What makes the lag in beta-blocker adoption puzzling is that the clinical benefits have been understood for years,” wrote Jonathan S. Skinner and Douglas O. Staiger, economists at Dartmouth, in a recent study about these regional patterns.
Congress has decided that some treatment decisions may be best taken out of doctors’ hands. In one of their last acts this year before adjourning, lawmakers passed a bill entitling doctors to a bonus from Medicare if they report data on the quality of their care, using criteria like whether they prescribe aspirin or beta blockers to heart attack victims. In the future, this data would permit Medicare to reward doctors who followed government guidelines.
Many doctors criticized the decision, saying it would impose a form of medicine by cookbook that could endanger patients. Still, some experts contend that this form of accountability is a necessary step to deal with inefficiencies that riddle the health care system and fuel much unnecessary spending on care.
Several new studies suggest that there is no relationship between the amount spent on treating a patient and the quality and outcome of the care.
Consider chronically ill elderly patients in the last two years of their lives. According to a comparison of hospitals across the country done by researchers at Dartmouth, if the patients die in a hospital in New York State, the average cost of those two years would be $38,369. In Florida, by contrast, it would be $29,604, while in Iowa it would be only $23,746.
To be sure, much spending on health care provides enormous benefits. A study published this year by Mr. Skinner, Mr. Staiger and Dr. Elliott S. Fisher of Dartmouth Medical School found that Medicare spending on hospital care for heart attack victims surged two-thirds from 1986 to 1996, after accounting for inflation. But the percentage of victims who were alive a year after their attacks also increased, though by just 10 percentage points, to roughly 68 percent.
The relationship — rising costs bringing increased benefits — has broken down recently. From 1996 to 2002, Medicare spending on treatments for heart attack victims increased about 14 percent, after inflation. But there was virtually no improvement in survival rates.
There is mounting evidence that the zeal to treat and spend may actually hurt patients. The study by Mr. Skinner, Mr. Staiger and Dr. Fisher found that hospitals in regions where spending grew fastest from 1986 to 2002 had some of the worst practices, in terms of providing tried-and-true therapies, and recorded the smallest gains in survival rates.
Treatment of heart disease underscores the deeply idiosyncratic nature of many choices made by America’s doctors and hospitals. Coupled with a fee-for-service system that encourages aggressive treatment, these choices stimulate health spending that provides little benefit to patients. “A lot of the innovation and spending growth are going into gray areas that are not helping people that much,” Mr. Skinner said.
But perhaps the most puzzling inefficiency in how doctors treat heart disease is not the spending on fancy yet ineffective therapies. It’s the lack of spending on treatments that have been known to work for years, like beta blockers.
“The biggest failure of the American health care system is not that we overuse stuff but that we underuse stuff,” said David Cutler, an economist at Harvard. Consider aspirin. It helps prevent formation of blood clots, and its widespread use has probably been the cheapest breakthrough in the history of heart disease treatment.
A study five years ago by Dr. Mark McClellan, who was to become the commissioner of the Food and Drug Administration, and Dr. Paul A. Heidenreich of the Veterans Affairs Palo Alto Health Care System in California, estimated that growing aspirin use explained more than a third of the decrease in the death rates of heart attack victims from 1975 to 1995.
Still, a Duke University study of about 32,000 patients with coronary artery disease who were treated from 1995 to 2002 found that only 83 percent took aspirin. And only 71 percent did so consistently.
The financial incentives in the health care system are part of the problem, experts say. These incentives encourage hospitals and clinics to provide more services, hire more specialists and install more devices. They shuttle patients from one specialist to the other — providing more-scattered care. All too often, when the patient leaves the hospital, nobody among the crowd of doctors takes responsibility for prescribing the beta-blockers. “The system rewards throughput and higher-margin services,” Dr. Fisher said. “This leads us inadvertently to waste and inadvertently to harm.”
He argued that hospitals and doctors must gather into bigger units that coordinate care smoothly — sharing medical records and responsibility for a patient’s overall health. They should provide information about treatments and outcomes. And, he said, Medicare must start paying for results, measured in terms of lives improved and extended and of value for the money.
Congress has taken a step in this direction. But changing entrenched practices is not easy.
MR. SKINNER and Mr. Staiger found an odd pattern in the regional propensities of doctors to prescribe beta blockers: it closely matched the propensities of farmers to embrace hybrid corn early in the 20th century.
Hybridization spread through Iowa’s cornfields as early as the mid-1930s. By contrast, in Alabama and Georgia it didn’t take hold until the late 1940s. In other words, the lag in the prescription of beta blockers is not simply a problem of the health care system. It also reflects regional attitudes about the adoption of new technologies, the study concluded. That problem could take generations to solve.
Sunday, December 03, 2006
Healthcare Pricing
PLEASE VISIT MY BLOG AT http://floridadocs.blogspot.com FOR A COMPLETE LISTING OF ALL ARTICLES AND E-MAILS.
Dear Friends and Colleagues:
Attached an article from todays Miami Herald discussing the issue of healthcare pricing. According to the reporter many health insurers and governments are already charging ahead to make information about hospital and doctor quality performance available to the public, but many believe the biggest push -- and the biggest battleground -- will be the revelation of healthcare pricing. It sis true that at the moment, healthcare prices are so convoluted that even experts struggle to make sense of them.At some point, however, this abstract knowledge will be used for specific economic ends. Insurers are already calculating the costs of care and comparing it with the quality of a provider's care. Some even start steering customers towards doctors who provide "cheaper"care by rewarding customers financially.
Even though I am supporting transparency in healthcare pricing and the patients right to receive high-quality care, I am concerned that insurers may just focus on cheaper and not necessarily better care.
This in the end will reward those docs that lowball others and comply with checklists and protocols to maintain their competitive edge.
The patients choice in physicians selection will thereby severely hampered.
Yours
Bernd
Posted on Sun, Dec. 03, 2006
HEALTHCARE | THIRD IN AN OCCASIONAL SERIES
Lifting veil on healthcare costs
Exposing the super-secret lists of healthcare pricing could lead to huge changes -- and give consumers a real understanding of the true costs of their treatment.
BY JOHN DORSCHNER
jdorschner@MiamiHerald.com
At Broward General or Mercy Hospital, a coronary bypass operation can be expected to cost $30,909 to $43,407. At Baptist Hospital, the cost is likely to be far more -- $43,070 to $58,271, according the health insurer Cigna.
For women ages 40-64 insured by Aetna, gynecologist Moises Lichtinger in Fort Lauderdale charges $86.93 for a comprehensive exam. In Miami Beach, gynecologist Pedro J. Brasac charges $106.99.
For the first time, insurers are starting to reveal some of the most deeply held secrets of healthcare -- what things really cost. Those revelations may ultimately change what providers charge -- and how much consumers pay.
''We're at the leading edge of a huge change,'' says Brian Klepper of the Center for Practical Health Reform.
Many health insurers and governments are already charging ahead to make information about hospital and doctor quality performance available to the public, but many believe the biggest push -- and the biggest battleground -- will be the revelation of healthcare pricing.
At the moment, healthcare prices are so convoluted that even experts struggle to make sense of them.
The list of prices for Baptist Hospital, for example, is contained in a foot-thick document called a chargemaster. No outsider is allowed to see it. What's more, virtually no one pays those prices. Medicare, Medicaid and consumers with private health plans all pay negotiated rates that may be only a third of the official prices. That means only those without insurance get hit with a full-price bill.
Uwe Reinhardt, the widely respected healthcare economist at Princeton, compares present hospital pricing to entering a department store blindfolded and shopping for a ``clothes benefit program.''
''Only months after a shopping trip would the employee receive . . . a statement explaining how much the employee had to pay for whatever he or she had stuffed, blindfolded, into the shopping cart,'' wrote Reinhardt in the January/February issue of Health Affairs.
That meant the department store/hospital had finally presented its charges, and the insurer then decided what was a ''reasonable'' rate for those charges that it deemed appropriate. Finally, the customer is told to pay a certain percentage of that mysterious figure.
At present, persons with insurance generally don't care about this mysterious pricing. For that coronary by-pass surgery mentioned above, for example, the Cigna patient in one typical high-deductible plan would have an out-of-pocket expense of $3,000 at each facility, regardless of the cost.
Knowing prices now ''helps provide clarity on how much things cost,'' says Joe Mondy, a Cigna spokesman.
''The more people understand the cost of healthcare, the better off we will be,'' says Charles Cutler, national medical director for Aetna.
At some point, however, this abstract knowledge will be used for specific economic ends. Insurers are already calculating the costs of care and comparing it with the quality of a provider's care. ''That's going to start a huge shift,'' says Klepper of the Health Reform group.
The Bush administration in Washington and private insurers believe that hospitals and doctors who do the best in this quality-cost scenario should be rewarded with higher payments -- the so-called ``pay for performance.''
The flip side is steering consumers to those providers who provide quality efficiently. Cigna is already starting to do that, with its Cigna Care Network, made up of doctors who score well for quality and cost-efficiency. Starting in January in 58 markets (including South Florida), members who use the Cigna Care doctors will be rewarded by saving $10 to $30 per office visit.
Doctor quality by itself is a complex issue -- as The Miami Herald discussed in a report last Sunday -- but efficiency may be even more complicated.
Spokesmen for programs like Aetna's Aexcel, UnitedHealthcare's Premium Physicians and Cigna's Care Network insist that efficiency ratings are given only to those physicians who have already shown quality performance, but none of them go into detail about what makes for efficiency.
Theoretically, efficiency could mean keeping patients out of expensive emergency rooms or not requesting unnecessary tests and procedures, but in practice, doctors are suspicious that it might mean simple cost-cutting.
''You have to look very carefully at those efficiency numbers,'' says Nancy Nielsen, a Buffalo internist who's head of the American Medical Association's House of Delegates. ``Some are only about costs. That's where it gets tricky. That's where the biggest fights and negotiations are.''
The AMA is so concerned about insurers forming networks using efficiency measurements that its delegates, meeting in Las Vegas in November, passed a resolution seeking laws to prohibit insurers from creating networks ''based solely on economic criteria.'' Last week, the national organization of doctors joined its first lawsuit on the issue, against Regence BlueShield in Washington state. Insurers insist it won't be ''solely'' on costs, but they say something must be done about cost disparities, many of which have nothing to do with quality of care.
In South Florida, Aetna reports, the negotiated rates -- the real rates insurers pay -- vary widely right now. Knee arthroscopy in an orthopedist's office can cost from $1,922 to $4,000. For a hysteroscopy (the insertion of a small telescope to study a uterus) at an OB/GYN office, the price ranges from $1,200 to $4,756. For a heart catheterization, at a cardiology office, the price ranges from $600 to $2,500.
Of course, top doctors charging more might explain those variations, but what explains differences in radiology tests, such as a magnetic resonance imaging?
''These are commodities,'' says Mondy of Cigna. ''An MRI is an MRI is an MRI.'' But Cigna's studies show that their costs vary by an average of 30 percent.
An MRI without contrast agent at the Cleveland Clinic in Weston costs $400 in Cigna's negotiated fees. Broward General's price is $450. Hollywood Medical Center charges $660.
Some insurers are more focused on advising consumers about estimates for procedures -- without showing the differences between facilities. Blue Cross Blue Shield of Florida, for example, tells its members that coronary bypass surgery for a 45- to 64-year-old in Miami-Dade will cost $55,562 to $80,257 in network, $124,260 to $179,488 out of network, for everything including hospital, surgeon and related costs. In Broward, it would be a couple of thousand less.
A Florida government website also offers pricing information, but it is based on hospitals' gross charges, which persons rarely pay. Still, an uninsured person who is likely to be charged full fare can learn from the website (floridacomparecare.com) that for coronary bypass surgery at Baptist Hospital is $135,573, well below Broward General's $140,227 and Mercy's $154,261.
But the data of Cigna and other insurers reveal that Baptist, which has a near monopoly on the affluent area of southern Miami-Dade, is able to negotiate a much better deal for itself than the others can.
When it comes to real prices -- the negotiated rates -- Cigna pays Baptist about 35 percent of its full charges (around $47,500), while Broward General gets about 26 percent ($37,000) and Mercy receives about 24 percent ($37,000). And, as Cigna members are told on the insurer's website, the three hospitals are all ranked at the top level of three stars for the quality of patients' outcomes.
Eric Shatanof, vice president of Baptist Health South Florida, says that the price of one procedure, such as coronary bypass, doesn't mean that the Baptist hospitals (which include Doctors, South Miami and Homestead) are more expensive in all charges. ``Pricing is pretty complex. We could be more expensive on heart surgery and less expensive on something else.''
However, executives of four other insurers have told The Miami Herald that Baptist is consistently and considerably higher in its pricing. The executives don't want their names used because they don't want to anger the hospital system, which the insurers regard as crucial to maintaining customer satisfaction.
Shatanof acknowledges that ''our cost structure is quite a bit higher than our competitors. We have a higher clinical staffing ratio. We have higher investments, like the remote [intensive care unit] monitoring. So it's not necessarily apples to apples comparisons'' on quality and price.
But if insurers go to tier systems, in which consumers would have to pay more to go to higher-priced hospitals, ''it could change the mix,'' said Shatanof. ``Then you have to change the pricing.''
Dear Friends and Colleagues:
Attached an article from todays Miami Herald discussing the issue of healthcare pricing. According to the reporter many health insurers and governments are already charging ahead to make information about hospital and doctor quality performance available to the public, but many believe the biggest push -- and the biggest battleground -- will be the revelation of healthcare pricing. It sis true that at the moment, healthcare prices are so convoluted that even experts struggle to make sense of them.At some point, however, this abstract knowledge will be used for specific economic ends. Insurers are already calculating the costs of care and comparing it with the quality of a provider's care. Some even start steering customers towards doctors who provide "cheaper"care by rewarding customers financially.
Even though I am supporting transparency in healthcare pricing and the patients right to receive high-quality care, I am concerned that insurers may just focus on cheaper and not necessarily better care.
This in the end will reward those docs that lowball others and comply with checklists and protocols to maintain their competitive edge.
The patients choice in physicians selection will thereby severely hampered.
Yours
Bernd
Posted on Sun, Dec. 03, 2006
HEALTHCARE | THIRD IN AN OCCASIONAL SERIES
Lifting veil on healthcare costs
Exposing the super-secret lists of healthcare pricing could lead to huge changes -- and give consumers a real understanding of the true costs of their treatment.
BY JOHN DORSCHNER
jdorschner@MiamiHerald.com
At Broward General or Mercy Hospital, a coronary bypass operation can be expected to cost $30,909 to $43,407. At Baptist Hospital, the cost is likely to be far more -- $43,070 to $58,271, according the health insurer Cigna.
For women ages 40-64 insured by Aetna, gynecologist Moises Lichtinger in Fort Lauderdale charges $86.93 for a comprehensive exam. In Miami Beach, gynecologist Pedro J. Brasac charges $106.99.
For the first time, insurers are starting to reveal some of the most deeply held secrets of healthcare -- what things really cost. Those revelations may ultimately change what providers charge -- and how much consumers pay.
''We're at the leading edge of a huge change,'' says Brian Klepper of the Center for Practical Health Reform.
Many health insurers and governments are already charging ahead to make information about hospital and doctor quality performance available to the public, but many believe the biggest push -- and the biggest battleground -- will be the revelation of healthcare pricing.
At the moment, healthcare prices are so convoluted that even experts struggle to make sense of them.
The list of prices for Baptist Hospital, for example, is contained in a foot-thick document called a chargemaster. No outsider is allowed to see it. What's more, virtually no one pays those prices. Medicare, Medicaid and consumers with private health plans all pay negotiated rates that may be only a third of the official prices. That means only those without insurance get hit with a full-price bill.
Uwe Reinhardt, the widely respected healthcare economist at Princeton, compares present hospital pricing to entering a department store blindfolded and shopping for a ``clothes benefit program.''
''Only months after a shopping trip would the employee receive . . . a statement explaining how much the employee had to pay for whatever he or she had stuffed, blindfolded, into the shopping cart,'' wrote Reinhardt in the January/February issue of Health Affairs.
That meant the department store/hospital had finally presented its charges, and the insurer then decided what was a ''reasonable'' rate for those charges that it deemed appropriate. Finally, the customer is told to pay a certain percentage of that mysterious figure.
At present, persons with insurance generally don't care about this mysterious pricing. For that coronary by-pass surgery mentioned above, for example, the Cigna patient in one typical high-deductible plan would have an out-of-pocket expense of $3,000 at each facility, regardless of the cost.
Knowing prices now ''helps provide clarity on how much things cost,'' says Joe Mondy, a Cigna spokesman.
''The more people understand the cost of healthcare, the better off we will be,'' says Charles Cutler, national medical director for Aetna.
At some point, however, this abstract knowledge will be used for specific economic ends. Insurers are already calculating the costs of care and comparing it with the quality of a provider's care. ''That's going to start a huge shift,'' says Klepper of the Health Reform group.
The Bush administration in Washington and private insurers believe that hospitals and doctors who do the best in this quality-cost scenario should be rewarded with higher payments -- the so-called ``pay for performance.''
The flip side is steering consumers to those providers who provide quality efficiently. Cigna is already starting to do that, with its Cigna Care Network, made up of doctors who score well for quality and cost-efficiency. Starting in January in 58 markets (including South Florida), members who use the Cigna Care doctors will be rewarded by saving $10 to $30 per office visit.
Doctor quality by itself is a complex issue -- as The Miami Herald discussed in a report last Sunday -- but efficiency may be even more complicated.
Spokesmen for programs like Aetna's Aexcel, UnitedHealthcare's Premium Physicians and Cigna's Care Network insist that efficiency ratings are given only to those physicians who have already shown quality performance, but none of them go into detail about what makes for efficiency.
Theoretically, efficiency could mean keeping patients out of expensive emergency rooms or not requesting unnecessary tests and procedures, but in practice, doctors are suspicious that it might mean simple cost-cutting.
''You have to look very carefully at those efficiency numbers,'' says Nancy Nielsen, a Buffalo internist who's head of the American Medical Association's House of Delegates. ``Some are only about costs. That's where it gets tricky. That's where the biggest fights and negotiations are.''
The AMA is so concerned about insurers forming networks using efficiency measurements that its delegates, meeting in Las Vegas in November, passed a resolution seeking laws to prohibit insurers from creating networks ''based solely on economic criteria.'' Last week, the national organization of doctors joined its first lawsuit on the issue, against Regence BlueShield in Washington state. Insurers insist it won't be ''solely'' on costs, but they say something must be done about cost disparities, many of which have nothing to do with quality of care.
In South Florida, Aetna reports, the negotiated rates -- the real rates insurers pay -- vary widely right now. Knee arthroscopy in an orthopedist's office can cost from $1,922 to $4,000. For a hysteroscopy (the insertion of a small telescope to study a uterus) at an OB/GYN office, the price ranges from $1,200 to $4,756. For a heart catheterization, at a cardiology office, the price ranges from $600 to $2,500.
Of course, top doctors charging more might explain those variations, but what explains differences in radiology tests, such as a magnetic resonance imaging?
''These are commodities,'' says Mondy of Cigna. ''An MRI is an MRI is an MRI.'' But Cigna's studies show that their costs vary by an average of 30 percent.
An MRI without contrast agent at the Cleveland Clinic in Weston costs $400 in Cigna's negotiated fees. Broward General's price is $450. Hollywood Medical Center charges $660.
Some insurers are more focused on advising consumers about estimates for procedures -- without showing the differences between facilities. Blue Cross Blue Shield of Florida, for example, tells its members that coronary bypass surgery for a 45- to 64-year-old in Miami-Dade will cost $55,562 to $80,257 in network, $124,260 to $179,488 out of network, for everything including hospital, surgeon and related costs. In Broward, it would be a couple of thousand less.
A Florida government website also offers pricing information, but it is based on hospitals' gross charges, which persons rarely pay. Still, an uninsured person who is likely to be charged full fare can learn from the website (floridacomparecare.com) that for coronary bypass surgery at Baptist Hospital is $135,573, well below Broward General's $140,227 and Mercy's $154,261.
But the data of Cigna and other insurers reveal that Baptist, which has a near monopoly on the affluent area of southern Miami-Dade, is able to negotiate a much better deal for itself than the others can.
When it comes to real prices -- the negotiated rates -- Cigna pays Baptist about 35 percent of its full charges (around $47,500), while Broward General gets about 26 percent ($37,000) and Mercy receives about 24 percent ($37,000). And, as Cigna members are told on the insurer's website, the three hospitals are all ranked at the top level of three stars for the quality of patients' outcomes.
Eric Shatanof, vice president of Baptist Health South Florida, says that the price of one procedure, such as coronary bypass, doesn't mean that the Baptist hospitals (which include Doctors, South Miami and Homestead) are more expensive in all charges. ``Pricing is pretty complex. We could be more expensive on heart surgery and less expensive on something else.''
However, executives of four other insurers have told The Miami Herald that Baptist is consistently and considerably higher in its pricing. The executives don't want their names used because they don't want to anger the hospital system, which the insurers regard as crucial to maintaining customer satisfaction.
Shatanof acknowledges that ''our cost structure is quite a bit higher than our competitors. We have a higher clinical staffing ratio. We have higher investments, like the remote [intensive care unit] monitoring. So it's not necessarily apples to apples comparisons'' on quality and price.
But if insurers go to tier systems, in which consumers would have to pay more to go to higher-priced hospitals, ''it could change the mix,'' said Shatanof. ``Then you have to change the pricing.''
Prescription Drug Abuse
Dear Friends and Colleagues:
Attached an article from today’s Sun Sentinel highlighting the rampant use of prescription painkillers in Florida.
In the absence of any statewide prescription drug tracking system doctors and pharmacists often have to rely on their best judgment to fill or refill narcotics.
The article states that –“as of June, 32 states had adopted prescription-tracking programs to curb problems such as those in Florida, the most populous state without such a law.”
Furthermore the article correctly reports that – “despite the known dangers, Florida lacks a system for tracking prescription drugs. That, according to law enforcement officials, makes it a haven for addicts and "pill mills," where doctors churn out prescriptions without thoroughly examining patients.”
The Florida Medical Association in cooperation with the State Attorneys Office has released a comprehensive guide for physicians on how to diagnose, manage and treat patients with acute and chronic pain.
I want to EMPHASIZE that the MAJORITY of physician are prescribing narcotic pain medications in a responsible and professional manner!!!!
Nevertheless,we need to continue taking a proactive stand against unethical and unscrupulous “physicians”, who churn out prescriptions for their own financial gain. Those so-called “Pain Management “clinics are sprouting like mushrooms all over the State often owned and operated by doctors, who have little or no special training in pain management. Contrary to common belief these “doctors” are not being duped by patients to write prescriptions or trying to help patient suffering from pain. These “doctors” abuse their prescribing privileges to issue THOUSANDS or highly addictive opioids for ANYONE who pays. These “doctors” are driven by profits and not by the motivation to help patients. We need to protect our profession and point out those drug dealers in white coats and at the same time support legislation creating a statewide prescription pain medication-monitoring program.
Bernd Wollschlaeger,MD,FAAFP
Alarm in South Florida over prescription drug trade
Deaths skyrocket as dealers and addicts flock to S. Florida.
By Vanessa Blum
South Florida Sun-Sentinel
December 3, 2006
Out-of-state drug dealers and addicts are traveling long distances to visit Florida pain clinics, targeting the state because its lax oversight of prescription drugs makes scoring pills easier.
The unwanted tourism alarms state officials who have watched deaths from prescription pain medication skyrocket in recent years. In 2005, such prescription drugs as hydrocodone, methadone and oxycodone contributed to more overdose deaths than all other narcotics combined, according to Florida medical examiners.
Despite the known dangers, Florida lacks a system for tracking prescription drugs. That, according to law enforcement officials, makes it a haven for addicts and "pill mills," where doctors churn out prescriptions without thoroughly examining patients.
The problem was noted in a national drug threat assessment released Nov. 15 by the U.S.Department of Justice. The report outlined the "drug run" phenomenon in South Florida, saying residents of states with prescription monitoring "have in some cases turned to traveling to nearby states ... to illegally obtain pharmaceuticals."
That was the case for more than two dozen people from Kentucky who drove 1,000 miles each way to see doctors in Palm Beach County and Fort Lauderdale. They came by the van-load throughout 2005 and early 2006, returning with doses of OxyContin, Endocet, Percocet, Methadose -- drugs that were more difficult to get at home, according to federal prosecutors.
Eight people involved in the trips pleaded guilty to drug-trafficking charges in Palm Beach federal court, and several more are being tried in Kentucky state courts for alleged drug-related crimes.
The Fort Lauderdale medical office that supplied some of their prescriptions also is being investigated.
Drugs prescribed by Florida doctors caused the deaths of five people in Kentucky, according to prosecutors. One man died from a fatal overdose during the 18-hour drive home.
"We've seen people coming from all over the Southeast United States," said Rick Zenuch, an agent with the Florida Department of Law Enforcement who monitors drug-related trends. "The fact is, illicit drug traffickers don't see state lines as any boundary."
As of June, 32 states had adopted prescription-tracking programs to curb problems such as those in Florida, the most populous state without such a law.
While each system follows slightly different rules, their primary goal is to identify forged prescriptions and to expose so-called doctor shoppers who visit multiple physicians and pharmacies seeking drugs.
The programs generally require doctors to submit information on prescriptions to a centralized database. When an order is filled, the pharmacist also sends an electronic record.
If a doctor or pharmacist were to notice anything amiss in a patient's file, they could contact law enforcement or state health officers.
Kentucky's system is a model for other jurisdictions. Its effectiveness drove illicit drug seekers to surrounding states like Indiana, Ohio, Virginia and West Virginia. Each, in turn, created tracking programs, said Danna Droz, a former administrator of Kentucky's system.
In 2004, Florida's Legislature seemed poised to jump on the bandwagon. OxyContin manufacturer Purdue Pharma agreed to pay the state $2 million to cover start-up costs. But key legislators blocked a vote on the proposal citing its annual $2.8 million price tag and patient privacy considerations.
Dr. Rafael Miguel, a professor of pain medicine at the University of South Florida, called the inaction "infuriating and depressing."
"You have to provide Florida doctors with tools so they can safely prescribe these medications and know they're in the right hands," Miguel said. "Right now doctors are being made unwilling and unknowing participants in the drug trade."
A similar proposal languished and died this year as the legislature focused on other issues. Drug enforcers like Bill Janes, director of the Florida Office of Drug Control, vow to continue their push. Janes said working with lawmakers to pass a prescription-tracking program is his top priority for the new legislative session.
Soon legislators may have no choice. Under a federal law passed in 2006, states that do not implement prescription-tracking within three years will take a backseat for federal funding of drug-related programs.
A prescription tracking system is not a cure-all, Janes said, but could help prevent doctors and pharmacists from unwittingly aiding addicts and drug dealers. Moreover, if criminal activity were suspected, police could get evidence much more quickly.
"It would be a first step," Janes said. "Certainly the opportunity to obtain illegal drugs is much higher if you don't have this."
Maureen Barrett of Fort Lauderdale will support those efforts. She lost her son to a painkiller overdose in 2002 and thinks prescription monitoring might have saved his life.
Drew Parkinson, a student at Florida Atlantic University, received prescriptions for 1,455 pills in 57 days. He died at 25, two days after picking up his final doses.
"Somewhere along the line, a red flag should have come up so they wouldn't have kept giving him the pills," Barrett said.
Privacy concerns cited by opponents are overblown, she added.
"If you go to CVS or Walgreens they have a complete list of all the medicine you've gotten," Barrett said. "We have laws in place to make sure that information is not disseminated."
Dr. Robert Yezierski, director of University of Florida's Comprehensive Center for Pain Research, isn't convinced. He said prescription-tracking is "a good idea in theory," but people who want to abuse the system will find a way.
"What we don't want to do is deny treatment to people who legitimately need pain medication," Yezierski said.
Pain relievers such as methadone and oxycodone -- both chemically altered opioids similar to heroin -- are among the most commonly abused prescription drugs. According to a report published by the Florida Department of Law Enforcement, methadone caused 620 Florida deaths in 2005 -- either alone or in combination with other drugs. The report listed oxycodone as the cause of 340 fatal overdoses.
Used at recommended doses, oxycodone is a powerful treatment for pain and is often prescribed to cancer patients. The drug also is highly addictive and dangerous when taken in large quantities or mixed with alcohol.
Oxycodone tablets sell on the street for about $1 per milligram -- almost 10 times what they cost at a pharmacy.
The Kentucky group frequented clinics in Broward and Palm Beach counties. Some pills went to feed their own addictions, prosecutors and law enforcement say. Others they sold on the street or to friends and neighbors in their small towns near Lexington.
Kentucky law enforcement alerted the Drug Enforcement Administration after a number of overdoses were linked to Florida prescriptions. The individuals charged in federal court range in age from 21 to 64 and face sentences of about four to nine years.
So far, no physicians have been charged in the connection with the case.
In May, federal agents raided the offices of a Fort Lauderdale pain clinic where some Kentucky travelers received prescriptions.
Kentucky grandmother Jewel Padgett, 64, was among those prescribed pills by physicians at the AMMA Pain Care Center in Fort Lauderdale, according to her attorney.
She pleaded guilty to four felonies connected to her Florida trips, including conspiracy to distribute controlled substances and traveling across state lines to promote drug trafficking.
Government lawyers contend Padgett organized and paid for many of the trips from Kentucky in exchange for a portion of the others' pills, earning roughly $30,000.
Padgett's son said his mother went to Florida because she couldn't find a doctor in Kentucky willing to treat neck and back pain caused by a 1998 car accident.
"They wouldn't give her medication she needed," said Don Padgett. "They're scared up here. They got them so restricted."
Fort Lauderdale attorney Theresa Van Vliet, who represents AMMA, said her client supports prescription monitoring and hired a Tallahassee lobbyist earlier this year to push the measure.
"They think it's a good thing," Van Vliet said of her clients. "Pain management is a very new medical field and it is one that clearly can be manipulated."
Van Vliet declined to discuss the Kentucky cases, citing medical privacy laws.
She said AMMA physicians are told to verify medical reports before prescribing pain medication and discouraged from treating out-of-state patients. "It's not foolproof," Van Vliet said, "but nothing is foolproof."
Vanessa Blum can be reached at vbblum@sun-sentinel.com or 954-356-4605.
Attached an article from today’s Sun Sentinel highlighting the rampant use of prescription painkillers in Florida.
In the absence of any statewide prescription drug tracking system doctors and pharmacists often have to rely on their best judgment to fill or refill narcotics.
The article states that –“as of June, 32 states had adopted prescription-tracking programs to curb problems such as those in Florida, the most populous state without such a law.”
Furthermore the article correctly reports that – “despite the known dangers, Florida lacks a system for tracking prescription drugs. That, according to law enforcement officials, makes it a haven for addicts and "pill mills," where doctors churn out prescriptions without thoroughly examining patients.”
The Florida Medical Association in cooperation with the State Attorneys Office has released a comprehensive guide for physicians on how to diagnose, manage and treat patients with acute and chronic pain.
I want to EMPHASIZE that the MAJORITY of physician are prescribing narcotic pain medications in a responsible and professional manner!!!!
Nevertheless,we need to continue taking a proactive stand against unethical and unscrupulous “physicians”, who churn out prescriptions for their own financial gain. Those so-called “Pain Management “clinics are sprouting like mushrooms all over the State often owned and operated by doctors, who have little or no special training in pain management. Contrary to common belief these “doctors” are not being duped by patients to write prescriptions or trying to help patient suffering from pain. These “doctors” abuse their prescribing privileges to issue THOUSANDS or highly addictive opioids for ANYONE who pays. These “doctors” are driven by profits and not by the motivation to help patients. We need to protect our profession and point out those drug dealers in white coats and at the same time support legislation creating a statewide prescription pain medication-monitoring program.
Bernd Wollschlaeger,MD,FAAFP
Alarm in South Florida over prescription drug trade
Deaths skyrocket as dealers and addicts flock to S. Florida.
By Vanessa Blum
South Florida Sun-Sentinel
December 3, 2006
Out-of-state drug dealers and addicts are traveling long distances to visit Florida pain clinics, targeting the state because its lax oversight of prescription drugs makes scoring pills easier.
The unwanted tourism alarms state officials who have watched deaths from prescription pain medication skyrocket in recent years. In 2005, such prescription drugs as hydrocodone, methadone and oxycodone contributed to more overdose deaths than all other narcotics combined, according to Florida medical examiners.
Despite the known dangers, Florida lacks a system for tracking prescription drugs. That, according to law enforcement officials, makes it a haven for addicts and "pill mills," where doctors churn out prescriptions without thoroughly examining patients.
The problem was noted in a national drug threat assessment released Nov. 15 by the U.S.Department of Justice. The report outlined the "drug run" phenomenon in South Florida, saying residents of states with prescription monitoring "have in some cases turned to traveling to nearby states ... to illegally obtain pharmaceuticals."
That was the case for more than two dozen people from Kentucky who drove 1,000 miles each way to see doctors in Palm Beach County and Fort Lauderdale. They came by the van-load throughout 2005 and early 2006, returning with doses of OxyContin, Endocet, Percocet, Methadose -- drugs that were more difficult to get at home, according to federal prosecutors.
Eight people involved in the trips pleaded guilty to drug-trafficking charges in Palm Beach federal court, and several more are being tried in Kentucky state courts for alleged drug-related crimes.
The Fort Lauderdale medical office that supplied some of their prescriptions also is being investigated.
Drugs prescribed by Florida doctors caused the deaths of five people in Kentucky, according to prosecutors. One man died from a fatal overdose during the 18-hour drive home.
"We've seen people coming from all over the Southeast United States," said Rick Zenuch, an agent with the Florida Department of Law Enforcement who monitors drug-related trends. "The fact is, illicit drug traffickers don't see state lines as any boundary."
As of June, 32 states had adopted prescription-tracking programs to curb problems such as those in Florida, the most populous state without such a law.
While each system follows slightly different rules, their primary goal is to identify forged prescriptions and to expose so-called doctor shoppers who visit multiple physicians and pharmacies seeking drugs.
The programs generally require doctors to submit information on prescriptions to a centralized database. When an order is filled, the pharmacist also sends an electronic record.
If a doctor or pharmacist were to notice anything amiss in a patient's file, they could contact law enforcement or state health officers.
Kentucky's system is a model for other jurisdictions. Its effectiveness drove illicit drug seekers to surrounding states like Indiana, Ohio, Virginia and West Virginia. Each, in turn, created tracking programs, said Danna Droz, a former administrator of Kentucky's system.
In 2004, Florida's Legislature seemed poised to jump on the bandwagon. OxyContin manufacturer Purdue Pharma agreed to pay the state $2 million to cover start-up costs. But key legislators blocked a vote on the proposal citing its annual $2.8 million price tag and patient privacy considerations.
Dr. Rafael Miguel, a professor of pain medicine at the University of South Florida, called the inaction "infuriating and depressing."
"You have to provide Florida doctors with tools so they can safely prescribe these medications and know they're in the right hands," Miguel said. "Right now doctors are being made unwilling and unknowing participants in the drug trade."
A similar proposal languished and died this year as the legislature focused on other issues. Drug enforcers like Bill Janes, director of the Florida Office of Drug Control, vow to continue their push. Janes said working with lawmakers to pass a prescription-tracking program is his top priority for the new legislative session.
Soon legislators may have no choice. Under a federal law passed in 2006, states that do not implement prescription-tracking within three years will take a backseat for federal funding of drug-related programs.
A prescription tracking system is not a cure-all, Janes said, but could help prevent doctors and pharmacists from unwittingly aiding addicts and drug dealers. Moreover, if criminal activity were suspected, police could get evidence much more quickly.
"It would be a first step," Janes said. "Certainly the opportunity to obtain illegal drugs is much higher if you don't have this."
Maureen Barrett of Fort Lauderdale will support those efforts. She lost her son to a painkiller overdose in 2002 and thinks prescription monitoring might have saved his life.
Drew Parkinson, a student at Florida Atlantic University, received prescriptions for 1,455 pills in 57 days. He died at 25, two days after picking up his final doses.
"Somewhere along the line, a red flag should have come up so they wouldn't have kept giving him the pills," Barrett said.
Privacy concerns cited by opponents are overblown, she added.
"If you go to CVS or Walgreens they have a complete list of all the medicine you've gotten," Barrett said. "We have laws in place to make sure that information is not disseminated."
Dr. Robert Yezierski, director of University of Florida's Comprehensive Center for Pain Research, isn't convinced. He said prescription-tracking is "a good idea in theory," but people who want to abuse the system will find a way.
"What we don't want to do is deny treatment to people who legitimately need pain medication," Yezierski said.
Pain relievers such as methadone and oxycodone -- both chemically altered opioids similar to heroin -- are among the most commonly abused prescription drugs. According to a report published by the Florida Department of Law Enforcement, methadone caused 620 Florida deaths in 2005 -- either alone or in combination with other drugs. The report listed oxycodone as the cause of 340 fatal overdoses.
Used at recommended doses, oxycodone is a powerful treatment for pain and is often prescribed to cancer patients. The drug also is highly addictive and dangerous when taken in large quantities or mixed with alcohol.
Oxycodone tablets sell on the street for about $1 per milligram -- almost 10 times what they cost at a pharmacy.
The Kentucky group frequented clinics in Broward and Palm Beach counties. Some pills went to feed their own addictions, prosecutors and law enforcement say. Others they sold on the street or to friends and neighbors in their small towns near Lexington.
Kentucky law enforcement alerted the Drug Enforcement Administration after a number of overdoses were linked to Florida prescriptions. The individuals charged in federal court range in age from 21 to 64 and face sentences of about four to nine years.
So far, no physicians have been charged in the connection with the case.
In May, federal agents raided the offices of a Fort Lauderdale pain clinic where some Kentucky travelers received prescriptions.
Kentucky grandmother Jewel Padgett, 64, was among those prescribed pills by physicians at the AMMA Pain Care Center in Fort Lauderdale, according to her attorney.
She pleaded guilty to four felonies connected to her Florida trips, including conspiracy to distribute controlled substances and traveling across state lines to promote drug trafficking.
Government lawyers contend Padgett organized and paid for many of the trips from Kentucky in exchange for a portion of the others' pills, earning roughly $30,000.
Padgett's son said his mother went to Florida because she couldn't find a doctor in Kentucky willing to treat neck and back pain caused by a 1998 car accident.
"They wouldn't give her medication she needed," said Don Padgett. "They're scared up here. They got them so restricted."
Fort Lauderdale attorney Theresa Van Vliet, who represents AMMA, said her client supports prescription monitoring and hired a Tallahassee lobbyist earlier this year to push the measure.
"They think it's a good thing," Van Vliet said of her clients. "Pain management is a very new medical field and it is one that clearly can be manipulated."
Van Vliet declined to discuss the Kentucky cases, citing medical privacy laws.
She said AMMA physicians are told to verify medical reports before prescribing pain medication and discouraged from treating out-of-state patients. "It's not foolproof," Van Vliet said, "but nothing is foolproof."
Vanessa Blum can be reached at vbblum@sun-sentinel.com or 954-356-4605.
Saturday, November 11, 2006
AMA Interim Meeting Day 1 - HHS Secretary and AMA President Address The House of Delegates
LIVE FROM THE FLOOR OF THE AMA HOUSE OF DELEGATES MEETING:
On the first full day of the AMA Interim Meeting our Florida delegation under the leadership of Drs. Troy Tippett and Coy Irvin met for four hours to discuss resolutions and to plan our strategy for the AMA meeting.We have submitted nine resolutions including Recover Audit Contract Appeals, Payer Measures for Private and Public Health Measures, Counterfeit Drug Prevention, Arbitrary and Abusive Economic Profiling, Insurance Reimbursements, Repeal of Sustainable Growth Rate in Medicare Payments to Physicians, Educate the Public on Potential Lack of Access to Healthcare for Medicare Recipients.
In his remarks our AMA President William G. Plested,MD addressed the looming Medicare reimbursement crisis with an anticipated cut of the 2007 rates by 6%-20%!!!
He emphatically called upon physicians to act NOW and not to be content with halfhearted solutions. He criticized Pay-for-Performance Measures as attempts solely focused to curb medical expenditures and NOT as an attempt to improve the quality of medical care.
He called upon physicians to adhere to an uncompromising commitment to the principles of medicine, to curb and reject any attempts to further encroach on the practice of medicine and to resist any interference with the physicians-patient relationship.
In his remarks our AMA President William G. Plested,MD addressed the looming Medicare reimbursement crisis with an anticipated cut of the 2007 rates by 6%-20%!!!
He emphatically called upon physicians to act NOW and not to be content with halfhearted solutions. He criticized Pay-for-Performance Measures as attempts solely focused to curb medical expenditures and NOT as an attempt to improve the quality of medical care.
He called upon physicians to adhere to an uncompromising commitment to the principles of medicine, to curb and reject any attempts to further encroach on the practice of medicine and to resist any interference with the physicians-patient relationship.
His address was followed by remarks of the Secretary of Health and Human Services, Mike Leavitt, who cautioned us that healthcare expenditures continue to rise exponentially soon to reach 25% of the GDP. Furthermore, he expressed his concern that we do not have an interconnected healthcare system enabling us to seamlessly exchange information to improve and maximize quality care and to safeguard patient safety.He urged physicians to embrace medical information technology and to integrate certified EHR solutions.
In his opinion we have to move from a volume-based reimbursement system to an algorithm of quality-based payment modality and calls upon physician to embrace this concept and the voluntary quality reporting system.
In a Q&A session he answered several questions submitted in writing by the HOD delegates focusing on the unfair reimbursement practices that will jeopardize the viability of our medical practices.
In my opinion, Secretary Leavitt does not seem to understand the potential impact of the Medicare cuts and tries to couple increased payments with demonstrated quality of care. He ignores that Baby-Boomers are eligible for Medicare resulting in an increased volume of Medicare services.
Unfortunately, the SGR is still focused on a volume-based reimbursement formula, which is penalizing physicians for seeing more Medicare patients.
The solution may be to freeze Medicare services rendered thereby diminishing access to care for Medicare recipients.
Our AMA has decided to FIGHT BACK.
I urge you to order the "Medicare Physician Payment Action Kit" . You can obtain more information regarding Medicare cuts and suggestions how to address this crisis by visiting our website at http://www.ama-assn.org/ama/pub/category/13409.html .
Monday, November 06, 2006
Election Issues
Dear Friends and Colleagues:
Attached you find an interesting article from todays Miami Herald emphasizing election issues that got buried in the election hysteria.
Foreign policy and National Security issues are being stressed as the crucial topics in the campaign. What has been forgotten by most candidates , including both Gubernatorial candidates, that small businesses are facing double-digit increases in healthcare expenditures. Employers can simply not afford offering affordable health insurance. They can drop health insurance, offer health insurance for a few employees and let go of the others, or try providing barebone health insurance with significant out-of pocket expenditures for all.
These issues need to be addressed at once to maintain the viability of small businesses and to guarantee jobs for Americans that actually offer meaningful health insurance coverage.
Unfortunately, short-term solutions seem to make the headlines such as the decision by Baptist health systems in Miami to prefer business vendors that offer health insurance to their employees. That maybe a nice PR stunt, but its not a solution.
Baptist hospital decision may very well push small companies out of the market, which just cannot compete under those conditions leaving big corporations in the game. We should assist instead of punishing small employers.
What we need are: national insurance purchasing pools, risk diversification to minimize the impact of catastrophic medical bills on small companies, individualized insurance packages not limited by state insurance mandates, and not-for profit state or national prescription purchasing plans that can negotiate the most competitive prices with drug manufactures.
It requires a sustained bipartisan effort to fix our healthcare system now to save small businesses from certain demise.
Bernd Wollschlaeger,MD,FAAFP
Vice-President Dade County Medical Association
16899 NE 15th Avenue
North Miami Beach,FL 33162
(305) 940-8717
Healthcare, taxes top election wish list for small business owners Miami Herald, 11/06/06
Small business owners want to see improvements on issues such as rising healthcare costs, regulation and taxes after the midterm elections.
BY JOYCE M. ROSENBERG
Associated Press
Some of the most frustrating problems facing small business owners -- the ever-rising cost of health coverage, expanding government regulations and uncertainty about taxes -- are again concerns as the midterm elections approach. Owners have hopes for change on some of these issues, but they realize that others are likely to remain unresolved, no matter who wins in November.
Many small business owners say healthcare costs is one of their biggest problems -- they want to offer insurance to attract the best workers, but it's becoming more and more expensive.
Businesses have been looking to the federal government for help, but a possible solution known as association health plans, which would allow small businesses to band together across state lines to buy insurance in groups, has continually stalled in Congress. In the meantime, the cost of insurance coverage is soaring.
''It's gone up pretty much by double digits every year and they're finding it harder and harder to get,'' Dan Danner, executive vice president for public policy with the National Federation of Independent Business, said of small business owners and insurance. ``They don't feel like they have many choices in the marketplace.''
Brian Drum, CEO of Drum Associates, a New York-based executive recruiter, voiced the frustration about healthcare costs felt by many small business owners: ``It seems like it's out of sync with other things that are inflating.''
TAX CONCERNS
Business owners are concerned about taxes on several levels -- they want to see current tax rates cut, but they're also concerned about their taxes in the future.
Danner, whose advocacy group is based in Washington, D.C., said the federal estate tax laws remain an issue with business owners, many of whom want their families to be able to continue owning and running the company after they die.
The laws currently exempt the first $2 million of an estate, and the top rate is 46 percent; those numbers will continue to decline through 2010, but then, unless Congress acts to extend the law, they will revert to older and higher rates in 2011.
If an estate including a family business is valued at above the law's threshold, an owner's heirs could be forced to sell it in order to pay the estate tax.
Danner said he believed Congress would act before then to extend those provisions, but there's no way of knowing at this point how lawmakers might change the law. And with the possibility of more Democrats in the new Congress when it convenes in January, business owners might be even more uneasy; it is the Republican party that has backed reductions in the estate tax.
''They would like A, for it to be lower and B, to have some certainty,'' Danner said of business owners and the tax. ``They're trying to plan for the future.''
Similarly, small business owners want to know what's ahead for what's called the Section 179 tax deduction, said Cheryl Womack, chairwoman of Leading Women Entrepreneurs of the World, an association of businesswomen based in Kansas City, Mo.
The deduction, named for a provision of the Internal Revenue Code, allows small businesses to deduct upfront rather than depreciate the costs of certain equipment. For the 2006 tax year, the deduction is $108,000.
MORE REGULATION?
A nebulous and multipronged issue has to do with government regulations that affect many different aspects of running a business.
Jennifer Kluge, president of the National Association for Business Resources, said the growing number of regulations administered by federal agencies is another reason why business owners are concerned about a more heavily Democratic Congress.
''It seems like when we have Democrats in office, we get a lot more regulatory issues to deal with,'' Womack said.
But regulations also come from state and local governments. And because of the multitude of rules that affect a cross-section of industries, change in the form of repealed regulations will be hard to come by.
''It's a long shot, it'll probably never happen,'' said Kluge, whose business group is based in Warren, Mich.
Attached you find an interesting article from todays Miami Herald emphasizing election issues that got buried in the election hysteria.
Foreign policy and National Security issues are being stressed as the crucial topics in the campaign. What has been forgotten by most candidates , including both Gubernatorial candidates, that small businesses are facing double-digit increases in healthcare expenditures. Employers can simply not afford offering affordable health insurance. They can drop health insurance, offer health insurance for a few employees and let go of the others, or try providing barebone health insurance with significant out-of pocket expenditures for all.
These issues need to be addressed at once to maintain the viability of small businesses and to guarantee jobs for Americans that actually offer meaningful health insurance coverage.
Unfortunately, short-term solutions seem to make the headlines such as the decision by Baptist health systems in Miami to prefer business vendors that offer health insurance to their employees. That maybe a nice PR stunt, but its not a solution.
Baptist hospital decision may very well push small companies out of the market, which just cannot compete under those conditions leaving big corporations in the game. We should assist instead of punishing small employers.
What we need are: national insurance purchasing pools, risk diversification to minimize the impact of catastrophic medical bills on small companies, individualized insurance packages not limited by state insurance mandates, and not-for profit state or national prescription purchasing plans that can negotiate the most competitive prices with drug manufactures.
It requires a sustained bipartisan effort to fix our healthcare system now to save small businesses from certain demise.
Bernd Wollschlaeger,MD,FAAFP
Vice-President Dade County Medical Association
16899 NE 15th Avenue
North Miami Beach,FL 33162
(305) 940-8717
Healthcare, taxes top election wish list for small business owners Miami Herald, 11/06/06
Small business owners want to see improvements on issues such as rising healthcare costs, regulation and taxes after the midterm elections.
BY JOYCE M. ROSENBERG
Associated Press
Some of the most frustrating problems facing small business owners -- the ever-rising cost of health coverage, expanding government regulations and uncertainty about taxes -- are again concerns as the midterm elections approach. Owners have hopes for change on some of these issues, but they realize that others are likely to remain unresolved, no matter who wins in November.
Many small business owners say healthcare costs is one of their biggest problems -- they want to offer insurance to attract the best workers, but it's becoming more and more expensive.
Businesses have been looking to the federal government for help, but a possible solution known as association health plans, which would allow small businesses to band together across state lines to buy insurance in groups, has continually stalled in Congress. In the meantime, the cost of insurance coverage is soaring.
''It's gone up pretty much by double digits every year and they're finding it harder and harder to get,'' Dan Danner, executive vice president for public policy with the National Federation of Independent Business, said of small business owners and insurance. ``They don't feel like they have many choices in the marketplace.''
Brian Drum, CEO of Drum Associates, a New York-based executive recruiter, voiced the frustration about healthcare costs felt by many small business owners: ``It seems like it's out of sync with other things that are inflating.''
TAX CONCERNS
Business owners are concerned about taxes on several levels -- they want to see current tax rates cut, but they're also concerned about their taxes in the future.
Danner, whose advocacy group is based in Washington, D.C., said the federal estate tax laws remain an issue with business owners, many of whom want their families to be able to continue owning and running the company after they die.
The laws currently exempt the first $2 million of an estate, and the top rate is 46 percent; those numbers will continue to decline through 2010, but then, unless Congress acts to extend the law, they will revert to older and higher rates in 2011.
If an estate including a family business is valued at above the law's threshold, an owner's heirs could be forced to sell it in order to pay the estate tax.
Danner said he believed Congress would act before then to extend those provisions, but there's no way of knowing at this point how lawmakers might change the law. And with the possibility of more Democrats in the new Congress when it convenes in January, business owners might be even more uneasy; it is the Republican party that has backed reductions in the estate tax.
''They would like A, for it to be lower and B, to have some certainty,'' Danner said of business owners and the tax. ``They're trying to plan for the future.''
Similarly, small business owners want to know what's ahead for what's called the Section 179 tax deduction, said Cheryl Womack, chairwoman of Leading Women Entrepreneurs of the World, an association of businesswomen based in Kansas City, Mo.
The deduction, named for a provision of the Internal Revenue Code, allows small businesses to deduct upfront rather than depreciate the costs of certain equipment. For the 2006 tax year, the deduction is $108,000.
MORE REGULATION?
A nebulous and multipronged issue has to do with government regulations that affect many different aspects of running a business.
Jennifer Kluge, president of the National Association for Business Resources, said the growing number of regulations administered by federal agencies is another reason why business owners are concerned about a more heavily Democratic Congress.
''It seems like when we have Democrats in office, we get a lot more regulatory issues to deal with,'' Womack said.
But regulations also come from state and local governments. And because of the multitude of rules that affect a cross-section of industries, change in the form of repealed regulations will be hard to come by.
''It's a long shot, it'll probably never happen,'' said Kluge, whose business group is based in Warren, Mich.
Friday, November 03, 2006
Baptist Hospital and the Uninsured - Another Perspective
RE: Editorial, Help for uninsured
Baptists hospital’s decision to favor vendors who provide health coverage to their employees may me just one of those PR bubbles.
Facing double-digit increases in healthcare expenditures employers can simply not afford offering affordable health insurance. They can drop health insurance, offer health insurance for a few employees and let go of the others or try providing barebones health insurance with significant out-of pocket expenditures for all.
Baptist hospital decision may very well push small companies out of the market, which just cannot compete under those conditions leaving big corporations in the game.
We should assist instead of punishing small employers.
What we need are: national insurance purchasing pools, risk diversification to minimize the impact of catastrophic medical bills on small companies, individualized insurance packages not limited by state insurance mandates, and not-for profit state or national prescription purchasing plans that can negotiate the most competitive prices with drug manufactures.
The US health insurance system is broken favoring the healthy and punishing the sick.
It requires a sustained bipartisan effort to fix it now to save small businesses from certain demise.
Bernd Wollschlaeger,MD,FAAFP
Vice-President Dade County Medical Association
16899 NE 15th Avenue
North Miami Beach,FL 33162
(305) 940-8717
TRAIGHT TO THE POINT
Help for uninsured
Baptist Hospital’s new policy of favoring vendors who provide health coverage to their employees is a good example of doing well by doing good. The policy will affect more than 10,000 suppliers -- and undoubtedly will make a difference.
It is based on a simple, effective idea: Encourage firms to offer vital health benefits. This is good for employees and for communities that often subsidize uninsured patients at public hospitals and clinics. Studies have shown that insured people seek more preventive care, which promotes better health and lessens the need for more-expensive, last-minute treatment.
Baptist will benefit, too, because it provides health care for many uninsured -- at a cost of more than $100 million last year. Let us hope that the trend catches on and shrinks South Florida's uninsured population.
Baptists hospital’s decision to favor vendors who provide health coverage to their employees may me just one of those PR bubbles.
Facing double-digit increases in healthcare expenditures employers can simply not afford offering affordable health insurance. They can drop health insurance, offer health insurance for a few employees and let go of the others or try providing barebones health insurance with significant out-of pocket expenditures for all.
Baptist hospital decision may very well push small companies out of the market, which just cannot compete under those conditions leaving big corporations in the game.
We should assist instead of punishing small employers.
What we need are: national insurance purchasing pools, risk diversification to minimize the impact of catastrophic medical bills on small companies, individualized insurance packages not limited by state insurance mandates, and not-for profit state or national prescription purchasing plans that can negotiate the most competitive prices with drug manufactures.
The US health insurance system is broken favoring the healthy and punishing the sick.
It requires a sustained bipartisan effort to fix it now to save small businesses from certain demise.
Bernd Wollschlaeger,MD,FAAFP
Vice-President Dade County Medical Association
16899 NE 15th Avenue
North Miami Beach,FL 33162
(305) 940-8717
TRAIGHT TO THE POINT
Help for uninsured
Baptist Hospital’s new policy of favoring vendors who provide health coverage to their employees is a good example of doing well by doing good. The policy will affect more than 10,000 suppliers -- and undoubtedly will make a difference.
It is based on a simple, effective idea: Encourage firms to offer vital health benefits. This is good for employees and for communities that often subsidize uninsured patients at public hospitals and clinics. Studies have shown that insured people seek more preventive care, which promotes better health and lessens the need for more-expensive, last-minute treatment.
Baptist will benefit, too, because it provides health care for many uninsured -- at a cost of more than $100 million last year. Let us hope that the trend catches on and shrinks South Florida's uninsured population.
Sunday, October 22, 2006
Healthcare and the American Public
Dear Friends and Colleagues;
Americans say that high costs and the lack of insurance and access to care are the most pressing health care problems for government to address, Robert Blendon and coauthors report in an article published October 17 as a Health Affairs Web Exclusive.
Writing a month before the 2006 congressional election, the researchers also say that health care overall is a "second-tier issue" for the American public, ranking behind Iraq, the economy, and gasoline prices as a priority for government action. However, health care still ranks higher today than issues such as education, the environment (including global warming), Social Security, poverty, and crime.
Understanding The American Public’s Health Priorities: A 2006 Perspective
Health issues are on Americans’ minds,but they are not the top priority in 2006.
by Robert J. Blendon, Kelly Hunt, John M. Benson, Channtal Fleischfresser, and Tami Buhr
ABSTRACT:
Opinion surveys conducted in 2006 show that health care is an important but second-tier issue in terms of priorities for government action. Americans’ top health care concerns are mostly related to economic insecurity: rising costs and the problems of the uninsured. The biggest perceived health threats are cancer, HIV/AIDS, and avian flu. Although most Americans do not think that the health system is in crisis, the public remains dissatisfied with both the country’s health care and public health systems. These attitudes are likely to create a climate that is supportive of increased health spending and substantial policy changes. [Health Affairs 25 (2006): w508–w515 (published online 17 October 2006; 10.1377/hlthaff.25.w508)]
This is the fifth in a series of essays published by Health Affairs examining Americans’ health and health care priorities.1 As in our earlier reviews of this subject, findings show that the American public has a clear set of priorities for the country, which have changed over time in response to specific events and the emergence of new health concerns. Public priorities typically emerge either when an issue is high on policymakers’ agendas and written up regularly in the popular press or when it represents a serious, real-life problem that people experience. Immigration, for example, rose to become one of the top three public priorities in April 2006, while it was high on policymakers’ agenda and written about daily in the newspapers.2 On the other hand, some issues, such as health care, that are part of people’s everyday lives remain much more enduring concerns in poll findings.
The Role Of Public Opinion
Over the past thirty-five years, there has been a huge jump in the number of polls conducted by decisionmakers in U.S. society, to monitor public opinion on a variety of topics.3 These include polls paid for by the media, political parties and leaders, interest groups, and foundations.4 Studies have shown that politicians continually monitor public opinion, attempt to shape it, and enlist it to gain leverage over other political actors. For example, research shows that polling done for U.S. presidents has gone from a relatively rare activity to a continuous information-gathering effort.5 Public opinion surveys provide politicians with information about what their constituents want across a wide variety of issues. This might lead them to be more responsive to general public opinion or to some subset such as members of their own political party or so-called swing voters.
Notwithstanding this substantial increase in monitoring of public opinion by decisionmakers, the role that public opinion actually plays in leaders’ ultimate policy decisions is not completely clear. There is general but not complete consensus among political scientists that public opinion plays a role in government decision making in certain circumstances and on certain issues, but not in all. But there is no agreement among all scholars about the particular circumstances and issues where decisionmakers pay attention to or ignore public opinion.6 What the research does show is that if an issue is salient to the public (a subject we examine in this paper), decisionmakers are more likely to pay attention to public opinion than they are for issues that are not very salient to the public.7
Research has shown that both the president and Congress respond to public opinion on issues that rank high in public concern or that people confront in their day-to-day lives.8 Health care is one such issue. Decisionmakers show greater responsiveness to public opinion when determining government spending on health care than in policy areas that are more remote from people’s daily lives, such as foreign aid.
In this paper we examine Americans’ health priorities along six dimensions: (1) the relative importance of health care as an issue for government to address, (2) the top health care issues for government, (3) views on national health spending and health care costs, (4) current ratings of the health care system and personal experiences with health care, (5) top general health concerns for future government action, and (6) ratings of the nation’s public health system and the general health conditions in their communities.
Study Data And Methods
To present a comprehensive picture of the public’s health priorities in 2006 and the changes that have taken place over time, this paper analyzes polling results from nineteen national opinion surveys conducted between 1940 and 2006. We pay particular attention to trends since the time of the Clinton health reform plan (early 1990s).
The survey data are from two main sources. The first consists of two Harvard School of Public Health/Robert Wood Johnson Foundation polls. International Communications Research (ICR) conducted fieldwork for both polls via telephone. For “Americans’ Views of the Healthcare System,” ICR conducted interviews 5–9 April 2006 with a nationally representative sample of 1,108 adults (age eighteen and older). For “Americans’ Views of Public Health,” ICR conducted interviews 31 March–4 April 2006 with a nationally representative sample of 1,107 adults. The margin of error for the total samples in each survey was plus or minus three percentage points at the 95 percent confidence level.9
The second source consists of seventeen other national opinion surveys that contain current and historical data. The criteria for inclusion in the paper are that the poll questions (1) reflect the public’s current priorities and the salience of the issues; (2) are the most current on a particular issue; or (3) represent trends that shed light on the public’s views and priorities over time. A number of organizations conducted these polls: Harris Interactive, Gallup, ABC News/Washington Post, the Pew Research Center, and the National Opinion Research Center/General Social Survey. All of the surveys were conducted by telephone, except for a 1940 Gallup poll and the General Social Survey, which were conducted in person. The sample sizes range from 1,000 to 1,500. The margin of error (at the 95 percent confidence level) for a sample of 1,000 is plus or minus three percentage points; for a sample of 1,500, it is plus or minus 2.5 points.
Survey Findings
Relative importance of health care as an issue for government to address. Elected officials can work on only a limited number of major issues at one time. To ascertain what the public thinks the priorities for government action should be, respondents were asked in August 2006 to say in their own words what they considered the top two issues for government to address. The results suggest that in terms of priority for government action, health care is a second-tier issue (Exhibit 1). Today it ranks as the fourth most important issue for government to address, behind the war, the economy, and gasoline/oil prices/energy. This is a lower ranking for health care than in 1993, a time of major national debate about health care reform. In the 2006 survey, health care was one of the top two issues for 13 percent of the population. This compares to 31 percent in 1993, when it was ranked second, and 9 percent in 2002, when it also ranked fourth.10
The list of the most important issues for government to address often corresponds the public’s ranking of issues that they say will be most important in their voting choices. In August 2006, health care ranked fourth when respondents were asked which of six issues would be most important in their vote for Congress. Once again, health care ranked behind Iraq, the economy, and gasoline prices, but ahead of terrorism and education.11
Of note, although health care is not among the top-priority issues for government action, it ranks higher today than many other national problems often identified as being very important. Health care issues rank higher than terrorism, the top issue in late 2001, as well as education, the environment (including global warming), Social Security, poverty, crime, and problems in the developing world.12 This consistent rating of health care among the top four concerns signifies that it is an issue of ongoing concern for the public, regardless of how high a priority policymakers make it.
Top health care issues. More specifically, respondents were asked to say, again in their own words, what they thought were the two most important health care problems that government should address. Health care costs and the lack of insurance/access to care were the most frequently cited (Exhibit 2). Medicare and the prescription drug benefit, the subject of current national attention, ranked third but well behind these other two. Quality of care, an issue of considerable concern to many national health policy leaders, ranked fourth.13
These priorities correspond with the public’s assessment of the state of health care in the country. In November 2005, only 20 percent of Americans were satisfied with the cost of health care, and only 21 percent rated health care coverage in this country as excellent or good.14 In April 2006, about four in ten Americans (41 percent) approved of the Medicare prescription drug program.15 And in November 2005, just over half (53 percent) rated the quality of health care in the United States as excellent or good.16
Views on national health spending and health care costs. Multiple survey results show that the public favors increased health spending in the years ahead but is concerned about the impact of rising health care costs on the financial situation of American families. In 2004, 78 percent of the public thought that national spending to improve health was too low; only 4 percent said that it was too high.17 Similarly, in 2006 a survey asked specifically about overall national spending on health care and national health care spending by government. The majority of respondents (57 percent) thought that the United States as a country was spending too little on health care in the aggregate, and 70 percent said that government health care spending was too low. Only 26 percent thought that the country as a whole was spending too much, and 11 percent thought that the government was spending too much. Around one-tenth of Americans thought that these spending levels were “about right” (9 percent, nation as a whole; 11 percent, government).18
What concerns Americans is not aggregate spending, but the perceived negative impact on American families of their direct health care outlays (insurance premiums, copayments, deductibles, and direct payments for services and products). When asked about spending for health care by average Americans in 2006, 65 percent of respondents said that the average American spends too much, while only 17 percent said too little.19 (Twelve percent felt that the level of spending was “about right.”) This is what Americans mean when they list health care costs as the top health care priority for government action.
Ratings of the health care system and their own care. As of spring 2006, most Americans were dissatisfied with the state of the U.S. health care system. About seven in ten respondents (69 percent) rated the nation’s system for providing medical care as fair or poor (Exhibit 3).20 Furthermore, in August 2006, only about four in ten respondents expressed “a great deal” or “quite a lot” of confidence in the health care system, a level that has remained relatively constant for more than ten years.21
Although the public is critical of the health system, only 22 percent think that it is in a state of crisis. However, this is a much higher proportion than in 2002 (11 percent). Most people think that the system has major problems, a view that has remained relatively stable since 1994 (Exhibit 4).22
In contrast to their views on the health system, most Americans are satisfied with their own most recent medical care experiences. Three-fourths of respondents had received medical care in the past year. Of those who received care, more than four in five people said that the services (84 percent) and physician care (85 percent) they received were excellent or good.23 This pattern has appeared in multiple surveys in previous years.24
A likely reason for the difference in opinions about the overall health system versus personal health care experiences could be that general health system questions tend to measure broader public concerns about the insecurity of health insurance coverage, high prices, bureaucracy, waste, and disparities in access to care in the United States. Measures of personal experiences are narrower and reflect individuals’ mostly positive recent experiences with care received from doctors and nurses; they do not take into account these other perceived societal problems.
Top general health concerns for government action. Respondents were also asked to state in their own words what they thought were the two most important diseases or health conditions for government to address. Cancer (51 percent) and HIV/AIDS (41 percent) were the top two health priorities stated.25 Smaller percentages also identified avian flu (21 percent), heart disease (16 percent), and diabetes (11 percent) as top priorities. Of interest, a parallel question asked respondents about the diseases and health conditions that posed the greatest threats to the American public. On this question, the rankings were essentially identical to the findings about priorities for government action, except that obesity tied with diabetes for fifth place. This suggests that a share of the public sees obesity as a serious national health concern but not as a current top priority for government action (3 percent), even though almost half (47 percent) see obesity as a major problem in their communities.26
Of historical note, these health priorities can change markedly over long periods of time. In 1940, Americans were asked to name the most serious health problem from a list of diseases considered very important at the time. Syphilis was the public’s top concern (46 percent), followed by cancer (29 percent), tuberculosis (16 percent), and polio (9 percent).27
Ratings of the public health system and health conditions in their communities. The country faces a number of public health threats that have emerged since 2001, such as severe acute respiratory syndrome (SARS), anthrax, smallpox, avian flu, and obesity. These threats have raised concerns about the adequacy of the U.S. public health system. When asked their assessment, the majority of respondents reported that they were not satisfied with the nation’s current system for protecting the public from these threats and preventing illness. Just over half of respondents rated the public health system as fair or poor, while fewer than half rated it as excellent or good (Exhibit 3).28
More Americans report satisfaction with the public health conditions in their own communities than with the overall public health system. About three-quarters of respondents gave excellent or good ratings to the quality of life in their communities (76 percent). The majority gave excellent or good ratings to the quality of emergency services such as police, fire, and ambulance (78 percent), as well as to air quality (69 percent), the availability of preventive health services (69 percent), the quality of drinking water (67 percent), and the availability of recreational facilities (65 percent). In addition, respondents were asked about whether health conditions in their community had changed during the last two years. Almost seven out of ten (69 percent) reported no change. Relatively small percentages thought that conditions had gotten better (14 percent) or worse (13 percent).29
Discussion And Conclusions
Most U.S. news coverage about medical care issues during the past year has concentrated on Medicare’s new prescription drug benefit, while many in the research and professional community have focused on the nation’s quality-of-care problems. What is important to recognize is that these are not the American public’s top health care priorities today. Americans want their government to do something about their rising health care costs and the problems of the uninsured. When Americans talk about health care costs, however, their concern is not for the share of the nation’s gross domestic product (GDP) going toward health care, but rather the financial impact on their own families.
Also important to recognize is that cancer and HIV/AIDS are the public’s top priorities as health threats that they want government to address. Even though there have been no human cases of avian flu in the United States, that emerging disease has now joined this list. Cancer has remained a major health concern to the American public for more than sixty years. Although there have been major medical advances in cancer care, it is still an issue that worries many Americans.
Another issue that could become more important to the public in the future is obesity. Although it has emerged as a major concern for the public in general and in their communities, the government role in obesity prevention is unclear for many Americans. This could change over time, as obesity receives more attention from the media and health professionals.
The public considers the wars in Iraq and Afghanistan to be the top issues for government. But the survey findings also indicate that from a public perspective, health issues are very likely to remain prominent on the national agenda. Although health care is not the top issue for Americans, it consistently ranks among the top five issues for government to address. In addition, contrary to the concerns of many experts, the public continues to favor more rather than less health spending in the aggregate.
Moreover, although most Americans do not think that the health system is in crisis, the public remains dissatisfied with the country’s health care and public health systems. These attitudes are likely to create a climate supportive of both increased health spending and substantial change in the years ahead.
This work was supported by a grant from the Robert Wood Johnson Foundation. The views expressed are solely those of the authors, and no official endorsement by the sponsor is intended or should be inferred.
NOTES
1. R.J. Blendon et al., “Americans’ Health Priorities: Curing Cancer and Controlling Costs,” Health Affairs 20, no. 6 (2001): 222–232; R.J. Blendon et al., “Americans’ Health Priorities Revisited after September 11,” Health Affairs 20 (2001): w96–w99 (published online 13 November 2001; 10.1377/ hlthaff.w1.96); R.J. Blendon et al., “The Impact of Terrorism and the Recession on Americans’ Health Priorities,” Health Affairs 21 (2002): w420–w425 (published online 17 January 2002; 10.1377/ hlthaff.w2.420); and R.J. Blendon et al., “The Continuing Legacy of September 11 for Americans’ Health Priorities,” Health Affairs 21 (2002): w269–w275 (published online 14 August 2002; 10.1377/hlthaff.w2.269).
2. Harris Interactive, “President Bush’s Job Approval Ratings Remain Low,” Harris Poll no. 30, 19 April 2006, http://www.harrisinteractive.com/harris_poll/index.asp?PID=654 (accessed 13 September 2006).
3. J.G. Geer, From Tea Leaves to Opinion Polls: A Theory of Democratic Leadership (New York: Columbia University Press, 1996).
4. Our search of the iPOLL database at the Roper Center for Public Opinion Research, the country’s largest archive of public opinion data, found a steady growth in the number of polling questions asked during each successive election cycle: from 8,752 questions in 1980, to 14,132 in 1988, to 19,458 in 1996, to 22,448 in 2004. See also E.C. Ladd and J.M. Benson, “The Growth of News Polls in American Politics,” in Media Polls in American Politics, ed. T.E. Mann and G.R. Orren (Washington: Brookings Institution, 1992), 19–31.
5. R.M. Eisinger, The Evolution of Presidential Polling (Cambridge: Cambridge University Press, 2003).
6. J. Manza, F.L. Cook, and B.I. Page, eds., Navigating Public Opinion: Polls, Policy, and the Future of American Democracy (Oxford: Oxford University Press, 2002); R.S. Erikson, G.C. Wright, and J.P. McIver, Statehouse Democracy: Public Opinion and Democracy in American States (New York: Cambridge University Press, 1993); L.R. Jacobs and R.Y. Shapiro, Politicians Don’t Pander: Political Manipulation and the Loss of Democratic Responsiveness (Chicago: University of Chicago Press, 2000); A.D. Monroe, “Public Opinion and Public Policy: 1980–1993,” Public Opinion Quarterly 62, no. 1 (1998): 6–28; and J.A. Stimson, M.B. MacKuen, and R. Erikson, “Dynamic Representation,” American Political Science Review 89, no. 3 (1995): 543–565.
7. B. Canes-Wrone and K.W. Shotts, “The Conditional Nature of Presidential Responsiveness to Public Opinion,” American Journal of Political Science 48, no. 4 (2004): 690–706; J. Manza and F.L. Cook, “A Democratic Polity: Three Views of Policy Responsiveness to Public Opinion in the United States,” American Politics Research 30, no. 6 (2002): 630–667; and C. Wlezien, “Patterns of Responsiveness: Dynamics of Public Preferences and Policy,” Journal of Politics 66, no. 1 (2004): 1–24.
8. B. Canes-Wrone, Who Leads Whom? Presidents, Policy, and the Public (Chicago: University of Chicago Press, 2006); Canes-Wrone and Shotts, “The Conditional Nature”; and Wlezien, “Patterns of Responsiveness.”
9. Harvard School of Public Health/Robert Wood Johnson Foundation, “Americans’ Views of Public Health” poll (Storrs, Conn.: Roper Center for Public Opinion Research, 31 March–4 April 2006); and HSPH/RWJF, “Americans’ Views of the Healthcare System” poll (Storrs, Conn.: Roper Center, 5–9 April 2006).
10. For 1993 and 2002, Harris Interactive, “The National Mood Changes as Ratings of Bush, Cabinet Members and the Congress Fall Sharply—TABLES,” Harris Poll no. 34, 24 July 2002,
http://www.harrisinteractive.com/harris_poll/tables/ 2002/july_24_2002.htm (accessed 13 September 2006); for 2006, Harris Interactive, “Democrats Continue to Hold Substantial Lead over Republicans in Race for Congress,” Harris Poll no. 63, 11 August 2006,
http://www.harrisinteractive.com/harris_poll/index.asp?PID=689 (accessed 13 September 2006).
11. ABC News/Washington Post poll (Storrs, Conn.: Roper Center, 3–6 August 2006).
12. Harris Interactive, “President Bush’s Job Approval Ratings Remain Low”; for 2001 results, see Blendon et al., “The Continuing Legacy,” w270.
13. HSPH/RWJF, “Americans’ Views of the Healthcare System” poll.
14. Gallup poll (Storrs, Conn.: Roper Center, 7–10 November 2005).
15. ABC News/Washington Post poll (Storrs, Conn.: Roper Center, 6–9 April 2006).
16. Gallup poll, 7–10 November 2005.
17. J.A. Davis and T.W. Smith, General Social Survey (Chicago: National Opinion Research Center, 2004).
18. Pew Research Center for the People and the Press poll, “March 2006 News Interest Index, Final Topline,” 8–12 March 2006, http://people-press.org/reports/questionnaires/273.pdf (accessed 13 September 2006).
19. Ibid.
20. HSPH/RWJF, “Americans’ Views of the Healthcare System” poll.
21. Gallup Poll, “Confidence in Institutions” (Princeton, N.J.: Gallup Organization, 14 August 2006).
22. Gallup polls (Storrs, Conn.: Roper Center, 6–7 September 1994, 11–13 September 2000, 11–14 November 2002, 3–5 November 2003, 7–10 November 2005); and HSPH/RWJF poll (Storrs, Conn.: Roper Center, 10–15 August 2006).
23. HSPH/RWJF, “Americans’ Views of the Healthcare System” poll.
24. R.J. Blendon, M. Brodie, and J.M. Benson, “Health Policy,” in Polling America: An Encyclopedia of Public Opinion, ed. S.J. Best and B. Radcliff (Westport, Conn.: Greenwood Press, 2005), 289–291.
25. HSPH/RWJF, “Americans’ Views of Public Health” poll.
26. Ibid.
27. Gallup poll (Storrs, Conn.: Roper Center, 8–13 March 1940).
28. HSPH/RWJF, “Americans’ Views of Public Health” poll; and HSPH/RWJF, “Americans’ Views of the Healthcare System” poll.
29. HSPH/RWJF, “Americans’ Views of Public Health” poll.
Robert Blendon (rblendon@hsph.harvard.edu) is a professor of health policy and political analysis at the Harvard School of Public Health (HSPH) in Boston, Massachusetts. Kelly Hunt is senior program director at the New York State Health Foundation, in New York City. At the time the study was conducted, she was a research officer at the Robert Wood Johnson Foundation in Princeton, New Jersey. John Benson is managing director, Channtal Fleischfresser is a research assistant, and Tami Buhr is assistant director at the Harvard Opinion Research Program, HSPH.
DOI: 10.1377/hlthaff.25.w508
Americans say that high costs and the lack of insurance and access to care are the most pressing health care problems for government to address, Robert Blendon and coauthors report in an article published October 17 as a Health Affairs Web Exclusive.
Writing a month before the 2006 congressional election, the researchers also say that health care overall is a "second-tier issue" for the American public, ranking behind Iraq, the economy, and gasoline prices as a priority for government action. However, health care still ranks higher today than issues such as education, the environment (including global warming), Social Security, poverty, and crime.
Understanding The American Public’s Health Priorities: A 2006 Perspective
Health issues are on Americans’ minds,but they are not the top priority in 2006.
by Robert J. Blendon, Kelly Hunt, John M. Benson, Channtal Fleischfresser, and Tami Buhr
ABSTRACT:
Opinion surveys conducted in 2006 show that health care is an important but second-tier issue in terms of priorities for government action. Americans’ top health care concerns are mostly related to economic insecurity: rising costs and the problems of the uninsured. The biggest perceived health threats are cancer, HIV/AIDS, and avian flu. Although most Americans do not think that the health system is in crisis, the public remains dissatisfied with both the country’s health care and public health systems. These attitudes are likely to create a climate that is supportive of increased health spending and substantial policy changes. [Health Affairs 25 (2006): w508–w515 (published online 17 October 2006; 10.1377/hlthaff.25.w508)]
This is the fifth in a series of essays published by Health Affairs examining Americans’ health and health care priorities.1 As in our earlier reviews of this subject, findings show that the American public has a clear set of priorities for the country, which have changed over time in response to specific events and the emergence of new health concerns. Public priorities typically emerge either when an issue is high on policymakers’ agendas and written up regularly in the popular press or when it represents a serious, real-life problem that people experience. Immigration, for example, rose to become one of the top three public priorities in April 2006, while it was high on policymakers’ agenda and written about daily in the newspapers.2 On the other hand, some issues, such as health care, that are part of people’s everyday lives remain much more enduring concerns in poll findings.
The Role Of Public Opinion
Over the past thirty-five years, there has been a huge jump in the number of polls conducted by decisionmakers in U.S. society, to monitor public opinion on a variety of topics.3 These include polls paid for by the media, political parties and leaders, interest groups, and foundations.4 Studies have shown that politicians continually monitor public opinion, attempt to shape it, and enlist it to gain leverage over other political actors. For example, research shows that polling done for U.S. presidents has gone from a relatively rare activity to a continuous information-gathering effort.5 Public opinion surveys provide politicians with information about what their constituents want across a wide variety of issues. This might lead them to be more responsive to general public opinion or to some subset such as members of their own political party or so-called swing voters.
Notwithstanding this substantial increase in monitoring of public opinion by decisionmakers, the role that public opinion actually plays in leaders’ ultimate policy decisions is not completely clear. There is general but not complete consensus among political scientists that public opinion plays a role in government decision making in certain circumstances and on certain issues, but not in all. But there is no agreement among all scholars about the particular circumstances and issues where decisionmakers pay attention to or ignore public opinion.6 What the research does show is that if an issue is salient to the public (a subject we examine in this paper), decisionmakers are more likely to pay attention to public opinion than they are for issues that are not very salient to the public.7
Research has shown that both the president and Congress respond to public opinion on issues that rank high in public concern or that people confront in their day-to-day lives.8 Health care is one such issue. Decisionmakers show greater responsiveness to public opinion when determining government spending on health care than in policy areas that are more remote from people’s daily lives, such as foreign aid.
In this paper we examine Americans’ health priorities along six dimensions: (1) the relative importance of health care as an issue for government to address, (2) the top health care issues for government, (3) views on national health spending and health care costs, (4) current ratings of the health care system and personal experiences with health care, (5) top general health concerns for future government action, and (6) ratings of the nation’s public health system and the general health conditions in their communities.
Study Data And Methods
To present a comprehensive picture of the public’s health priorities in 2006 and the changes that have taken place over time, this paper analyzes polling results from nineteen national opinion surveys conducted between 1940 and 2006. We pay particular attention to trends since the time of the Clinton health reform plan (early 1990s).
The survey data are from two main sources. The first consists of two Harvard School of Public Health/Robert Wood Johnson Foundation polls. International Communications Research (ICR) conducted fieldwork for both polls via telephone. For “Americans’ Views of the Healthcare System,” ICR conducted interviews 5–9 April 2006 with a nationally representative sample of 1,108 adults (age eighteen and older). For “Americans’ Views of Public Health,” ICR conducted interviews 31 March–4 April 2006 with a nationally representative sample of 1,107 adults. The margin of error for the total samples in each survey was plus or minus three percentage points at the 95 percent confidence level.9
The second source consists of seventeen other national opinion surveys that contain current and historical data. The criteria for inclusion in the paper are that the poll questions (1) reflect the public’s current priorities and the salience of the issues; (2) are the most current on a particular issue; or (3) represent trends that shed light on the public’s views and priorities over time. A number of organizations conducted these polls: Harris Interactive, Gallup, ABC News/Washington Post, the Pew Research Center, and the National Opinion Research Center/General Social Survey. All of the surveys were conducted by telephone, except for a 1940 Gallup poll and the General Social Survey, which were conducted in person. The sample sizes range from 1,000 to 1,500. The margin of error (at the 95 percent confidence level) for a sample of 1,000 is plus or minus three percentage points; for a sample of 1,500, it is plus or minus 2.5 points.
Survey Findings
Relative importance of health care as an issue for government to address. Elected officials can work on only a limited number of major issues at one time. To ascertain what the public thinks the priorities for government action should be, respondents were asked in August 2006 to say in their own words what they considered the top two issues for government to address. The results suggest that in terms of priority for government action, health care is a second-tier issue (Exhibit 1). Today it ranks as the fourth most important issue for government to address, behind the war, the economy, and gasoline/oil prices/energy. This is a lower ranking for health care than in 1993, a time of major national debate about health care reform. In the 2006 survey, health care was one of the top two issues for 13 percent of the population. This compares to 31 percent in 1993, when it was ranked second, and 9 percent in 2002, when it also ranked fourth.10
The list of the most important issues for government to address often corresponds the public’s ranking of issues that they say will be most important in their voting choices. In August 2006, health care ranked fourth when respondents were asked which of six issues would be most important in their vote for Congress. Once again, health care ranked behind Iraq, the economy, and gasoline prices, but ahead of terrorism and education.11
Of note, although health care is not among the top-priority issues for government action, it ranks higher today than many other national problems often identified as being very important. Health care issues rank higher than terrorism, the top issue in late 2001, as well as education, the environment (including global warming), Social Security, poverty, crime, and problems in the developing world.12 This consistent rating of health care among the top four concerns signifies that it is an issue of ongoing concern for the public, regardless of how high a priority policymakers make it.
Top health care issues. More specifically, respondents were asked to say, again in their own words, what they thought were the two most important health care problems that government should address. Health care costs and the lack of insurance/access to care were the most frequently cited (Exhibit 2). Medicare and the prescription drug benefit, the subject of current national attention, ranked third but well behind these other two. Quality of care, an issue of considerable concern to many national health policy leaders, ranked fourth.13
These priorities correspond with the public’s assessment of the state of health care in the country. In November 2005, only 20 percent of Americans were satisfied with the cost of health care, and only 21 percent rated health care coverage in this country as excellent or good.14 In April 2006, about four in ten Americans (41 percent) approved of the Medicare prescription drug program.15 And in November 2005, just over half (53 percent) rated the quality of health care in the United States as excellent or good.16
Views on national health spending and health care costs. Multiple survey results show that the public favors increased health spending in the years ahead but is concerned about the impact of rising health care costs on the financial situation of American families. In 2004, 78 percent of the public thought that national spending to improve health was too low; only 4 percent said that it was too high.17 Similarly, in 2006 a survey asked specifically about overall national spending on health care and national health care spending by government. The majority of respondents (57 percent) thought that the United States as a country was spending too little on health care in the aggregate, and 70 percent said that government health care spending was too low. Only 26 percent thought that the country as a whole was spending too much, and 11 percent thought that the government was spending too much. Around one-tenth of Americans thought that these spending levels were “about right” (9 percent, nation as a whole; 11 percent, government).18
What concerns Americans is not aggregate spending, but the perceived negative impact on American families of their direct health care outlays (insurance premiums, copayments, deductibles, and direct payments for services and products). When asked about spending for health care by average Americans in 2006, 65 percent of respondents said that the average American spends too much, while only 17 percent said too little.19 (Twelve percent felt that the level of spending was “about right.”) This is what Americans mean when they list health care costs as the top health care priority for government action.
Ratings of the health care system and their own care. As of spring 2006, most Americans were dissatisfied with the state of the U.S. health care system. About seven in ten respondents (69 percent) rated the nation’s system for providing medical care as fair or poor (Exhibit 3).20 Furthermore, in August 2006, only about four in ten respondents expressed “a great deal” or “quite a lot” of confidence in the health care system, a level that has remained relatively constant for more than ten years.21
Although the public is critical of the health system, only 22 percent think that it is in a state of crisis. However, this is a much higher proportion than in 2002 (11 percent). Most people think that the system has major problems, a view that has remained relatively stable since 1994 (Exhibit 4).22
In contrast to their views on the health system, most Americans are satisfied with their own most recent medical care experiences. Three-fourths of respondents had received medical care in the past year. Of those who received care, more than four in five people said that the services (84 percent) and physician care (85 percent) they received were excellent or good.23 This pattern has appeared in multiple surveys in previous years.24
A likely reason for the difference in opinions about the overall health system versus personal health care experiences could be that general health system questions tend to measure broader public concerns about the insecurity of health insurance coverage, high prices, bureaucracy, waste, and disparities in access to care in the United States. Measures of personal experiences are narrower and reflect individuals’ mostly positive recent experiences with care received from doctors and nurses; they do not take into account these other perceived societal problems.
Top general health concerns for government action. Respondents were also asked to state in their own words what they thought were the two most important diseases or health conditions for government to address. Cancer (51 percent) and HIV/AIDS (41 percent) were the top two health priorities stated.25 Smaller percentages also identified avian flu (21 percent), heart disease (16 percent), and diabetes (11 percent) as top priorities. Of interest, a parallel question asked respondents about the diseases and health conditions that posed the greatest threats to the American public. On this question, the rankings were essentially identical to the findings about priorities for government action, except that obesity tied with diabetes for fifth place. This suggests that a share of the public sees obesity as a serious national health concern but not as a current top priority for government action (3 percent), even though almost half (47 percent) see obesity as a major problem in their communities.26
Of historical note, these health priorities can change markedly over long periods of time. In 1940, Americans were asked to name the most serious health problem from a list of diseases considered very important at the time. Syphilis was the public’s top concern (46 percent), followed by cancer (29 percent), tuberculosis (16 percent), and polio (9 percent).27
Ratings of the public health system and health conditions in their communities. The country faces a number of public health threats that have emerged since 2001, such as severe acute respiratory syndrome (SARS), anthrax, smallpox, avian flu, and obesity. These threats have raised concerns about the adequacy of the U.S. public health system. When asked their assessment, the majority of respondents reported that they were not satisfied with the nation’s current system for protecting the public from these threats and preventing illness. Just over half of respondents rated the public health system as fair or poor, while fewer than half rated it as excellent or good (Exhibit 3).28
More Americans report satisfaction with the public health conditions in their own communities than with the overall public health system. About three-quarters of respondents gave excellent or good ratings to the quality of life in their communities (76 percent). The majority gave excellent or good ratings to the quality of emergency services such as police, fire, and ambulance (78 percent), as well as to air quality (69 percent), the availability of preventive health services (69 percent), the quality of drinking water (67 percent), and the availability of recreational facilities (65 percent). In addition, respondents were asked about whether health conditions in their community had changed during the last two years. Almost seven out of ten (69 percent) reported no change. Relatively small percentages thought that conditions had gotten better (14 percent) or worse (13 percent).29
Discussion And Conclusions
Most U.S. news coverage about medical care issues during the past year has concentrated on Medicare’s new prescription drug benefit, while many in the research and professional community have focused on the nation’s quality-of-care problems. What is important to recognize is that these are not the American public’s top health care priorities today. Americans want their government to do something about their rising health care costs and the problems of the uninsured. When Americans talk about health care costs, however, their concern is not for the share of the nation’s gross domestic product (GDP) going toward health care, but rather the financial impact on their own families.
Also important to recognize is that cancer and HIV/AIDS are the public’s top priorities as health threats that they want government to address. Even though there have been no human cases of avian flu in the United States, that emerging disease has now joined this list. Cancer has remained a major health concern to the American public for more than sixty years. Although there have been major medical advances in cancer care, it is still an issue that worries many Americans.
Another issue that could become more important to the public in the future is obesity. Although it has emerged as a major concern for the public in general and in their communities, the government role in obesity prevention is unclear for many Americans. This could change over time, as obesity receives more attention from the media and health professionals.
The public considers the wars in Iraq and Afghanistan to be the top issues for government. But the survey findings also indicate that from a public perspective, health issues are very likely to remain prominent on the national agenda. Although health care is not the top issue for Americans, it consistently ranks among the top five issues for government to address. In addition, contrary to the concerns of many experts, the public continues to favor more rather than less health spending in the aggregate.
Moreover, although most Americans do not think that the health system is in crisis, the public remains dissatisfied with the country’s health care and public health systems. These attitudes are likely to create a climate supportive of both increased health spending and substantial change in the years ahead.
This work was supported by a grant from the Robert Wood Johnson Foundation. The views expressed are solely those of the authors, and no official endorsement by the sponsor is intended or should be inferred.
NOTES
1. R.J. Blendon et al., “Americans’ Health Priorities: Curing Cancer and Controlling Costs,” Health Affairs 20, no. 6 (2001): 222–232; R.J. Blendon et al., “Americans’ Health Priorities Revisited after September 11,” Health Affairs 20 (2001): w96–w99 (published online 13 November 2001; 10.1377/ hlthaff.w1.96); R.J. Blendon et al., “The Impact of Terrorism and the Recession on Americans’ Health Priorities,” Health Affairs 21 (2002): w420–w425 (published online 17 January 2002; 10.1377/ hlthaff.w2.420); and R.J. Blendon et al., “The Continuing Legacy of September 11 for Americans’ Health Priorities,” Health Affairs 21 (2002): w269–w275 (published online 14 August 2002; 10.1377/hlthaff.w2.269).
2. Harris Interactive, “President Bush’s Job Approval Ratings Remain Low,” Harris Poll no. 30, 19 April 2006, http://www.harrisinteractive.com/harris_poll/index.asp?PID=654 (accessed 13 September 2006).
3. J.G. Geer, From Tea Leaves to Opinion Polls: A Theory of Democratic Leadership (New York: Columbia University Press, 1996).
4. Our search of the iPOLL database at the Roper Center for Public Opinion Research, the country’s largest archive of public opinion data, found a steady growth in the number of polling questions asked during each successive election cycle: from 8,752 questions in 1980, to 14,132 in 1988, to 19,458 in 1996, to 22,448 in 2004. See also E.C. Ladd and J.M. Benson, “The Growth of News Polls in American Politics,” in Media Polls in American Politics, ed. T.E. Mann and G.R. Orren (Washington: Brookings Institution, 1992), 19–31.
5. R.M. Eisinger, The Evolution of Presidential Polling (Cambridge: Cambridge University Press, 2003).
6. J. Manza, F.L. Cook, and B.I. Page, eds., Navigating Public Opinion: Polls, Policy, and the Future of American Democracy (Oxford: Oxford University Press, 2002); R.S. Erikson, G.C. Wright, and J.P. McIver, Statehouse Democracy: Public Opinion and Democracy in American States (New York: Cambridge University Press, 1993); L.R. Jacobs and R.Y. Shapiro, Politicians Don’t Pander: Political Manipulation and the Loss of Democratic Responsiveness (Chicago: University of Chicago Press, 2000); A.D. Monroe, “Public Opinion and Public Policy: 1980–1993,” Public Opinion Quarterly 62, no. 1 (1998): 6–28; and J.A. Stimson, M.B. MacKuen, and R. Erikson, “Dynamic Representation,” American Political Science Review 89, no. 3 (1995): 543–565.
7. B. Canes-Wrone and K.W. Shotts, “The Conditional Nature of Presidential Responsiveness to Public Opinion,” American Journal of Political Science 48, no. 4 (2004): 690–706; J. Manza and F.L. Cook, “A Democratic Polity: Three Views of Policy Responsiveness to Public Opinion in the United States,” American Politics Research 30, no. 6 (2002): 630–667; and C. Wlezien, “Patterns of Responsiveness: Dynamics of Public Preferences and Policy,” Journal of Politics 66, no. 1 (2004): 1–24.
8. B. Canes-Wrone, Who Leads Whom? Presidents, Policy, and the Public (Chicago: University of Chicago Press, 2006); Canes-Wrone and Shotts, “The Conditional Nature”; and Wlezien, “Patterns of Responsiveness.”
9. Harvard School of Public Health/Robert Wood Johnson Foundation, “Americans’ Views of Public Health” poll (Storrs, Conn.: Roper Center for Public Opinion Research, 31 March–4 April 2006); and HSPH/RWJF, “Americans’ Views of the Healthcare System” poll (Storrs, Conn.: Roper Center, 5–9 April 2006).
10. For 1993 and 2002, Harris Interactive, “The National Mood Changes as Ratings of Bush, Cabinet Members and the Congress Fall Sharply—TABLES,” Harris Poll no. 34, 24 July 2002,
http://www.harrisinteractive.com/harris_poll/tables/ 2002/july_24_2002.htm (accessed 13 September 2006); for 2006, Harris Interactive, “Democrats Continue to Hold Substantial Lead over Republicans in Race for Congress,” Harris Poll no. 63, 11 August 2006,
http://www.harrisinteractive.com/harris_poll/index.asp?PID=689 (accessed 13 September 2006).
11. ABC News/Washington Post poll (Storrs, Conn.: Roper Center, 3–6 August 2006).
12. Harris Interactive, “President Bush’s Job Approval Ratings Remain Low”; for 2001 results, see Blendon et al., “The Continuing Legacy,” w270.
13. HSPH/RWJF, “Americans’ Views of the Healthcare System” poll.
14. Gallup poll (Storrs, Conn.: Roper Center, 7–10 November 2005).
15. ABC News/Washington Post poll (Storrs, Conn.: Roper Center, 6–9 April 2006).
16. Gallup poll, 7–10 November 2005.
17. J.A. Davis and T.W. Smith, General Social Survey (Chicago: National Opinion Research Center, 2004).
18. Pew Research Center for the People and the Press poll, “March 2006 News Interest Index, Final Topline,” 8–12 March 2006, http://people-press.org/reports/questionnaires/273.pdf (accessed 13 September 2006).
19. Ibid.
20. HSPH/RWJF, “Americans’ Views of the Healthcare System” poll.
21. Gallup Poll, “Confidence in Institutions” (Princeton, N.J.: Gallup Organization, 14 August 2006).
22. Gallup polls (Storrs, Conn.: Roper Center, 6–7 September 1994, 11–13 September 2000, 11–14 November 2002, 3–5 November 2003, 7–10 November 2005); and HSPH/RWJF poll (Storrs, Conn.: Roper Center, 10–15 August 2006).
23. HSPH/RWJF, “Americans’ Views of the Healthcare System” poll.
24. R.J. Blendon, M. Brodie, and J.M. Benson, “Health Policy,” in Polling America: An Encyclopedia of Public Opinion, ed. S.J. Best and B. Radcliff (Westport, Conn.: Greenwood Press, 2005), 289–291.
25. HSPH/RWJF, “Americans’ Views of Public Health” poll.
26. Ibid.
27. Gallup poll (Storrs, Conn.: Roper Center, 8–13 March 1940).
28. HSPH/RWJF, “Americans’ Views of Public Health” poll; and HSPH/RWJF, “Americans’ Views of the Healthcare System” poll.
29. HSPH/RWJF, “Americans’ Views of Public Health” poll.
Robert Blendon (rblendon@hsph.harvard.edu) is a professor of health policy and political analysis at the Harvard School of Public Health (HSPH) in Boston, Massachusetts. Kelly Hunt is senior program director at the New York State Health Foundation, in New York City. At the time the study was conducted, she was a research officer at the Robert Wood Johnson Foundation in Princeton, New Jersey. John Benson is managing director, Channtal Fleischfresser is a research assistant, and Tami Buhr is assistant director at the Harvard Opinion Research Program, HSPH.
DOI: 10.1377/hlthaff.25.w508
Tuesday, October 17, 2006
Oppose Resolution 06-5 And Preserve Medicare Reimbursement
Dear Friends and Colleagues:
At the upcoming FMA Board of Governors & Council Days Joint meeting(October 19-22,2006) in Miami Resolution 06-5 (Medicare Reimbursement) will be discussed. This resolution calls upon the FMA to ask the Center for Medicare & Medicaid Services to make Florida a single geographic locality for physician reimbursement.
The supporters of the resolution claim that the resolution has three intentions:
1. UNITY:
“when people have the same interest they work together for the common good.Currently our (FMA) members have been divided by CMS into three camps. We want to become one camp…to assure that our FMA represents the interests of all physicians of Florida, not just a minority. Only then can we be assured that our congressional delegation has the same interest to fight for Medicare patients.”
2. ACCESS:
“ we have to make sure that Medicare patients have access to doctors all over the state. There are areas in the state where Medicare patients cannot find doctors.”
3. PARITY:
“ all physicians in Florida should be paid the same for the same work and the same standard of care. It is increasingly more expensive to live and work all over the state , not just in some small areas. Parity is the reason so many states long ago changes to one locality.”
Attached you find a recent letter from the CMS Presidents of Dade,Broward and Palm Beach addressed to the Florida Board of Governors and the Council on Medical Economics OPPOSING the proposed resolution.
The South Florida Caucus including the Dade, Broward, and Palm Beach Medical Society stand opposed to Resolution 06-5.
We agree that the current reimbursement formula does not fairly or accurately address the costs of operating a medical practice.
We agree with and support current FMA and AMA policy and efforts to FUNDAMENTALLY reform the formula on which physicians’ reimbursement is based by either abandoning, replacing or reforming the flawed Sustainable Growth Rate (SGR).
We believe strongly, however, that the Medicare physician reimbursement formula must take into account geographic disparities in reimbursement and expenses (i.e. housing, practice lease, salaries, and insurance).
These disparities are real. Professional liability rates are not only significantly higher in South Florida, but notoriously among the HIGHEST in the nation. Other professional practice expenses such as salaries, leases and rents, non – PLI insurance (Property, Windstorm etc.), as well as general living expenses are SUBSTANTIALLY higher for physicians and their staffs in South Florida than in other areas of Florida.
Ignoring these realities and suggesting non-differential reimbursement is neither fair nor reasonable and it is thus unacceptable.
Other large and small businesses have differential financial structures based on location as evident with professional liability insurers. No doubt, South Florida physicians would embrace the lower PLI rates available in other parts of Florida and the nation, but that is not reality.
To raise North Florida Medicare rates, as presumably aspired to by this resolution, CMS would have to lower South Florida rates to maintain budget neutrality.
If this were to pass, South Florida physicians would not accept such a rate reduction on top of the accepted Medicare physicians’ reimbursement cuts and lobby openly against it to CMS.
Clearly, this would become a highly divisive issue for physicians and for the FMA and could impact its political credibility, agenda and membership.
Asking CMS to make Florida a single geographic locality for physician reimbursement does NOT guarantee as hoped for, an increase for North Florida physicians. Asking CMS to pay Florida doctors at one rate regardless of geographic and economic disparities,would likely result in CMS choosing the LOWEST current rate for EVERYONE. In fact, we would be sending the message to payers that physicians again would be willing to accept a lower fee schedule at a time when rates are already subject to annual REDUCTIONS.
Any lowering of Medicare rates would have a ripple effect on managed care rates and cause them to drop as they reimburse at a percentage of Medicare. This would impact ALL Florida physicians even the ones NOT caring for Medicare patients, such as pediatricians.
Further any lowering of Medicare rates in South Florida would create an economic incentive to leave South Florida and relocate to other parts of Florida or the US where cost of living expenses are less.
In the unlikely scenario that CMS would increase North Florida rates without lowering those in South Florida, it would invite the unintended and undesirable consequences of increasing managed care penetration in North Florida as HMO income also is tied to Medicare rates.
Again, with regard to fairness, if Medicare were to pay all physicians at the same rate, then the same should apply for managed care which, again is not consistent with reality. Similarly, professional liability rates should be the same all across the state, which they are not.
Finally, any decreases in Medicare rates equals reduced access to care for patients, because physicians in South Florida will reach an economic tipping point and have to drop or limit Medicare patient services
Thus, instead among ourselves over the geographic factor, which, at least, is based on economic disparities across the state, we must continue UNITED and TOGETHER in our annual struggle to correct the terminally FLAWED SGR formula and increase reimbursement fairly FOR ALL physicians.
We hope and respectfully request that the Council on Medical Economics and the FMA Board of Governors will vote down Resolution 06-5 to preserve access, parity and unity.
At the upcoming FMA Board of Governors & Council Days Joint meeting(October 19-22,2006) in Miami Resolution 06-5 (Medicare Reimbursement) will be discussed. This resolution calls upon the FMA to ask the Center for Medicare & Medicaid Services to make Florida a single geographic locality for physician reimbursement.
The supporters of the resolution claim that the resolution has three intentions:
1. UNITY:
“when people have the same interest they work together for the common good.Currently our (FMA) members have been divided by CMS into three camps. We want to become one camp…to assure that our FMA represents the interests of all physicians of Florida, not just a minority. Only then can we be assured that our congressional delegation has the same interest to fight for Medicare patients.”
2. ACCESS:
“ we have to make sure that Medicare patients have access to doctors all over the state. There are areas in the state where Medicare patients cannot find doctors.”
3. PARITY:
“ all physicians in Florida should be paid the same for the same work and the same standard of care. It is increasingly more expensive to live and work all over the state , not just in some small areas. Parity is the reason so many states long ago changes to one locality.”
Attached you find a recent letter from the CMS Presidents of Dade,Broward and Palm Beach addressed to the Florida Board of Governors and the Council on Medical Economics OPPOSING the proposed resolution.
The South Florida Caucus including the Dade, Broward, and Palm Beach Medical Society stand opposed to Resolution 06-5.
We agree that the current reimbursement formula does not fairly or accurately address the costs of operating a medical practice.
We agree with and support current FMA and AMA policy and efforts to FUNDAMENTALLY reform the formula on which physicians’ reimbursement is based by either abandoning, replacing or reforming the flawed Sustainable Growth Rate (SGR).
We believe strongly, however, that the Medicare physician reimbursement formula must take into account geographic disparities in reimbursement and expenses (i.e. housing, practice lease, salaries, and insurance).
These disparities are real. Professional liability rates are not only significantly higher in South Florida, but notoriously among the HIGHEST in the nation. Other professional practice expenses such as salaries, leases and rents, non – PLI insurance (Property, Windstorm etc.), as well as general living expenses are SUBSTANTIALLY higher for physicians and their staffs in South Florida than in other areas of Florida.
Ignoring these realities and suggesting non-differential reimbursement is neither fair nor reasonable and it is thus unacceptable.
Other large and small businesses have differential financial structures based on location as evident with professional liability insurers. No doubt, South Florida physicians would embrace the lower PLI rates available in other parts of Florida and the nation, but that is not reality.
To raise North Florida Medicare rates, as presumably aspired to by this resolution, CMS would have to lower South Florida rates to maintain budget neutrality.
If this were to pass, South Florida physicians would not accept such a rate reduction on top of the accepted Medicare physicians’ reimbursement cuts and lobby openly against it to CMS.
Clearly, this would become a highly divisive issue for physicians and for the FMA and could impact its political credibility, agenda and membership.
Asking CMS to make Florida a single geographic locality for physician reimbursement does NOT guarantee as hoped for, an increase for North Florida physicians. Asking CMS to pay Florida doctors at one rate regardless of geographic and economic disparities,would likely result in CMS choosing the LOWEST current rate for EVERYONE. In fact, we would be sending the message to payers that physicians again would be willing to accept a lower fee schedule at a time when rates are already subject to annual REDUCTIONS.
Any lowering of Medicare rates would have a ripple effect on managed care rates and cause them to drop as they reimburse at a percentage of Medicare. This would impact ALL Florida physicians even the ones NOT caring for Medicare patients, such as pediatricians.
Further any lowering of Medicare rates in South Florida would create an economic incentive to leave South Florida and relocate to other parts of Florida or the US where cost of living expenses are less.
In the unlikely scenario that CMS would increase North Florida rates without lowering those in South Florida, it would invite the unintended and undesirable consequences of increasing managed care penetration in North Florida as HMO income also is tied to Medicare rates.
Again, with regard to fairness, if Medicare were to pay all physicians at the same rate, then the same should apply for managed care which, again is not consistent with reality. Similarly, professional liability rates should be the same all across the state, which they are not.
Finally, any decreases in Medicare rates equals reduced access to care for patients, because physicians in South Florida will reach an economic tipping point and have to drop or limit Medicare patient services
Thus, instead among ourselves over the geographic factor, which, at least, is based on economic disparities across the state, we must continue UNITED and TOGETHER in our annual struggle to correct the terminally FLAWED SGR formula and increase reimbursement fairly FOR ALL physicians.
We hope and respectfully request that the Council on Medical Economics and the FMA Board of Governors will vote down Resolution 06-5 to preserve access, parity and unity.
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