Minnesota Health Reform Caucus

Yesterday’s Minneapolis Star Tribune published an article praising electronic medical records (Thomas Lee, “A sort of ‘Turbo Tax’ for doctors,” March 23, 2009, D1). The article illustrates how corporate propaganda — in this case, the claim promoted by the computer industry that electronic medical records save money – becomes accepted “fact” among the nation’s reporters and politicians.

The research on the impact of electronic medical records (EMRs) on quality is mixed — some studies show EMRs improve quality, others show EMRs have no impact on quality, and others indicate EMRs damage quality. Given the mixed evidence on the impact of EMRs on quality, it is no surprise that there is no credible evidence that EMRs can cut health care costs. But the mainstream media and the Star Tribune do not pass this information on to their readers.

The Star Tribune article began with an anecdote about a Bloomington surgeon that illustrated a statement that is almost certainly true – that EMRs can improve the speed and accuracy with which doctors fill out claim forms for insurance companies.  But then the article veered off into hype — hype that wasn’t obvious to readers. The article leaped from an illustration of how EMRs can help doctors submit bills faster to the much broader claim that electronic medical records (which cost about $40,000 per doctor to buy and install, and $5,000 to $10,000 per doctor per year to maintain) save money.   The article stated:

[A] study by the RAND Corp., a think tank based in Washington, DC… estimates that EMR [sic] could save more than $77 billion … a year by reducing patients’ length of stay and the amount of time doctors and nurses devote to administrative tasks such as billing and updatng patient records.

The RAND study has been cited hundreds of times since it was published in 2005 in Health Affairs (Richard Hillestad et al., “Can electronic medical record systems transform health care? Potential health benefits, savings, and costs,” Health Affairs 2005;1103-1117). This “study” was cited by the websites of Hillary Clinton and Barack Obama during their campaigns for the presidency, for example.

But this “study” is junk science.

The first thing you need to know about it is that it was financed by the computer industry. You can see the names of the companies that financed this study at the end of the Health Affairs article (they were Hewlett-Packard, GE, Cerner, Johnson and Johnson, and Xerox).

Second, the “study” was roundly criticized by three articles published in the same edition of Health Affairs.

Third, the $77 .8 billion dollar savings predicted by the RAND scholars (don’t ask me why Hillary Clinton and the Star Tribune rounded down to $77 billion) will not materialize until 2019, at which time it will amount to a grand total of 1.6% of total health care spending, according to one of the three papers critical of the RAND paper published in the same edition of Health Affairs (Clifford Goodman, “Do it for the quality,” 1125). 

Fourth, this magnificent savings of 1.6% that we will allegedly realize a decade from now was based on an absurd assumption. The authors decided they would exclude from consideration any published research which found that EMRs had a negative impact on patients. Why? Because they decided such an outcome had to be the fault of the people who used the EMR, not of the EMR. Here is how the RAND authors expressed this assumption: “We chose to interpret reported evidence of negative or no effect of HIT [health information technology, a phrase that incorporates EMRs and a few other medical uses of computers] as likely being attributable to ineffective or not-yet-effective implementation.” This should remind you of the National Rifle Association’s mantra: “Guns don’t kill people, people kill people.”

The Congressional Budget Office, the nonpartisan research arm of Congress, rejected the RAND paper in its May 2008 report on EMRs (Evidence on the Costs and Benefits of Health Information Technology, http://www.cbo.gov/doc.cfm?index=9168). It did so for several reasons, including the RAND authors’ absurd belief that papers that report negative effects of EMRs can be ignored.

The CBO reviewed all of the claims made for EMRs by the RAND paper and by other advocates of EMRs, including:

(1) EMRs reduce the cost of pulling paper charts;

(2) EMRS reduce the number of tests because they alert doctors when tests have previously been ordered;

(3) EMRs cut prescription drug costs by (a) inducing doctors to order more generics and (b) by reducing the number of adverse drug reactions;

(4) EMRs make it easier to create patient medical records and in other ways improve the productivity of doctors and nurses;

(5) EMRs cut the average length of stay in hospitals because EMRs permit faster ordering and administration of tests and faster printing of discharge instructions;

(6) EMRs cause doctors to adhere to guidelines more often;

(7) EMRs, when they are adopted by all clinics and hospitals, will create a virtual national medical records database, and this in turn will permit researchers to discover cures and better treatments for less than the cost of traditional biomedical research.

CBO concluded that research supported only the first claim — that EMRs reduce the cost of retrieving records. CBO said research on the other claims was either nonexistent or mixed.

 But despite the criticism of the RAND paper by the CBO and other experts, politicians and reporters continue to endorse the computer industry mantra that EMRs save money, and they continue to site the RAND paper as evidence for the mantra.

Kip Sullivan

For the past 40 years, advocates of market-based solutions to the American health care crisis have promoted report cards on doctors, clinics, hospitals and other “providers.” Virtually every presidential candidate in the last election promoted report cards. The Minnesota Legislature enacted legislation in May 2008 that requires the Minnesota Department of Health to start publishing report cards on some or all of the 10,000-plus medical services offered by some or all of Minnesota’s 131 hospitals and 17,000 doctors beginning July 1, 2010.

Advocates of report cards believe report cards should be used to punish and reward providers two ways: (1) by publishing report cards and thereby causing patients to abandon “bad” providers in favor of “good” providers; and (2) by reimbursing “bad” providers at lower rates and “good” providers at higher rates. The latter method of using report cards is often called “pay for performance,” or “P4P.”   According to report card advocates, report cards are supposed to set off a chain reaction that leads to lower health care costs. The chain reaction allegedly looks like this: 

(1) providers respond to the threat of lost income caused by bad grades by improving the quality of the medical services they offer,

(2) patients get healthier, and

(3) health care costs go down because healthier patients use fewer medical services.

Report card advocates speak with great confidence about report cards. For example, Thomas Scully, George W. Bush’s director of Medicare, stated in 2003, “There’s no question that pay for performance will work” (Meredith B. Rosenthal and Richard G. Frank, “What is the empirical basis for payhing for quality in health care?” Medical Care Research and Review 2006;63:135-157, 135). 

But in fact the research on medical report cards does not support the claim that report cards improve care, improve health, or lower costs. Here is how two experts summarized the state of the research as of 2005: “Despite … extensive adoption of quality measurement and reporting, little research examines the effect of public reporting on the delivery of health care, and even less examines how report cards may improve care. … [T]he potential … negative consequences of public reporting are largely unexplored.”(Rachel M. Werner and David A. Asch, “The uintended consequences of publicly reporting quality information,” Journal of the American Medical Association 2005;293:1239-44, 1239). A 2006 review of the literature on P4P concluded, “Despite the assetions of its proponents, the empirical foundations of pay-for-performance in health care are rather weak” (Rosenthal and Frank, 151).

Two studies published last week confirm the existing research. The March/April 2009 edition of Health Affairs contained a paper which examined the progress of the largest P4P project in America — a program sponsored by the Integrated Health Care Association (IHCA), a coalition of  California insurers and providers. This project involves 225 California medical groups and the state’s seven largest HMOs.  The March/April 2009 edition of  Annals of Family Medicine contained a paper that reported on the opinions of report cards held by doctors in California who are subject to the IHCA’s report cards, as well of as doctors in the United Kingdom. The UK has been publishing report cards on all its primary care doctors since 2004. The report card projects in California and the UK are probably the largest medical report card projects underway anywhere in the world.

The authors of the Health Affairs paper,  Cheryl Damberg and colleagues, began their paper by acknowledging how little we know about the effects of report cards. “[L]ittle is known about what behavior changes have occurred as a result of P4P and whether the changes made by providers have led to desired improvements,” wrote Damberg et al. (Damberg et al., “Taking stock of pay-for-performance: A Candid assessment from the front lines,” Health Affairs 2009;28:517-525, 517). This is typical of the American insurance industry and of large, self-insured employers. They launch expensive and risky experiments affecting tens of thousands of doctors and millions of patients without asking first, Do we have any research that indicates our proposed experiment will improve care, will have minimal side effects, and/or will lower costs? Damberg et al. concluded the Integrated Health Care Association’s report cards have had little effect on quality and cost. Damberg et al. quoted a representative of one of the California HMOs saying there is “no evidence of any savings or moderation in cost trends to justify increased investment in the [P4P] program” (Damberg et al., 522).

The authors of the Annals of FamilyPractice study, McDonald and Roland, found evidence of negative side effects of report cards in the UK and in California. The side effects were of three types — interference in physician-patient interaction, “firing” of noncompliant patients and other undesirable efforts by physicians to get around patient resistance to behaviors demanded by the publishers of the report cards, and dissatisfaction among doctors (Ruth McDonald and Martin Roland, “Pay for performance in primary care in England and California: Comparison of unintended consequences,” Annals of Family Medicine 2009;7:121-27).

 The interference with doctor-patient communication — the “crowding out of the patient’s agenda” — was worse in the UK because the UK collects data on many more measures of quality– roughly seven times more – than the IHCA project in California does. Here is how one British doctor described coping with the numerous dialog boxes that show up on his computer screen with each patient visit: “You look at the screen and the screen’s completely obsured by the list of yellow boxes, and it’s alway trying to balance up the mood the patient’s in and getting the boxes ticked, especially with people that don’t come in that often. You know, they come in and tell you …, ‘Oh, my son died last week,’ and you go, ‘Yeah, yeah, whatever. Do you smoke?’”

The tendency of doctors to feel hostile toward noncompliant patients was worse among California than UK doctors because the UK doctors are allowed to create “exceptions” for noncompliant patients, that is, they can just decide on their own not to report data on patients they believe are not cooperating. One UK clinic “excepted” 85 percent of its patients. The California doctors don’t have that luxury, and were understandably more likely to take action against their noncompliant patients, which often means their sicker, poorer, and less-English-speaking patients. One California doctors stated, “I tell them to leave. I told someone, you’re killing my pay for performance. You are the one that keeps being my outlier. Go join another medical group.” Other physicians invaded their patient’s privacy without their consent. “Some physicians … reported bypassing informed consent procedures to meet screening targets for Chlamydia trachomatis,” reported the study. These doctors simply collected urine from their female patients and had it tested for C trachomatis, a sexually transmitted infection, without asking their patients if that was ok.

The California doctors were much more likely to express dissatisfaction with report cards even though the reporting burden was less for them. McDonald and Roland believed this was due to the fact that the California doctors were not consulted about what quality measures would be used and did not have the freedom to “except” more difficult patients that the UK doctors did. This caused them to feel they were being graded on factors outside their control.

Note that McDonald and Roland made no effort to examine another serious side effect of report cards — the “teaching to test” problem. The problem of doctors shifting resources away from unmeasured to measured patients has to be a real problem. The only reason it would not be a real problem would be if doctors have lots of  idle time on their hands, or if doctors receive substantial increases in pay at the same time report cards are introduced.  We know the first assumption is not true. When the UK introduced report cards, it did raise payment levels for primary care doctors substantially. But in the US reimbursements rarely go up when report cards are implemented.

Kip Sullivan

There are currently 47,000,000 people living without health insurance in the United States of these, about 440,000 live in our state (440,000 is roughly the number of people living in Minneapolis and St. Cloud, combined).  How one chooses to interpret these numbers depends on their political beliefs.  Some believe that the high number of uninsured can be attributed to government interference with the health care industry.  They believe that the whole health care industry (and presumably our health) would benefit if the entire health care system acted more like a business.  Of course, this isn’t the first time these arguments have been used.  In 1970 we were introduced to HMO’s, the prescribed solution to our health care needs.  HMO’s were the free market solution.  A system derived to make doctors and hospitals more efficient.  30 years after the conception of HMO’s we are once again in a “health care crisis”.  The fact the HMO’s haven’t solved our problem is proof of their failure.  If you don’t believe it look at the numbers at the top.  We live in the strongest, richest and most democratic nation on this planet, and we cannot provide adequate care for one sixth of our citizens. 

Now, some people will tell you that the uninsured have no one to blame but themselves.  If they were just accountable and harder working they would be fine…  In fact the Minnesota Chamber of Commerce endorses this belief with their statement “Health care is a benefit employers offer to attract and retain good employees, not a requirement.”  Read that carefully,  “good employees”.   They don’t mention the 11,000,000 uninsured children.

            Being a “good employee” is something that should be valued in our society.  I, as well as the chamber of commerce, believe that personal accountability should be promoted.  However, if were going to believe that health insurance is entirely dependant on one’s work ethic, then we should ensure that our system reflects that belief.  So, the people who lack health insurance should guilty of something (in the words of the Chamber of Commerce, not a “good employee”) thus justifying their lack of insurance.  Their children are apparently guilty of being born into a less privileged family.  It’s unwise to settle for this type of rhetorical explanation to the “health care crisis”.  Luckily, the U.S. Census Bureau did a report in 2006 called Income, Poverty and Health Insurance in the United States.  The purpose of this report was to determine the economic condition, family size, age and racial background of these 47,000,000 people in question.  The report helps to debunk the conservative perception of the uninsured.

22,010,000 (about half of the uninsured) worked forty hours a week throughout the year.

10,000,000 (about one-fifth of the uninsured) claimed themselves as the head of household

-23,778,000 (about half of the uninsured) earned between $25,000 and $75,000 annually

-29,500,000 (more than half of the uninsured) were between the ages of 24-64

To me there seems to be something fundamentally wrong in these statistics.  The uninsured live above the poverty line but are not extremely rich.  Many work forty hours a week.  They are middle aged.  Many have families.  You see, in our country the extremely poor and the dependant are placed onto some type of state insurance program.  In Minnesota, it’s called Minnesota CARE.  So they do not make up a significant percentage of the uninsured.  On the other hand, the rich have little problem paying their premiums.  No, these 47,000,000 did not come from the extremely poor or the extremely rich. 

I know some of these uninsured people.  Many are struggling for their chance at the “American Dream”.  They work a full time job, they rarely call in sick and they don’t get fired.  These people are the “good employee’s” that the Chamber of Commerce would love to hire.  The sad part is these same people choose between diabetic testing strips or rent.  They let tooth infections become so severe that the Emergency Room cannot turn them back (which by the way, taxpayers pay for).  I am in school with a friend who is unable to afford health insurance, because he had a brain tumor, and he is too “high risk”.  Furthermore, I dare anyone to go to my friend and tell him that he somehow deserves not to be insured.  That if he just worked a little harder, he would no longer have to fear economic ruin from a medical emergency.  Tell them there is a legitimate reason their children cannot afford their prescriptions.  That them their situation is somehow a reflection of justice.  I wouldn’t dare say something that offensive, but the Chamber of Commerce would.  Remember? “Health care is a benefit employers offer to attract and retain good employees, not a requirement.”

Keep in mind that health care is a needed service in our society, therefore is cannot be a “benefit”.  Also keep in mind that the problem of the uninsured in this country is more complex than simple laziness.  Nearly half of the uninsured are currently employed full time, and the other fifth are their children.  That means that two-thirds of the uninsured in the country, probably cannot be blamed for the situation.  It’s time that we start objectively looking at the realities of the “health care crisis” and enact legislation that targets the root of the problem.  We should probably start with the massive Insurance and Pharmaceutical companies that made record profits of the premiums of hard working Americans.  We should at least stop exclusively blaming those without insurance.  To continue to do so is a display of ignorance.

By Chris Gray

Works Cited

Minnesota Chamber of Commerce

http://www.mnchamber.com/priorities/healthcare-regulations-2008.cfm

U.S. Census Bureau

www.censusbureau.biz/hhes/www/hlthins/hlthin05.html

Some thoughts about the irony of the health care debate…

By Chris Gray

The “health care crisis” is a topic that is currently being debated by politicians on all levels of government. While most agree that there is a problem with our health care system, there are many different opinions about the solution. A small group of Minnesota legislators are advocating the “single payer” or “single plan” system. The term “single payer” refers to a universal health care plan, where health care would be considered a civil right, not a privilege. Premiums would be taken directly out of taxes. Imagine “Medicare for all”, that’s the basic idea. Among the press and politicians this is portrayed as the radical solution to our problem. Likewise, the people who support “single payer” are perceived as radicals. The irony of this perception becomes apparent once you take a glance beyond the borders of this country.

There are many nations that we consider to have values and beliefs similar to our own. They are fundamentally similar to the United States. They hold democratic elections and support capitalism. They are the great democracies of Western Europe: England, France, Denmark, Norway, Sweden, Italy, Germany and Spain. Of these countries, all have adopted some form of universal health care. Other nations have followed suit. Australia, Canada and Japan have all adopted “single payer” health care. These nations constitute the bulk of what we consider the “free world”.

You see… We are the renegade country when it comes to health care. Our ideology about privatization in the field of health care is radically different than most of the free world. No other nation in the free world is seriously considering adopting our system. These countries are not debating the fundamentals of health care in their elections. These nations are not experiencing a “health care crisis”. The truth is, we stand alone in our views about health care. You could conclude that our resistance is a monument to our ingenuity, or our ignorance, depending on which side of the debate you’re on.

We should ask ourselves some fundamental questions.

Could we learn from the experiences of our ideological allies?

How can a change that aligns us with these countries, be considered a radical change?

How can the “single payer” politicians be considered radicals, when their beliefs are similar to the beliefs shared by the majority of the free world?

A change to “single payer” is not controversial. It’s not even groundbreaking. It simply requires adopting a system that has already been proven in the democracies of Western Europe. According to the CIA World Factbook, an infant born in these countries has a better chance of survival than an infant born in America. The life expectancy in these countries is higher than in the United States. So the claim that their system is failing, is ludicrous. Furthermore, according to the U.S Census Bureau, one in six American adults, and one in ten American children are uninsured, and these numbers increase each year. Every citizen in a nation that has adopted a “single payer” system has insurance. In those countries health care is considered a civil right, here we consider a visit to the doctor a privilege.

So, the next time you hear that “single payer” is too radical of a solution. Keep in mind that what we perceive as radical, other citizens of the free world perceive as ordinary. When you hear that such a change is too drastic and impossible to achieve, remember that many other nations have already accomplished that change, and I’d like to think that our nation, or state is capable of the same thing.

Works Cited:

CIA World Factbook: Rank Order- Infant Mortality Rateshttps://www.cia.gov/library/publications/the-world-factbook/rankorder/2091rank.htmlCIA World Factbook: Rank Order- Life Expectancy at Birthhttps://www.cia.gov/library/publications/the-world-factbook/rankorder/2102rank.htmlIncome Poverty and Health Insurance in the United States; 2006, United States Census Bureuwww.census.gov/prod/2007pubs/p60-233.pdf

   On February 15, 2008, the US Government Accountability Office (GAO) released a report that throws more cold water on the claim that “disease management” will save money(Medicare Physician Payment: Care Coordination Programs Used in Demonstration Show Promise, but Wider Use of Payment Approach May Be Limited. GAO-08-65, February 15 http://www.gao.gov/cgi-bin/getrpt?GAO-08-65).

“Disease management” is a phrase popularized first by the drug industry in the early 1990s, and then by the insurance industry in the late 1990s. These industries use the term to make two false claims: 

(1) they have figured out how to reduce the severity of chronic illnesses like diabetes, asthma, heart disease, and depression; and

(2) the savings caused by the (allegedly) improved health of patients with these diseases are so large they exceed the cost of the services that led to the improved health.

“Disease management” (DM) is now part of virtually every health care “reform” proposal out there. Hillary Clinton, Barack Obama, and John McCain talk about it. DM is hailed by both of the Minnesota commissions (the Health Care Access Commission and the Transformation Task Force) that released reports early in February. As with most health policy fads promoted by the insurance industry, this one has no scientific support for it. Papers that have reviewed the scientific literature on DM conclude that, with few exceptions (DM of heart failure is one), DM does not save money and may well raise costs. The February 15 GAO report confirmed these literature reviews. But the scientific evidence hasn’t prevented the insurance industry from marketing DM programs to employers, and it hasn’t prevented policy-makers from hailing it as the next new, new thing to extract us from the health care mess.

In the year 2000, Congress passed a law requiring the Centers for Medicare and Medicaid Services (CMS) (the agency that oversees Medicare and Medicaid) to conduct several experiments to test the idea that “paying for performance” (P4P) would save money for Medicare. In other words, Congress wanted to know if paying doctors who scored well on report cards would improve health and lead to lower Medicare spending. The 2000 law also required the GAO to evaluate the experiments CMS set up. 

The first experiment CMS set up was a four-year ”demonstration” called the Physician Group Practice Demonstration which tested not only the P4P theory, but DM as well. It tested the hypothesis that if CMS paid doctors a bonus for following guidelines for the treatment of certain chronic diseases like diabetes, this incentive would cause patients to become so much healthier that Medicare’s costs for these patients would fall by at least 2 percent compared with a “control” group of Medicare patients to whom doctors gave their usual plain vanilla care (care without the DM components). CMS insisted on at least a 2-percent reduction because they believed any reduction smaller than 2 percent might not be real (it might just be due to random fluctuations that had nothing to do with the efforts of doctors to minimize the severity of chronic illness).

CMS selected ten clinics and clinic chains to participate in the PGP demonstration. Every one of the participating clinics and clinic ”systems” was huge. They all had at least 200 doctors in them (less than 1 percent of all US clinics are in systems with more than 150 doctors in them [p. 6 of the GAO report]).

The February 15 report of the GAO reported on the results of the first year of the Physician Group Practice demonstration. Here is what the GAO found:

    (1) Only two of the ten clinics or clinic chains reduced their Medicare costs by 2% or more.

    (2) This miserable performance is despite the fact that the change-in-growth-of-Medicare-expenditure figures the GAO reported are gross figures, not net figures. That is, the figures do not include the cost to the clinics of participating in the demonstration. (The GAO reported both start-up costs and year-one operating costs for all ten clinics and clinic chains. The average start-up cost was $489,000, and the average year-one operating cost was $1.3 million.) Nor do the change-in-growth figures reflect the cost to CMS of figuring out who should get bonuses. The GAO report suggests CMS spent a ton of money crunching numbers and auditing some of the clinics’ records in order to ascertain whether the DM programs saved money (see p. 29 of the the GAO report).

    (3) The GAO report states that it is very unlikely that physicians in smaller physician groups will be able to afford to pay for the people and hardware necessary to replicate the DM projects evaluated in this demonstration.

    In short, this report says

    * DM is not saving money,

    * start-up and operating costs are substantial and are not included in the “savings” estimates, and

    * most clinics won’t be able to afford to do what the ten clinics and clinic systems in this demonstration are doing. 

Kip Sullivan

Covering test strips for diabetics (Letter)

What do high premiums cover? (Letter)

I’ve posted a couple of letters I received about how our current health care system is really hurting Minnesota families. These letters put a fine point on why we must take serious steps to reform our health care system. Our little HMO experiment isn’t working! The verdict is in and letters like these are testimony to this fact.

The letter from a diabetic who describes how her HMO is forcing her to use a substandard test strips is a good example of how our broken HMO system limits our choices. This is especially ironic since the fear of losing our freedom of choice is a concern that is raised whenever a “single-administrator” system is proposed as a way to cut administrative waste and achieve universal health care. It’s actually the other way around. Universal coverage provided by private medical professionals and a single administrator will give us more choices, not less.

In the second letter my young constituent wonders why his parents have to argue with their insurance company to pay for essential medical services. He writes, “I’m confused, isn’t that why my parents pay health care premiums every month?”

I’m confused too, my friend. It’s not right. We legislators need to make it right.

Have you written to your state representative? They need to hear from you.

David Bly

Yet another poll demonstrates that a majority of Americans support universal coverage under a single-payer system. A poll conducted during the week of December 14-20, 2007 by the Associated Press and Yahoo found that 65 percent of Americans support extending Medicare to everyone, and that 54 percent are willing to identify themselves as single-payer supporters. 

Here are the questions asked by the AP-Yahoo poll:

“The United States should adopt a universal health insurance program in which everyone is covered under a program like Medicare that is run by the government and financed by taxpayers.”

“Do you consider yourself a supporter of a single-payer health care system, that is a national health plan financed by taxpayers in which all Americans would get their insurance from a single government plan, or not?”

Sixty-five percent answered yes to the first question, and 54 percent said yes to the second one. (Poll results available through link at: http://news.yahoo.com/page/election-2008-political-pulse-voter-worries. After you click on the link at this address, scroll down to page 15.)

A single-payer system and a Medicare-for-all system are synonymous. Why, then, was support higher for extending Medicare to all than for a system described as a “single-payer”? The answer, it seems obvious to me, is the level of familiarity people have with Medicare versus the concept of “single payer.” Medicare is a familiar program, while the phrase “single-payer” is not.

These data tell me that as people become more familiar with single-payer their support for it will rise. I believe the same applies to Medicare for all. As people become more familiar with what that means, and as more political leaders and other opinion-makers promote Medicare for all, support for Medicare for all will rise beyond the two-thirds level that exists today.

The 2007 AP-Yahoo poll confirms a 2003 ABC News Poll which asked a nearly identical question about universal coverage under Medicare. That poll reported that 62 percent of Americans supported extending Medicare to all in the fall of 2003. Statistically speaking, the results if the ABC News poll and the AP-Yahoo poll are identical (in other words, the 3 percent difference is within the margin of error). Between 2003 and 2007, the awful Medicare Part D drug program began (it began on January 1, 2006). Despite the justifiably bad publicity the Part D program has gotten, support for a Medicare-for-all system has not fallen. I’m not sure whether that means Americans have mixed feelings about the Part D program, or dislike it but don’t blame Medicare for it.

Kip Sullivan

On January 8, 2008, the Minneapolis Star Tribune published an op-ed I wrote criticizing report cards on doctors and other health care providers (”Report cards won’t improve health care”). I noted that both of the Minnesota health care commissions due to report in the next few weeks will recommend greatly expanding the use of medical report cards, and that such a recommendation is likely to harm some patients and do nothing to lower health care costs.  To illustrate why medical report cards can do little to solve the health care crisis, I compared them to the school report cards required by the No Child Left Behind (NCLB) Act. The NCLB report cards have not improved the quality of education for all kids, but they have driven up the cost of education and have caused some schools to rid themselves of their more troubled students.

In this post and the next several I will offer some additional arguments and evidence supporting my criticism medical report cards that I didn’t have room to offer in my op-ed.

In my op-ed I focused on a report card on the 150 or so doctors in New York who operate on patients with heart disease and the 36 hospitals where these procedures are performed. The quality measure in this report card is the rate at which patients die within 30 days of surgery. I focused on this report card because it is among the oldest medical report cards published in America, it is the most sophisticated and most studied medical report card in America, and yet it has recently been shown to harm sicker patients. If a report card as sophisticated, as highly regarded, and as expensive as the New York heart surgery report card is harming patients, then it is reasonable to conclude that the vast majority of all other report cards in use now or to be published in the future have the potential to harm patients.

Here is a quote from a highly regarded researcher on medical quality to the effect that the New York report card (published by the New York Department of Health) is widely regarded as the gold standard: “New York State’s measurement and publication of coronary artery bypass graft (CABG) surgery mortality rates has emerged as a model in the campaign for useful performance data…. The reality is that these measures of performance are … the best available, and that substantial improvements are not likely for some years.” (Stephen F. Jencks, “Clinical performance measurement — a hard sell,” Journal of the American Medical Association 2000;283:2015-2016, 2015, 2016).

Now here’s a quote from a study published in 2003 which found that the New York report card on coronary artery bypass grafts (CABGs) is harming sicker patients: “[O]ur results show that report cards [on heart surgeons] led to … marginal health benefits for healthy patients, and major adverse health consequences for sicker patients.” (p. 577). “[M]andatory reporting mechanisms inevitably give providers the incentive to decline to treat more difficult and complicated patients” (p. 581). “[M]ore severely ill … patients experienced dramatically worsened health outcomes.” (p. 583) “Report cards led to a decline in the illness severity of patients receiving CABG in New York … relative to patients in states without report cards” (p. 583). (David Dranove et al., “Is more information better? The effects of ‘report cards’ on health care providers,” Journal of Political Economy 2003;111:555-588, 583.)

Several other studies have reached the same conclusion: New York’s report card is causing heart surgeons to refuse to perform surgery on sicker patients because they believe the higher death rates of these patients will make them look bad on the evening news. (The New York TV stations lavish much attention on this report card.) Obviously, the New York Department of Health did not want this to happen. The Department in fact went to great pains to minimize the probability that doctors who performed surgery on sicker patients would be given low grades because of their sicker patients as opposed to their inferior skills. The Department sought to adjust the mortality rates of the doctors and hospitals being graded by collecting data on 72 factors outside of the surgeons’ and hospitals’ control that affect mortality rates. These factors include whether the surgery was done on an emergency basis or was scheduled in advance, whether the patient was in shock or had a normal pulse when surgery began, whether the patient was 80 years old or 50, the number of clogged coronary arteries and their degree of narrowing, the patient’s prior history of heart attacks, and on and on.

Collecting and crunching all these data is very expensive. New York’s Department of Health has five full-time employees working on this one report card, and each of the three dozen hospitals has to employ a full-time data coordinator just to funnel all the information on heart patients demanded by the report card publishers at the Department of Health. (Edward L. Hannan et al. “Public release of cardiac surgery outcomes data in New York: What do New York state cardiologists think of it?” American Heart Journal 1997;134:55-61).

Has the bad news about the New York heart surgery report card caused anything to change? Nope. The Department of Health continues to crank out the report card, and Pennsylvania and several other states have passed laws requiring agencies in their states to start publishing similar report cards. The fascination with report cards among policy-makers in the face of evidence indicating they are expensive and could be harming patients illustrates a serious problem with how health policy is established in this country.

Kip Sullivan

A favorite refrain of apologists for America’s sick health care system is that if we were so bold as to bypass the bloated insurance industry in favor of a Medicare-for-all system rationing would become common place. The alleged “evidence” for this claim is that Canada’s single-payer system causes rationing. The never articulated corollary is that rationing just doesn’t happen in the US.

But when we ignore the silly assumption that rationing doesn’t occur in the US and ask, Is rationing worse in the US than Canada, the answer turns out to be a resounding yes. The research indicates rationing is on the order of 25 to 50 percent worse in the US than in Canada.

I’m aware of three studies that have used scientific methods to compare rationing in the US with rationing in Canada. The method used in all three studies was to ask Americans and Canadians if they did not get health care services they believed they needed in the previous year.  I invite readers to post any other study they can find that has been published in a peer-reviewed journal that uses a similar or better methodology.

 Here are short descriptions of the three studies.

A 1995 survey reported that rationing was 50 percent worse in the US. The survey determined that 12 percent of Americans and 8 percent of Canadians reported they were unable to get “needed medical care” in the previous year (Karen Donelan et al., “All payer, single payer, managed care, no payer: Patients’ perspectives in three nations,” Health Affairs 1996;15(2):254-265).

A 1998 survey reported that rationing was 40 percent worse in the US than Canada. Fourteen percent of Americans versus 10 percent of Canadians said “there was a time in the past 12 months when they needed medical care but did not get it” (Karen Donelan et al., “The cost of health system change: Public discontent in five nations,” Health Affairs 1999:18:206-216).

A survey conducted during 2002-2003 jointly by Statistics Canada and the US National Center for Health Statistics reported data indicating rationing was 27 percent worse in the US. This survey indicated that 13.7 percent of Americans and 10.7 percent of Canadians reported having “unmet health care needs” in the previous year. When other investigators adjusted these results to reflect differences between the US and Canadian respondents in age, gender, race, income and immigration status, they found that rationing was 27 percent worse in the US (Karen E. Lasser et al., “Access to care, health status, and health disparities in the United States and Canada: Results of a cross-national, population-based survey,” American Journal of Public Health 2006;96:1300-1307).

I’m aware of a fourth study that asked about rationing due to cost only. This study reported that rationing was four times worse in the US than in Canada.

It is important to remember that single-payer advocates are not calling for a reduction in US spending levels to the Canadian level (which is about 40% below the US level on a per capita basis). So rationing under an American single-payer system will not only be a lot less than under the current American system, but a lot less than under the current Canadian system.

Kip Sullivan

Henry Aaron of the Brookings Institute is not my favorite health policy expert. His solution to rising health care costs is rationing. Nevertheless, his latest article in Health Affairs is well worth reading. It makes the point that health care inflation is going to be reduced somehow in the next quarter-century, and the only question is whether it will be done sensibly or irrationally.

Aaron’s article (”Budget crisis, entitlement crisis, health care financing problem — which is it?” Health Affairs 2007;26:1622-1633) begins with the observation that annual inflation in US health care spending has exceeded annual growth in income by 2.7 percent for the last four decades. Then Aaron presents some data on what will happen over the next several decades if the gap between health care inflation and income growth persists at the 2.5 percent level. I offer here two of Aaron’s conclusions.

 First, Aaron predicts total health care spending will exceed 20% of Gross Domestic Product by 2016, and 30% by 2033 (by comparison we were at about 7% in 1970). Second, he predicts that the amount of after-tax money Americans will have to spend on non-health goods and services will grow by only 1% between now and 2019, and then flatten out between 2020 and 2045, and then decline.

Aaron predicts that the great pressure health care spending will place on all other types of spending  (education, transportation, military spending, recreation, etc.) will lead to immense political pressure to cut back on health care spending. I don’t subscribe to the notion implied by some observers that there is some magic limit to the amount of national income that can be devoted to health care. But I do agree with Aaron that as health care spending impinges ever more seriously on all non-health spending, the political pressure to do something will grow.

As has been the case for the last four decades (which is approximately when the modern health care reform debate began), we have two basic choices. We can reduce health care inflation by cutting the waste in the system (the administrative waste generated by the insurance industry, the over-purchasing of capital equipment by hospitals and clinics, the overcharging by specialists and drug companies, and fraud), or by rationing. If we want to solve the problem by cutting out waste, we need to implement a single-payer system. If we prefer rationing, then we should continue on our current course — we should leave the insurance-industry middleman in control of our health care system. There is no escaping having to make this choice.

 Kip Sullivan