HR 676 - The Good and the Bad - Part 5

Continued from Part 1, Part 2, Part 3, and Part 4.

"Non-profit health maintenance organizations that actually deliver care in their own facilities and employ clinicians on a salaried basis may participate in the program and receive global budgets or capitation payments as specified in section 202."
"Other health maintenance organizations, including those which principally contract to pay for services delivered by non-employees, shall be classified as insurance plans. Such organizations shall not be participating providers, and are subject to the regulations promulgated by reason of section 104(a) (relating to prohibition against duplicating coverage)."

Ugly
So, these sections serve to clarify how different HMOs will be treated. Non-profit HMOs that provide care will be treated as service providers that can qualify for reimbursement by the federal plan. Other HMOs will be treated as insurance plans.

This probably has to do with cost containment and standardization, making it easier to prevent outsourced and possibly for-profit doctors or clinics from indirectly charging the federal plan for services that would be harder to efficiently monitor. We're still on section 103, and have not gotten to the later sections that explain payment more thoroughly. On the face of it, this seems potentially unnecessarily restrictive, and may strong-arm doctors to become salaried or capitated employees of non-profits. I admit to an incomplete understanding of HR676's rationale for requiring salaried or capitated providers. I will explore different payment types and their consequences in the future.

"Patients shall have free choice of participating physicians and other clinicians, hospitals, and inpatient care facilities."

Good
Most hospitals will be participants from the beginning. Many more will make the transition. Most people who already have health insurance are already familiar with "in-network" versus "out-of-network" providers, so this idea will not be confusing. The difference will be that "in-network" with HR676 means most facilities throughout the whole country.

Freedom of choice will also put pressure on facilities to be more competitive with regard to quality. Since services will be free to people under HR676, service differentiation (covered services) will involve quality instead of price. Low quality providers will be less able to rope in clients by cutting deals with third-party payers.

Bad
I am at a loss.

HR 676 - The Good and the Bad - Part 4

Continued from Part 1, Part 2, and Part 3.

Health care delivery facilities must meet regional and State quality and licensing guidelines as a condition of participation under such program, including guidelines regarding safe staffing and quality of care.

Good
This is a measure to appease people who oppose federal involvement in state affairs.

Bad
Some states insist on having unnecessarily low standards. "Best Practices" is the idea that everyone should do what has been shown to lead to the best outcomes. We are constantly measuring health care outcomes related to different policies, and it blows my mind that there are factions out there who refuse to do what is best for the people in their care. Mississippi's quidelines for quality of care are not the same as Connecticut's, and Mississippi has significantly worse health care outcomes. A single-payer has a great opportunity to use its leverage to require uniformly high standards instead of allowing states to choose whether or not they will slack off. Residents of Mississippi are still Americans, and the American government has a responsibility to them.

Participating clinicians must be licensed in their State of practice and meet the quality standards for their area of care. No clinician whose license is under suspension or who is under disciplinary action in any State may be a participating provider.

Good
Pretty standard.

Bad
Same as above about variance in state standards, but with an added gripe. It is a pain in the tuchas for clinicians to move from one state to another because licensure requirements are all different. Clinicians who live near a border are either stuck working in one direction, or have to go through multiple licensure procedures. I don't know if this constitutes an undue burden on interstate-commerce or what, but it is ridiculous. There should be at least the option of satisfying a single, high standard that would allow clinicians to move without getting a new license. There is a similar situation with gun laws, and many states accept a Florida license because it is more difficult to get than their own. Some states are easier to move to than others.

The complaints in this post are about our current system, and not about HR 676 in particular. It is just that HR 676 is accepting of these problems, and they are included in the bill. Causing as little turmoil as possible will help the bill's progress, though our system really does need some improvements.

HR 676 - The Good and the Bad - Part 3

Continued from Part 1and Part 2.

No institution may be a participating provider unless it is a public or not-for-profit institution.
Investor-owned providers of care opting to participate shall be required to convert to not-for-profit status.
The owners of such investor-owned providers shall be compensated for the actual appraised value of converted facilities used in the delivery of care.
There are authorized to be appropriated from the Treasury such sums as are necessary to compensate investor-owned providers as provided for under paragraph (3).
The conversion to a not-for-profit health care system shall take place over a 15-year period, through the sale of U.S. Treasury Bonds. Payment for conversions under paragraph (3) shall not be made for loss of business profits, but may be made only for costs associated with the conversion of real property and equipment.

Okay, this is a bit confusing, and not something that's been covered much in the media compared to the prior points. Fifty-nine percent of America’s non-federal hospitals are not-for-profit (Government Accountability Office (2008)). With a single-payer system, hospitals and other service providers will be practically forced to obey the requirements of that payer in order to stay in business. For-profit service providers will either shrink and offer only premium services at high cost to private payers (uncovered procedures or immediate procedures without waits), or they will have to make this conversion to not-for-profit status.

What do they have to convert? A common difference between for-profit (FP) and not-for-profit (NFP) hospitals is the presence of an emergency room (ER). ERs are expensive and tend to lose money, but are required for NFP status. The trade off is providing a lot of uncompensated emergency care instead of paying taxes. To work with HR 676, many FP hospitals would have to build ERs. The bill would have Treasury Bonds sold to pay for this construction, along with any other conversion costs, though I am not sure what else would be involved. They have 15 years to convert.

Good
NFP hospitals are generally more efficient than FP hospitals. It sounds like the government will pay FP investors for the conversions. 15 years is a fairly long amount of time for conversion. After transition, we will have a more efficient system overall that cares more about health care provision and less about profit.

Bad
Everyone who currently profits from their FP facilities is going to fight the bill. They will not be compensated for "lost profits". FP facilities and private insurance companies will suffer immediately as many of their customers switch insurance. NFP facilities may not be able to accommodate a sudden rise in customers. There will be a stormy transition in which we do see a temporary increase in wait times for people with the federal insurance, which the opposition will capitalize on in their complaints, and an increase in misinformation as providers and private insurance providers compete.

HR 676 - The Good and the Bad - Part 2

Continued from Part 1.

The health insurance benefits under this Act cover all medically necessary services, including at least the following:
(1) Primary care and prevention.
(2) Inpatient care.
(3) Outpatient care.
(4) Emergency care.
(5) Prescription drugs.
(6) Durable medical equipment.
(7) Long term care.
(8) Mental health services.
(9) The full scope of dental services (other than cosmetic dentistry).
(10) Substance abuse treatment services.
(11) Chiropractic services.
(12) Basic vision care and vision correction (other than laser vision correction for cosmetic purposes).
(13) Hearing services, including coverage of hearing aids.

Good
All medically necessary services are covered. One of the cost containment measures may be to reduce unnecessary testing and procedures. A huge problem with our US system is unnecessary services, also known as "defensive medicine" because they protect doctors from getting sued. People need to accept that even best practices don't always work, and it's not malpractice. Doctors should be protected from lawsuits as long as they follow best practices. This will reduce costs without disproportionately reducing quality of care. It is also good that HR 676 explicitly includes mental health and substance abuse treatment, which both have cascading effects on health and quality of life over time and generations.

Bad
"Medically necessary" will still usually mean "whatever a doctor says". Many doctors fall prey to biases in their decisions that reduce quality of care in the face of current medical research, but doctors as a group refuse to let anyone else question them, no matter how much data suggests they do something different. Large payers have had varying success controlling service provision by controlling payments per diagnosis ("prospective payment" for "diagnostically-related groups" (DRGs)), but also have had trouble spotting shenanigans like hospitals "upcoding" patients to more severe diagnoses to justify additional treatment.

Chiropractors? Seriously? They seem to have had good lobbyists since at least the early 1970's. What an unnecessary waste.

Such benefits are available through any licensed health care clinician anywhere in the United States that is legally qualified to provide the benefits.

Good
Totally standard.

No deductibles, copayments, coinsurance, or other cost-sharing shall be imposed with respect to covered benefits.

Good
No financial barriers to treatment means that everyone can afford health care. Fewer poor people avoiding basic and preventative care means fewer poor people in the ER increasing our costs and reducing their productivity.

Bad
This is an obvious lesson we should have learned from other socialized health care systems, and from experiments within the US: cost-sharing is good. When health care is completely free, people go to the doctors when they don't really need to. This is when the lines and waits get unnecessarily long. This is when practitioners' time is wasted. Even the poorest people can scrape together a $10 co-payment if they really need a doctor, and just $10 will make people think twice before running to the doctor every time they sneeze. This is not about the money as much as it is about disincentivizing waste.

We should also charge for missed appointments. Years of working providing services in poor communities has given me much experience with no-shows and last-minute cancellations. This population has many reasons for missing appointments: no transportation, the health complication itself, being unable to better schedule other necessary conflicting appointments, but often they are just not motivated to do things. The linking factor between their poor health and poverty is often that they are characterologically immediately-gratifying and avoidant of putting forth effort or exposing themselves to additional stressors such as discussing problems with a doctor. For a number of etiological reasons, they are compelled to sit at home, watch TV, eat junk food, smoke, complain, and have kids that they don't raise effectively. These behaviors lead to both poverty and health problems, and perpetuate the problems through generations. I am not saying that this describes all poor people. This is just a common issue among the poor. Service providers of Medicaid recipients are lucky to have show rates over 60%. My current clinic has instituted a number of measures to improve the show rate, and is happy to report consistent rates between 70% and 75%, and we do not get paid when the clients don't show. We use phone call reminders, and we discharge anyone who misses two consecutive appointments, but we have no cost-sharing at all. I am privy to an experiment conducted by a dental practice that serves a poor area. They tried different charges for no-shows or same-day cancellations. They found that clients were more cooperative when the charges were used for a specific and known purpose (toys and magazines for the waiting room). They also found that $20 was the sweet spot for motivating attendance. Anything less than $20, and the clients would rather stay at home and pay it. Anything over $20 and the clients would never come back. $20 kept clients on the list and coming in for appointments. Take advantage of the people's desire to avoid stressors. Make the possible loss of money more stressful than the trip to the doctor.

Charging some money makes the system more effective and efficient than making everything free.