Healthcare Professionals for Healthcare Reform

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A Conversation Comparing EMBRACE with Emanuel/Fuchs Plans

I have been having a “conversation” on Facebook (in the group called Doctors for America) with a Dr. John Lee about the relative merits of the EMBRACE plan compared with the Emanuel/Fuchs Plan. Here are some of the highlights of the exchange:

… “single payer” seems DOA in the Senate. (Conyers valiantly labors on in the House.) So, apparently, we have to get behind something that Susan Collins will support. Ezekiel Emanuel, Rahm’s brother, has a plan that might serve as a compromise. He supports vouchers and advocates turning all insurance companies into HMO’s. Susan Collins might go for that. He was just appointed special advisor to the director of the White House Office of Management and Budget for health policy.

 

Our group, Healthcare Professionals for Healthcare Reform (www.hpfhr.org), realized a couple of years ago that even though we believe that a single payer plan may be best for the health of the country, it would never make it politically in this country. We just published our proposal called EMBRACE in the Annals of Internal Medicine . We would be interested in your thoughts.

I’ve been seriously studying your article and re-reading the Emanuel/Fuchs Plan which I mentioned in my last post.
Your article differentiates yourself from “single-payer”, but, in a major sense, you both cling to the same, familiar fee-for-service payment system. In contrast, the Emanuel/Fuchs Plan is capitated, which goes beyond “centralized billing “ to no billing. Just take your voucher to any insurance company/ HMO. Capitated payment could most easily be applied to your basic Tier One benefits, well defined entities in an unselected actuarial pool (no cherry-picking allowed, but some risk-adjustment—voucher worth more– for sicker patients). Think of the huge savings in overhead if we stop itemizing and billing for actuarially predictable events? And should we not encourage Tier One benefits be delivered within an HMO system of primary care anyway? The other major advantage, which the all-important fiscally conservative Senators will like, is a capped, global budget that will force a rationalization of the current chaos.

I don’t mind the concept of Tier 3. It is a free country; buy whatever extras you want. But the definition of “quality of life”, which will distinguish Tier 2 interventions from Tier 1, makes me a little uncomfortable. Emanuel/Fuchs give the Federal Employee Benefits to everyone. What Congressmen get. We are all in this together. Social solidarity, which is language politicians from Britain to Switzerland use when discussing their very different solutions.

Re-read the goals of your plan in your conclusion section. Then read the Emanuel/Fuchs Plan and see if they don’t come closer.

HPfHR was specifically established by healthcare providers to address healthcare reform from the provider’s point of view. We wanted a system that was both effective in improving everyone’s health while being user friendly to physicians and patients alike. We also were looking for a system that would be politically viable and easily understandable to the public (including physicians!)
I am familiar with the Emanuel/Fuchs plan and I know that since Ezekiel Emanuel is Rahm’s brother it is likely it will have the ear of the President. As you point out, there are several similarities between their plan and the EMBRACE plan promoted by our group. There is a central Healthcare Board and there is universal coverage, and frankly this would be better than the current system and better than most of the plans that are now actively being considered in Congress.
However, there are important differences:
• 1) In the Emanuel/Fuchs plan the role of the Healthcare Board seems to be mostly limited to the “business” management of the system. Its only method of improving healthcare is by “recommending best practices to health care providers and organizations based on (the Board’s) evaluations.” In truth, this Board will have no effective power to dictate what best practice is. In addition the “monitoring compliance industry-wide” and “monitoring the quality of health care delivery industry-wide” that they advocate will be a bureaucratic nightmare on the level of the worse managed HMOs around today.In contrast, the evidence based tiers in EMBRACE predetermines “best practice” services within the system with minimal bureaucratic oversight, yet allows the provider to offer, and the patient to request “unapproved” services (but the patient may have to pay for it if he/she does not have insurance).
• 2) Because physician participation in the voucher plan is optional and there are other forms of coverage, the Emanuel/Fuchs plan will most likely lead to a system where there are one set of doctors for the “voucher patient” and another for the others. Although the “voucher patient” most likely will have good care, the truth is that as a provider, I would never want to have to decide if I am going to be one type of doctor or another.
• 3) The voucher system in Emanuel/Fuchs, although steering away from an employer based system, will not be universally portable. EMBRACE will do both: eliminate employer based basic coverage AND all insurance, whether public or private will be fully portable.
• 4) In the Emanuel/Fuchs system, the price of the Private insurance is set (no competition). The consumer must negotiate with the insurance company for the content of the plan. This assumes that the average American knows all the nuances of health insurance coverage and may understand what he/she may need in the future. In EMBRACE, the Board decides on the content of the plans and the insurance companies compete on price, deductibles, additional features etc. that the consumer is much more likely to understand.

The details of regulation would have to be negotiated and fine tuned. Any system that attacks cost, as only capitation can, would involve some provider hassles, I grant. But think of the money we’d save if we stopped itemized billing!! That would buy a lot of primary care.

By the way, with respect to “best practices” did you notice that “The president’s Federal Coordinating Council for Comparative Effectiveness Research, formed last month, includes Ezekiel Emanuel, brother of White House Chief of Staff Rahm Emanuel, to oversee the studies. The council’s first report to Obama and Congress, containing recommendations of what treatments should be studied, is due June 30” And the hiring of new lobbyists is showing the “…..drug industry’s resolve to stop Obama from using comparisons of medical treatments to force cuts in health costs. More than half of medical care may be based on insufficient evidence of effectiveness, the Congressional Budget Office said in March.”
http://www.bloomberg.com/apps/news?pid=20601085&sid=aHjr0BP1zvgo&refer=europe

Your other points:
• “I would never want to have to decide if I am going to be one type of (voucher) doctor or another”. Don’t see why private practice doctors couldn’t continue with a mix of patients, as they do now. What percent would opt out of the constraints of a no-frills voucher plan? Don’t know, but MediCare cost is about 22% out-of-pocket & National Health in Britain looses about 12% to the private sector. So I’d guess vouchers would cover 80-90% of care. Is it the monolithic aspect of this that worries you?
• Don’t understand why Emanuel/Fuchs wouldn’t be just as portable.
• With Emanuel/Fuchs the consumer would have a choice among many different plans which would compete on variations of benefits, deductibles and co-pays. As I recall, they would make sure each region had a half-dozen plans to choose from.

You asked about my background. I suppose I am a fan of capitation because our county hospital system, the Contra County Health Plan, was the first federally-qualified, government-run HMO in the country (1972). Our resulting primary-care clinic system is second to none in the national public sector. Happily, I’ve been spared the hassles and inefficiencies of itemized billing. Capitation puts the outpatient system is in the driver’s seat, not the hospital. We are also a teaching hospital (Family Practice, Martinez, Ca) affiliated with the UC Davis Network. What is your background?

I am a cardiologist who has been in 4 different types of practices in my 20+ years since finishing my fellowship. I have been in a busy inner-city “public” hospital in NYC; in a full time hospital based private practice; in an office based private practice group and am now the director of non-invasive cardiology and associate director of a cardiology fellowship program in Connecticut (i.e. in academics). I am also a council member in the CT chapter if the ACC and have been in DC lobbying (too) many times.
In my travels I have learned that 1) politicians will listen to you, but unless you either have money or a large measure of support of their constituency, they will not help you; 2) most doctors want change but feel that someone else who knows more and has more time should do the work (I know because I was one); 3) most doctors and patients hate the words “capitation” and “HMO” and 4) the more complex something is (like a healthcare plan), the more likely it will be opposed, and destroyed by people who can easily claim faults (mostly untrue or major exaggerations) or dire predictions. The reason for the latter is that the more complex something is, the less people (including politicians and doctors!) are able to reason for themselves what is true or not, and rely on “experts” or pundits to interpret it for them.
I think that my background and my experience led me to seek others who felt like me, and this is how we ended up with HPfHR and the EMBRACE plan. EMBRACE is simple in structure and keeps everything transparent. It has all the benefits of a single payer system, but allows participation of private insurers. It eliminates the bureaucratic nightmares for practitioners and patients and allows freedom of choice for both groups (doctors to choose any test/procedure/therapy he/she feels is needed and patients to choose among doctors and hospitals).
Back to our discussion:
1) Don’t understand why Emanuel/Fuchs wouldn’t be just as portable: The portability of a system depends on the uniformity of plans that are available. In the Emanuel/Fuchs plan, there will be multiple plans to choose in each region and no oversight that these plans will be the same if you get it in NY or in CO. So if you move to a new state you have to get a new plan. In EMBRACE you have a menu of the Tier 2 (private) plans (predetermined by the Board) that assure that the plan you purchase is complete and is identical no matter if you purchase it from Aetna or from Blue Cross. Because of this and because Tier 1 is identical all over the country, you are covered no matter what job you have or where you travel in the US (and even abroad!)
2) With Emanuel/Fuchs the consumer would have a choice among many different plans which would compete on variations of benefits, deductibles and co-pays. As I recall, they would make sure each region had a half-dozen plans to choose from: As we saw in Medicare D, consumers don’t do well when they have lots of choices of items, the content of which they may not really understand. How many people actually know all the details of the healthcare plan that they are covered by? I would guess next to none (except those in the business). However, I agree that for financial concepts like price, deductibles and co-pays, the consumer can understand this better. In EMBRACE the private insurance plans are predetermined but the price, deductibles and co-pays are not; allowing for “free market’ like competition on an even and transparent playing field.
3) What percent would opt out of the constraints of a no-frills voucher plan? Don’t know, but Medicare cost is about 22% out-of-pocket & National Health in Britain looses about 12% to the private sector. So I’d guess vouchers would cover 80-90% of care. Is it the monolithic aspect of this that worries you?: Many things worry me about this. One thing is that the US is not Britain or even Canada. There is a history of free enterprise (for the insurers) and private practice (for the docs). As we have seen with Medicare, which was once a straight “publicly funded” system, when private insurers are allowed to participate within the system, it inherently establishes competition between private and public sectors, to the detriment of both (but more to the public sector). This is well demonstrated with Medicare Advantage (or “Managed Medicare”) where privatized Medicare has managed to leach the low risk patients, leaving the higher risk, more expensive patients to “public Medicare”. So I fear that having vouchers compete with private insurance will recreate this scenario. What EMBRACE has done is separate public insurance from private, allowing private insurance to compete with itself (which I believe is fairer).
4) Any system that attacks cost, as only capitation can, would involve some provider hassles, I grant. But think of the money we’d save if we stopped itemized billing!! That would buy a lot of primary care.: As mentioned above, “capitation” is anathema to both providers AND patients (and patients tend to be both Democrats and Republicans and they vote in large numbers). The problem for docs is obvious: you have to negotiate (if the system allows negotiations) a per-patient fee for care and hope that you don’t get one or two hypochondriacs or even worse, really sick patients in your practice. This clearly is worse for the smaller practices and/or solo practitioners, and will lead, in the long run to large HMO like practices (with better risk pooling). For the patient there is the knowledge that your doctor is being paid by volume rather than service or quality. If this is the case, and the patient has a chance to go to a doctor who does not have to practice under these constraints, then the patient will switch doctors. EMBRACE will allow doctors/providers to itemize but still have NO overhead (due to the free internet based Universal Billing Form). In addition, there is no need for capitation to save cost. If something is not in Tier 1 it will not be covered by Public insurance! And yet, you can still go to the same doctor and get the same service even if you go “outside” the public system.
5) More than half of medical care may be based on insufficient evidence of effectiveness, the Congressional Budget Office said in March.: I totally agree and that is why we believe that there should be an independent Board to oversee the commission of studies to get these data. The Federal Coordinating Council for Comparative Effectiveness Research is an excellent first step but unless it is overseen by a Federal Reserve like board, as we advocate in EMBRACE, there will be no clear direction with these studies.

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April 18, 2009 Posted by | Uncategorized | Leave a comment

A response to an “Annals dialogue” comment

Before the Annals published EMBRACE, it had an on-line “dialogue” which I joined. There were a couple of entries that I thought might be of interest that the Annals did not keep after publication. Here is one comment and my reply:

Umesh stated: I fear that the focus on ‘universal coverage’ and the consequent debate almost completely ingores another very important priniple that should be an integral part of the current health care reform effort: a 
single payer system. The massive chunk of health care dollars (abuot 30%) being siphoned off by for-profit intermediaries is almost enough to pay for all uninsured Americans (about 18%). Is the academic health care establihment so weakened that they cannot withstand the vested interests?  

My response:

There IS a “single payer” proposal that has been making the rounds for over 6 years and has been stuck in Congress for over 4 years. It is called H.R. 676 and it is based on the 2003 JAMA white paperby a group called PNHP. It has garnered a fair amount of support by healthcare professionals, especially academicians, who understand that a single payer model that preserves some autonomy for doctors will be more effective in improving the health of the country than the current system (even if the current system is expanded to achieve universal coverage).  

   

The problem is that HR 676 and all single payer plans are not POLITICALLY viable.  

   

On both sides of the aisle, from John McCain to Ted Kennedy, from John Boehner to Nancy Pelosi, all agree that “Single Payer” is dead in the water. The reasons are many, but the most important is that the insurance (and pharmaceutical) lobby is one of the strongest in Washington and getting stronger. It is very telling that when President Obama had his White House Health Care summit, only the representatives of PNHP were not invited (it took huge effort with a last minute phone-in campaign to get a representative to finally be admitted).  

   

That is why we at Healthcare Professionals for Healthcare Reform (HPfHR) developed the EMBRACEplan that is published on-line here. In it you will find that we have all the benefits of a single payer system (universal free coverage for all “basic” healthcare needs), while including a more transparent and portable private insurance system. We have also attempted to preserve all the benefits of the present system (such as access to all providers and easy availability of testing and therapy etc).  

   

This fight is not going to be won by the academic health establishment; it needs the input and support of all who are involved in healthcare. Please review the EMBRACE planand consider it versus the alternatives. There is a limited time to get involved and get our voices heard. If you want more information about HPfHR please visit our website: www.hpfhr.org or email me: gl@hpfhr.org.

Gil

 

April 7, 2009 Posted by | Uncategorized | Leave a comment