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Texas Bans Nearly All Abortions

Summary: Texas passed a ban on all abortions after 6 weeks, enlisting citizens to enforce it. This week, the U.S. Supreme Court let the law stand without hearing arguments. Roe v. Wade took a huge hit. So did health care justice.

Supreme Court, Breaking Silence, Won’t Block Texas Abortion Law
New York Times
September 1, 2021
August 23, 2021
By Adam Liptak, J. David Goodman and Sabrina Tavernise

The Supreme Court refused just before midnight on Wednesday to block a Texas law prohibiting most abortions, less than a day after it took effect and became the most restrictive abortion measure in the nation.

[…]

In the emergency application urging the justices to intervene, abortion providers in the state said the new law “would immediately and catastrophically reduce abortion access in Texas,” and most likely force “many abortion clinics ultimately to close.”

Comment by Isabel Ostrer and Jim Kahn

On Wednesday, the U.S. Supreme Court let stand Texas’ near-total ban on abortion (SB8). The law prohibits abortion once fetal cardiac activity can be detected — typically at six weeks of gestation, when most women don’t even know they’re pregnant — in effect banning 85-90% of abortions. Rape and incest are not excepted. The law evades Roe v. Wade’s restrictions on state action by empowering citizens (not the police, not the government) to enforce the ban using civil litigation, with the rules stacked against anyone who facilitates an abortion. There is no precedent for this bizarre enforcement design.

SB8 is the perfect storm of abusing law-making to take away the right to control one’s own body. It strikes at the nexus of health, human rights, and democracy. It will harm health both physically and mentally, predominantly for poor people of color. 

Representative Cori Bush wrote, “I’m thinking about the Black, brown, low-income, queer, and young folks in Texas. The folks this abortion health care ban will disproportionately harm. Wealthy white folks will have the means to access abortion care. Our communities won’t.”

Prior to SB8 taking effect, Texan’s seeking abortions had to travel an average of 24 miles round trip to access care. Now they will have to travel nearly 500 miles to access this same care out of state, putting safe abortions out of reach for many. 

When abortion bans go into effect, women don’t stop seeking abortions, rather abortions become less safe. Abortions performed by a trained health-care provider are incredibly safe — much safer than child birth. When the U.S. legalized abortion in 1973, the number of abortion-related deaths dropped drastically, mainly due to a decline in the absolute number of deaths from illegal abortion. Total abortions have also dropped to below 1973 levels. With the new law, women’s lives are being sacrificed.

We must ensure access to health care for all — including the full-spectrum of reproductive care, which encompasses abortion care.

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Learning from Costa Rica

Summary: Atul Gawande writes a compelling New Yorker report of how Costa Rica melded medicine and public health to greatly reduce disease and lengthen life. If the U.S. is to learn from this inspiring example, we’ll need universal coverage with no cost barriers, robust health data, and strong primary care. Single payer will help pave the way.

Costa Ricans Live Longer Than Us. What’s the Secret?
The New Yorker
August 23, 2021
By Atul Gawande

“People who have studied Costa Rica, including colleagues of mine at the research and innovation center Ariadne Labs, have identified what seems to be a key factor in its success: the country has made public health—measures to improve the health of the population as a whole—central to the delivery of medical care. Even in countries with robust universal health care, public health is usually an add-on; the vast majority of spending goes to treat the ailments of individuals.

[…]

As the pandemic ebbs, countries will be assessing what went wrong with their public-health systems. A fundamental failure has been the separation of public health from health-care delivery. Getting that right, across the globe, could present our greatest opportunity to secure longer and better lives.”

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Comment by: Isabel Ostrer

Atul Gawande’s captivating article about Costa Rica’s robust public health system describes a framework for how to improve health outcomes — one that a single payer healthcare system can facilitate. In fact, I contend that a unified health system is a prerequisite for implementing this type of comprehensive delivery.

Gawande recounts the three principal elements of Costa Rica’s universal approach to care: 1) merge public health services with hospital- and clinic-based care, 2) collect and integrate household-level demographic data with medical records to drive national health priorities, and 3) emphasize local primary care delivery.

Single payer provides the prerequisites for this transformation by:

1) Facilitating marginalized communities’ access to care: For the Costa Rican model to work, everyone needs excellent access to care. In the U.S, 33 million Americans are uninsured and nearly ⅓ of insured adults are inadequately insured. Single payer would eliminate barriers to care by ensuring every American has health insurance, with no point of care costs (premiums, co-pays, and deductibles) which discourage care seeking.

2) Creating a unified electronic health record: Electronic health records (EHR) are clunky and disparate, and don’t communicate with each other. A 2018 report revealed that fewer than half of office-based physicians were able to exchange health information with providers outside their organization electronically. A single payer system would prioritize a single EHR that allows easy exchange of information among medical providers. This foundation could be expanded to include public health data, mirroring the Costa Rican system Gawande describes.

3) Prioritizing a primary health workforce: Greater primary care is associated with lower mortality, lower costs, and higher quality of care. But the number of primary care physicians (PCPs) decreased from 46.6 to 41.4 per 100,000 people between 2005 and 2015. This is unsurprising given that the median PCPs’ income is just 60% of specialists’. The Medicare for All Act of 2019 establishes an Office of Primary Health Care to expand the primary care workforce and ensure greater access to care, particularly in underserved areas. Moreover, primary care compensation would increase through two mechanisms. First, a single payer system would compensate previously unreimbursed care. Second, it would free up time previously spent on administrative work for reimburseable direct patient care.

Gawande writes that as countries assess how they could have better responded to the Covid-19 pandemic there will be more focus on public health infrastructure. Indeed, this moment of reflection is an opportunity to fundamentally rethink how we deliver care with emphasis on universal coverage as a foundation to “braid together public health and individual health.”

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Expensive Drugs are Becoming Ultra-Expensive

Health Affairs, June 2021, Ultra-Expensive Drugs And Medicare Part D: Spending And Beneficiary Use Up Sharply, By So-Yeon Kang, Daniel Polsky, Jodi B. Segal, and Gerard F. Anderson

Drugs with exceptionally high prices have sparked debate on their sustainability and affordability. We refer to these as “ultra-expensive” drugs, defined as drugs with average annual per beneficiary total spending in excess of the annual US per capita gross domestic product ($62,996 in 2018). In the context of Medicare, this includes both Medicare’s and the beneficiary’s responsibilities. Our findings show a rapid increase in the share of Medicare Part D spending on these drugs compared with other drugs.

It is a limitation of our study that we analyzed only Medicare Part D data and thus could not draw any conclusions regarding Medicaid or private insurance.

Medicare Part D spending for ultra-expensive brand-name drugs, 2018:

  • 122 – Total number of drugs
  •  278,000 – Total number of beneficiaries
  •  $24,550,000,000 – Total spending
  •  $175,513 – Average spending per beneficiary per drug

(The table also includes a section for drugs that are only expensive, defined as those that were not ultra-expensive but whose annual per beneficiary total spending was more than the yearly average Social Security benefits of retired workers [$16,848 in 2018]. These expensive drugs were consumed by 651,000 beneficiaries at an average of $34,451 per drug for total Medicare Part D spending of $21,552,000,000.)

The number of ultra-expensive drugs covered by Medicare Part D increased from 23 in 2012 to 122 in 2018.

We note that sixty-one drugs (50 percent of ultra-expensive drugs in 2018) entered the market as ultra-expensive drugs between 2012 and 2018; 31 percent were on the market but not ultra-expensive in 2012 and became ultra-expensive by 2018.

One challenge for policy makers is that half of these ultra-expensive drugs are new, and their sustained therapeutic and economic benefit for the price has not yet been demonstrated.

The concentration of Part D spending on the growing number of beneficiaries using ultra-expensive drugs suggests that policy makers should pay attention to this drug category.

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Comment by Don McCanne

Drug spending is out of control and getting much worse. By the standards in the article, the newly released, likely-ineffective Alzheimer’s drug, aducanumab, at $56,000 per year, is considered onl expensive and not ultra-expensive.

Imagine, single drug pricing per beneficiary in excess of the per capita GDP. Wasn’t the equivalent of taking a full year’s Social Security retiree benefits for a single drug enough?

Perhaps the most important statement in this article, which is decidedly an understatement, is that “policy makers should pay attention to this drug category.”

Perhaps we should approach Sen. Joe Manchin, as a moderate conservative, and explain the situation to him so he can lead a unified Congress to do something about it. But, wait a minute, wasn’t it his daughter, Heather Bresch, as CEO of Mylan, who purchased the company, Abbott, that sold the EpiPen brand of epinephrine, and then increased its price by 461 percent?

Sadly, this Congress has already shown its lack of concern by its inaction; this price gouging is taking place under its very nose. No, we need to elect a Congress that will not only pay attention, but one that will actually do something about it. We certainly can no longer leave it up to the pharmaceutical industry to come up with fair pricing for its products.

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Colorado’s Pseudo-Public Option

By Adam Gaffney

Last week, lawmakers in Colorado passed a bill that would establish what some might call a “state public option” plan, although that’s not what it is. The bill would require, as the Colorado Sun and Denver Post describe, private insurance companies to offer a health plan on the individual and small-marketplaces with premiums that are 15% lower in 2025 than they are today after adjustment for medical inflation; if that goal was not met, the state could potentially regulate payment rates under these plans.  

The bill was heavily opposed by state Republicans and, variably, by healthcare industry players. Its advocates tried to achieve more. But unfortunately, the impact of the law is likely to be paltry, potentially even difficult to perceive. If that pans out, it could be used to discredit the notion of true public health insurance.    

For one thing, as the Colorado Sun describes, the source of the 15% savings is not entirely unclear. It quotes one of the bills’ chief sponsors: “The spirit of this bill is to ask everyone to come to the table to work on decreasing cost and increasing access.”  But these plans would still be run by private insurers, so there is no reason to expect any savings on insurer administration — the primary source of savings under Medicare for All according to the Congressional Budget Office. On the other hand, government rate-regulation (or the threat of it) might give insurers more leverage to reduce reimbursements to providers. Whether this process will succeed, however, is uncertain. After all, Colorado is following in the footsteps of Washington state, which passed a quasi-public option in 2019. Premiums for these “public option” plans (which are actually private insurance plans sold on the marketplaces that pay rates tethered at a percentage above Medicare) were actually 5% higher in 2021 relative to 2020 ACA marketplace plans, per Bloomberg Law.

But the reach of these plans, even if they achieved modestly lower premiums, will also be highly limited. They are available only to those buying insurance on the individual and small-business market. They would hence provide no benefits for those with employer-sponsored coverage and high premiums or deductibles, or for those with holes and gaps in their public insurance plans. Moreover, although they have been advocated as a tool to expand coverage, they are unlikely to be more affordable for the vast majority of uninsured individuals even if they achieve lower premiums. That is because, under the ACA, premium contributions for marketplace plans are set as a proportion of income for all those earning under 400% of the federal poverty level, which is now also the case for those of any income under Bidens’ America Rescue Plan (at least through 2022). Hence, there is no real popular constituency for these programs: at best, if totally successful, they would mostly serve to bring about a modest reduction in government expenditures on ACA subsidies, with little gain in coverage, access, or affordability of care for patients. 

And that is not just a policy problem, but a political one. To bring about meaningful change in healthcare, you need a powerful popular constituency behind you, because invariably you encounter opposition from powerful interests. This sort of reform, however, fails to generate such a constituency; its weakness is, in this sense, a feature and not a bug of its design. In contrast, although single-payer reform poses far larger political obstacles for passage, it is unique in that it could benefit nearly every segment of society, and hence potentially help generate the constituency needed to achieve it.

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Uninsured Adults Nearing Medicare Age More Likely to Die from Cancer

Cancer Outcomes Among Medicare Beneficiaries And Their Younger Uninsured Counterparts, Health Affairs, May 2021, Gerard Silvestri, Ahmedin Jemal, K. Robin Yabroff, Stacey Fedewa, and Helmneh Sineshaw

Abstract: Proposals for expanding Medicare insurance coverage to uninsured Americans approaching the Medicare eligibility age of sixty-five has been the subject of intense debate. We undertook this study to assess cancer survival differences between uninsured patients younger than age sixty-five and older Medicare beneficiaries by using data from the National Cancer Database from the period 2004–16… We found that uninsured patients ages 60–64 were nearly twice as likely to present with late-stage disease and were significantly less likely to receive surgery, chemotherapy, or radiotherapy than Medicare beneficiaries ages 66–69, despite lower comorbidity among younger patients. Compared with older Medicare patients, younger uninsured patients had strikingly lower five-year survival across cancer types. For instance, five-year survival in younger uninsured patients with late-stage breast or prostate cancer was 5–17 percent lower than that among older Medicare patients. We conclude that… expanding comprehensive health insurance coverage to people approaching Medicare age eligibility may improve cancer outcomes in the US.

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Comment by Isabel Ostrer

Cancer is a leading cause of death in the United States. However, there are stark disparities in cancer outcomes among different populations. Lack of insurance is an unfortunate and unnecessary contributor to these disparities. 

In this Health Affairs paper, we learn that uninsured patients ages 60-64 with a new cancer diagnosis had significantly worse one-, two-, and five-year survival rates compared to their Medicare-insured counterparts — who were also older (66-69) and more likely to have comorbidities. The reasons for these discrepancies are varied but certainly include lack of access to care. Patients who are uninsured are less likely to have a usual source of primary care and to participate in cancer screening programs leading them to present with later-stage disease that is not easily curable. Of note, patients in the younger age group who had insurance coverage had better survival rates than their older counterparts, as would be expected due to age differences. 

Disparities in cancer outcomes also vary by race, with Black patients faring worse than white patients. When adjusting for insurance coverage these disparities decrease, although they are not eliminated. 

The authors posit that lowering the Medicare eligibility age to 60 could improve cancer outcomes and reduce disparities. Why stop at 60? Patients across their lifespan are at risk of developing not just cancer, but other conditions that respond to early treatment and intervention. Nearly 20% of adults in the 45-64 age group have diabetes. Furthemore, nearly one in five deaths among adults 25-64 is due to cardiovascular disease. 

We know that insurance coverage both improves survival and reduces racial disparities in outcomes, not only for cancer but also for other medical conditions – chronic and acute. It’s time to assure that all Americans have high-quality insurance. The only way to achieve this is thorough Medicare for All.

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The Buffett-Bezos-Dimon-Gawande insurance fail? A powerful policy lesson!

How Amazon, JPMorgan, and Berkshire Hathaway took on America’s health care system—and lost, Fortune, June 1, 2021, By Erika Fry

Was it a press release, or a declaration of war?

How else to explain the media and market frenzy that followed the announcement, issued on Jan. 30, 2018, that Amazon, Berkshire Hathaway, and JPMorgan Chase — three of the nation’s largest, most high-profile, and best-run companies, then with some $534 billion in revenues between them — were teaming up to take on the ever-more-expensive, ever-more-complex problem that is American health care.

To those who had toiled in the world of employer-sponsored health care for decades, trying but never really succeeding to come up with new ways to control costs and improve outcomes … the statement, from three powerful CEOs, was cause for celebration.

Five months in, the team announced another star would lead the venture: Atul Gawande, the surgeon and influential New Yorker writer whose clear-eyed analysis of America’s dysfunctional health care system had earned him the admiration of Barack Obama and Buffett. In March 2019, the venture finally got a name, Haven.

The project officially sputtered to an end earlier this year. Even with its star power, Haven couldn’t break the black box that is U.S. health care.

So, did Haven make a difference? Some argue the effort undermined progress by raising the obvious question: If they couldn’t do it, who can? In a recent Kaiser Family Foundation survey of very large employers, 85% of top executives think government support will be necessary to control costs and provide coverage.

Gawande goes further and has recently argued that the employer-sponsored system can’t be fixed. Noting how many Americans lost their health insurance in a global pandemic, he said, “A job-based system is a broken system.”

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Comment by Don McCanne

I contend that the Haven health reform effort of Warren Buffett, Jeff Bezos and Jamie Dimon, along with Atul Gawande, was a spectacular success, as an experiment in health policy. They proved beyond any reasonable doubt that the private sector is incapable of fixing our highly dysfunctional health care financing system. The only model that has shown promise is a single payer Medicare for All system. But you cannot set that up as an employer-sponsored system; it will have to be a public system for all the people.

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Insurers That Squeeze Care are Killing Thousands of Enrollees Each Year

Mortality Effects and Choice Across Private Health Insurance Plans, The Quarterly Journal of Economics, May 6, 2021, Jason Abaluck, Mauricio Caceres Bravo, Peter Hull, and Amanda Starc. 

*The abstract is available at https://doi.org/10.1093/qje/qjab017  While the full text is behind a paywall, an earlier version of the full paper is available here. 

From the Abstract: “We develop and apply a novel instrumental variables framework to quantify the variation in causal mortality effects across plans and how much consumers attend to this variation. We first document large differences in the observed mortality rates of Medicare Advantage plans within local markets. We then show that when plans with high (low) mortality rates exit these markets, enrollees tend to switch to more typical plans and subsequently experience lower (higher) mortality. . . . 

We then extend our framework to study other predictors of plan mortality effects and estimate consumer willingness to pay. Higher-spending plans tend to reduce enrollee mortality, but existing quality ratings are uncorrelated with plan mortality effects. Consumers place little weight on mortality effects when choosing plans. Good insurance plans dramatically reduce mortality, and redirecting consumers to such plans could improve beneficiary health.”

From the text:  “We find that the most widely used measure of plan quality, CMS star ratings, is uncorrelated with plan mortality effects. Higher premium plans have better mortality effects, as do plans with more generous prescription drug coverage and higher medical-loss ratios. Thus, in every way we measure, plans that spend more tend to reduce enrollee mortality.”

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Comment by David Himmelstein and Steffie Woolhandler

A simple message emerges from this complex econometric analysis: insurers that skimp on paying for care (as measured by a low medical-loss ratio – the share of premiums devoted to patient care) or provide highly restrictive drug coverage, are killing their enrollees.

The study examined the mortality rates of patients covered by different Medicare Advantage (MA) plans. Not surprisingly, mortality varied among plans. That could just reflect differences in how sick the enrollees were to begin with, not anything the insurers did.

The compelling finding is that when plans with high mortality rates stopped offering coverage in a particular county – forcing their enrollees to switch to a different plan – the mortality rate for those forced to switch went down. (Similarly, when low-mortality plans shut down, the mortality rate of the enrollees forced to look elsewhere for coverage went up.) In sum, the study provides quite convincing, quasi-experimental evidence that MA plans’ quality influences the mortality of their enrollees. Indeed, the effect is so large that shifting MA enrollees from the worst 5% of plans to the average (not even the best) plan would save about 12,000 lives each year.

The researchers then looked at what differed between high and low mortality MA plans.  They found no correlation with the CMS star rating – a one star-rated plan was just as likely to do well by its enrollees as a five star plan. And, not surprisingly, seniors, who often look to these ratings were bad at choosing a plan with low mortality.

What made a difference – and a big one – was how much a plan spent on its enrollees. Plans that had a higher medical loss ratio (i.e. they spent more of their premiums on care, and less on overhead and profit) had lower mortality rates. (The medical loss ratio of  MA plans averaged 83% in 2020 vs. traditional Medicare’s 97.7%). Additionally morality was lower in plans with better drug coverage and those with higher premiums. 

As is often true of economists, these researchers drew the wrong conclusions from their important findings, clinging to the pro-market notion that additional tweaks could finally make commercially-driven health insurance work to patients’ advantage. They recommend that CMS improve its rating system to take account of MA plans’ mortality performance. As the authors note, however, private insurers would game any mortality-based rating system, just as they have successfully gamed CMS’ star system. The authors further suggest that health and life insurance be merged so that MA plans that kill people by squeezing care would have to pay out more in life insurance benefits.  

They ignore the obvious better choice: a single payer system that would have a loss ratio of 97.7%, as well as better drug coverage than the best MA plan. The data indicate that would save tens of thousands of seniors’ lives annually.

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Let’s Not Mourn the Death of the Public Option

The health insurance public option might be fizzling. The left is OK with that., NBC News, June 5, 2021, By Benjy Sarlin and Sahil Kapur

“A decade later, Joe Biden campaigned on making the public option a reality, but so far, he’s done little to get Congress to enact one. Instead of outrage, influential progressives seem to be OK watching the promise go unfilled, preferring to pursue universal health care through other means, like expanding Medicare eligibility.

Elected officials, health care activists and experts who spoke to NBC News said the issue has fallen off the national radar and will be difficult to revive without a major push by the White House.

Responding to the pandemic has consumed much of Biden’s attention in his first months in office. And beyond that, he has a long list of agenda items to get to first, including many that are popular with progressives.

“I don’t think there’s a dynamic where we see it at the center of a political fight again,” said Alex Lawson, the executive director of the left-leaning group Social Security Works.”

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Comment by Eagan Kemp

No one should mourn the end of a push for a public option in health care. It was never the solution the country needed for health reform. 

The risks inherent in a public option completely overwhelm any potential gains. Given the rapid rise in for-profit companies gaming Medicare through Medicare Advantage, there is no reason to believe that a public option would be any different when it comes to insurers dumping patients with high health needs, while retaining patients that are profitable. If the for-profit insurers can cherry-pick healthier Americans through seemingly more favorable plans (while they are healthy), then the public option could become overly burdened and unsustainable. 

In addition, a public option would have just been one more area of added complexity in our already fragmented health care system, which already struggled to respond to the COVID-19 crisis. 

A public option would also further entrench the power of for-profit insurers. And the massive administrative waste of private insurance companies would continue under a public option, whereas under Medicare for All the reduction in administrative savings would be more than $500 billion a year. 

In terms of political feasibility, there is the perception that less comprehensive reforms could have an easier chance of passing. However, the companies that profit off our healthcare system have shown they are just as opposed to the most basic public option proposal as they are to Medicare for All. Both the Partnership for America’s Health Care Future and Coalition Against Socialized Medicine—which strongly oppose Medicare for All as well as a public option —have shown they will not compromise on behalf of their corporate backers. 

While proponents of a public option may try to make their proposal sound “reasonable,” it wouldn’t come close to matching Medicare for All. Whether it is savings for families, savings for the country or ensuring that everyone in the country has guaranteed access to medically necessary care, only Medicare for All would create the health care system we need.

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Public Insurers Provide Better Access, Financial Protection, & Satisfaction Than Private Insurers

Access to Care, Cost of Care, and Satisfaction With Care Among Adults With Private and Public Health Insurance in the US, JAMA Network Open, June 1, 2021, By Charlie M. Wray, Meena Khare, Salomeh Keyhani

Introduction: In the past decade, health insurance expansion has been a major aspect of health care reform in the US, with the Patient Protection and Affordable Care Act (ACA) increasing coverage to more than 20 million US adults.

We used the Behavioral Risk Factor Surveillance System (BRFSS) to compare experiences related to access to care, costs of care, and satisfaction with care among the 5 major forms of health insurance coverage (private employer–sponsored insurance, private individually purchased insurance, Medicare, Medicaid, and Veterans Health Administration [VHA] or military coverage) after accounting for respondents’ underlying health.

Results: …Compared with those covered by Medicare, individuals with employer-sponsored insurance were less likely to report having a personal physician (odds ratio [OR], 0.52; 95% CI, 0.48-0.57) and were more likely to report instability in insurance coverage (OR, 1.54; 95% CI, 1.30-1.83), difficulty seeing a physician because of costs (OR, 2.00; 95% CI, 1.77-2.27), not taking medication because of costs (OR, 1.44; 95% CI, 1.27-1.62), and having medical debt (OR, 2.92; 95% CI, 2.69-3.17). Compared with those covered by Medicare, individuals with employer-sponsored insurance were less satisfied with their care (OR, 0.60; 95% CI, 0.56-0.64)…

Conclusions and Relevance: In this survey study, individuals with private insurance were more likely to report poor access to care, higher costs of care, and less satisfaction with care compared with individuals covered by publicly sponsored insurance programs. These findings suggest that public health insurance options may provide more cost-effective care than private options.

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Comment by Don McCanne

How many times do we have to say it? Public health insurance is designed to make health care accessible and affordable for the people. Private health insurance is designed to make a profit for the insurers. The policies used in the design of the various insurance products are selected on the basis of the desired results. Access to care, cost of care, and satisfaction with care are very important in the design of public insurance. In contrast, profits are of utmost importance in private insurance.

This study confirms that the private insurers will sacrifice access, cost, and satisfaction in order to increase profits. Patients have much higher access to care, financial protection, and satisfaction with public insurance. Shouldn’t we be demanding single payer Medicare for All so that we can all have what we want in health care, and so that we can free up the private insurers to engage in productive occupations that would be a greater benefit to society?

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Time to Abandon Pay For Performance

Time and Financial Costs for Physician Practices to Participate in the Medicare Merit-based Incentive Payment System: A Qualitative Study, JAMA Health Forum, May 14, 2021, By Dhruv Khullar, Amelia M. Bond, Eloise May O’Donnell, Yuting Qian, David N. Gans, and Lawrence P. Casalino

“Participating in the MIPS program results in substantial financial and time costs for physician practices. We found that, on average, it cost practices $12 811 per physician to participate in MIPS in 2019. We found that physicians themselves spent a considerable amount of time to participate in MIPS. In 2019, physicians spent more than 53 hours per year on MIPS-related activities, which translates to nearly $7000 per physician. If physicians see an average of 4 patients per hour, then these 53 hours could be used to provide care for an additional 212 patients a year—equal to more than a full week’s work for a physician.”

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Comment by Adam Gaffney

Pay-for-performance (P4P) is an increasingly central part of the American healthcare landscape. The Affordable Care Act added a multitude of new P4P programs to Medicare, including the Hospital Readmissions Reductions Program (HRRP) and the Hospital Value-Based Purchasing Program (HVBP). Then, the Medicare Access and CHIP Reauthorization of 2015 gave us the Merit-based Incentive Payment System (MIPS), a new P4P program that imposes financial sticks and carrots on individual clinicians across the country based on a slew of complicated performance metrics.

Much research suggests that these programs have little effect on patient outcomes. The HRRP was much lauded for apparently reducing readmissions, but later research attributed much (or all) of this apparent reduction to changes in diagnostic coding. There is also some evidence HRRP may have harmed some cardiac patients. Meanwhile, studies of the HVBP have found virtually no impact. Fewer studies, however, have examined the costs of such programs.

That’s what makes this study, led by Dr. Dhruv Khullar at the Weill Cornell Medical College, so valuable. The researchers interviewed the leaders of 30 physician practices across the nation who participated in the MIPS, and quantified the costs of participation in the program. Overall, they found that we spend more than $12,000 per physician annually to cover the administrative costs of participation in MIPS. Additionally, “MIPS-related activities” suck up over 200 hours of labor per year from practice staff, including 53.6 hours from frontline clinicians. And this is merely for a single P4P program.

There is little evidence, in other words, that P4P programs substantively improve care — and growing evidence that they further inflate our already enormous administrative costs while sapping the time and energy of practicing doctors. For these reasons, P4P should not be included in a Medicare for All reform. Notably, the House Medicare for All Bill excludes this payment mechanism. The underlying political idea of P4P is a fundamentally neoliberal one: the idea that we are all motivated only by pursuit of the dollar. Instead, doctors want to provide the best care they can. That it is not to say that there isn’t room for quality improvement in our healthcare system — far from it — but a paucity of profit incentives is not the culprit. Further, an increasing number of studies show that P4P is redistributive — shifting funds from providers that care for poorer patients (who tend to have worse outcomes) to the providers of the wealthy.