Where Is The Mercy?

As published in the Health Care for ALL Oregon website:

Mercy Killers brings the human story behind cancer statistics
to Oregon

Cancer has a major impact on society in the United States and across the world. Cancer statistics describe what happens in large groups of people and provide a picture in time of the burden of cancer on society. According to the National Cancer Institute, an estimated 40% of American men and women will be diagnosed with cancer at some point during their lifetime: one of three women and one of two men. Additionally, prominent oncologists are calling for support of a grass-roots movement to stem the rapid increases of prices of cancer drugs. More than 60% of bankruptcies in the US are caused by such out-of-control medical expense.

Award-winning playwright/actor Michael Milligan portrays the human face of these statistics, dramatizing the crushing psychological and financial impact of such a diagnosis on ordinary people with his one-man play, Mercy Killers. At the invitation of Health Care for All-Oregon and sponsored by Physicians for a National Health Program, Milligan is bringing the play on an Oregon tour in September. His performances will be followed by “talk-back” audience participation with Milligan and local medical personnel and advocates. Proceeds, after expenses, will benefit HCAO and its regional groups

Milligan has performed Mercy Killers hundreds of times in churches, homes and theaters across the land. The play, inspired by his personal experience, chronicles the reality, not just the statistics, of the corporate culture that runs our market-based health care system; of the struggle with insurance companies, drug companies and hospitals that profit from medical distress and then discard terminally ill people when they no longer can pay.

Joe is an all-American apple pie, Rush Limbaugh-loving, blue-collar patriot with conservative values of self-reliance and personal responsibility. His love of country, life and liberty are thrown into question when his wife becomes sick. Suddenly, the American Dream is not what it seems. Joe is being interrogated by an unseen police investigator over the death of his terminally ill wife. His tragic tale of love and anger illuminates the dark side of the American medical system

Milligan was a member of a working group of Occupy Wall Street called Health Care for the 99 Percent and works with the advocacy group Health Care Now. He is committed to theater that tells the story of ordinary people, that allows audiences to see themselves and their experiences reflected on stage. Mercy Killers is a surprisingly tender love story, a cry from the heart, not a prescription. With this play, Milligan delivers a message that must be honored, regardless of ideology.

Bring your friends and buy your tickets now. This is a message you won't want to miss.

Mercy Killers performances are scheduled for:

Portland: Thursday September 17, 8 p.m. at The Alberta Rose Theater, 3000 NE Alberta street. Buy your tickets NOW.  Sponsored by the Portland Health Action Group.
Contact Tom Sincic for more information.

Newport:  Friday September 18, 7 p.m. at the Newport Performing Arts Center,777 W Olive St. Sponsored by HCAO Newport. Ticket price is $15 at the door, with advance sales available HERE. Contact Jerry Robbins for more information.

Albany/Corvallis:  Saturday September 19, 7 p.m. at the Linn-Benton Community College Russell Tripp auditorium, 6500 Pacific Blvd. SW in Albany. Sponsored by Mid-Valley Health Care Advocates. Tickets may be purchased at Grass Roots Bookstore on Second Street in downtown Corvallis and will also be sold at the door. In addition, people can call Tessa Green at 541-961-8436 to have tickets mailed. Tickets will be $10 regular, $7 for seniors and students.

Springfield:  Sunday September 20, 2 p.m. in the Richard E. Wildish Community Theatre, 630 Main St. Buy your tickets NOW. Sponsored by HCAO Eugene/Springfield.
Contact Vicki Anderson for more information.

Florence:  Thursday September 24, 7 p.m. at the City Light Cinemas, 1930 HWY 101 in Florence. Sponsored by HCAO Florence. Advance tickets will be sold at City Lights Cinemas, 2006 Hwy 101, every day between noon and midnight until Sept. 24. They are also available online HERE. Get tickets early to avoid delays the night of the show.
Contact Stuart Henderson for more information.
Eugene:  Friday September 25, 7:30 p.m. in The very Little Theatre, 2350 Halyard St. in Eugene. Buy your tickets NOW  Sponsored by HCAO Eugene/Springfield.
Contact Lou Sinniger for more information.

You can help MVHCA as we work for publicly funded universal health care like the rest of the developed world by donatinghosting a house party, signing up for the newsletter, and attending our monthly meetings. You can also Like us on Facebook, and Follow us on Twitter. Thank you.

One-Man Play: Mercy Killers

More on our Upcoming Events Page.  Invite your friends through Facebook

You can help MVHCA as we work for publicly funded universal health care like the rest of the developed world by donatinghosting a house party, signing up for the newsletter, and attending our monthly meetings. You can also Like us on Facebook, and Follow us on Twitter. Thank you.

Why Canadian Hospitals Outperform U.S. Hospitals

From the Huffington Post:

by Co-founder, Physicians for a National Health Program, Professor, Public Health, CUNY, advisor, EvidenceNetwork.ca, and David Himmelstein Co-founder, Physicians for National Health Program, Professor Public Health, CUNY, advisor, EvidenceNetwork.ca

In many countries, bereaved families get condolence cards and flowers. In the U.S., they are also deluged with hospital bills and insurance paperwork.

That paperwork isn't merely an insult. It costs U.S. society a fortune. Take hospitals, for instance. According to research we recently published in Health Affairs, U.S. hospitals spent $215 billion in 2011 on billing and administration, a striking 1.43 per cent of GDP.

Put another way, about $1 of every $4 of U.S. hospital spending goes to bureaucracy rather than patient care.

Other countries manage modern, first-rate hospital systems for far less. While administration devoured $667 per capita annually in the U.S., we found that Canada spent only $158, Scotland $164, England $225 and the Netherlands $325.

If U.S. hospitals ran as efficiently as Canada's, the average U.S. family of four would save $2,000 annually on health care.

Moreover, U.S. hospital paperwork costs have risen sharply since 2000, even after adjusting for inflation. In contrast, administration's share of hospital budgets in Canada has actually fallen since 1999.

A generation ago, it took just one or two managers to run a U.S. hospital. Now, the CEO has been joined by "chief officers" for operations, finance, compliance, information, quality management, and more.

Each chief commands his/her own legions - hundreds of billing and registration clerks, referral managers, upcoding specialists (to translate doctors' diagnoses into the most profitable billing codes), and massive IT departments whose first commandment is "get the bill right."

Why are U.S. hospitals so inefficient? Our multiple-payer insurance system forces every hospital to negotiate rates with dozens of insurance plans, each with its own coverage rules, billing procedures and documentation requirements. And each hospital must collect deductibles, co-payments and co-insurance from tens of thousands of patients.

In contrast, Canada and Scotland -- where bureaucratic costs are lowest -- have single-payer systems that reject this kind of red tape and the need to bill for every Band-Aid. They pay hospitals simple lump-sum budgets, the way we fund local fire stations. And like fire departments, their hospitals don't need to collect from each victim of misfortune.

But the complexity of hospital billing isn't the only thing driving bureaucracy. Hospitals have been forced to add layers of business expertise in order to survive in our market-driven system.

A hospital that doesn't show an operating profit can't fund essential new investments in new equipment and cutting-edge services, or modern buildings. That means administrators have to devote resources to financial gaming like marketing lucrative services (e.g. sports medicine); billing units to squeeze every penny from insurers and patients; and strategies to recruit profitable (well-insured) patients, and avoid unprofitable (e.g. uninsured) ones.

The dismal record of for-profit hospitals illustrates the problem with running hospitals as businesses. The for-profits have higher death rates and employ fewer clinical personnel like nurses than their non-profit counterparts. But care at for-profits actually costs more, and they spend much more on the bureaucracy, a reflection of the high cost of implementing shrewd financial strategies.

Canadian and Scottish hospital administrators don't have to play financial games to assure their survival. Government grants -- rather than operating profits -- pay for new buildings and equipment. Even in France and Germany, where hospitals bill multiple payers, bureaucratic costs are modest because government directly funds most hospital investments.

England and the Netherlands provide unfortunate counter-examples. Pro-market reforms initiated during the Thatcher era have driven English hospital administrative costs sharply higher. And only U.S. hospitals have higher administrative costs than those in the Netherlands, where radical market-oriented reforms now pressure hospitals to show a profit.

Economics textbooks hold that subjecting medicine to market forces will stimulate efficiency and root out waste. But reality stubbornly refuses to obey. In health care, market-oriented policies encourage hospitals to shift resources to business strategies that boost the bottom line, but contribute nothing to care.

Dr. Steffie Woolhandler is an advisor with EvidenceNetwork.ca and co-founder of Physicians for a National Health Program. She is professor of public health at the City University of New York and lecturer in medicine at Harvard Medical School. She is also an internist at the Montefiore Medical Center in New York.

Dr. David Himmelstein is an advisor with EvidenceNetwork.ca and co-founder of Physicians for a National Health Program. He is professor of public health at the City University of New York and lecturer in medicine at Harvard Medical School. He is also an internist at the Montefiore Medical Center in New York.

You can help MVHCA as we work for publicly funded universal health care like the rest of the developed world by donatinghosting a house party, signing up for the newsletter, and attending our monthly meetings. You can also Like us on Facebook, and Follow us on Twitter. Thank you.

How U.S. Health Care Came to Cost Insanely More

From H&HN Daily

Cost is the big factor. Cost is why we can't have nice things. The overwhelmingly vast pile of money we siphon into health care in the United States every year is the underlying driver of almost every other problem with health care in the United States from lack of access to waste to fragmentation to poor quality. We can't afford to fix the problems, cover everyone, do real outreach, build IT systems that are interoperable and transparent and doc-friendly — or so it seems, because at least on weak examination, every fix seems to add even more cost. And in the old ways of doing things in health care, the way we have been used to doing business, the conclusion of the weak examination has been correct: Despite the tsunami of money, there is never enough to do it right.

Health care that costs more than it needs to is not just an annoyance; it's a big factor in income inequality in the United States. The financial, physical and emotional burden of disease are major drivers of poverty. At the same time, the high cost of health care even after the Affordable Care Act means that many people don't access it when they need it, and this in turn deprives large swathes of the population of their true economic potential as entrepreneurs, workers and consumers. People who are burdened by disease and mental illness don't start businesses; don't show up for work; and don't spend as much money on cars, smartphones and cool apartments. Unnecessary sickness is a burden to the whole economy.

How did we get this way? What was the mechanism that differentiated U.S. health care from all other advanced countries? The usual suspects (such as "We have the most sophisticated research and teaching hospitals," or "It's the for-profit health insurers" or "Doctors make too much") all fail when we compare our system with other sophisticated national systems such as those in Germany and France. Other countries have all of these factors in varying amounts — private health insurers, world-class research, well-paid physicians — and cost a lot, but still spend a far smaller chunk of their economy on health care. Blame has been leveled in every direction but, in reality, no single part of health care has been the driver. The whole system has become drastically more expensive over the last three decades.

What's the Mechanism?

Since the difference between the United States and other countries is so large and obvious, there should be some way we can look at health care spending that would make that mechanism jump out at us. And there is a way.

The Organization for Economic Cooperation and Development gathers and publishes huge amounts of information about the top 40 or so national economies in the world. Go online and search for its database on national health expenditures as a percentage of each country's economy. Don't just look for recent data. We already know what that says: The United States throws twice as large a chunk of its economy into health care as most other countries; 50 percent more than the most expensive other countries. No, take the search back to the middle of the last century. Pull the data into a spreadsheet. Make the spreadsheet into a graph. Here's what you get:

Wow. Suddenly a rather startling pattern emerges. Right side: Yes, the United States costs twice as much. Left side: Didn't use to.

As economies grow in absolute size, they tend to dedicate a greater percentage to health care. After a certain point, somewhere around 9 percent, the cost continues to increase, but the rate of increase tends to flatten somewhat. Through the '60s and '70s we can see that happening. The United States, as the largest economy, is one of the most expensive, but it's just there at the top of the pack. In the mid-1960s Medicare is implemented — the first big infusion of federal money into the health care economy — and does the U.S. line jump up? Not really. It flatlines for a year, then continues its moderate climb.

Something Wicked This Way Comes

Then something happens that is stark, sudden and large. Health care economies tend to lag national economies by a year or two; in bad economic times, governments and private purchasers can't cut health care expenditures immediately, but they do tighten their belts for the future. At a moment when the other most expensive health care economies (Germany, Sweden, Denmark) are flatlining or drifting lower in response to the global economic malaise of the early 1980s, the U.S. line goes nearly vertical, flatlines for a year or so, then leaps ever higher in a series of startling S-curves.

That first big leap is between 1982 and 1983. What was different in 1983 that was not there in 1982? DRGs, diagnosis-related groups — the first attempt by the government to control health care costs by attaching a code to each item, each type of case, each test or procedure, and assigning a price it would pay in each of the hundreds of markets across the country. The rises continue across subsequent years as versions of this code-based reimbursement system expand it from Medicare and Medicaid to private payers, from inpatient to ambulatory care, from hospitals to physician groups and clinics, to devices and supplies, eventually becoming the default system for paying for nearly all of U.S. health care: code-driven, fee-for-service reimbursements.

Cost Control Drives Costs Up?

How can a cost control scheme drive costs up? In a number of ways: In an attempt to control the costs of the system, the DRG rubric controlled the costs of units, from individual items like an aspirin or an arm sling to the most comprehensive items such as an operation or procedure. The system did not pay for an entire clinical case across the continuum of care from diagnosis through rehab; or for an entire patient per year on a capitated basis, which would capture the economic advantages of prevention; or for an entire population. While it is more cost-effective (as well as better medicine) to provide a diabetes patient with medical management, in-home nursing visits and nutritional counseling rather than, say, waiting until the patient needs an amputation, the coding system actually punished that efficiency and effectiveness. Under this system, we got paid for our inefficiencies, and even for our mistakes: Do-overs often would drop far more to the bottom line than the original procedure did.

The system punished, rather than rewarded, spending more time with patients, trying to help patients before their problems became acute, or maintaining a long-term, trusted relationship with patients. Under a code-driven, fee-for-service system, getting serious about prevention and population health management would be a broad road to bankruptcy.

If extra items were deemed necessary (an extra test or scan, say), there were codes for that, and reimbursements awaiting. In so doing, the system rewarded doing more (volume) rather than whatever would be the best, most appropriate, most efficient treatment path (value). It provided a written, detailed catalog of reimbursements which rewarded diagnoses of greater complexity, rewarded new techniques and technologies with new and usually higher reimbursements, and especially rewarded systems that invested in a greater capability to navigate the coding system. At the same time, the reimbursements were constantly open to pressure from the industry. Each part of the industry, each region, each specialty, each part of the device industry, became fiercely focused on keeping those reimbursements up, and getting new codes for more costly procedures.

The business and strategic side of health care became a matter of making money by farming the coding system. Do more of what gets better reimbursement, less of what does not. Make sure every item gets a code and gets charged for. The codes became a manual for success, a handbook for empire.

The Smoking Gun

The smoking gun is right there in the chart, at the big split between the trajectories of the United States and other countries. And today, at this moment, the code-based, fee-for-service payment system is still by far the basis of most revenue streams across health care.

The unifying factor between multiple new strategies unfolding in health care right now, including patient-centered medical homes, pay for performance, bundled prices, reference prices, accountable care organizations, direct pay primary care and others, is to find some way around the strict code-based, fee-for-service system, either by avoiding it entirely or by adding epicycles and feedback loops to it to counter its most deleterious effects.

There is no perfect way to pay for health care. All payment methods have their drawbacks and unintended consequences. But the code-based, fee-for-service system got us here, and any path out of the cost mess we are in has to get us off that escalator one way or another.

Joe Flower, CEO of the Change Project Inc., serves on Speakers Express, the speaking faculty of the AHA's Health Forum, and on the board of the Center for Health Design. He is also a regular contributor to H&HN Daily.

You can help MVHCA as we work for single payer health care by donatinghosting a house party, signing up for the newsletter, and attending our monthly meetings. You can also Like us on Facebook, and Follow us on Twitter. Thank you.