Kip Sullivan and Dr. Matthew Hahn on How Value Based Programs Are Undermining Medicare and Single Payer

There is a growing sentiment, bubbling from the ground up, that before we get to Medicare for All, we need to first fix Medicare.

Richard Bazarian, an eye surgeon in Portland, Maine, is supportive of the idea.

“The senators who tout Medicare for All could prove their commitment by sponsoring legislation to expand coverage for existing Medicare beneficiaries,” Bazarian wrote to the New York Times last week. “Prove a willingness to cover all costs by eliminating the current Medicare deductible and covering 100 percent rather than the current 80 percent of allowed charges. Show the ability to take on the big corporations by dismantling privately run for-profit Medicare Advantage plans.”

“Once they have proved this can be done for current Medicare enrollees, then it may be a plausible health care solution for all,” Bazarian wrote.

Get rid of the $135 a month premium for Medicare Part B. Get rid of the 20 percent Medicare deductible. Get rid of Medicare Advantage corporate medicine. And get rid of the value based programs — with mind numbing acronyms like MACRA, MIPS, PVBM, HRRP — that have infected Medicare like a bad virus.

One piece of Medicare for All single payer legislation does the job — the House version, Congresswoman Pramila Jayapal’s (D-Washington) HR 1384 with 116 co-sponsors.

The other piece of Medicare for All single payer legislation does part of the job, but leaves the nasty value based programs in the tent. That would be Senator Bernie Sanders’ (I-Vermont) S 1129 with 14 co-sponsors in the Senate.

Kip Sullivan, a health care policy analyst based in Minneapolis, Minnesota, says that the Sanders bill is not a single payer bill because it leaves the value based programs in. (See Kip Sullivan on Why the Bernie Sanders Bill is Not Single Payer.)

Last week, the Single Payer Action Podcast brought Sullivan together with Dr. Matthew Hahn, a family doctor based in Hancock, Maryland and author of Distracted: How Regulations Are Destroying the Practice of Medicine and Preventing True Health-Care Reform for a deep dive into how value based programs are undermining Medicare and the drive for single payer.

“Every single payer advocate I am aware of takes a position we’ve got to get rid of the Medicare Advantage program, because we sure as heck aren’t proposing to enroll one third of Americans in insurance companies and call that a single payer,” Sullivan said. “The single payer movement recognizes that Medicare is gradually being privatized by these overpayments to Humana and United Healthcare and Blue Cross and they use those overpayments to seduce more elderly people to enroll in them.”

“In addition, the Affordable Care Act inflicted a host of obnoxious managed care programs on the fee for service Medicare program, the classic program — not Medicare Advantage — where two thirds of all Medicare beneficiaries are enrolled. The Affordable Care Act, on the basis of nothing other than conventional wisdom, imposed Accountable Care Organizations, medical homes, pay for performance, more and more reporting burdens on doctors. They don’t cut costs. They worsen disparities.”

“If we were to pass legislation that inflicted all of that, in addition to Medicare Advantage, on the American populace, there would eventually be hell to pay. We would all be embarrassed to have had anything to do with such a system.”

“The problem is there’s a single section in Bernie’s bill, section 611(b). It’s one sentence long. And it basically says that all the nonsense programs that were inflicted on the fee for service Medicare program by the Affordable Care Act, and subsequent legislation, all of that nonsense will not only not be repealed under Bernie’s bill, it’ll be extended to the entire country. Single payer advocates simply are not aware of that.”

“Part of the problem is, they feel that Bernie is part of our tribe. God knows I love the man. I supported him during the Democratic primary of 2016. But there’s an awful lot of reluctance out there to say — Bernie, you’ve got to get that section 611(b) out of your bill. And until you do, you don’t get to call it a Medicare for All bill.”

Dr. Hahn gave some examples of what Sullivan was talking about.

“I am a family doctor in a small, somewhat rural community taking care of a lot of older lower income patients,” Dr. Hahn said. “There are some evil abbreviations. And when you say that doctors are now burned out, you just have to say MACRA or MIPS or MU — meaningful use — and doctors will start ripping their shirts off and throwing punches. And here’s why. Let’s let’s take the most basic measure of health care quality, and see what happens when you set up an idiotic program of penalties.”

“Let’s take the most basic version of a quality measure. I take care of diabetics. The number one measure of diabetes is a test called the Hemoglobin A1c. It reflects the average glucose level for a diabetic over the past two to three months. And it guides our care in many ways. The objective is to try to get that Hemoglobin A1c in general under the level of seven or so. So a patient of mine comes in and we’re reviewing their labs and I say — hey, I noticed your Hemoglobin A1c went up from 7 to its 8.5. And the patient says to me — Doc, that’s because of the bag of candy I eat every day.”

“Years ago that was my opportunity to say — hey, you need to take better care of yourself, you need to eat healthy. Whereas today, there may be a penalty associated with my number. If there are more patients like this gentleman in my practice and my Hemoglobin A1c numbers go above the national average, I might get a substantial penalty to how much I’m paid.”

“So now rather than wanting to help this gentleman, I start to think — well, gosh, I’ve been working on this with him for the last ten years. I know him like family. And one of the things I know is that it’s very difficult for me to change his behavior. Maybe I shouldn’t even take care of him. Maybe I’d be better off if he wasn’t in my practice. And you know, that breaks my heart — I can’t tell you because it is my life’s goal, it was my mission to take care of people like this.”

Sullivan said he wants every listener to ask themselves — “How stupid is it to pass a law or regulation that assumes that doctors didn’t learn in medical school that you should worry about the glucose levels of your diabetic patients?”

“We will not only assume you’re too stupid to remember that or were you not trained well enough, we’re going to pass a law that requires you to give us little reports on the A1c levels of all your diabetics. And by gosh, If your diabetics can’t stop eating candy, we’re going to punish you. How stupid is that?”

Dr. Hahn said — “Beyond that, to collect that data they require doctors like me to use these horrible electronic medical record systems, these computerized systems that are absolutely destroying doctors ability to practice medicine. These things are so slow and cumbersome, that doctors can’t document their notes anymore while they’re seeing their patients.”

“They stay up at night,” Dr. Hahn said. “They’re called pajama doctors. They have to wait until the end of the day to write their notes. That introduces the possibility of errors, which are now very real and happening. And also it starts to tire out the doctors. So in order to impose this system on us, they require us to use these horrible electronic medical record systems which are an immense cost to the healthcare system.”

“Matt, the story you have just told is what happens to a doc in a rural, slightly poor community,” Sullivan said. “Now imagine you’re a doctor in a wealthier community where everybody is much more health conscious. You’ve got fewer diabetic patients. What happens in a system where you, through no fault of your own, are penalized? And the penalties are then taken and given to doctors in wealthier areas. That sets off worsening of disparities that many of us are so critical of when we’re talking about these value based payment programs.”

“The people who promote this obsession with measuring everything that moves in doctors’ offices, they will tell you — oh, well, fairly soon, we’re going to learn how to adjust scores or Matt’s score on how well he’s taking care of his diabetics, we will adjust the scores to reflect factors that are outside of Matt’s control. That process is called risk adjustment. It makes eyes roll when you try to get people to think about it. But it is the ultimate Achilles’ heel of all of this nonsense that has been promoted ever since the HMO was invented in 1970. They are never going to risk adjust accurately. They will always wind up punishing someone like Matt in a poorer area for reasons not within his control, and rewarding doctors and wealthier areas for no good reason other than they serve wealthier and healthier patients.”

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