Reports and OpEd Brigade on Healthcare in the U.S.

Selected reports and opinion editorials on healthcare reform and administration in the U.S. and Oregon

Committee Formed to Dismantle Cover Oregon
By Taylor W. Anderson / The Bulletin / Nov 19, 2014    For the full report, click title or The Bulletin icon
SALEM ­— After more than a year of setbacks for the state’s health care exchange, Oregon is a step closer to ending Cover Oregon after top lawmakers Tuesday unveiled a committee that will write a bill to dismantle the muddled public corporation next year.  The move came after lawmakers from both parties in September called for moving the agency’s remaining responsibilities to other existing agencies. It also came three days after the start of the new enrollment period.
“This committee has the policy expertise to ensure the marketplace functions of Cover Oregon will be subject to complete public scrutiny and oversight,” House Speaker Tina Kotek, D-Portland, said in a statement. 
Kotek and Senate President Peter Courtney, who last week were re-elected to leadership positions for next session, appointed longtime health care leaders to the joint committee. The 10-person committee consists of six Democrats and four Republicans, all from west of the Cascades.
The state spent more than $300 million in federal grants developing its health insurance exchange website that never worked. After the failed launch, the state used a costly hybrid system to enroll people on paper by hand. Cover Oregon decided, under fire, to move its marketplace of insurers to the federal website,, where Oregonians on Saturday began enrolling for coverage in 2015. The period to enroll runs through Feb. 15.
After the initial 2013 enrollment period, Cover Oregon miscalculated the amount of tax credits insurance customers were supposed to receive. That resulted in nearly 13,000 customers getting too much federal tax money to help pay for their coverage, according to a Cover Oregon estimate in October. The October estimate was far higher than the one Cover Oregon gave in September, when it told lawmakers the number was 775. 
Lawmakers argued during election season over whether they should dismantle the public corporation immediately, as Republicans preferred, or wait until next session, as Courtney, Kotek and Gov. John Kitzhaber wanted.  “We need this committee to get to work now to ensure that Oregon has a viable state health care marketplace moving forward,” Courtney said. ...
“Those ought to go into a state agency where we can have some more oversight,” Kitzhaber said in an October interview. “My preference would be the Insurance Division.” 
The state is involved in two lawsuits over the failure of its insurance website. Cover Oregon contractor and technology giant Oracle filed suit in August for $23 million. Oregon Attorney General Ellen Rosenblum two weeks later filed a much-anticipated lawsuit alleging Oracle executives were responsible for the website’s failure. 

Applaud Goals of ACA
By Marie Bernardy of Bend  /  My Nickel's Worth  /  The Bulletin  /  January 19, 2014
Yes, the launch of Cover Oregon, the state’s insurance exchange, has been rocky. But, as of Dec. 27, my husband and I were both able to sign up for health insurance through Cover Oregon. We’ve selected health plans that provide better coverage than our previous plans, with $1,500 (vs. $5,000) deductibles. And we will be paying $8,400 less per year for coverage.  If you’re over 50 and had to buy insurance as an individual, getting affordable coverage in Oregon was difficult and terrifically expensive. Now it’s something we can afford, as can many other Oregonians. The Affordable Care Act was enacted with the goals of increasing the quality and affordability of health insurance, lowering the uninsured rate by expanding public and private insurance coverage, and reducing the costs of health care for individuals and the government. I applaud these goals and am glad to benefit from the ACA.

Politics and Obamacare
By Arthur Lezin of Bend / In My View / The Bulletin / January 17, 2014     For the entire oped, click the title
Since the Patient Protection and Affordable Care Act was passed in 2010, the Republican Party has done everything in its power to delay or weaken implementation of the law, ... All indications are this will continue in 2014 and beyond, particularly given the administration’s serious mistakes setting up the federal exchange. Further, governors or legislatures in 25 states have opted out, so far, of federally financed Medicaid expansion.
The history of Medicare is instructive. At its inception, Medicare, in the eyes of its opponents, was touted to be a major calamity, — the end of our Republic as we know it. Ronald Reagan, circa 1961: “If you don’t stop Medicare, and I don’t do it, one of these days, you and I are going to spend our sunset years telling our children and our children’s children what it once was like in America, when men were free.”
While there is widespread recognition — after half a century — that the program can (and should) be improved, it is difficult to argue with the dramatic change for the better in the lives of the country’s elderly and disabled. Despite the missteps in its initial implementation, ... here are some of the promising developments in the short time since the ACA became the law of the land:
• The Congressional Budget Office and Joint Committee on Taxation estimate the legislation will reduce deficits over the next 10 years.
• The ACA has encouraged hospitals and other providers to test new initiatives designed to reward quality of care, rather than quantity. An estimated 70,000 hospital readmissions were prevented in 2012. ...
• All insurance plans must now provide for free wellness visits. At least 71 million consumers have taken advantage of this provision. We can anticipate substantial early diagnosis of diabetes, cancer and heart disease.
• The cap on insurance industry revenue earmarked for profit led to consumer savings of $3.6 billion in 2011 and 2012.
• Lifetime and annual limits on benefits are banned (an estimated 105 million insured).
• 7.8 million young adults (19 to 25) enrolled in their parents’ plans since passage of the ACA.
• 17.6 million children with pre-existing conditions have been insured who would not have been otherwise. About half of the population has pre-existing conditions as defined by the insurance industry.
• ...
May I humbly suggest, that this might be an opportune time for the Republican Party to reconsider the political wisdom of all-out opposition to health reform, all of the time.  ... the ACA is a significant improvement over the system we had. It is an attempt to address our costly, inefficient delivery of health care based on evidence.  ...

Bitter Pill: Why Medical Bills Are Killing Us  
Steven Brill uncovers the hospital charge master in this 36-page March 4, 2013 report on hospital billing in the U.S. --- the entire issue of Time Magazine is devoted to one report for the first time in the 90 year history of the magazine.

Questions for Costa
By Rick Burns of Bend / My Nickel's Worth / The Bulletin / September 30, 2013

Editor John Costa writes about his concerns about entering the “brave new world of Affordable Health Care" from the point of view of someone with good health insurance. He piles on the sagging bandwagon questioning “Obamacare." Alas, many working-class jobs no longer offer health care benefits. As well, part-time workers, people laid off by no fault of their own and the unemployed lack the advantage of health care plans. These people often put themselves and their children at risk by avoiding the cost of a doctor visit and go without necessary medications. Why are we the only developed country in the world that does not offer some sort of national health plan? I have three questions for Costa: 1. Does he think Sweden, Canada or Britain would trade their national health programs for the expensive mess we have? 2. Do health insurance companies, which often deny legitimate claims, deserve their massive profits? 3. Is health care in a wealthy country like ours a right or a privilege? Obamacare has passed and been upheld by the Supreme Court. Let’s give it a chance.

ACA has Legitimacy and Valuable Purpose
By James W. Mahoney, M.D. of Bend  /  My Nickel's Worth  /  Dec 11, 2013
... Argue against [the ACA] if you will, but please consult your Bible, Torah, Koran or Kant (categorical imperative, anyone?) about how we should treat the poor and the sick.
Perhaps you oppose this “new” system. But it is based on market economics, relies on private insurers and is modeled after a successful system in Massachusetts (thanks, Mitt!). The structure was debated endlessly, incorporated conservative ideas, was passed by a majority in Congress and was signed by the president, all in accord with democratic principles. It was upheld by the Supreme Court and debated again in the 2012 election. You can disagree with the mechanism, but you cannot argue that the ACA does not have legitimacy.
Finally, the problem-plagued website. Certainly, it will be fixed, though there will be no shortage of anecdotes arguing to the contrary. I remind you that Wal-Mart’s website crashed on Black Friday. But nobody wants to repeal Wal-Mart.
Many of our fellow citizens need, want and deserve health care. Lacking any alternative from the other (Republican) side, we all should support and welcome the ACA. Unless schadenfreude* is what you are all about. Just remember, please, whose misfortune gives you such joy.                        For full letter, click here                  *enjoying the misfortune of others

Saddened by Costa Column
By Arthur Lezin of Bend / My Nickel's Worth / The Bulletin / September 29, 2013

I was saddened by John Costa’s Sunday column, “Brave New World of Health Care." After describing the excellent treatment he received, he wonders if that will continue under Obamacare. “Would they (the medical establishment) have been allowed or encouraged to order the tests in a system that stresses cost reduction, even for those with good insurance?" By all means, let’s not put in place incentives to control costs and minimize unnecessary procedures. Just as long as we — the privileged few — continue to have unlimited access to state-of-the-art medical care. Costa does not mention the 40 million plus who would be able to obtain health insurance under Obamacare. One can’t critically evaluate the legislation without taking account of the benefits to the uninsured and to society at large: longer, more productive lives, lower infant mortality, reduced emergency room visits, etc. In all these areas, the U.S. lags far behind most other industrialized countries, even though we spend far more. Costa believes Obamacare is a “political solution" to the problem of rising costs. May I suggest that all decisions concerning allocation of a country’s resources, and how those resources are generated, are political. If one carries his analogy to a logical conclusion — all ships in a convoy are limited to the speed of the slowest — any government program targeting the disadvantaged is suspect. I prefer not to live in a society where what’s mine is mine and everyone else can fend for themselves.

Dead Man Walking  
Two physicians who see primarily medically-uninsured patients at the University of Louisville School of Medicine lament our national problem of the uninsured.

Rationing Health Care
By John Costa, Editor-in-Chief / The Bulletin / September 25, 2013

Over thirteen years ago, I ran into a significant health challenge.
I was in my mid-fifties with access to excellent health care and a superb company-based medical insurance plan. I liked — still do — to run and hadn't inhaled a cigarette in over three decades.
But something was wrong.
To shorten a long story, I went to the doctor several times over a few months and was told there was nothing seriously wrong. So I kept running and bouncing off the same wall. Finally, however, my doctor told me to have a stress test. That was on a Tuesday, and on Saturday I had heart bypass surgery at St. Charles. But what if I hadn't been insistent through multiple, insured visits that something was off? One doc put it succinctly: You'd go running one day and you wouldn't come back. But that was then, and now we are about to venture into the brave new world of Affordable Health Care or, in Oregon, Coordinated Care Organizations. There are differences between the two, but they spring from the same well.
Health care costs are excessive — even exploitative — and not enough needy folks are covered.
Get the privately insured costs for the privileged under control, so the reasoning goes, and more people without care will have something other than a hospital emergency room to depend on.
How controlling the costs for one group, which inevitably reduces its access to some treatments, increases the access for another group is hard for me to understand. It seems less a health care solution than a political or social one, based on a belief that we all should share the shortages of the system and that all should only have what the least of us can afford.
It has echoes of the wartime convoy system. The fleet can only sail at the speed of the slowest ship. To read the rest of the oped, click title above

Diagnosis: Insufficient Outrage
By H. Gilbert Welch, MD / New York Times> / July 4, 2013
Hanover, N.H. — Recent revelations should lead those of us involved in America’s health care system to ask a hard question about our business: At what point does it become a crime? Medical care is intended to help people, not enrich providers. But the way prices are rising, it’s beginning to look less like help than like highway robbery. And the providers — hospitals, doctors, universities, pharmaceutical companies and device manufactures — are the ones benefiting.
To read the rest of the oped, click title above

Colonoscopies Help Explain Our $2.7T Medical Bill  
By Elisabeth Rosenthal / New York Times News / June 03. 2013
Also published in The Bulletin / June 3, 2013

In Merrick, N.Y., Deirdre Yapalater's recent colonoscopy ... racked up what is likely her most expensive medical bill of the year: $6,385. ... In Keene, N.H., Matt Meyer's colonoscopy was billed at $7,564. Maggie Christ, of Chappaqua, N.Y., received $9,143 in bills for the procedure. In Durham, N.C., the charges for Curtiss Devereux came to $19,438, which included a polyp removal. While their insurers negotiated down the price, the final tab for each test was more than $3,500. ...  In other developed countries, a basic colonoscopy costs just a few hundred dollars and certainly well under $1,000.
That chasm in price helps explain why the United States is far and away the world leader in medical spending, even though numerous studies have concluded that Americans do not get better care.
Whether directly from their wallets or through insurance policies, Americans pay more for almost every interaction with the medical system. They are typically prescribed more expensive procedures and tests than people in other countries, no matter if those nations operate a private or national health system. A list of drug, scan and procedure prices compiled by the International Federation of Health Plans, a global network of health insurers, found that the United States came out the most costly in all 21 categories — and often by a huge margin. ...
While the U.S. medical system is famous for drugs costing hundreds of thousands of dollars and heroic care at the end of life, it turns out that a more significant factor in the nation's $2.7 trillion annual health care bill may not be the use of extraordinary services, but the high price tag of ordinary ones. ...
Colonoscopies offer a compelling case study. ...  Largely an office procedure when widespread screening was first recommended, colonoscopies have moved into surgery centers — which were created as a step down from costly hospital care but are now often a lucrative step up from doctors' examining rooms — where they are billed like a quasi operation. They are often prescribed and performed more frequently than medical guidelines recommend.
The high price paid for colonoscopies mostly results not from top-notch patient care, according to interviews with health care experts and economists, but from business plans seeking to maximize revenue; haggling between hospitals and insurers that have no relation to the actual costs of performing the procedure; and lobbying, marketing and turf battles among specialists that increase patient fees. ...
“We've defaulted to by far the most expensive option, without much if any data to support it," said Dr. Gilbert Welch, a professor of medicine at the Dartmouth Institute for Health Policy and Clinical Practice.

Lessons from Vermont's Health Care Reform
NEJM  /  368(14):1276-7  /  April 6, 2013
Laura Grubb, MD, from the Department of Pediatrics at the University of Texas Health Science Center at Houston, describe the remarkable progress Vermont has achieved in implementing healthcare reform.  Vermont and Oregon are ahead of the pack, and can further the cause by learning from each other.

The Oregon ACO Experiment — Bold Design, Challenging Execution
By Eric C. Stecker, MD, MPH  /  NEJM  /  February 14, 2013    For the full report, click here
From the Knight Cardiovascular Institute, Oregon Health and Science University, Portland.
Dr Stecker describes how risky the plan the Gov. Kitzhaber, MD, has undertaken with a successful waiver of the ACA implementation and a promise of $1.9B from the White House if goals are met (and a severe penalty if not). The whole country is depending on Oregon's experiment.
For Washington Post coverage of Oregon's experiment, click here

St. Charles, Bend and Prineville in Washington Post, January 18, 2013
Gov. John Kitzhaber (M.D.) has a plan to save Oregon $2B in healthcare costs that is being pioneered in Central Oregon.  Click here for the report.

U.S. Governors and the Medicaid Expansion- No Quick Resolution Sight  
Sommers BD, Epstein AM  /  NEJM 368:496-9 (February 2) 2013
How are states planning to participate in the expansion of Medicaid eligibility to all adults with family incomes at or below 138% of the federal poverty level in the aftermath of the 2012 election? Smmers and Epstein review each state's support or opposition before and since the election. Oregon is a pacesetter in implementing ACA's Medicaid requirements and provisions.

Are Oncologists' Financial Incentives Aligned With Quality Care?
Wong YN / J Clin Oncol 31(5):517-519, (Feb. 10) 2013    Click here for full Abstract
Data from the Cancer Outcomes Research and Surveillance study (CanCORS) on the association between medical oncologists' compensation structure and their perception of whether their income will increase if they administer chemotherapy or growth factors. Compared with medical oncologists who were paid a fixed salary, those who were in fee-for-service (FFS) practices or who were paid a salary with a productivity incentive were more likely to anticipate greater income if they administered chemotherapy (odds ratio, 7.05 and 7.52, respectively; both P < .001). Similar associations were found for growth factor administration.

Medicare Plan Requires Seniors to Pay More — and That’s Good  
By Jeffrey Miron / Los Angeles Times  /  September 7, 2012
Also published by The Bulletin

In the Obama campaign’s attack on the Romney-Ryan proposal to “voucherize" Medicare, one accusation is that the plan would force seniors to pay more of their health care costs: about $6,400 more per beneficiary, according to a recent TV ad known as “Facts." Regardless of the “facts" in the ad, this attack takes as a given that any such outcome is undesirable. Yet asking seniors to pay substantially more is precisely the way to improve Medicare. Here’s why.

Why Can't We Spend Less, Live Longer  
Brian Lawrence / Washington Post / July 30, 2012
The founder of Oakcliff Capital, a New York-based investment partnership, argues in a Washington Post editorial that the U.S. has to overcome petty politics to enjoy the better health, lower infant mortality rate, and longer lifespans of many other countries that spend much less on healthcare. His examples of Switzerland and Singapore are poignant.

Taking One for the Country with Health Care Ruling  
Tom Friedman  /  New York Times  /  July 8, 2012
Also published by The Bulletin  /  July 8, 2012

The NYT columnst finds two lessons from the Supreme Court’s decision to support the PPACA: 1) how starved the country is for leadership that puts the nation’s interest before partisan politics, which is exactly what Chief Justice John Roberts did; and 2) the virtue of audacity in politics and thinking big.

Focus on Alternate Health Plan  
David Brooks   /  New York TImes  /  July 8, 2012
Also published by The Bulletin  /  July 8, 2102
Republicans say they trust the people. If that’s true, then they won’t waste another futile breath bashing the court for upholding “Obamacare.” They’ll explicitly tell the country how they would replace it. Democracy is a contest between alternatives, not a deus ex machina stroke from the lords in black robes.

Cancer Will No Longer Be a Financial Death Blow to Many Patients
By James B. Yu, MD / Yale School of Medicine, Department of Therapeutic Radiology  /  Cancer_Network / July 6, 2012
For oncologists, the impact of the Supreme Court's decision on the Affordable Care Act will likely mean that their patients will no longer be in danger of losing insurance or being denied insurance because of cancer. The number of uninsured patients will be reduced dramatically.  I am hopeful that this will mean that cancer will no longer be a financial death blow to many patients, and that patients will not have to choose between paying the mortgage and paying for increasingly expensive chemotherapies and radiation treatments. As someone who researches comparative and cost effectiveness, I think any reexamination of cost-benefit for patients and emphasis on evidence-based practice is welcome.

Any Supreme Court Ruling Hurts Nonprofit Hospitals  
Reuters / New York  /  June 14, 2012
No matter how the U.S. Supreme Court decides on the national healthcare law, nonprofit hospitals will face a rocky future, Moody's Investors Service said in a study published on Thursday.

Bad Start for Health Care Plan  
Victor Davis Hanson  /  The Bulletin  /  July 8, 2012
This classicist and historian at the Hoover Institution, Stanford University, and the author of the just-released “The End of Sparta” critiques the downside of the PPACA as upheld by the Supreme Court.

The PPACA: No Rhetoric, Just the Facts  
Valerie Arkoosh, MD, MPH  /  Community Oncology  /  June 2012
This University of Pennsylvania Anesthesiologist and President of the National Physicians Alliance and Chair of its "Secure Health Care for All" Campaign reviews the facts of the PPACA before the SPOTUS rendered its judgment. With one exception (Medicaid expansion was ruled unconstitutional), Dr. Arkoosh's summary is accurate.

Emails Suggest Obama was Pushed by Drug Industry on Health Care Deal
By Peter Baker / New York Times / June 9. 2012
Also published by The Bulletin
Recently discovered emails indicate that Obama’s staff signaled a willingness to put aside support for the reimportation of prescription medicines at lower prices and by doing so solidified a compact with an industry he had vilified on the campaign trail. Central to Obama’s drive to remake the nation’s health care system was an unlikely collaboration with the pharmaceutical industry that forced unappealing trade-offs.

Insurance Plans Fall Short of Health Law Standards, Study Finds
By Maggie Clark, (MCT) / The Bulletin / May 31. 2012
More than half of the nation’s insurance plans for individuals do not meet the minimum standards of coverage set by the Affordable Care Act, according to a new report by researchers at the University of Chicago and Towers Watson, a risk-management research organization. In contrast, the study found that most group plans did meet the standards of the act.  The study analyzed individual and group insurance data from 2010 for more than 2,000 public and private employers in five states: California, Pennsylvania, Florida, Utah and Michigan. These states make up about 31 percent of enrollment in the U.S. insurance market.
Under the Affordable Care Act, health plans sold through the new state exchanges that will be operational by 2014 must cover at least 60 percent of health costs. The average group plan in 2010 covered 83 percent of costs, but a majority of the individual plans were under 60 percent.
The differences in average annual out-of-pocket expenses were striking: For a family with group coverage, the average out-of-pocket expenses were about $1,765 per year (not including premiums), compared with $4,127 per year for people with individual coverage.
For the rest of the report, click here

Oregon and Kitzhaber Celebrate Two Healthcare Reform Victories
The first was the federal agreement that will send money allowing Oregon to devise a new way of providing Medicaid services. The second was that enough health care providers have signed up for Kitzhaber's plan, that 90 percent of Medicaid recipients will be covered.

To read the OPB report, click here.   To read The Bulletin report, click here

Five Supreme Court Justices Put Our Health Care On The Line
By Paul Begala / Newsweek & The Daily Beast  / April 2, 2012
Five justices put our lives on the line.

Samuel Alitos's ideas about healthcare are frightenly detached from reality
My fellow americans, your health care is now in the hands of the right-wing majority of the Supreme Court. These are the folks who disgraced themselves in Bush v. Gore and who auctioned off democracy in the Citizens United decision. You thought it was bad when Congress and the insurance companies were making health-care policy? Wait till you see what five Republican lawyers can do.  For full report, click here

Wyden-Ryan Health Care Reform Proposal Review in NEJM  
Antos J  /  NEJM  /  March 9, 2011
Joseph Antos, PhD, of the American Enterprise Institute considers the Wyden-Ryan proposal to strengthen or replace Medicare portion of the Affordable Care Act of 2010.  His review includes a discussion of the likelihood of a 23% cut in physician fees.

Oregon Debate Paying Nurse Practitioners Same as Physicians  
By Markian Hawryluk  /   The Bulletin  /  February 23, 2012
A bill in the Oregon legislature that would require private insurance companies to pay nurse practitioners the same rates as doctors for the same services has become stuck in the tangled web of health care financing. And lawmakers may not be able to untangle that mess in the short time left in this year’s abbreviated legislative session.

Oregon Legislature Approves Health Care Reforms
Governor will sign bill meant to lower costs by improving access
By Lauren Dake / The Bulletin / February 24. 2012
SALEM — Gov. John Kitzhaber’s push to reform the state’s health care system cleared its final hurdle Thursday when the House voted in favor of the idea.
“Lower costs come from better health,” Kitzhaber said in a statement.
“With today’s vote, the Legislature set Oregon on a path for a better health care system that saves public dollars. This is good for patients, good for the state budget, and good for business.”
As part of an effort to overhaul the state’s Medicaid system, known as the Oregon Health Plan, the measure creates coordinated care organizations.
The goal is to keep people out of hospitals and emergency rooms to drive down costs and improve care. Initially the focus will be on people with chronic conditions. The bill passed the House on a 53-7 vote. It passed the Senate last week.
Rep. Jason Conger, R-Bend, said there are risks in approving the bill, “which you would expect in any kind of fundamental reform.”
He would like to see the bill address medical malpractice to help with physicians’ concerns. But despite its weaknesses, he said, “the alternative — to do nothing — is simply unacceptable.”
Rep. Vicki Berger, R-Salem, echoed the concerns of several lawmakers when she voted no because she thought lawmakers should take more time and not rush the bill through the short legislative session. She said it’s a “giant leap,” and dangerous to “just open the floodgates and see what happens.”
“The devil we know is bad,” she said, referring to the current health care system. “But the devil we don’t know could be very much worse.”
Before casting his vote, Rep. Mitch Greenlick, D-Portland, a co-chair of the House Health Committee and someone who has publicly battled health problems, jokingly declared a conflict of interest.
“I’m a frequent flier of the health care system,” Greenlick said. “This has the potential of improving the health care system for me.”

Dropping Public Option Was a Mistake  
A Bend resident compares the United States with five comparable countries and finds that our healthcare system is behind all of the others at twice the cost.  As a Medicare recipient, he argues that the public option should have not been deleted in the Affordable Care Act and blames the health insurance lobby for this mistake.

Editorial: Don’t Shroud Health Reform in Secrecy
The Bulletin Editors  /  January 15. 2012
When it’s the public’s money, the public’s business and the public’s health care, the state of Oregon should be letting the public into the meetings in which the decisions are made. But the question is: Will the state let the public in or shroud it in secrecy?
The state is making the rules for new entities — called coordinated care organizations, or CCOs — that will manage state Medicaid dollars. The state will give CCOs a specific amount of money. In return, the CCOs will provide physical, mental, behavioral and dental care for a region. The goal is to save money and improve care.
If there’s time in the short February session, the state Legislature will be considering the critical questions about how transparent and accountable the CCOs will be. Last week, the Oregon Health Policy Board listened to testimony about how CCOs should be governed. Who should be on the boards? How will the state hold CCOs accountable? What should the metrics be? What if CCOs flounder? Do they get fined?
One issue that was vague in the bill that created the reform — House Bill 3650 — is whether the meetings of CCOs will be required to be open to the public.
Many of the entities that will likely be represented on the boards of CCOs will be private businesses. They are not going to be used to making policy decisions with direct public scrutiny. They may not be comfortable with it. They may not want to do it.
Of course, CCO boards should not be discussing in public particular patients or lawsuits. There would need to be exemptions similar to those that exist under the law now for such discussions to take place in executive session.
Gov. John Kitzhaber has not taken a position on whether the meetings should be closed or open, according to his health policy adviser Mike Bonetto. Kitzhaber should make his position clear and not allow CCOs to operate in secret.
If Oregonians want a better guarantee of transparency and accountability, the only option is to make the meetings open. Any exceptions should be extremely narrow.

Editorial: Oregon’s Health Reforms can’t just be a New Cost Shift
The Bulletin Editors  /  January 12. 2012
Some doctors limit the number of Medicare or Medicaid patients they see. In Oregon, a medical professional’s ability to limit patients may soon be curtailed.
The state Legislature passed House Bill 3650 in 2011. The goal was to get state Medicaid payments under better control and to improve care. But to make that happen, it may need medical professionals to participate who don’t want to.
Right now, the state’s Medicaid payments are mushrooming faster than growth in the general fund. Gov. John Kitzhaber decided rather than reducing payments, the number of people covered or benefits, he wanted to try something new. HB 3650 restructures the way Medicaid is delivered to try to create incentives for spending less and improving health.
Medical businesses or groups of them will form what are called “coordinated care organizations” or CCOs. CCOs will apply to the state to provide coordinated physical, mental, behavioral and dental care for a region. The state will give CCOs a fixed amount of money. In return, CCOs will be given targets for quality and held accountable.
For that to work, CCOs need to provide the necessary services. And it may be that a CCO needs a particular clinic or doctor in a region to participate or it can’t do the job.
What if a needed doctor says no?
The state law says a “health care entity may not unreasonably refuse to contract with an organization seeking to become” a CCO, if it’s necessary for a CCO to qualify as a CCO. An issue the Legislature will consider in the February session is how to resolve disputes.
The proposal on the table is basically: If they can’t get a deal, it goes to an arbitrator. The arbitrator decides if the health care entity and the CCO are being reasonable.
Nobody would like being forced to work with a CCO against his or her will. There may be court challenges.
Doctors limit Medicare and Medicaid patients because they don’t want government hassles or they say they are not paid enough. Kitzhaber’s reforms should not be just a new way to reduce payments and shift costs to other patients. The state must ensure medical professionals are not shortchanged.

Bend Bulletin Editorial: U.S. Can’t Afford Medicare Status Quo
Editorial Staff  /  The Bulletin  /  December 20. 2011
The White House slammed Democratic Sen. Ron Wyden’s push last week for Medicare reform, saying it “would end Medicare as we know it.” But ending Medicare as we know it is not a bad thing. Medicare is the Godzilla of federal health care. The federal program covers about 48 million elderly and disabled people. In 2010, that coverage took $509 billion in outlays.  Medicare spending has doubled since 2001. It’s going to grow even more. The oldest members of the baby boom generation are just moving into Medicare now.  If the U.S. is going to get its budget under control, one of the keys is reforming Medicare.
What does Wyden’s plan do? It doesn’t change a thing for people currently on Medicare. The benefits stay the same. The plan only proposes making changes for people who are now 54 or younger. Under Wyden’s plan, when those people reach 65, they would get a fixed amount to spend. Those with greater needs would get more help. Seniors would then have an opportunity to choose between traditional Medicare and private insurance plans. Seniors could either use the money to buy traditional Medicare or opt for a private plan.
That’s a key difference from what the U.S. has now. Regulated private plans would compete head to head with the federal plan on quality, service and cost. Consumers would get more choice. And in theory, the competition might help hold down the cost curve of health spending, while seniors could still get traditional Medicare. Critics say that would turn Medicare from an automatic guaranteed benefit to a voucher. OK, it would seem to, but people could still get traditional Medicare. The plan also puts a cap on the growth of Medicare spending. The limit would be no more than 1 percent per year over the growth of the GDP.  Critics say that could mean seniors would face higher premiums, because they would be picking up the difference. They might, if Congress did nothing to keep premiums down.
Medicare is a partisan battlefield. And Wyden has done something about it that’s all too rare. He went across the aisle and joined Republican Rep. Paul Ryan of Wisconsin to see what they could agree on to improve Medicare. They aren’t asking to make any changes now. They haven’t even put the proposal in a bill form. They have started a debate. They are trying to force Americans to confront choices. The status quo is something the nation can’t afford.

Wyden-Ryan Medicare Plan is Complicated, Fascinating  
By Matt Miller / Special to The Washington Post  /  The Bulletin  /   December 17, 2011
The new Wyden-Ryan Medicare framework is the most fascinating policy and political maneuver of the year.

Wyden’s Plan keeps Medicare Payments, Adds Patient Options  
By Andrew Clevenger / The Bulletin  / December 16. 2011
As they introduced their new plan for Medicare on Thursday, Sen. Wyden, D-Ore., and Rep. Ryan, R-Wis., spoke repeatedly about building a bipartisan consensus by using the best ideas of both progressives and conservatives.

Wyden Teams with House Republican in Bipartisan Plan to Revamp Medicare  
By Robert Pear  /  New York Times  /  The Bulletin  /  December 15. 2011
The lawmakers aim to reshape the debate over the giant health insurance program by addressing concerns that have provoked fierce opposition to similar ideas.

Beriwck Summarizes Federal ACO Plans  
Donald M. Berwick  /  NEJM  /  365:1753-4, 2011
In this NEJM leading report, the author of the Triple Aim and current CMMS Administrator summarizes the changes planned for the Final ACO Rule as a result of commentary during the Proposed Rule posting.

2012 - A Watershed Election for Health Care  
David Blumenthal, MD, MPP, Harvard Medical School  /  NEJM  /  December 1, 2011
The author predicts what will happen to the Affordable Care Act with the most likely election outcome: the President is re-elected but the Senate switches from predominantly Democratic to Republican, whether or not the Supreme Court nixes part of, or the entire, Act.

MDs versus Hospitals as Leaders of ACO  
Robert Kocher, M.D., and Nikhil R. Sahni, B.S.  /  NEJM  /  363;27:2582-4, December 30, 2010
The implications will be profound for hospitals’ dominant role in the health care system and for physicians’ income, autonomy, and work environments.

Becoming Accountable — Opportunities and Obstacles for ACOs  
Harold S. Luft, Ph.D.  /  N Engl J Med  /  363(15, Oct. 7):1389-91;2010
A Palo Alto Medical Foundation Research Institute summarizes the challenges of physicians, especially primary care providers, to created Accountable Care Organizations by January 2011

St. Charles Faces Down Its Problems  
John Costa  /  The Bulletin  /  July 25, 2010
The Bulletin's Editor-in-Chief, lauds the PHA in its battle to overcome Oregon's economic crisis, national healthcare reform, and and naysayers

Defining Medical Expenses — An Early Skirmish over Insurance Reforms  
Iglehart JK, N Engl J Med  Sept 9, 2010; 363:999-1001

Creating Accountable Care: Organizations: The Extended Hospital Staff  
Fisher E, Staiger DO, Bynum JPW, Gottlieb DJ: A new approach to organizing care and ensuring accountability. Health Affairs 26(1)w44–57, 2007
The seminal article on ACOs, written by Eliott Fisher, MD and colleagues at the Dartmouth Medical School and theCenter for the Evaluative Clinical Sciences

Accountable Care Organizations: Accountable for What, To Whom, and How  
Fisher ES, Shortell SM / N Engl J Med / October 20, 2010 / Vol 304(15):1517-8
Elliott Fisher, MD, MPH of the Dartmouth Institute for Health Policy and Clinical Practice and Stephen Shortell, PhD, MPH, MBA of the University of California (Berkeley) School of Public Health summarize the ACO landscape

Impact of Health Care Reform on Cancer Patients   
The November/December issue of The Cancer Journal: The Journal of Principles and Practices of Oncology has is devoted to the expected impact of the Patient Protection and Affordable Care Act on cancer patients, including a review of the potential favorable impact on young adults by the 2009 President of COMS.

Potential Favorable Impact of the Affordable Care Act on Young Adults  
This review by the 2009 President of the Central Oregon Medical Society applies the cancer paradigm to young adults and older adolescents

Medical Malpractice Liability in the Age of Electronic Health Records  
A physician-attorney, a PhD-attorney and MPH-attorney summarize the changes in medical jurisprudence likely to occur with EHR imlementation, a topic of central relevance to Central Oregon and its informatics history and legal challenges

Healthcare Reform Drives Docs Together  
The speaker at the annual meeting of COIPA and COMS recommends this article in prepartion for his presentation at the Riverhouse Convention Center on October 11, 2010

Health Care Reform and Cost Control  
Peter Orszag, PhD, Ezekiel Emanuel, MD, PhD  /  N Engl J Med  /  Aug 12, 2010 363(7):601-3
The former director and current special advisor to the White House Office of Management and Budget argue that the Affordable Care Act puts into place virtually every cost-control reform proposed by physicians, economists and health care policy experts

Quality Measures and the Individual Physician  
Ofri D  /  N Engl J Med  /  August 12, 2010 363(7):606-7
Dr. Ofri, an internist in New York City, find the report cards meaningless and, worse, tending to make her feel like a nilhilist

Facing The Wild West of Healthcare Reform - Donald Berwick, Pioneer  
John Iglehart  /  N Engl J Med  /  July 15, 2010
Dr. Berwick is author of the Triple Aim.  He was appointed by President Obama to head the Center for Medicare and Medicaid Services during a recess of Congress, thereby avoiding approval by the Senate usually required of Presidential appointees

U.K. Poised to Break Up Centralized Health Care  
By Sarah Lyall / New York Times  /  July 25. 2010

Bundled Payments Explained by The Rand Corporation  
As bundled payments approach via the 2010 Afforadable Healthcare Act, questions about what they are and how they have been used to date are answered by Rand Choice

How the Healthcare Act of 2010 Impacts Physicians  
The benefits appear to outweigh the deficits, but how the U.S. (and the world) will pay for it all remains to be determined

The Spector of Financial Armageddon - Health Care and the Federal Debt in the U.S.  
Chernew ME, Baicker K, Hsu J  /  N Engl J Med  /  362(13):1166-8, April 1, 2010
The growing federal debt largely reflects anticipated increases in health care spending, the basics of deficits and debt and their implications for health care reform must be understood before the U.S. goes broke

The Timeline for Affordable Care Act Implementation  
Year-by-year implementation over 10 years

National Geographic Chart Capture Essence of our Unaffordable Healthcare Cost Conundrum

The average life span in the U.S. is years shorter than countries that spend far less on health care.
The next 15 countries that spend the most on healthcare, averaging half of what the U.S. spends, each have longer average life spans.

AMA Urges Insurers To Adopt New Code Of Conduct

Ten principles help ensure greater transparency and accountability from health insurers
CHICAGO – May 24, 2010
The American Medical Association (AMA) released its Health Insurer Code of Conduct Principles and called on all U.S. health insurance companies to adopt consistent corporate practices that will bring transparency and accountability to the multibillion-dollar health insurance industry.
“Health insurers should provide access to necessary health care, protect the patient-physician relationship and accurately process medical claims, but too often they are an obstacle,” said AMA President J. James Rohack, M.D. “The new Health Insurer Code of Conduct Principles will help protect patients and physicians from questionable insurance practices by holding the health insurance industry accountable.”
The code of conduct developed by the AMA, and endorsed by 68 state and specialty medical societies, contains 10 clear principles critical to an efficient, patient-centered health care system. The principles shine light on health insurer practices that influence the health care of patients, including cancellation of coverage, medical services spending, access to care, fair contracting and patient confidentiality, medical necessity, benefit management, administrative simplification, physician profiling, corporate integrity and claims processing.
“Commitment to these fundamental principles will demonstrate a health insurer’s dedication to truly putting patients first,” said Dr. Rohack.
It has been 15 years since the health insurers’ trade association adopted a Philosophy of Care, which pledged insurers to “high standards of quality and professional ethics, and to the principle that patients come first.” The insurance industry’s record of compliance with its standards has been questionable. The AMA’s code of conduct offers a unique opportunity for insurers to renew their commitment and earn the trust of patients and physicians.
“The health insurance industry has a crisis of credibility,” said Dr Rohack. “With the enactment of federal health reform legislation, it’s time for insurers to re-commit to patients’ best interests and the fair business practices necessary to re-establish trust with the patient and physician communities.”
The AMA has sent letters to the nation’s eight largest health insurers seeking their pledge to comply with the National Health Insurer Code of Conduct Principles. It will widely distribute a CD-ROM with resources to help physicians monitor insurer compliance with the code, that includes:

  • Relevant provisions of federal health reform legislation.
  • Relevant state managed care laws available through the AMA’s National Managed Care Contract
  • Model legislative bills available through the AMA’s Advocacy Resource Center
  • Regulatory fines, financial information and CEO compensation for the largest national health insurers
  • Details on national legal settlements against health insurers.
  • Instructions for filing an online complaint through the AMA’s Health Insurer Complaint FormThe
    Note: The Oregon Society of Physician Assistants endorsed the Code of Conduct, as announced in their Summer 2010 Newsletter

  • 37th Ranking - Measuring the Performance of the U.S. Health Care System  
    Murray CJL, Frenk J  /  N Engl J Med  /  January, 2010

    Reform of Helathcare and Congress  
    by Robert Pear  /  New York Times  /  January 11, 2010

    Medicine's Ethical Responsibility for Healthcare Reform  
    Howard Brody, MD, PhD  /  N Engl J Med  /  Deciember 24, 2009
    Dr. Brody describes the only organization unwilling to compromise on healthcare legislation is the medical profession. "In some cases" he writes, "physician support has been made contingent on promises that physicians income would not be negatively affected by reform."

    Senate Healthcare Reform Bill SB(3590)  
    The healthcare reform bill passed by the U.S. Senate on Christmas eve, December 24, 2009 ... all 2,074 pages

    Implementing Healthcare Reform: Why Medicare Matters  
    Robert Berenson  /  N Engl J Med  /  July 8, 2010

    House Healthcare Reform Bill HR3962  
    The healthcare reform bill that passed the U.S. House of Reprsentative on November 21, 2009 ... all 1,990 pages

    In the U.S., Health Status is Highly Correlated with Health Insurance Coverage  
    State by state analysis shows a strong linear correlation (p = 0.000003) of overall health ranking and lack of health insurance (data from the United Health Foundation)

    Much Cheaper, Almost as Good: Decrementally Cost-Effect Medical Inovation   
    Aaron Nelson, et al  /  Annals Int Med  /  November 3, 2009
    Much cheaper, almost as good" medical interventions/procedures are as rare as hen's teeth;  only 8 or 2128 intervention published in the medical literature between 2002 and 2007 met the critiera in this report in the Annals of Internal Medicine

    Tort Reform Estimated to Save $54 Billion over Next Decade  
    In a 10/13/09 etter to Sen. Orrin Hatch, the Congressional Budget Office (CBO) estimates a $54 billion savings during 2000-2019 if the healthcare reform bills included tort reform

    Doctors, Patients, and the Need for Health Care Reform  
    Senator Max Baucus  /  N Engl J Med  /  November 3, 2009

    Doctors as the Key to Health Care Reform  
    Arnold S. Relman  /  N Engl J Med  /  September 24, 2009

    The Baucas Bill and Hope for Heathcare Reform  
    John K Iglehart  /  N Engl J Med  /  October 14, 2009

    A Growth Vision for Health Reform   
    Newt Gingrich  /  Wall Street Journal  /  September 21, 2009
    Former Speaker of the Houses argues that the high cost of our healthcare is to our advantage 

    Getting Past Denial — The High Cost of Health Care  
    JM Suitherland, ES Fisher, JS Skinner  /  N Engl J Med  /  September 24, 2009

    Reform, Regulations, Research - An Interview with Gail Wilensky  
    John Iglehart, MD / N Engl J Med / August 19, 2009

    How American Health Care Killed My Father  
    David Goldhill  /  The Atlantic  /  September, 2009
    A business executive, describes viz. the death of his father how our health-care industry has delivers poor service and irregular quality at astonishingly high cost, . It is a system, he argues, that is not worth preserving in anything like its current form and that current health-care reform plans will not fix.

    10 Steps to Better Health Care  
    Atul Gawande, the author of The New Yorker report on medical procedure overutilzation (McAllen, Texas et al) and co-authors prioritize actions for most effective healthcare reform -- New York Times, August 13, 2009

    ObamaCare and Me  
    Zane F. Pollard, MD, / AmericanThinker / August 6, 2009
    A pediatric ophthalmologist explains how ObamaCare would not work for him.

    10 Things I Hate About Current Plans for Healthcare Reform  
    A cardiologist describes the short- and over-comings of the current plans in Congress, on the eve of the President's address to a joint session of Congress

    Health Care 2009: A Win–Win Approach to Financing Health Care Reform  
    J. Gruber - New Engl J Med, July 2, 2009

    Why the Rush  
    Stephen Imbeau, MD / / July 29, 2009
    The President of the Joint Council of Allergy and Past President, South Carolina Medical Society describes how our health system needs more than reform [Submitted by David Coutin, MD]

    Health Care 2009: The Individual Mandate — An Affordable and Fair Approach to Achieving Un  
    L.J. Blumberg and J. Holahan - New Engl J Med, July 2, 2009

    Health Care 2009: The Role of Medical Liability Reform in Federal Health Care Reform  
    M.M. Mello and T.A. Brennan - New Engl J Med, July 2, 2009

    Easing the Shortage in Adult Primary Care — Is It All About Money  
    Robert Steinbruck - New Engl J Med, June 25, 2009

    Health Care Reform: How Physicians Can Help  
    ES Fisher, DM Berwick, K Davis - N Engl J Med, June 11, 2009

    A Lifeline for Prmiary Care  
    Thomas Bodenheimer, Kevin Grumbach, Robert Berenson - New Engl J Med, June 25, 2009

    The Cost Conundrum - New Yorker, June 1, 2009  

    Now famous report by Atul Gawande illustrates how physicians can grossly overutilize healthcare, as in McAllen, Texas, and how collaboration among physicians can control runaway healthcare costs and simultaneously improve healthcare, as exemplified by Grand Junction, Colorado.

    See also Mr Gawande's article, with co-authors at the New York Times, below:  10 Steps to Better Health Care (August 13, 2009)

    Controlling Conflict of Interest: Perspective of the Institute of Medicine  
    Robert Steinbrook, N Engl J Med, May 7, 2009

    Picking the Right Poison, Options for Funding Health Care Reform  
    Jonathon Oberlander, N Engl J Med, May 14, 2009

    Congressional Action on Health Care Reform — An Update  
    John Iglehart - New Engl J Med, May 31, 2009

    Heatlhcare and the American Recovery and Reinvestment Act  
    R Steinbrook:  N Engl J Med, February 19, 2009

    Health, Medical Care, Economic Crisis  
    R Catalano:  N Engl J Med, February 19, 2009

    Slowing the Growth of Health Care Costs - Lessons from Regional Variation  
    Fisher ES, Bynum JP, Skinner JS, N Engl J Med, February 26, 2009

    The Struggle for Reform — Challenges and Hopes for Comprehensive Health Care Legislation  
    John Iglehart: N Engl J Med, April 23, 2009

    FDA Challenge in Obama Administration  
    Susan Okie:  N Engl J Med, March 13, 2009

    Investing in Healthcare Reform  
    K Davis:  N Engl J Med, February 19, 2009

    Obama Down Payment on Healthcare Reform  
    J Iglehart:  N Engl J Med, March 4, 2009

    Reforming Medicare's Physician Payment System  
    G Wilensky: N Engl J Med, February 12, 2009

    The Independent Physician - Going, Going, ...  
    SL Isaccs, PL Jellinak, WL Ray: N Engl J Med, February 12, 2009

    5 Myths About Our Ailing Health-Care System  
    S Brownlee, E Emmanuel: Washington Post, November 23, 2008

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