Fw: [Health Disparities Policy] New comment on Fw: John Geyman's submission for Health Disparitie....

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Subject: [Health Disparities Policy] New comment on Fw: John Geyman's submission for Health Disparitie....

Kimmy kard has left a new comment on your post "Fw: John Geyman's submission for Health Disparitie...":

Good thing this is so, hopefully provide fast and effective solutions since many people will be grateful ... in findrxonline indicate that we must all fight against cancer ....



Posted by Kimmy kard to Health Disparities Policy at 8/24/2010

Fw: John Geyman's submission for Health Disparities Policy Blog / with hotlinks

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Sent: Wed, August 4, 2010 8:12:29 PM
Subject: John Geyman's submission for Health Disparities Policy Blog / with hotlinks

Disparities within the U. S. health care system result in serious impacts on access to care for patients with cancer at all stages from screening and prevention to treatment and survival. Access barriers further lead to disparities in the quality of care received. These concerns led the American Cancer Society to launch a national effort in 2007 calling for system reform that will provide "4 As coverage":

•  Adequate—timely access to the full range of evidence-based health care including prevention and early detection.
•  Affordable—costs are based on the person's ability to pay.
•  Available—coverage available regardless of health status or prior claims.
•  Administratively simple—processes are easy to understand and navigate. (1) (Sack, K. Cancer society focuses its ads on the uninsured. New York Times, August 31, 2007)

Access barriers take a wide variety of forms and affect many disadvantaged groups within the U. S. population. The single most important aspect of access is the status of the patient's health insurance coverage. (2) (Siminoff, LA, Ross, L. Access and equity to cancer care in the USA: a review and assessment. Postgrad Med J 81: 674, 2005) For all types of cancer, the uninsured are 1.6 times more likely to die within five years compared to cancer patients with insurance. (3) (Ward, E, Halpern, M Schrag, N et al. Association of insurance with cancer care utilization and outcomes. CA Cancer J Clin 58: 19-20, 2008) 8/1/9

The lack of health insurance is much more common among racial and ethnic minorities than among whites. According to the U. S. Census Bureau, when 15.9 percent of the population was uninsured in 2005, the uninsurance rate for whites was 11.3 percent compared to 19.6 percent for non-Hispanic blacks and 32.7 percent for Hispanics. (4) (Income, poverty, and health insurance coverage in the United States: 2005, update.)

These examples illustrate how the lack of insurance adversely impacts patients with cancer across the entire spectrum of care:
•  Women aged 40 to 64 without insurance are only half as likely to have had a mammogram within the last two years as those with insurance. (5) (Ibid #3)
•  One in four uninsured cancer patients delay or forego care because of cost. (6) (Ibid #3)
•  Uninsured African-American women with breast cancer have a five-year survival rate of only 63 percent compared to 89 percent for insured Caucasian women. (7) (Ibid # 3)
•  Cancer has become a chronic disease for the estimated 12 million cancer survivors in this country, many of whom have co-morbidities such as heart disease, diabetes and arthritis as well as under-recognized and under-treated anxiety and depression. A 2008 national study found that uninsured cancer patients were three times more likely than their insured counterparts to have not seen health professional in the last year, twice as likely to have no regular source of care, and five times more likely to use the emergency room for care. (8) (Wilper, AP, Woolhandler, S, Lasser, KE et al. A national study of chronic disease prevalence and access to care in uninsured U. S. adults. Ann Intern Med 149: 170-76, 2008)

Under-insurance is another big problem for many patients with cancer, since many insurance policies provide little protection against the rapidly rising costs of cancer care. Two examples illustrate the financial burdens placed on cancer patients and their families even when insured:

•  Despite being consistently insured, a 2006 study by the Kaiser Family Foundation and the Harvard School of Public Health found that almost one-half of cancer patients used up most or all of their life savings, while 8 percent were turned away or unable to get a specific treatment because of insurance issues and 3 percent ended up declaring bankruptcy. (9) (Kaiser Family Foundation. Survey of families affected by cancer shows people with and without health insurance suffer serious financial hardships. USA Today/Kaiser Family Foundation/Harvard School of Public Health National Survey of Households Affected by Cancer, November 20, 2006)
•  Some "insurance" policies are ludicrous in the extent of their undercoverage—one example is the limited-benefit basic cancer policy marketed by AllState, starting at $420 a year for family "coverage", which pays a one-time benefit of $2,000 if diagnosed for the first time with cancer (other than skin cancer). (10) (McQueen, MP. The shifting calculus of workplace benefits. Wall Street Journal, January 16, 2007: D1)

Do patients with cancer covered by Medicare and Medicaid fare any better than their counterparts with or without private insurance? Here again, their access to care falls far short of their needs. An increasing number of physicians will not accept new patients on Medicare or Medicaid because of low reimbursement. Medicare Advantage plans may impose high cost burdens on patients who are referred to out-of-network physicians and facilities for cancer care, sometimes leading to disenrollment. (11) (Medicare Rights Center. Why consumers disenroll from Medicare private health plans. Summer 2010) Medicaid remains an underfunded porous safety net with many restrictions on coverage varying from state to state. (12) (Ramirez de Arrelano, AB, Wolfe, SM. Unsettling Scores: A Ranking of State Medicaid Programs. Washington, D.C. Public Citizen Health Research Group, April 2007)  Medicaid enrollees are more likely to have late-stage cancers when diagnosed, resulting in worse outcomes. (13) (Halpern, MT, Ward, EM, Pavluck, AL et al. Association of insurance status and ethnicity with cancer stage at diagnosis for 12 cancer sites: A retrospective analysis. Lancet Oncol 9 (3): 222-31, 2008) Many oncologists refuse to provide chemotherapy for Medicaid patients in their offices due to low reimbursement, sending them on to hospitals. (14) (Lung Cancer Connections. Caring 4Cancer. An introduction to Medicaid. Web site accessed October 31, 2008)

Because of access barriers to care and other factors in our market-based system of care (based as it is on ability to pay, not medical need), the quality of care for cancer patients in our present system leaves much to be desired for these kinds of reasons:

•  Perverse financial incentives pervade our business-oriented health care system. Hospitals and physicians make higher revenues by providing services that are often unnecessary, inappropriate or even harmful. When Medicare reduced reimbursement rates for outpatient chemotherapy drugs in 2005, oncologists switched from drugs that were most reduced in profitability to other high-margin drugs at increased cost but without good evidence of improved outcomes. (15) (Jacobson, M, Earle, CC, Price, M, Newhouse, JP. How Medicare's payment cuts for cancer chemotherapy drugs changed patterns of treatment. Health Affairs 29 (7): 1391-99, 2010)  A 2008 study by United Health found that Procrit, a very expensive anti-anemia drug also highly remunerative to prescribing oncologists, was being prescribed for about one-third of patients who were not anemic at all. (16) (Culliton, BJ. Interview: Insurers and 'targeted biologics' for cancer: A conversation with Lee N Newcomer. Health Affairs Web Exclusive 27 (1): W 41-W51, 2008)  More than 30 million full-body CT scans are performed each year for screening purposes despite the lack of evidence of benefit or the approval by the FDA or the American College of Radiology. (17) (Brenner, DJ, Hall, EJ. Computed tomography—An increasing source of radiation exposure. N Engl J Med 357: 2277-84, 2007)  Over-screening, over-diagnosis and over-treatment of prostate cancer are endemic in this country, without evidence of improved outcomes. A 2009 report of a randomized ten-year trial of 76,000 American men found that widespread screening does not lower the death rate from the disease. (18)  (Andriole, GL, Grubb, RL, Buys, SS et al. Mortality results from a randomized prostate-cancer screening trial. N Engl J Med online. March 18, 2009).  Dr. Peter Bach, oncologist at Sloan-Kettering Cancer Center and former senior advisor on health care quality at the Centers for Medicare and Medicaid Services (CMS), estimates that 30 to 40 percent of spending on cancer care is of marginal value. (19) (Bach, P, as quoted in McNeil, C. Sticker shock sharpens focus on biologics. News. J Natl. Cancer Inst 99 (12): 911, 2007)
•  We have an industry-friendly system of deciding what services and treatments will be covered. Coverage policies are not rigorously evidence-based, and the use of cost-effectiveness as a criterion for coverage decisions is vigorously opposed by industry. Many expensive and toxic drugs are used for indications beyond FDA approval—so-called "off label" use. In 2009, Medicare coverage of off-label cancer drugs was expanded despite the lack of clinical evidence for effectiveness. (20) (Abelson, R, Pollack, A. Medicare widens drugs it accepts for cancer care: More off-label uses. New York Times, January 27, 2009)
•  Quality of care breaks down at the interface between primary care and oncology-related subspecialty care. A just-published monograph by the National Cancer Institute documents the scope and magnitude of this serious problem, ranging from lack of communication and collaboration to overlapping and ambiguous roles. (National Cancer Institute. Division of Cancer Control and Population Sciences. Toward Improving the Quality of Cancer Care: Addressing the Interfaces of Primary and Oncology-Related Subspecialty Care. Number 40, 2010)  For the best quality of care, cancer patients need to be followed by both groups of physicians working together in their areas of expertise. One study of almost 15,000 survivors of colorectal cancer, for example, found that patients followed by oncologists were less likely to receive influenza vaccination, cervical screening and bone densitrometry, while those followed by primary care physicians reported less screening by colonoscopy and mammography. (21) (Earle, CC, Neville, BA. Under-use of necessary care among cancer survivors. Cancer 101 (8): 1712-19, 2004) Continuity of primary care throughout the care of cancer from screening to survivorship is essential to the best outcomes. We cannot expect subspecialists to care for co-morbidities so common among cancer patients, and treatment decisions often require consideration of co-morbidities, personal and family considerations.

As is clear from the above, access and quality of care are closely entwined and multi-dimensional. Addressing these problems is a complex challenge since they are embedded in a dysfunctional health care system. But that is the subject of our next post, which will consider to what extent the new health care reform law, the Patient Protection and Affordable Care Act of 2010, can remedy these problems.

Adapted in part from The Cancer Generation: Baby Boomers Facing a Perfect Storm, 2009, with permission of the publisher, Common Courage Press.

TAGS: cancer,cancer care, Access and Quality of Cancer Care, Under-use of necessary care, The Cancer Generation: Baby Boomers Facing a Perfect Storm, John P. Geyman M.D., patient's health insurance coverage,  lack of health insurance, cancer chemotherapy drugs, Patient Protection and Affordable Care Act of 2010, PPACA, wellness plans, AHA, American Hospital Association, America's Affordable Health Choices Act, America's Health Care Plans

Fw: John Geyman's blog 45: Lessons From the Inevitable Failure of Health Care Reform 2010

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Sent: Tue, August 10, 2010 4:29:22 PM
Subject: John Geyman's blog 45: Lessons From the Inevitable Failure of Health Care Reform 2010

Lessons From the Inevitable Failure of Health Care Reform 2010

In a recent post, we brought together an overall assessment of the Patient Protection and Affordable Care Act of 2010 (PPACA), showing how it cannot be expected to remedy our health care system's four major problems—lack of universal access, unrelenting surge in costs, decreasing affordability for much of the population, and variable, often mediocre quality of care. That was followed by other posts that took cancer as a bellwether for how patients with serious illness are likely to fare under the new law, again with disappointing results.

Even though the new law is just entering its implementation phase, we already know how and why it will fail to meet urgent needs for reform. More fundamental reform that more directly attacks the forces responsible for system problems will be required, sooner rather than later. But to be more successful the next time around, we need to learn the lessons as to how and why this last reform effort went off the tracks if we are to avoid making the same mistakes once again. That is the subject of this post.

Here are some of more important ways in which the politics of reform diverted the process from the real goals of reform, ending up instead with a nearly $1 trillion bill that serves corporate interests in the medical-industrial complex and Wall Street much better than Main Street and ordinary Americans.

1. Framing of the issues and the entire political process were hijacked by the very interests that are largely responsible for the system's problems of access, cost and
quality. The opening assumption was that we had to build on the existing system, thereby serving the interests of insurers, drug and medical device makers, hospitals, organized medicine and other parts of the system that would resist structural change. Missing from the subsequent health debate were more basic issues, such as whether health care is a right or a privilege based on ability to pay for just another commodity on the open market, and whether the business model underlying our system is consistent with the long-term public interest. Instead, the language of the debate was dominated on the right by defense of markets as the solution and that government is the enemy, and on the left by such meaningless slogans as "competition" and "guaranteed affordable choice". The debate then devolved to such arcane details as public options, exchanges and triggers, which much of the public found difficult to track and understand.

2. The democratic process was commandeered by corporate money. Corporate interests, intent on expanding their markets through the "reform" bill, pushed their agenda through lobbying, campaign contributions to key legislators, advertising campaigns through disease advocacy groups and Astroturf organizations, and feeding talking points the media (which thrived on the 24-7 coverage of the battle over a year and a half). These examples illustrate this coordinated effort by industry: Industry representatives were often in critical places as illustrated by these examples: (1) (MSNBC. Obama health czar directed firms in trouble) (2) (Center for Public Integrity, as cited in Moyers, B, Winship, M. The unbearable lightness of reform. Truthout, March 27, 2010)
• Elizabeth Fowler, insurance industry representative turned staffer of the Senate Finance Committee, largely wrote that bill.
• Nancy-Ann DeParle, White House Director of the Office of Health Reform, had received $6 million previously while serving on boards of directors of at least half a dozen companies that were targets of federal investigations, whistleblower lawsuits and other regulatory actions.
• By the time the reform law was finally passed, about 1,750 businesses and organizations had hired some 4,525 lobbyists, eight for every member of Congress, at a cost of $1.2 billion.

3. Market failure was not recognized as the wellspring of our system problems. Market advocates were successful in perpetuating the myth that competition in health care markets can rein in uncontrolled costs, even when experience and many studies confirm the opposite. These examples make the point:
• Continuous escalation of prices and costs by drug and medical device manufacturers, hospitals, physicians and other members of the medical-industrial complex.
• A nine-year study by the Community Tracking Study of 12 major U. S. health care markets found these four barriers to efficiency and quality of care: (1) providers' market power; (2) absence of efficient provider systems; (3) employers' inability to push the system toward efficiency and quality; and (4) insufficient health care competition, (3) (Nichols, L et al. Are market forces strong enough to deliver efficient health care systems? Confidence is waning. Health Aff (Millwood) 23 (2): 8-21, 2004))
• Consolidation among providers limits choice and competition in many markets. (4) (Kronick, R, Goodman, DC, Weinberg, J, Wagner, E. The marketplace in health care reform. The demographic limitations of managed competition. N Engl J Med 328: 148, 1993)
• A 2006 AMA study found near-monopolies by private insurers in 95 percent of HMO/PPO metropolitan markets. (5) (Associated Press. Study: Health insurers are near monopolies. April 18, 2006)

4. The private insurance industry, already dependent on various kinds of government subsidies, does not offer enough value to retain its 1,300 insurers.
These are the main reasons that the present multi-payer system should be replaced by a not-for-profit single-payer financing system: (6) (Geyman, JP. Do Not Resuscitate: Why the Health Insurance Industry is Dying, and How We Must Replace It. Common Courage Press, 2009)
• continued inflation of health care costs, which insurers cannot control.
• growing unaffordability of premiums and health care.
• decreasing coverage of policies with often unaffordable out-of-pocket costs.
• growing economic insecurity and hardship, even for the insured.
• shrinking private insurance markets and cutbacks in public markets.
• adverse selection in shrinking risk pools.
• increasing profits despite declining enrollments (e.g. Aetna profits up by 42 percent in second-quarter 2010). (7) (Veiga, A. Aetna posts higher 2Q profit up 42 percent. Associated Press, July 28, 2010)
• Stockpiling large surpluses even while hiking premiums. (8) (Young, A. Consumer group: Insurers kept surplus while hiking premiums USA Today, July 22, 2010)

5. The Obama Administration has so far been unwilling to confront the special interests and address the real problems. After winning the 2008 election, with the Democrats taking both the House and Senate as well as the White House, the pragmatic and overly cautious incoming president did a 180-degree turn from this statement made five years previously to the Illinois AFL-CIO:
I happen to be a proponent of a single payer universal health care program… (applause)…I see no reason why the United States of America, the wealthiest country in the history of the world, spending 14 percent of its Gross National Product on health care, cannot provide basic health insurance to everybody….But as all of you know, we may not get there immediately. Because first we have to take back the White House, we have to take back the Senate, and we have to take back the House. (9) (Obama. Speech to the Illinois AFL-CIO, June 30, 2003)
As a result of the deals the president made with corporate interests through their voluntary, unenforceable pledges, he joined forces with them in gaining political support for "reform". But this "alliance" with corporate interests assured that the legislative outcome would meet corporate interests more than those of ordinary Americans. And it leaves the president with little clout to rein in these interests, since he now depends on the PPACA to work. It would be a PR and political disaster if more insurers leave the market, more physicians refuse to see newly "insured" patients, and growing numbers of patients and families see affordable care and choice as disappearing. The state of Maine has already asked the federal government to waive its medical loss ratio (MLR) requirement, fearing disruption of the individual and small business market. (10) (Pear, R. Covering new ground in health system shift. New York Times, August 3, 2010: A13)

6. Policy makers and politicians ignored the lessons of history in attempting incremental "reforms" that had already failed over the last 30 years. Improved access and containment of health care costs have been addressed by many initiatives over the last 30 years, including managed care, employer and individual mandates, tax credits, association health plans, chronic disease management, pay for performance, and expansion of health information technology. Although all have failed to redress these two system problems, they were included in one way or another in the PPACA as more fundamental financing reform, such as shifting to a not-for-profit financing system, was intentionally kept off the table for political reasons.

In sum, the medical-industrial complex won this last battle over health care reform. Robert Kuttner, co-founder of The American Prospect 20 years ago, reminds us of the political challenge ahead: President Obama took office at a moment when free-market ideology, Wall Street hegemony, and conservative incumbency were thoroughly disgraced by recent events. But Obama has not yet been able to translate that failure into a durable progressive counterrevolution. (11) (Kuttner, R. A 20-year odyssey. The American Prospect 21 (7): 3, 2010)

Adapted in part from Hijacked! The Road to Single Payer in the Aftermath of Stolen Health Care Reform, 2010, with permission of the publisher Common Courage Press. 

Fw: Disparities blog on cancer

----- Forwarded Message ----
From: John Geyman <jgeyman@u.washington.edu>
To: Roger Bulger <roger.bulger@yahoo.com>
Sent: Wed, August 11, 2010 11:25:47 PM
Subject: Re: Disparities blog on cancer

Roger.  This is the second one on cancer.  John