CPR Means “DNR” for Health Care Reform

Terrance Heath

They’re at it again. Conservatives, in concert with the health insurance industry, are desperately reaching for relevance on health care. But what they call CPR is really DNR — a “do not resuscitate” order for a health care system in critical condition.

“Conservatives for Patient Rights” they call themselves, a name which suggests reform. And just in case you don’t get it, their “five pillars of health care” should do the trick. Or they would, except that they don’t change what doesn’t work about health coverage in this country, and promise to do for health insurance what conservatism did for the Wall Street. (You know, the people they wanted turn lose on your Social Security?)

Their four hollow “pillars” of “reform” are easily tipped over.

Choice.

A patient must have the right to choose their own doctor, and must protect a consumer’s right to choose the health insurance that best fits their needs and budget.

Actually, no arguments here. The Health Care for America plan, on which president Obama’s health care plan is based, preserves choice where and provides choice where it doesn’t. 

Under this plan, if you already have health insurance that you’re satisfied with, you keep it. Like your doctor? Good. Keep him, or her. If not, you’re free to shop for better private coverage elsewhere if you want. That remains unchanged.

CPR’s “choice” pretty much stops there. That’s the problem. If you can’t afford health care — or you’re among the more than 47 million uninsured (or the 87 million who have been uninsured at some point in the last two years), whose ranks now include the 2.6 million who lost jobs (and their employer provided health insurance) in 2008, and are growing by about 14,000 per day — well…that’s your problem. (Though, as former president Bush pointed out, you can always go to the emergency room. Sure, but it’s expensive care, and probably the reason why the uninsured pay $30 billion a year for health care. Plus, the uninsured are overwhelming emergency rooms, as their numbers continue to grow.)

One of the central elements of the Health Care for America plan is that it’s open to every legal U.S. citizen without workplace coverage (or without a legal spouse who has workplace coverage). Premiums are based on a family’s ability to pay. Under our current system, if you don’t have a job (which is the case for a growing number of Americans), you don’t have health insurance. Sure, you have COBRA, but COBRA is unaffordable for many people who lose their jobs and thus have no income. Payments can exceed $400 a month for an unemployed individual and $1,000 for a family of four, but conservatives in Congress voted against the stimulus package that helps laid-off workers with COBRA payments.

According to CPR, if you fall into the category of Americans who don’t have and/or can’t afford health insurance, you’re on your own. By contrast, Health Care for America is a truly inclusive and accessible health care system in which no one is left out.

Competition.

Leveling the playing field for doctors, insurers, and consumers will result in healthy competition that drives down costs and increases favorable outcomes. Providers should publicly post their prices so consumers can shop and compare. States should eliminate burdensome regulations so insurance companies can compete equally across state lines.

Again, no initial arguments here. Competition is fine. Families and individuals can and will chose their coverage based on which plans meet their needs. However, Health Care for America offers the choice the choice of keeping the private insurance you have if you like it, or a public health insurance plan without a private insurer middleman, which guarantees affordable coverage.

If private insurers can compete with the public plan, by offering better coverage and better value, they’ve got nothing to worry about.

But, as Monica pointed out, competition is already a myth in the private health insurance market place.

You don’t have to search far to find people rhapsodizing about the virtues of competition. Nowadays, “competition” is the hot topic of health care reform. Free-market fundamentalists claim competition in the health insurance market is critical. And, the implementation of a new public health insurance option, as President Obama proposes, will undermine it.

But the simple fact is that there is very little competition in the health care marketplace. The government has allowed health insurance companies and providers to do pretty much as they will. And what they have willed is to merge and buy each other out until there are just a few dominant insurance companies and provider groups in each market.

…The way to inject true competition into our health care system is to give people a choice of a public health insurance plan. Only a public health insurance plan can break the quasi-monopoly premium pricing power insurance companies have in most areas, and the high provider fees set by large provider groups that dominate most markets.

Where real competition exists, consumers are fully informed about what they are and are not getting with their purchase. Providers go out of their way to make sure of it. Not so with health insurance.

Let’s be clear. Consumer Reports puts consumer products through rigorous tests in its National Testing and Research Center, in Yonkers, N.Y. They measure how good a vacuum cleaner’s suction power is, how durable a treadmill is, and how well a car performs “avoidance maneuvers.” They do collect satisfaction surveys on all the consumer products they test, but these are “to supplement laboratory testing.”

Yet, for the private health insurance industry all Consumer Reports can do is what they consider “supplemental” for everything else they test.

That is not the fault of Consumer Reports. That is the problem of a broken health insurance market that allows insurance companies to hide their practices behind a wall of proprietary information–also referred to as “business trade secrets.” For example, you cannot know how the plan defines medical necessity for a certain treatment, the very foundation of health coverage. That is what determines whether the plan will pay for a covered service. Yes, the booklet from your health insurance company may say that MRIs are covered, but it may not be covered for you when you need it if the company does not consider it medically necessary for you and your condition.

The public Medicare plan, on the other hand, makes its coverage determinations (the medical circumstances under which it will cover various treatments and equipment) available to the public on its web site. It even asks for public comments on its draft coverage determinations before they are made final.

You also don’t know how much a private insurance company will pay for a service, so you don’t know how much of the bill you will be stuck with. You also have no way of knowing how they determined that rate. Since there is no transparency in how they set their provider payment rates, it is easy for insurance companies to swindle us. 

There are moments when values are defined and choices become crystal clear; usually forged in the heat and pressure of crises that catalyze change, when our values drive our choices. When it comes to our health care system, already in crisis and further stressed by the economic downturn, progressives envision change that expands coverage to all, while conservatives opt for stagnation at best, or at worst a version of “reform” that duplicates the most dysfunctional and destructive aspects of our current system.

In other words, “you pays your money and you takes your chances.” But you gamble with your health (and your family’s), and you can’t know what cards you’re holding. There’s no shortage of people who discovered that the deal the thought they got wasn’t what they actually got. 

That’s bad enough, but then conservative devotion to deregulation rears its head in that last sentence: “States should eliminate burdensome regulations so insurance companies can compete equally across state lines.”  We already know how well deregulation worked on Wall Street. When it comes to health care, not only do insurance companies hold all the cards, but they control all the choices. For the consumer that means fewer real choices.

Tip the second “pillar” and the first one falls. On the the third.

Accountability.

Making health care services more accessible, transparent and open through standardized insurance claims forms and equal tax breaks for individuals and companies will control costs by helping consumers and businesses compare “apples to apples” across the health care spectrum.

We’ll ignore, for the moment, the cognitive dissonance of preaching accountability on the heels of hyping deregulation. 

Sure, there’s plenty of accountability that needs to be build into health care reform.

  • Effective cost controls that promote quality, 
  • Lower administrative costs and long term financial sustainability, including: 
    • standard claims forms, 
    • secure electronic medical records, 
    • using the public’s purchasing power to instill greater reliance on evidence-based protocols and lower drug and device prices, 
    • better management and treatment of chronic diseases, and 
    • a public role in deciding where money is invested in health care.

What the CPR plan is really means standardizing benefits, across the board, to make buying health insurance as “easy” as ordering a combo at your local fast food restaurant.

That might work for Happy Meals, and it certainly works well for insurance companies, by limiting choices. But what Americans need is a standard that covers what people need to stay healthy, and to get better when they are ill. Health care benefits should cover all necessary care including preventative services and treatment needed by those with serious and chronic diseases and conditions.

We already have enough trouble with insurance companies denying coverage for necessary care and coverage. Sometimes these stories make national news, like Nataline Sarkisyan

An insurance company that initially refused to pay for a liver transplant for a 17-year-old Northridge girl who died in a hospital should face criminal charges and pay civil damages, an attorney for the girl’s family said Friday.

Cigna HealthCare “literally, maliciously killed” Nataline Sarkisyan, attorney Mark Geragos told reporters in downtown Los Angeles.

Sarkisyan died at 5:50 p.m. Thursday after being pulled off life support at UCLA Medical Center.

Geragos said Cigna twice took Sarkisyan off the liver transplant list and purposely waited until she was near death to approve the transplant because the company didn’t want to pay for her after-care.

Cigna announced yesterday — just hours before the girl died — it would pay for the transplant. “Cigna decided that they were going to take profits over this little, beautiful princess’ life,” Geragos said. “We believe that they single- handedly decided that they wanted to have her die and wait so they would not have to take the after-care coverage.”

And Patsy Bates.

Patsy Bates is a self-employed hairdresser who was in the middle of cancer treatment when Health Net, one of California’s biggest health care companies, canceled her coverage.

Bates told ABC News, “I have two chemotherapy sessions, then we find out the surgeon hasn’t been paid. The anesthesiologist hasn’t been paid, and the cancer doctor has not been paid.”

With $200,000 in medical bills, she sued for $6 million. Her lawsuit revealed that Health Net actually set goals for its employees to cancel policies, and the carrier paid more than $20,000 in bonuses to its senior cancellation specialist.

Court documents show that over six years Health Net canceled 1,600 policies, avoiding at least $35.5 million in medical expenses. In 2002, the goal was set at 180 cancellations and was exceeded by its cancellation specialist, who dropped 275 policies that year.

The cancellation specialist’s supervisor wrote on the employee’s 2005 evaluation, “Barbara’s successful execution of her job responsibilities have been vital to the profitability of the [Individual Family Policy] product line.”

(Bates was awarded more than $9 million in her case against Health Net.)

And this is an industry they want to deregulate further?

Sarkisyan and Bates are just two stories that made national headlines. For each one that does, there are likely tens, even hundreds of thousands of similar cases that never make headlines, because families are too busy deal with catastrophic illness, and most likely have no idea how to engage the media. How many? Most likely more enough than enough to justify covering treatments in cases that receive extraordinary coverage — like Sarkisyan’s — and outweigh fines in the few cases that insurance agencies lose in court — like Bates’.

Of course, insurance companies will usually say “We aren’t denying care. We’re just not covering it.” Translation: “You’re free to try and get the care you need. Good luck paying for it, since you wouldn’t need us if you had that kind of money in the first place. Maybe you could try holding a fundraiser to get the money. Car washes and bake sales are pretty popular.”

CPR is right about one thing. More accountability is needed. But it’s the insurance industry that needs a dose of it.

Personal Responsibility.

Placing responsibility squarely where it belongs, on the shoulders of the patient, will encourage individuals make to make healthy lifestyle choices. Infusing personal responsibility into health care reform allows us all to maintain our cherished freedom to live our lives without government intrusion.

Last but not least: “personal responsibility.” Again, who can argue that people should be encouraged to make healthy lifestyle choices? And the Health Care for American plan, again, “provide[s] that the individual patient can make their own choices regarding the health care they seek.” But responsibility is, or ought to be a two way street.

It makes sense that “personal responsibility” follows “accountability,” but we’ve already seen that most of the burden of “accountability” in the CPR plan serves the insurance industry more than the needs of the consumers. What’s missing is something that’s absent from every conservative “solution” offered to every challenge we face: corporate responsibility. That’s responsibility to consumers and the communities they serve, not just to their bottom line and shareholders. 

It’s obvious to anyone whose fundamental beliefs don’t impede them from seeing it that where responsibility and accountability are one way streets, the likelihood that profit will be prioritized above public good. Health Net is one example. There are plenty more. Monica pointed out that the countries two largest health insurance providers— WellPoint and United Health Group— were chastised by the government already this year, for defrauding people.

Even CPR’s own Richard Scott, who was among the lobbyists lined up to torpedo health care reform isn’t unsullied. He was CFO of HCA – The Healthcare Company, until fraud charges led to his resignation.

Yesterday, the nation’s largest hospital chain, known until recently as Columbia/HCA Healthcare (nyse: HCA – news – people), pleaded guilty to a variety of fraud charges. It admitted to bilking various government programs and agreed to pay a total of $840 million in fines and penalties. The fraud settlement is the largest in U.S. history, breaking the old record held by Drexel Burnham. Even so, parts of the investigation into the company’s practices remain unsettled.

The guilty plea follows a seven-year federal investigation that resulted in charges being filed in five different federal courts in Florida, Texas, Georgia and Tennessee, where HCA is headquartered. The fraud revealed by that investigation ran deep within HCA’s way of doing business. Speaking at a news conference yesterday, U.S. Attorney General Janet Reno said about the plea deal, “It’s a simple message–if you overbill the U.S. taxpayer, we’re going to make you pay it back, and then some.”

The company admitted to systematically overcharging the government by claiming marketing costs as reimbursable, by striking illegal deals with home care agencies, and by filing false data about how hospital space was being used.

The company increased Medicare billings by exaggerating the seriousness of the illnesses they were treating. It also granted doctors partnerships in company hospitals as a kickback for the doctors referring patients to HCA. In addition, it gave doctors “loans” that were never expected to be paid back, free rent, free office furniture, and free drugs from hospital pharmacies.

The investigation and the plea is an obvious blow to a company that became a Wall Street darling by promising to bring first-class business practices to the hospital sector, still dominated by not-for-profits. Under former Chief Executive Richard Scott, it bought hospitals by the bucketful and promised to squeeze blood from each one.

Scott was forced to resign in the wake of the initial fraud charges in 1997. Dr. Thomas Frist Jr., a founder of the original Hospital Corp. of America and the brother of U.S. Sen. Bill Frist, R-Tenn., was brought in to replace him as chairman and CEO.

Health care reform should make it easier to prevent stories like those above, not make them more likely. Yet, that’s what CPR does, by limiting choices, placing most of the responsibility and accountability on consumers, and further deregulating an industry that’s shown a tendency to avoid both responsibility and accountability, and yet are the only gateway millions of Americans have to health care.

Tap on CPR’s “pillars” and they ring as hollow as the conservative “values” that are supposed to be at their core. We’ve had ample time by now to see how well those values have served us in everything from foreign policy to food safety and finance. Americans don’t need or want more conservative failure where our health, and the health of our families and communities is concerned.

We need affordable, inclusive, accessible health care coverage that leaves no one out, preserves choice, includes equity in access to treatments and other resources, and covers what people to get healthy and stay healthy.

Our system of access to health care is in critical condition, and getting worse as more of us face the reality of losing our employer-provided health insurance, at the same time that states are cutting their own health care budgets. CPR doesn’t offer a remedy, but instead slaps a “do not resuscitate order” on a system that needs saving, for all of our sakes.

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