February 3, 2014

Will Oncologists Lead the Way to Single-Payer Healthcare?

In an editorial last week, oncologists Ray Derasga, MD and Lawrence Einhorn, MD explained their “moral and ethical obligation” to advocate for single-payer, universal healthcare.

Their call-to-action faces odds many would consider insurmountable. There’s no political hot potato hotter than healthcare, and the private, for-profit providers – to say nothing of Big Pharma – have deep pockets and powerful lobbies to make their case for maintaining the status quo.

There is also strong opposition to any notion that smacks of “socialized medicine.”

Still, the two doctors made their pitch: "Because the [Affordable Care Act] will fail to remedy the problems of the uninsured, the underinsured, rising costs, and growing corporate control over care giving, we cannot in good conscience stand by and remain silent. Life is short, especially for some patients with cancer; they need help now."

Derasga and Einhorn laid out the improvements they think a new, single-payer system would bring:
  • Reduced administrative costs, which currently account for almost a third of healthcare expenditures
  • Eliminating many bankruptcies attributable to healthcare costs, which accounted for more than 60% of family bankruptcies identified in a 2009 report
  • Improved health, as indicated by evidence that being uninsured increases the mortality hazard by 40%
  • Building on an existing structure, noting that about 60% of all healthcare in the U.S. is publicly funded
  • Implementation of proven cost-containment strategies, which are absent from the ACA
  • Improving quality of care and outcomes by increasing access to care
  • Reverse the trend toward for-profit, investor-owned healthcare plans
  • Preserve physician's income potential, as judged by experience with the Canadian healthcare system
As Charles Bankhead explained in an article published January 29 in the online journal MedPage Today, the cost of drugs and devices is a particular concern for the two oncologists. They reference a study that shows pharmaceutical companies charge 50% more for the same drug in the U.S. than in Europe, a difference driven by massive marketing expenses here and the expectation of a 20%+ profit margin. Research and development costs represent only about 13% of drug costs in America.

Derasga and Einhorn mention, too, that while the Veterans Administration receives a 40% discount for bulk drug purchases, Medicare – which covers increasing millions of Americans – cannot by law negotiate drug prices.

The men urged the American Society of Clinical Oncology (ASCO) to assume a leadership role in moving toward a single-payer system to re-orient our system toward “care giving, not toward maximizing investors’ profits.” No doubt the various monied interests will hear that call-to-action as “fightin’ words.”

How did the ASCO respond? As you might expect – blandly. ASCO’s CEO Allen Lichter, MD said:
ASCO has taken no position on a single-payer or other type of healthcare system. We have long advocated that every American deserves to have insurance coverage. We have advocated that those patients who receive a new cancer diagnosis and don't have insurance should be placed into Medicare because facing a cancer diagnosis without insurance lowers your risk of survival, as Dr. Derasga and Dr. Einhorn pointed out in their paper.
Perhaps anticipating the Derasga-Einhorn dispatch, the ASCO and the Community Oncology Alliance (COA) together issued a statement identifying principles they see for oncology payment reform:
  • Oncologists taking a leadership role in payment reform
  • The inadequacy of current reimbursement models
  • The need for new models for delivering oncology services to ensure high quality and value
  • Retaining choices in payment models at the local level
  • Improved measurement of quality
  • The inadequacy and inequity of reimbursement for oncology drugs under Medicare Part B
COA president Mark Thompson, MD described the editorial from Derasga and Einhorn “a good look at Nirvana.” He continued:
You can't dispute a lot of the facts that they lay out in the article. We do spend a huge amount of money in administering healthcare in the U.S. The difficulty that most of us who have spent any time in Washington -- and I've spent a lot of time there -- is the idea of making this public, which to me translates into government. I don't think we have a government or a Medicare program that can handle all of the wonderful suggestions that they talk about.
In spite of the massive resistance that surely lies ahead for any national single-payer plan, Derasga thinks it’s inevitable and cites Vermont’s plan to establish a statewide single-payer program by 2017. Among its other tasks ahead, the state will need to secure waivers from the ACA and Medicare. Still, Derasga seems confident. "Once one or two states get programs in place and see that they can save millions and millions of dollars, plus insure everybody, I think we could see a snowball effect," he said.

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What exactly IS “single-payer” healthcare? Here’s the primer from Wikipedia:

Single-payer health care is a system in which the government, rather than private insurers, pays for all health care costs. Single-payer systems may contract for healthcare services from private organizations (as is the case in Canada) or may own and employ healthcare resources and personnel (as is the case in the United Kingdom). The term "single-payer" thus only describes the funding mechanism—referring to health care financed by a single public body from a single fund—and does not specify the type of delivery, or for whom doctors work. The actual funding of a "single payer" system comes from all or a portion of the covered population. Although the fund holder is usually the state, some forms of single-payer use a mixed public-private system.

Single-payer health insurance collects all medical fees, then pays for all services, through a "single" government (or government-related) source. In wealthy nations, this kind of publicly managed insurance is typically extended to all citizens and legal residents. Examples include the United Kingdom's National Health Service, Australia's Medicare, Canada's Medicare, and Taiwan's National Health Insurance.

The standard usage of the term "single-payer health care" refers to health insurance, as opposed to healthcare delivery, operating as a public service and offered to citizens and legal residents towards providing near-universal or universal health care. The fund can be managed by the government directly or as a publicly owned and regulated agency. Some writers describe publicly administered health care systems as "single-payer plans". Some writers have described any system of health care which intends to cover the entire population, such as voucher plans, as "single-payer plans", although this is uncommon usage.

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