CA presidential primary: Healthcare plans of 2020 candidates | The Sacramento Bee

 Before the 2020 presidential primary in California, learn where top candidates like Joe Biden, Elizabeth Warren, Bernie Sanders, and Pete Buttigieg stand on healthcare, the Affordable Care Act and Medicare for all.

California Democrats most want to hear candidates presidential candidates talk about health care as the state’s March 3, 2020 primary approaches. It’s the top issue among likely voters, according to the most recent survey conducted by the Public Policy Institute of California.

Here’s how the top candidates on the Democratic ballot would try to improve the country’s health care system, sorted in order of their recent national polling averages and performance in early-voting states:

JOE BIDEN

Former Vice President Joe Biden wants to preserve the Affordable Care Act passed under the Obama administration, rather than eliminate private health insurance. His plan would cost $750 billion over the next decade and be funded by reversing some provisions of the Tax Cuts and Jobs Act that President Donald Trump signed into law in December 2017.

BERNIE SANDERS

Vermont Sen. Sanders “wrote the damn bill” calling for a government-run, single-payer health care system that eliminates private health insurance. It would cost a hefty $34 trillion over 10 years, according to a report from the Urban Institute.

“The function of health care is not to make huge profits for the wealthy, it is to guarantee health care to every man, woman, and child through a Medicare-for-All, single-payer system,” Sanders said at an August 2019 rally in Sacramento.

WHILE HE HAS ACKNOWLEDGED TAXES WOULD GO UP FOR AMERICANS IN THE MIDDLE CLASS, HE INSISTS OVERALL COSTS WOULD GO DOWN BECAUSE HE’D ELIMINATE COPAYS, DEDUCTIBLES, AND SURPRISE BILLS. TOP ARTICLES

ELIZABETH WARREN

Massachusetts Sen. Elizabeth Warren has said she is “with Bernie” on health care. But unlike Sanders, Warren doesn’t talk about taxes going up. She instead focuses on overall health care costs going down.

“Because I have identified trillions in revenue to finance a fully functioning Medicare for All system — without raising taxes on the middle class by one penny — I can also fund a true Medicare for All option,” Warren wrote in a November post on Medium.

PETE BUTTIGIEG

Former South Bend, Indiana, Mayor Pete Buttigieg is pushing a “Medicare for All Who Want It” plan that would cost about $1.5 trillion over 10 years and be funded almost entirely by rolling back the tax cuts law Trump approved in 2017.

Buttigieg wants people to have access to a government-run public option that would present a more affordable alternative to private health insurance and guarantee contraception coverage. Poorer Americans living in states that have refused to expand Medicaid would be automatically enrolled in his public option plan.

He’d eliminate surprise billing, which commonly occurs when in-network hospital patients receive treatment from a doctor outside of their insurance network.Warren wants to prove the viability of her plan before implementing a universal, single-payer plan that abolishes private health insurance.

MICHAEL BLOOMBERG

The former New York City mayor is looking to build on Obamacare by creating a Medicare-like public option administered by the federal government but paid for by customer premiums.

To reduce insurance costs, he’d extend tax credits for individuals and families who spend more than 8.5 percent of their income on health insurance premiums. If elected president, he’d work with Congress to have the Department of Health and Human Services negotiate drug prices with pharmaceutical companies and make prices more comparable with other industrialized countries

AMY KLOBUCHAR

Minnesota Sen. Klobcuhar has called Sanders’ Medicare for All proposal a “bad idea” because “149 million Americans will no longer be able to have their current insurance” within four years.

She instead wants a non-profit public option that gives Americans the ability get lower insurance costs and drug prices. Like Sanders, though, she would allow people to personally buy drugs from countries like Canada. She also wants to allow Medicare to negotiate for cheaper prescription drug costs.

In her first 100 days, Klobuchar would direct the Centers for Disease Control and Prevention to “study gun violence as a public health issue and help identify approaches to reduce gun violence and save lives.” She’d also allow health providers like Planned Parenthood to receive funding under Title X.

ANDREW YANG

Entrepreneur Andrew Yang believes Democrats are “having the wrong discussion on healthcare,” arguing that the 2020 field is spending all its time “arguing over who is the most zealous in wanting to cover Americans.”

While he supports “the spirit of Medicare for All,” he wants to focus on the underlying causes of rising drug and insurance costs. He’s open to allowing the importation of drugs from other countries, but only if his three other preferences fail. He’d rather have Congress pass a law to negotiate drug prices, adopt pricing models more in line with costs people from other countries are paying and create public manufacturing sites in the United States to produce generic drugs.

TOM STEYER

Tom Steyer, a billionaire activist in California who has pushed for solutions to global warming, wants a public option that would administered by the Centers for Medicare and Medicaid Services, a federal agency within the Department of Health and Human Services. That public option would be financially separated from Medicare and Medicaid.

Private health insurance providers wanting to participate in Medicare or Medicaid would also need to participate in the public option. He estimates his plan will cost about $1.5 trillion over 10 years.

CORY BOOKER

New Jersey Sen. Cory Booker, as well Warren, is a sponsor on Sanders’ Medicare for All bill. As president, Booker would push a health care plan that includes universal paid family and medical leave.

He would lower prescription drug costs by importing drugs from countries like Canada and allowing Medicare to negotiate for lower prices. He also wants to create a tax penalty for drug companies that “unfairly raise the cost of their drugs and take patents away from drug companies that sell the same medication for less in other countries.”

CA presidential primary: Healthcare plans of 2020 candidates | The Sacramento Bee:.

Patient Expectations Then vs. Now

There was a time when a whole family went to one doctor and it was paid for by their insurance. They rarely saw a specialist because they trusted their doctor’s word as law. Patients were patients and doctors were doctors but lines have blurred and patient experience has changed. Today’s patients have consumer expectations and they are knowledgeable. Healthcare is making the transition from the pure traditional model of patient to the world of patient/consumer. Understanding what this shift from patient to consumer looks like is the first step toward successfully navigating these changes.

The rapidity of health care transformation can overwhelm even the most knowledgable patient and provider. Patients and providers must collaborate to ensure avoiding errors and excellent patient care. The battle is now between the allies (patients and providers) vs bureaucracy.  Without intention CMS, payors, information technologists have unleashed a gordian knot upon us all, funded by the government with your tax dollars. 

The integration of parts, patient engagement patient-centered, electronic health records, interoperability, patient portals, remote monitoring, telehealth, text messaging for patient and provider notifications. 

Health Train Express is hoping to narrow that new divide and we also publish Digital Health Space and Occupy Health on Facebook to that end.

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Hospital Profitability Declines Due to Weak Volumes

Hospital Profitability Declines Due to Weak Volumes, Revenues   By Jacqueline LaPointe (email)

"Margins indicating hospital profitability, including EBITDA and operating, fell as volume and revenue performance weakened in November 2019.

An analysis of November 2019 data from over 800 hospitals revealed weakened hospital profitability as margins significantly declined compared to the previous month.

Conducted by consulting firm Kaufman Hall, the National Hospital Flash Report from December 2019 detailed the drop in margins. The firm found that the operating earnings before interest, taxes, depreciation, and amortization (EBITDA) margin was down 14.5 percent of 200.1 basis points (bps) year over year while operating margins experienced a 21.3 percent or 208.1 bps decline.

Month over month, operating EBITDA margin dropped by 14.3 percent in November, or 215.6 bps, and operating margin decreased by 23.4 percent or 239.2 bps.

"A one month report of hospital profitability may not be a solid indicator for a hospital, especially during a holiday season. Many patients chose not to be hospitals during this time of year.  However, profitability margins are small, to begin with, except for some exceptional institutions.  The fragility of even major hospitals such as the former Hahnemann Medical School and it's supporting hospital in Philadelphia supports this concern. Hospitals in highly competitive markets may be impacted more."

Hahnemann Sale and Closure

Researchers attributed the drop in hospital profitability to weak performance across volumes and revenues, as well as higher-than-excepted expenses.

“Expense data from 2018 and 2019 illustrate the rough road hospitals and health systems face in trying to get a handle on the high costs of providing healthcare,” the analysis stated. “While year-over-year variances show dramatic fluctuations from month to month, overall expenses continue to creep steadily upward.”

In November 2019, both labor and non-labor expenses rose. The most recent National Hospital Flash Report showed that total expense per adjusted discharge increased by 2.7 percent year over year and 5.2 percent month over month. Other metrics indicate a general decline in revenues, an increase in expenses and overall decreases in volume and income.

It is predicted this trend will be reversed in the first quarter of 2020. These predictions are also subject to further unknown changes in CMS reimbursements.

Hospital Margins Decrease again

in November 2019

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Are Primary Care Visits on the Decline?

Primary care is essential for a high-performing healthcare system, as patients with a regular primary care physician (PCP) have higher rates of recommended screenings and lower rates of preventable hospital admissions and mortality. Although recent studies suggest declining rates of primary care visits during the last decade in the United States, the contribution of practice changes, such as the use and content of such visits, to this decline is still undetermined. To address this question, researchers used nationally representative data from the National Ambulatory Medical Care Survey to analyze adult visits to PCPs and physician practice characteristics from 2007 to 2016.

The goal of a second study was to examine changes in individuals' contact with the medical system during the implementation of the Patient Protection and Affordable Care Act (ACA) within longer-term trends.

This study used data from the 2002 to 2016 Medical Expenditure Panel Survey to determine rates of contact per 1000 individuals per month for physicians, PCPs, specialty physicians, and emergency departments; inpatient hospitalizations; dental visits; and home health visits for the overall population and by age, financial status, health status, and race/ethnicity.

The number of primary care visits in the United States is unexpectedly decreasing at a time when the ACA has reduced financial barriers to care and ushered in a new era of prevention and wellness, 2 studies have found.

Experts disagree on whether this trend is good or bad for the health system. The passage of the Affordable Care Act should have increased the frequency of visits, while the use of telehealth would decrease face to face visits.  The availability of online laboratory test results obviates a clinic visit.

Other factors also changed. The length of a patient visit increased with the addition of education, coaching,  and more comprehensive visits.

In 1 study, Aarti Rao, BA, from the Icahn School of Medicine at Mount Sinai, New York City, and colleagues found that from 2008 to 2015, the average number of PCP visits per person dropped by 20% in a sample of 3.2 billion visits (−0.25 visits per person; 95% confidence interval [CI], −0.32 to −0.19). Visits dropped particularly for acute and chronic diseases, but not for general medical exams and mental illness.

Appointment Length Increased

The time of each appointment lengthened, on average, by 2.4 minutes, and each appointment addressed more concerns, enabled in part by electronic health records, and provided more preventive services and procedures, such as vaccines and wound care. In addition, appointments were less likely to have scheduled a follow-up for certain patients and conditions.

Physicians also offered much more non-face-to-face care, such as secure messaging and virtual care. For instance, it is no longer necessary in most cases for patients to come in to obtain laboratory results.

The researchers say that fewer visits can be explained partially by more comprehensive appointments and more out-of-office care.

They acknowledge, however, that the rise of high-deductible health plans may also be keeping some people from coming in at all; in addition, other factors could play a role, such as more patients seeking care at retail and urgent centers or appointments with nurse practitioners or physician assistants, which the investigators were not able to measure.

Specialist Care and Emergency Department Care Have Not Increased

The decrease in the numbers of primary care visits has not, for the most part, resulted in an increase of visits to specialists and emergency departments, Michael Johansen, MD, from Grant Medical Center, OhioHealth in Columbus, and Caroline R. Richardson, MD, from the University of Michigan, Ann Arbor, write in a second study published in the journal.[2]

In fact, the likelihood of visiting a specialist decreased for all patients younger than 65 years, Donald Pathman, MD, MPH, director of the Program on Primary Care at the University of North Carolina at Chapel Hill, explains in an accompanying editorial.[3]

That is a welcome finding, he writes, considering some "balloon" theorists have suggested when primary care visits go down, the use of more expensive care goes up.

Some changes were specific to age groups.

In this second study, emergency department visits did not change for individuals aged 18 to 40 years and those aged 65 years and older but increased for those aged 41 to 65 years.

Even though the intent of the ACA was to have a heavier primary care focus, what may be happening is that we are receiving more efficient primary care, albeit, in fewer visits, he said.

The intent of models such as accountable care organizations, he notes, is that care will be delivered and received where it is most appropriate, "and that oftentimes means you don't need an office visit," he explained.

Patients are getting more questions answered electronically, and more follow-up telephone calls are taking the place of in-office visits.

It seems the changes in the system are working in unplanned ways and most of it is good.  Perhaps we are getting more bang for ours. expensive health system.

Providers are becoming more proficient at using all the resources that have developed in IT and administrative matters.

He added that the studies show a surprising lack of response to the ACA, in that it appears the ACA did not increase the numbers of contacts with primary care or influence where people were seeking care.

In the end, neither of these studies gives a clear answer on whether less contact with primary care is a good or bad thing, Dr. Johansen explained, noting that who is not accessing primary care, where they are going instead, and how the trend affects outcomes are still unknown.









Are Primary Care Visits on the Decline?: US primary care visits are unexpectedly declining, despite the

Affordable Care Act implementation, which was intended to lower financial barriers to care and improve access to prevention and wellness.

Who Are the Key Players in Social Determinants of Health Strategy?

As healthcare organizations continue to target the social determinants of health, they must collaborate with other key players to deliver on programs.

 - The healthcare industry has come to a consensus that the social determinants of health and population health are essential considerations for delivering value-based care. But it takes a village, as the adage says, and organizations need to anticipate a number of stakeholders for making these programs a reality.

SDOH programs are inherently multi-stakeholder — they require the medical provider who will identify high-risk patients, fund sources, care coordinators or caseworkers, and the community-based partners that will help carry out interventions. Each of these stakeholders needs to be working in the same direction in order for programs to be successful.

Some hospital boards have already considered the SDH and how hospitals can effect change in SDOH for prospective patients.  The question being "Is there a return of investment? "Will this lower the direct cost of health care?

READ MORE: How Addressing Social Determinants of Health Cuts Healthcare Costs

Nutrition programs, housing initiatives, and ridesharing partnerships are some of the ways providers are reducing healthcare costs by addressing social determinants of health.

And as a fundamental part of that duty, board members are considering where to allocate financial resources to fund SDOH programming.

Adjusting Medicaid Payments for Social Determinants to Boost Care

Using a per-person adjustment for Medicaid payments to hospitals would address social determinants of health and help hospitals fund more comprehensive care, experts say. While some hospitals and organizations have outreach programs to increase accessibility for higher risk groups, this approach is to directly influence  SDH by other means. Some of these programs are already funded by other organizations, non-profits, food banks, homelessness programs. Hospitals can be a source of information as well.  Emergency room demographics reveal the data on homelessness, substandard housing, and poor nutrition. Substance abuse organizations can network with hospitals to deliver this information as well.  Emergency rooms function as social crisis centers. Public health and federally qualified health centers are organized centers of SDOH information. The information is already in place from Medicare and county hospitals.

READ MORE: How Food Security Programs Target Social Determinants of Health

How Social Risk Factors Influence Value-Based Reimbursement

The AHA (American Hospital Association) recommends that provider organizations take the following steps to implement similar housing initiatives:

Identify issues, opportunities, and risk
Establish strategic partnerships inside and beyond the hospital
Research potential interventions, such as successful programs run by other health systems
Consider funding implications and what sources are available for funding (i.e. local government and community agencies)
Educate patients, providers, and the community about the initiative
Assess and modify initiative to improve housing options, patient eligibility, and outcomes

Population health management and value-based reimbursement success hinge on reducing healthcare costs not only when a patient is in the exam room, but also when they are beyond the walls of the practice or hospital. Therefore, understanding where a patient lives, their income, education level, job status, and other social determinants of health (SDOH) is critical as providers aim to reduce healthcare costs and unnecessary utilization.

Socioeconomic factors are responsible for approximately 40 percent of a patient’s health, while just 20 percent were tied to care access and quality of care, the American Hospital Association (AHA) recently reported.

Despite the impact SDOH has on a patient’s outcomes and costs, many providers are not equipped to address housing, economic stability, education, food security, and other social determinants.

Providers in a recent Leavitt Partners survey cited insufficient appointment time and lack of compensation as top barriers to addressing SDOHs. Fee-for-service payments do not reimburse providers for extending care beyond the practice’s or hospital’s walls and even some alternative payment models have yet to branch out into integrating medical, social, and behavioral services.

This approach requires a collaborative approach and unique leadership skill to develop, maintain and develop resources, both financial and human to attain.

It is a brave new world with enormous opportunities as organizations and providers realize an ability to influence SDOH as never before.

In the past providers have recognized this aspect of patient care, with little resources to affect the major SOH affecting patient care as well as prevention

Patients can also contribute to this concept by communicating these needs and fully encompass a patient-centered health system.


Readers who want a deeper look









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Factors Affecting Clinician Well-Being and Resilience – Conceptual Model – Clinician Well-Being Knowledge Hub

What is  Physician Burnout?

It is the beginning of a new year and a new decade. Most of this month's work will address physician wellness, which very much affects every patient. Patients have become aware of physician burnout. Burnout is characterized by three components: (1) emotional exhaustion or loss of passion for one’s work, (2) depersonalization or treating patients as objects, and (3) the sense that your work is no longer meaningful;  caused by the rapid influx of technology, increased patient volume, a new payment method based upon the value, rather than the volume of patient visits. Physicians and patients usually have their forums and spaces. It used to be the 'doctor's lounge' or the doctor's dining room. This has become much less true in recent years. While the administrative suites have grown larger, the spaces set aside for physicians has decreased and perhaps has contributed to a loss of self-esteem.

Many physicians now blog in public blog spaces, have their facebook pages and Instagram page While web pages are static social media offers an almost synchronous platform for doctors and patients to communicate. Add to that secure messaging and telemedicine, the internet provides an almost spider web for communications, physician-patient-patient-physician.

This conceptual model was developed by the National Academy of Medicine Action Collaborative on Clinician Well-Being.

What is Clinician Burnout?

This conceptual model depicts the factors associated with clinician well-being and resilience; applies these factors across all health care professions, specialties, settings, and career stages; and emphasizes the link between clinician well-being and outcomes for clinicians, patients, and the health system. The model should be used to understand well-being, rather than as a diagnostic or assessment tool. The model will be revised as the field develops and more information becomes available.

The external and individual factors of the conceptual model are hyperlinked to corresponding landing pages on the Knowledge Hub, allowing users to navigate seamlessly between the two resources. By viewing the Conceptual Model on your computer, you will find that each factor is linked to a landing page within the Knowledge Hub. Each landing page provides additional information and resources.

 The body of medical literature on burnout has demonstrated significant professional repercussions including decreased patient satisfaction, increased medical errors and litigation, and the personal consequences of substance abuse and depression [5–7]. One proposed solution to physician burnout is to address physician wellness [8, 9]

Numerous study groups have evaluated this subject and published their results and recommendations.

Transforming Clinical Documentation in EHRs for 2020: Recommendations from the University of Minnesota's Big Data Conference Working Group

The Royal Society of Medicine Open Section’s Medical Humanities Conference: Physician Resilience and Compassionate Practice

Physicians have in the past been at the top of the hierarchy of responsibility.  Leadership is a lonely place, and the inability to share responsibility and authority comes with a price. Today's brand of medicine is a team approach. This is demonstrated by a number of reports

Team Structure and Culture Are Associated with Lower Burnout in Primary Care

Factors Affecting Clinician Well-Being and Resilience – Conceptual Model – Clinician Well-Being Knowledge Hub: Factors Affecting Clinician Well-Being and Resilience – Conceptual Model

******HAPPY NEW YEAR 2020*****