An Appeal to Paul Krugman

Paul, Paul

You have recently expressed rejection of the idea that we can adopt single payer, expand coverage and services and still save lots o' money. 

Please, Please, if you haven't already, read Lewin report 2005 on California Single Payer and any of several of Gerald Friedman's  economic review of several SP plans, including for New York. (And just about every, if not every, SP study done.) They all consistently point out the savings and expansion in coverage and services that you decry as impossible.   Perhaps you have strong economic disagreement with them.  If so, I am sure we would be happy for your insight.

Why Economists Took So Long to Focus on Inequality

Over at Bloomberg Views Justin Fox has an excellent article of the same name.  In fact it inspired my thoughts.  He does  a very good job of explaining the what--  needing data--  but not so much the why.   As always, "The Grail Question,"  -- Who does it Serve? helps us focus on understanding the underlying dynamics. 

The push for "data" to prove what we already know is a time honored delaying tactic.  It is endemic and, in  general, serves those who, we already know, will be disadvantaged once what we already know has been sufficiently "proven."

E.g. ,  We knew not only that there was growing inequality but that it is harmful to society ("children and other living things." ) Yet, for 30 years "no one had the data"  for what we all could see if we only looked. No one had the data for "welfare queens" either but that seemed more readily believed and influential in our economic and political discourse.  

End of the day--  there are plenty enough resources for education, mental health, health care, the 99%... It is just that it all resides in the pockets of those who are benefiting from a rigged system  (euphemism for--"they stole it !") and are "awaiting the date."

Fee for Service and the Consolidationistas

 This post  will be need more background to be completely comprehensible. But I will pay that background foward by excising some of the referenced material and posting it later... Meanwhile I do not want to lose the thrust energy of the below thoughts--

 

First of all -- I am talking  about how I see the proposed reimbursement structure for single payer.  Yes,  HR686 and other discussions allow for FFS.  But what I see is a continuing thrust not only to lower the already inadequate reimbursements but to marginalize, if not eventually eliminate, the utilization of that process. 

 Pay for Performance, Global Budgeting, Accountable Care Organizations, etc are already being pushed as the main administrative structures.  And MediCare, et al, are setting targets for enhancing this process.

As I see it these structures are being pushed as if they are already proven approaches.  This is far from true.  In vivo they are only retreads of Managed Care, Capitation , Case Rates, etc that proved such failures in the 90’s.   In research and logic they seem to primarily promote more administrative game playing in the service of  capturing income/profit at the expense of actual appropriate service delivery.

Further, it seems to me,  one of the largely unspoken drivers away from FFS is distrust of the professional—as if some big administrative agency can be held more accountable.  Do we need to appropriately monitor services for fraud and incompetency—of course we do.  But incentivizing ever larger corporate entities only makes it more difficult to hold them accountable.

All this would be moot, or, at least,  of less concern,  if  there were  actual co-committed efforts towards  sustainability and enhancement of FFS .  However, I certainly do not read the current environment (and tea leaves) that way. 

Two recent commentaries illuminate my concerns from opposing ends of the spectrum.   The first is Lessons from an Early Adopter  ACO  (free subscription may be required. ) This is from Open Minds—a Mental Health data advocate par extraordinaire,   that promotes- despite its own internal evidence to the contrary--  subservience to ACO’s as the only way to accrete the mountain of data that is seen as a good in its own right.   The second is from a  Don McCanne discussion of concerns about consolidators missing the point of interference with, not enhancement of, service delivery.

Anyway, I suspect much of this is falling on sympathetic ears.  But the main point I want to address is finding some way to enlarge this discussion.  I do not pretend to be in the know about all that is going on.  But, from twenty five years of public health, non-profit and political service and private practice it seems pretty clear to me that the corporatizing consolidationists continue to control the discussion and the actual people who deliver and receive the service are marginalized.   

Strong advocacy  for the efficacy and preference for FFS does not seem to be very visible.  I want to help change that. 

BTW--- I WON!

Probably not many have read the two previous blogs.  However, it occurs to me, belatedly?, that I should at least note that -----    I WON the election for membership to the Board of AAMFT-CA. ( 3 years beginning in January.)  As time permits, I will add to this post-- or add new ones for further thoughts/actions in re: ....

For now, suffice to express  my gratitude and  my excitement for the opportunity to  further  engage/educate/impact the process of a more people-sized mental health, medical and social reality.  NUF-SAID (stanlee)

AAMFT-CA BOARD ELECTIONS

 I am on the ballot for the AAMFT-CA  Board of Directors-- with my main "platform plank" as  getting our organizations to be  proactive re: reimbursement and administrative issues with insurance companies, Affordable Care act, and more responsive to member concerns, etc

The ballot was e-blasted on 8/27.  And voting closes 9/20.  (If you have any difficulty with voting, please contact Gita Seshadri, Ph.D, Elections Council Chair, at gseshadri01@yahoo.com.)
  

DID YOU KNOW  that  the general thrust of the corporatization of health care has, for example,  led the AAMFT to passively accept and advise those of us who are  insurance plan providers  to  “expect that the plans…will ask (us) to accept 2014 FEE RATES BELOW THOSE” we presently receive. (AAMFT Family Therap-eNews, 5/31/13)

I do NOT accept this.  It is one, very big, example of how we need to be more proactive in protecting our profession and expanding—not reducing-- its efficacy.  I believe I bring the experience in health care advocacy and organizing to help AAMFT-CA be an active, effective participant in this on-going process.

  

Further, as mundane as it may sound—the current AAMFT-CA  Board (it seems ) is all located in Southern California.  I am in the S. F./East Bay area--perhaps I can help bring some bioregional balance.   

Please VOTE FOR ME  and TELL YOUR AAMFT FRIENDS and COLLEAGUES  (Two vacancies but voting for only one increases chances of winning)

Happy to address any questions and to hear your comments and ideas.  Any help you can render-- of course-- greatly appreciated   Stephen@stephenvernonmft.com

THANK YOU VERY MUCH  (and my apologies if you have received multiple announcements)

AAMFT-CA BOARD (For those who want to know more about me and my "platform.")

The ever increasing influence/control of our profession by the mostly for-profit insurance industry will only be enhanced by the developments of the Affordable Care Act (ACA- Obama Care.)  A high percentage of our fellow professionals  now rely a great deal on either public or non-profit  employment or insurance contracting and reimbursement—as do our clients.  The ACA will be providing many more people with at least some degree of mental health coverage.  The pool of private pay clients is likely to be reduced and the demand for services increased.  At the same time, the mostly unrestrained for-profit insurance bureaucracy will make therapeutic services more difficult to provide and burdened with over administration.  AAMFT must enhance alliances with other state and national organizations to act as an effective voice for clinicians, clients/consumers and society to enhance services and reduce bureaucratic restrictions.

Related to this is developing and having an understanding and an impact on what the therapeutic landscape  will look like in the near, mid and long range future.  Will we all have to work for large groups --private, public or non-profit-- in order to be able to meet the systems’ policy and funding structures ?  What will be the fate of the individual, mostly out-of-pocket private practice ? We need to prepare ourselves to have influence on the future and to participate in it.

As a more specific example--With funding streams attached to more Integrated/Accountable  Care Systems will even small group practices be able to provide the administrative services needed for documentation,  Global Budgeting, Evidenced Based Best Practice, demonstrated Outcomes, etc.  Will we, like most physicians, have to develop administrative entities to negotiate and interact with various funding and regulatory organizations?   Or, alternatively, what can we do to promote Practice Based Best Evidence and the ability of the individual practitioner to survive in the environment and develop therapeutic structures—not bureaucratic ones?

Universal Health Care:

It’s clear that the U.S. has the least efficient and, in many measurements, among the least effective health system in  the “developed” world (and beyond.)  What is not clear is exactly the structure of Mental Health systems in other countries.   Taking the above concerns into account, we must learn from and about them and promote and adapt useful ideas and structures into our policy proposals and goals.  (A project I have already initiated.)

Parity:

It is well known that the Wellstone-Domenici Parity Act (2008) calls for parity with medical services for mental health  and substance abuse services.  What is less understood is that it also calls for reimbursement parity.  This means it is incumbent on the field’s leadership to “examine fee structures to be sure that insurers are reimbursing at rates comparable to medical and surgical benefits”  (National Council for Community Behavioral Healthcare--  2010) 

BEWARE

Voter Purges,

Citizens United,

Voter IDs,

Proprietary Binary Ballots,

Dog Whistles and Road Blocks

(Of all kinds and sizes.)

Romney-Ryan,

Can Not Happen! ?

Beware the Coup

Of

Twenty-One-Two

Medicare Vouchers,

War Machine Values, 

Stealing the Earned,

Entitling the Entitled,

Criminally Low Taxes

(For the Rich),

Regulation Elimination,

Takers On the Take !

Beware the Coup

Of

Twenty-One-Two

      --Adair