Thursday, December 6, 2018

A "little information" can be dangerous to your health


“A little information can be a dangerous thing.”

I don’t know who first said that; no one seems to. But it is used all the time, and as a physician I both see the impact of that little knowledge on people’s health and the difficulty of striking a balance between providing meaningful information in a form that people can use and oversimplifying to the point of danger. I have worked very hard on honing this skill, and think I do it reasonably well, but I am absolutely certain that I have failed abysmally time and time again. Hopefully, it has not hurt too many people, but who knows?

I have written before that one of my roles, as a friend and family member, is to try to interpret for them what their doctor meant by what s/he told them. Or, more correctly, what my friends and family members think s/he told them. Indeed, a key part of this is trying to figure out what the doctor (presuming they are reasonably competent) might have said that led my friend/relative to think that what they are telling me is what s/he said.

And, just as I make the assumption that these doctors are reasonably competent, I make the assumption that those friends and relatives are reasonably intelligent, or at least not particularly less so than the bulk of the population (side note: I honestly think that, on average they are far more intelligent). This is borne out by the fact that it is not just friends and relatives. From time to time, I overhear conversations between other people about their health. One of the most common places is the locker room at the gym; this is because I am there dressing for long enough to be able to overhear a conversation, and also because, as a retired person, I go in the middle of the day when all the other retired – and, therefore, older, and more likely to have health problems – people are there. Usually the conversation is bi-directional but almost always one of the people is acting as a health consultant to the other, advising based on their personal experience of having had, or having a friend or relative who had, the same thing. Or, and here is where a lot of the danger comes from, something that seems very similar.

[This is the time to review, either via YouTube or its transcription on one of my old blogs, "Eggs Benedict" and "Choosing Wisely": often the best thing to do is nothing, the Woody Allen bit “Eggs Benedict”.]

Things that seem similar may not be the same – or even similar. To a health professional, there is a huge difference between an orthopedist (a bone surgeon) and an orthodontist (a dental specialist who straightens crooked teeth), but to a regular person they sound a lot alike. And it is not only confusion of words; lots of conditions that are very different sound very similar (you know, a lot of diseases end in “-itis”, which just means “inflammation of”). And even conditions that are very similar – or even the same – manifest differently in different people depending upon a lot of personal characteristics (just to name a few: age, sex, weight, co-existing conditions [another term that doctors use all the time that people may not understand], and duration and exact character of symptoms and findings). Lots of stuff is treated differently in its early stages than in its later stages, and often many different treatments are available. Maybe the one the doctor chose for you isn’t the best, and maybe the one you see advertised on TV or the home remedy advised by your aunt will work better. Or maybe not. Maybe, even, there was some scientific rationale behind that choice of treatment.

Which, of course, leads inevitably to a short discussion of direct-to-consumer advertising of drugs, particularly on television. I see these a lot more than I used to, not because I sit around in retirement watching daytime TV but because of the same gym; while I’m on the elliptical I am often unable to choose shows (ones with plots) because someone else has already chosen the program on the group TV, and there are a lot of ads. Many of them for treatments for pretty uncommon diseases. Which is, by the way, a guarantee that they cost a fortune. After all, why advertise on TV, a very expensive proposition, unless you stand to make a lot of money either because a lot of people have the problem your drug treats (e.g., arthritis) or the drug you are selling (clue: anything whose generic name ends in “-ib”, made from recombinant DNA) is so expensive that even a small market will make you a fortune? There is absolutely nothing at all good (and I’ll say that again!) about direct to consumer advertising of drugs on TV (“ask your doctor about whether [incredibly expensive] ‘Blorkamib’ is right for you!”). Except, of course, for the drug company that makes it and advertises it. These ads create unrealistic hope and expectation, create doubt as to whether your doctor is up-to-date on the latest treatments (you know, s/he is busy seeing patients all day so may not see the ads on daytime TV!), and sets you up to expect miracles. (By the way, there are very few of these.) If you must watch such commericials, I suggest you only focus on the fine print possible – often common and very bad – side effects in the small print at the end.

The late, great Hawai’ian singer Israel Kamakawiwo’ole makes a valiant effort on the last cut of his album “IZ” to explain the cause and treatment of the congestive heart failure (along with, and in part caused by, his tremendous obesity) that eventually killed him at the age of 38. It’s a pretty good discussion of the role of oxygen, although it doesn’t quite get it right, but it may have helped some of those who heard it. He had great influence; his recording of “Somewhere over the rainbow” mixes up the lyrics from different verses, but I suspect that for many people, hIZ lyrics are now the ones they know (so if they seem disconnected to you, don’t blame original lyricist Yip Harburg!).

But it is not just singers who have trouble with it; being educated and smart doesn’t make one medically knowledgeable. I know this from treating lawyers, accountants, engineers, English professors, and even medical school faculty in the basic sciences (although the physiologists, unsurprisingly, understand heart failure better than IZ…). It makes it hard to try to convey accurate information, as completely as possible, without losing people’s ability to grok it and without using metaphors that, while intended to help, may unintentionally send folks off to the wrong conclusions. It is important to try, though, and to ask not if people understand (usually they’ll say yes) but what they understood, so you can correct any misinterpretations.

People will probably do what their mother tells them to anyway.

Tuesday, November 27, 2018

Kickbacks, corruption, and graft are not models for efficiency in health care

The Trump administration has labored zealously to cut federal regulations, but its latest move has still astonished some experts on health care: It has asked for recommendations to relax rules that prohibit kickbacks and other payments intended to influence care for people on Medicare or Medicaid.’

So begins the article Trump Administration Invites Health Care Industry to Help Rewrite Ban on Kickbacks by Robert Pear in the NY Times, November 24, 2018. The next sentence provides the ostensible motivation for the rule change: ‘The goal is to open pathways for doctors and hospitals to work together to improve care and save money,’ but the sentence immediately after goes to the meat of the issue: ‘The challenge will be to accomplish that without also increasing the risk of fraud.’

The reason that there are anti-kickback laws in any industry is, of course, to prevent fraud. It is bad enough when we discover that a supposed impartial reviewer of a film or a book, or an item we may want to purchase like a car or a computer, is in fact being paid by one manufacturer to recommend their product. It is even worse if it turns out that the product that they are recommending is us, and that someone that we have trusted with our lives and our health, like a doctor, is being paid to send us to a particular lab or x-ray facility or hospital or specialist. Maybe the one we are being referred to is the best one, but it is hard to trust that if we discover that the doctor has a financial interest in that facility, or is receiving a kickback for those referrals. Most people are afraid of this and thus support anti-kickback laws; the exception is always those within the industry who stand to benefit. Surprise! And, it should be noted, it seems to be a core part of the business model of the Trump Organization.

But what about that middle sentence? The one that says that ‘the goal is to open pathways for doctors and hospitals to work together to improve care and save money’? Isn’t that a worthwhile goal? And both the American Medical Association (AMA) and American Hospital Association (AHA) are supporting the proposals. Am I saying that they are crooks or corrupt? Doesn’t it make sense that there can be not only savings but enhanced quality from the efficiencies that can come from such arrangements? How can we realize the efficiencies if doctors and hospitals are prevented from coordination of care?

The answer, as I see it, is “yes, but..”. There should not be unreasonable restrictions to care coordination, provided that they are upfront and obvious to the consumers (patients) such as in health maintenance organizations (HMOs) and the like which use limited panels of doctors, or public hospitals where care is often provided by employed physicians. The core issue, in health care, is to ensure that these arrangements are truly for the benefit of the health of patients, and not mainly to make more money for the providers. When your physician, Dr. Smith, refers you to a particular specialist (Dr. Jones) because they know them and think they are smart, competent and do good work even though another physician across town may have better results by some measures, it may be good or bad but it is honestly being done by Dr. Smith for your benefit. But if you discover that Dr. Jones is paying Dr. Smith for referrals, you might well be chary of the motivation.

There are several important things to remember in this discussion:
1.     Not everyone is, or is likely to become, a crook. There are many, maybe most, individual health care providers (like doctors) who actually care more about people’s heath than profit. There are even some institutional health care providers, hospitals and health systems, that may.
2.     There will always be people and institutions who “push the envelope”, and game the system. They will do everything that is legal, even if it violates the spirit and intent of the law, if it makes them more money. “Give them an inch and they’ll take a mile”.
3.     The looser the rules, the more these people and institutions will game it. There is no reason to suspect that money-grubbing cheaters will be satisfied if given a little more. Think about those (maybe me and you) who routinely feel ok about driving 5-10 MPH above the speed limit on a highway. If the speed limit is 65, we may drive 70 or 75. But if it is 75, we drive 80 or more. Raising the limit on what constitutes corruption will not obviate it.
4.     Carrots don’t work very well to change such behavior, although sticks might work a little better.

Don McCanne recently discussed a study from RAND called ‘Effects of Health Care Payment Models on Physician Practice in the United States’ which described the many different models being employed by various health systems and physician groups in the US, but alertly appened a reference to a NY Times article on October 27, 2018 by Alfie Kohn titled ‘Science Confirms It: People Are Not Pets: Research on the efficacy of rewards tells us that we can’t bribe others into doing what we want’. It reviews the psychological science that there is a difference ‘between intrinsic motivation (wanting to do something for its own sake) and extrinsic motivation (for example, doing something in order to snag a goody). The first is the best predictor of high-quality achievement, and it can actually be undermined by the second. Moreover, when you promise people a reward, they often perform more poorly as a result.’ Indeed, Kohn shows that sticks are not that effective either at changing behavior; I advocate them to some degree because at least they can put the biggest violators in jail!

The Pear article on kickbacks, trying to describe what its supporters see as the good side of loosening restrictions on them, says: ‘‘Federal law generally prevents insurers and health care providers from offering free or discounted goods and services to Medicare and Medicaid patients if the gifts are likely to influence a patient’s choice of a particular provider. Hospital executives say the law creates potential problems when they want to offer social services, free meals, transportation vouchers or housing assistance to patients in the community. Likewise, drug companies say they want to provide financial assistance to Medicare patients who cannot afford their share of the bill for expensive medicines.’ First of all, this is not “likewise”; drug companies who want new customers (and fend off efforts to regulate prices) are different from a hospital or provider offering free or discounted services; extra benefits to attract patients (as opposed to, say, free lunches to attact doctors) are quite different,  provided that these are really free, and the cost is not passed on to Medicare or Medicaid!

There is, in fact, a difference between ‘coordinated care’ and ‘graft’.

Pear also writes ‘‘The Justice Department in April accused Insys Therapeutics of paying kickbacks to induce doctors to prescribe its powerful opioid painkiller for their patients. The company said in August that it had reached an agreement in principle to settle the case by paying the government $150 million. The line between patient assistance and marketing tactics is sometimes vague.’

Vague? This is not vague at all. Creating efficiencies to improve care to patients, and reduce costs, especially to patients, is fine. Kickbacks and graft are not.

Friday, November 9, 2018

Can corporate power continue to keep Americans sick? Maybe the election will help


Do you think that insurance companies should be allowed to deny insurance to people with pre-existing conditions? If not, you are in agreement with most Americans, 81% of whom feel this way according to a survey conducted by the Commonwealth Fund, the Harvard School of Public Health, and the NY Times for the report Being Seriously Ill in American Today (the link is to the Commonwealth Fund site discussing the study, and you can download the PDF there). That is a lot of people, and is why most politicians give at least lip service to the idea. Of course, despite the fact that you may have heard Republicans who are currently in Congress saying that they support it as they ran for re-election, the fact is that virtually all of them voted against it when they voted to repeal the Affordable Care Act (ACA, Obamacare) and, when that was unsuccessful, to strip it of its major impacts. This protection was one of the most important of ACA’s rules, and is highly valued even by most Americans who profess to hate Obamacare, Obama, love Donald Trump and vote for the Republican Party. And this is, in no small way, a reason for the Democratic takeover of the House.

Sadly for the GOP supporters who want their pre-existing conditions covered, their love is not being reciprocated by their elected officials. As discussed by the President of the Commonwealth Fund, David Blumenthal, in an article in The Hill, 20 Republican-led states, led by Texas, are filing suit against the federal government arguing that they should not have to enforce the ACA’s ban on refusing insurance to people with pre-existing conditions. What is more is that the federal government, under the GOP and the Trump administration’s Department of Justice, is refusing to defend the suit; this means that they are not arguing in favor of the law of the land, but more that they are not defending the right of the American people to have this guarantee. Tough luck, 81% of Americans!

Of course, this would not necessarily mean that people with pre-existing conditions (about 52 million Americans, depending upon a fairly strict definition*) would not be able to get insurance, although it is likely that many (such as those with terminal cancer) would not. It does mean that they could be charged much higher premiums for their insurance, though. This would go back to what is called “individual rating” where the individual’s health risk determines the amount of their premium, as opposed to the “community rating” required under ACA. And, of course, as discussed in another Commonwealth Fund brief this would also impact the premiums of those actuarially deemed to be a greater risk: mainly older people (including those Trump and GOP voters), but also for many conditions, women – the majority of the population! Even the insurance companies are not sure what to do as they set their rates for 2019.

It is clear that President Trump is doing all he can to distract people from the result of the November 6 elections – he is a master of distraction – such as by firing Attorney General Sessions the next morning. But the Democratic House of Representatives will not be confining itself to investigations of him and his campaign, but also moving forward with legislation to accomplish what are seen as “progressive” goals, or goals I would reframe as “actually in the interests of the people of the US, as opposed to the billionaires and large corporations. Health care is the foremost of these. It will start with ensuring that the important provisions of the ACA are kept in place, in particular the protection for those with pre-existing conditions. The House can do this because it is current law, and it can block any Senate effort to change it.

Moreover, the House is likely to work on advancing the goal of “Medicare for All” in the coming session. This is the opinion of Sen. Bernie Sanders (D-VT), the most well-known advocate for single payer, makes this point clearly in an excellent interview with Rolling Stone’s Matt Taibbi. This will not pass the GOP-controlled Senate, and may not even pass the House, but the effort will definitely be made and it will have strong support, a big change from the Clinton plan of the 1990s and even ACA when single payer was “not on the table”. Establishment Democrats, beholden to their own very wealthy donors (especially Wall St.) may not be happy to go against corporate America, but they will if they have to and they will have to because their voters want it. As Sanders says, “…it’s wildly popular. And that’s what Democrats have got to do.”

On one side, we have the interests of the vast majority of the American people. There are those without health insurance coverage, including those who would be eligible for Medicaid under ACA if they lived in states that had expanded Medicaid, but have the misfortune of living in Republican-controlled states that did not. This will get better soon, as three states, Idaho, Nebraska, and Utah, just voted to expand Medicaid, and Maine will likely do so now that its soon-to-be-former governor won’t be around to veto it. It is a popular program, even in these “red” states. But those who will still be uncovered in the 14 states that remain is a lot of people. Then there are the people who have insurance, but terrible insurance, with absurdly low annual and lifetime caps, that should not be legal. But they are. Then we have the people who have more “standard” employer based insurance, who are being killed by the premiums, deductibles, co-payments, and co-insurance costs. Then we have those who are on Medicare who are unable to afford a Medicare Supplement policy to cover the things Medicare doesn’t – especially the 20% of the cost, since Medicare covers only 80%. Maybe not so big on a $100 office visit (although $20 is a lot for many people) but a big deal for a $5000 hospitalization.

So how many people is that altogether? I don’t have the numbers, but it is certainly the large majority of the American people. In fact, 90% is probably a conservative guess, which would mean 10% of Americans have insurance with affordable premiums, copays, deductibles, or are so rich it doesn’t matter. Of course, this small group includes not only most legislators, but corporate executives, pundits, and even many liberal leaders. Remember: the median US household income is about $61K, and a household (not individual) income of $150,000 is the top 8% and of $200,000 the top 3.65%!

Who is on the other side? Well, drug companies, consistently the #1 profit industry in the US. Insurance companies, making huge amounts of money skimming from the “health care expense” pool. Large health systems, doing very well, thank you. In other words, incredibly wealthy vested interests and their lobbyists that contribute a lot to politicians. This is not a fair match-up either way, most of the people vs. most of the money.

But maybe the “most of the people” finally have a chance. Wouldn’t that be a refreshing change?

Monday, October 22, 2018

"Single Payer", "Medicare for All": Good ideas and about time!


The call for a universal health care system in the US is probably greater than it ever has been. While, of course, the Republicans, whose only firm position is completely kowtowing to billionaires and major corporations, are opposed to it, many Democrats have signed on to the “Improved and Expanded Medicare for All” bill in Congress (120 at last count). Democrats running across the country have been calling for “single payer” as well as “Medicare for All”, from outspoken Democratic socialists like Alexandria Ocasio-Cortez in NY (and of course Bernie Sanders) to moderate Democrats running in states and districts that Trump won. They correctly see this as an issue that cuts across traditional liberal-conservative lines, and even racial lines, and may be their path to victory.

Many Republicans (although not the Republican congressional leadership) are reading the same tea leaves, and are hedging, trying to say that they favor the things that people like about the ACA (most important, the protection against insurers denying coverage for pre-existing conditions). Of course this often requires major dissembling for those who, like our Arizona GOP candidate for Senate Martha McSally, voted to gut the ACA, and even Texas senator Ted Cruz who authored the “Cruz Amendment” that would strip virtually all protections for people under ACA. President Trump, never one for nuance, has no difficulty having it both ways: he calls for the repeal of ACA while insisting that his health care plan will protect people’s ability to have health insurance, pre-existing conditions or not (it won’t).

It is in this context that the recent Sunday NY Times’ Magazine article by Elisabeth Rosenthal and Shefali Luthra, ‘“Don’t get too excited” about Medicare for All’ becomes important. For starters, “Don’t get too excited” is not necessarily the opinion of the authors but a quotation from Rep. Jim Cooper (D-TN). Rep. Cooper was responding to the surprise of one of his Nashville constituents, Dr. Carol Paris, President of the leading physician advocacy group for single payer, Physicians for a National Health Program (PNHP), that he had signed onto the Medicare for All bill. Nonetheless, the article does raise many cautions about the movement to single payer or Medicare for All, mainly about different interpretations of the meanings of this by different advocates, and incomplete and sometimes inaccurate understanding of them by regular people. The most important thing about it, however, is that it had to be written at all because there is such a movement; long-time activists, including PNHP physicians, remember that it was not too long ago that such an idea was poo-pooed, dismissed. Not now.

Clearly, the quantum step forward was the 2016 presidential campaign of Bernie Sanders. The establishment pundits of both parties were shocked at how popular and successful this old Jewish socialist from Vermont (ok, originally Brooklyn) was across the country. He didn’t win the Democratic nomination, true, but he might have won the general election against Trump. Certainly, his straight talk and the fact that he directly addressed the felt needs of regular people was the main reason for his popularity, and people’s fears about their health risks and costs were central to this (see A majority of Americans are worried about health care costs -- and a majority of Congress doesn't care, October 16, 2018). Bernie had advocated for single payer for decades, as had great leaders before him including the late Representative Ron Dellums of California (see Ron Dellums: Loss of a great leader and a job for the rest of us, July 31, 2018), but the visibility of his presidential campaign skyrocketed the visibility of single payer.

Rosenthal and Luthra utilize a good bit of ink describing what single payer is --the government is the only payer for health care, rather than multiple private insurers; Canada is the best example of this, and Britain has a government-owned national health service. They also note that Medicare for All means exactly that, that everyone, not just those over 65 and the blind and disabled, would be in the Medicare program. Of course, since Medicare is a single payer program, it would be single payer. They describe the misconceptions people have (“would I be able to keep my present plan?”), and also talk about other countries, such as France and Germany, that have universal health care without a single payer but with a heavily-regulated marketplace. They observe that partialist solutions do not generate the enthusiasm of single payer, but that the latter would be the hardest and thus (perhaps) most difficult to institute. Among the concerns they note are the displacement of insurance company employees and the decrease in doctors’ income.

But these are the most important points.
  1.       Our health care system is not working. Our life expectancy is much lower than other developed countries, about 43rd, and a recent article in Smithsonian Magazine covers work that projects that it will drop another 21 places by 2040, to 64! Other measures of access to care and quality of care are comparably poor. Yes, there are heroic and wonderful things that medical care can do for people, but if these are not accessible to everyone, and if the cost of them precludes spending on even basic care for everyone, it is not working.
  2.   Our health care system is incredibly costly. By far, we spend more, overall, as % of GDP, and per capita, than any country in the world, as illustrated by the graph from the Kaiser Family Foundation. It is more than twice as much as most of the developed countries, all of which have far better health status.
  3. Profit is the problem. Specifically, corporate profit made from providing health care services (or, in the case of insurance companies, not providing health care). This is how we manage to do both #1 and #2 – because the functional goal of the US health system is not to increase the population’s health but to make as much money as possible for insurers, hospitals, drug companies, and providers.


These are the core issues that need to be addressed, and what sets the US apart from all other developed countries. Yes, Canada has a single payer system such as we might have with Medicare for All (and they even call it Medicare). Britain has a National Health Service, with most hospital and health care facilities owned by, and some doctors employed by, the government. Britain, however, allows private insurance for those who can afford it, Canada does not. France and Germany and Switzerland have multiple insurers, but they are not unfettered to maximize profit by denying care. In Switzerland, for example, insurers have to be non-profit, have to offer the same benefits, and have to charge the same amount. They compete on quality of service! Can you imagine that here?

So, while Rosenthal and Luthra repeat the idea that single payer, although the most enthusiasm-generating, would involve the biggest change, it is also, in another sense, the least complicated. Trying to get to a system like that that evolved in these other countries over decades will be more complicated to understand and to implement. Many of the suggestions for incrementalism (“Medicare for More”, “public option”) will not solve the problems we have because they do not include everybody, and because they do not eliminate the incentive for making money on the back of denying care that is the core flaw in our current situation.

“Medicare for All” and “single payer” are popular among people because their core meaning is understandable, and they would address the needs that they have.

  • ·        Everybody in, nobody out!
  • ·        No profiteering!

Simple message. Needed solution.

Tuesday, October 16, 2018

A majority of Americans are worried about health care costs -- and a majority of Congress doesn't care


People in the US are worried about a lot of things, but apparently the top one is whether, and how, they are going to be able to pay unexpected medical bills. The chart below, based on an August, 2018 survey, is provided by Drew Altman, President of the Kaiser Family Foundation, in the September 24 Axios. Indeed, concern about medically-related costs come in not only as #1, but as #2 (health insurance deductible), #4 (prescription drugs), and #6 (monthly health insurance premium), making up 4 of the top 8 concerns, all of them ahead of “rent or mortgage” (#7) and “food” (#8). All 8 of these concerns are upsetting; it is outrageous that over one-third (37%) of Americans are very or somewhat worried about being able to afford food, or 41% rent or mortgage. But a twice as many people, two-thirds, 67%, are very or somewhat worried about being able to afford unexpected medical bills, and over half (53%) about their health insurance deductibles.
 Of course, those who are worried are not evenly distributed among all Americans. They are not the suburban men who are turning more toward Trump, as they sit on the golf course by their $500,000 homes. They are certainly not the people in power in Washington, whether in the administration like Jared Kushner, who pays no income tax, or his father-in-law, President Trump, who has not released his tax returns, or the senators and even congressmen who make policy, or the members of the Supreme Court.

They certainly do include the poor, including many who are members of minority groups; those who, even in the best of circumstances are barely hanging in there – or often are not. These are the folks for whom paying for housing and food is an all-consuming concern, who do not know where their next meal may be coming from. For them, extraordinary medical bills are not even something that they can spend time worrying about, although they would certainly not be able to afford them.

Those worried, however, also include the large percentage of Americans (see the numbers) who are not poor, but are not all that far from it, people who are not that many paychecks from homelessness (a good measure of real risk). These are people who do not qualify for Medicaid (especially in the states that have not expanded it under the ACA), do not yet qualify for Medicare (and even many of those who do), and who often have health insurance either through their employers or through the ACA marketplaces. The employer health plans, overall, are cutting back on benefits, increasing employee contributions (#6), requiring higher deductibles (#2), and even instituting lifetime caps on benefits as well as excluding many times of illnesses. Fortunately for these people, the ACA has important requirements that help protect them: that people with “pre-existing” conditions be eligible for health insurance (without that, many folks with chronic disease would not be covered), and that there be “community rating”, which means insurance companies can’t charge individuals with particular conditions many times more than they charge others (without which most folks wouldn’t be able to afford the premiums).

It is also true that the current administration and Congress have been trying very hard to limit, when they cannot repeal, these very protections that provide a minimum safety net for most Americans. They are also keeping up a drumbeat about the “cost” of programs such as Medicaid (it’s just poor people, after all, except it is also your elderly parents and grandparents in nursing homes, and this is the bulk of the cost), Medicare (a bit of a “third rail” in politics, but which lots of Republicans keep bringing up as needing to have its benefits cut), and even Social Security, the program that keeps many, many American seniors from being in real poverty even as it continues them in near-poverty. The fear of losing insurance because of having a pre-existing condition is, scarily described by Kurt Eichenwald in a NY Times Op-Ed on October 16, 2018.

The fear of #1, “unexpected medical expenses” is, I assume, primarily about getting sick when you weren’t planning on it. Most folks are not hoping to get sick, but for some the exposure is particularly great because part of the way they handle #6, monthly health insurance premiums, and #2, high deductibles, is not be either uninsured or poorly insured. The latter is particularly common, both in many employer plans and even in ACA individual plans. Indeed, while they call it something different (“free choice” and “granting Americans the freedom to buy health care across state lines”[1]), the administration and Congress are actively encouraging high-deductible, low-coverage policies. This makes premiums seem affordable (or more affordable), but is a disaster when someone gets sick (back to #1).

In addition, limited networks are a quicksand trap for many people, who try to carefully go to doctors and hospitals that are in their networks, only to find themselves faced with huge bills from emergency room physicians, specialists, surgical assistants, and lab and imaging services that are not. This is truly a kind of “gotcha”, a quicksand trap. It is unbelievable; or maybe it is too believable. What may be more unbelievable, to many Americans, is that in most other developed countries health care systems are designed to serve people’s health, not trick and bait-and-switch for the purpose of corporate profit.

Medicare, as currently structured, is not a panacea; 31% of US seniors go without health care because of cost. But it is much better than nothing, and could be really good if it was better funded, and for-profit insurers were not skimming the “cream” (the least sick) into Medicare Advantage plans (which have much higher overhead/administrative costs than traditional Medicare).

Sadly, the issue of whether Americans should have adequate and affordable health care has become highly partisan. This is in some part because at least a portion of the Democratic Party has moved to positions in support of health care as a right, and a universal health insurance system (such as Medicare for all). But it is much more because the Republican Party has moved into complete opposition to any plan to expand health coverage to more Americans (e.g., Medicaid expansion, ACA) and is actively and aggressively moving to cut funding for ACA, for CHIP, for Medicaid, and even for Medicare (“we can’t afford it” is the stated reason, although it really means “we can’t afford it while giving multi-trillion-dollar tax cuts to corporations and the wealthiest”).

Sadder is the fact that many of those most affected, many of those with the greatest worries about health costs, whether unexpected illness, high deductibles, high prescription drug costs, high premiums, are reliable Republican voters. The Associated Press published a piece describing how the Democrats are focusing on health care for the midterm elections, citing the senate race in my state, Arizona. It describes how the Republican candidate, Martha McSally (currently my congressperson) tries to talk with business executives about the tax cuts but is regularly interrupted with questions about health care:
‘They are asking about Democratic ads saying McSally, currently a congresswoman, supported legislation removing the requirement that insurers cover people with pre-existing medical conditions.
"It's a lie," McSally said quickly, accustomed to having to interrupt a discussion of the tax cut to parry attacks on health care. But she had voted for a wide-ranging bill that would have, among other things, undermined protections for people with pre-existing conditions and drastically changed and shrunk Medicaid.’

Actually, then, it is she who is lying. Hopefully she, and other GOP legislators, will pay a price because people vote for those who are actually trying to solve their health care problems, regardless of party. We can hope that more and more Americans will, at least on this important issue, stop voting against their own interests.

I hope.


[1] This is actually the phrase used in the “survey” – completely non-scientific and filled with leading or directive questions – that Trump sends out to his supporters.


Sunday, October 7, 2018

Corporate control corrupts medicine and reduces healthcare quality


Medicine and health care is always changing, and the pace of change seems to be accelerating. Some of this change is good for people -- some of the new drugs that come out actually help, either a lot of people, or more commonly a few people. Sometimes new treatments are more effective, less painful, shorter, or less debilitating than older ones. And, sometimes, they are not. One thing we can be sure of, though, when we see a new treatment advertised, whether on TV or in a magazine or on a billboard, is that someone is making a lot of money on it.

There has been a great deal of coverage of two of the most important and egregious industries in which large corporations make lots of money at the expense of our health: pharmaceuticals and insurance. They deserve it, and I have written about them often. But another extremely important area where corporatism and corporate culture has taken hold and is expanding is in the ownership and management of hospitals. The most important thing about this increasing corporatism is that it is about making money (even in “non-profit” hospitals), not primarily about providing the health care that people need; of course, if what you need (or can be persuaded to buy) is profitable for the hospital, they’re all about it. For example, new surgical techniques and imaging, and particularly high-margin, low risk procedures like joint repair and replacement in otherwise relatively young healthy people (let’s go for that high school quarterback or 40-something weekend warrior). Not so much problems that occur in people who have multisystem disease, are old, are high risk, or are poor and uninsured. And some stuff – like psychiatric treatment for the most needy, or trauma care, are big money losers. Hate that if you’re a CEO, although might be good if you are a person who needs it.

This trend has been going on for a long time, particularly in large metropolitan areas, where most big hospitals are, and most of them are now part of hospital systems. Of course, big hospitals were always big, but the overemphasis on making decisions based upon money rather than people’s health has been accelerating. And more recently the process has taken over hospitals in smaller communities, including Critical Access Hospitals in rural areas. The Critical Access designation is meant to reflect the geographic isolation of a community, such that travel to the next-closest hospital creates real health risks for the population, and so even if operating it is inefficient, it receives federal support.

This is discussed in an outstanding editorial by Andrea Wendling in the October 2018 issue of Family Medicine, Times Are Changing”. Dr. Wendling focuses on two major areas, the reinterpretation of the “value” of physicians and the role of family physicians. Family physicians are the most common specialists in rural areas, in part because they can have such a wide scope of practice. They can care for the medical problems of adults and children, deliver babies, provide care for many musculoskeletal problems, mental health, women’s health care, and provide many procedures. At least as important to patients, they can see them in all the venues where they need to be seen – the office, the hospital, the nursing home, and even the patient’s home. Dr. Wendling notes that this is threatened by the corporate perception of physicians’ value, which is their value to the system, measured financially, rather than their value to the health of the community. Yes, you might find it beneficial to have a doctor who knows you, who has cared for you and your family for years, be able to see you in whatever setting you find yourself in, but the system has decided it is more efficient (read “more profitable”) to have your doctor be only an ambulatory care provider, or only a hospitalist.

It is not only family physicians who are affected, although they predominate in rural areas. While some specialists – those that provide care that is not necessarily the most important, but is the most profitable – have always been more highly paid and more sought after by health systems, even they are seeing decreases in their pay and status. It is hard for the family physician to cry for slight cuts in the income and power of doctors (like orthopedists and radiologists) who are making many times what they do, and in fact it is hard for most Americans to cry for the plight of even the lowest-paid doctors. Perhaps it feels like crying for the white men who bemoan their loss of privileges (real and desired) because women and minorities are finally moving the playing field to being, at least a little, more equal. But the corporate influence is far more malignant.

Family doctors believe that their contribution to people’s health is relatively greater than their income. Doctors believe that, whatever their income, they are working to improve people’s health. CEOs and corporations believe that health is a good thing to try to sell, provided we sell the kind that makes money. They do not put the health of the community first; they put the financial well-being of the corporation first. And, not surprisingly, this affects both poor and rural communities the most, because of the limited access to services they had in the first place; an arrogant and self-serving corporation taking over the only hospital in a community does not bode well for the overall health of the people who live there.

And, adding insult to injury, it is not only the dollar-centered approach that is a problem, it is the egos of the local leaders who, emulating their corporate bosses and our political class, think that they as individuals are important and deserve respect and obeisance. I have a friend who led the physician group at a rural hospital when it was taken over by a larger system, and helped negotiate the criteria for bonuses for the medical staff. Soon after, that physician was fired by the local CEO for “embarrassing them”! The doctor got their job back with the help of lawyers, but imagine the gall of that CEO! If what they were doing was right and good, they had no reason to be embarrassed; if they had reason to be embarrassed because what they were doing was corrupt, self-centered, not good for the physicians or for the community’s health, what they were doing was wrong and should have been exposed. I have no doubt that if the people in that town were asked who they valued more, the physician who had cared for them for years or the new CEO put in by a corporation, which one would get more votes. Maybe the CEO would get that of their spouse.

So we have a health care system that is structured to be corrupt, from the insurance companies, to the drug and device makers, to the big health systems, all geared to profit. We have many physicians, in all specialties from the rich and powerful subspecialists to the family physician, who are trying to figure out how to stay on the “good side” of these corporate systems and of the local martinets. We have physician leaders, in hospitals and medical societies and academic departments who often are looking mostly at themselves and how to show that they as individuals are important (like that rural CEO), maybe believing that what is good for them is somehow good for people. Sadly, this is even true in family medicine, no longer the ‘counterculture’[1] its founders, like Gayle Stephens, wrote about, but now often simply other supplicants for corporate largesse.

All of this is at worst immaterial and at best subsidiary. The criteria for whether a healthcare system or aspects of it are good is whether it improves the health of people and the community. We have a long way to go in our healthcare system. And it’s long since time to get started.



[1] Stephens GG. Family Medicine as Counterculture. Fam Med 1989; 21(2):103-9.

Total Pageviews