12 Questions Republicans Need to Answer on Infant Mortality in Ohio

Individual Irresponsibility in the President’s Healthcare Reform Plan

A response to the above titled post from “Health Leaders”

“The result is that nearly everyone will be “covered” whether they’re insured or not. They’ll be treated, and someone else will pay the cost. That’s the way it is now, and that’s the way it will continue to be if these bills pass—just under a different mechanism.”

And with considerably fewer uninsured to require that cost shifting. That’s the whole point, isn’t it? Less uninsured.

Look, a certain percentage of the population will always try to game the system, by paying the penalty rather than buying insurance. But even those people will stop that behavior as soon as someone in their family has an illness requiring more than a couple visits to the doctor. So, yes there are gamers, but most people want to do the right thing, I still believe.

“Premiums from commercial insurers will be sky-high, if commercial plans even continue to exist long-term.”

That’s not what the CBO says.

“What better way to get the deeply unpopular public option back in the mix in a few years?”

Except it isn’t unpopular, except with the Fox News crowd, who still think it is some sort of Sino-Soviet hybrid system.

And, just for the record, the 10 largest physicians organizations support reform with the option.

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Go forward on health reform – Washington Greene PA Letter to Editor – www.observer-reporter.com

I didn’t realize this had been published until just now. Here is my letter for the DFA LTE Campaign:

I am a practicing physician who routinely sees the suffering and deaths caused by a health care system that leaves tens of millions of people on the outside, unable to access health care except when so desperately ill, they find their way to an emergency room, and often end up in my ICU, far sicker than they would have been with access to a doctor earlier in their illness – and at this point a drastically more expensive illness as well. Every doctor you know can tell you similar stories.

That is why it is no accident that the 10 largest physicians organizations support health reform including the House Bill that passed last year, which includes a public option and an individual mandate, so that private insurers will have a competitor and benchmark, and so that everyone will be “in,” with an option to buy insurance from a true, not-for-profit insurer if they can’t get it anywhere else.

It is no accident that the American Cancer Society has made reform its top advocacy priority, because they see the needless anguish of cancer patients trying to get the care that they need, fighting with insurers, struggling to pay the bills, begging not to be thrown off insurance plans.

So when you hear the naysayers complaining about this or that aspect of the bills, remember that your friends, your families, and our patients continue to struggle with getting good care and paying for it.

Forty-five thousand of us die every year due to lack of access to health care. And that number is only a fraction of those suffering due to untreated or under-treated illness and chronic conditions.

We need to move forward, not step back for all of our sakes.

The comments from the right wingers are, sadly, all too predictable, but hey, it had been read 422 times when I checked a bit ago.

Ezra Klein – The six Republican ideas already in the health-care reform bill

Yes, they are already in there.

As Ezra sums up in his last paragraph:

On Sunday, John Boehner and Mitch McConnell responded to Barack Obama’s summit invitation by demanding Obama scrap the health-care reform bill entirely. This is the context for that demand. What they want isn’t a bill that incorporates their ideas. They’ve already got that. What they want is no bill at all. And that’s a hard position for the White House to compromise with.

Mary Landrieu Blasts Obama Over Health Care

“I think the president should have been more clear about a way forward on health care last night,” Sen. Mary Landrieu told reporters on Capitol Hill Thursday. “I’m hoping in the next week or two he will be, because that’s what it’s going to take if it’s at all possible to get this done.” [from CNN]

I agree with her in this much: Until the White House steps up and says what it wants from the House bill and what it wants from the Senate Bill AND WHY and clearly elucidates its reasoning and priorities, they are doing us all a disservice.

I have heard they are negotiating behind the scenes, in the vernacular. Man up and say what it is you want to do.

Bill Clinton was right when he said better to be strong and wrong than weak and right. Last night was a start trowards strong, but until they say what they are willing to go to the mat for, they are not being strong enough!

A lot of us out here in the fields (I’m with Doctors for America) are waiting for some forceful language and commitment from this group. If they learned nothing this year it should be this: The anti-HillaryCare approach of not getting involved AT ALL has been a failure. Get in the trenches and fight!
Read the Article at HuffingtonPost

Testimony to GOP Doctors Caucus

I am giving testimony on Health Care Reform to the GOP Doctors Caucus on Thursday morning, Jan. 21, 2010.

UPDATE: My notes on the back and forth are posted here.

I am representing myself for sure, and, if I do well, will claim to be representing Doctors for America, as well (just kidding).

Here is my opening statement:

Thank you for this opportunity to speak to you today.

A study published recently in the New England Journal of Medicine[i] indicated that 78% of physicians “agreed that physicians have a professional obligation to address societal health policy issues. Majorities also agreed that every physician is professionally obligated to care for the uninsured or underinsured (73%), and most were willing to accept limits on reimbursement for expensive drugs and procedures for the sake of expanding access to basic health care (67%).”

I was greatly encouraged by this study. But also, sometimes being a glass-half-empty kind of guy, I also was disappointed that 22% of physicians do NOT think they have a duty beyond their individual practice or owe a duty only to the patients in patients in front of them.

In 2004, the American College of Physicians and the American Board of Internal Medicine Foundation published the Charter on Medical Professionalism,[ii] which included language that very pointedly noted that physicians have a duty to social justice in health care:

Principle of social justice. The medical profession must promote justice in the health care system, including the fair distribution of health care resources. Physicians should work actively to eliminate discrimination in health care, whether based on race, gender, socioeconomic status, ethnicity, religion, or any other social category.

It also states that we have a duty to improve access to care and to a just distribution of finite resources. The ACP reports that more than 50 professional organizations in America and around the world have signed on to this Charter.

I am pleased to say that the leadership of most of our medical professional organizations are now not only talking the talk, but walking the walk, and in an unprecedented manner, the 10 largest physician organizations are supporting health care reform that coincides with their stated goals of universal access to health care in America.

But it is not only organized medicine in favor or reform, as most physicians support reform as well. Another survey from the New England Journal showed overwhelming support (63%) for either reform with a public option or straight up single payer health care.[iii]

It is estimated that 45,000 people die in America every single year due to lack of access to health care.[iv] Whether this is twice as high or half as high as the “true” number is almost immaterial, as it is unacceptable in any case. My experiences, and the experiences of my colleagues, convince me that this number is true, and perhaps even a gross underestimate. Every physician I know has stories of patients who ignored some illness or deferred seeking treatment due to lack of health insurance. I had a patient who was literally coughing up blood for months and had a severe cough for many more months before that before he finally came into the hospital with respiratory failure and advanced cancer.

And, just as in war there are multiples of wounded for every casualty, so too, in our struggle with illness, we see much more suffering that does not get counted. The cab driver supporting a family of five who ignores his diabetes (he knows that is what it is), because he is trying to get health insurance and knows this diagnosis will doom his chances. So he ends up in my ICU with severe diabetic ketoacidosis. The construction worker with a seizure disorder who cannot see a neurologist to adjust his medications because of lack of money to pay for his last visit. He develops uncontrolled seizures for the second time in a few months and ends up in the ICU on life support.

Every physician you know can tell you stories like this. And there are more than 800,000 of us in the US, so the 45,000 number strikes me as not only low for preventable deaths, but only the tip of the iceberg in terms of the human cost in physical suffering and anguish. Remember, all these patients had families who loved them.

I know you hear from many disgruntled physicians who are concerned and even fearful of change. It is unfortunate that this fear prevents many from listening to the “better angels of our nature,” and, instead of striving to improve reform as proposed, simply attack and reject any and all proposals on the table.

It is also worth noting that the changes Congress makes now will certainly affect me and my peers with gray hair, but these bills are really about physicians just starting practice, still in medical school or still just thinking about medical school. And, if you have kids, you know this: they don’t think like us. In medicine, in particular, surveys have shown that they view medicine as a chance to help people and serve society, and don’t have that “calling” to medicine as older generations did. They don’t expect to make a small fortune, but they do expect fair compensation for all they have had to go through to get through medical school and residency, financially and in opportunity cost. So, remember when you hear grumbling about reform, consider the source, and, to channel Yogi Berra, remember the future.

In this final minute, I do want to run through some particulars of what we like in the current House and Senate Bills and would like to see in the final reform bill:

Provide health insurance coverage for 96 percent of Americans while reducing the federal deficit by $30 billion.
Provide substantial subsidies to help make coverage more affordable for our patients.
Implement insurance market reforms to prevent individuals from being denied coverage because of pre-existing conditions, and to limit premium differentials based on age, gender and other factors.
Establish a public health insurance option to ensure there is adequate competition and affordable health insurance options in all areas of the country.
Provide a 10% bonus payment for all primary care providers and a 10% bonus payment for general surgeons and PCPs practicing in underserved areas to ensure a strong physician workforce.
Increase Medicaid payment for primary care services to at least Medicare payment rates and expand Medicaid.
Expand the National Health Services Corp and Title VII health professions training programs.
Expand the medical home pilots and other health care delivery improvement models in addition to creating the Innovation Center to focus on improving the health care delivery system
Invest billions to strengthen our public health system and focus on prevention and wellness.
Establish a new program to encourage states to implement alternatives to traditional medical malpractice litigation – the first step .
Create the Innovation Center and expand the medical home pilots – the kinds of health care delivery models that will improve care coordination and efficiency.
Create an Independent Medicare Advisory Board, isolated from the political process to ensure patients get the care they need, to make recommendations on cost containment and improvements.
Focus on prevention and wellness including reimbursement for an annual Medicare wellness visits, advance care planning, and eliminating the cost burden on patients for preventive services

So, in conclusion, I would ask all of you to strive for health care reform where our bottom line is quality affordable health care for everyone. Because ultimately, our goal is to reduce the number of deaths and needless suffering due to lack of access to care as close to zero as possible, and to leave our children with a better system than we inherited.

Thank you.

Christopher M. Hughes, MD, FCCP, FACP, FCCM
State Director, Pennsylvania, Doctors for America
Board of Trustees, Pennsylvania Medical Society

[i] Antiel, Ryan M., Curlin, Farr A., James, Katherine M., Tilburt, Jon C.Physicians’ Beliefs and U.S. Health Care Reform — A National SurveyN Engl J Med 2009 361: e23

[ii] Medical Professionalism in the New Millennium: A Physician Charter
Project of the ABIM Foundation, ACP–ASIM Foundation, and European Federation of Internal Medicine Ann Intern Med February 5, 2002 136:243-246

[iii] Keyhani, Salomeh, Federman, AlexDoctors on Coverage — Physicians’ Views on a New Public Insurance Option and Medicare Expansion. N Engl J Med 2009 361: e24

[iv] Health Insurance and Mortality in US Adults.Wilper et al. Am J Public Health.2009; 99: 2289-2295

Et Tu, Mayo? Medicare Expansion Won’t Get Us There – Mayo Health Policy Center Blog

Medicare Expansion Won’t Get Us There « Health Policy Blog:

A very disappointing post from the Mayo Health Policy Center:

Proposal Would Not Increase Access to Health Care Services or Control Costs
The current Medicare payment system is financially unsustainable. Any plan to expand Medicare, which is the government’s largest public plan, beyond its current scope does not solve the nation’s health care crisis, but compounds it. We need to fix Medicare by moving it to a system that pays for value – quality health outcomes that are affordable over time – and ensure its success, before bringing more people into a broken system.
Expanding this system to persons 55 to 64 years old would ultimately hurt patients by accelerating the financial ruin of hospitals and doctors across the country. A majority of Medicare providers currently suffer great financial loss under the program. Mayo Clinic alone lost $840 million last year under Medicare. As a result of these types of losses, a growing number of providers have begun to limit the number of Medicare patients in their practices. Despite these provider losses, Medicare has not curbed overall spending, especially after adjusting for benefits covered and the cost shift from Medicare to private insurance. This is clearly an unsustainable model, and one that would be disastrous for our nation’s hospitals, doctors and eventually our patients if expanded to even more beneficiaries.”

I simply have to call BS on the figure of how much money Mayo loses to Medicare. We know Mayo is one of the high performing providers and so should be doing far better.

From Ezra Klein:

On March 17th, Glenn Hackbarth, the chairman of MedPAC, testified before the House Ways and Means Committee on this very issue. Hospitals, Hackbarth argued, are inefficient. Their costs are too high. And this was backed up in the data. “MedPAC analysis has identified a set of low-cost hospitals that consistently out-perform other hospitals on a series of quality measures, including mortality and readmissions,” Hackbarth explained. “Among this set of hospitals, we found that Medicare payments on average roughly equaled the hospitals’ costs.” In less “efficient” hospitals, Medicare’s payments were below costs.

…

Among the major differences between “efficient” and “non-efficient” hospitals was that the less-efficient hospitals were not under financial pressure: They made a lot more money from other sources. As such, they spent a lot more money on things like capital expansion. As example, compare the amount a young journalist spends to the amount a young investment banker spends. The banker requires more income to break even on that lifestyle. His “cost” is higher. But he doesn’t need that lifestyle. He doesn’t need that “cost.” And if that banker is being paid on taxpayer dollars, I don’t want him to have that lifestyle. I want him to have what he needs, rather than what he wants. Because I’m paying for it.
And so too with Medicare payments. Indeed, what MedPAC found was that hospitals under “financial pressure” — hospitals that made less money, in other words — managed to control their “cost” better. Medicare’s payments sufficed for them. And their quality outcomes weren’t any worse.

This is a remarkably “retro” viewpoint from Mayo, which has taken progressive stands on cost containment, reducing over utilization of procedures and testing, chronic care management and the like. To hear them call Medicare unsustainable is surprising. While I agree that Medicare payment has to be radically changed in some areas, the only thing unsustainable is our current course!

And, regardless of what Mayo “believes” about government run entities (which they disparage in their piece), government run or strictly regulated systems consistently outperform the US system in France, Germany in many other places. The ACP Policy Committee has recognized this for years and has advocated for a single payer system like France or a hybrid system like Germany’s for many years.

And one more thing, wouldn’t you rather get paid by those expensive 55-65 year olds who don’t have insurance instead of eating it (or eating part of it, and bankrupting families)? I realize the Mayo’s catchment area has few uninsured, but consider the rest of the country in making pronouncements!

And the Mayo release has been picked up by Fox News for goodness sake! In a fair and balanced piece on Medicare expansion, of course.

Gawande on what agricultural reform can teach us…

Testing, Testing by Atul Gawande

“America’s agricultural crisis gave rise to deep national frustration. The inefficiency of farms meant low crop yields, high prices, limited choice, and uneven quality. The agricultural system was fragmented and disorganized, and ignored evidence showing how things could be done better. Shallow plowing, no crop rotation, inadequate seedbeds, and other habits sustained by lore and tradition resulted in poor production and soil exhaustion. And lack of coördination led to local shortages of many crops and overproduction of others.

You might think that the invisible hand of market competition would have solved these problems, that the prospect of higher income from improved practices would have encouraged change. But laissez-faire had not worked. Farmers relied so much on human muscle because it was cheap and didn’t require the long-term investment that animal power and machinery did. The fact that land, too, was cheap encouraged extensive, almost careless cultivation. When the soil became exhausted, farmers simply moved; most tracts of farmland were occupied for five years or less. Those who didn’t move tended to be tenant farmers, who paid rent to their landlords in either cash or crops, which also discouraged long-term investment. And there was a deep-seated fear of risk and the uncertainties of change; many farmers dismissed new ideas as “book farming.”

Another inciteful piece showing how far agriculture came in a few short decades by experimenting and scientifically evaluating methods for improvement and the parallels for us in this centuries health reform debate. How does he come up with these?

An Interview With Thomas Russell for Health Affairs

Health Affairs Blog link to full interview.

John Iglehart, one of the Founders of Health Affairs posts an interview with surgeon and retiring Executive Director of the American College of Surgeons. There are quite a few pleasantly surprising moments in the interview, which I’ll bullet here, but you can go read on your own.

Q. I would assume that more than a few surgeons regard such activity as an intrusion into the independent practice of medicine. Is there a generational difference among surgeons in their willingness to cooperate or at least participate in these kinds of initiatives?
Russell: Absolutely. The younger surgeons have trained in an environment in which they to expect that the quality of care they deliver will be measured and evaluated, so they don’t really have any difficulty participating in these activities. It’s some of the older physicians who entered practice in a more autonomous era who struggle with these new forms of oversight.
First, let me say that the surgical community is not homogeneous, and they’re all over the map on reform. The College has a split membership. Some surgeons think that the status quo is just fine and that greater oversight and accountability are unnecessary. They view them as intrusions into the autonomy of a sovereign profession, while others are all in favor of reform.
There is at least one matter on which I think we mostly agree, and that is the fact that we have to do something to fix our broken payment system. So, the number-one change that I would like to see emerge from the health care reform debate is fundamental, long-term improvement in how physicians are paid, so that they really are being paid for providing cost-effective, high-quality services.
Iglehart: Would that mean, according to your vision, an abandonment of the fee-for-service payment model and going to an alternative model, or some kind of a hybrid?
Russell: I recently addressed a large group of surgeons and asked them whether they are paid a salary, and most of them raised their hands. Throughout the nation, more surgeons are becoming salaried professionals. Most academic surgeons as well as those in integrated delivery systems—such as the Mayo Clinic, Geisinger, Kaiser, and many others, including Veterans Affairs—are on salary. So are doctors who are employed by the VA. I think it’s safe to say that more than 50 percent of the nation’s physicians are paid a salary. And, some of the happiest doctors whom I’ve met are the salaried ones because they don’t have to deal with the hassles of malpractice insurance, including the high premiums they pay, or coding, or any of the other administrative burdens that confront physicians who are in private practice and reimbursed through the complicated fee-for-service system.
We also need to look in a very thoughtful, ethical way at rational – I’m not using the word rationing, I’m using the word “rational”–ways to improve end-of-life care.
In addition, the medical and surgical professions need to develop protocols for the best ways to approach diseases. We need policies about when scans, such as a CTs and MRIs, are indicated, and to make sure they are not unnecessarily repeated by another physician. And we must develop standardized ways of treating diseases so that every health care professional involved in coordinating a patient’s care is addressing the condition in the most cost-effective way that follows the scientific evidence.
For instance, I think that the Number One way to help patients avoid frivolous trips to the ER is to educate them about where they should turn to receive appropriate care for nonemergency conditions and to make certain they have access to primary care physicians. [We do a poor job of getting people into PCPs– cmhmd]
Here’s how this maldistribution of surgeons has arisen. About 80-90% of medical school graduates who pursue surgery as a specialty begin their residency training in general surgery. After five or six years of residency, and at ages 32 to 34, many pursue additional training in a fellowship that will allow then to focus on just one type of disease or organ that general surgeons treat and operate on. That is to say, they become super-specialized in breast surgery, minimally invasive surgery, bariatric surgery, cardiac surgery, or cancer surgery. So they’re taking themselves out of the pool of professionals who can perform the broad range of general surgery procedures. And, most of this highly specialized surgery is performed in large cities, so these surgeons are not typically accessible to rural patients.
Organized medicine and many Republican legislators have long argued in favor of capping awards for noneconomic damages, but I don’t believe the nation will ever reach a consensus on that proposal, although a few states have implemented the limits. I think instead more efforts should be made to educate, in this case surgeons, about how to avoid or better manage risk by staying within their scope of practice. Communication with the patient and his or her family throughout the surgical experience is also key to helping these individuals understand why there was a negative outcome. When a mistake is made, apologize, if you practice in a state that has passed legislation providing legal protections for saying, “I’m sorry.”
Very important, too, is for the profession to develop evidence-based best practice protocols and for physicians to follow them closely. In my era, we objected to this form of standardization and called it “cookbook medicine.” But, as calls for accountability have increased, lawmakers should consider setting policies that protect physicians who adhere to professionally developed protocols. In these cases, if a patient sues because of a bad outcome, the physician can respond with a legitimate defense: ”Look, I followed the protocol that we all agreed was best practice. I’m sorry for the bad outcome, but a bad outcome does not equal malpractice. [Except for this and people like Bernadine Healy, who should know better -cmhmd]

Thanks to Mr. Iglehart and Dr. Russell for the informative interview.

A Senate Minority Hijacks Health Care – Pittsburgh Post-Gazette

According to the U.S. Constitution, each state is represented by two senators, regardless of population. This arrangement is the legacy of a deal struck in 1787 at the nation’s founding, partly to keep the slave-owning states from exiting the then-fledgling nation. As a result, California, with more than 36 million people, has the same number of senators as Wyoming, with a half-million people.

That disproportional allocation has only gotten worse over time. When the Senate was created, the most populous state had 12 times more people than the least populous state; now it has 70 times more people. In the 1960s, the Supreme Court established the groundbreaking principle of majority rule based on ‘one person, one vote,’ meaning that all legislative jurisdictions must be equal in population. This applied to the U.S. House of Representatives, yet the U.S. Senate completely violates this fundamental principle.

As a result, the 40 Republican senators represent a mere third of the nation, meaning Republican voters have more representation than everyone else. That overrepresentation is bad enough, but it gets even worse. For the United States has added an arcane layer of parliamentary procedure known as the ‘filibuster’ that takes us out of the frying pan and into the fryer.

The Senate’s use of the ‘filibuster’ means you need not a majority of 51 votes, but 60 votes to stop unlimited debate on a bill and move to a vote. So a mere 41 senators can kill any legislation. The 40 Republican senators representing only a third of the nation need to peel away only a single conservative Democratic or independent representing a low-population state like Montana, Nebraska or Connecticut to torpedo what the senators representing two-thirds of the nation want.

Given such a vastly mal-apportioned and unrepresentative Senate wielding its anti-majoritarian filibuster, it is hardly surprising that minority rule in the Senate consistently undermines majoritarian policy. Besides health care, senators representing a small segment of the nation have thwarted renewable-energy policy, sensible automobile mileage standards, cuts in subsidies for oil companies, tougher campaign-finance reform, congressional oversight of national security and war, and more.

Minority rule in the Senate has been with the nation for a long time; in fact, it is widely blamed for perpetuating slavery for decades (between 1800 and 1860, eight antislavery measures passed the House, only to be killed in the Senate). For all these reasons, two of America’s most revered founders, James Madison and Alexander Hamilton, opposed the creation of the Senate, with Hamilton warning in Federalist Paper no. 22 that representation in the Senate “contradicts the fundamental maxim of republican government, which requires that the sense of the majority should prevail.

This was written by Steven Hill, “director of the Political Reform Program for the New America Foundation and author of “Europe’s Promise: Why the European Way is the Best Hope in an Insecure Age,” which will be published in January.”

Welcome WMNY Listeners

If you found your way here after listening to Will Clower on WMNY, thanks for checking this out.
My interview ( MP3 link ) with Will Clower is here.

This is my ICU week, so I don’t get a lot of time to post usually, so feel free to go over to the right side of the blog and explore the topics.

If you want the information I gave about organized medicine’s support for reform, click on “organized medicine,” if you want more on surveys of physicians, click on “physicians surveys,” and so on.

I highly recommend “Anecdote-off” for all of your friends and relatives who tell you how swell we have it here and how horrible it is in other countries!

Cheers,