Category: Doctors For America

Three Books: A Summary of a Doctors for America Session held at the National Leadership Conference

Three Books: A Summary of a Doctors for America Session held at the National Leadership Conference on November 9, 2019

I recently did a workshop session at the Doctors for America National Leadership Conference in Baltimore. The session was titled Prospect Theory, Medical Industrial Complex and Social Justice in Health Care: 3 Important Books. I have recently had the opportunity to be able to devote some time to thinking about healthcare reform in general, and the distressing lack of progress toward universal healthcare in America spanning my entire career and beyond.
I came across the late Uwe Reinhardt’s last book, Priced Out, which was a summary of his life’s work: the ludicrousness of “America’s Healthcare Wonderland,” as he calls it, and the ineffectiveness of any moral arguments to persuade the American political class to move towards universal healthcare. I had the opportunity to exchange a few emails with Prof. Reinhardt about 5 years ago. At that time, he seemed quite pessimistic about the opportunity of America moving forward. In his book, however, his life partner, Prof. Cheng, in her epilogue, makes it clear that he remained optimistic about America’s chances for universal healthcare. He thought, she said, that we would probably stumble towards it and not actually make a cultural or societal decision, but that we would eventually get there in fits and starts.
Prof. Reinhardt’s chief concern is that we never have the moral discussion required to propel us towards a universal healthcare ethic. Without the ethic, he argues, there can be no successful transition to a universal system. He has said that during healthcare debates, we have an incantation, “’we all want the same thing; we merely disagree on how best to get there.’ That is rubbish.”
He is right. We do not agree. We agree on the left that universal healthcare is an imperative, and those on the right agree that healthcare is a market commodity and should be treated like any other good or service. Of course, progress is made by convincing enough people in the middle that one’s policy proposals or political arguments are worthy of implementation. One need not win over everyone. Medicare, Social Security, civil rights, and so much of America’s progress in the past century was not unanimous. Given the opportunity, many conservatives would still reverse the New Deal, the Great Society, and of course, the Affordable Care Act.
Progressives have failed to win the moral and political arguments in favor of universal healthcare. As Wendell Potter has pointed out, the methodology of the entrenched and well-funded interests opposing progress are simple: fear, uncertainty, and doubt. Simple and devastatingly effective.
The Undoing Project: A Friendship That Changed Our Minds by Michael Lewis holds many of the answers as to why it is so effective. The book tells the story of the two psychologists who developed Prospect Theory. Prospect Theory was the basis of what we now call behavioral economics. It is the exploration of why we make the decisions we make. It is about why we make the irrational decisions that we make.
Briefly, our brains are fooled in a variety of manners. We have fast, intuitive thinking. This thinking is swayed by a variety of biases. Gains and losses are perceived from specific reference points. The fear of loss, risk aversion, is far more powerful than the lure of gain. Things that come to our mind easily, either through recency or frequency (availability) greatly impact our decision-making. The fast, intuitive mind is influenced heavily by these biases. And unfortunately, the fast, intuitive mind is very confident.
Our more logical, slow thinking brain is analytic. It is also unsure of itself because of its self-critical analysis. That is why a plausible and emotionally resonant feeling, as Mark Twain might say, is halfway around the world before a detailed policy proposal gets its pants on. Or, as Stephen Colbert might say, truthiness works.
There are many lessons to be gained from Prospect Theory, but the key insight from Daniel Kahneman is that “We don’t choose between things, we choose between descriptions of things.”
After reading The Undoing Project I was somewhat optimistic and excited about the possibility of using some of these techniques to combat the campaign of fear and uncertainty and doubt that is awaiting us as we march into an election year with healthcare reform as a major point of contention.
Unfortunately, I then read An American Sickness: How Healthcare Became Big Business and How You Can Take It Back, by Elisabeth Rosenthal. Dr. Rosenthal provides a discouragingly comprehensive evaluation of the medical industrial complex and how it has come to dominate every aspect of the provision of healthcare. The chapters catalog the breadth: health insurance plans, hospitals, physicians, the pharmaceutical industry, the medical device industry, testing, laboratory, and all other manner of ancillary services, contractors, billers, coders, collections agency, researchers, not-for-profit organizations, and of course the rise of the massive healthcare conglomerates, euphemistically known as “integrated delivery systems.”
As Don Berwick recently wrote, there is $1 trillion of waste in the healthcare system. And one man’s waste is another man’s revenue. Dr. Rosenthal details all that waste and in doing so, lays down the markers on the battlefield. One side is well-funded and is fighting for its very existence. Or at least fighting for the very upscale version of its current existence, and desperate to avoid a comparatively spartan OECD-like existence.
As Upton Sinclair once said, “It is difficult to get a man to understand something if his livelihood depends upon his not understanding it.” As Wendell Potter more recently said, “Health insurers have been successful at two things, making money and getting the American people to believe they’re essential.”
I finished my remarks, and opened up the floor for discussion. We spent a fair amount of time reviewing the concepts above. I specifically asked for help in developing framing and arguments that might help us in our advocacy work. Several themes emerged, and I have highlighted them here.
1.    Talk about the moral case for health care. We discussed the deserving-undeserving framing, the puritanical streak in American politics, and the fear of others “getting over on us.” I told the story of having gone to a progressive conference after the 2018 election. I had the opportunity to hear from four progressive candidates who lost their races in conservative districts. All four of these candidates said they were surprised that so many of the conservative voters were afraid, almost exactly as I had phrased it to you, of having others ‘get over on them.” That these others would get free healthcare when they were going to have to pay for it, for “those people” to be freeloaders that they would have to subsidize, etc.
2.    Talk about work arounds and hassles. I pointed out that the second half of Dr. Rosenthal’s book was a guide for those who are trying to deal with the Wonderland of American healthcare. While quite useful in the here and now, it amounts to a series of workarounds of the system as it exists. Useful, to be sure, but it is not a prescription for ending the need for workarounds. As Teresa Brown recently put it in a New York Times piece, American healthcare system is one giant workaround.
3.    Talk about student debt, medical school tuition and physician income. We had a discussion about the rabbit holes, as I call them, of excruciatingly detailed policy points surrounding any healthcare reform. As Uwe notes, whenever this happens, we then engage in protracted and useless arguments over the value of quarter hour of an anesthesiologist time, or other some such parochial detail of concern. It was pointed out that these concerns arise out of the value of medical school education and residency training, the heady medical school costs and student debt, as well as physician income. The group argued to take these issues head-on. Have a discussion about subsidizing medical school and have a discussion about the relative value of the various specialties. Have a discussion about work hours and on-call time, medical liability, and the many other practical issues moving towards universal healthcare system.
4.    Talk about price control and administrative simplification. There is no love lost between physicians and the rest of the healthcare industry. There is also no love lost between consumers of healthcare services and the healthcare industry. The group felt that it was well worthwhile to point to alternative methods of controlling costs in the healthcare system. We discussed Prof. Reinhardt’s maxim that “It’s the prices, stupid!” We discussed the unconscionable waste of time and money spent dealing with health plans, from in-hospital utilization management to outpatient prior authorization for everything from procedures to medicines to wheelchairs. These issues potentially put us on the same side with the public and politicians.
While driving home from the conference, I began listening to Daniel Ariely’s Predictably Irrational. Prof. Ariely spends a significant amount of time discussing the difference between market norms and social norms. The way we behave around wages, prices, rents, and other payments are our market norms. The way we behave around doing each other favors, helping one another and other activities that do not involve financial exchanges, are our social norms. He provides many examples showing that things one might do unhesitatingly under the structure of social norms, are out of bounds under market norms. For example, lawyers asked to do work for a nonprofit company at a very low rate reject the proposal. Lawyers asked to do pro bono work readily agree. Injecting finance into a situation that normally operates on social norms profoundly alters the perception.
It occurs to me that this is at the center of Prof. Reinhardt’s assertion in his book. We will endlessly and vociferously debate on the number of and reimbursement for, angels dancing on the head of a pin, and always avoid the underlying discussion of whether we, as Americans should be the keepers of our less fortunate brothers and sisters for their healthcare needs.

Testimony for PA Senate Democratic Appropriations Committee Public Hearing on Medicaid Expansion, March 8, 2013

Good morning. Thank you for conducting this session and for inviting me to speak. I am Dr. Chris Hughes, state director for Doctors for America, a nation-wide group of physicians advocating for high quality, affordable health care for all. I have been an intensive care physician for my entire career, now approaching 25 years, and within the past year I have also begun practicing hospice and palliative medicine. I am a former Trustee of the Pennsylvania Medical Society and Chair of the Patient Safety Committee. I have completed graduate studies in health policy at Thomas Jefferson University, and I am now teaching there, in the Graduate School of Population Health.

I tell you this to let you know that I can get down in the weeds with you about the nuts and bolts of implementation of the Affordable Care Act, and I know a fair amount about health care financing, access, cost shifting, and all the rest. But you have fine panelists assembled here today who have been doing this for you, and I know you all know your way around these topics as well. That’s why you’re here.

I am here as a physician and a representative of my profession. Every doctor you know, and every nurse and pharmacist and social worker and everyone in the front lines of health care, for that matter, can tell you stories of how our health care system has failed someone. Our system fails people regularly, and often spectacularly, and often cruelly, day in, day out.

I’ve had patients who work full time in jobs that fall far short of the American dream. They get by, but they can’t afford health insurance.

I’ll give you a few of my patients’ stories here, not just to point out the obvious- that we are mistreating our fellow human beings – but that we are misspending countless dollars on the wrong end of the system.

There’s the cabbie who recognizes his diabetes and determines to work harder and longer so he can buy insurance before he is stricken with the label even worse than diabetes: preexisting condition! He doesn’t make it and ends up in the ICU with diabetic ketoacidosis.

There’s the construction worker who has a controllable seizure disorder that goes uncontrolled because he can’t afford to go to the doctor. He ends up in the ICU, on a ventilator – life support – multiple times.

There’s the woman who stays home to care for her dying mother and loses her insurance along with her job. When her mother is gone and she finally gets to a doctor for herself, her own cancer is far advanced. She goes on hospice herself.

The laid-off engineer whose cough turns bloody for months and months before he “accesses” the health care system – through the Emergency room and my ICU with already far advanced cancer.

Shona’s attendant, of course. [Shona Eakin, Executive Director of Voices for Independence, in her earlier testimony.]

These are people who are doing the right thing – working, caring for family members – and still have to go begging for health care. How many hours does an American have to work to “deserve” health care? 40? 50? 60? We, as a society, are telling these people that their work, their lives, are not valuable enough to deserve access to health care until they meet some standard of employment in a job that has health insurance.

While doing some research on Medicare cost savings, I ran across a paper from US Sen. Tom Coburn with this quote: "Medicaid is a particular burden on states, consuming on average 22 percent of state budgets." I don’t quibble with the number, I quibble with the mindset that leads one to think that the suffering of millions is a non-factor in the decision making. And the fate of patients is not mentioned in his paper.

Not long ago, expanding access to health care was a nonpartisan goal. As recently as 2007, a bipartisan group of U.S. senators, including Republicans Jim DeMint and Trent Lott, ( let me repeat that, “Jim DeMint and Trent Lott” ) wrote a letter to then-President George W. Bush pointing out that our health care system was in urgent need of repair. "Further delay is unacceptable as costs continue to skyrocket, our population ages and chronic illness increases. In addition, our businesses are at a severe disadvantage when their competitors in the global market get health care for ‘free.’ "

Their No. 1 priority? It was to "Ensure that all Americans would have affordable, quality, private health coverage, while protecting current government programs. We believe the health care system cannot be fixed without providing solutions for everyone. Otherwise, the costs of those without insurance will continue to be shifted to those who do have coverage."

Medicaid expansion and the Affordable Care Act will get us closer to this than at any time in our history.

You will hear some physicians speak out against all of this. But what you generally will not hear is their leadership and organizations speaking out against it, except perhaps in the deep south. There is a reason for this. As leaders of our profession, we have to come to terms with the idea that we are not just in it for ourselves. We are in it for our profession as well, and that means we have to put our patients’ interests above our own, and that means we have to do our best to ensure that everyone has access to high quality, affordable health care. Don’t just take my word for it. The American Board of Internal Medicine Foundation and other organizations put together a Charter on Medical Professionalism about ten years ago, specifically making this, fair distribution of health care resources, a part of our professional responsibility. If you go to their website, you will find that virtually every physician organization you can think of has endorsed it. That means the anesthesiologists and orthopedic surgeons as well as the pediatricians and the family practitioners.

For Medicaid expansion specifically, we should note here that the major national physician organizations, including the AMA, and the organizations representing internists, family practice, pediatricians, psychiatry and more, all endorse Medicaid expansion. On the state level, all of these organizations state chapters endorse it as well, with the exception of the Pennsylvania Medical Society, which I am chagrined to say, has endorsed general terms of expansion only.

But this concept is really not controversial among physicians and health care providers. We see everything from the catastrophes to the small indignities. They are tragic, unnecessary, and we are on the road to ending them.

Some in the provider community have expressed concerns about Medicaid in particular as the way we are providing access, so I would like to take a moment to address the concerns we hear most often.

First, that Medicaid is “bad” insurance. What is bad about Medicaid is largely fixed in the ACA. Namely, it is very poorly reimbursed for providers. You’ve already heard from others why hospitals want it, why advocates want it, but for providers in primary care, the frontlines of health care, they get a major boost in reimbursement under the new law. Pennsylvania has historically had awful reimbursement in the Medicaid program, among the worst in the nation. Now, reimbursement will go to par with Medicare reimbursement, a huge incentive for providers to take on Medicaid patients whom they may have been reluctant to see previously. There are other new innovations such as Patient Centered Medical Homes, the new Medicaid Health Homes (which, by the way, we have also not begun implementing in PA – maybe another panel?), and other innovations, coming down the pike, that should really give people who previously had no chance at excellent care, a chance to avoid complications, avoid the ER and avoid the hospital. To live in good health.

I’ve also heard the strange claim that having Medicaid is worse than having no insurance. I suppose that in a vacuum where there is no good data, and where one sees, like I do, patients with no insurance or Medicaid, who don’t know how or aren’t able to access a doctor, you could look at patients who get very sick and mistake that association and attribute that to Medicaid, but we do have data now. In Oregon, due to a fairly bizarre set of circumstances a few years ago, Medicaid eligibility was determined by lottery, creating a natural experiment of haves and have-nots. In the first year, those who were enrolled were 70 percent more likely to have a usual source of care, were 55 percent more likely to see the same doctor over time, received 30 percent more hospital care and received 35 percent more outpatient care, and much more. Incidentally, I heard a cable talking head complain about the Oregon data because it didn’t examine outcomes, such as deaths and such. A fair point if we had more than a year’s worth of data! I, and most other health professionals, would argue that the results they have seen already are impressive and worthwhile in and of themselves.

People often ask me why I am so passionate about this, and I always tell them, “I blame the nuns.” Growing up Catholic, there was nothing so drilled into me as Matthew 25. We used to sing a hymn based on it, “Whatsoever you do to the least of my brothers,” on a regular basis at Mass. And we went to Mass before school every day!

It turns out this is a pretty universal sentiment. I checked. Go to the websites of every mainstream religious denomination – Anglican, Methodist, Mormon, you name it – and it will be in there somewhere: The Social Gospel and Social Justice. Dignity of the individual. Our duties to the less fortunate. It is part of our national Judeo-Christian heritage, and a component of every major religion and philosophy in the world, with one notable exception – Ayn Rand’s. And I mention Ayn Rand and her most famous book, Atlas Shrugged, because it is perennially listed as the second most influential book in America, after the Bible. A damning fact for us.

In spite of that, I am glad that social justice and a commitment to the fair distribution of our health care resources is integral to the sense of duty of my profession, the nursing profession and all health professions.

I often say that I encourage debate about how we get to universal health care, but I refuse to accept that America, alone among all modern nations, and Pennsylvania in particular, will reject the idea that we need to get there.

A final thought from health care economist Uwe Reinhardt, regarding all of the reasons given about why we cannot achieve universal health care; he says, “Go tell God why you cannot do this. He will laugh at you,”

Right now, Medicaid expansion, the Health Insurance Exchanges and many other components of the Affordable Care Act are our best hope. Let’s not squander it.

Thank You.

Remarks on Medicaid Expansion

I had the privilege of testifying in favor of Medicaid expansion for Pennsylvania at a hearing of the PA House Democratic Policy Committee, chaired by Rep. Dan Frankel of Allegheny County. (Follow the link for the agenda and other speakers.)

Good morning. I am Dr. Chris Hughes, state director for Doctors for America, a nation-wide group of physicians advocating for high quality, affordable health care. I have been an intensive care physician for my entire career, now approaching 25 years, and within the past year I have also begun practicing hospice and palliative medicine. I am a former Trustee of the Pennsylvania Medical Society and Chair of the Patient Safety Committee. I have completed graduate studies in health policy at Thomas Jefferson University, and I am now teaching there as well in the Graduate School of Population Health.

I tell you this to let you know that I can get down in the weeds with you about the nuts and bolts of implementation of the Affordable Care Act, and I know a fair amount about health care financing, access, cost shifting, and all the rest. But you have a fine panel assembled here today who can do that for you, and I know you all know your way around these topics as well.

I am here as a physician and a representative of my profession. Every doctor you know, and every nurse and pharmacist and social worker and everyone in the front lines of health care, for that matter, can tell you stories of how our health care system has failed someone. Our system fails people regularly, and often spectacularly, and often cruelly, day in, day out.

I’ve had patients who work full time in jobs that fall far short of the American dream. They get by, but they can’t afford health insurance.

I’ll give you a few of my patients’ stories here, not just to point out the obvious- that we are mistreating our fellow human beings – but that we are misspending countless dollars on the wrong end of the system.

There’s the cabbie who recognizes his diabetes and determines to work harder and longer so he can buy insurance before he is stricken with the label even worse than diabetes: preexisting condition! He doesn’t make it and ends up in the ICU with diabetic ketoacidosis.

There’s the construction worker who has a controllable seizure disorder that goes uncontrolled because he can’t afford to go to the doctor. He ends up in the ICU multiple times.

There’s the woman who stays home to care for her dying mother and loses her insurance along with her job. When she finally gets to a doctor for herself, her own cancer is far advanced.

The laid-off engineer whose cough turns bloody for months and months before he “accesses” the health care system – through the ED and my ICU with already far advanced cancer.

These are people who are doing the right thing – working, caring for family members – and still have to go begging for health care. How many hours does an American have to work to “deserve” health care? 40? 50? 60? I’ve seen all of these.

Not long ago, expanding access to health care was a nonpartisan goal. As recently as 2007, a bipartisan group of U.S. senators, including Republicans Jim DeMint and Trent Lott, ( let me repeat that, “Jim DeMint and Trent Lott” ) wrote a letter to then-President George W. Bush pointing out that our health care system was in urgent need of repair. "Further delay is unacceptable as costs continue to skyrocket, our population ages and chronic illness increases. In addition, our businesses are at a severe disadvantage when their competitors in the global market get health care for ‘free.’ "

Their No. 1 priority? It was to "Ensure that all Americans would have affordable, quality, private health coverage, while protecting current government programs. We believe the health care system cannot be fixed without providing solutions for everyone. Otherwise, the costs of those without insurance will continue to be shifted to those who do have coverage."

Medicaid expansion and the Affordable Care Act will get us closer to this than at any time in our history.

You will hear some physicians speak out against all of this. But what you generally will not hear is their leadership and organizations speaking out against it, except perhaps in the deep south. There is a reason for this. As leaders of our profession, we have to come to terms that we are not just in it for ourselves. We are in it for our profession as well, and that means we have to put our patients’ interests above our own, and that means we have to do our best to ensure that everyone has access to high quality, affordable health care. Don’t just take my word for it. The American Board of Internal Medicine Foundation and other organizations put together a Charter on Medical Professionalism about ten years ago, specifically making this part of our professional responsibility. If you go to their website, you will find that virtually every physician organization you can think of has endorsed it. That means the anesthesiologists and orthopedic surgeons as well as the pediatricians and the family practitioners.

For Medicaid expansion specifically, we should note here that the major national physician organizations, including the AMA, and the organizations representing internists, family practice, pediatricians, psychiatry and more, all endorse Medicaid expansion. On the state level, all of these organizations state chapters endorse it as well, with the exception of the Pennsylvania Medical Society, who have endorsed general terms of expansion only.

But this concept is really not controversial among physicians and health care providers. We see everything from the catastrophes to the small indignities. They are tragic, unnecessary, and we are on the road to ending them.

Some in the provider community have expressed concerns about Medicaid in particular as the way we are providing access, so I would like to take a moment to address the concerns we hear most often.

First, that Medicaid is “bad” insurance. What is bad about Medicaid is largely fixed in the ACA. Namely, it is very poorly reimbursed for providers. You’ve already heard [I assume] from HCWP why hospitals want it, but for providers in primary care, the frontlines of health care, they get a massive boost in reimbursement under the new law. Pennsylvania has historically had awful reimbursement in the Medicaid program, among the worst in the nation. Now, reimbursement will go to par with Medicare reimbursement, a huge incentive for providers to take on Medicaid patients whom they may have been reluctant to see previously. There are other new innovations such as Patient Centered Medical Homes and others, coming down the pike, that should really give people who previously had no chance at excellent care, a chance to avoid complications, avoid the ER and avoid the hospital.

I’ve also heard the strange claim that having Medicaid is worse than having no insurance. I suppose that in a vacuum where there is no good data, and where one sees, like I do, patients with no insurance or Medicaid, who don’t know how or aren’t able to access a doctor – you’d be amazed at how often this happens – you could look at patients who get very sick and attribute that to Medicaid, but we do have data now. In Oregon, due to a fairly bizarre set of circumstances a few years ago, Medicaid eligibility was determined by lottery, creating a natural experiment of haves and have-nots. In the first year, those who were enrolled were 70 percent more likely to have a usual source of care, were 55 percent more likely to see the same doctor over time, received 30 percent more hospital care and received 35 percent more outpatient care, and much more.

People often ask me why I am so passionate about this, and I always tell them, “I blame the nuns.” Growing up Catholic, there was nothing so drilled into me as Matthew 25. We used to sing a hymn based on it, “Whatsoever you do to the least of my brothers,” on a regular basis at Mass. And we went to Mass before school every day!

It turns out this is a pretty universal sentiment. I checked. Go to the websites of every mainstream Christian denomination in America and it will be in there somewhere: The Social Gospel and Social Justice. Dignity of the individual. Our duties to the less fortunate. It is a component of every major religion and philosophy in the world, with one notable exception – Ayn Rand’s. And I mention Ayn Rand and her most famous book, Atlas Shrugged, because it is perennially listed as the second most influential book in America after the Bible. A damning fact for us.

In spite of that, I am glad that social justice and a commitment to the fair distribution of our health care resources is integral to the sense of duty of my profession, the nursing profession and all health professions.

I encourage debate about how we get to universal health care, but I refuse to accept that America, alone among all modern nations, and Pennsylvania in particular, will reject the idea that we need to get there. And right now, Medicaid expansion, the Health Insurance Exchanges and many other components of the Affordable Care Act are our best hope. Let’s not squander it.

Thank You.

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

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.

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:

  1. Provide health insurance coverage for 96 percent of Americans while reducing the federal deficit by $30 billion.
  2. Provide substantial subsidies to help make coverage more affordable for our patients.
  3. 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.
  4. Establish a public health insurance option to ensure there is adequate competition and affordable health insurance options in all areas of the country.
  5. 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.
  6. Increase Medicaid payment for primary care services to at least Medicare payment rates and expand Medicaid.
  7. Expand the National Health Services Corp and Title VII health professions training programs.
  8. 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
  9. Invest billions to strengthen our public health system and focus on prevention and wellness.
  10. Establish a new program to encourage states to implement alternatives to traditional medical malpractice litigation – the first step .
  11. Create the Innovation Center and expand the medical home pilots – the kinds of health care delivery models that will improve care coordination and efficiency.
  12. 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.
  13. 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

Physician’s Perspective on Health Reform Slides

I updated my slides on physicians’ opinions on health reform for a talk tonight for the Pittsburgh Chapter of Drinking Liberally.

The new slides are here. ( I hope I fixed the link!)

I had to strip out the slides of me (and Doctors for America) at the White House, and on our way TO the White House, already in our white coats in order to get under the 5 MB Google docs limit.

Cheers,

Interviews with KDKA and PCNC for Doctors for America

I had a couple of interviews with conservative talk hosts here in Pittsburgh Monday night on the Pittsburgh Cable News Channel with Kevin Miller and Tuesday morning on KDKA radio with Mike Pintek as representative for Doctors for America on health care reform. I thought I’d share, and perhaps get a little constructive input.

I have to say that I thought both hosts were fair to me, though the television host seemed to try to bait me into peripheral discussions [He is a moon landing skeptic, for instance!] while the radio host was more focused on getting detailed information out of me, which I appreciated.

The issues that seem to be the most concerning to conservatives, or at least get them the most stirred up, are those concerning the cost of the program and the impact on
the budget and, of course, taxes, the ceding of control of health care decisions, or rationing decisions, in their minds, to the dreaded government bureaucrats, and euthanasia. Believe it or not.

My response to the cost argument is the one you all know, that our current non-system costs way too much, far more than any other place on the planet, including the countries like
France and Germany who cover everyone, don’t ration in any significant way, and have no longer waiting times than our own.

Skepticism abounds about drawing any lessons on health care reform from other nations, as the utter failure, in the conservative mind, of Canada and Britain, necessarily precludes us from learning anything at all from them. I did manage to point out that while both Canada and England have had problems with their systems due primarily to inadequate spending, they did manage to insure everyone. I also pointed out that in Britain, since the liberal Labor Party took over from the Conservative Thatcher/Major governments, things have improved significantly on the waiting times front.

They expressed concerns about the cost of the Public Option being thrown about of a trillion dollars or more. In the context of health care spending currently of 2.4 trillion, one trillion over ten years, or 0.1 trillion per year does not seem like much. On the other hand, we are in danger of putting a layer of something that should be good over top a heap of a messed up non-system. I specifically agreed that Obama’s message that, if we were starting from scratch, single payer makes the most sense was true. “Government Bureaucrats!” Mr. Pintek played a clip of Barney Frank saying that if the public option were done well and performed well, it could very well lead to single payer. Mr. Pintek suggested that they were trying to be sneaky with this, but I suggested that if they were, this was not a very sneaky way to do it. But even if this was how it would turn out, where’s the harm? If the public option proves to be so wildly popular that private insurers get crowded out and the public in the end decides that perhaps this is the best way to provide health care, isn’t that a great thing? “Government Bureaucrats!”

So, rationing is next, and is always the real subtext of all of this. Both hosts were aware that insurance companies sometimes deny care, but neither seemed to consider that we
ration by income. I told both the story of a patient of mine who was a middle aged man, without insurance for quite a while. He’d had a cough for close to a year followed by an intermittently bloody cough for a couple months and then developed such difficulty breathing that he finally came to the emergency room and then into my ICU with respiratory failure. He had, by this time, metastatic lung cancer. I pointed out that while you can go to the emergency room for emergency care, the familiar canard of “they can just go to the emergency room,” rings hollow in nearly every basic health care situation. I paraphrased from a wonderful letter from the New York Times, and pointed out that ER’s don’t do cancer care nor manage asthma nor prenatal car nor diabetes and don’t do any of the things we think of when we talk about every day health care needs.

But what about government bureaucrats rationing health care? They both seemed disbelieving that this did not seem to concern me terribly. I argued that we could be well served by a commission made up of physicians who used comparative effectiveness research and analyzed the benefits and costs of treatment to help guide us , rather than medical directors at private health insurers making these determinations.

I regret that we did not get to end of life issues on the PCNC show, but we did on KDKA. I was asked what I thought of the House Bill and what it would mean to us with respect to Advance Directives and forcing the elderly to forego treatment. I think that it will finally make decent payment available for physicians to do Advance Care Planning, which is the term for having discussions on what a patient’s wishes are when they are at the end of their lives. This is a very good thing, something that physicians involved in EOL care have been advocating for for years because it is the right thing to do. I have EOL discussions with patients and families literally every day I spend in the ICU. Letting your family know what you want at the end of life is a great gift to them. I tell this to patients and families all the time and it is so true: these are agonizing decisions to make when you have not had these important discussions. If people think about this even for a minute, they will know it is true. I also pointed out that advance directives can go either way, and if you want every last treatment until they are nailing your coffin shut, you can specify that in your AD as well.

We took a few emails/calls on KDKA. The first was not so much supportive, as antagonistic to the host and the conservative listeners. Thanks, but no thanks for that email. The
second was from a nurse who wanted an “American” solution and seemed to resent my referring to France and germany, but in the end, seemed to agree that we needed reform and I think was OK with a
public option as a way to get there. I think it was at this point, Mr. Pintek caught me flat footed when he followed up and asked how Germany makes decisions on what is covered and what is not. I recalled that the benefits packages provide by the insurers there were standardized, but what I wasn’t aware of was that they have a commission that does do cost benefit analysis on treatments before they are approved as benefits. This commission has been accused of dragging its feet on new treatments, but this likely reflects a bias among many physicians to not adopt treatments until the evidence is solid. This has actually been studied in the US, and Massachusetts, with Harvard and Mass General and some of the finest health care in the world has this same regional bias and are slow to adopt new treatments. I’ll try to remember this for next time!

The last call was from a physician’s spouse who had heard me speak about Medicare and what I consider its adequate reimbursement. The host had said he thought the reimbursement was low and that some doctors would not accept it. I pointed out that, depending upon where in the country you practice, Medicare may be your best payer (Nevada, Southeastern PA) or at least, as in the Pittsburgh area where we are, not too far off from private insurance plans. I also pointed out the cost
of $82K per physician annually to deal with insurers and billing.

I had also pointed out that most doctors support some form of national health insurance, particularly PCPs and even a majority of general surgeons, but not some specialists like radiologists, anesthesiologists, and surgical specialists. I think she was a little peeved by that, because that’s what she started her comment with. She said that many doctors won’t take Medicare, and especially when they go to national meetings she hears this from people around the country. I have heard this before, even from fellow Doctors for America physicians telling me what they hear from colleagues. But if you look at what Medicare actually pays us, the regional variation is very small, with the exception of Alaska (the physicians of Alaska owe fromer Sen. Stephens for that). So whether Medicare fees look like a pittance to you or not has more to do with what your private insurers are paying you than what medicare is paying you. So, certainly physicians will look at a $150 fee from a private plan and a $100 fee from Medicare and conclude that Medicare may not be worthwhile. That is not unreasonable, but when you factor in the cost of dealing with private insurers, $82K per doc or about 14% of overhead, maybe Medicare is subsidizing the private plans! Anyway, I wish I’d had the presence of mind to ask what her husband’s specialty was!

Things I didn’t get to squeeze in but will try to next time:

  • “It is a mistake for any nation to merely copy another; but it is even a greater mistake, it is a proof of weakness in any nation, not to be anxious to learn from one another and willing and able to adapt that learning to the new national conditions and make it fruitful and productive therein.” Teddy Roosevelt, “Man in the Arena” The Sorbonne, Paris, France, 1910

  • Public
    opinion favors not only the public option, but national health insurance     of some kind. And they are willing to pay more in taxes for it, even if this is phrased in such a misleading way in every polling I’ve ever seen.

  • England’s NICE, by analyzing cost of care in the context of benefits to patients has led to price reductions from pharmaceutical companies in order to meet their cutoff. And NICE can be pressured if it is felt to be making unwise recommendations.

  • Having an independent commission running Medicare, rather than Congress, might be quite an improvement.

  • If we do manage to get to a German or French style system, which party would be more likely to demand cost cutting resulting in longer waiting times and rationing of care?

  • I was asked about Massachusetts and demurred because I really don’t know enough to comment intelligently. I wish I had referred them to the PNHP site, as they have lots of information and intelligent critiques of what’s going on there.

And things to add from your comments will go here:

450,000 Doctors Demand: ‘Heal Health Care Now’ — Media Center — American Academy of Family Physicians

450,000 Doctors Demand: ‘Heal Health Care Now’ — Media Center — American Academy of Family Physicians:

Today marks the launch of “Heal Health Care Now.” This Web-based initiative (HealHealthCareNow.org) consists of several elements, including a provocative video of family doctors speaking in support of the health system reform legislation Congress is debating currently. The video culminates with a call to action encouraging viewers to let their legislators know they stand behind nearly half a million doctors to support reform. The Web site also provides a quick and easy tool that encourages viewers to contact their legislators directly.

Also today, organizations representing 450,000 doctors signed and delivered a joint letter indicating their support of health care reform to Sen. Harry Reid (D-Nev.) and his colleagues in the U.S. Senate. The American Academy of Family Physicians along with the American College of Physicians, the American Osteopathic Association, the American Medical Student Association, Doctors for America and the National Physicians Alliance signed the letter which reads in part, “We are confident that the reforms being proposed will allow us to provide better quality care to our patients, while preserving patient choice of plan and doctor.”

Two national nonpartisan health care organizations — the AAFP and the Herndon Alliance — developed the online “Heal Health Care Now” initiative in a strategic effort to counter some of the most potent anti-reform arguments with the most trusted spokespersons — front-line family doctors. The AAFP represents more than 94,000 family physicians and medical students. The Herndon Alliance is a nationwide coalition of more than 200 minority, faith, labor, advocacy, business, and health-care provider organizations, including the American Nurses Association, the American Academy of Pediatrics, the AARP, the Mayo Clinic and Families USA.