To the Editor:

Fink parses the ethics of hospital staff rather than those who abandoned them during Katrina.  What if Tenet and LifeCare, the owners of the two health facilities at Memorial Hospital, decided to take immediate responsibility for evacuating their patients?

LifeCare wanted first FEMA and then Tenet to take care of it. Tenet got on the horn to friends in Washington.

Tenet’s CEO was compensated 9.7M in 2008. Tenet’s history is littered with scandals including unnecessary surgeries and repeated fraud.  LifeCare, which has found funds to make illegal campaign contributions, has 20 locations and assets of $484M. Surely, in absolute terms, either could have paid for timely helicopter evacuation.  This was a business decision.

Dr. Pou and others stepped up to the plate and most patients were saved.  Tenet came up with helicopters 3 days into the crisis, LifeCare never did.  Fink digs up already dismissed charges of “euthanasia” against Samaritan heroes who stayed put to work under unspeakable conditions while asserting, “LifeCare deployed the full array of modern technology to keep alive its often elderly and debilitated patients.”

Fink’s sensational article is an unfitting commemoration of Katrina and a missed opportunity for investigating a case scenario of how for-profit healthcare works.

Laura S. Boylan, MD

New York City

Link to original article: http://www.nytimes.com/2009/08/30/magazine/30doctors.html

By Laura S. Boylan, MD and Joanne Landy, MPH

One can only feel sorrow and dismay at the bullying and hate-mongering that is taking place at health care forums around the country.

Massive job losses, the devaluation and foreclosures of people’s homes, and precipitous declines in lifetime savings produce widespread fears of further loss. In an era of insecurity, mainstream Democratic Party proposals for reforming the health system have played into such fears.

A health care “reform” that protects private insurers and massive profits for the pharmaceutical industry inevitably becomes an ugly game where ordinary people’s interests are pitted against each other. Witness, for example, the proposed cuts to Medicaid and Medicare to fund an initiative that subsidizes the mandated purchase of private insurance with taxpayer dollars. Relatively little is offered to the already insured majority who are told of upcoming belt-tightening.

The near-total exclusion of single payer from the health care debate by our political leaders and the media has contributed to the present state of affairs. Single payer is an expanded and improved Medicare for All (“Medicare 2.0”).  Many, perhaps most, Americans have come to believe in the false choice between universal coverage and quality health care.

Our nation needs a meaningful dialogue, including a fair hearing of the views of the 20 million constituents of the Leadership Conference on Guaranteed Health Care (of which Physicians for a National Health Program is a founding member), who advocate for single-payer national health insurance. Polls show that most of the public and their physicians favor such an approach.

There is simply no other viable solution to the problems facing us all, insured and uninsured. With Medicare 2.0, the already insured would benefit from radically reduced out-of-pocket costs for comprehensive insurance and expanded choice of doctors and hospitals. Medicare 2.0 stays with you for life, independent of your employment. The epidemic of medical bankruptcies would be just a bad memory.

It is unnecessary to pit the insured against the uninsured, or those with Medicare and Medicaid against those with private insurance.

Multi-payer, for-profit health insurance adds cost but not value to American health care. Savings of $400 billion a year can be obtained through the conversion to a single-payer system. With the money we are now spending (twice as much per capita as other developed nations), we can provide full service “what you need, when you need it” health care for everyone and control costs going forward.

With the “everybody in, nobody out” approach of a Medicare 2.0 system, we can all get more freedom, choice and security.

Single-payer advocates have been excluded from debate not because our premises or facts are wrong but because special interests, including the private health insurance industry and the big drug companies, have been allowed to define the limits of “politically feasible.”

We support the right to lively and dramatic expression of all views about health care and other issues in American political life. We share a common sense of frustration expressed by many protesters that it often seems that Washington’s ear is tuned to special interests over public interests. However, we strongly condemn the bullying and hateful speech that has precluded meaningful discussion at many town hall meetings.

The ugliest language suggests that the uninsured or undocumented should be allowed to “die in the streets” and asserts that areas with less racial and ethnic diversity are “the real America.” President Obama’s citizenship is questioned and he is likened to Hitler.

These actions have been facilitated and promoted by networks of well-funded, right-wing interest groups who have tapped into a vein of fear and discontent in a time of rapidly rising hardship and anxiety.

With this deteriorating public dialogue, we should affirm that we can get better health care by sticking together to support single payer. We support meaningful dialogue. We affirm the dignity of all persons and insist that health care is a universal human right.

Health care is instrumental to “life, liberty and the pursuit of happiness.” We continue, as ever, to insist that “everybody in, nobody out” is best for all of us and embodies the best of American values.

Panelists from Staten Island Community Groups and PNHP encountered angry jeers from “anti-government” mob in Staten Island Church Healthcare Forum Wed Aug. 12^th.  Differences between single payer and current house bill were felt to be irrelevant by the vocal audience members.

Details

This meeting was organized by Staten Island Family Health Care Coalition.  Katie Robbins (Healthcare Now) and I were asked to present the House Bill 3200 and our critique.  Katie missed our talk part due to a subway mishap but videotaped the event and will edit it.  Event organizers told us that OFA was invited but did not send anyone to the meeting.  There were police present as a menacing call was received by organizers prior to the event saying “there better not be any illegal immigrants there.”

I explained the basics of 3200 and where 3200 fits into the legislative process.  I said I was for single payer, Medicare 2.0 for all and that it is a terrible misconception that healthcare is a zero sum game whereby the some must sacrifice to cover the uninsured.   With “everybody in, nobody out” public insurance for all there would be plenty to go around and we could all do better by getting better value for our healthcare dollar with this fiscally conservative program.  Jeers and interruptions came from the audience.

Other panelists included the MC, an internist with the Richmond MSSNY (AMA affiliate), a representative from the Richmond Chamber of Commerce, who outlined her members concerns with high costs of compliance with 3200, a representative from an HHC “safety net” facility who told stories of how help was needed for many, a representative from Jewish Community Services who tries to connect people with insurance about current problems of loopholes in eligibility as well as eligibles who don’t know they can get Medicaid, the director of a SI FHQC who described hardships at his centers and expressed concern that primary care physician supply would be inadequate to meet needs if everyone were insured.   Many in the audience were impatient with all presentations, wanting to speak and clearly angry that Cong. Mc Mahon was not there.  This was expressed through heckling, groaning, eye-rolling and interruptions.

A representative from McMahon’s office was present and attempted to field questions from the jeering crowd about McMahon’s non-presence.  He committed to a future event with McMahon to explain the legislation as it evolves.

The MC then had audience members line up at a microphone to speak and tried to limit those who were yelling out.  The first audience member mocked the bodyweight of the woman who convened the conference.  This drew disapproval even from some among the “angry yeller” ranks, but also laughter.  Major themes expressed by the group in an apparently orchestrated fashion: need to minimize government and taxes, accusations that proposed health reform is, variously “Trojan horse” for single payer or “Soviet” “Socialized medicine”.  Someone yelled out from the sidelines questioning Obama’s citizenship.  Right after that, one man, one of few blacks in the audience got up and left.

Other recurrent themes were the need for personal responsibility to buy insurance (“they got ipods, they should buy health insurance”), that illegal immigrants and others who “contribute nothing” are getting free services at the expense of “hard working Americans”.  In response to a panelist’s story about a foot amputation in a diabetic who could not afford healthcare someone called out “Come on, she really couldn’t afford the $200 podiatry visit?”.  When one panelist told the story of an insured person who nearly lost her house to pay for chemo an audience member called out to say “My insurance covered my chemo”.

Along with demands that the government get out of healthcare was rage at proposed cuts to Medicare and purported ineligibility for Medicaid for homeowners (sometimes in the same sentence) while illegals get a “free ride”.   One of the panelists who worked getting people insurance had earlier said that the “homeowner exclusion” was a misconception.    One person demanded “an end to class warfare”.

Other ideas expressed: Tort reform will control costs, tax cuts would lead to more jobs and then everyone could afford “to take care of themselves without the government”.  I and others occasionally interjected to indicate points of fact on what was and was not in the bill (ie many of the suggested changes to public programs made by “the angry” are in the bill, the bill does not provide insurance to undocumented immigrants etc.).

We ended late when we had to leave the venue (a Moravian Church).  Someone from the audience came up to me afterwards and made a comment I think is correct.  He said noone cares what’s in the bill, it’s not really about the bill or healthcare but a bigger worldview.

In this worldview all of the panelists are part of an elite monolith who “don’t get it”.   Some or all of the “the angry” were from the Staten Island Tea Party Organization.  I’d estimate they made up half the crowd of about 150.  They were coordinated and had notes.   A rallying cry to throw representatives who vote for reform out of office and “keep listening to talk radio” led to fist pumping and cheers.

A soft spoken young man working with the forum organizers volunteered to give Katie and I a lift to the train.  In the car he said he was really for socialized medicine rather than single payer.

Press coverage in Staten Island Advance (no mention of single payer) http://www.silive.com/news/advance/index.ssf?/base/news/1250163911258370.xml&coll=1

Single payer:  freedom, choice and quality

Healthcare is a human right.  It is fundamental and instrumental to life, liberty and the pursuit of happiness.

We are paying for a first rate system but getting a mediocre one, getting phenomenally low value on the dollar.  We spend twice as much as other developed nations but are not healthier as a result.  In many indices of major health outcomes we trail other developed nations.  We have scarcity in the midst of excess.  This is a scandal and a shame and we can do better.

I reject the notion that many propose, that healthcare is a zero-sum game in which universal access threatens quality.  Universal access combined with public accountability will enhance quality.  The whole system is stronger and better if we all go in together to one big risk pool.  By publically insuring everybody, we could, with the money we are spending now, provide what we need/when we need it healthcare for everyone.  This is single payer, Medicare 2.0.  It is public insurance with private delivery.

Single payer is controversial in some circles.  However, it’s beneficial effects regarding cost containment are generally conceded on all sides.  I will not dwell on these.  I will focus instead on how single payer can enhance freedom, choice, and quality in American medicine.

The “Other in our midst”

Before going on I want to first address a pernicious idea promoted by many who oppose health reform head on.  It is rarely spoken of directly.  There are many who would like you to believe that there is some “other” in our midst whose ills and lifestyles account for the poor health status and high costs of Americans.  These are, variously, overweight, substance abusing, drunken driving, gun-fighting, illegal immigrant, unwed mothers, smokers and others.

“Others” aren’t the cause of high costs

The idea that the bad aspects of our system are limited to various “others” is a folly, and a dangerous one.   The “expensive” people in healthcare are the sick and, alas, we will all be there someday, somehow.  The single biggest risk factor predicting high utilization of healthcare services is not obesity, smoking, drinking or other putatively “voluntary” lifestyle factors.  It is age.  The bulk of healthcare spending in any given year is on a very sick minority.  The majority has an interest in protecting this minority because, literally, we could join them anytime.

“Others” aren’t the cause of bad US healthcare outcomes.

There are more unwed mothers and many, many more smokers in Europe.  Conventional wisdom about alcohol use aside, there is no evidence that Europeans suffer fewer medical complications of alcohol overuse than we do.  They are also rapidly gaining on us in girth and also have large populations of documented and undocumented immigrants.

Quality and Quantity of US Care

As I have said we have scarcity in the midst of excess with healthcare distribution according to ability to pay/get reimbursed.  Up to a third of overall medical expenses are judged to be due to unnecessary interventions.  At the same a third of Americans say they are cutting back on medications and routine medical care due to cost.

Make no mistake, unnecessary procedures are not just expensive, they cause net harm including permanent injury and deaths.   High costs are not just lamentable for bean counters, they mean large numbers of Americans don’t seek timely care and don’t take meds.

High Tech Care, Research and Innovation

Our supposed reward for accepting the harsh reality of un- and under-insurance is high tech medicine and a system on the cutting edge of research and innovation.  This is a false choice.  Systems without for profit insurance are clearly able to support high quality and high tech medical care as well as cutting edge research.

There are more frequent hip replacements in Sweden and more bone marrow transplants in France and Italy.   Japan and several European countries have many more CT and MRI machines per capita than we do.

Biomedical researchers benchmark advances in knowledge by numbers of journal articles and how often other researchers cite those articles.  The US trails several European nations in this regard. Half the top ten pharmaceutical companies are European and pharmaceutical industry R&D per capita is greater in Sweden, Denmark and the UK than in the US.

We do a lot of clinical trials, but, frankly, these are rarely designed to answer questions clinicians want answered (like is this medicine any better than what we’ve got already) instead they are focused on marketing needs.

The case of “proton pump inhibitors”

I want to discuss one particular type of drug because I think the case illustrates how profit incentives can distort quality and value in healthcare and why it’s so important to Big Pharma to negotiate with many different payers rather than a single powerful one.  Multiple payers keep Americans paying the highest drug prices in the world and make it profitable to recycle old inventions rather than come up with new ones.

Take, for example proton pump inhibitors (PPIs ).  This category of medication was discovered in the late 80s and was a significant advance.  It’s used for stomach problems. The bedrock science research used to discover the drug was supported by US taxpayers via the National Institute of Health.  Nexium, the purple pill you may have heard of or actually take, is manufactured by an Anglo Swedish company which is the market leader in the PPI field. It is used mostly to treat heartburn, re-christened by industry marketers more ominously as GERD or gastroesophageal reflux disease.

New developments in this area since the late 80s looks like this:  6 new branded PPIs in 15 different forms made by 5 different pharmaceutical companies only 2 of which are American.  There is no scientific basis for believing any of the new formulations are better than the original one.

The original idea and basic research was done by an Austrian born and Scottish educated American.  He was working for a Swedish company at the time and is now at the US Dept of Veteran’s Affairs.

The basis for the most recent new PPI patent, issued over 20 years after the innovative compound was discovered, was for compounding the drug with baking soda so it would be “immediate release”.   Ultimately $44M was spent on product research and $48M was spent on marketing including a full time sales force of 400.   This is poor health value for dollars spent.

The PPI market is now driven largely by inappropriate prescriptions which are now estimated to accounting for up to 70% of all usage.  The problem is bigger than the money wasted.  Stomach acid fights infection as well as causing stomach irritation.  Use of these drugs causes increased rates of pneumonia and has contributed to the emergence of a treatment resistant superbug known in shorthand as “c diff”.

Now I’d like to address choice.

We need to get real on choice.  If there’s a single payer, everyone takes it.   I looked up my choice with my current plan (Aetna FEHB) versus traditional non-privatized Medicare.  I looked up my choices in two places: Wilkes-Barre PA and zip 10025 on UWS Manhattan where I live and work.  In both places I had more choices of doctors in a range of specialties with Medicare.  Sometimes Medicare recipients had over four times as many doctors to choose from as I did.  No, I didn’t get “just the best”, most everyone on Aetna also took Medicare.

I also know about choice available with private versus public Medicare from the range of referral options I discovered I had for my patients at Bellevue.  Want cancer care at Sloan Kettering or deep brain stimulation neurosurgery for Parkinson’s at Columbia?  You better have “real” public Medicare, not one of the privatized “Advantage” plans, because they don’t take them.

Private insurance offers the false “choice” of picking which for-profit shareholder accountable entity will get to limit your choices.   Let me say it again. Private insurance means limited choices.   Single payer means you choose to see anyone you want.

Let’s talk Wait Times

When I was pregnant many years ago I had private insurance but had to pull strings to get an appointment with an OB/GYN anytime in the first trimester of my pregnancy.

Last week I called up my gynecologist’s office to check on appointment availability and found there is a two 2 month wait.

Wait times for various services are related to the profitability of delivering those services rather than to medical urgency.

These are the wait times I found for Columbia Presbyterian Eastside Practice on East 60th Street in Manhattan:

To see dermatologist to evaluate a “suspicious mole”: 3 months

To see a dermatologist for a cosmetic evaluation: 2 weeks

For medical evaluation for insomnia which may include a lucrative “sleep study”: 3 weeks.

To get a mammogram: 3 months

I could get my hip replaced electively in Toronto sooner than I can get a mammogram or see my GYN in Manhattan.  I know that because wait times and procedure availability for all sites is web published in Ontario to help patients choose where to go for care.  No equivalent information is available to me in NY.

Let me address the feared army of bureaucrats:

I have seen this army.  It is not coming, it has already arrived!  US physicians report MORE external reviews of their clinical decisions to control costs than doctors in other countries.  Here’s a recent example from my practice to show you why we feel that way:

This was at a model private rural care delivery system in Pennsylvania with sophisticated electronic health records.   I ordered an ultrasound of the carotid arteries in a patient who had just had a stroke.  This is deeply within standard non-controversial medical practice since carotid artery disease can cause strokes.  A screen popped up informing me that the patients insurance would not cover the test.  I don’t know how much the test costs, our medical culture involves ordering from a menu with no prices.  It seemed safe to assume it was at least several hundred dollars an amount my clinical judgment told me might be challenging for this particular person.

In the great tradition of modern medicine, using all the bureaucratic skills as I have learned in dealing with multiple payers and random requirements over many years, I jiggered his ICD-9 diagnosis codes until the procedure was flagged as approved.  This was a waste of my time.  My time, by the way, was paid for by the greater “system”.

That same week I was also called on to consult on a patient who found herself in the “donut hole” of the entirely private Medicare part D drug plan, unable to afford critical medicines for multiple sclerosis.  I confess, I had nothing to add.  She needed the drug, it’s massively expensive (>1K/mo), there is no cheap alternative, and she could not afford it.  Industry patient assistance programs had multiple barriers to access and, when Part D was initiated, categorically declined to assist most of these patients.  I suggested a social worker get involved although I knew a social worker had already been involved. End of depressing consult.  She was in the hospital for timely performed elective knee replacement, paid for by her insurance.

All of the drugs which can change the course of multiple scleroris are “biologics”.  There is no current pathway for these to become generic and deal making in the production of current democratic legislation includes protections to further protect these agents from generic competition.

I want to adress freedom.

Single Payer separates insurance from employment, thus liberating business from a major drag on international competitiveness.  Single payer also ends the “job lock” phenomenon where people stay in dead jobs because of insurance availability.  The end of job lock supports a flexible labor market and the healthy entrepreneurship, which is the backbone of American innovation.

Private Health Insurance: not enough security

There is no freedom without security.  Private insurance does not provide even the relatively healthy population they cover with health security.  Most US bankruptcy involves medical debt.  Medical bankruptcy is unknown in other developed nations.

This past june the LA Times reported that congressional investigators found that three private health insurers canceled the coverage of more than 20,000 people, allowing the companies to avoid paying more than $300 million in medical claims over a five-year period.

It also found that policyholders with breast cancer, lymphoma and more than 1,000 other conditions were targeted for rescission and that employees were praised in performance reviews for terminating the policies of customers with expensive illnesses.

A Texas nurse said she lost her coverage, after she was diagnosed with aggressive breast cancer, for failing to disclose a visit to a dermatologist for acne.

The sister of an Illinois man who died of lymphoma said his policy was rescinded for the failure to report a possible aneurysm and gallstones that his physician noted in his chart but did not discuss with him.

One employee, for instance, received a perfect 5 for “exceptional performance” on an evaluation that noted the employee’s role in dropping thousands of policyholders and avoiding nearly $10 million worth of medical care.

American Values

Now I do not always feel that Uncle Sam is my best friend.  Nonetheless, I do feel better about Uncle Sam than I do about these private insurance companies.  It’s not very complicated, the government is publically accountable, privately held companies are accountable to their shareholders.

Most Americans including most physicians support single payer health insurance.  Special interest health industry lobbies are spending $1.4M DAILY to help spread a message of fear about health reform and continue on with a “business as usual”.  But American values and American health are best supported by a single payer system.

I am not afraid of the postal system.   I am not afraid of the highways.  I am not afraid of Medicare and I am proud to serve in our Department of Veteran’s Affairs.  I have seen the rough edges and devastating human consequences of our failed system over and over again.  Government provision of health insurance is the best way to guarantee healthcare quality and assert individual freedom and choice in obtaining this basic human right.

An organizer with Healthcare-NOW!, Robbins is helping to ratchet up protests to push Congress to establish a single-payer healthcare system.

As part of the campaign, Robbins and others are donning hospital gowns and shiny plastic buttocks that stick out the back of their gowns. Once dressed, the activists take their message to the public: “Private health insurance is like a hospital gown, chances are your ass is not covered.”

On a recent Saturday afternoon, Robbins and other activists jumped on a subway train on the 1 line. They handed out flyers explaining that healthcare should be a human right and publicly funded insurance for everyone was the best solution to the healthcare crisis. The activists happened upon a Mariachi band, and the combination of outlandish outfits and festive music seemed to inspire subway riders to scoop up the leaflets.

In the past, proponents of single-payer healthcare took a more conventional approach. For 20 years, Physicians for a National Health Program (PNHP) have used academic journals, traditional media and PowerPoint presentations to spread its message. But things are heating up.

In January, doctors, nurses, students, labor unions, religious organizations and activists launched the Leadership Conference for Guaranteed Health Care. Inspired by the Leadership Conference for Civil Rights, which helped pass groundbreaking legislation in the 1960s, the healthcare alliance claims to represent more than 20 million people.

Single-payer healthcare advocates argue that only by having the federal government provide business-and taxpayer-funded health insurance can everyone receive guaranteed healthcare access. This system would also save money by eliminating the health insurance industry’s profits and extensive bureaucracy.

In contrast, the Obama administration and Congress propose new industry regulations, mandates and public subsidies for individuals to purchase private insurance, and perhaps some type of public insurance. These proposals would still leave millions of Americans uninsured while subsidizing for-profit insurers.

To pay for the plans, Democrats, with no shortage of Republican support, are considering $600 billion in cuts to Medicare and Medicaid, a first-ever national sales tax and taxes on employer-based health insurance.

Single-payer healthcare has more support in the public than in the halls of power. Only after single-payer healthcare advocates mobilized a mass call-in campaign and threatened a demonstration of health professionals were they invited to Obama’s healthcare summit in March.

Yet they were excluded from key hearings in the Senate Finance Committee chaired by Sen. Max Baucus (D-Mont.), who raked in more than $1.8 million in healthcare industry donations in the 2008 election cycle.

In May, 13 protesters, including doctors and nurses, were arrested after they disrupted committee hearings by standing up and demanding a seat at the table. Robbins was the third to speak out. She declared, “We want a seat at the table.” In response, Baucus snapped, “We need more police.”

Baucus told one activist at a public event in Washington, D.C., in May that he supports single-payer healthcare but does not push for it because “we don’t have the votes.”

Activists targeted Baucus when he came home on recess after the finance committee hearings. Single-payer healthcare supporters were a visible and vocal presence at town hall meetings across Montana. Baucus canceled personal appearances, sending instead a video and a representative for this “listening tour.” A “buy back our senator” campaign is in the works.

Single-payer healthcare advocates have made modest inroads into legislative hearings. Dr. Margaret Flowers, one of the “Baucus 13,” was invited to testify before a Senate committee. Flowers said, “We are no closer to having more support for singlepayer in the Senate, [but] things are a little better in the House,” Flowers said. She added that one goal is to get the Congressional Budget Office to do a financial analysis of single-payer healthcare this year.

Healthcare industry lobbying groups reported $127 million in lobbying expenditures in the first three months of this year. Five trade associations combined have hired more than 20 former government employees as lobbyists, including ex-congressional staffers. PNHP has five staffers for all operations and an annual budget of less than $1 million.

Some opponents of single-payer healthcare have resorted to artificial grassroots movements known as “Astro Turf.” One Boston consulting firm hired by the insurance industry reportedly faked letters from senior citizens in support of Medicare privatization.

Instead of relying on money and underhanded tactics, Flowers says, “We must build a civil rights movement like those that have come before.”