By Maureen Miller
Occupy, an OWS-inspired Gazette, Nov. 10, 2011

In 1970, Stephen Bergman, then a Harvard medical student, missed his renal block exam to protest Kent State. He was one of many medical students who were transformed by the antiwar movement, and he went on to ask if we could transform physician training.

In 1978, Bergman published the satire “The House of God,” loosely based on his experiences an internal medicine intern at Beth Israel Deaconess Medical Center, under the pseudonym Samuel Shem.

“The House of God” is best known for popularizing medical students’ passive-aggressive argot. (“Gomer” is short for “get out of my emergency room”; “NAD” means “no acute distress.”) But its enduring accomplishment is that it brought to light an attitudinal shift among American physicians.

While doctors have been perfecting their gallows humor for centuries, Bergman concluded that his colleagues used theirs as a defense against the depersonalization they experienced as part of what is now often described as the “medical-industrial complex.”

The first authors to use the term “medical-industrial complex,” John and Barbara Ehrenreich, were with Health-PAC, a universal health care advocacy group. Their “American Health Empire: Power, Profits, and Politics” (1971) came to the attention of physicians nationwide after Arnold Relman, editor of the New England Journal of Medicine, wrote about it in 1980.

The Ehrenreichs argued that structural inequalities in health care undermine medical professionalism, and that health care corporations and consulting groups cannot exist without these inequalities—and that therefore we cannot work with them.

The Ehrenreichs and others continue to insist that we have trouble relating to our patients because we are ambivalent about our own roles as guardians (or gatekeepers) of an unjust distribution system. So the rise of the medical-industrial complex has been paralleled by the rise of a consciousness movement, “mindful medicine,” which encourages physicians to pursue activities such as narrative medicine, meditation practice, and exercise in order to cultivate a more introspective medical practice even within the complex.

At the same time, real political reforms have taken place. Student-driven curriculum reform has brought HIV-AIDS prevention, global health internships and electives, health care disparities, topics in LGBTQ health care, and primary care recruitments to medical schools.

A more outward-looking movement, the American Medical Student Association’s PharmFree campaign, which aims to diminish the pharmaceutical industry’s influence on medical practice, has been featured in the New York Times, Newsweek, and CNN.

Harvard Medical School even invited Bergman to address students at its commencement in 2009. He told them, “You are about to enter a disaster area: the health care industry. The system is broken. It is worse for doctors, worse for patients, and better only for the insurance industry.”

As a medical student, I get to ask tons of stupid and naïve questions, so here’s one: What if we tried to change the system?

A 2011 study by the American Medical Students Association found that about 95 percent of medical students believe their patients are underinsured, and that 80 percent don’t think the Affordable Care Act went far enough in narrowing that gap.

Their elders tend to agree. A 2009 study by the New England Journal found that 78 percent of physicians believe they have a professional obligation to address societal health policy issues, and 67 percent are willing to accept limits on their reimbursements in order to expand access to basic health care.

Although we may not seem like likely protesters, medical residents and many doctors with decades of practice behind them are the 99 percent, and we treat the 99 percent. We are part of the same system as our patients, and it also causes us distress. And when we speak, people listen.

An October 23 speak-out at Zuccotti Park by Health care for the 99 percent, a coalition of health care professionals, attracted more attention than any other teach-in so far.

What would it take to recruit more medical students and physicians to try to collectively change American health care? The challenge will be overcoming a decades-long tradition of isolation and resignation within a dysfunctional system.

Half a decade ago, the New England Journal published an article called “White Coat, Mood Indigo,” which noted that medical students become depressed as they enter their clinical training. These years are the first time most students interact with the American health care system as physicians, and what we see can be deeply discouraging.

We begin to infer that the best way to manage patients is to answer their questions on a need-to-know basis. We learn to order tests in sequences that are not always evidence-based or clinically sound partly because these tests can be expensive. Everyone in the industry is constantly working around the cost problem, and the complexity and dysfunction of these efforts make us increasingly depressed as we go about our first rounds.

Yet medical students do have an opportunity to learn another way. We learn it from colleagues who speak out. In my experience, most medical student advocates come into the health care reform movement after some nudging from a clinical or academic mentor. Many students I know (I’m a third-year medical student at NYU) have gotten into global health activism after reading “Mountains Beyond Mountains,” Tracy Kidder’s book about Partners in Health founder Paul Farmer.

More broadly, one of the best-known medical activist organizations is Physicians for Human Rights, which organizes medical professionals against violations of the Hippocratic Oath, such as torture.

There is also a national organization specifically devoted to ensuring that everyone has access to high-quality, comprehensive health care, Physicians for a National Health Program (PNHP), which has over 18,000 members across the country. For us to have a real impact, a large proportion of practicing physicians will have to coalesce behind groups like this one. We need organization almost on the scale of the global health projects.

PNHP advocates for an improved Medicare for All, shorthand for a single-payer American health care system that would cover every person under a federal insurance program. It is analogous to the universal health care legislation Vermont passed in May 2011, which will guarantee every resident state-financed health insurance, and it is a more expansive vision of the public option that multiple polls found the majority of American supported during the 2009 health care reform debate.

The public option, which would have allowed the federal government to provide Medicare-like insurance coverage to all Americans as a price competitor to private insurers, was viewed by many as a stepping stone to a federal single-payer program.

Right now there is some internal debate within PNHP about whether we should promote reform on a state-by-state level, as in Vermont, or continue to advocate for reforms on the national level. In any case, we believe that single-payer is “ambitious but feasible” for America.

And there is a lot we can learn from the ambitious project going on right now in Zuccotti Park. Medics attend to the occupiers around the clock; full-time practitioners moonlight with them. The time I spend at the park is what I can offer between clinical commitments — which, granted, is not much. But I am hoping to pick up some habits from the Occupy Movement to take to my classmates.

The last time I went to the park, on Oct. 23, I put it this way on a dorm-style dry erase board:

I am a med student.

I suppor
t Medicare for All.

I am studying for my surgery clerkship, yet I am here.

Do I need a CT scan?

I was standing next to a Yippie pie-thrower who saw my sign. He asked me about how better to manage his myriad chronic medical conditions, and I had to tell him I didn’t know.

Soon I was no longer alone, and I felt more comfortable in the crowd. I was standing with my medical school classmate Josh Klindienst. Josh and I have been in school together for three years, but I can’t remember us having a conversation about health care reform before then.

I talk about health care reform a fair amount at my medical school — I am the campus contact for Physicians for a National Health Program — but everyone always tells me they don’t know enough about health care reform to join. Perhaps with the question of knowing enough, Josh suggested I simplify my message. I tried:

Medical Students for Medicare for All: Health care is a Human Right!

The new iteration got a better response than my previous sign. Flavio Casoy, a psychiatry resident from San Francisco, approached us.

“Why Medicare for All?” he asked.

“It makes more sense to most people than ‘VA-for-All.’”

He wanted us to make sure we knew why we believed it. Casoy was in town to attend a national conference of the Committee of Interns and Residents (CIR), a member organization of the SEIU. I’d never heard of it, but apparently Bellevue Hospital, the public teaching hospital where I train, has had a CIR chapter for 20 years. Within two days I noticed two CIR flyers in one of the hospital call rooms.

What do we need to do, to for lack of a better expression, put our colleagues on call?

Introspection is critical to thoughtful medical practice, but an outward turn, to the advancement of health care as a human right, is essential if we are to defend our professionalism and retain our peace of mind.

Turning outward is a habit of mind to which we devote much of our training. If you work in a health care system, you must learn how to work well in teams. An embrace of the communal work ethic — coordinated care, collaborative interviews with family members, and faculty consults — is really the only way for us to get anything done.

The Occupy Movement reminds us that simply talking to one another about our problems with the system would at least make us feel less isolated. Whatever our ideological or strategic differences about the best way to change the system, being willing to participate in these conversations would remove the barrier of feeling that we’re each in this alone.

Maureen Miller is a medical student in New York City and is a member of Physicians for a National Health Program (www.pnhp.org). The text above is a slightly revised version of her article titled “Check Up,” which can be found on pages 32-34 of the following issue of Occupy: http://www.nplusonemag.com/GAZETTE-2.pdf.

By Alan Panebaker
VTDigger, November 14, 2011

In reaction to the Shumlin administration’s push for a single-payer style health care system, doctors have resuscitated a bargaining group that will represent the interests of physicians.

The Green Mountain Care board is developing plans for reforms that will likely have an impact on doctors’ earning power, and members of the Vermont Medical Society are worried about their future compensation and working conditions.

At the Society’s annual meeting last month, members voted to reconvene a bargaining group called the Physician Policy Council that was originally formed in the 1990s.

Unlike a union, where employees negotiate with their employer for fair wages and benefits, the council will bargain directly with the state as it creates a benefits package for all Vermonters and possibly implements a “single pipe” payment mechanism for health care providers as part of a reform effort that would set the stage for a universal health care system. Payment reform plans will likely result in a uniform pricing system for physician care.

Paul Harrington, executive director of the Vermont Medical Society, told the Vermont Press Bureau last week that the group’s aim was to provide the Green Mountain Care Board with the “best information possible reflecting the experiences of Vermont physicians.”

The vast majority of physicians working for Fletcher Allen Health Care, the state’s largest health care provider, are members of the Vermont Medical Society, according to Mike Noble, a spokesman for Fletcher Allen.

The commissioner of the Vermont Department of Banking, Insurance, Securities and Health Care Administration will need to approve the group’s status under the agency’s regulations.

Madeleine Mongan, vice president for policy with the Vermont Medical Society, said the organization formed a bargaining group in 1994 when the law first allowed health care provider bargaining groups to negotiate with the state regarding provider regulation, reimbursement and quality of health care.

Physicians say the purpose of a collective bargaining group is to ensure doctors can talk to each other and negotiate with the state without running afoul of antitrust laws, which are designed to promote or maintain market competition by regulating anti-competitive conduct by companies, essentially prohibiting monopolies.

Dr. Paul Reiss, a family practitioner in Williston, said the original idea of allowing a collective bargaining group was to permit doctors to negotiate and discuss rates with each other in anticipation of more control by the state over setting rates for plans like Medicaid and Catamount Health.

“It will be very important if there’s limited options for physicians to contract; physicians naturally will have to have the ability to talk to each other in terms of the fee schedules that the board comes up with,” Reiss said.

Essentially, this is what happens in Canadian provinces with single-payer systems, Reiss explained. Physicians and other health care providers bargain for rates of compensation. In a single-payer system, one entity, run by the government, would collect all health care fees and pay out all health care costs. Although Vermont’s health care reform bill, Act 48, does not specifically use the words “single-payer,” it permits an appointed board to develop a payment system to move away from a “fee-for-service” model and toward an alternative method of compensation.

Reiss said, “The payer will control the flow of all health care dollars essentially.”

The payer would effectively be the state, and doctors would be subject to the reimbursement rates it sets. Reiss said other organizations can and probably will apply to be recognized as a bargaining group. For example, the group Healthfirst, which works to promote independent health care practices, will likely want the ability to bargain as well. Reiss is vice-chair of that organization’s board of directors.

Jim Daily, CEO of Porter Medical Center in Middlebury, said physician participation in reform is a good thing.

“For us collectively to solve health care problems takes as many people pulling together as possible,” Daily said.

The Vermont Association of Hospitals and Health Systems will be working on budget issues and payment reform as well, Daily said.

Act 48 includes a reference to the statute allowing bargaining groups in its definition of “payment reform.” The Green Mountain Care Board will spearhead the effort to shift payment for health care providers away from a “fee-for-service” model where providers receive compensation for each separate service.

One option, called “bundling,” compensates physicians and hospitals for “episodes” of care. For example, a provider could receive payment for an entire surgery rather than separate payments for individual visits, MRIs, and the actual procedure.

The idea is to reduce costs by discouraging unnecessary care and encouraging coordination. Proponents of the idea say it will improve overall quality of care.

Anya Rader Wallack, chair of the Green Mountain Care Board, said the bargaining council will give physicians a vehicle for negotiating fair compensation.

The question is, “how do we change reimbursement and make it fair?” Wallack says.

She said there appears to be some nervousness in the specialty medical community (physicians who practice in a specific area like orthopedics) about what the plan means for them. Critics of the federal efforts to reform health care have said an expansion of access to care for more patients could result in decreases in pay for highly-compensated specialists.

Wallack said the board welcomes the input. “It’s the state discussing with providers fair, adequate, value-based compensation,” she said.

http://vtdigger.org/2011/11/14/single-payer-plan-prompts-docs-to-bargain-with-the-state-on-reforms/

By the Editorial Board
Newsday, Nov. 14, 2011

Imagine a health insurance system with runaway costs, millions left without coverage, administrative headaches galore and unhealthier people than in many other countries spending less.

Actually, you don’t have to bother imagining such a system. You’re already living with it. And it’s bankrupting our country.

Curing the ills of our health care delivery system is a topic that has been and will be addressed extensively by the editorial board. More specifically, health care “entitlements” are at the very heart of our nation’s fiscal troubles, so they are a crucial factor in our financial recovery.

Medicare and Medicaid account for 23 percent of federal spending and cover more than 100 million Americans. But the problem is even larger, because government at all levels pays 45 percent of the nation’s $2.6-trillion annual medical bill. Private spending is outlandish too, which also matters; money spent by individuals and companies on exorbitantly priced health care is money unavailable for investing in business, rebuilding bridges or paying off loans.

In general, compared with other rich countries, we spend perhaps $1 trillion a year too much on health care, a sum that would all but solve our fiscal troubles if it could be put to better uses. So applying the brakes to increases in public and private medical spending is critical — especially because it doesn’t buy us much.

Thirty years ago, our health-care spending was in line with that of other advanced nations, but now we spend about twice as much proportionately — nearly 18 percent of national output. Yet in countries that spend far less, people live longer. The cost burden on the unlucky in this country is particularly crushing; one study found that medical bills caused 62 percent of bankruptcies in 2007. The researchers said their findings show that “the U.S. health care financing system is broken.”
 
It’s a form of single-payer already

President Barack Obama spent enormous political capital to push a health-care plan through Congress, and it is designed expand coverage. Yet even if it survives legal challenges and unrelenting Republican opposition, it will still leave millions of people uncovered — and do far too little to rein in costs.

The salient fact about health care in America is that we already have a single-payer system. That payer is you. You pay for your neighbors, they pay for you, and everyone pays for the uninsured, unless of course they simply die untreated. By its nature, after all, insurance collectivizes costs. Our system is also riddled with tax deductions, employer coverage and other cost-shifting features that effectively hide who’s paying what and how much it really amounts to.

Overall, it’s a recipe for out-of-control spending, which is just what it’s given us. Indeed, in Australia, Britain, Japan and some other affluent countries, the sum spent here by government alone (on a per-person basis) would be enough to cover everybody without a dime of additional spending.

Once we acknowledge that we already have a single-payer system, we might as well go ahead and make it a sensible one.

What would such a system look like?

First, it will have to change how health-care providers are compensated, so that they’re paid for producing health rather than performing costly procedures. Second, it would have to turn back the tsunami of paperwork that threatens to inundate American health care in costs, errors and frustration. And third, it would have to cover everybody. Hospitals already have to treat any emergency patient — they just pass the costs along to everyone else — and universal coverage, according to a Harvard study, might prevent the deaths of nearly 45,000 Americans annually, which is more than die each year on U.S. roads.

It would also have to find ways to change behavior, since so much of what ails us — obesity, for instance — is self-inflicted. Since the health insurer would be the same outfit that makes the laws, the government would have strong incentives to abandon policies that make us less healthy and support ones that make us more so.

While we’re at it, let’s acknowledge that any sane single-payer system must ration care — just as our current system does — only based on science rather than affluence or insurance-company fiat. Today, a third of health-care resources are spent on patients in the last year of life, when it often does more harm than good. Ending some of this tragic waste will require a change in attitudes. But spending that money on hospices, prevention and coverage for the uninsured would be vastly more beneficial, both for the elderly and for everyone else. Hospice care, for example, can actually prolong life even while saving money.
 
Leverage to hold down costs

Most of all, a sensible single-payer system would be basic, providing decent care for all while allowing anyone with the money and inclination to buy a private add-on plan to upgrade coverage. Since people would pay for these plans from their own pockets, market forces should work to keep costs down. Such add-on coverage could pay for a private hospital room or procedures not covered by the basic government plan. But the cost of such extra coverage can’t be tax-deductible, because that would encourage people to overspend and pass the bill to their fellow taxpayers.

A basic single-payer plan could mean Medicare for all, or it could just as well mean 50 single-payer programs in 50 state capitals. Vermont has already started building a single-payer plan that would pay health care providers a set fee to care for patients. Either way, the entity that increasingly pays our medical bills — government — would finally get the hammer it needs to tamp down costs. And the United States would finally have a prescription for solvency.

Watch videojournalist Meredith Soaring interviewing editorial board member Daniel Akst about how U.S. medical spending poses a mortal threat to our fiscal health, yet we’re unhealthier than comparable countries and leave 50 million without insurance: http://www.newsday.com/users/user-content/balancing-act-ii-an-editorial-series-1.3311755