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Are workplace wellness programs enough to make you sick?

Workplace Wellness Programs

Health Policy Brief
Health Affairs, May 10, 2012

The Affordable Care Act of 2010 will, as of 2014, expand employers’ ability to reward employees who meet health status goals by participating in wellness programs–and, in effect, to require employees who don’t meet these goals to pay more for their employer-sponsored health coverage. Some consumer advocates argue that this ability to differentiate in health coverage costs among employees is unfair and will amount to employers’ policing workers’ health.

Wellness program content

Typical features of wellness programs are health-risk assessments and screenings for high blood pressure and cholesterol; behavior modification programs, such as tobacco cessation, weight management, and exercise; health education, including classes or referrals to online sites for health advice; and changes in the work environment or provision of special benefits to encourage exercise and healthy food choices, such as subsidized health club memberships.

Inducements to participate

Although almost all workplace wellness programs are voluntary, employers are increasingly using incentives to encourage employee participation. These incentives range from such items as t-shirts or baseball caps to cash or gifts of significant value

Employers are also linking participation in wellness programs to employees’ costs for health coverage–for example, by reducing premium contributions for workers who are in wellness programs, or by reducing the amounts they must pay in deductibles and copayments when they obtain health services. Another trend among employers who offer multiple health plans is to allow participation in a comprehensive plan only to those employees who agree to participate in the wellness program. Those employees who do not participate in a wellness program are offered a less comprehensive plan, or one that requires them to pay more in premiums or cost sharing.

What are the concerns?

There is widespread support for wellness initiatives in the workplace among both employers and employees. At the same time, there is conflict over programs that tie rewards or penalties to individuals achieving standards related to health status–and especially over those arrangements that affect employee health insurance premiums or cost-sharing amounts.

In general, business groups want employers to have maximum flexibility to design programs with rewards or penalties that will encourage employees to not only participate but also to achieve and maintain measurable health status goals, such as quitting tobacco use or reducing body mass index. They argue that individuals should bear responsibility for their health behavior and lifestyle choices and that it is unfair to penalize an employer’s entire workforce with the medical costs associated with preventable health conditions as well as the costs of reduced productivity.

Unions, consumer advocates, and voluntary organizations such as the American Heart Association are generally wary of wellness initiatives that provide rewards or penalties based on meeting health status goals. They are concerned that, rather than improving health, such approaches may simply shift heath care costs from the healthy to the sick, undermining health insurance reforms that prohibit consideration of health status factors in determining insurance premium rates.

They argue that such incentives are unfair because an individual’s health status is a result of a complex set of factors, not all of which are completely under the individual’s control. For example, genetic predisposition plays a significant role in determining many health status factors, including such attributes as excess weight, blood pressure, blood sugar, and cholesterol levels. Consumer advocates also caution that poorly designed and implemented wellness initiatives may have unintended consequences, such as coercing an individual with a health condition to participate in an activity without adequate medical supervision.

Another concern is that tying the cost of insurance to the ability to meet certain health status goals could discriminate against low-income individuals or racial and ethnic minorities. These individuals are more likely to have the health conditions that wellness programs target and also may face more difficult barriers to healthy living.

These barriers may include some that are work related, such as having higher levels of job stress; job insecurity; and work scheduling issues, including shift work. Barriers outside of work may include personal issues, such as financial burdens, and environmental factors, such as unsafe neighborhoods, poor public transportation, and lack of access to healthy food.

In addition, some critics warn that wellness program requirements may be used to discourage employees from participating in their employers’ health benefits plan by making their participation unaffordable. Employers might use a system of rewards or penalties totaling thousands of dollars annually to coerce employees who cannot meet health status goals to seek coverage elsewhere, such as through a spouse’s plan; a public option, such as Medicaid; or a separate private plan purchased through the new health insurance exchanges.

http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=69

Comment:

By Don McCanne, MD

Altruistic employers who, out of the goodness of their hearts, offer wellness programs to their employees, also theoretically benefit by improving productivity through having a healthier work force. These are admirable goals. But employers are now playing the blame game as they use their programs to penalize employees who have medical needs, by reducing their health care benefits and increasing financial barriers to care.

Employers can enhance employee health through work-sourced exercise and nutrition programs, through work safety measures, and through programs such as smoking cessation. In sharp contrast, disease screening should be provided privately in an entirely separate primary care environment where the screening is a part of a comprehensive, integrated health care program that belongs to the patient, not the employer.

Above all, whereas the medical health status of employees should be maintained through the health care delivery system, never, never should the employer be allowed to reduce health care benefits because the employee has greater needs.

This is yet one more reason why health insurance should be totally dissociated from employment. If we had an improved Medicare that covered everyone, health care access would be continuous throughout life, and barriers to care could never be used to punish individuals unfortunate enough to have manifested or contracted medical problems.

Physicians say U.S. needs single-payer national health insurance program

By Roger Brown
Bristol Herald Courier, May 10, 2012

BRISTOL, Va. — The United States must move toward adopting a single-payer national health insurance program or continue to risk seeing its future threatened by an inadequate system that wastes huge amounts of money and keeps millions of Americans from getting necessary medical care, two longtime physicians and health care advocates said Wednesday.

“Our current health care system has made medical care too much of a commercial business, instead of a basic right for every American,” said Dr. Garrett Adams, a Louisville, Ky., pediatrician and president of Physicians for a National Health Program (PNHP), which represents some 18,000 physicians across the U.S.

Dr. Art Sutherland, a retired Memphis cardiologist and president of PNHP’s 150-member Tennessee chapter, echoed Adams’ statements and said more and more Americans – realizing that the current medical system isn’t adequate – are showing support for a national health insurance program that would cover all Americans, dramatically expand Medicare and be publicly funded.

“The public is getting smarter about this, and so are physicians,” Sutherland said. “They know that what we have doesn’t work and that [a national health insurance program] has got to happen.”

Adams and Sutherland made their comments during an interview at the Bristol office of East Tennessee State University Family Physicians, part of their two-day tour across the Tri-Cities to promote PNHP’s call for the U.S. to adopt a publicly financed, national health insurance program.

The doctors said that in addition to providing medical care for all Americans and saving money in general, a national plan would eliminate the financial burden on businesses to provide health care insurance for employees. Companies, like individuals, would simply pay taxes designed to support the program.

A national, single-payer health program, Adams and Sutherland said, would also reduce the excessive influence of health-insurance companies that are largely focused on making profits for shareholders – and often make decisions on whether to cover patients based solely on financial factors.

“If we have the best health care system in the world, why are ranked No. 37th in the world for health care efficiency, which includes issues like infant mortality, life expectancy and immunization?” Adams said, noting a 2010 report by the World Health Organization.

“It’s because the quality of our health care has dropped because of the increasing commercialization of our health care system,” he said. “We’ve got too much money being wasted on administrative costs and too many Americans unable to afford or receive the medical care they need.”

According to a Gallup poll conducted earlier this year, 17.1 percent of Americans have no health insurance, an increase from 16.8 percent in 2010. Both physicians said that while President Obama’s efforts to reform health care, which became law in 2009, have had some benefits, the measure still won’t cover the medical needs of millions of Americans.

And they added that the current health reform law hasn’t lessened the influence of insurers, who have actively resisted major change to the current, costly medical system.

“We give President Obama credit for trying,” Adams said. “But [the current health reform law] just makes some things much more complex. And it’s still keeping the fox in the henhouse.”

http://www2.tricities.com/news/2012/may/10/physicians-say-us-needs-single-payer-national-heal-ar-1903697/

Early retirement is un-American

By Richard Davis
The Brattleboro Reformer, May 9, 2012

A sensible person might think that promoting a health care system that covers everyone with a basic benefits package that everyone can afford would be an easy sell. In some parts of the world entire populations have seen the wisdom of universal health care, but not here. It’s about politics and it’s about preserving the free market at all costs, even if people die in the process.

This is nothing new. Many of us have been talking about this for more decades than we wish to reveal. So when I come across a new way of looking at things — something I haven’t seen or heard — I feel compelled to share it with others.

There is a retired doctor in California, Don McCanne, who sends out a daily e-mail, Quote of the Day, which is usually a reference to a professional paper or media story that points out the need for a single payer system in this country. McCanne is tireless in his efforts and I often pass on his missives to friends and colleagues.

Last week one of McCanne’s pieces grabbed me. It resulted in an epiphany of sorts. It seemed so obvious, yet I have not heard of anyone making this point. It was in the form of a letter written to him by Dr. Khati Hendry who works in the single payer health system of British Columbia as a family physician at the Rosedale Medical Associates.

This is what Hendry had to say: “One of the things that really impressed me when I first moved from the U.S. to practice in Canada seven years ago — I started seeing all these patients who were retiring way before age 65. What was up? They didn’t all seem independently wealthy. Some were taking up other avocations, running B&Bs, but others were, well, just retired. Of course the big difference is that they don’t have to take into account health insurance. They are covered working, retired, laid-off, in transition, in school, married, single, rich, poor — you understand completely. What a difference it makes to a life when you don’t have the angst of health financial disaster looming, and you can make your decisions on all the other things important to you.”

Imagine living in a country where you don’t have to be a slave to people who provide you with health insurance. We have heard the stories about people who keep a job they hate just because the health insurance benefits are good. It creates a lot of unhappy people, can be the indirect cause of domestic violence and no doubt causes a lot of stress-induced disease.

Too many Americans who are over 50 but under 65 may be in a financial position to think about retiring from a job they have held for 20 or more years. They sit down to run the numbers and they quickly become depressed.

If they give up their job and their insurance benefits they will have to pay anywhere from $10-$20,000 a year for adequate health insurance coverage. That means that if they are 55 and are worn out from years of working, they would have to set aside an additional $100,000-$200,000 just to pay for health insurance until they are eligible for Medicare.

Even when they turn 65 they will still have health insurance bills to deal with. Medicare Part A is free, part B costs about $100 a month and if they want to be covered by the 20 percent not covered by Medicare they need to pay an additional $150-$200 a month for a Medigap policy. If they are on medications, the total yearly health care tab for a post-65 retirement could be $4,000-$5,000 a year. This is a uniquely American phenomenon.

I suspect that this situation may be why some smart Americans choose to retire to countries where they have universal health care. They become health care ex-pats so they can afford to enjoy their lives and have a functional retirement.

The next time you hear someone trash the health reform efforts in this country, show them the paragraph by Dr. Hendry. Maybe a light will go on and, just maybe, you will have given someone a reason to become a supporter of American universal health care.

Richard Davis is a registered nurse and executive director of Vermont Citizens Campaign for Health. He writes from Guilford, Vt.

http://www.reformer.com/ci_20579419/early-retirement-is-un-american

Health Affairs article on saving through consumer-directed health plans

Letter to Commissioner Jesson

Southside Pride (Minneapolis), May 7, 2012

Dear Commissioner Jesson:

I am a family practice physician and a supporter of single-payer health care for all. There are nearly 1000 doctors and providers in Minnesota that advocate for this kind of public financing of health care. I am not alone. As you know, single-payer has been popular in Minnesota for years. In fact, it has been endorsed by the DFL for over 20 years and is supported by Governor Mark Dayton.

I am writing because I am concerned that your task force on health reform is not investigating the single-payer option. Recently, a major report was released by the progressive think tank Growth and Justice. It showed how a publicly financed health system such as single-payer would meet Minnesota’s goals of affordable health care more successfully than anything proposed by your task force. The study showed that single-payer would save Minnesotans $4 billion in the first year while expanding comprehensive care to all.

These savings would stimulate the economy and create jobs.

The task force on health reform that you lead is tasked with many important goals: to increase access, decrease disparities, and to keep Minnesotans healthy. I am concerned, however, that the task force may be more focused on the financial welfare of the insurance sector than the health of Minnesotans. Why else would it ignore the one solution that saves money and expands care?

Please prove me wrong by putting single-payer “on the table.”

Thank you.

Elizabeth Frost, MD

http://www.southsidepride.com/2012/05/articles/letter-to-commissioner-jesson.html

What is single payer? A radio interview with Dr. Tom Clairmont

By WSCA Radio, 106.1 FM, Portsmouth, N.H.

Dr. Thomas Clairmont, a leader of Physicians for a National Health Program in New Hampshire, gave the following radio interview to WSCA, Portsmouth Community Radio, on May 1, 2012. In the course of the interview Dr. Clairmont provides a rather comprehensive exposition of what a single-payer system will look like. This audio recording lasts about 30 minutes.

Bill introduced to make health care a right in New York State

Doctors, nurses, patient advocates applaud updated Single-Payer Medicare-for-All legislation

By Single Payer New York
Healthcare-Now, May 9, 2012

ALBANY, N.Y. — Doctors, nurses, patients, senior citizens, anti-poverty advocates, faith leaders and medical administrators joined Assemblymember Richard Gottfried and state Sen. Thomas Duane in unveiling an updated and revised single-payer legislative proposal for New York State on Tuesday. More than 70 state lawmakers are co-sponsors.

Gottfried had initially drafted a single-payer plan for New York in the early ’90s. The revised legislation incorporates changes that have been made in the state’s oversight of health care in the interim, advances in how to provide medical services, and the recent federal changes in the health care system. The legislation builds upon the momentum from last May when Vermont became the first state to enact a universal health care system which the governor plans to make a single-payer system, where one program pays all bills.

“The current system doesn’t work for patients or health care providers, or for the employers, individuals, and taxpayers who pay for care and coverage today,” said Gottfried, author of the bill. “We can get better coverage, get all of us covered, and save billions by having New York provide publicly-sponsored, single-payer health coverage, like Medicare or Child Health Plus but for everyone.”

“Our current health insurance system is driven by uncertainty,” said Sen. Duane. “Will my family have coverage? Can we afford it?

“Single-payer is about removing that fear from peoples’ lives,” Duane continued. “It will allow all New Yorkers the same comfort that our seniors get from Medicare, and that our veterans get from TRICARE. It will allow entrepreneurs to worry about product innovation, not health insurance costs. It is time for single payer in New York.”

Joining Gottfried and Duane at the press conference were Katie Robbins of Health-Care Now!, Vito Grasso, executive vice-president of the NYS Academy of Family Physicians, Dr. Asiya Tschannerl of Physicians for a National Health Program, Mark Dunlea of Single Payer NY / Hunger Action Network of NYS, Shaun Flynn of the NYS Nurses Association, and Rev. Bebb Stone.

Gottfried convinced lawmakers four years ago to fund a study of the most cost-effective way to provide health care to all New Yorkers. The answer was single payer, which would reduce overall health care expenditures in New York by $20 billion annually by 2019. The state study said that single payer would be $28 billion cheaper annually by 2019 than the insurance mandate enacted by Congress. In addition to saving money, single payer was the only plan that guaranteed that everyone would have access to health care services.

The Rev. Bebb Stone said, “The Presbyterian Church U.S.A. has called single-payer health care reform ‘a moral imperative’ since 2008. If I want health care coverage for myself, and I do, how can I not want it equally for my neighbor whom I am commanded to love as myself?

Stone added, “We believe that the value of persons requires that each person have full access to essential services without regard to ability to pay and on terms that enhance the dignity of the individuals,” citing the church’s 2008 resolution.

The proposal would provide comprehensive health coverage for all New Yorkers. Every New York resident would be eligible to enroll, regardless of age, income, wealth, employment, or other status. There would be no premium, deductibles, or co-pays. Coverage would be publicly funded. The benefits will include comprehensive outpatient and inpatient medical care, primary and preventive care, prescription drugs, laboratory tests, rehabilitative, dental, vision, hearing, etc.

“Even if the recent federal health insurance mandates survives the legal challenges, it fails to provide health care coverage to everyone and is financially unsustainable,” said Mark Dunlea, executive director of Hunger Action Network. “Tens of millions of Americans will discover that the insurance they are forced to buy fails to pay for the health services they will need. Everyone knows that there is a better solution — single payer, expanded and improved Medicare for all — and New York should be the first one to put it in place.”

“The simplest and quickest way to reduce health care costs is to eliminate the money wasted on health insurance, its profits and administrative costs, and the bureaucratic barriers it presents to health providers and consumers. If we got rid of insurance companies nationally, the annual savings would be more than $400 billion,” added Dunlea, chair of the state legislative committee of Single Payer New York, an umbrella organization.

“As a physician working in the Bronx, I see every day the profound limits of medicine when patients must ration their care due to high co-pays and deductibles,” said Dr. Asiya S. Tschannerl with Physicians for a National Health Program. “And too many patients have told me that they earn just a few dollars too much to qualify for Medicaid, and are now facing the horrible dilemma of ‘Do I reduce my income or go without insurance since I couldn’t afford it?’ Enough is enough. We need a truly universal health care system like every other industrialized nation on this planet. Health care is a human right, not a privilege! A single-payer expanded and improved Medicare for all would guarantee health care for all.” Tschannerl is also a member of Doctors for the 99 percent and Occupy Wall Street.

Katie Robbins of Healthcare-NOW NYC said, “We must end funding the waste, greed, and corruption of the health insurance companies, and move these resources to funding and providing actual health care. Insured or not, the Affordable Care Act pits people’s needs against profits for corporate-run health care. We can reverse this trend and recognize the right to health care by implementing the New York Health bill.”

Deborah Elliott, RN, MBA, deputy executive director, New York State Nurses Association, said, “The Nurses Association firmly supports the establishment of a more equitable coverage system that directs scarce health care dollars towards providing universal access to high quality, cost-efficient health care for all New Yorkers — regardless of their age, income, health or employment status.”

Under the revised bill, health care would no longer be paid for by insurance companies charging a regressive “tax” –
premiums, deductibles and co-pays – imposed regardless of ability to pay. Instead, New York Health would be paid for by assessments based on ability to pay, through a progressively graduated payroll tax (paid 80 percent by employers and 20 percent by employees, and 100 percent by self-employed) and a surcharge on other taxable income. A specific revenue plan, following guidelines in the bill, would be submitted to the Legislature by the governor.

Federal funds now received for Medicare, Medicaid, Family Health and Child Health Plus would be combined with the state revenue in a New York Health Trust Fund. New York would seek federal waivers that will allow New York to completely fold those programs into New York Health. The “local share” of Medicaid funding – a major burden on local property taxes – would be ended.

Private insurance that duplicates benefits offered under New York Health could not be offered to New York residents.

Assemblymember Gottfried, in his official sponsor memo, noted that “New Yorkers have experienced a rapid rise in the cost of health care and coverage in recent years. This increase has resulted in a large number of people without health coverage. Businesses have also experienced extraordinary increases in the costs of health care benefits for their employees. An unacceptable number of New Yorkers have no health coverage, and many more are severely underinsured.

“Health care providers are also affected by inadequate health coverage in New York State. A large portion of voluntary and public hospitals, health centers and other providers now experience substantial losses due to the provision of care that is uncompensated.”

Social Responsibility of Physicians

By Bernard Lown, M.D.
Dr. Bernard Lown’s Blog, April 26, 2012

The following address was presented to the “Avoiding Avoidable Care Conference” in Cambridge, Mass., on April 26, 2012.

Introduction

Ever since starting clinical practice 62 years ago I have looked forward to this conference. Mercifully, good fortune and good genes enable me to attend. From my earliest days in medicine I have struggled against the prevailing model of health care. My opposition in part was provoked by the growing prevalence of overtreatment. Resort to excessive interventions seemed to be the illegitimate child of technology in the age of market medicine. If more than a half century ago overtreatment was at a trickle pace, it is now at flood tide. Reflecting back on early days, the first overtreatment I encountered was not related to technology. It involved keeping patients with acute MI’s at strict bed rest for 4 to 6 weeks. This was a form of medieval torture. It promoted depression, bed sores, intractable constipation, phlebitis, lethal pulmonary embolism and much else. Worse it augmented cardiac ischemia and predisposed to malignant arrhythmias. Physicians were aware of what was transpiring but felt it was necessary to protect patients against cardiac rupture which activity may provoke.

The great Brigham clinician, SA Levine, my teacher and mentor, believed that patients would fare better when nursed in comfortable chairs. Yet he was not ready to challenge established practice. With his backing I launched such a study in 1951. The house staff initially was vehemently opposed, even greeting me with Sig Heil Hitler salutes. Soon they became avid supporters.

Patient improvement was striking. In fact, hospital mortality from acute MI’s more than halved, depression diminished, pulmonary emboli nearly vanished, hospitalization was markedly shortened, rehabilitation and resumption of work was hastened. I am not aware of a single cardiovascular measure since then that improved survival of CHD patients as much as this common sense change in medical management. We published two articles on our findings in 1952. They evoked no comments as though reflecting a shameful era best forgotten. One should mention, if only as a historical footnote, that there was not a scintilla of evidence supporting prolonged bed rest. While patients were harmed, doctors profited.

Recognition that new technologies were driving overtreatment became evident with introduction of implanted pacemakers in the 1960’s. Compared to colleagues I was implanting about a third as many and inactivating like numbers. Pacemakers though were small cost items compared to what soon followed.

Coronary disease

The problem of overtreatment grew exponentially after Favoloro at the Cleveland clinic opened an innovative terrain by introducing bypass vein grafting. This was followed by technical virtuosities involving angioplasty and later stenting. Within 30 years after Favoloro, the number of revascularizations exceeded a million. Presently a majority of newly minted cardiologists are adept interventionists.

At the same time significant developments were occurring in the medical management of coronary artery disease. These included effective anti hypertensive measures in the 1940’s, introduction of beta blockers in the early 1960’s, and ever more effective lipid lowering agents thereafter. A profound advance was the recognition that risk factors, largely tethered to life style, accounted for the progression of coronary artery disease (CAD). In a rational social order, preventive medicine would have been the focus of resource allocation and physician concentration. Instead, prodigious investments flowed to halfway technologies.

No robust clinical evidence guided the onrush of revascularizations . The Coronary Artery Surgery Study (CASS), the first randomized investigation, published 16 years after Favoloro, provided no comfort for those trumpeting interventions. Instead of being a wake up call alerting to irresponsible overindulgence, coronary procedures continued to escalate.

Lown Clinic

Justification for revascularization is based on claims of increased survival, reduced toll of myocardial infarction and improved quality of life. By the late 1960’s I learned that in a majority of patients, CHD was largely stable and did not demand a rush for or even need for revascularization. I was persuaded that investigating this problem would be difficult once patients were hospitalized. As a result I founded the Lown Clinic. Almost immediately we launched a study. We intended to randomize post angiography patients to either revascularization or medical therapy. The study aborted before it began. After patients were informed by interventionists and house staff of their coronary anatomy, coached in the lurid prose then and now in use, every patient opted for coronary artery bypass grafting (CABG).

Coronary angiography was a funnel for interventions. Its purpose was largely to guide the operator to the narrowed vessel. To diminish coronary procedures required bypassing coronary angiography. We decided to study patients with multivessel disease over a long time frame without resort to angiography.

During the ensuing 35 years we published four studies in high profile medical journals involving about one thousand patients. Outcome data were remarkably consistent. Cardiac events were extraordinarily low, about 1.0 percent annual mortality rates. Our referral for revascularization increased from 1.1 percent annually during the CABG era to around 5 percent during the stenting era. Since a majority were second opinion patients, nearly all would have been revascularized.

Let me repeat. Over any five year period we referred less than 30 percent of patients with multivessel coronary disease for revascularization.

Our medical management was individually tailored. We rigorously treated risk factors. We encouraged optimism. We addressed social and family problems.

We discussed significant psychosocial stresses. We minimized shuttling patients to other specialists. Foremost, doctors spent much time listening, thereby fostering trust and adherence to prescribed lifestyle changes. We did much for the patient and as little as possible to the patient.

One commonly hears that fear of malpractice litigation is a significant reason for doctors resorting to overtreatment. The Lown Group, with its minimalist approach, shou
ld have been deluged with malpractice suits. After all, we deviated from community norms. We did not adhere to the standard of practice prevailing nationwide. Yet during the past forty years we have not had a single malpractice suit for denying a patient with coronary artery disease a revascularization procedure.

We remain a tiny minority voice. Our observations have been ignored by mainstream cardiology. This has not been due to an absence of randomization in our investigations. Large randomized studies from CASS to Courage likewise have had no impact on the scale of interventions.

Health Crisis

Experience of the Lown clinic speaks to the uniformly acknowledged crisis in American health care. Politicians and health policy experts relate the crisis largely to run away costs. In my mind the crisis is far more than fiscal, far deeper than economic. For the past half century doctors have been distancing from patients.

Four points, well known to you, deserve emphasis.

1. Outside the hospital environment one becomes aware that problems bringing someone to a doctor are mostly minor. They largely derive from the rough and tumble of living. They don’t augur far advanced disease. These are healed by the passage of time. This is largely the reason that Hippocratic medicine held sway for nearly 2000 years.

2. A carefully taken history and physical exam identify the underlying condition in the overwhelming majority of patients.

3. Much clinical information is epidemiological and statistical. But statistical fact is not the same as individual truth. Data, irrespective of how comprehensive, may not be relevant for the individual patient. Each person is not only different, but different in a unique way.

4. The more time invested by the doctor at the outset, the more cost effective is the encounter and the more satisfied the patient. The number of specialist referrals and requests for technologic procedures are inversely related to the time spent with a patient especially during initial visits.

Sixty years of doctoring has taught me that taking a history, namely listening, is the quintessential part of doctoring. Proper listening is a skill, an art and a core element of medical professionalism. History taking is far more than providing key elements for a diagnosis. It is the basis for nurturing trust. I am persuaded that nothing of science taught to medical students is as difficult to master as is the fine art of listening. Numerous adverse consequences follow if a doctor does not listen. If time is short shrifted, the doctor treats the chief complaint. But the chief complaint is merely an admission ticket and frequently has little to do with what is troubling a patient. If you were a theater critic, it would be foolhardy to write a comment about a play merely from the scanty information on an admission ticket. Yet that is what doctors far too frequently do.

Treating the chief complaint commonly leads to unnecessary and costly interventions. When the chief complaint is unrelated to what truly bothers a patient, whatever medication prescribed will prove ineffective. As a result polypharmacy multiplies as new complaints are assaulted with still more drugs.

When doctors do not spend enough time listening, they become triage officers for specialists, as the patient is reduced to an assemblage of dysfunctional parts each part being served by some expert. Interest in the patient is replaced by preoccupation with disease. The human dimension is leached out from the clinical encounter. Dissatisfaction by the patient with the visit aggravates symptoms and adversely affects outcome. It encourages internet foraging and second opinion shopping.

When a doctor doesn’t listen, the focus necessarily shifts to the acute and emergent. Since preventive medicine, though the most cost effective approach to illness, is time intensive, it is largely neglected.

Prevention

The small role allotted to primary prevention is a major deficiency of our dysfunctional health care. Community support for healthy life styles are vastly underfunded. The largest investment goes to chronic illness when manifesting as acute disease. Prevention, the foundation of a sound health system, though honored in preachment, commonly plays second fiddle to the loud drumbeat for hospital focused care. This lacks medical rationale and is devoid of economic sense.

Looking around the globe there are numerous persuasive demonstrations of the effectiveness of government sponsored programs promoting community prevention of cardiovascular disease. In 1972 Finland had the highest CVD mortality rate in the world. The Finnish government sponsored large scale programs educating the public about risk factors. It promoted availability of low-fat dairy products, passed antismoking legislation, and improved nutritional quality of school meals. Within a quarter of a century, CVD mortality in Finland was reduced by 75 percent. Another striking example is what occurred in Poland. In 1990, as the iron curtain toppled, Poland opened trade with the West, increasing import of fruit and vegetables. The government also stopped promoting and subsidizing butter and lard consumption. Within less than a decade CVD mortality dropped by a third.

I am persuaded that doctors devoting time listening to patients and shifting medical traffic to the proven road of prevention would profoundly reduce health care costs. Yet these two measures are largely ignored in the ongoing national debate.

Marketization of Health Care

A major factor accounting for these neglects relates to the dominance of market forces which favor and even compel the industrialization of health care delivery.

An essence of industrialization is reducing cost of production by increasing efficiency, namely, lessening the time to make a widget. Productivity is increased by speeding up assembly lines and replacing costly human labor with technology, especially with robotics. The product, irrespective of how socially necessary or value laden, if not profitable, will not be produced.

Listening was an early casualty. Since listening consumes much time, but is minimally reimbursed, it grew cursory, circumscribed, and frequently completely bypassed. It left patients frustrated and doctors uninformed. The consequences for the health care system are ruinous. Aiming to foster increased productivity, industrialization shifted the focus of the debate to efficiency, to competition, to cost containment. Industrial
efficiency is in part obtained by rapid patient through-put during encounters with primary care physicians or during specialist referrals. In such a model of health care doctors are providers, patients are consumer/customers, hospitals are industrial plants and major profit centers.

Medicalization, and overtreatment are an essential part of a market system. As a result patients are morphed into amalgams of dysfunctional parts, with the human dimension commonly shredded in the gears of innovative technologies. The more patients are reduced to widgets, the more amplified is the verbiage that the bed rock of the system is patient centered.

Limitations of Markets in Health Care

Market medicine is organized like any other business to generate profit. Withholding care for those who can not afford it, as well as overtreatment of those with means, are profit maximizers and therefore sound business policy. In order to survive the well intentioned must hew to the competitive pressures of the market or get out of business. This was spelled out by the panjandrum of market theory, the ultimate market triumphalist, Milton Friedman, “Few trends could so thoroughly undermine the very foundations of our free society as the acceptance by corporate officials of a social responsibility other than to make as much money for their shareholders as possible.” In the business model, like any other business, the major goal is profitability. Good intentions and high sounding principles are incidental. I believe that the market is not a solution. Indeed it is a major part of the problem.

Moral Issues

My objection to market dominated health care is on deeper grounds than economic. In a democratic society health care must be a right, not a privilege. The underlying issues relate to essential moral principles. Medicine is a calling. At the core it is a moral enterprise grounded in a covenant of trust between health professionals and patients. The primary mission of a clinician is to heal, to care, to advocate for the sick and to work for the promotion of everyone’s health. Central to the doctor patient relationship is the expectation that patient’s needs will be placed first, over and beyond personal interests or the interests of any third party.

There is a moral absolute in medicine to help and never to wrong the patient. No such moral absolute can be found in the marketplace. Caveat emptor, let the buyer beware, is its underlying admonition. The warm and fuzzy rhetoric that “patients come first” is a transparent marketing ploy. For-profit health care is essentially an oxymoron. The moment care is rendered for-profit it is emptied of genuine caring. This moral contradiction is irreparable by any conceivable palliative. We talk of overtreatment as though it was merely an improper financial transaction. Overtreatment harms patients thereby negating the first principle of doctoring, primum non nocere.

I am reminded in Herman Melville’s Moby Dick; Captain Ahab, experiencing a terrifying moment of illumination, cries out, “All my means are sane; my motives and object mad.”

Where do we go from here?

Any challenge becomes doable when it is shown to be possible. A four minute mile was deemed impossible until Dr. Roger Bannister broke the record. Now it is common-place. So first, the good news. In the present adverse health environment it is still possible to drastically circumscribe overtreatment. For more than 40 years the Lown Clinic has substantially curtailed cardiovascular interventions. The possibility is no longer in question. We have done it!

The bad news relates to the acrimonious partisan health debate now convulsing American politics. When I was in medical school, 70 years ago, universal health insurance seemed a certainty. The Wagner, Murray, Dingell Bill was assured passage through Congress and would have been enacted except for a misbegotten wartime compromise. To maintain a work force in the face of a national wage freeze, industry diverted some wages into health benefits. We are still afflicted with the unintended consequences of that Faustian bargain. We need to get back on the track of history. Medicare has proven to be a remarkable advance in improving health for the elderly. It grants dignity to old age. It operates at lower cost than market driven health systems. Everyone would be covered regardless of employment or health status. It is constitutional.

Half measures will no longer suffice. A single-payer health care embracing the model of Medicare for all deserves to be at the forefront of consideration in addressing what now constitutes close to a fifth of our economy. It would bind our nation, improve health care, contain costs, and lessen moral ambiguities for health workers. A crisis affords an opportunity for deep changes. We should not demure by resorting to creeping partial measures. Self regulation, presumably works among saints. Appeals to our better nature is welcome. History teaches though that curtailing incentives for misdeeds and providing recognition for good outcomes proves far more effective.

Creating a more just health care delivery system will not solve a host of other vexingly difficult issues. Unless fee for service is replaced, we will not restore the centrality of the patient nor lessen reimbursement driven over treatment.

More is better, or less is better are improper catch phrases. The ultimate litmus is what is best for the uniquely individual patient. In 55 years of practice I recall but a single patient who insisted on having coronary angiography. Fully informed patients, trusting their physicians, do not insist on tests or procedures. In overtreatment the patient is victim not instigator.

Health care with a human face requires drastic restructuring of medical education. Promotion of personal communication skills has to be part of a core curriculum during each of the four years.

Furthermore medical education should be subsidized. Health security is integral to our national security. Among other gains it would reduce the pressure for specialization in order to cope with mammoth student debt.

Beyond the breakdown of health care is a far deeper phenomenon. It relates to the onrushing marketization of all human activities. The result is to denature fundamental human values and tear apart ties that promote communal life. We in the health field, who nurture science for the sake of human health and well being, need to be in the forefront in promoting r
espect for the dignity of human life. This has to begin with listening to the patient.

One final thought: about three decades ago a small band of doctors contributed to a historic transformation. They spoke out against the stockpiling of nuclear weapons capable of destroying the world many times over. They believed that there is no greater force in modern society than an educated public, aroused and angered to effect change. This Gideon army of passionately committed physicians made millions aware that medicine had nothing to offer in case of nuclear war. They maintained that the two super-powers either lived together or died together. They offered humankind a prescription for survival. The involvement of multitudes in the antinuclear movement compelled governments to serious negotiations which ultimately lifted the Damoclean sword.

At present we physicians are challenged on our home turf. We need to offer people a prescription for health. Each American deserves dignified, person centered, and affordable health care. At the same time we must convince a wide public that our principles embody responsible stewardship of finite national resources. I have always believed that those who see the invisible can do the impossible.

Bernard Lown, M.D., is professor of cardiology emeritus at the Harvard School of Public Health, the inventor of the defibrillator, and the founder of the Lown Cardiovascular Center in Brookline, Mass. A world-renowned peace activist, he was a co-founder of Physicians for Social Responsibility and the International Physicians for the Prevention of Nuclear War, receiving a Nobel Peace Prize in 1985 for his efforts with the IPPNW.

http://bernardlown.wordpress.com/2012/04/29/social-responsibility-of-physicians/

Provider clout driving up private insurance prices

The Growing Power Of Some Providers To Win Steep Payment Increases From Insurers Suggests Policy Remedies May Be Needed

By Robert A. Berenson, Paul B. Ginsburg, Jon B. Christianson and Tracy Yee
Health Affairs, May 2012

Abstract

In the constant attention paid to what drives health care costs, only recently has scrutiny been applied to the power that some health care providers, particularly dominant hospital systems, wield to negotiate higher payment rates from insurers. Interviews in twelve US communities indicated that so-called must-have hospital systems and large physician groups — providers that health plans must include in their networks so that they are attractive to employers and consumers — can exert considerable market power to obtain steep payment rates from insurers. Other factors, such as offering an important, unique service or access in a particular geographic area, can contribute to provider leverage as well. Even in markets with dominant health plans, insurers generally have not been aggressive in constraining rate increases, perhaps because the insurers can simply pass along the costs to employers and their workers. Although government intervention — through rate setting or antitrust enforcement — has its place, our findings suggest a range of market and regulatory approaches should be examined in any attempt to address the consequences of growing provider market clout.

From the Discussion

More concretely, increased recognition of the role of provider pricing in rising health spending could stimulate both market-oriented and regulatory responses. Market-oriented approaches are generally based on benefit designs that make consumers more aware of costs and give them direct incentives to select low-cost options. However, these approaches, such as tiered networks, have been discussed for many years and are proceeding slowly. Nevertheless, renewed employer willingness to support choice-limiting networks with few providers could help balance negotiating leverage between providers and health plans.

Alternatively, in the face of rising premiums, employers unwilling to adopt more restrictive benefit designs might support more direct regulation of provider rates, perhaps setting upper bounds on permissible rates negotiated between health plans and providers in relation to Medicare rates.

http://content.healthaffairs.org/content/31/5/973.abstract

And…

Further Acceleration in US Healthcare Costs in February 2012 According to the S&P Healthcare Economic Indices

S&P Indices
April 19, 2012

The S&P Healthcare Economic Composite Index indicates that the average per capita cost of healthcare services covered by commercial insurance and Medicare programs increased by 5.75% over the 12-months ending February 2012.

Specific S&P Healthcare Economic Indices:

7.73% – S&P Healthcare Economic Commercial Index

6.78% – S&P Professional Services Commercial Index

8.41% – S&P Hospital Commercial Index

2.72% – S&P Healthcare Economic Medicare Index

3.55% – S&P Professional Services Medicare Index

1.94% – S&P Hospital Medicare Index

http://www.standardandpoors.com/indices/sp-healthcare-economic-indices/en/us/?indexId=sp-healthcare-economic-indices

Comment:

By Don McCanne, MD

This Health Affairs article explains how health care providers – particularly dominant hospital systems – through consolidation and other market manipulations, have been able to position themselves as “must-have” hospital and physician group systems that health plans must include in their networks so that they are attractive to employers and consumers. This “must-have” status allows these providers to demand steep payment increases from the private insurers.

Note that this leverage is applied through private insurers. Government programs such as Medicare are not intimidated by the market clout of these provider systems. Medicare simply pays rates that are enough to keep the provider systems from dropping out of the government program.

How much difference is there between the administered rates of Medicare and the market negotiated rates of the private insurers? Look at the most recent S&P Healthcare Economic Indices.

The latest twelve month per capita increase in the S&P Hospital Medicare Index was 1.94%. For the same twelve months, the per capita increase in the S&P Hospital Commercial Index – the rate increase for private insurers – was an astonishing 8.41% – more than four times the increase in the Medicare Index!

The highly respected authors of the Health Affairs article state that “a range of market and regulatory approaches should be examined in any attempt to address the consequences of growing provider market clout.” Fine. The health policy literature is replete with data that will explain why Medicare is so much more effective than the private insurers in controlling health care costs. Have another look at the literature. Then let’s reject the private insurers and their market manipulations, and move forward with adopting an improved Medicare for all.

Access deteriorating not just for uninsured but also for Medicaid and privately insured

A Decade Of Health Care Access Declines For Adults Holds Implications For Changes In The Affordable Care Act

By Genevieve M. Kenney, Stacey McMorrow, Stephen Zuckerman and Dana E. Goin
Health Affairs, May 2012

Over the past decade, access to health care deteriorated among nonelderly adults. The likelihood of having a usual source of care, having seen a dentist, and having had an office visit all declined. In addition, the likelihood of having had an emergency department visit rose slightly.

Consistent with other sources, the National Health Interview Survey data pointed to significant increases in rates of Medicaid coverage and uninsurance and decreases in rates of private coverage for adults between 2000 and 2010.

The declines in access found among all adults are also reflected within each coverage category. Among the privately insured, significant declines occurred for half of the access measures. There was improvement in one measure — a 1.6-percentage-point increase in the likelihood of having an office visit. However, privately insured adults were more likely to have unmet medical and unmet dental needs in 2010 compared to 2000, and they were more likely to have delayed needed care because of cost and noncost reasons.

Similarly, adults with public coverage experienced reductions in receiving an office visit and increases in unmet medical needs from 2000 to 2010. Especially striking were the increases in unmet dental need and delayed care for noncost reasons (increases of 9.1 and 4.7 percentage points, respectively) among adults with public coverage.

We also found that people with public coverage were less likely to have a usual source of care, to have received an office visit, and to have received a dental visit in 2010 compared to 2000.

Although the above indicates that the deterioration in access was not limited to uninsured adults, it was particularly pronounced for this population. Access to care worsened for uninsured adults for all eight access measures.

From the Discussion

This analysis revealed a noticeable deterioration in access to care among nonelderly US adults during the first decade of the twenty-first century. Access declined for adults in every category, but the most dramatic declines occurred among the uninsured.

More fundamental systemic problems may be reflected in the increased likelihood of delays in care for noncost reasons that we observed among both children and adults. These increases were particularly large among publicly insured adults during the past decade — a time of substantial increases in Medicaid enrollment. This may have strained providers’ capacity or willingness to serve Medicaid patients in some areas of the country.

In addition, despite increased funding for community health centers and continued supplemental payments through Medicare and Medicaid, the safety net has not been able to fully meet the increased need for care among the nation’s growing uninsured and publicly insured population.

Experience also indicates that there is no guarantee providers could adapt quickly to meet the needs of an influx of a large number of newly insured adults. When reforms similar to the Affordable Care Act were implemented in Massachusetts, overall access to care improved; however, some measures of unmet need for care also increased as more people sought care.

The US health care system could respond similarly under the Affordable Care Act, meaning that both the newly insured and those who already have coverage could have problems getting timely appointments or could experience long waits at the doctor’s office. This could be especially true in areas that experience large increases in coverage relative to provider capacity. If these problems with access emerge, they could dampen the potential benefits of the Affordable Care Act.

http://content.healthaffairs.org/content/31/5/899.abstract

Comment:

By Don McCanne, MD

This study from the Urban Institute provides further confirmation of what we already knew. Uninsured individuals have impaired access to health care. What should be particularly alarming to us about this report is that the two coverage expansions in the Affordable Care Act – private insurance and Medicaid – have also been associated with further impaired access over the past decade.

Medicaid’s problem is that it is chronically underfunded. As it expands, health care professionals and institutions are finding that they are less able to serve this population as their losses escalate.

Private insurance also has been associated with a decline in access resulting in greater unmet medical needs. This is most likely due to the unique nature of private insurers competing in the marketplace. To slow the increases in premiums, insurers have shifted more costs to patients, especially through high deductibles, which impairs access because of lack of affordability. They also have reduced access to providers through the use of network contracting. The actuarial values of their plans are declining, leaving greater financial exposure to patients in need of health care. The business model of private insurance works better for the insurers when barriers are erected to care.

This study is receiving wide coverage in the press today, with headlines to the effect that health care access will decline if the Affordable Care Act is overturned. What needs to be emphasized is that health care access has been declining under the two programs to be expanded by the Affordable Care Act – private insurance and Medicaid.

What should be covered in these articles is that if we want to improve access, we can do it by removing financial barriers for everyone, simply by adopting a single payer national health program – an improved Medicare for all.

Why emergency rooms don't close the health care gap

By Aaron Carroll, M.D., Special to CNN
CNN, May 7, 2012

For decades, the attempts at health care reform have aimed to increase access. The United States is one of the few industrialized nations in the world that does not provide universal health care to its citizens. And repeatedly, those who oppose it have been forced to argue that access isn’t the problem some make it out to be. Why?

The emergency department, they say. After all, it is a commonly held belief that no one can be denied care there. So — in essence — everyone can get free health care if they need it. We have a universal system after all.

That, of course, is not true.

It’s not even close. Let’s start with the idea that emergency rooms must provide you care.

What’s important to remember is that you can’t be refused emergency care. That’s because the Emergency Medical Treatment and Active Labor Act (EMTALA) requires that any hospital that takes Medicare or Medicaid must check you for emergent conditions and treat them if they exist. Since nearly every hospital in the country takes federal funds from one of these programs, nearly all hospitals are subject to EMTALA.

But “emergency medical condition” has a pretty narrow definition. It includes active labor for women and acute conditions that would cause death, serious bodily organ harm or serious bodily function impairment if they were not treated right away.

If politicians are meaning to say that women have universal access to delivery care, then I suppose there’s an element of truth to that. But there’s no guarantee of prenatal care in the emergency department.

If they are saying that we have universal access if we’re acutely having a heart attack, then I suppose there’s truth to that as well. But there’s no such access for lipid panels, stress tests or prescriptions for cholesterol medications that might help you avoid the heart attack in the first place.

If you’re acutely obstructed by massively advanced colon cancer, it’s likely you can get emergency surgery to end the blockage. But your cancer is likely too far advanced to cure at that point. Moreover, you’re not going to get chemotherapy in the emergency department nor could you have gotten the colonoscopy that might have detected the cancer far earlier.

You can’t get preventive care in the emergency department. You can’t get screened for a host of disorders. You can’t get treatment for your depression there or really for any chronic mental disorders. You can’t get help with your child’s autism, ADHD or developmental delay.

And even if you could, it wouldn’t be free.

That’s the second and perhaps more misunderstood part of this emergency department misconception. The costs of treatment in the emergency room are not quickly dismissed or written off. You’ll get that emergent care, but you’ll also be charged for it.

And hospitals aren’t going to let that go easily. A recent article in the New York Times detailed how Accretive Health, a medical debt collector, is using aggressive tactics such as confronting patients in their hospital beds to collect the money owed for even emergent care. The article also describes how collection agencies have long been used to go after patients after they’ve left the treatment facility. In some cases, patients were even confronted and stalled by debt collectors as they entered the emergency department on some later occasion so that the company could collect on old bills before more care was offered.

An even more recent story covered by Kaiser Health News and NPR reported on a family of four sued by its local nonprofit hospital. The family earned about $25,000 a year — below the poverty line — but the parents did not qualify for Medicaid in Ohio. It seems that the hospital had sued almost 1,600 people for unpaid medical bills from 2009 to 2011. Further, the piece reported, “[w]hile Ohio has a law that prevents foreclosures based on medical debt alone, it is legal for hospitals to garnish patient wages, attach bank accounts and get a lien on any future earnings, including from the sale of a house.”

It might even be worse in North Carolina, where a group of nonprofit hospitals sued 40,000 patients from 2005 to 2010. This is problematic because nonprofit hospitals are supposed to provide a certain level of charity care in exchange for their tax-exempt status. A recent review found that three hospitals in Illinois were providing a very small amount of care for free or at discounted rates. This has led to a number of facilities losing their nonprofit status and legislators to try to pass new laws requiring specify charity care minimums for nonprofit status.

Before you get all riled up, I understand that hospitals need money to run. The American Hospital Association reports that hospitals lost upward of $40 billion in unpaid bills in 2010 alone. I’m not suggesting care should be given out freely or that hospitals should be forced to operate at a loss. But let’s acknowledge that patients will be held accountable for the costs of their care, even in the emergency room. If they can’t pay those bills, their credit can be ruined. Medical bills are a very significant cause of bankruptcy in this country.

So it’s true that an emergency room won’t let you die if you show up at the door, but short of that, you can’t get care for a host of medical issues. And, while they will provide that lifesaving care to you even if you have no insurance and no money, they will send you a bill. And if you can’t pay, it may cause you, and your family, financial ruin.

That’s a far cry from universal health care, and nothing to brag about.

Editor’s note: Dr. Aaron E. Carroll is an associate professor and vice chair of health policy and outcomes research in the department of pediatrics at the Indiana University School of Medicine. He blogs about health policy at The Incidental Economist and tweets at @aaronecarroll.

http://www.cnn.com/2012/05/07/opinion/carroll-emergency-rooms/index.html