PNHP

“Damaged Care” Premiere Features HMO Whistleblower

pnhpf3a

“Damaged Care” Premiere Features HMO Whistleblower

Contacts:
Linda Peeno MD (502) 548-7878
Steffie Woolhandler MD (617) 665-1032
Quentin Young MD (312) 782-6006

Screening on Capitol Hill to be followed by panel with Dr. Linda Peeno,
Former HMO physician who denied a heart transplant

Former Humana Medical Evaluator Dr. Linda Peeno was so disturbed by what she experienced working for the giant HMO — including denying a young patient’s heart transplant — that she went into medical ethics and is now a vocal advocate for health care reform.

A film based on the experiences of Dr. Peeno, called “Damaged Care” and including a scene showing her denying a patient’s heart transplant, will have its world premiere on Capitol Hill on Friday, May 10. Laura Dern (“Jurassic Park”) plays Dr. Peeno. Dr. Peeno testified before Congress in May of 1996 about her heart transplant case and has been outspoken about the right to health care ever since.

“As a physician working for Humana, I denied a young man a heart transplant that would have saved his life, and thus caused his death,” testified Dr. Peeno. “No person or group has held me accountable for this, because, in fact, what I did was I saved a company a half a million dollars.”

“Humana’s only concern was costs,” says Dr. Peeno. “The young man fit all the criteria, a donor had been found, his doctor was ready to do the operation. Meanwhile, behind the scenes Humana employees scrambled to find a loophole in the patient’s contract. When they did, I was the one who had to tell the surgeon that the operation would not be covered.”

“The doctor asked me if I knew that the patient would likely die of his condition without the surgery, and I said I knew.” says Dr. Peeno. “When I hung up the phone my colleagues at Humana were thrilled, even joyful. I was sickened.”

In addition to Laura Dern, “Damaged Care” stars James LeGros, Adam Arkin, and Michelle Clunie, and features Regina King and Dianne Ladd. It will air on Showtime at 8 pm EST May 26 and May 29.

Dr. Peeno recalls that shortly after denying the patient their heart transplant, a gigantic piece of sculpture was purchased for Humana’s headquarters — costing about the same amount as the heart transplant she had denied.

“When HMO’s came on the scene, we were told that they would eliminate only the ‘inappropriate care’ and they would reduce costs so everyone could have insurance. Exactly the opposite has happened. They deny and delay needed care with sophisticated techniques, consume enormous resources for overhead costs and profits, and health care costs are rising dramatically.”

“Our corporate-dominated health care system is sick,” said Dr. Quentin Young, Past President of the American Public Health Association and National Coordinator of Physicians for a National Health Program. “It’s time to end the experiment with market-driven health care and adopt a non-profit national health insurance program.”

“The US health system is the most bureaucratic in the world, wasting over $150 billion annually on excessive paperwork,” said Dr. Steffie Woolhandler, Associate Professor of Medicine at Harvard. “Meanwhile, 600,000 retired steelworkers just lost their health benefits and joined the ranks of the 40 million uninsured. There is more than enough money in our health system — over $4,300 per person — to provide quality health care for all if we exclude the corporate middleman and implement single payer national health insurance.”

When the film “John Q” came out — about a young man denied a heart transplant by his insurer — many people said that “it couldn’t happen in America.” “Damaged Care” not only shows that it is possible, but that because of the conflict between patients and profits, that it is inevitable.

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Physicians for a National Health Program (PNHP) is an organization of over 9,000 physicians that supports a single payer national health insurance program. PNHP is based in Chicago with chapters across the US. For local contact information, call (312) 782-6006. www.pnhp.org

Dr. Linda Peeno is a family physician, medical ethicist and medical-legal consultant in Kentucky.

Rep. John Conyers is hosting the D.C. screening with Director Harry Winer.
Rep. Conyers will introduce legislation this spring calling for single payer national health insurance and excluding for-profit, investor-owned corporations in the delivery of health care.

Bleeding the Patient: The Consequences of Corporate Health Care

JAMA
May 1, 2002
Book Review by Jerrold P. Schwartz, M.D.

By David Himmelstein and Steffie Woolhandler with Ida Hellander Common Courage Press

“The seven years since the failed attempt of the Clinton administration to enact health care reform have seen the burgeoning of for-profit corporations in all aspects of health care. Giant health insurance and pharmaceutical corporations, for-profit hospital corporations with hundreds of hospitals, hemodialysis and nursing home chains, mental health and home care corporations, and many others less visible, such as quality-of-care and credentialing companies, are now well entrenched in our uniquely American system of health care and are profiting handsomely. But in the free-enterprise free-for-all, how are patients – and doctors – faring? To find out, read this book.”

“Judging by the tone of the book, the authors clearly uphold the US ideals of democracy and egalitarianism.”

“As advocates for our patients and to preserve the ethical underpinnings of our profession, all US physicians should read this compelling argument for medicine as a public service.”

Comment: “Bleeding the Patient” is available from the publisher, Common Courage Press at: http://www.commoncouragepress.com/himmelstein_bleeding.html

Professor Donald W. Light on Price Discrimination:

An old, dishonorable practice needs to be seen in a new light, namely making people without health insurance pay far more than others for needed health care. This especially affects immigrant groups, and among them, Latinos have the highest rate of uninsurance.

For decades, providers and especially hospitals, have kept raising their charges, far higher than their costs, in order to raise their “profile” for discount payments from government programs and insurers. Each year they raise the charges, and each year the payers respond by lowering the percentage of “charges” they will pay. This game is fine for those in them, and conversations about those not in them usually focus on Sheiks. In a recently conversation, a sub-specialist at a famous hospital was explaining how only millionaires and Sheiks pay full charges – they are so outrageous -and these windfall sums help pay for the uninsured.

But first, the uninsured are billed the “standard charges” (which no insured person pays). Then, when they cannot pay, bill collectors are sent, who attach their credit cards or homes (if they have one), and who threaten to report them to the INS. These charges are typically 3-6 times greater than what is normally collected from HMOs, insurers, and managed care plans. I recently experienced this personally, when a routine blood test was deemed not covered. The lab (a large national company) normally collects $85 for the test from discount contractors, but because they were billing me as an individual, their itemized bill was $401, more than 4 times greater. I got my physician to write a note and the bill was adjusted down to $85. If this had been for a hospitalization, the bill might have been $8500 to a plan or insurer, but $40,100 to an individual.

These practices have been documented by Consejo De Latinos Unidos, and they have a class action suit against Tenet, the huge managed care corporation, for ethnic discrimination. They have even shown in what unsystematic data they have been able to gather, that a hospital recovers more income from uninsured Latinos than from HMOs, i.e., the collection agents get them to pay a third of the bill, or $12,000 before taking them to court and/or getting them deported, when a routine payment would be $8500. Their material include a number of case studies that are an embarrassment to read.

Of course, Tenet replies they are doing what they always do, and that is correct. That’s “how the system works.” The judge on the case happened to speak about it off the record and comments that courts are not set up to change systems. In short, a dishonorable old practice of charge inflation has tragic consequences for the uninsured and especially for immigrants. All discussions about the uninsured, and about individualizing health care by having employees get health insurance for themselves, need to include these issues and practices.

Joanne Landy, Executive Director of the New York Chapter of Physicians for a National Health Program, responds to Rima Cohen on the Health Care Access Resolution – House Concurrent Resolution 99 (HCAR or HCR 99):

I was happy to see on the Q of the D that Rima Cohen, Vice President at the Greater New York Hospital Foundation and Director of the Insurance Options for the Uninsured Project, supports the Health Care Access Resolution – House Concurrent Resolution 99. As a statement committing Congress to enact universal health care by 2004, it is an urgent and necessary resolution.

It’s important to note that HCAR goes beyond calling for universal care; it calls for a guarantee that every person in the United States, regardless of income, age, or employment or health status, has access to decent, humane and affordable care, as detailed in the resolution (see below.)

It is important, however, to urge the public and members of Congress to work simultaneously for a single-payer health care system in the United States that can actually achieve the crucial goals enumerated in HCAR. A single payer system would create a universal risk pool and would finance health care through progressive taxation rather than through an employer-based system that depends on private insurance companies. A single payer system (essentially an improved and expanded Medicare-for-All) would save enormous amounts of precious health care dollars currently spent on marketing, on profits, and on the administrative costs built in to a system that forces providers to comply with hundreds of different insurance plans.

HCAR was introduced by U.S. Representative John Conyers, who is to be congratulated for his vision in doing so. He will shortly be introducing a single-payer health care bill, which will address the question of how to contain health care costs while assuring universal access to quality health care. I hope that Rima Cohen and other supporters of House Concurrent Resolution 99 support the Conyers single-payer bill as well.

HCAR calls for healthcare that: (1) is affordable to individuals and families, businesses and taxpayers and that removes financial barriers to needed care ; (2) is as cost efficient as possible, spending the maximum amount of dollars on direct patient care; (3) provides comprehensive benefits, including benefits for mental health and long term care services; (4) promotes prevention and early intervention; (5) includes parity for mental health and other services; (6) eliminates disparities in access to quality health care; (7) addresses the needs of people with special health care needs and underserved populations in rural and urban areas; (8) promotes quality and better health outcomes; (9) addresses the need to have adequate numbers of qualified health care caregivers, practitioners, and providers to guarantee timely access to quality care; (10) provides adequate and timely payments in order to guarantee access to providers; (11) fosters a strong network of health care facilities, including safety net providers; (12) ensures continuity of coverage and continuity of care; (13) maximizes consumer choice of health care providers and practitioners; and (14) is easy for patients, providers and practitioners to use and reduces paperwork.

Does anyone seriously believe that our private, employer based heath care system can deliver this package? To ask the question is to answer it.

–Joanne Landy Executive Director Physicians for a National Health Program New York Chapter

Comment: It is very easy to ask your member of Congress to support House Concurrent Resolution 99 by sending a message through the following link: http://www.house.gov/writerep/

HealthCare access Resolution – House Concurrent Resolution 99

America’s Health Together (www.healthtogether.org)
April 30, 2002
Washington, DC

Rima Cohen,Vice President at the Greater New York Hospital Foundation and Director of the Insurance Options for the Uninsured Project, whose mission is to devise and implement strategies for expanding health insurance coverage in New York:

… we know for sure that the market has not taken care of the problem. Indeed, about a million people every single year since the census began collecting these statistics, have been added to the ranks of the uninsured. So, that’s a difficult thing for me to grapple with looking back on so many years working on health insurance coverage.

So, I jumped at the chance to move into the state health policy arena, thinking that this is where the action is going to be in the coming years, and to a certain extent, I was right. And I was very fortunate when I moved to New York to be involved with an effort that started off with a coalition of organizations where we developed a health insurance plan that was meant to build on our Child Health Plus Program. It was for parents and childless adults, and within a couple of years of my arrival in New York, that legislation passed into law. And, it was the single biggest expansion in New York’s history since–or I should say, since the creation of Medicare and Medicaid in 1965.

So, having been through that experience, you would think that I might be a big advocate of states as the laboratories of democracy, states experimenting with health insurance coverage initiatives, maximum state flexibility to develop locally tailored solutions to the health insurance crisis, but actually, I came away with exactly the opposite sense.

… health insurance coverage is really something that should not be thrown onto the states. And indeed, New York, with all the fanfare of this huge health insurance expansion, we really have not seen a drop in the uninsured. I think all we’ve done is managed to keep people–more people from losing their coverage.

So, let me just tie this all together with a couple of pearls of wisdom that I think can be used to think about strategies going forward. And the most important one is the one that I call, “Bigger is better when it comes to health insurance coverage.” And what I mean by that is, the lens through which I look at every health reform solution is always, “Does it pool the greatest number of people in the largest pool and the greatest number and the most diverse in terms of their ages and illnesses and so forth?” Because that’s the only way that health insurance works.

Health insurance does not work when people can segment themselves into tiny groups and divide themselves based on their illnesses or even geography or their age. And the system now really divides people, and what we really should be doing is pooling people. That’s the principle of health insurance and that’s why–one of the reasons why I think a resolution like this is so important. It’s saying, “Everybody needs health insurance coverage. Let’s pool the largest number of people together,” and a corollary of that is, “Don’t be fooled by calls for more choice.” I think all Americans want choice of their health care providers. I don’t see individuals clamoring as much for their choice of health plans, their–lots of other kinds of choices that you hear set up. Choices of benefit packages. That only allows people to segment themselves again. We need to be thinking about large solutions, comprehensive solutions. That’s the only way we’re really going to–to see a real program for all Americans.

And that’s why I think a Resolution like this is so important (H Con Res 99). Because it doesn’t say that this is exactly the way the health–the health care solution has to be built, but it says, regardless of the method, it has to be done. And the appropriate place to start is in the U.S. Congress passing this resolution, saying that by a date certain, the feds will come up, hopefully in partnership with the states and with lots of organizations that care about this issue, will come up with a solution but it cannot be done by states alone.

For the transcript: http://www.kaisernetwork.org/health_cast/uploaded_files/Transcript_HealthTogether.pdf (cut and paste to rest of link)

For House Concurrent Resolution 99: http://www.house.gov/conyers/hr99.PDF

The resolution calls for legislation by October 2004 that would guarantee that every person has access to health care that meets fourteen specific criteria that we all support. Read it, and then contact your Congressional representative to enlist his or her endorsement.

Doctors, Ideals and Bottom Lines

The New York Times
May 3, 2002

As a private psychiatrist with about 45 percent of my patients on Medicaid or Medicare, I agree with Marc Siegel (Op-Ed, May 1) that Medicare should be expanded. But let’s not stop with prescription drugs. The program should cover all Americans. We could change its name to National Health Insurance. Were this to happen, I’d gladly accept a pay cut.

J. WESLEY BOYD, M.D. Northampton, Mass. The writer is a lecturer in religion at Smith College and in psychiatry at Harvard Medical School.

http://www.nytimes.com/2002/05/03/opinion/L03DOCS.html

The original Op-Ed by Marc Siegel (“… choosing not to take Medicare patients should not be seen as simply a neutral business decision.”): http://www.nytimes.com/2002/05/01/opinion/01SIEG.html

Comment: “National Health Insurance” or “NHI” is a neutral term that can be used for broad audiences. Now that health reform is back in the news and on many agendas, it is helpful to have a term that represents comprehensive reform but without invoking concepts for which organized opposition already exists. “Medicare for All” provokes negative responses from those that are unhappy with the affects of neglect and political damage done to our Medicare program. “Single payer” provokes responses from those that have been saturated with misinformation about the Canadian system. These terms are certainly acceptable for selected, targeted audiences, but might not be the best terms for large, broad audiences.

“National Health Insurance” suggests the option of comprehensive reform, a concept that is now being accepted as an alternative to our current incremental approaches, now that the public is showing concern about the failures of incrementalism (skyrocketing premiums, excessive cost-sharing, and more uninsured). Once the forum is opened up to National Health Insurance, we can use this opportunity to explain to the public the beneficial features such as equity in funding, comprehensiveness, improved access, and elimination of financial barriers while containing costs.

Although no single terminology would be appropriate for all circumstances, National Health Insurance, or NHI, should be in our tool box as we communicate to the nation the advantages of reform that would provide affordable, comprehensive care for everyone.

PRI's "Marketplace"

May 2, 2002

Academics, analysts, lawmakers and the public: from all sides there are complaints that the country’s health care system isn’t working. More than 40 million are uninsured. Costs are soaring and so are premiums, nowhere more than in California, where many will see their rates rise 25% in the next year.

James Kahn, M.D., an epidemiologist and health services researcher at the Institute for Health Policy Studies at the University of California, San Francisco:

“We spend ($15 billion in California) every year to administer the health care system, and what do we get for that? Are people pleased that they have to change health plans? Are they pleased that they have to change doctors, that they have to fight with insurance plans about what’s covered and what isn’t?”

… single payer advocates claim that they can give more people more services for less money, a claim substantiated by an independent review of California’s single payer proposals from the Lewin Group.

In order to overhaul the system there needs to be broad political backing and extensive public education and support, but California advocates of a single payer system point to the increasing premiums, dwindling benefits, and the growing number of uninsured. The time is right for change, they say, and California, with its history of political independence, stands the best chance of making it happen.

This audio report is available through a link at KFF’s Daily Health Policy Report at: http://www.kaisernetwork.org/daily_reports/rep_index.cfm?DR_ID=10945 Those with RealPlayer can hear PRI’s three minute report by clicking “online” at the end of the KFF written report.

James Kahn’s co-authors of the UCSF single payer proposal for the California Health Care Options Project include Thomas Bodenheimer, Kevin Grumbach, Vishu Lingappa, Krista Farey and Don McCanne. All proposals and the analyses of them are now available at: http://www.healthcareoptions.ca.gov/doclib.asp

PRI’s “Marketplace”

May 2, 2002

Academics, analysts, lawmakers and the public: from all sides there are complaints that the country’s health care system isn’t working. More than 40 million are uninsured. Costs are soaring and so are premiums, nowhere more than in California, where many will see their rates rise 25% in the next year.

James Kahn, M.D., an epidemiologist and health services researcher at the Institute for Health Policy Studies at the University of California, San Francisco:

“We spend ($15 billion in California) every year to administer the health care system, and what do we get for that? Are people pleased that they have to change health plans? Are they pleased that they have to change doctors, that they have to fight with insurance plans about what’s covered and what isn’t?”

… single payer advocates claim that they can give more people more services for less money, a claim substantiated by an independent review of California’s single payer proposals from the Lewin Group.

In order to overhaul the system there needs to be broad political backing and extensive public education and support, but California advocates of a single payer system point to the increasing premiums, dwindling benefits, and the growing number of uninsured. The time is right for change, they say, and California, with its history of political independence, stands the best chance of making it happen.

This audio report is available through a link at KFF’s Daily Health Policy Report at: http://www.kaisernetwork.org/daily_reports/rep_index.cfm?DR_ID=10945 Those with RealPlayer can hear PRI’s three minute report by clicking “online” at the end of the KFF written report.

James Kahn’s co-authors of the UCSF single payer proposal for the California Health Care Options Project include Thomas Bodenheimer, Kevin Grumbach, Vishu Lingappa, Krista Farey and Don McCanne. All proposals and the analyses of them are now available at: http://www.healthcareoptions.ca.gov/doclib.asp

Aetna Ends a Drought in Health Care Profit

The New York Times
April 26, 2002
By Milt Freudenheim

Aetna reported a turnaround in its troubled health insurance business yesterday, reflecting sharply higher premiums and the loss of millions of members that it said had been money losers.

Aetna said its premiums would rise 18 percent this year, ahead of medical costs, which are expected to grow 15 to 16 percent.

Dr. John W. Rowe, chief executive of Aetna, said that as premiums rose many employers were passing some costs to employees. Workers, who are paying more in premiums, deductible amounts and copayments, may hesitate before going to a hospital emergency room for, say, a sprained ankle, he said.

http://www.nytimes.com/2002/04/26/business/26CARE.html

Comment: It is reassuring to learn that everyone now knows how to determine whether an ankle injury is a tear of the anterior talo-fibular ligament or a fracture of the distal fibula. If it is a tear, they also know the degree of the tear and the management of each level of severity. Not only that, they also know how to prevent the prolonged disability that results from an enlarging hematoma typical of these injuries. They also understand the rehabilitation measures that will optimize their return to normal function. Or do they? Have we come to the point that any medical problem that is not a life-threatening event is to be considered an abusive use of our health care system by a woose and therefore not worthy of being funded by health insurance?

Dr. Rowe’s insensitive comments confirm that he and others like him should no longer control our health care funds. Let’s throw out this egregiously wasteful middleman industry that is now abandoning its essential role of funding health care.

We know that we can replace this abusive system with a program of national health insurance which would provide truly comprehensive coverage for everyone at a lower cost. What are we waiting for?

Jack Lewin, M.D., EVP and CEO of the California Medical Association, responds on the quote of AMA President Richard Corlin

On the need a pragmatic solution for the uninsured: “irreducible minimum, probably about 15 million”:

Don and other Folks—Corlin has been misunderstood here. I talked with him. He supports doing SOMETHING to get as many people covered as possible, rather than waiting forever for a universal solution—which he nonetheless fully supports also. Please make sure Barbara (author of response) gets this too—I don’t have an e-mail address for her.—-Jack Lewin

Comment: Dr. Lewin is absolutely correct. Dr. Corlin has repeatedly stated that he supports covering the uninsured, and he supports expanding coverage through pragmatic approaches. The “Quote of the Day” messages are intended to provoke constructive thought on health policy issues facing us today. Dr. Corlin’s isolated comment accomplished this, but failed to communicate the sincere dedication of Dr. Corlin to creating a better health care system for all of us.

But our concepts of pragmatism in health care reform are in sharp contrast. The difference can be illustrated by comparing the recent actions of the House of Delegates of the California Medical Association (a leader in influencing AMA policies) with the recent results of the California Health Care Options Project.

In March, 2002, the CMA House adopted a resolution (Report B-1-02) that “CMA participate in health care reform efforts by creating, convening and/or joining coalitions… whose purpose will be to create necessary national and state legislative packages designed to achieve health insurance coverage for all Californians.” But in the same resolution, they called for establishing policy “supporting defined contributions,” “expanded choices of health care financing,” continuing to “provide charitable care,” and combining “economic incentives and reasonable regulations.”

The intent of the CMA House is quite apparent in the concomitantly adopted Resolution 209a-02, “Consumer-Driven Financing of Health Care.” The CMA House resolved “That CMA assert a leadership role in the support, expansion, and design of consumer-driven and consumer-controlled health care financing programs that bring patient choice to health care financing such as Medical Savings Accounts, Flexible Savings Accounts, Personal Care Accounts, Health Freedom Accounts, Health Savings Accounts, and other versions of consumer-driven health care purchasing, and forward same for national action; and be it further resolved: That CMA assert a leadership role in the support, expansion, and design of refundable tax credit programs for the purchase of health insurance, and forward same for national action; and be it further resolved: That CMA work with California’s Congressional delegation to support the right of all patients to use pre-tax dollars for the purchase of their medical care; and be it further resolved: That CMA help physicians bring such recommendations directly to our patients for their education and political support; and be it further resolved: That CMA work with the AMA to support federal legislation to provide a refundable tax credit for the purchase of catastrophic health insurance, consistent with Report B-1-02.”

Conservative and progressive economists agree that these policies can never result in universal health care coverage and will erect greater financial barriers to care for precisely those individuals that have a greater need for care. Pragmatism? Solutions that control costs by preventing access to necessary care may be pragmatic, but they are also inhumane.

(Physicians for a National Health Program provided information to the Technical Advisory Committee of the CMA that produced the report on financing health care. Although the proposals of the Heritage Foundation were enthusiastically endorsed, PNHP’s proposals were cursorily dismissed with the false statement that a single payer system could not control health care costs. Obviously, the committee did not understand the fundamentals of single payer reform since a major advantage of single payer is to establish a structural mechanism of containing costs in an equitable system. The only other possible conclusion is that the committee did understand the proposal but denied the truth because of their own ideology. Regardless, the CMA and AMA have a pressing need to inject more objectivity into their process.)

In contrast, our concept, a model supported by the results of the California Health Care Options Project, would provide comprehensive care to everyone and reduce costs. Pragmatic? The CMA calls for taking recommendations to patients for education and political support. Our position is that ALL models should be taken to all patients and potential patients for their education. Once they understand which model serves physicians well at the cost of health care access, and which model serves the public well with the benefit of access and coverage for all, then the public will tell us which is the “pragmatic” approach.

CMA resolutions: http://www.cmanet.org/upload/FinalB02.pdf

California Health Care Options Project: http://www.healthcareoptions.ca.gov/

LANDMARK STUDY OF OPTIONS FOR HEALTH CARE REFORM

The final results of the California Health Care Options Project have been posted: http://www.healthcareoptions.ca.gov/

Two page summaries of the nine options: http://www.healthcareoptions.ca.gov/final/Summaries_ALL%20040502.pdf

Cost and coverage analysis by the Lewin Group: http://www.healthcareoptions.ca.gov/final/CA%20Report%20-%20Medi-Cal.pdf

Qualitative analysis by AZA Consulting: http://www.healthcareoptions.ca.gov/docs/Final%20presentation%20document%201-22.pdf

Now that Harry and Louise are no longer under contract with the Health Insurance Association of America, just imagine the possibilities…

“Harry, did you see this article on the California study on single payer?”

“Is that like that terrible Clinton plan?”

“No, honey. This one’s really different. This study was done by reputable health policy researchers, including many from the University of California. It shows that absolutely everyone could have truly comprehensive health care while saving Californians billions in health care costs.”

“Now Louise, that’s impossible.”

“No. Really. By replacing the hodgepodge of health plans with a single insurance program, enough administrative waste would be eliminated to pay for comprehensive health care for everyone. And we wouldn’t be limited to that list of doctors that our current plan requires. We’d have free choice again.”

“Wow. It sounds like the voters should be checking this out.”

“And our legislators too.”

Donald W. Light, Ph.D., responds on the increased funding for the British National Health Service:

The NHS reforms under Tony Blair go much farther than to make up for years of underfunding, which previous Prime Ministers denied was the case. Mr. Blair and Mr. Milburn have open acknowledged central flaws in the NHS that resulted from compromises that Bevan had to make to the medical profession in 1948, and they are rectifying them all.

Severe shortages in nearly every subspecialty are coming to an end. The lack of quality standards is being addressed more systematically than here. The coordination of training of all clinical staff is starting up (like the vision out of PEW in the 1990s here but unlikely to be realized). The hospital-centric system is being systematically transformed into the obverse, with community-based primary care as the center of the system and with GPs and community nurse teams holding the budgets for nearly all health care. These will be population-based and risk-adjusted, roughly what David Kindig envisions in Population-Based Purchasing (Wisconsin 1996). The waiting lists are being transformed. They will be taken away from consultants and coordinated through referral centers. Patients will be given appointments as much as possible. The conflicts of interest in the consultants’ contract are being replaced with productivity-based terms. This is a reform I have been working to bring about for several years, and the Blair Government has accepted most of the recommended changes.

There are serious problems in implementing all this, but the design and vision are worth serious attention by anyone interested in a population-based, community-centered model of health care like that envisioned in the Dawson Report of 1920. I have written several short pieces on aspects of all this as I have worked on the reforms every quarter since 1990.

Don Light

Prof. Donald W. Light
Fax: 1-609-924-1830
Tel: 1-609-924-9220

AMA President Richard Corlin’s insensitive remark on the uninsured provoked more responses than any prior “Quote of the Day” message. Barbara Rylko-Bauer eloquently expresses the innate emotional response that most of us felt on reading his words. My comments follow hers.

Barbara M. Rylko-Bauer:

Dear Don:

According to your “quote of the day,” Dr. Richard Corlin, president of the AMA, during a trip to Cedar Rapids last week, was supposed to have said the following with regards to the uninsured:

“We need a pragmatic, not an ideological solution. Reduce the number from 39 million to its irreducible minimum, probably about 15 million, and consider that a victory and not a terrible tragedy.”

If Dr. Corlin truly did say these very words, then I think that all responsible physicians should call for his resignation…for he has served medicine and the physicians he represents, as AMA president, very poorly, to say the least.

By responsible physicians I mean those :

* who consider that their role is not just to treat a disease that walks in the door, but also to be concerned about larger health care issues facing communities and populations,

* who are compassionate,

* who are concerned with what is happening in health care delivery in this country… NOT just in relation to how it affects medicine’s autonomy, not just in relation to how it is affecting doctor-patient relations, not just in relation to how it affects their pocket book…(ALL valid things to be concerned about.)… but also in terms of how it is affecting the patients they are privileged to treat,

* and who are concerned about all the other people who ARE NOT patients because they have no real access to care…..in other words, those pesky uninsured folks that Dr. Corlin so readily dismisses.

Dr. Corlin should also do a little reading about the state of affairs of health care in the United States. He might discover that it’s not just those 40 million that are the “problem.” There are also another 40 million or so who are unstably insured (with gaps during the year) or underinsured. What, oh what, are we going to do with them?

Of course, the bigger question is why, in the wealthiest country in the world, which in the year 2000 spent $1.3 trillion on health care — that averages to $4,637 per person….(but of course, not distributed evenly) — we even have to be discussing problems like:

* the large and growing number of people who are uninsured,

* the fact that despite all our advanced biotechnology, we are plagued with serious safety and quality problems in health care delivery,

* the large racial and ethnic disparities in health care delivery,

* and the fact that our headlong race to embrace a market-oriented health care system (of which managed care is just one part) has undermined the “health care safety net” which so many of the poor and vulnerable populations rely on?

These are all topics that the prestigious Institute of Medicine of the National Academy of Science has been exploring. Within the last few years there have been in-depth reports published on all these topics. We are not talking here about some tangential problems, but rather things that are AT THE CORE of health care delivery in the United States. I would be happy to order copies of these for Dr. Corlin… to help him get “up to speed” about the state of affairs for health care in the United States.

I am not a physician. I have, however, studied U.S. health care for many years, as a social scientist. I am frankly astounded that in this day and age, a physician could so glibly erase 15 million people, could stand up and publicly say that if we got the numbers down to 15 million, we could pat ourselves on the back and say, “job well done.” And then to have the insensitivity (and amorality) to consider that having ONLY 15 million uninsured would be a victory, not a tragedy…it boggles the mind. I am also, as a scholar-of-sorts, curious as to how he came to this magical number of 15 million as the “irreducible” denominator. Not from studying health care delivery in other industrialized countries; from where, then?

Dr. Corlin should do even more reading and find out WHO these uninsured folks are….

* he would find out that most of them are employed, hard-working citizens who are in lower paying jobs or with small firms that can’t afford health insurance;

* he would find out that 5.9 million of them are mothers;

* he would find out that about 1/4 of them are children;

* he would find out that many of them are members of minority groups.

I would be willing to bet that herein lies one of Dr. Corlin’s problems. I am looking at a picture of Dr. Corlin as I write…and I can tell you that he:

* is not one of the hard-working poor, not even one of the hard-working middle income Americans who simply can’t afford health insurance,

* is not one of those 5.9 million mothers with small children,

* is not, obviously, a child,

* and is most likely not a member of a minority group.

Dr. Corlin can’t relate to these folks. What I can’t tell from the picture, but can tell from his remarks of last week, is that Dr. Corlin is not a true physician. And he has shamed his profession and his professional position with the irresponsible remarks he made in Cedar Rapids last week. He owes all the uninsured people of this country an apology….and he also owes one to the physicians he is supposed to be representing, as president of one of the major medical associations.

With Dr. Corlin at its head, organized medicine is beginning to look a bit like a ship adrift, these days. Doctors dropping Medicare, opting out of Medicaid, setting up boutique practices, complaining loudly about the abuses of managed care (and there certainly is plenty to complain about, that I agree with) but going along with the for-profit program for the most part, and largely remaining silent about the ways in which big business is shaping health care delivery for its own interests. Its time for more courageous, visionary leadership….and some better ideas for how to solve the problems of health care delivery in this country.

Sincerely,

Barbara Rylko-Bauer

Comment: Dr. Corlin’s apparent insensitivity mandated responses such as Barbara’s. But Dr. Corlin is not the evil person implied by his isolated comment. He is a very fine person, representing the best of the Hippocratic traditions in medicine. So how could he have made such an awful statement?

Health policies that the members of the AMA leadership support include tax credits, MSAs, shifting costs (risk) to individual patients, multiple health plan products (multi-tiered benefits), and eliminating the employment link for health insurance. Dr. Corlin is aware that these policies can never provide true universal coverage. His comment was based on his belief that the AMA policies are in the nation’s interest, and that we have to accept the consequences of these “great” policies. We accept that employment rates will never be 100%, and, likewise, we should accept that health insurance coverage will never be 100%. From his perspective, his comment was a very benign remark on the realities of health care reform.

But what a remark! The AMA leaders are so sold on the righteousness of their approach that they cannot see the cruelty and inhumanity that would be inflicted on those for whom they should be leading the charge: the patients that are most in need of health care! The outrage expressed in response to Dr. Corlin’s comment should bring the AMA Board of Trustees out from their board room to find out what the ruckus is about.

Actually, Dr. Corlin and other members of the AMA leadership, in their tours of the communities, are hearing more and more from many members of the medical profession that we should be taking a very serious look at single payer reform. It is time for the AMA and state and county medical associations to set aside their conservative political ideology and rhetoric, and place on the table all options for reform. It is essential that all policy implications be clearly understood and discussed objectively. The single payer model would provide equitable, comprehensive coverage for absolutely everyone while providing free choice of providers of care and controlling costs. The policies currently supported by the AMA would accomplish none of those goals. But they are goals truly worthy of pursuit.

Don McCanne