PNHP

Accountability for Medicare Advantage plans is long overdue

Accountability for Medicare Advantage plans is long overdue

PNHP Comments on CY 2024 Advance Notice of Methodological Changes for Medicare Advantage Capitation Rates and Part C and Part D Payment Policies

By Physicians for a National Health Program
March 1, 2023

PNHP welcomes CMS’ efforts to begin to rein in abuse of the payment system by Medicare Advantage (MA) plans and rampant overpayments to the plans from CMS, which up to this point has been extensive and threatens the solvency of the Medicare Trust Fund.1,2 Accountability to both Medicare beneficiaries and taxpayers instead of to investors and corporate greed is long overdue. We encourage CMS not to give in to industry lobbying pressure, and to implement the proposed changes without compromising, and we believe even stronger measures are needed. After all, it is the mission of CMS to protect the integrity of the Medicare program.

We speak as advocates for a universal national health program which would be as cost-effective as possible, and we believe this could be constructed as an improved form of Traditional Medicare. The long unbroken record of gaming the payment system and overpayments to MA plans without evidence for improved outcomes (and easily gamed quality metrics do not qualify as evidence of improvement) point to the folly of expecting capitated fiscal intermediaries to reduce Medicare cost.3 The track record of MA is antithetical to the “Triple Aim” goals of improved quality of care, improved population health, and reduced cost. 

The profitability of MA plans has rested heavily on gaming strategies and fraud. Their strategies include gaming their risk pools by marketing to the healthy and discouraging the sick from enrolling, and by encouraging beneficiaries to disenroll once they develop expensive chronic conditions by making their care as frustrating as possible.4 CMS attempted to correct risk pool gaming with risk adjustment via the Hierarchical Condition Categories (HCC) formula, but this tied diagnosis to payment and opened the door to up-coding as a new gaming strategy, which has become widespread among MA plans, as CMS is well aware.5 CMS is also aware of extensive evidence that MA plans use proprietary prior authorization policies to deny care that meets Medicare medical necessity criteria.6

The proposed changes include cracking down on deceptive marketing practices and restricting prior authorizations to ensure that they are appropriate and timely and issued only after review by a physician with the appropriate specialty or sub-specialty training. The new rules would require all MA plans to establish utilization management committees to review prior authorization policies annually to ensure consistency with Medicare coverage decisions and guidelines. They also require adequate networks of behavioral health and substance abuse providers. However, we are concerned that up to now CMS has not had the resources to enforce such requirements, and when plans claim “network adequacy,” “secret shopper” surveys have found that a high percentage of “network” providers are not actually accepting new patients with that plan. We urge CMS to resist industry pressure and not only follow through with imposing the new rules, but to ensure adequate resources to enforce them as well.

The new rules for MA plans also include changes to the HCC risk adjustment formula to eliminate codes that are commonly up-coded and place caps on upcoding. We also applaud CMS’ audits of coding practices and recoupment of billions in overpayments to MA plans over the past several years. These measures are much needed, but the MA plans are highly motivated to continue to exploit upcoding. They will apply intense lobbying pressure to water down the changes, and the proposed rule changes may not be adequate to stop coding abuse. We encourage CMS to hold firm in implementing the new rules and deploy the resources necessary to enforce them.

Although the proposed rule changes may be helpful in restricting fraud and abuse by MA plans, we recommend that CMS consider the more effective measures recommended in the letter from Rep. Pramila Jayapal and 69 co-signers to President Biden, HHS Secretary Becerra, and CMS Administrator Brooks-LaSure dated Feb. 16, 2022. These include: 

  1. Strongly enforce the proposed rules prohibiting MA plans from imposing any additional clinical criteria for prior authorization approvals outside of current Medicare coverage policies, and ban step-therapy policies. Research has shown that prior authorization and step-therapy policies for Medicare Part B are associated with higher health costs, hospitalizations, and office visits, so there is no justification for continuing these destructive policies.
  2. Require MA plans to cover services from any medical provider that accepts Medicare’s approved rate. This would end networks that unreasonably restrict access to necessary care. Plans claim their networks assure quality providers, but in reality they serve the goal of restricting access to care so as to drive beneficiaries with more costly conditions out of the plan, a “lemon dropping” strategy used to game the plan’s risk pool.
  3. Implement stronger measures to curb up-coding, as CMS’s proposal to use the statutory minimum coding intensity adjustment of 5.9 percent for 2023 is inadequate to keep up with increased upcoding by MA plans. Jayapal’s letter recommends using the Demographic Estimate of Coding Intensity (DECI) risk adjustment scheme to correct for up-coding under the HCC system. However, we believe this, too, would be inadequate unless 1) and 2) above were implemented and enforced, because even if the rules substantially reduced up-coding, that would not eliminate “lemon dropping” sicker, more expensive beneficiaries within a diagnostic category by making their care as frustrating as possible, or evicting doctors who care for more expensive illnesses from the plan’s network.

All the problems with fraud and abuse via gaming of risk pools, upcoding, and skimping on necessary care are direct consequences of the incentives inherent in paying for health care via capitated fiscal intermediaries, including Medicare Advantage plans, as well as Medicaid Managed Care plans, Accountable Care Organizations, ACO REACH, and other forms of so-called “value-based” payment. Research has shown time and time again that use of capitated fiscal intermediaries raises cost, interferes with care and care coordination, and leads to adverse patient outcomes. 

When providers of care are paid directly by Medicare with fee-for-service, or if hospitals (or a hospital with an affiliated physician group practice) were paid with global operating budgets with professionals paid with salaries (without capitation, pay-for-performance, or incentive bonuses), then there would be no shifting of insurance risk onto providers, no risk pools to game, no upcoding because there would be no reason for risk adjustment and no linking of diagnosis to payment, and no incentive to deny necessary care. Global budgeting of hospitals without “value-based” overlays would be incentive-neutral and would not introduce incentives to either over-treat or under-treat. 

We believe a universal single-payer system could be designed to markedly reduce opportunities for fraud and abuse compared to what we have been seeing in the Medicare Advantage program. CMS has a duty to protect and defend Medicare, but the presence of fiscal intermediaries is undermining the program. Capitation was assumed to introduce better incentives than fee-for-service, but experience with MA has shown it to be fertile ground for gaming, fraud, and abuse. We urge CMS to consider simpler, more incentive-neutral, and less administratively burdensome payment systems for reform that could actually achieve the “triple aim” goals: improved quality of care, improved population health, and reduced cost. A properly designed universal and improved version of Traditional Medicare could achieve these goals.

References:

  1. Rep. Report to the Congress Medicare Payment Policy. Washington, DC: MedPac, 2022. https://www.medpac.gov/wp-content/uploads/2022/03/Mar22_MedPAC_ReportToCongress_v3_SEC.pdf
  2. Cubanski, Juliette, Juliette Cubanski, and Tricia Neuman. “Higher and Faster Growing Spending Per Medicare Advantage Enrollee Adds to Medicare’s Solvency and Affordability Challenges.” KFF, August 17, 2021. https://www.kff.org/medicare/issue-brief/higher-and-faster-growing-spending-per-medicare-advantage-enrollee-adds-to-medicares-solvency-and-affordability-challenges/
  3. Frank, Richard G., and Conrad Milhaupt. “Profits, Medical Loss Ratios, and the Ownership Structure of Medicare Advantage Plans.” Brookings. The Brookings Institution, July 13, 2022. https://www.brookings.edu/blog/usc-brookings-schaeffer-on-health-policy/2022/07/13/profits-medical-loss-ratios-and-the-ownership-structure-of-medicare-advantage-plans/  
  4. Meyers DJ, Belanger E, Joyce N, McHugh J, Rahman M, Mor V, “Analysis of drivers of disenrollment and plan switching among Medicare Advantage beneficiaries,” JAMA Intern Med. 2019;179(4):524–532. doi: 10.1001/jamainternmed.2018.7639
  5. Brown, J., M. Duggan, I. Kuziemko, et al. 2011. How does risk selection respond to risk adjustment? Evidence from the Medicare Advantage program. NBER working paper 16977. Cambridge, MA: National Bureau of Economic Research. doi: 10.3386/w16977
  6. Grimm, Christi A, Inspector General. Some Medicare Advantage Organization Denials of Prior Authorization Requests Raise Concerns About Beneficiary Access to Medically Necessary Care. OIG Report OEI-09-18-00260. https://oig.hhs.gov/oei/reports/OEI-09-18-00260.pdf

pdf version:
https://pnhp.org…

Medicare for All Explained Podcast: Episode 93

Fifty Years of Failure

March 1, 2023

Podcast host Joe Sparks marvels at the stubborn persistence of managed care in the U.S., which began in earnest with the HMO Act of 1973.

“We keep trying programs that assume for-profit intermediaries can save money and improve health outcomes,” he says, “even though 50 years of failure have shown that these programs don’t work.”

Additional episodes will be uploaded twice monthly. Subscribe in iTunes, or access a complete archive of the podcast, below.

https://medicareforallexplained.podbean.com

Large Insurer Exiting Workplace Health Insurance Market

Summary: Humana announced a pivotal business strategy change that suggests the looming culmination of a massive shift in US health insurance. Job-based insurance started in WWII, and dominated the health insurance business … until insurers convinced government to let them manage large parts of Medicare & Medicaid, while also buying up prescription benefit managers and providers. The privatization train must be stopped, with single payer.

Humana lays out exit from employer-sponsored coverage, ABC News, February 23, 2023, by Tom Murphy

The health insurer Humana will stop providing employer-sponsored coverage as it focuses on bigger parts of its business, like Medicare Advantage.

The insurer said Thursday it will leave the employer-sponsored business over the next 18 to 24 months. That includes coverage provided through private companies and for federal government employees.

Employer-sponsored health insurance is one of the most common ways for Americans to get coverage, but it amounts to a small part of Humana’s enrollment. That is centered largely on Medicare Advantage, the privately run version of the federal government’s Medicare program for people age 65 and older.

Humana also will continue to provide coverage to nearly 6 million military service members and their families.

Humana also runs Medicaid coverage for states and provides stand-alone Medicare prescription drug coverage. The insurer covered about 13.5 million people last year, not counting the stand-alone prescription drug plans.

Employer-sponsored coverage made up around 7% of that total.

Humana CEO Bruce Broussard said in a prepared statement that the exit from employer-sponsored coverage lets Humana focus its “greatest opportunities for growth.”

The company also said its employer-sponsored business “was no longer positioned to sustainably meet the needs of commercial members over the long term or support the company’s long-term strategic plans.”

Enrollment growth in employer-sponsored insurance has stagnated for many years for insurers, including market leaders like UnitedHealthcare. Insurers have turned more to government-backed coverage like Medicare Advantage or managing state Medicaid coverage for enrollment growth.

They also have pushed deeper into managing prescription drug plans and buying care providers in order [they say] to control health care costs.

Shares of Humana Inc., based in Louisville, Kentucky, climbed about $1 to $504.60 Thursday.

Comment:

By Don McCanne, M.D. and Jim Kahn, M.D., M.P.H.

The key paragraph is: “Enrollment growth in employer-sponsored insurance has stagnated for many years for insurers, including market leaders like UnitedHealthcare. Insurers have turned more to government-backed coverage like Medicare Advantage or managing state Medicaid coverage for enrollment growth.” And they’re expanding their role and power: ”They have pushed deeper into managing prescription drug plans and buying care providers …”

Private insurers are taking over public health insurance programs, reaping profits from each step in medical care funding and delivery. They recognize government largesse when they see it, and reel it in. They exercise massive market and lobbying power to create rules that help them gobble up our public health insurance resources, fueling record profits.

What intentions do they have for Medicare For All? Doesn’t this look like a setup for Medicare Advantage for All? A public insurance program under control of the private insurers? With their additional use of private equity to gain ownership of the delivery system?

We know this would waste massive resources while denying needed care. Private insurance-mediated Medicare and Medicaid are more expensive and deny or delay care through prior authorization, narrow networks, and patient cost-sharing obligations.

The battle lines are set! The wealth of the billionaires versus the health of the people. Further inertia on the part of us, the people, will result in their inevitable control.

We have the ultimate move that can tip the balance toward health, if we act soon. That, of course, is to implement an improved, publicly-administered Medicare that covers everyone. What do we want to use the people’s money for? More wealth for the wealthy, or more health for the people?

http://healthjusticemonitor.org…

Stay informed! Subscribe to the McCanne Health Justice Monitor to receive regular policy updates via email, and be sure to follow them on Twitter @HealthJustMon.

California Survey on Health Care Access, Debt & Equity

Summary: The newest survey of California health issues finds access limited by cost, causing clinical harm; pervasive medical debt; and racial differences around provider interactions. These ongoing health system failures highlight the desperate need for real reform.

The 2023 CHCF California Health Policy Survey, February 16, 2023, by Lucy Rabinowitz Bailey, et al.

Key findings from this year’s survey include:

Health care costs. Like prior years, half of Californians (52%) report skipping or delaying health care due to cost in the past 12 months.  Of those who skipped or delayed care, half of them (50%) say their condition got worse as a result.

Medical debt. More than 1 in 3 (36%) report having medical debt, and of those, 1 in 5 (19%) report owing $5,000 or more. Californians with lower incomes (52%) are more likely than those with higher incomes (30%) to report medical debt. [Rates for Black (48%) and Latino/x (52%) respondents are nearly twice as high as among Whites and Asians.]

Equity. More than half of Californians (54%) experienced at least one negative interaction with a health care provider in the last few years. Black and Latino/x Californians were more likely (69% and 62%, respectively) to report having negative experiences than White and Asian Californians (48% each).

Comment:

By Don McCanne, M.D.

This is California, land of affluence with Blue State politics where we care about each other, or do we? We have the resources to provide health care to everyone, and we have the knowledge of how to distribute those resources equitably to everyone through a single payer system. And yet look at our current health policy survey: Californians skipping care due to cost, half experiencing worsening of their medical condition as a result, over one-third facing medical debt, all while perpetuating racial and ethnic inequities.

We can end this now, not just for California, but for the entire nation. We merely need to enact and implement a well-designed, single payer, health care financing system. We have the right policy; it is long past time to break down the political barriers.

http://healthjusticemonitor.org…

Stay informed! Subscribe to the McCanne Health Justice Monitor to receive regular policy updates via email, and be sure to follow them on Twitter @HealthJustMon.

Support CMS 2024 Medicare Advantage Payment Rules

Summary: Today’s post is a request to comment favorably (by March 3rd) on proposed payment adjustments for Medicare Advantage for 2024.

CMS issued a draft of a plan for 2024 payments to Medicare Advantage plans. Overall it’s a 1% increase, after taking into account various technical factors. While it doesn’t address all serious Medicare Advantage over-charging problems, it does address some. It’s a decent start. A big change from last year when the MA plans got an 8.5% increase. Insurers are asking for a larger increase. We should support CMS on this one.

Write to CMS to endorse this proposed approach. By March 3rd. Below are some bullets to consider for your comment to CMS. Please adapt them into your own words … thanks!

Fact sheet on this announcement is HERE.

Comment submission instructions:

Comments are due by Friday, March 3, 2023.

Go to www.regulations.gov, enter the docket number “CMS-2023-0010” in the “search” field, and click on “Comment”. You can paste or type your comment, or upload a file.

  • Writing to support — CMS 2024 Advance Notice of Methodological Changes for Medicare Advantage Capitation Rates and Part C and Part D Payment Policies.
  • The changes proposed by CMS are critically important. They begin to correct overpayment of Medicare Advantage plans by tens of billions of dollars per year due to exaggerated diagnostic coding. Further billions in excess payments are created by recruiting healthier patients and shedding sicker ones. These massive excess payments are depleting the Medicare Trust fund in order to feed huge profits for health insurers.
  • Although the proposed payment adjustments do not address all problematic diagnostic coding practices, they correct important flaws in coding rules and risk adjustment that contribute to the magnitude of overcharging.
  • As a [current or prospective] Medicare beneficiary, I count on CMS to provide responsible stewardship of the program. The proposed adjustments are part of this stewardship.
  • As a taxpayer, I expect the same.
  • The proposed net 1% increase in revenue for Medicare Advantage plans will permit continuation of current benefits and ample profits for the plans. Past increases of 8% were a gift to the insurers, at the expense of beneficiaries and taxpayers.
  • Please issue the final procedures as drafted.

Respectfully submitted,

YOUR NAME

http://healthjusticemonitor.org…

Stay informed! Subscribe to the McCanne Health Justice Monitor to receive regular policy updates via email, and be sure to follow them on Twitter @HealthJustMon.

An ER doc reflects on life, death and uncertainty in the early days of COVID-19

Interview with Dr. Farzon Nahvi

By Dave Davies
NPR, Fresh Air, February 21, 2023

Dr. Farzon Nahvi spent the first few months of the pandemic as an emergency room physician in Manhattan. He talks about trying to improvise treatments during that time. His new book is Code Gray.

Transcript

DAVE DAVIES, HOST: This is FRESH AIR. I’m Dave Davies, in for Terry Gross. In the first year of the pandemic, more than 3,600 American health care workers died after being infected with the COVID-19 virus. Our guest, emergency room physician Farzon Nahvi, says that was a time when he and his colleagues were improvising means to treat patients and protect themselves. He writes in his new book that public health officials and hospital administrators were, like frontline medical workers, in over their heads and not quite sure what to do. For a time, some hospitals banned physicians and nurses from wearing masks at work, fearing it would frighten patients more than reassure them.

Most of Nahvi’s memoir, though, focuses on his life as an ER doc and the health care system in pre-COVID times. He writes that COVID was not a wrecking ball for health care delivery, but a magnifying glass illuminating flaws already inherent in the system. He describes systemic failures in American health care and dilemmas that physicians face in treating and communicating with patients and their families.

Farzon Nahvi is an ER physician at Concord Hospital in New Hampshire and the clinical assistant professor of emergency medicine at the Dartmouth Medical School. Before that, he worked in hospitals in Manhattan. He’s written for The New York Times, The Washington Post and other publications, and has testified before a congressional committee on health care reform. His new book is “Code Gray: Death, Life And Uncertainty In The ER.” Well, Farzon Nahvi, welcome to FRESH AIR.

FARZON NAHVI: Thank you for having me, Dave. It’s a pleasure to be here.

DAVIES: You know, in the early part of this book about the early months of the pandemic, it’s interesting. The book is filled with excerpts of text messages exchanged among you and other doctors you’ve known. You know, I guess you guys met in training and spread out around the country. And you’re talking about really important stuff that you didn’t feel you had clear guidance from public health authorities or your own hospital management. What kinds of things were you sharing with each other?

NAHVI: Well, you’re absolutely right. This is a text message exchange between 15 of us. They’re all 15 ER doctors that – we did our residency training together, and we spread out all over the country. And the text message thread had been there for a while. It’s usually a benign thread where we talk about our lives and experiences. But then it really came to life in the earlier parts of COVID. And we shared all sorts of experiences.

It felt in that moment that we were one step ahead of all the guidance we were getting because we were there on the ground experiencing this. And then the guidance we would get would often come one or two weeks later. So we were really relying on each other for everything – what to do, how to treat people, what our situations were like in our different hospitals. If our family members got sick, we would ask each other to check up on each other’s family members. So it really covered every aspect of life during that early part of the pandemic where things were really being done on the fly.

DAVIES: Yeah. Among the things that you communicated with your colleagues about was, you know, physicians and other health care workers who had died from the infection. And you write that in the first 12 months, 3,600 American health care workers would die of COVID-19, and that a Kaiser Health News investigation found that many were preventable. How could they have been prevented?

NAHVI: I think the early stance that COVID is not an airborne disease, when in fact we later on learned that it was, and other countries said that it was – by not treating it that way, I think we put a lot of ourselves at risk by not encouraging mask use early on. Two physicians that I worked with died early on. There was one patient transporter I know and one overnight clerk that I worked alongside – both of them died. And two PAs, two physician assistants that worked in the ER very closely with me – they didn’t die, but they were young guys. They were in their 30s and 40s, and they were intubated in the ICU with COVID.

So it was a very different time period. And it’s very difficult to kind of get into that mindset again, to remember what it was really like, because we’ve come such a long way with vaccines and kind of with time and the virus mutating on its own. I was speaking with a colleague of mine a while back, and she’s an internal medicine doctor, and she related it to childbirth, actually. She had just given birth to a child. And she said that earlier period, just like that childbirth period where you kind of have this very huge, very dramatic experience and then it’s over so quickly and everything is more or less back to normal.

And you look back and you say, hey, is that really as I remembered it? Was it really as crazy? And it was. But it was just so brief that it’s hard to look back and appreciate it for that dramatic episode that it really was.

DAVIES: You were working very, very long hours. You know, you described getting home and having to think about how do I not bring the virus into my apartment. So were there was this whole crazy thing of disrobing and hitting the shower immediately. And then you’re losing people. I mean, friends die. And you got to get right back in the ER. I mean, do you feel like there was post-traumatic stress here?

NAHVI: I’d say, yeah. I mean, in the text message thread in the book, there are parts where we have colleagues kind of asking each other, hey, is it safe to use our work health insurance to see a psychiatrist for this? And I know a lot of people that saw therapists for the first time because of this. And I think it’s not just that people were dying, and it’s not just that this was a scary time for us. It’s also, as I was saying, this kind of loss of confidence in our system making the right calls to protect us.

The CDC and kind of our health care institutions at the highest levels weren’t making the right calls to make us feel safe because it’s one thing to say, hey, you know, there’s this big scary thing that’s happening, but you guys are in the position to help, and we’re calling on you to help out. And it might be risky, but we’re all in it together. But it’s another thing to say, hey, this big thing is happening. We’re calling on you to help out, and, you know, we’re going to support you 50% of the way. So I think a lot of people had that sense that there wasn’t as much trust in our institutions as we would like to have had. And because of that, it became a much scarier time. And I think maybe the PTSD comes from that.

DAVIES: You mentioned a lot of colleagues for the first time sought therapy. Did you seek help yourself?

NAHVI: I did, yeah, for the first time in my life. There’s this wonderful collaboration between those of us who are in it together and texting one another. And one of those things was there’s a group of therapists that actually got together, and they weren’t ER doctors, so they couldn’t help out in those early stages of COVID in the ER, but they decided that they wanted to help out by supporting us who were working in the ER. And they got together and provided free therapy for anyone who wanted it, no questions asked.

I’ve never experienced that in my life where I felt that I needed therapy. But because it was so available and because these people were coming from just this genuine desire to help us, I took him up on it, and it really was – it was very helpful, actually. And I appreciate that. And I think, right now, three years later, I’m doing OK, and I’m doing pretty well. And it’s probably largely because of that experience I had.

DAVIES: Therapy is, of course, a private matter, but if you feel comfortable sharing, what do you think about it helped you get through this?

NAHVI: You know, there was just a lot of anger at that time. I’m not necessarily an angry person by nature. That’s not my go-to. But I just remember being kind of uncharacteristically angry during that time period and having someone there to help me through that, I think was extraordinarily valuable.

DAVIES: We need to take a break here. Let me reintroduce you. We’re speaking with Farzon Nahvi. He’s an emergency room doctor at Concord Hospital in New Hampshire. He spent the early months of the COVID pandemic as an emergency room physician in Manhattan. His new memoir is “Code Gray: Death, Life, And Uncertainty In The ER.” We’ll continue our conversation in just a moment. This is FRESH AIR.

(SOUNDBITE OF YO LA TENGO’S “HOW SOME JELLYFISH ARE BORN”)

DAVIES: This is FRESH AIR. And my guest is Farzon Nahvi. He’s an emergency room physician at Concord Hospital in Concord, N.H. His new memoir is called “Code Gray: Death, Life, And Uncertainty In The ER.”

So the book is about life in the ER. And you describe being on duty in an outer borough of New York once when you get word that an ambulance is on its way with a 43-year-old woman who has not had a pulse for 30 minutes, and the ambulance is still six minutes away. It’s clear to you that she’s died and is not going to be revived. What do you and your team prepare to do when the ambulance arrives?

NAHVI: Well, yeah, like you said, just from hearing that report, it’s clear that she’s died, and there’s going to be no successful chance at bringing her back. And yet we do what we always do, which is that we prepare to do everything in full capacity. You always worry that there’s some sort of miscommunication or something else might have happened that we didn’t really catch word of ’cause the communications in the pre-hospital setting, they can be a little rocky. We could lose our phone connection. Who knows? So we get ready for everything. So it’s this funny kind of feeling where you kind of know everything is done, and yet you get prepared to do everything. And that’s kind of how we – where we live in the ER. We live in that space where you do everything, but you’re kind of prepared for the worst. And then, yeah, so she comes in, we get ready to receive her, and we continue that first set our paramedics had initiated, which is CPR, a bunch of medications, an intubation for her airway protection and all that stuff until we eventually do call her time of death.

DAVIES: Now, her husband arrives a few minutes later, and you and the team are still working on her. And you give him the option of staying in the room and watching. And I’m picturing this ’cause you describe it. And she is, you know, on the table, naked and unresponsive, being subjected to a lot of, you know, invasive stuff. There are tubes and IVs and chest compressions going on. I could imagine it would be traumatizing for a husband to see this. What goes into your thinking about whether it’s a good idea to have, you know, a relative or a loved one in the room?

NAHVI: I think there’s two ways to think about that. The first way – and for me, the most important way – is that that’s their right. It’s their right to have the option whether to come in or not. The second thing is – your question has a lot of validity. In previous generation, in previous eras, we didn’t used to let people in the room. We used to protect them from that experience. But more recent research has demonstrated that actually helps the people who survive that experience. The family members who witness their loved one having died and are in the room with them actually have a less difficult grieving experience than those who are not witness to that. And you can imagine it gives you some kind of closure, some kind of understanding what – to what happened and also an understanding that the medical team that was there was really doing everything that they could have done.

And so if the person didn’t make it and they did end up dead, that every effort to keep them alive was made. And, I mean, we could go through the research and the data, but I think a lot of people experienced this during COVID itself, when people weren’t allowed there. I think we think that it’s horrifying to watch someone during the final moment as they die, and it is, but the more horrifying thing is to not watch it, is to not be allowed to be in that room. And a lot of people had to go through that during COVID.

DAVIES: You know, as you describe what happens here – and this is a conversation that moves as a thread throughout the book while you discuss related topics. But it’s interesting that you tell us in the book that there’s no set standard for how long you continue CPR after you’re not getting a pulse. And you and this team – and it’s quite a team – really work on this woman. I mean, it’s clear at some point that it’s not going to be successful. And you have the husband here, and you want him to feel comfortable that everything that could be done was done. And so you talked to the team. I’d like you to kind of just reconstruct this, what you say to your team, ’cause it sounds to me like part of that is done for the benefit of the husband.

NAHVI: You know, it is. Yeah. Well, we also need to make sure that we’re all on the same page. So what we do is that we – we’re communicating my thoughts to the team as I lead this resuscitation attempt, this code, and we talk out loud, and we say, hey, we have a 45-year-old female. She came in with X, Y or Z. We did X, Y, or Z. We felt no pulse. We have no return of spontaneous circulation. It’s been 45 minutes. I think it’s time to call this code and call a time of death. Does anybody else have any ideas? And we do this to review to make sure we’re not missing anything because we want input from everyone on the team. Sometimes our nurses have great ideas, our physician assistants have great ideas that we’re missing, and it’s very important to continue that.

But also, it’s this dramatic thing where someone’s about to die, and we want everyone in that room, whether that’s the patient’s family members or anyone that’s on my team with me, to feel comfortable with that. The last thing I would want as a physician leading a code is for someone to say, hey, I think we should have done this, afterwards. So we do review that. As long as everyone buys in and we’re all on the same page, then we proceed, and we say, OK, time of death, 10:32 a.m. or whatever it is. And that’s usually how it ends.

DAVIES: It was really striking to me that you’re saying to everyone, OK, we have this woman; is there anything else we’re missing? And when you all agree, then it is over. You have to, here – at some point here, communicate this to the husband. And a good part of what you discuss in the book is communicating with patients and patients’ families. And it’s not easy. And one of – you write about a moment early in your career where you had to communicate bad news. And it was a woman who had come in with a persistent cough. It turns out when she gets – what? – I don’t know. Was it a scan of some kind?

NAHVI: Yeah, she had a CAT scan.

DAVIES: That it appeared she had metastatic cancer, and you had to talk to her. You felt you didn’t handle it well at the time. Tell us about it.

NAHVI: Yeah. No, I didn’t handle it well at all because they teach this stuff in med school and residency but it’s all theoretical. The real-life doing it is an entire different level. And in that particular example, I knew the information I had to tell her, and yet I just found myself literally unable to speak the words. Up until that in my whole entire life, I’ve never had to confirm someone’s deepest anxieties and fears.

Generally in life, if we have friends or family members and they’re going through a hard time, we tell them everything’s going to be fine. We give them reassurance ’cause usually it is. And this was the first time in my life where someone came in, and they probably had some fear deep back in their mind that something catastrophic was happening, and I had to go confirm that. And I was fighting this deep, deep desire inside of me to not want to tell her that truth, to try to avoid that as much as possible.

So I went through the whole conversation, and I walked away realizing that I didn’t tell her she had cancer. I had used all these euphemisms. I told her, you know, the CAT scan came back, and there were some masses in there. And she said, what could those masses be? And I said, oh, they could be some pretty bad things. And then, she eventually asked me, what could those bad things be? And I said, oh, you know, we’re going to need a biopsy to confirm it. And I just couldn’t get myself to do it ’cause I – it just went so against the grain of everything that I want to do and everything I had done before that. So it was a troubling experience in that sense.

DAVIES: So you left her kind of maybe a little unclear as to how serious this was. Did you go back and have another conversation with her?

NAHVI: Well, yeah, absolutely. I had this recognition immediately after I walked away. I just – kind of my mind was reeling, that, oh, geez, I didn’t even tell her (laughter). And then, I had to have this awkward about-face where I walked back and say, hey, you know, I don’t think I actually communicated as well as I could have, and I had to. So those things that I was talking about, those bad things, it does look like you have metastatic cancer.

And the ER’s a tough place to break that news because we have no information except that you have cancer, right? If you go somewhere else and you get a biopsy, we might be able to say this is the type of cancer, or this is what the next step is in your treatment, or this is the prognosis. But we know so little. So all I could tell her was that she had cancer. And every follow-up question, we don’t really have the answer to that. So it makes it quite difficult.

DAVIES: I mean, this was terrible news to her, I’m sure. I’m curious, when you came back the second time, had she been confused before? Did she think it was something more benign or it wasn’t cancer?

NAHVI: I don’t think that she was confused. I think she knew. I think she probably held on to some hope ’cause I didn’t close that book for her. But I think that she knew.

DAVIES: I’m sure she went on and got, you know, treatment beyond the ER. Do you know what happened with her illness?

NAHVI: That’s one of the kind of funny things about the ER. We see patients – we see them one time, and often, we never see them again. And some patients, I am able to follow up on. I track down their medical record number. I’ll follow them up in the hospital the next day and see what happened. But if they go to a different hospital or they don’t have a clinic appointment for a few months, we don’t necessarily always follow up or know what happened. So for her, no, I can’t say that I actually know what happened to her.

DAVIES: When it was time to talk to the husband of the woman who had come in and had died – and he watched your team try and resuscitate her. When you sat down – by then, you were more experienced – what was your approach in talking to him? What was that like?

NAHVI: Well, the first thing you do is just ask them what they know. Before I even say anything, I say, hey, we were in the same room together. Tell me what you know up until this point, and let me fill you in on the rest. And that gives me some time to actually get a better understanding of who this person is. What do they know medically? What have they seen? But also, how am I going to speak with them? And it kind of helps me frame my conversation. And then, I might fill them in on the rest.

And generally, when I try to do this, when someone’s died, there’s not a lot of information that I feel that I need to give in terms of, this is the next step in your process, or this is your treatment. A lot of it is just reassurance for that person that they did the right thing, that the paramedics that took care of the patient on the way to the hospital did the right thing, that, you know, we in the hospital did all of these things. And I might give them specific examples of the things we did to try to resuscitate her and how those were unsuccessful. And it’s very important to me to try to let them know that everything that could have been done to save that person’s life was done, and it was just an event that was outside of our capacity to treat.

DAVIES: And then, when it was over, you said, you can stay in the room if you like. And he chose to do that – right? – that is to say, with his deceased wife?

NAHVI: Yeah. Yeah, a lot of things – the ER is a busy place. It’s a chaotic place. And we have a lot of rules on visitors, on who is allowed where and who is allowed to do what. But when someone’s died, we generally let their family members do what they feel that they need to do. There’s no more visitor rules. If four or five people want to come in, that’s OK. If they want to stay in the room with the patient, that’s OK.

DAVIES: We’re going to take another break here. Let me reintroduce you. We are speaking with Farzon Nahvi. He’s an emergency room doctor at Concord Hospital in New Hampshire. He spent the early months of the COVID pandemic as an emergency room physician in New York. His new memoir is “Code Gray: Death, Life, And Uncertainty In The ER.” He’ll be back to talk more after this short break. I’m Dave Davies, and this is FRESH AIR.

(SOUNDBITE OF DAVID ZINMAN, DAWN UPSHAW AND LONDON SINFONIETTA PERFORMANCE OF GORECKI’S “SYMPHONY NO.3, OP.36: II. LENTO E LARGO – TRANQUILLISSIMO”)

DAVIES: This is FRESH AIR. I’m Dave Davies, in for Terry Gross. We’re speaking with Dr. Farzon Nahvi, an emergency room physician at Concord Hospital in Concord, N.H. He spent the early months of the COVID pandemic on the front lines in emergency rooms in New York City. His new memoir is about his experiences in the ER and his frustrations with American health care. It’s called “Code Gray: Death, Life, And Uncertainty in the ER.”

You write about death and how physicians deal with it. I’ve asked you to read a little selection from this here. This is in the middle of the book. You want to just share this with us?

NAHVI: Absolutely. (Reading) Upon learning that I’m an emergency medicine doctor, people often ask how I deal with encountering death. It must be stressful. How do you do it? It’s a difficult question to answer. I usually shrug it off. You get used to it, I say. That is a lie. You don’t get used to it. I have been intimately involved in a wide variety of deaths. I have experienced grandparents dying of cancer and heart disease and have seen children die of illness and injury. I’ve filled out the morbid paperwork required after a successful suicide attempt. I have informed a pair of French tourists that the precarious selfie they warned their daughter not to take would be the last picture they would have of her. I’ve told an intoxicated driver of a rollover car crash that he would be spending the remainder of spring break and beyond without his best friend. I have never gotten used to any of it.

DAVIES: It’s something that’s a part of your life. You mentioned in the book that your father-in-law became ill with COVID and had stopped breathing once. He was not near you. And he had been picked up by an ambulance crew that had inserted a breathing tube. You called the ER where he was being treated to check on him. And when a clerk answered the phone, you knew immediately, you write, without her telling you that he had died. How did you know?

NAHVI: When you work in the ER, you kind of get used to every little detail in every little tone of voice. And I remember our beginning of our conversation was normal. She was a little bit hurried. She was helpful, but she wanted to get to know kind of why I was calling. And I told her the name of who I was calling for. And immediately, once she heard that name, she slowed down her cadence. And she took the time to speak with me. She didn’t necessarily get kinder. She was nice from the beginning. But she just slowed down to a degree that I knew that that’s the kind of slowing down that you get on the other end of the phone when someone’s died.

I know her job. I know what she’s doing. She’s sitting by a computer reviewing a list of patients. And she has a lot of stuff going on. And she’s very busy. And if it’s a patient with an ankle sprain or with, you know, even a heart attack, you get that information. And you look it up. And you kind of say, all right, I’ll get back to you in a little bit. But when she looked at the board, I presume, and she saw that we were calling for my wife’s father and he died, she just changed her tone completely. And it was very evident to me of exactly what happened on the other end of that line.

DAVIES: You know, you write that you’ve never gotten used to death despite being around it so much. And people wonder how you deal with it. How do you?

NAHVI: People give all sorts of answers for this. And I think the honest, honest truth of what we do is that we kind of just ignore it. We pretend that it doesn’t exist. And we don’t really acknowledge it. And that’s our culture. I think medicine is a very apprenticeship kind of culture where we see people before us, and we emulate the way they do things. And I think, for better or for worse, the way it’s always been, we kind of just ignore it.

And I think there’s a lot of people out there who say that this kind of compartmentalization and detachment is necessary, that if you get too close to those experiences and take them too seriously that you’re going to get too attached and you can’t perform your job. But I think that’s a misread. I think that’s certainly a coping mechanism, but I think it’s a poor coping mechanism. I don’t think you could pretend to be unaffected by this stuff. And one of the reasons I wrote this book was to kind of explore that, for myself and for others to share in that experience.

DAVIES: Yeah. Well, it’s interesting, you know? You say that ignoring it is, I guess, a way to function and get back in there and handle the next day. But it’s, in the long run, not healthy. And I’m wondering what the alternative is. I mean, writing a book, for you, was helpful. But that’s…

NAHVI: (Laughter).

DAVIES: Not everybody’s going to do that. And you’re not going to do it, you know, all the time.

NAHVI: Yeah.

DAVIES: Is there an alternate?

NAHVI: Well, I could share an experience I had, actually. It was about three, four years ago now. And it’s an example of how we can do better. So I – in the ER when someone dies, traditionally, we call a time of death. And I just can’t overstate, it’s just an awkward, strange circumstance. We call a time of death. Everyone kind of just shuffles about and makes awkward eye contact. And then we just walk away. And nothing happened. And that’s always felt so unsatisfying to me because you’re a part of this very important thing. You don’t know the person. You’re anonymous. You might not even know their name. But they died. And it’s a human being that died. And we do nothing. And I never did any better. I didn’t have an answer to this question of how we could do better if you asked me five, six years ago.

But then one time, I was an attending physician. I was supervising one of the residents that I worked with. And at the end of a code, someone had died. We called a time of death. And he just spoke up on his own. And he said, hey, I just hope everyone can stay in the room for another 30 seconds. I just want to appreciate that a human being has died. And what he said was – word for word, he said, we didn’t know this gentleman. We don’t know his name. But just as we have people in our lives that we love and people who love us, we can assume that this gentleman had people in his life that he loved and people who loved him. So in recognition of that and in recognition that someone has died, let’s just have a moment of silence. And the whole thing lasted maybe 15 seconds. But it just transformed the way I experienced those things from then on out.

And I copied him. He was my resident. I was supposed to be a supervisor teaching him, but I took that from him. And since then, I’ve been doing that every time that someone dies in the ER. And every time I do that, I have people come up to me – nurses that I work with, technicians, respiratory therapists – and they say, thank you for what you’re doing. So you can tell that there’s this unmet need of how we deal with things in the ER. And I don’t know that I have all the answers of all the things we could do to make this better. But from this experience that I’ve had, I know that there are ways that we can do better. And I think the first thing we need to do is start talking about it to see how we can kind of have that conversation and begin this process.

DAVIES: Oh, that’s so interesting, you know? I mean, everybody is so busy. They have other tasks to get to. But taking a moment to just acknowledge this pain makes a difference.

NAHVI: Huge difference. Yes.

DAVIES: In the case of the woman who – the 43-year-old woman who had died and, you know, you let the husband sit with the wife’s body, and then you spoke to him. And at some point, then you have to put in your notes. I mean, you fill out a death certificate. You put in your notes. And one of the note – things that you note is that these notes that you are writing are going to be gone over in detail by the hospital’s business department. What are they going to be looking for?

NAHVI: They’re looking for profit, Dave. So there’s billers and coders, and they exist in a whole different universe than we exist in. We live in the clinical space, but we are employees of a hospital, and they too are employees of a hospital. And they live in different buildings, working on computers, and they use software, and they have methods to extract what we write for profit. So they look for phrases that say, hey, this indicates a level of sickness which can be a code that we put in to get billed for this or that. And they generate a bill from what we do.

And in this particular case, it’s kind of disconcerting for me because this person just died, and it’s not really front of mind for me, but I have to write this note, and I do it. And the note itself is not problematic because you do have to write a note to document what happened medically. But then kind of I’m very well aware of all the steps that happen down the line.

DAVIES: Do you get training or advice or pressure to write notes which will generate the most expensive billing opportunities?

NAHVI: It depends on the hospital I’ve worked for. I’ve worked for public hospitals who do have a mission to just take care of people. And no, I don’t get that pressure there. But many of the private hospitals I work for, there’s a phrase that’s called strive to five, meaning try to get that Level 5 billing code, you could say.

DAVIES: Level 5 of service is higher priced, more profitable.

NAHVI: Correct.

DAVIES: Let’s take another break here. Let me reintroduce you. We are speaking with Farzon Nahvi. He’s an emergency room doctor at Concord Hospital in New Hampshire. His new book is “Code Gray: Death, Life, And Uncertainty In The ER.” We’ll continue our conversation after this break. This is FRESH AIR.

(SOUNDBITE OF SOLANGE SONG, “WEARY”)

DAVIES: This is FRESH AIR, and we’re speaking with Dr. Farzon Nahvi. He’s an emergency room physician at Concord Hospital in Concord, New Hampshire. He spent the early months of the COVID pandemic on the front lines in emergency rooms in New York City. His new memoir is about his experiences in the ER and his frustrations with American health care. It’s called “Code Gray: Death, Life, And Uncertainty In The ER.”

There are plenty of cases in this book where you find just frustration with the way our health care system works or does not work. You know, one interesting story you tell is of a woman who comes into the emergency room. This is not during the COVID days. She comes into the emergency room, and she wants chemotherapy treatments, and she knows she has cancer. And in fact, she has detailed instructions from the oncologist who has been treating her. Why was she coming to the emergency room?

NAHVI: Well, she came to the emergency room because her oncologist had stopped treating her. So what her story was – she was a young lady. She was diagnosed with cancer. And then she started getting treatment for her cancer with an oncologist at a private – not-for-profit but private institution. And then what happened was that because of her chemotherapy and her cancer treatments, she took too many sick days from her job. So she ended up losing her job. Then she lost her health insurance because of losing her job.

So her chemo – her oncologist wasn’t able to see her anymore because she didn’t have insurance anymore. So he or she referred this patient to our hospital, which was a public hospital where I was working at the time. She didn’t understand that she had to go see an oncologist. So she just came to the emergency room. And I thought there was a misunderstanding.

I saw her, and I said, you know, I’m an ER doctor. I – if I could treat you, I absolutely would. I just don’t have these tools. I don’t have that capability. And then we ended up kind of going from there. But that’s how she ended up in the emergency room with me.

DAVIES: But it’s interesting – I mean, it would take her, I think she said, weeks or months to get an appointment with an oncologist. And she knew that if you come to the ER, they have to treat you, right? I mean, so she figured, hey, you can’t send me away.

NAHVI: That was what she told us, yes. She said that she was familiar, that there was some law out there, that if you are uninsured under any circumstances, you come to an emergency room, we have to treat you. And she’s right. Except the caveat to that, which kind of is what made me so uncomfortable at that time, was that she had a great understanding of the situation, except that what we have to do in the ER is stabilize you, not necessarily treat you. So you have to be evaluated by law. And whatever we can do to stabilize you, we have to do.

In the eyes of this legislation, she was stable. So she had cancer, and she was dying, but she was dying slowly. She wasn’t dying quickly. So she was technically stable. And it became this kind of horrible thing that I had to explain to her that, yes, you’re protected by this law and yes, you have cancer and yes, you’re dying, but I can’t help you.

And not that I don’t want to, again, is just that I am not an oncologist. I don’t have chemotherapy. I’m not trained for that. I don’t know how to do that. And in the eyes of the law, you’re stable. And she kind of got a little upset, rightfully so. And she said, you know, if I was dying quickly, you had to take care of me. But because I’m dying slowly, all bets are off. And I had kind of no choice but to agree with her.

DAVIES: Yeah. So what does that do to you emotionally? I mean, how do you – what did you say?

NAHVI: Well, it’s terrible. I mean, I think there’s a lot of injustices in our health care system. And we see this stuff all the time. And it’s funny because I think when you’re in med school, you’re told by your professors all the time that you’re going to be entrusted with these important situation with your patients, and you have to really value that trust that patients put in you. But they don’t tell you about the opposite. They don’t tell you about the shame of being a doctor, sometimes, the shame of being a part of a system where you’re complicit in these problems, and you can’t do anything to help people that – despite seeing them and knowing that they need your help and the system is not serving them.

DAVIES: Right. One other case – you mentioned a time when a patient came in and had had serious complications from having taken antibiotics that they had bought, I think on a pet supplies website. And you called poison control. And the guy who answered immediately had a guess about what kind of antibiotics. Share this with us.

NAHVI: Well, yeah. So the patient – for a lot of reasons, she thought she was ill. She didn’t have health insurance, and she thought that she needed antibiotics. So she went ahead and took pet antibiotics. And I went to report this to the poison control center, who keep logs of this kind of thing to protect the public. And I told him, you know, you’re never going to believe this, but this patient took pet antibiotics. And far from not believing me, he responded immediately. He says, let me guess – is it the fish formulation? And I said, how do you know? And he said, whenever people have problems with this and they overdose, it’s always with the fish formulation.

What he told me was that people take veterinary antibiotics all the time, and he gets cases reported about that routinely. But when you take dog or cat antibiotics, people usually do fine because they’re pills, and they’re the right dosage. Whereas fish formulation, it’s just highly dense, highly concentrated ’cause you’re supposed to dissolve it into a fish tank so that the fish can eventually drink it when they have their water. So people who take fish antibiotics, generally, they overdose by an order of magnitude. So it was kind of shocking how often it must happen.

DAVIES: Right. And to get the dog or cat antibiotics, they actually need a prescription from a vet. Whereas…

NAHVI: Right.

DAVIES: …For the fish antibiotics, they can just order them. What kind of complications does one risk by taking fish antibiotics?

NAHVI: Well, so this lady, she took – actually, I remember the specific antibiotic was erythromycin. She took fish erythromycin, and she had some neurological side effects. So she had something called ataxia, which is a change in your balance and your gait. So she lost her balance. And she had nystagmus, so her eyes were twitching, and she couldn’t walk well. And the grand irony – and you can’t make this stuff up. It’s just so terrible. She came in, and the whole reason she had taken the fish antibiotics was that she had a job interview coming up. So she took the fish antibiotics, she overdosed, and she had some balance issues, and she fell down a staircase during her job interview.

I just can’t identify where she went wrong – right? – where someone would argue that she should have done better. She – here we have this lady trying to do everything right. She was working hard to try to get a job so that she could get health insurance, but she didn’t at the time, so she did the best that she could to try to get herself a job and health insurance. And yet even that process caused her to have some CNS – central nervous system – toxicity and then fall down a staircase, and she ended up in the ICU.

DAVIES: You know, at the end of the book, you say that there are a lot of these tough questions about patients and their treatment and how you talk to them and their families. And you write that you don’t have a chapter where you can answer these questions, I mean, that these are unsolved dilemmas that – you say you hope you provide we, your readers, with a measure of discomfort so we can consider some of life’s important questions…

NAHVI: Yeah.

DAVIES: …That defy easy answers. I mean, that makes sense. These aren’t easy questions. They aren’t easy answers. I’m wondering, has writing these stories and the process of considering these dilemmas, do you think, made you a better doctor?

NAHVI: I think it’s made me a better doctor and a better person (laughter). I think these stories live within us, whether we acknowledge them or not. And they percolate, and they come out in different ways. And I think really sitting down and processing them and kind of getting a better understanding of them has made me get a better understanding of life itself. I think what the funny thing is, these stories are – it’s an exploration of life in the ER, but really, they’re just an exploration of life in general. The ER is just life in its most extreme. There’s nothing unique about it, right?

I think the ER is this fascinating place where it exists as a contradiction. It’s this place where there’s a whole team of people who are ready, willing and able to take care of you at any time of day, no matter when you want to come. And yet no one ever wants to go there, right? We stick you with needles. There’s long wait times. You can’t get any rest. It’s America, so it’s expensive. So it’s this funny place where the only people that will ever come there are people that don’t want to be there. And we see extremes as a result. So we see medical, ethical, social and health care extremes and kind of going through that process and understanding those things helps you understand how you feel about things in life in general.

DAVIES: Well, Dr. Farzon Nahvi, thanks for all your good work and thanks for speaking with us.

NAHVI: Thank you so much, Dave. It was a pleasure to be here. I really appreciate it.

DAVIES: Farzon Nahvi is an emergency room doctor at Concord Hospital in New Hampshire. He spent the early months of the COVID pandemic as an emergency room physician in New York. His new memoir is “Code Gray: Death, Life, And Uncertainty In The ER.” Coming up, TV critic David Bianculli reviews the 10th anniversary episode of “Last Week Tonight With John Oliver.” This is FRESH AIR.

(SOUNDBITE OF KYLE EASTWOOD’S “SAMBA DE PARIS”)

https://www.npr.org…

Needed: Political Will to End the Violence in Ukraine & in our Health System

Summary: A Russian opponent of the war in Ukraine calls for the cease-fire that will stop the killing and permit finding a solution. We need the political will to end the ongoing deaths of untold thousands, and implement an enduring solution. Just like we need to reach single payer.

Stop the Killing, The Nation, February 9, 2023, by Gregory Yavlinsky

The war in Ukraine has been going on for almost a year. During this time, thousands of people have died on both sides, entire cities have been destroyed, and millions of people have become refugees.

But now, before our eyes, preparations for even larger-scale military action are in full swing. And all the key players—Moscow, Kiev, Washington, Brussels, NATO, and along with them the crowds of militaristic fans sitting in cafés and restaurants, hotels and cozy apartments, as well as numerous Internet media outlets—are all demanding the continuation of hostilities, fantasizing about victories, takeovers, and breakthroughs, agitating for new offensives.

Almost no one understands—or is afraid to say out loud—that the dangers are growing very seriously and the continuation of military action has no positive outlook. There is none!

Many territorial conflicts are known to have no end. There is only one successful example of territorial peace: the European Union. The idea accepted by all members of the European Union that human life, human dignity and human rights are valued higher than any national boundaries has become the guarantee of peace in Europe.

Sooner or later, this is what Russia, Ukraine and Belarus will come to—peaceful coexistence with each other and with other European countries. There is no alternative way to peace. But this way is complex and long.

What should be done now? Stop it! Everything else is a stupid and very dangerous illusion.

Declare a cease-fire. Stop killing people!

A cease fire is a political demand, the realization of which depends entirely on the willingness and understanding of the people making the decisions. In practice, it can only be implemented if at least Putin, Zelensky, Biden, and the EU and NATO leadership are willing to do so. But the problem is that none of them is willing right now. To date, all sides are intent on continuing large-scale hostilities, mistakenly counting on a military victory that is beyond anyone’s reach in the current climate. We must therefore insist: A cease-fire is necessary! If this does not happen, the consequences will be catastrophic and most likely, as already mentioned, irreversibly destructive.

And the main thing is that we will never get back people who are dying hourly in this catastrophe: not 18-month-old Makar and 15-year-old Anya from Dnipro, not 5-year-old Milana from Donetsk, not 9-year-old Ivan and 8-year-old Nina from Yeisk.

It is perfectly clear that all this has to stop. Everyone. And only after that should we try to talk. The main thing is that during this time people won’t be killed.

This is the only way to discuss territorial issues, borders, and movement of troops. Then diplomacy will also be needed—tough, difficult, with failures and limitations. We are in a situation where we are left with either bad options or even worse ones. The good options are gone now.

But there is still an option that can be avoided without further colossal casualties—that is, an immediate cessation of hostilities. And the demand to use this option must now be made by everyone who does not want to kill innocent people and does not want this to be done on their behalf. To make their position known by all available means.

Shout on every corner: Come to your senses! Stop!

Grigory Yavlinsky is the founder and leader of the Yabloko Party, the only party in Russia to protest the war and call for peace.

Comment:

By Don McCanne, M.D.

Why can’t we seem to get our policy and our politics in order? Policy-wise, we have demonstrated that a well-designed single payer system, an improved Medicare For All, could provide high quality care for everyone in the nation while reducing our health care costs. Yet our politics are screwed up enough such that the chairman of our Senate HELP Committee, Bernie Sanders, lacks the support of all Republicans and a significant proportion of Democrats for single payer and is having to resort to much more modest incremental reform proposals.

Where do we stand as far as politics and policy on the Russian military invasion of Ukraine? It seems that our policy should be to end the killing: the tragic killing of both the young Ukrainian and Russian soldiers and the tragic killing of the Ukrainian citizens, young and old alike, not to mention the extensive property destruction. But what is our politics? We are sending them more tanks to increase the killing? Shouldn’t the politics be directed to all efforts to end the killing? Shouldn’t the politics be more narrowly directed to obtaining a humane response from Vladimir Putin and his political gaggle?

Where should that political power come from? Us, the people. We need to let our president know that we want the killing in Ukraine to stop! Sending killing machines is not the way to stop killing. Providing political support to those who should have support and political opposition to those who should be opposed should help provide long range solutions, but we do need that immediate cease fire that Yavlinsky is calling for! No more killing!

But then, as we have been saying over and over again, we need to get our own politics right. We have the policy we need in the form of the single payer Medicare For All model, but we still need to be sure that the public at large has an excellent understanding of the clear benefits of the policies of the single payer model so that they will create the unmistakable political demand that Congress and the Administration cannot ignore: a health care system that is universal, comprehensive, affordable, equitable, efficient, with improved health outcomes for all.

On either front, national health or war, we should not be having people dying needlessly when the problem is merely a failure of national political application of appropriate national policies. Let’s get our politics right; it’s a matter of life and death!

http://healthjusticemonitor.org…

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The Fight for the Soul of American Medicine

More and more physicians are rejecting the forces of conservatism within their field and joining the grassroots movement to revolutionize American medicine.

By Gregg Gonsalves
The Nation, February 16, 2023

The injustices at the heart of the American health care system are clear to anyone with eyes and common sense. So is the need for dramatic reform of that system. Yet the status quo in American medicine is well-defended, and little real change has been forthcoming. One could even make the case that the situation has gotten appreciably worse over the past few decades.

But, at long last, there are signs that something might be changing from within the system itself. More and more physicians are rejecting the forces of self-interest and conservatism within their field and joining the emerging grassroots movements that are trying to revolutionize American medicine and safeguard the public health institutions that so many people rely on.

In early February, my friend and colleague Eric Reinhart wrote a piece in The New York Times on physician burnout. What made it unique was that Reinhart didn’t focus on the issues that such articles usually tackle, like grueling hours or the added burdens of the pandemic Instead, he went deeper, to the very fundamentals of American medicine—specifically, its unending quest for profit.

Reinhart’s column touches on all of the most rapacious aspects of US health care: the predatory billing of patients; deliberate cutbacks in staffing to cut costs, while hospitals rake in record profits; the way the system defines health according to what it can charge people for. He also talks about the complicity of the medical profession, which for decades has, as he writes, “[defended] health care as a business venture” because doctors believed that “if health care were made a public service, we would lose our professional autonomy and make less money.”

But Reinhart goes further than a diagnosis. He presents a treatment plan: “Regardless of whether we act through unions or other means, the fact remains that until doctors join together to call for a fundamental reorganization of our medical system, our work ‌won’t do what ‌we were promised it would do, nor will it prioritize the people we claim to prioritize.”

Reinhart’s cry in the wilderness—albeit in the pages of one of our nation’s leading newspapers—could not be more timely, or more reflective of a new generation of health care workers who are unwilling to accept the status quo—and are organizing to overturn it.

But Reinhart wasn’t the only person raising the alarm this month about the remorseless venality of American health care. Only a week or so before his piece, another commentary was published in the Journal of the American Medical Association, “Salve Lucrum: The Existential Threat of Greed in US Health Care,” by Dr. Don Berwick. Unlike Reinhart, Berwick is a pillar of the medical establishment: a former administrator of the Centers for Medicare and Medicaid Services under President Obama, and a former CEO of the Institute for Healthcare Improvement. In recent years, though, he has shifted his interests into the political realm, where he seems to have found a voice unconstrained by the conventions of academic life.

Berwick comes to the same conclusions as his junior counterpart: “The glorification of profit, salve lucrum, is harming both care and health.” Like Reinhart, he calls for health care professionals to get “noisy” about the “unchecked greed” in American medicine, to challenge the complicity of their professional organizations, the hospitals, and other institutions for which they work, and take the fight to Congress.

However, one research article from early February, in the Journal of General Internal Medicine, takes Drs. Reinhart and Berwick’s challenge one step further. In it, Drs. Suhas Gondi, Sanjay Kishore, and J. Michael McWilliams turn a spotlight on the top 20-ranked hospitals in the United States, according to U.S. News and World Report, in an article rather blandly titled “Professional Backgrounds of Board Members at Top-Ranked US Hospitals.”

If you want to know how greed drives American health care, you probably should ask questions about who’s in charge of the way things work. After all, as the proverb goes, a fish rots from the head. The trio’s findings are striking: “At top-ranked US hospitals, the most common professional background for board members is finance, far exceeding representation from physicians, nurses, and other health care workers. Over half (~56%) of board members are from finance or business, while a small minority (~15%) have clinical training or are from the health services sector.”

The authors are modest about their conclusions, but suggest that the prioritization of financial success over the needs of health care workers, patients, and communities—the same ones that Reinhart and Berwick detail—may have its roots in this financialization of the leadership of American medicine. We should all be grateful to these five physicians for breaking the professional code of silence and speaking out against what is happening in their profession, and even more grateful for the nurses, physicians, and other health care workers organizing for something better.

But having more honest conversations about these problems isn’t important just for health care workers. It’s crucial to understanding why our system is so uniquely dreadful compared to most of our peers.

Here’s one statistic: According to a new report the United States spends more on health care than any other nation per capita, yet we have terrible health outcomes. As I have said here before, we’re heading towards 64th in life expectancy in global rankings by 2040, with many countries far poorer than we are leaping ahead of us.

Here’s another statistic: Despite all of that money, American medical care can only be credited with a tiny percentage of health outcomes. That’s right: According to the National Academy of Medicine, “Medical care is estimated to account for only 10-20 percent of the modifiable contributors to healthy outcomes for a population. The other 80 to 90 percent are sometimes broadly called the SDoH [social determinants of health]: health-related behaviors, socioeconomic factors, and environmental factors.” In other words, there are endless dollars swimming around in the health care system, but almost none of them are actually dealing with the structural inequalities—poverty, racism, sexism, environmental degradation, and so on—that are the true drivers of so many medical problems in this country.

Ten years ago, my Yale colleague Elizabeth Bradley, now president of Vassar College, along with Lauren Taylor, published a book, The American Health Care Paradox: Why Spending More Is Getting Us Less. Bradley and Taylor compare the US to other rich countries in the book and something not-unexpected emerges: What makes us different from other nations in terms of health care outcomes is not how much we spend on medical care but how much we spend on social protections.

If we want to remedy the sorry state of health in America, we have to address racism and boost social programs to get at the root causes of what ails us. We have to deal with the 80–90 percent of our survival that is not connected to clinical care. (You can hear the heads of Republicans, conservative Democrats, and centrist pundits exploding now.) And we have to resist the growing trend towards the medicalization of public health, in which every public health issue gets reconfigured as a clinical problem to solve, and the social and economic factors that drive so many of our health outcomes get kicked to the curb again and again in favor of a pill (or other lucrative medical intervention) to prescribe.

As medicine seeks ever-greater financial gains, public health, which requires investment rather than extraction of profits, stands squarely out of step with the times. And ever since the early 20th century, medicine has been trying for a hostile takeover of the field, as I’ve written about before. In The New Public Health, from 1913, Dr. Hibbert Hill wrote: “The old public health was concerned with the environment; the new is concerned with the individual. The old sought the sources of infectious disease in the surroundings of man; the new finds them in man himself.” You can draw a straight line from those words to the physicians and others who have been talking about individualized risk, individualized choice, and “you do you” as the preferred strategy of dealing with this pandemic for several years now. You can also find echoes in the oft-repeated White House mantra when it comes to vaccines and treatments—“we have the tools”—even as the administration prepares to surrender all of us to the private market for these interventions. The undermining of public health as a common good since 2020 is just more of the same, but in hyperdrive, with the predatory instinct of a financialized modern American medicine here to kill what it cannot absorb and compromise.

Nation public health correspondent Gregg Gonsalves is the codirector of the Global Health Justice Partnership and an associate professor of epidemiology at the Yale School of Public Health.

https://www.thenation.com…

Prior Authorization Scrutinized

Summary: Managed care advocates argue that prior authorization saves money and improves quality of care. But the evidence is unclear. Mainly, it’s an irritant for doctors and patients. An anonymous prior auth practitioner describes how it looks from the inside. Bottom line: another money-making scheme in our profit-driven health care system.

LIFE AND DOLLARS: a health care insider’s account of how prior authorization really works, Health Care Un-Covered, Editor Wendell Potter, February 7, 2023, by Anonymous

Requiring patients to get prior authorization from an insurance company for medical procedures and drugs was supposed to lower medical costs. The theory was that it would prevent doctors from charging for unnecessary care.

The process frustrates patients and burdens health-care providers. And, the numbers show, it doesn’t really work.

I worked at one of the largest prior-authorization companies, running a team that supported the non-clinical side of our business. Most of our business was in radiology and cardiology medical-benefit management.

It may surprise people to know that many of the biggest health-insurance companies outsource their prior authorization programs. In fact, it would probably shock most people to understand just how much middle management exists between their doctor’s decisions and their ability to receive care. The commercial health insurance industry is overrun with opportunistic companies who profit off our complicated health care system, adding costs that lead to higher premiums and cost of care.
…

While working in the industry, it often seemed to me as if [T[he real value in prior authorizations isn’t in savings from clinically inappropriate procedures, and instead is a function of helping commercial insurers and third parties keep as much money as possible in the health-care system shell game. There is a large layer of middle management and profiteering that exists between the patient, the provider, and the insurance company. I know dozens of people who have made dopey amounts of money by rinsing-and-repeating the process, building small, ancillary companies that nibble on the edge of our high health-care costs. It all just gets baked into the cost of the premiums.

Examining Prior Authorization in Health Insurance, KFF Health Reform, May 20, 2022, by Kaye Pestaina and Karen Pollitz

Long used as a tool to control spending and to promote cost-effective care, prior authorization in health insurance is in the spotlight as advocates and policymakers call for closer scrutiny about its use across all forms of health coverage.

What is Prior Authorization?

Prior authorization (also called “preauthorization” and “precertification”) refers to a requirement by health plans for patients to obtain approval of a health care service or medication before the care is provided. This allows the plan to evaluate whether care is medically necessary and otherwise covered. Standards for this review are often developed by the plans themselves, based on medical guidelines, cost, utilization, and other information.

The process for obtaining prior authorization also varies by insurer but involves submission of administrative and clinical information by the treating physician, and sometimes the patient. In a 2021 American Medical Association Survey, most physicians (88%) characterized administrative burdens from this process as high or extremely high. Doctors also indicated that prior authorization often delays care patients receive and results in negative clinical outcomes.  Another independent 2019 study concluded that research to date has not provided enough evidence to make any conclusions about the health impacts nor the net economic impact of prior authorization generally.

Comment:

By Jim Kahn, M.D., M.P.H.

The insider story is compelling – give it a full read.

I have my own extended patient experience with PA. Multiple rounds of PA for one drug, with two insurers. Poorly documented requests by my ophthalmologist’s office. Denials, then appeals and approvals. Repeat with next insurer. All for a medicine that is clearly indicated, needed, and valuable. Most recently, some PA professional, or some AI program, seems to have decided that this medicine should just be routinely approved. No more PA battles. Phew. Fingers crossed.

Here’s my analysis of the state of prior authorization:

Prior authorization (PA) is supposed to lower medical costs and avoid unproven and dangerous care by confirming medical indications. Indeed, there’s plenty of inappropriate care in medicine, perhaps 20%, according to the National Academy of Medicine. With complete data and lots of time, we could reduce that. But there’s no good evidence that PA works in the real world (see the KFF excerpt above). Sophisticated review is too costly and burdensome, and the needed clinical data aren’t available to reviewers. So, as PA is actually practiced, it’s very hard to distinguish between unjustified services and typing errors or oversights. The process confuses & frustrates patients. It causes delays and may deny valuable care. It hugely burdens providers mentally and financially, and thus is contributes substantially to burnout.

Like so much of the business activity layered onto traditional health insurance activities (think: Pharmacy Benefit Managers), PA is driven by economic considerations. It’s much more a financial game than pursuit of quality care. Its real purpose is to save money. But that’s elusive, because practice is imperfect. Doctors learn to provide the right answers. So, as noted, evidence for overall savings is equivocal. Delay is part of the game – an expensive service is “kicked down the road”, perhaps to the next insurer.

So, if it doesn’t work, and it’s annoying, why does it persist? Ultimately, PA thrives because it creates business sectors. PA reviewers get paid to review, and consultants get paid to advise providers on how to succeed with reviews. It’s an arms race, profitable to all involved. The end result is that ancillary companies nibble at the edge of our costly healthcare, making “dopey amounts of money”, and it all “gets baked into premium costs”, as the PA insider so eloquently wrote. We all pay.

By the way, PA is only part of the story. A bigger issue is denials of submitted claims, which are estimated at 17% in-network for ACA exchange plans, 13% in private managed care, 7% in traditional Medicare, 8% in Medicare Advantage, and 13-21% in Medicaid. This largely reflects complexity of coverage rules and procedures.

Under single payer, quality and cost control would rely on methods other than PA. For starters, we’d have complete data on clinical diagnoses and services, thus much better information to use to identify and reduce medically inappropriate care. Denial rates would be lowered by broader and simplified benefits (identical for everyone) and thus less confusion. And by removing the profit motive that drives so many decisions today. More on this another day.

http://healthjusticemonitor.org…

Stay informed! Subscribe to the McCanne Health Justice Monitor to receive regular policy updates via email, and be sure to follow them on Twitter @HealthJustMon.

Medicare for All Explained Podcast: Episode 92

Interview with Dr. Ed Weisbart

February 15, 2023

PNHP board secretary and Mo. chapter chair Dr. Ed Weisbart describes the latest managed care boondoggle to threaten traditional—public—Medicare: the recently launched REACH program.

“REACH is new clothing for the old wolf of managed care HMOs,” he says, adding that “we’ve got mountains of data that shows this doesn’t work.”

Additional episodes will be uploaded twice monthly. Subscribe in iTunes, or access a complete archive of the podcast, below.

https://medicareforallexplained.podbean.com

PNHP celebrates win for activists as CMMI Director reveals Medicare REACH program is capping participation

Change follows sustained campaign of pressure from grassroots organizations and members of Congress

FOR IMMEDIATE RELEASE: February 13, 2022

Media Contact: Gaurav Kalwani, PNHP communications specialist, gaurav@pnhp.org

In a speech given to the California Public Employees’ Retirement System (CalPERS) on January 17, Center for Medicare and Medicaid Innovation (CMMI) Director Liz Fowler revealed that there are no plans to further expand the number of organizations or beneficiaries in the controversial Medicare REACH model.

Speaking about REACH at CalPERS’ Board Education Day, Fowler stated, “We have no plans to open up another application period…there will not be any more than 132 organizations in the model, and most likely no more than 2.1 million beneficiaries in the model.” 

REACH, which began officially operating in January, is a redesigned version of the Trump administration’s Medicare Direct Contracting program, which allows third-party entities (often private insurers) to administer traditional Medicare benefits. The program has faced sustained criticism from progressive activists, grassroots organizations, and members of Congress. In March of last year, PNHP delivered a petition to the Centers for Medicare and Medicaid Services (CMS) signed by over 250 allied organizations calling for an end to REACH.

“While the fight against REACH and Medicare privatization more broadly isn’t over, this is a great step forward,” said PNHP President Dr. Philip Verhoef. “It proves that our voices are having an effect, and that we must keep pushing to protect our public insurance programs against greed and profiteering.”

This was not the first instance in which CMMI adjusted the program in response to criticism. In December, 21 members of Congress, led by Representative Pramila Jayapal and Senator Elizabeth Warren, sent a letter to CMS Administrator Chiquita Brooks-LaSure raising serious concerns about REACH, based on initial research by PNHP. The letter described documented histories of bad behavior by numerous insurers and other profit-driven entities set to participate in the program. These companies faced allegations of overcharging Medicare and Medicaid, inflating diagnoses in an effort to increase payments, misleading seniors through dubious marketing, and more—often paying tens or even hundreds of millions of dollars to federal and state governments in settlements and fines.

Following the sending of the letter, several of the organizations mentioned were removed from the REACH program’s 2023 roster of participants.

“I am grateful to hear that CMS has no further plans to expand the REACH program which, let me be clear, is Medicare privatization,” said Rep. Jayapal. “I hope that CMS will stand by this announcement and instead of privatizing Medicare, explore other care models that put patients over profits. This step would not have been possible without the fierce advocacy of organizers across our country calling for an end to Medicare privatization and the partnership of my fellow members of Congress to push back against CMS.”

For more information on the REACH program and the danger it presents to our public insurance programs, please visit protectmedicare.net. 

Physicians for a National Health Program (pnhp.org) is a nonprofit research and education organization whose more than 25,000 members support single-payer Medicare for All reform.

Medicare privatization, ACO REACH & the ethics of for-profit health care

By Brenda Gazzar
Code Wack Podcast, February 13, 2023

What’s the latest threat to original Medicare? What could happen if we link health outcomes to physician compensation? How is it that a whole new program affecting millions of Americans on original Medicare can be rolled out without congressional oversight? 

To find out, we spoke to the new president of Physicians for a National Health Program (PNHP), Dr. Philip Verhoef, an adult and pediatric intensivist and Clinical Associate Professor of Medicine at the John A. Burns School of Medicine at the University of Hawaii-Manoa.

Learn more about the new program called ACO REACH, and the issues it raises around physician compensation. Could ACO REACH threaten the trust between patients and their doctors?

Transcript

Dispatcher: 911, what’s your emergency?

Caller: America’s healthcare system is broken and people are dying!

(ambulance siren)

Welcome to Code WACK!, where we shine a light on America’s callous healthcare system, how it hurts us and what we can do about it. I’m your host, Brenda Gazzar.

This time on Code WACK! Why are some physicians sounding the alarm over the privatization of Medicare? How could a program called ACO REACH be influencing the way physicians treat patients and patient care? To find out, we spoke to Dr. Philip Verhoef, president of Physicians for a National Health Program, a physician-led organization that advocates for single-payer health care in America. Dr. Verhoef is an adult and pediatric intensive care doctor and clinical associate professor of medicine at the John A. Burns School of Medicine at the University of Hawaii-Manoa.

Welcome back to Code WACK! Dr. Verhoef.

Verhoef: Thank You. It’s great to be here again.

Q: Tell us a little bit about yourself and your background.

Verhoef: Sure. So I am an ICU physician. I take care of both pediatric intensive care unit patients as well as adults who require the ICU and I’ve been doing this for about 15 years. I’m currently based in Hawaii, so I’m an associate clinical professor of medicine at the John A. Burns School of Medicine at the University of Hawaii and have been here for about four years taking care of patients.

I’ve been active in the single-payer movement since I was a resident at UCLA when I first heard a talk about our healthcare system and how single payer might be a potential solution, and this was back in 2006, I was absolutely blown away by the prospects and so decided to start getting more active in healthcare reform and healthcare advocacy at that time.

Q: Thank you. Today we’re facing a formidable challenge to Medicare. It’s increasing privatization through a government program called ACO REACH. Can you briefly explain what ACO REACH is in layman’s terms?

Verhoef: ACO stands for Accountable Care Organization and we saw ACOs be introduced into the healthcare system with the Affordable Care Act or the ACA and the notion of an ACO is that it’s an organization or a group where the outcomes for how patients do determine how much reimbursement doctors get in that context. And so that’s the accountable part of it, right?

So the idea is if your patients do well, then that’s a good thing. If your patients don’t do well, that may impact how much reimbursement that you get and it’s honestly not that different from the old school HMO or health maintenance organization. We saw the rise of those back in the eighties and nineties. The real difference is that ACOs are now groups of physicians. That’s kind of the idea. The idea behind the ACO REACH program is that the government will support enrolling Medicare patients into one of these ACO REACH programs.

You know, a Medicare patient would become a part of an ACO as a function of their doctor and their doctor would be a part of this ACO and then that would determine the kind of care that patients get, at least at some level. Now, this is a pilot program that’s been introduced through the Centers for Medicare and Medicaid Innovation and the reason that that’s important is [that] programs introduced under CMMI are not subject to the same degree of congressional oversight. In essence, the Centers for Medicare and Medicaid innovation was created also in the ACA back in 2010. The idea was “let’s create a program to allow innovative ideas to be tested out on Medicare patients potentially, or Medicaid patients.” Well, that seems like a nice idea in the sense that maybe this lets us get engaged in quality improvement more easily without having to have an act of Congress or some other kind of massive bureaucratic obstruction.

I think the problem here is with the ACO REACH program, the pilot is to take Medicare patients and put them in an ACO. That happens without the patient necessarily knowing. It happens, without Congress being able to oversee that and the reason that’s a problem is that these ACOs, even though they’re comprised of docs, they can actually be run by pretty much anybody. It could be run by a health insurance company. It could be run by a private equity company. It could be run by some individual who just wants to run their own ACO and that means that this is a defacto form of privatization of Medicare. And you know, I guess you’d ask yourself, why would an investor want to get involved in this? Well, if docs are reimbursed as a function of the patients that they have in their ACO and how much it costs to provide care for them, this is one of the common criticisms of capitation that if I give you x amount of money to take care of this patient, the only way you make money is by doing the least that you can for them.

And so ACO REACH is another way of saying to the doc, ‘Hey doc, do the least amount that you can for this patient because that’s the way that you are going to make the most money.’ Or more importantly, to the private equity investor, they are operating under the same sort of idea that they want to do the least that they can for patients in these ACOs because that means they recap the most money and so this kind of privatization is I think really sinister because it’s not putting patients’ health first, it’s putting the shareholders and whoever is vested in these ACOs, whoever’s running them, it’s putting their profits first.

Q: Mm-Hmm. You said ACO REACH is supposed to hold physicians or providers accountable for patient outcomes. So does it do that?

Verhoef: The short answer is potentially, but the problem is we’re creating financial incentives that are linked to outcomes and I think that that’s always going to be a problem, right? The real reason I take care of patients is to make people better and that’s enough. I don’t actually need financial incentives to improve the health of my patient. I want them to get better. So when you create a company or an organization or a process that gets in the middle of that and says, ‘hey, there’s an opportunity to make money here,’ you know, I think it sort of creates this problematic scenario where you’re saying, ‘Hey, you can make money and have healthier patients.’ People are making money, but that’s money that’s going into people’s pocket. It doesn’t necessarily mean that patients are absolutely getting better health. How do you measure that somebody’s doing better? I think that’s a really, really difficult thing to measure.

And in the end, we’ll see, or we would anticipate the same kinds of processes within these ACO REACHs that we see in Medicare Advantage, which is to say you do what we call cherry picking. You pick only the healthiest patients to bring them into your ACO because of course if they’re healthy, they’re not going to cost you any money. And you get to keep all of the money that you get for having that patient. And then you do what we call lemon dropping, which is get rid of the patients who cost the most, right? Find ways to kick them out or not provide care for them because again, they cost too much money and so those kinds of incentives are not geared towards the health of the population on the whole, it’s geared towards making money for somebody at, you know, within their own scale.

Got it. Thank you for explaining that.

Verhoef: Let me add one more point. The thing about the ACO REACH program is that it’s effectively a rebranding of a program that was initially going to be rolled out in the Trump administration called DCE – Direct Contracting Entity. These were plans that were designed to group patients from traditional Medicare into these ACOs and a DCE was no different, but they rebranded the program because, you know, the Biden administration doesn’t want to roll out a Trump administration program so let’s basically change the name, call it ACO REACH, where REACH stands for realizing equity access and community health and it really sounds like it’s a well-intentioned program, but I think the truth of the matter is it’s relying on a bunch of mechanisms that are really simply easily able to be gamed, mechanisms that involve opportunities for profit depending on what your outcomes are.

And whenever you do that, I think that it’s going to inevitably provide inequitable care. It’s not going to actually realize equity at all. It’s just going to allow organizations to find the patients that do the best and not take care of the ones that are the sickest and need it the most. And the thing that’s bothersome for us at PNHP is that one, this is a move towards privatizing Medicare, but also it’s done without Congressional oversight and it’s done without patients even knowing that they’re being enrolled into such a program. And the only way a patient could get out of an ACO REACH program is by changing their doctor cuz their doctor is getting enrolled into it and so you actually have to leave your doctor if you don’t want to be a participant in a program like this. And you know, it’s sort of ironic that people are talking about choice, right? I mean, what more does a patient want but to be able to stay with their doctor? And yet here we are creating a system where if a patient doesn’t want to be involved, they actually have to change doctors and that’s actually, I think, counter to the notion that you could see whatever doctor that you want and get the kind of care that you need that’s appropriate. These kinds of agreements actually limit that for patients.

Q: Hmm. I guess one of the questions I have is if doctors or providers are incentivized to not spend money on their patients and the concern is that doctors aren’t going to do the best thing for their patients to make more money. Isn’t that an awful thought?

Verhoef: And I think that’s a really astute question, right? You have to understand that the opportunities to make money are twofold. It’s doing the least that costs money, but it’s also trying to, because there are going to be incentives for you to, as a function of the outcomes for your patients, you know, you’ll actually get paid extra money, right? So the capitated part is you may not be penalized, but you may not have access to the additional money if all of your patients – sort of just trying to be much more of a carrot than a stick, right? You’ll still get paid for taking care of them under the regular fee for service agreements. You’re just not gonna get the extra amount of money that you would get depending on their outcomes or depending on whatever metric the ACO is using. So for instance, if the goal is to have patients have the least long length of stay in the hospital and you don’t achieve that, then you’re basically not going to get that bonus.

Right? If that makes sense. And so there is an inherent conflict in all of this with doing the right thing for the patient. I actually think the vast majority of doctors do want to do the right thing for the patient. And to be honest, I’ve actually heard from docs who like the idea of an ACO REACH where they’ve said, ‘look, this extra money that we’ve been given based on the good work that we’re doing has given us a little bit more flexibility to be able to provide other kinds of care for our patients.’ Right? I love that. Right? I love that it’s actually liberating for some docs and that’s exactly what the program was intended to do.

The problem is the program doesn’t have any restrictions on profiteers getting in there and finding a way to skim money off and make money themselves. And so, you know, like many things, I think this program was perhaps designed with good intentions, but there were enough back doors left open that you could get your way in there and in effect, privatize this thing and really be motivated more by at least somebody would be motivated more by finances than by truly the health of patients

Right, or maybe they could convince themselves that this other treatment or this other option might be just as good, it costs less, let’s try this first and maybe you’re wasting precious time in the patient’s treatment.

Verhoef: Yeah, it’s interesting. I think the fear also is that if you’re a doc enrolled in an ACO and you end up having patients that tend to be pretty expensive, that an ACO can actually just kick the doctor out and therefore sort of deny them the opportunity to get, you know, this additional funding to support taking care of patients and this gets at sort of a different but still really important problem with Medicare as we currently know it. The reimbursement rates are not terrific. You know, in general, Medicare’s reimbursement rates are less than they are for commercial insurance and so many physicians have to sort of ask themselves this question, can I even afford to take Medicare? Does the reimbursement that I get from Medicare, is it enough for me to pay the rent? Is it enough for me to pay my staff? Is it enough for me to keep the lights on and continue to do the work that I want to do?

And so physicians or physician group practices will very clearly monitor the number of commercially insured patients they have versus the number of Medicare patients versus the number of potentially Medicaid patients. And so one of the real problems is that Medicare reimbursement isn’t always very high relative to commercial reimbursement. And so, you know, this is in a way, a way of incentivizing docs to take Medicare patients cuz you can get this additional money on top of that. The problem is that that then begins to set up some incentives that aren’t really very sound right, where we’re doing things to make money more than anything else. Now, I would love to see Medicare overhauled, I would love to see reimbursement rates better than they are and so that physicians wouldn’t even have to make this choice. You know, I’ve, I’ve certainly known docs who don’t want to stop taking Medicare, but they simply can’t afford to based on the rates that Medicare reimburses if you’re in a particularly expensive area to practice medicine.

And so in a way a program like this can attract physicians because they want to take care of Medicare patients. They say, ‘oh, this is an opportunity for me to get a little additional income in the context of maybe meeting some of these metrics and whatnot and then that’s good for me, it’s good for patient care, it’s good that I can continue to take Medicare patients.’

There are more and more physicians who simply don’t take Medicare at all. Or even worse, they just choose to not even accept commercial insurance because they don’t like the headaches of having to deal with, you know, insurance companies denying care or limiting who you can go see or prior authorizations. The good thing about Medicare is it doesn’t have prior authorizations. It doesn’t have denial of care, it doesn’t have narrow networks like commercial insurance does, but commercial insurance just pays a whole lot better.

You know, and so this is definitely something that PNHP thinks about too, is it’s not just fighting the privatization of Medicare, it’s also how do we just make Medicare better? You know, how do we make it function more effectively for more people? You know, how do we make it so that you don’t have to buy separate insurance for your hearing and your dental? How do we make it so you don’t have to buy separate insurance to cover the co-payments, right? You know, Medicare doesn’t provide first dollar reimbursement for all of your care. And so there are certainly ways that Medicare itself can be improved.

We certainly don’t think that privatizing Medicare is the key to that improvement, but there are a number of ways that we could make it better. These ACO REACH programs are not it though. We really feel like this is, you know, privatization and potentially if all of traditional Medicare gets involved in this, that will make our job so much harder to try and actually advocate for a government-run insurance program that doesn’t have any middlemen in it.

Thank you Dr. Verhoef.

Do you have a personal story you’d like to share about our wack healthcare system? Contact us through our website at heal-ca.org.

Find more Code WACK! episodes on ProgressiveVoices.com and on Nurse Talk Media. You can also subscribe to Code WACK! wherever you find your podcasts.

This podcast is powered by HEAL California, uplifting the voices of those fighting for healthcare reform around the country. I’m Brenda Gazzar.

https://heal-ca.org…