By Thomas L. Fisher
Washington Post
Sunday, July 1, 2007; Page B02

CHICAGO At 4 a.m., the ambulance rushed the driver in a single-car accident to the emergency room where I was the attending physician. The victim, a man in his late 20s, had been knocked unconscious when his head slammed into the windshield. The paramedics handed me two-thirds of his scalp in a plastic bag.

That sounds horrible, of course, but modern medicine can do a lot in such cases — if it has the chance. Our team worked to stabilize the patient and to save his scalp. Human tissue can die in a just few hours if it’s cut off from its blood supply. So to avoid a disfiguring injury, our patient would need the care of a specialist who could reattach his scalp’s blood vessels. Unfortunately, my hospital didn’t have such a surgeon; the closest one worked at a sibling hospital in a more affluent neighborhood 15 miles away.

We raced against time to avoid permanent tissue damage. I called and called and called, searching for a physician willing to take care of our patient. But no one would accept him. After 40 minutes, we flew him — and his dying scalp — by helicopter to a hospital 45 minutes away.

The patient should have been recuperating after a close call. Instead, by the time he was whisked away from me, he was facing lifelong disfigurement. This is the reality I see every day as an ER doctor: Large groups of people — mainly those from communities of color, and also those who are poor and uninsured — are not receiving basic care that can make all the difference.

Many Americans have been talking more about health care these days because of the buzz around Michael Moore’s new documentary, “Sicko,” a polemical look at unfairness in the nation’s health care industry. However, the types of communities I care for are barely addressed. Moore says up front in the movie that he is not focusing on the nearly 50 million people who have no access to care at all. His decision to concentrate instead on the substandard care given to the working and insured is an understandable attempt to touch the heartstrings of Middle America. Unfortunately, by giving cursory treatment to race and class, he avoided tackling the most intractable problems in this country’s health care system.

Here’s the view from the front lines: Hospital waiting times of 10, 12 hours. Emergency rooms so packed that ambulances must be turned away. People suffering from ailments ranging from organ failure to psychotic breakdowns, all preventable.

These issues affect not only individuals, but whole communities and the health outlets serving them. I sympathize with those who are unhappy about the quality of their insured care, but I’m more worried about those with no insurance at all. The bigger problem is that we all want the finest of health care, and as a result, many of us — largely black and brown — are left with nothing.

One scene in “Sicko” does deal directly with race: A white woman questions whether her husband, who is black and has kidney cancer, would receive better care if he were white. I can’t speak to their situation, but my experience is that the influence of race and racism on health care is rarely that obvious. But it is unmistakable, nonetheless.

For instance, the young driver in the car accident essentially had the misfortune of getting hurt in the wrong part of town. At the time, I was an emergency medicine physician fresh out of residency, working in a community hospital system in the Midwest that consisted of two very different hospitals. Hospital A (where the patient started) served a blighted, post-industrial city of about 100,000 residents, about 85 percent of whom are black and largely poor and uninsured. Hospital B (the one we couldn’t get him into) is 15 miles away, in a more affluent community of about 30,000 people, about 70 percent of whom are white. Although technically the two comprised a single hospital system, physicians were allowed to choose to work at one or both of the locations. Most chose Hospital B, leaving few specialists on call for emergencies at Hospital A. By dumb luck, my patient wound up at the wrong hospital, and that made all the difference.

The reasons behind the two-tier structure weren’t malicious. In most hospital systems, physicians are not direct employees but instead have privileges to deliver care through the facility. In this structure, the patient receives one charge from the doctor and one from the hospital. That means there’s less of a financial incentive to work in communities with many uninsured members. Many specialists did not want to leave their neighborhoods and their families in the middle of the night and disrupt their upcoming workday schedule to care for a patient who may not be able to pay but could nevertheless file suit over care.

It’s honest to say that most poor people — not just those from communities of color — suffer from inadequate or nonexistent care. But I’ve found that decisions that seem race-neutral at face value can systematically hurt such groups. These decisions create racial disparities in health care that go beyond what can be explained by class alone. The challenge presented by that emergency case at 4 a.m. was determined by the earlier decision not to require physicians to provide care at both hospitals. The difference in care between these two facilities went beyond just a single car-accident victim and wounded the entire community that Hospital A was supposed to serve.

These are the kinds of systemic problems that lead to widespread racial disparities in health. Consider the medical picture for my black male peers. According to the Henry J. Kaiser Family Foundation, black men are the least healthy ethnic group in the United States. Their death rate (1,282 per 100,000 in 2004) outstrips that of all other ethnic groups, including non-Hispanic whites, 949; Native Americans, 750.2; Hispanics, 702.7; and Asians, 534.1. Black men also have higher rates of heart disease, HIV/AIDS and certain kinds of cancer, including prostate, lung and colon.

Such statistics send a larger message about medical care and race: The lack of equity seen in wealth, income, education and insurance has considerable impact on health.

On balance, the middle and upper-middle classes are relatively healthy, as evidenced by their lengthening life spans and rising quality of life. Meanwhile, the bad outcomes disproportionately affect the poor, including many working-class and poor whites but more often people of color. In these populations, health and health care in the United States are not dissimilar to the standards in some developing nations. For instance, in 2005, the average life expectancy for black men in this country was 69.2 years; according to CIA estimates for 2007, the life expectancy for all Iraqis is 69.3.

Health care is not a run-of-the-mill service like an oil change. It’s a massive industry that shapes our lives and sometimes saves them. But our health care options are more than just commodities. That being said, providing health care to the underserved alone will not solve every problem — broader issues of equity will need to be addressed.

Many Americans oppose a single-payer health care system. My support of this initiative has grown from witnessing inequities daily through years in an emergency room.

I hear the concern about such a system; people worry that they won’t get what they need, that the government will ration health care. But in fact, that’s exactly what we have right now. It’s just a little more subtle, a form of rationing that’s based on a person’s ability to endure hours of anxiety in the ER, to wait for the next medical appointment, to afford high-quality insurance.

So how can we have a public discussion about this subject? This country has limited resources to devote to health care. But it also is saddled with an inefficient health care system that gives advantages to the privileged and well-off while ignoring preventive care and abandoning those most in need.

In some ways, given escalating costs, health care is a zero-sum game. So what are people willing to give up, and what care should be provided to all? Many middle-class Americans take comfort from knowing that their health care is covered. But all those little choices add up to big society-wide choices and market incentives for drug companies — and produce an America where one man pops his Medicare-covered Viagra pills while another can’t get life-saving cancer medication.

Many Americans do get the Mercedes-Benz of health care. But given the scarcity of resources, they may be doing so at the expense of many others. Ultimately, we will need to find a middle option — providing all Americans with the health care equivalent of a Prius, a vehicle that will take efficiently to where you need to go and is affordable enough that nobody will have to walk. Because you never know what neighborhood you may wind up driving in.

tfishermd@gmail.com

Thomas L. Fisher serves on the faculty of the University of Chicago’s Department of Medicine and practices in the emergency room at the University of Chicago Medical Center.

Wall St. Journal
LETTERS
Sunday, July 8, 2007

The commentary by David Gratzer (“Who’s Really Sicko?”editorial page, June 28) presents an extremely prejudicial view of the publicly funded Canadian health system. It highlights the unfortunate story of a man from Ontario who had difficulty accessing a head MRI scan for a malignant brain tumour. Undoubtedly there are similar anecdotes describing difficulties in accessing care experienced by the 44 million Americans who lack health insurance. However, in making a rational comparison of the Canadian and American health systems it is more reasonable to contrast service levels and costs of the systems rather than trading anecdotes.

Canadians pay about 9% of national GDP to insure 100% of citizens in our single-payer system, compared with more than 14% of GDP to insure 85% of Americans. The Kaiser Family Foundation reports that the average compound annual growth rate in U.S. health insurance costs has been 11.6% over the past five years. It is therefore not surprising that polling by Kaiser found that 75% of Americans were worried or very worried about the amount they would need to pay for health insurance in the future and that 63% were worried or very worried about not being able to afford health-care services.

There is no question that restriction of supply with sub-optimal access to services has contributed to the lower cost of health care in Canada. However, a new approach of targeting investments to reduce waiting times combined with transparent reporting of wait times is having a substantial impact on access in the Canadian system. Dr. Gratzer wrote about prolonged waits for treatment in Ontario but did not refer readers to the public Web sites that detail Ontario waiting times for cancer surgery, chemotherapy, radiation, cataract, heart, arthroplasty and imaging procedures:

(http://www.health.gov.on.ca/transformation/wait_times/wait_mn.html and http://www.cancercare.on.ca)

Canadians spend about 55% of what Americans spend on health care and have longer life expectancy, and lower infant mortality rates. Many Americans have access to quality health care. All Canadians have access to similar care at a considerably lower cost. In “Sicko,” Michael Moore has apparently exaggerated the performance of the Canadian health system — there is no doubt that too many patients still stay in our emergency departments waiting for admission to scarce hospital beds. However, Mr. Moore’s description of the advantages of the Canadian system in the film is more accurate than the jaundiced view of our system proposed by Dr. Gratzer.

Robert S. Bell, M.D.
President and CEO
University Health Network
Toronto

(The letter was also signed by Carolyn Baker, R.N., president and CEO, St. Joseph’s Health Centre, Toronto, and Catherine Zahn, M.D., executive vice-president of Clinical Programs and Practice, University Health Network, Toronto.)

---

The introduction of private insurance or private-for-profit health care for medically necessary services is not the answer to challenges in the Canadian health-care system. In a systematic review of 38 studies published in Open Medicine in May, 17 leading Canadian and U.S. researchers confirmed the Canadian system leads to health outcomes as good, or better, than the U.S. private system, at less than 50% of the cost.

Unwanted side-effects of competitive health care include a drain of highly trained professionals from the public system and “cream skimming” of patients by private clinics who choose the healthiest patients, leaving the most complex to the increasingly overburdened public system.

In June 2006, the Canadian Medical Association reviewed all the evidence from other jurisdictions and concluded that private insurance for medically necessary physician and hospital services does not improve access to publicly insured services; does not lower costs or improve quality of care; can increase wait times for those who are not privately insured; and, could exacerbate human resource shortages in the public system.

Medicare is not only more equitable, but more efficient and produces higher quality health care than the alternatives. This conclusion is supported by the best national and international evidence, including reports from the World Health Organization and the Organization for Economic Co-Operation and Development.

So what should Canada do about patients who do not receive timely access to essential medical care? Numerous expert reports, including the 2002 Royal Commission on the Future of Health Care in Canada, have already told us we need to restore and strengthen Medicare, not decimate it.

In May the Canadian Centre for Policy Alternatives reported that successful initiatives in team-based care and improved administration produced dramatic cuts in waiting times for surgery in B.C. Alberta, Saskatchewan and Ontario, without any need for competition.

Danielle Martin
Board Chair
Canadian Doctors for Medicare
Toronto

Deborah Burger
SF Chronicle
Tuesday, July 10, 2007

What country endures such long waits for medical care that even one of its top insurers has admitted that care is “not timely” and people “initially diagnosed with cancer are waiting over a month, which is intolerable?”

If you guessed Canada, guess again. The answer is the United States.

Scrambling for a response to the popular reaction to Michael Moore’s “SiCKO” and a renewed groundswell for a publicly financed, guaranteed single-payer health care solution, such as SB840, the big insurers and their defenders have pounced on Canada, pulling out all of their old tales of people waiting years in soup kitchen-type lines for medical care.

But, here’s the dirty little secret that they won’t tell you. Waiting times in the United States are as bad as or worse than Canada. And, unlike the United States, in Canada no one is denied needed medical care, referrals or diagnostic tests due to cost, pre-existing conditions or because it wasn’t pre-approved.

U.S. waiting times are the elephant in the room few critics care to address. But, listen to what the chief medical officer of Aetna had to say in March.

Speaking to the Aetna Investor’s Conference 2007, Troy Brennan let these pearls drop:

The U.S. “health care system is not timely.”

Recent statistics from the Institution of Healthcare Improvement document “that people are waiting an average of about 70 days to see a provider.”

“In many circumstances, people initially diagnosed with cancer are waiting over a month, which is intolerable.”

In his former stint as an administrator and head of a physicians’ organization, he spent much of his time trying “to find appointments for people with doctors.”

Brennan’s comments went unreported in the major media. But some reports are now beginning to break through, spurred by the debate “SiCKO” has spawned.

Business Week reported (www.businessweek.com/technology/content/jun2007) that “as several surveys and numerous anecdotes show, waiting times in the United States are often as bad or worse as those in other industrialized nations — despite the fact that the United States spends considerably more per capita on health care than any other country.”

A Commonwealth Fund study of six highly industrialized countries (www.commonwealthfund.org), the United States and five nations with national health systems (Britain, Germany, Australia, New Zealand and Canada) found waiting times were worse in the United States than in all the other countries except Canada .

There’s something else you probably don’t hear about Canada. Substantial progress is being made.

Most of the wait-time problems derive from funding cuts by conservative national or provincial governments, or from the siphoning off of resources by private providers. But precisely because the Canadian system is publicly administered, Canadians are able to force their elected officials to fix problems, or get voted out of office.

Throughout Canada, there are multiple pilot programs that have succeeded in slashing wait times. Canada’s latest statistics show that median wait times for elective surgery in Canada is now three weeks — that’s less time than Aetna’s chief medical officer says Americans typically wait after being diagnosed with cancer.

Canada also has no waits for emergency surgeries. It also doesn’t have 44 million people who are uninsured because everyone has a national health-care card guaranteeing health care from any doctor or hospital they choose. And it doesn’t burden those with insurance with rising deductibles or co-pays. A study reported by Health Affairs, a policy journal, for example, found that out-of-pocket costs to U.S. consumers jumped 76 percent this year over last year alone.

Canada also surpasses the United States in a broad array of health barometers, including life expectancy, infant mortality rates, adult mortality rates, deaths due to HIV/AIDS, mortality rates for cardiovascular diseases and years of life lost to injuries and diseases, according to data from the World Health Organization and the Organization of Economic Co-operation and Development.

No wonder some people are so afraid we’ll learn the real comparative story about Canada’s system — and our own.

---

Deborah Burger, R.N., is president of the California Nurses Association.

http://sfgate.com/cgi-bin/article.cgi?f=/c/a/2007/07/10/EDG6QQ4VGD1.DTL

This article appeared on page C – 11 of the San Francisco Chronicle

By PAUL KRUGMAN
Op-Ed Columnist
New York Times
July 9, 2007

These days terrorism is the first refuge of scoundrels. So when British authorities announced that a ring of Muslim doctors working for the National Health Service was behind the recent failed bomb plot, we should have known what was coming.

“National healthcare: Breeding ground for terror?” read the on-screen headline, as the Fox News host Neil Cavuto and the commentator Jerry Bowyer solemnly discussed how universal health care promotes terrorism.

While this was crass even by the standards of Bush-era political discourse, Fox was following in a long tradition. For more than 60 years, the medical-industrial complex and its political allies have used scare tactics to prevent America from following its conscience and making access to health care a right for all its citizens.

I say conscience, because the health care issue is, most of all, about morality.

That’s what we learn from the overwhelming response to Michael Moore’s “Sicko.” Health care reformers should, by all means, address the anxieties of middle-class Americans, their growing and justified fear of finding themselves uninsured or having their insurers deny coverage when they need it most. But reformers shouldn’t focus only on self-interest. They should also appeal to Americans’ sense of decency and humanity.

What outrages people who see “Sicko” is the sheer cruelty and injustice of the American health care system — sick people who can’t pay their hospital bills literally dumped on the sidewalk, a child who dies because an emergency room that isn’t a participant in her mother’s health plan won’t treat her, hard-working Americans driven into humiliating poverty by medical bills.

“Sicko” is a powerful call to action — but don’t count the defenders of the status quo out. History shows that they’re very good at fending off reform by finding new ways to scare us.

These scare tactics have often included over-the-top claims about the dangers of government insurance. “Sicko” plays part of a recording Ronald Reagan once made for the American Medical Association, warning that a proposed program of health insurance for the elderly — the program now known as Medicare — would lead to totalitarianism.

Right now, by the way, Medicare — which did enormous good, without leading to a dictatorship — is being undermined by privatization.

Mainly, though, the big-money interests with a stake in the present system want you to believe that universal health care would lead to a crushing tax burden and lousy medical care.

Now, every wealthy country except the United States already has some form of universal care. Citizens of these countries pay extra taxes as a result — but they make up for that through savings on insurance premiums and out-of-pocket medical costs. The overall cost of health care in countries with universal coverage is much lower than it is here.

Meanwhile, every available indicator says that in terms of quality, access to needed care and health outcomes, the U.S. health care system does worse, not better, than other advanced countries — even Britain, which spends only about 40 percent as much per person as we do.

Yes, Canadians wait longer than insured Americans for elective surgery. But over all, the average Canadian’s access to health care is as good as that of the average insured American — and much better than that of uninsured Americans, many of whom never receive needed care at all.

And the French manage to provide arguably the best health care in the world, without significant waiting lists of any kind. There’s a scene in “Sicko” in which expatriate Americans in Paris praise the French system. According to the hard data they’re not romanticizing. It really is that good.

All of which raises the question Mr. Moore asks at the beginning of “Sicko”: who are we?

“We have always known that heedless self-interest was bad morals; we know now that it is bad economics.” So declared F.D.R. in 1937, in words that apply perfectly to health care today. This isn’t one of those cases where we face painful tradeoffs — here, doing the right thing is also cost-efficient. Universal health care would save thousands of American lives each year, while actually saving money.

So this is a test. The only things standing in the way of universal health care are the fear-mongering and influence-buying of interest groups. If we can’t overcome those forces here, there’s not much hope for America’s future.

Wall St. Journal
LETTERS
Sunday, July 8, 2007

The commentary by David Gratzer (“Who’s Really Sicko?”editorial page, June 28) presents an extremely prejudicial view of the publicly funded Canadian health system. It highlights the unfortunate story of a man from Ontario who had difficulty accessing a head MRI scan for a malignant brain tumour. Undoubtedly there are similar anecdotes describing difficulties in accessing care experienced by the 44 million Americans who lack health insurance. However, in making a rational comparison of the Canadian and American health systems it is more reasonable to contrast service levels and costs of the systems rather than trading anecdotes.

Canadians pay about 9% of national GDP to insure 100% of citizens in our single-payer system, compared with more than 14% of GDP to insure 85% of Americans. The Kaiser Family Foundation reports that the average compound annual growth rate in U.S. health insurance costs has been 11.6% over the past five years. It is therefore not surprising that polling by Kaiser found that 75% of Americans were worried or very worried about the amount they would need to pay for health insurance in the future and that 63% were worried or very worried about not being able to afford health-care services.

There is no question that restriction of supply with sub-optimal access to services has contributed to the lower cost of health care in Canada. However, a new approach of targeting investments to reduce waiting times combined with transparent reporting of wait times is having a substantial impact on access in the Canadian system. Dr. Gratzer wrote about prolonged waits for treatment in Ontario but did not refer readers to the public Web sites that detail Ontario waiting times for cancer surgery, chemotherapy, radiation, cataract, heart, arthroplasty and imaging procedures:

(http://www.health.gov.on.ca/transformation/wait_times/wait_mn.html and http://www.cancercare.on.ca)

Canadians spend about 55% of what Americans spend on health care and have longer life expectancy, and lower infant mortality rates. Many Americans have access to quality health care. All Canadians have access to similar care at a considerably lower cost. In “Sicko,” Michael Moore has apparently exaggerated the performance of the Canadian health system — there is no doubt that too many patients still stay in our emergency departments waiting for admission to scarce hospital beds. However, Mr. Moore’s description of the advantages of the Canadian system in the film is more accurate than the jaundiced view of our system proposed by Dr. Gratzer.

Robert S. Bell, M.D.
President and CEO
University Health Network
Toronto

(The letter was also signed by Carolyn Baker, R.N., president and CEO, St. Joseph’s Health Centre, Toronto, and Catherine Zahn, M.D., executive vice-president of Clinical Programs and Practice, University Health Network, Toronto.)

---

The introduction of private insurance or private-for-profit health care for medically necessary services is not the answer to challenges in the Canadian health-care system. In a systematic review of 38 studies published in Open Medicine in May, 17 leading Canadian and U.S. researchers confirmed the Canadian system leads to health outcomes as good, or better, than the U.S. private system, at less than 50% of the cost.

Unwanted side-effects of competitive health care include a drain of highly trained professionals from the public system and “cream skimming” of patients by private clinics who choose the healthiest patients, leaving the most complex to the increasingly overburdened public system.

In June 2006, the Canadian Medical Association reviewed all the evidence from other jurisdictions and concluded that private insurance for medically necessary physician and hospital services does not improve access to publicly insured services; does not lower costs or improve quality of care; can increase wait times for those who are not privately insured; and, could exacerbate human resource shortages in the public system.

Medicare is not only more equitable, but more efficient and produces higher quality health care than the alternatives. This conclusion is supported by the best national and international evidence, including reports from the World Health Organization and the Organization for Economic Co-Operation and Development.

So what should Canada do about patients who do not receive timely access to essential medical care? Numerous expert reports, including the 2002 Royal Commission on the Future of Health Care in Canada, have already told us we need to restore and strengthen Medicare, not decimate it.

In May the Canadian Centre for Policy Alternatives reported that successful initiatives in team-based care and improved administration produced dramatic cuts in waiting times for surgery in B.C. Alberta, Saskatchewan and Ontario, without any need for competition.

Danielle Martin
Board Chair
Canadian Doctors for Medicare
Toronto

[The following memo was written by Barclay Fitzpatrick, VP of Corporate Communications for Capital BlueCross]

I was able to see Sicko last night in Lancaster. There were about 30 other viewers in the theatre covering all age groups. I have attached the well-written memo from one of our partners, which describes cases used in the movie, to the end of my memo. Also attached are the latest talking points from BCBSA. I will focus on impact to our brands, issues, and suggested strategies in this memo.

The Movie
You would have to be dead to be unaffected by Moore’s movie, he is an effective storyteller. In Sicko Moore presents a collage of injustices by selecting stories, no matter how exceptional to the norm, that present the health insurance industry as a set of organizations and people dedicated to denying claims in the name of profit. Denial for treatments that are considered “experimental” is a common story, along with denial for previous conditions, and denial for application errors or omissions. Individual employees from Humana and other insurers are interviewed who claim to have actively pursued claim denial as an institutionalized goal in the name of profit.

While Humana and Kaiser Permanente are demonized, the BlueCross and BlueShield brands appear, separately and together, visually and verbally, with such frequency that there should be no doubt that whatever visceral reaction his movie stirs will spill over onto the Blues brands in every market. Here are some examples:

* Horizon BlueCross/BlueShield is picked out early in the film in a collage of stories citing bad treatment of members.
* BCBSA is cited for rejecting a woman for coverage due to a high BMI – “too fat” is written across the screen over a copy of her application denial letter, which describes the BMI rejection.
* BlueShield of California denied coverage for a diagnostic test, which the patient later received overseas. Patient sues BS of CA and medical director admits to not ‘seeing’ the actual denial letter, which was given an electronic signature.
* BlueCross of California denied payment for a major surgery after they discovered a previous yeast infection, then dropped the person for coverage. This is followed by an interview with a person who claims to have been a specialist at finding inaccuracies in applications to enable post-treatment payment denials.
* A BCBSA card is shown while the narrator describes how they (insurers) got wealthy.

In typical Moore fashion, Government and business leaders are behind a conspiracy to keep the little guy down and dominated while getting rich. Nixon Oval Office tapes are used to show how the initial idea of a ‘less care = profit’ enterprise was supported by the administration and became the HMO paradigm. Legislators are presented as bought stooges for the political agendas of insurers and big Pharma. Insurers are middlemen in the Medicare Modernization Act – which is presented as a trick to charge seniors more for their prescription drugs.

Doctors are barely touched – only in the course of discussing the AMA’s work to sink early efforts in the 40’s and 50’s to start universal health care. He takes efforts to show that doctors live well in other countries despite the existence of universal health care. In follow-up interviews, Moore has stated that he has spoken to and knows many doctors, and “doctors aren’t the problem”.

In the second half of the movie, Moore walks us through individual stories of the Canadian, British, French, and Cuban health care systems where everything is free and – he reminds us repeatedly – no one is ever denied service because they can’t pay. In addition to health care, the government provides free day care, college, and someone to do your laundry. Everybody gets along and takes care of each other and life is beautiful because there is universal health care. As a viewer, you are made to feel ashamed to be an American, a capitalist, and part of a ‘me’ society instead of a ‘we’ society – and the lack of universal health care is held up in support of that condemnation.

The Impact
Moore’s movies are intentionally intense and his objective in Sicko seems to be to revive the earlier Clinton efforts – not to achieve universal coverage with this movie, but to push the topic to the top of the agenda. He will be just as successful whether proponents mount momentum or discussion entails key stakeholders defending why it won’t work.

As a health care industry educated viewer it is easy to pick out where Moore is cultivating misperceptions to further a political agenda, but you will also recognize that 80%+ of the audience will have their perceptions substantially affected. In demonstration of its impact, an informal discussion group ensued outside the theatre after the movie. While some people recognized how one-sided the presentation was, most were incredulous and “I didn’t know they (the insurers) did that!” was a common exclamation followed by a discussion of the example.

The unfortunate reality for Capital BlueCross is that as the market leader, we will be affected both in brand and as employees as Moore’s efforts in the movie and surrounding PR activity are seen by more of the community. The impact on industry savvy Sales’ contacts should be minimal, while the impact on small business decision makers, our members, the community, and our employees could be significant. Ignoring its impact might be a successful strategy only if it flops, but that has not been the history of Moore’s films nor the way this one appears to be headed. If popular, the movie will have a negative impact on our image in this community.

There should be no doubt that many of our employees will be asked what they think of the movie by friends, family, and neighbors. We should anticipate that our customer service people will be asked about particular cases from the movie and if we follow similar policies. Word and phrases we have routinely used to date in policy change communications or denial letters, such as “Investigational”, will be seen as affirming the film’s contentions. The national BCBSA response – while coming out against the film’s divisiveness and focusing on the positive work of the Blues – steers media inquiries about policies and denials back to the plans themselves.

There are 4 key areas of misperception cultivated by the movie that we should consider in any messaging strategy:

1. That the industry is all about HMO’s. Moore cultivates this further in his interviews. The reality is that HMO’s are a minority product and have been for some time.
2. The movie attacks insurers for a profit motive, but makes no distinction among for-profit and non-profit insurers, and in its execution places the Blue Plans together with the for-profit insurers.
3. All plans and employees – from leaders to service representatives – are painted as motivated by profit to deny claims, and only those with crisis of conscience have come forward to confess their sins.
4. Perhaps most damaging of all, Moore completely fails to address the most significant driver of health care costs – our own lifestyle choices – and seeks to focus attention and efforts on the alluring ‘quick-fix’ of universal health care. It has taken a generation of poor nutrition and exercise to get obesity and related health issues – and subsequent costs – to their current levels, and Moore’s movie fails to acknowledge the causal relationship or need to change (he briefly touches the subject in a non-memorable way). Contrast this to the recent Health Care Symposium held in Harrisburg – where a panel of representatives from Government, Insurance, Hospitals, Business, Physicians, and even Lawyers agreed on one thing – that there was no quick fix and that Health and Wellness was the critical area of focus.

Suggestions
I believe the most successful strategy will not be in attacking the movie for its weaknesses or misperceptions, but in distancing ourselves and our brand from the groups and motivations he attacks, demonstrating the good that we do and achieve (aligns with BCBSA strategy), and in articulating our disappointment that he did not address the truly relevant issue of improving our health and wellness. We will convene a team to consider other approaches and work on potential messages for media inquiries, customer service, and employees.

Confidential Memo (from partner)

SiCKO – viewed on 6/26/2007

Takeaways

* The main theme of the movie is that American society needs to focus on the “we” and not the “me” in healthcare.

o This broad message is an overlay for the specific criticisms of the healthcare industry – the movie asks where the morality of the American public lies and contrasts America’s approach to health care unfavorably with other nations.

* SiCKO does not go into any depth about how health insurers operate how the health insurance business works – instead it fixates on what it characterizes as the profit incentive to deny care to patients (e.g. examples of barriers to getting health insurance if you are not healthy; examples of people being denied expensive tests or procedures; examples of efforts to deny reimbursement after care has been received.)

* The film draws no distinction between not-for-profit and for-profit insurers – in fact the Blue Cross/Blue Shield brand is intermixed with the for – profit brands as background reference points. o One scene shows a Blue Cross / Blue Shield logo as Michael Moore’s voice over begins, “While the healthcare companies get wealthy…”

* The health insurers that get the most airtime are:

o Kaiser Permanente
o Humana
o CIGNA
o Blue Cross of California
o Aetna

* No Pharma companies are mentioned – but SiCKO suggests in multiple instances that prescription drugs are overpriced

o At a pharmacy in London, prescription drugs are £6.65, no matter how large the dose
o In Cuba, one bankrupt 9/11 worker’s inhaler costs 5 cents, instead of $100

Further Notes

* Some of the examples of denial of care highlighted in the film:

o A woman with Kaiser Permanente takes her 18-month daughter to the hospital in an ambulance, only to be told to go to an in-network hospital. By the time they reach the second hospital, her daughter has stopped breathing and dies 30 minutes later in ER.

o A woman with Blue Shield of California has a tumor but is denied requests to get an MRI, or to see a specialist. While on vacation in Japan she is given an MRI, and eventually returns to the U.S. to demand treatment from her insurer.

* In the ensuing court case, a doctor admits to denying her request without having reviewed it.

o Blue Cross of California approves one woman’s $7,500 treatment, but the approval is later denied for her failure to report a previous medical incident – a yeast infection.

* “They’re just looking for a way out,” she says

* Other examples of how health insurers avoid paying for treatment:

o One graph (from Humana) shows that doctors with the highest % of denials get a bonus.

o Michael Moore interviews a former health insurance employee who specialized in denying care to patients retroactively – by finding inconsistencies in their medical records.

o A 5-minute piece in the beginning of the movie .

* The film also focuses on the politicians and the funds they raise from Pharma and other player in the health care industry and alleges that the system has been heavily influenced by lobbyists and contributions.

Barclay Fitzpatrick
Vice President
Corporate Communications
Capital BlueCross
(w) 717-541-7752
(c) 717-329-3648
barclay.fitzpatrick@capbluecross.com

MichaelMooreTalkingPoints61807.doc

Blue Cross and Blue Shield Association
Talking Points in Response to Michael Moore’s “Sicko”
June 2007

1) The Blue Cross and Blue Shield Association (BCBSA) and the 39 Blue Cross and Blue Shield companies are committed to improving the U.S. healthcare system for our nearly 100 million members through continuous innovation that reflects the ever-changing healthcare landscape and the needs of the consumer.

2) The Blues recognize the need for improvement of both the coverage and delivery of healthcare. But the divisive tone set forth by Michael Moore and his movie “Sicko” is not helpful. Positive change to our healthcare system can be best achieved through shared responsibility, not recrimination. To ensure Americans have access to the best healthcare that is both timely, efficient, and of high quality, requires the collective contribution of all stakeholders — consumers, providers, employers and the government.

3) The Blues participation in the Health Coverage Coalition for the Uninsured is a primary example of how the broader healthcare community is working together to reduce the number of uninsured in the United States.

4) The Blues are working on myriad initiatives that ensure Americans have access to quality and affordable healthcare. Each day, Blue Plans across the country are bringing healthcare value to their members in a number of ways such as new advances in health information technology and greater access to cost and quality information. In addition:

o The Blues recently created Blue Health Intelligence a data resource that will shine light on emerging medical trends and treatment options in an unprecedented way. To further the use of evidenced-based medicine, BCBSA has called upon Congress to establish an independent, payer-funded institute that will study the comparative effectiveness of new and existing medical treatments and procedures.

o Blue Cross and Blue Shield companies are at the forefront of healthcare transparency by providing their members with online access to real-time information related to provider quality and the cost of common healthcare services. In addition, the Blues have committed to making personal health records available to their members by 2008.

o We are working to ensure that Medicare is funded appropriately and that seniors continue to have access to comprehensive benefits.

5) The Blues are proud of these efforts and we will continue to work with consumers, providers, employers and the government to provide Americans with the healthcare services and information they need to lead full, healthy lives.

[The following memo was written by Barclay Fitzpatrick, VP of Corporate Communications for Capital BlueCross]

I was able to see Sicko last night in Lancaster. There were about 30 other viewers in the theatre covering all age groups. I have attached the well-written memo from one of our partners, which describes cases used in the movie, to the end of my memo. Also attached are the latest talking points from BCBSA. I will focus on impact to our brands, issues, and suggested strategies in this memo.

The Movie
You would have to be dead to be unaffected by Moore’s movie, he is an effective storyteller. In Sicko Moore presents a collage of injustices by selecting stories, no matter how exceptional to the norm, that present the health insurance industry as a set of organizations and people dedicated to denying claims in the name of profit. Denial for treatments that are considered “experimental” is a common story, along with denial for previous conditions, and denial for application errors or omissions. Individual employees from Humana and other insurers are interviewed who claim to have actively pursued claim denial as an institutionalized goal in the name of profit.

While Humana and Kaiser Permanente are demonized, the BlueCross and BlueShield brands appear, separately and together, visually and verbally, with such frequency that there should be no doubt that whatever visceral reaction his movie stirs will spill over onto the Blues brands in every market. Here are some examples:

* Horizon BlueCross/BlueShield is picked out early in the film in a collage of stories citing bad treatment of members.
* BCBSA is cited for rejecting a woman for coverage due to a high BMI – “too fat” is written across the screen over a copy of her application denial letter, which describes the BMI rejection.
* BlueShield of California denied coverage for a diagnostic test, which the patient later received overseas. Patient sues BS of CA and medical director admits to not ‘seeing’ the actual denial letter, which was given an electronic signature.
* BlueCross of California denied payment for a major surgery after they discovered a previous yeast infection, then dropped the person for coverage. This is followed by an interview with a person who claims to have been a specialist at finding inaccuracies in applications to enable post-treatment payment denials.
* A BCBSA card is shown while the narrator describes how they (insurers) got wealthy.

In typical Moore fashion, Government and business leaders are behind a conspiracy to keep the little guy down and dominated while getting rich. Nixon Oval Office tapes are used to show how the initial idea of a ‘less care = profit’ enterprise was supported by the administration and became the HMO paradigm. Legislators are presented as bought stooges for the political agendas of insurers and big Pharma. Insurers are middlemen in the Medicare Modernization Act – which is presented as a trick to charge seniors more for their prescription drugs.

Doctors are barely touched – only in the course of discussing the AMA’s work to sink early efforts in the 40’s and 50’s to start universal health care. He takes efforts to show that doctors live well in other countries despite the existence of universal health care. In follow-up interviews, Moore has stated that he has spoken to and knows many doctors, and “doctors aren’t the problem”.

In the second half of the movie, Moore walks us through individual stories of the Canadian, British, French, and Cuban health care systems where everything is free and – he reminds us repeatedly – no one is ever denied service because they can’t pay. In addition to health care, the government provides free day care, college, and someone to do your laundry. Everybody gets along and takes care of each other and life is beautiful because there is universal health care. As a viewer, you are made to feel ashamed to be an American, a capitalist, and part of a ‘me’ society instead of a ‘we’ society – and the lack of universal health care is held up in support of that condemnation.

The Impact
Moore’s movies are intentionally intense and his objective in Sicko seems to be to revive the earlier Clinton efforts – not to achieve universal coverage with this movie, but to push the topic to the top of the agenda. He will be just as successful whether proponents mount momentum or discussion entails key stakeholders defending why it won’t work.

As a health care industry educated viewer it is easy to pick out where Moore is cultivating misperceptions to further a political agenda, but you will also recognize that 80%+ of the audience will have their perceptions substantially affected. In demonstration of its impact, an informal discussion group ensued outside the theatre after the movie. While some people recognized how one-sided the presentation was, most were incredulous and “I didn’t know they (the insurers) did that!” was a common exclamation followed by a discussion of the example.

The unfortunate reality for Capital BlueCross is that as the market leader, we will be affected both in brand and as employees as Moore’s efforts in the movie and surrounding PR activity are seen by more of the community. The impact on industry savvy Sales’ contacts should be minimal, while the impact on small business decision makers, our members, the community, and our employees could be significant. Ignoring its impact might be a successful strategy only if it flops, but that has not been the history of Moore’s films nor the way this one appears to be headed. If popular, the movie will have a negative impact on our image in this community.

There should be no doubt that many of our employees will be asked what they think of the movie by friends, family, and neighbors. We should anticipate that our customer service people will be asked about particular cases from the movie and if we follow similar policies. Word and phrases we have routinely used to date in policy change communications or denial letters, such as “Investigational”, will be seen as affirming the film’s contentions. The national BCBSA response – while coming out against the film’s divisiveness and focusing on the positive work of the Blues – steers media inquiries about policies and denials back to the plans themselves.

There are 4 key areas of misperception cultivated by the movie that we should consider in any messaging strategy:

1. That the industry is all about HMO’s. Moore cultivates this further in his interviews. The reality is that HMO’s are a minority product and have been for some time.
2. The movie attacks insurers for a profit motive, but makes no distinction among for-profit and non-profit insurers, and in its execution places the Blue Plans together with the for-profit insurers.
3. All plans and employees – from leaders to service representatives – are painted as motivated by profit to deny claims, and only those with crisis of conscience have come forward to confess their sins.
4. Perhaps most damaging of all, Moore completely fails to address the most significant driver of health care costs – our own lifestyle choices – and seeks to focus attention and efforts on the alluring ‘quick-fix’ of universal health care. It has taken a generation of poor nutrition and exercise to get obesity and related health issues – and subsequent costs – to their current levels, and Moore’s movie fails to acknowledge the causal relationship or need to change (he briefly touches the subject in a non-memorable way). Contrast this to the recent Health Care Symposium held in Harrisburg – where a panel of representatives from Government, Insurance, Hospitals, Business, Physicians, and even Lawyers agreed on one thing – that there was no quick fix and that Health and Wellness was the critical area of focus.

Suggestions
I believe the most successful strategy will not be in attacking the movie for its weaknesses or misperceptions, but in distancing ourselves and our brand from the groups and motivations he attacks, demonstrating the good that we do and achieve (aligns with BCBSA strategy), and in articulating our disappointment that he did not address the truly relevant issue of improving our health and wellness. We will convene a team to consider other approaches and work on potential messages for media inquiries, customer service, and employees.

Confidential Memo (from partner)

SiCKO – viewed on 6/26/2007

Takeaways

* The main theme of the movie is that American society needs to focus on the “we” and not the “me” in healthcare.

o This broad message is an overlay for the specific criticisms of the healthcare industry – the movie asks where the morality of the American public lies and contrasts America’s approach to health care unfavorably with other nations.

* SiCKO does not go into any depth about how health insurers operate how the health insurance business works – instead it fixates on what it characterizes as the profit incentive to deny care to patients (e.g. examples of barriers to getting health insurance if you are not healthy; examples of people being denied expensive tests or procedures; examples of efforts to deny reimbursement after care has been received.)

* The film draws no distinction between not-for-profit and for-profit insurers – in fact the Blue Cross/Blue Shield brand is intermixed with the for – profit brands as background reference points. o One scene shows a Blue Cross / Blue Shield logo as Michael Moore’s voice over begins, “While the healthcare companies get wealthy…”

* The health insurers that get the most airtime are:

o Kaiser Permanente
o Humana
o CIGNA
o Blue Cross of California
o Aetna

* No Pharma companies are mentioned – but SiCKO suggests in multiple instances that prescription drugs are overpriced

o At a pharmacy in London, prescription drugs are £6.65, no matter how large the dose
o In Cuba, one bankrupt 9/11 worker’s inhaler costs 5 cents, instead of $100

Further Notes

* Some of the examples of denial of care highlighted in the film:

o A woman with Kaiser Permanente takes her 18-month daughter to the hospital in an ambulance, only to be told to go to an in-network hospital. By the time they reach the second hospital, her daughter has stopped breathing and dies 30 minutes later in ER.

o A woman with Blue Shield of California has a tumor but is denied requests to get an MRI, or to see a specialist. While on vacation in Japan she is given an MRI, and eventually returns to the U.S. to demand treatment from her insurer.

* In the ensuing court case, a doctor admits to denying her request without having reviewed it.

o Blue Cross of California approves one woman’s $7,500 treatment, but the approval is later denied for her failure to report a previous medical incident – a yeast infection.

* “They’re just looking for a way out,” she says

* Other examples of how health insurers avoid paying for treatment:

o One graph (from Humana) shows that doctors with the highest % of denials get a bonus.

o Michael Moore interviews a former health insurance employee who specialized in denying care to patients retroactively – by finding inconsistencies in their medical records.

o A 5-minute piece in the beginning of the movie .

* The film also focuses on the politicians and the funds they raise from Pharma and other player in the health care industry and alleges that the system has been heavily influenced by lobbyists and contributions.

Barclay Fitzpatrick
Vice President
Corporate Communications
Capital BlueCross
(w) 717-541-7752
(c) 717-329-3648
barclay.fitzpatrick@capbluecross.com

MichaelMooreTalkingPoints61807.doc

Blue Cross and Blue Shield Association
Talking Points in Response to Michael Moore’s “Sicko”
June 2007

1) The Blue Cross and Blue Shield Association (BCBSA) and the 39 Blue Cross and Blue Shield companies are committed to improving the U.S. healthcare system for our nearly 100 million members through continuous innovation that reflects the ever-changing healthcare landscape and the needs of the consumer.

2) The Blues recognize the need for improvement of both the coverage and delivery of healthcare. But the divisive tone set forth by Michael Moore and his movie “Sicko” is not helpful. Positive change to our healthcare system can be best achieved through shared responsibility, not recrimination. To ensure Americans have access to the best healthcare that is both timely, efficient, and of high quality, requires the collective contribution of all stakeholders — consumers, providers, employers and the government.

3) The Blues participation in the Health Coverage Coalition for the Uninsured is a primary example of how the broader healthcare community is working together to reduce the number of uninsured in the United States.

4) The Blues are working on myriad initiatives that ensure Americans have access to quality and affordable healthcare. Each day, Blue Plans across the country are bringing healthcare value to their members in a number of ways such as new advances in health information technology and greater access to cost and quality information. In addition:

o The Blues recently created Blue Health Intelligence a data resource that will shine light on emerging medical trends and treatment options in an unprecedented way. To further the use of evidenced-based medicine, BCBSA has called upon Congress to establish an independent, payer-funded institute that will study the comparative effectiveness of new and existing medical treatments and procedures.

o Blue Cross and Blue Shield companies are at the forefront of healthcare transparency by providing their members with online access to real-time information related to provider quality and the cost of common healthcare services. In addition, the Blues have committed to making personal health records available to their members by 2008.

o We are working to ensure that Medicare is funded appropriately and that seniors continue to have access to comprehensive benefits.

5) The Blues are proud of these efforts and we will continue to work with consumers, providers, employers and the government to provide Americans with the healthcare services and information they need to lead full, healthy lives.

Embargoed for Release
July 5, 2007

Contacts:
PNHP – Quentin Young, 312-782-6006.
CNA/NNOC – Charles Idelson, 510-273-2246

Nurses, Doctors Say It’s Time to Debunk the Myths
Even Aetna Admits U.S. System ‘Is Not Timely’

Waiting times in U.S. hospitals and clinics are becoming so lengthy that even one of the nation’s biggest insurers, Aetna, has admitted to its investors that the U.S. healthcare system is “not timely” and patients diagnosed with cancer wait “over a month” for needed medical care, said two leading organizations of doctors and nurses today.

Lost in the recent flurry of attacks on Canada and other nations with publicly funded healthcare systems, spurred by the popularity of Michael Moore’s “SiCKO,” is the reality of the huge hurdles faced by many American patients, said the Physicians for a National Health Program and the California Nurses Association/National Nurses Organizing Committee.

“As the cost and service failures of the U.S. health system become unbearable, those who profit from the system – the private health insurance giants and big drug companies – are bringing out the propaganda attacks on the experience in the many countries which have chosen a public insurance plan. As always, half truths and lies are the scare tactics of these profiteers,” said Quentin Young, MD national coordinator of PNHP.

“There’s been a lot of clamor lately about delays in care in some other countries. But if you want to see some really unsightly waiting times, look at U.S. medical facilities,” said Deborah Burger, RN, president of the 75,000-member CNA/NNOC.

While the problem has been largely overlooked by the major media, it was quietly exposed by the chief medical officer of Aetna, Inc. late in Aetna’s Investor Conference 2007 in March.

In his talk, Troy Brennan conceded that “the (U.S.) healthcare system is not timely.” He cited “recent statistics from the Institution of Healthcare Improvement… that people are waiting an average of about 70 days to try to see a provider. And in many circumstances people initially diagnosed with cancer are waiting over a month, which is intolerable,” Brennan said.

Brennan also recalled that he had formerly spent much of his time as an administrator and head of a physicians’ organization trying “to find appointments for people with doctors.”

While Brennan’s comments went unreported by the media, his data matches several studies and a report in a June 22 Business Week article which opened by citing the case of a New York woman who had to fight for a timely second exam following suspicious results from a first mammogram and then still had to wait a full month.

The article also noted a University of California San Francisco research report last year that documented average waits of 38.2 days to get an appointment with a dermatologist to examine a possibly cancerous mole.

A Commonwealth Fund study of six highly industrialized countries, the U.S., and five nations with national health systems, Britain, Germany, Australia, New Zealand, and Canada, found waiting times were worse in the U.S. than in all the other countries except Canada.

And, most of the Canadian data so widely reported by the U.S. media is out of date, and misleading, according to PNHP and CNA/NNOC.

In Canada, there are no waits for emergency surgeries, and the median time for non-emergency elective surgery has been dropping as a result of public pressure and increased funding so that it is now equal to or better than the U.S. in most areas, the organizations say.

Statistics Canada’s latest figures show that median wait times for elective surgery in Canada is now three weeks.

“There are significant differences between the U.S. and Canada, too,” said Burger. “In Canada, no one is denied care because of cost, because their treatment or test was not ‘pre-approved’ or because they have a pre-existing condition.”

“Furthermore, when a service problem emerges in Canada, prompt analysis and resource deployment is mobilized to resolve the problem,” noted PNHP’s Young. “In the U.S., the situation only worsens each year, hence we are presently in an enormous crisis. That’s why we a need a single payer system, such as HR 676 which is now before Congress, that can respond to new demands.”

Furthermore, U.S. statistics fail to account for the even longer waits for the nation’s 44 million uninsured and tens of millions of insured Americans who put off needed medical care due to their high co-pays or deductibles, CNA/NNOC and PNHP noted.

Canada also surpasses the U.S. in a broad array of health barometers, including life expectancy, infant mortality rates, adult mortality rates, deaths due to HIV/AIDS, mortality rates for cardiovascular diseases, and years of life lost to injuries and communicable diseases, according to data from the World Health Organization and the Organization of Economic Co-operation and Development.

“As nurses, we never worry about costs, billing, whether a procedure will be covered or anything like that. I never have to worry about whether one of my patients will get the treatment or care they need,” wrote Bev Dick, RN, vice president of the United Nurses of Alberta wrote in a Portsmouth (NH) Herald commentary July 1. “That’s the reason nurses are so supportive of our public system. And we have fought to protect it.”