By Brenda Gazzar
Code Wack Podcast, March 13, 2023

How does running a hospital like a business run counter to providing reliable and affordable healthcare? How would having Medicare for All change the way hospitals are financed and what would it mean for patients, doctors, and the hospitals themselves?

To find out, we spoke to Dr. David Himmelstein, a distinguished professor of public health at CUNY’s Hunter College and a lecturer in medicine at Harvard Medical School. He also serves as a staff physician at Montefiore Medical Center in the Bronx and is the co-founder of Physicians for a National Health Program. This is the second of a two-part series with Dr. Himmelstein (part one available HERE).

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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! How does running a hospital like a business run counter to providing reliable and affordable health care? How would having Medicare for All change the way hospitals are financed and what would it mean for patients, doctors, and the hospitals themselves?

To find out, we spoke to Dr. David Himmelstein, a distinguished professor of public health at CUNY’s Hunter College and a lecturer in medicine at Harvard Medical School. He also serves as a staff physician at Montefiore Medical Center in the Bronx and is the co-founder of the single-payer advocacy group Physicians for a National Health Program. This is the second of a two-part series with Dr. Himmelstein.

Welcome back to Code WACK!, Dr. Himmelstein.

Himmelstein: Thanks for having me.

Q: In 1987, you co-founded Physicians for National Health Program. What inspired you to do that?

Himmelstein: Well, the experiences of our healthcare system really making it so difficult to care for patients and many of my patients at public hospitals where I work, being unable to get the care they needed and deserve. At the same time, seeing that our country has ample resources to provide excellent care to everyone if they were distributed in a reasonable way and I spent some of my time during my career working at fancy private hospitals. During my residency, one or two months we rotated through a fancy private hospital and one month a year I used to be the attending physician, the staff physician on the wards at Mass General Hospital, one of Harvard’s banner teaching hospitals. So I saw excellent care that was available to privileged patients and often resources at those hospitals that went unused because the hospitals actually oftentimes had surplus resources. And (in the) meantime, the public hospitals where I spent most of my time working, patients weren’t getting the care they needed.

So my partner, Steffie Woolhandler and I looked around at what alternatives there were for how to finance health care and we saw that other countries really did it better and they had lessons to teach us about how you could construct a healthcare financing system that was both fairer, more efficient and improved health outcomes.

Q:  you give an example?

Himmelstein: We particularly looked at Canada because Canada’s health care system in many ways is very, very similar to that in the U.S. In fact, until we passed Medicare and Medicaid in the mid 1960s and Canada passed its national health insurance scheme around that same time, our healthcare systems and financing systems were almost identical. So it was easy to see how we could make a transition to national health insurance schemes like Canada, which is not perfect, but has huge advantages. So we really used that as an initial model and thought about what it would take to transition the U.S.

Q: Got it. Great. It’s no secret that hospitals, even nonprofit ones, are big businesses today in America. How are the incentives of running a business at odds with community needs for reliable access to affordable health care?

Himmelstein: Well, hospitals want to take in more money than they pay out to their staff and their suppliers. They want to make a profit at the end of the year, whether they’re nonprofit or not and that’s actually pretty much required, necessary if the hospital is going to keep going under our current financing system because in order to upgrade its facilities, stay modern, buy new equipment, renovate the rooms and wards when they get outdated, keep the ORs up to date, hospitals need to have money in the bank to pay for those new investments and the way you get money in the bank under this system is to take in more money each year than you pay out. Or the other alternative is to say, ‘well, we’ll borrow the money,’ but the only way you’re able to borrow it is if you assure the bondholders or the banks that you’ll pay them back from the surpluses from the profits you accrue in future years, so our system says to hospitals, you have to make a profit or your future is in doubt.

Q: Right. Thank you. What toll do standard business practices like mergers and acquisitions, consolidation and corporatization take on patients and doctors today?

Himmelstein: Well, increasingly the people who run hospitals have not just said, ‘well, we want to make sure our hospital can survive, but we’re going to really run up a huge surplus and become an extremely successful business and that’s going to allow me personally to be paid much more.’ So when I was first a doctor, the hospital CEO was paid like a doctor – handsomely paid. Now they’re routinely paid in the millions, sometimes tens of millions of dollars.

Oh, wow.

Himmelstein: So if you make a huge profit, you’re able to say, ‘well, I ran this business so wonderfully that the hospital is making a big profit and I deserve a huge paycheck and I can build the empire and assemble more power that way.’

Q: And what about the patients?

Himmelstein: And it impacts the care in multiple ways so increasingly the hospitals control what the doctors do. So 30, 40 years ago, the doctors were pretty much independent of the hospitals so the doctors mostly were not paid by the hospitals, they were paid directly by their patients and the hospitals didn’t rule over the doctors. Nowadays, most doctors are employees of the hospitals where they work or of group practices that are kind of a subsidiary of those hospitals. So the hospitals can really dictate to doctors much more what they need to do and they’ve really passed down many rules, regulations, surveillance about what we need to do that’s going to be profitable for them.

Q: So how do you feel knowing that that’s the case today?

Himmelstein: Well, I think most doctors are really horrified at it so that’s the root I think of a huge amount of doctor burnout and dissatisfaction. The bureaucratic stuff they’ve imposed on doctors is crushing. The average doctor is now spending, oh, something like 20%, 30% of their total time on paperwork, much of it imposed by their hospitals.

Q: Wow. That’s a lot of time.

Himmelstein: Yeah, we’ve become box checkers and our incomes in many cases depend on doing what’s profitable for the hospital. So you now have hospitals saying you can make bonuses of $30,000 or $40,000 a year if you do what’s called coding. You attach diagnoses that are profitable for the hospital to your patients.

Q: Wow. How do you think that affects the behavior of doctors?

Himmelstein: Oh, I think if you’re offered $40,000 for doing what the hospital wants, most of us try and do it.

Q: Wow. So attaching a diagnosis to somebody who you, I mean, would you say that people would do it even if they don’t think their patients have that diagnosis?

Himmelstein: Well, what they do, and I think this is routinely done, is stretch the limits. So it’s not that they don’t have that diagnosis, but there are these arcane rules about what makes money for hospitals. So if a patient had asthma 10 years ago but they no longer have any asthma symptoms, if you write down in the chart ‘asthma not active at this point,’ that counts. That’s profitable for the hospital. It’s medically not meaningful at this time. So you’re not lying, you’re not doing anything to harm the patient, but you make the hospital and maybe the insurance plan affiliated with the hospital lots of extra money and some of that’s going to trickle down to you.

Q: Interesting. Thank you. So we touched a little bit about this in the last episode, but can you explain how hospitals are financed today and how they would be paid under Medicare for All?

Himmelstein: Well, at this point, hospitals bill patients or their insurance plans for each hospital stay generally, and depending on what the insurance is, they may get more or less. So a patient with pneumonia, with insurance from a private insurance plan, generally the hospital gets paid more than the same patient if they’re covered by Medicare and much more if that patient is covered by Medicaid. And if they’re uninsured, the hospital will bill a patient themselves and try and collect from them. And sometimes hospitals get some money for uninsured patients from government funds. So there are multiple streams of payment. There’s private insurance, there’s Medicaid, there’s Medicare and patients themselves, both the uninsured and then co-payments and deductibles that patients have to pay even if they are insured in many cases. So the one impact of that is that some patients bring in more money than other patients do.

If you have private insurance, the hospital gets paid more than if you have Medicare and Medicare more than if you have Medicaid. And in most cases either of those more than if you’re uninsured. Single payer would really change that in two ways. One is everyone would have the same insurance, so there’d be no distinction among patients so there’d be no more for Sally than for Alice. And that’s one important piece. But the second is in countries like Canada where everyone has the same insurance, generally hospitals don’t bill for each patient and each time they’re admitted, they get paid one lump sum amount each month for their operation, much like a fire department gets paid in the U.S. So the Canadians and people in many other countries have said, ‘why would we bother trying to figure out how much it costs to care for Sally and how much it costs to care for Alice?’

Our concern is what does it cost to run the hospital and take care of everybody whom they take care of. So we’ll just pay the hospital a lump sum and that eliminates a huge amount of paperwork both for the hospital and for the organization doing the payer. So for the hospital, it means you don’t have to keep track of who got every bandaid and aspirin tablet, try and figure out what you can squeeze out of each patient’s care and for the payer, it means again, you don’t have to pay for that stuff and go over each of those bills in that kind of detail.

Hmm, I see.

That came home to me many years ago visiting a friend who was hospitalized at Toronto General Hospital, at that time a big really what’s called tertiary care, so a highly specialized hospital with a full range of services.

And the billing office at that hospital when we looked was three or four people whose main job seemed to be to send bills to Americans who happened to wander across the border, and when we got back to Boston where I was living at the time, we went and looked at the billing office at Massachusetts General Hospital, which was roughly the same size and same range of services and back then they had 352 full-time equivalent personnel in the billing department. Not because they were inefficient, but because that’s what they needed to do to get paid and since then, they’ve accumulated I think many more people than that. So the difference in the way a single payer system would pay for hospital care is really twofold. One is that there would be no financial distinction among patients. And the second is that you’d eliminate the need for the kind of detailed billing and paying that drives up the administrative costs and causes tremendous waste in our healthcare system.

Q: Right. I’ve heard people kind of who oppose single-payer, who have concerns about it, say things like, well, if I am willing to spend more money, if I have and I’m willing to spend more money, why wouldn’t I get the convertible, for example, instead of the Toyota Corolla? But is that really a fair analogy in the case of single payer, are they missing out on better care If it’s all one comprehensive insurance plan?

Himmelstein: Well, you know, the data actually shows that Canadians on average get better care than Americans do and even wealthy Americans have shorter life expectancies than average in most other wealthy nations. So I think the worry that Canadians or people in other countries with this kind of egalitarian national health insurance are not getting good care is misplaced. In fact, you know, it’s sort of a weird thing I guess. Rand Paul a few years ago got his hernia repaired at the Shouldice Clinic in Ontario, which is a world famous hernia repair specialty hospital and his spokesperson said, ‘well, it’s a private hospital. It’s not part of the Canadian healthcare system,’ which just isn’t true. In fact, when we looked on the website of the Shouldice Clinic – they have a provincial health insurance plan. So there are 10 different plans, I guess up there that each province has its own plan, but they’re all very similar.

Any Canadian with health insurance from their public plan can walk into the Shouldice clinic without an appointment and start their care and have their care fully covered with no co-payments, no deductibles whatsoever. So in fact, we can deliver very high quality care to the entire population if we organize and finance our care in a rational way. Now in any system, there’s a top surgeon and a surgeon who you might want to not go to quite as much and the surgeon with a better reputation is going to have a little bit longer waiting list. In fact, in New York at this point, there are surgeons with months-long waiting lists to get care. The question is whether the people at the front of the queue ought to get there because they’re wealthier or because they’re the people who need the care the most? And as a doctor, my view is, you know, it’s the people who need the care the most, who actually ought to be at the head of the queue. And to say to a kid with leukemia, you don’t deserve the top quality care because your parents aren’t rich so you’re going to die and the rich kid is going to live, that’s criminal.

Q: Right. Such a good example. Thank you. So how would having a single-payer system affect patients and doctors?

Himmelstein: It would tremendously simplify patients’ lives. So every hospital in the entire country, I mean, again following the Canadian model, would take your insurance and your insurance would be the same no matter who you are, no matter where you are. You’d have complete coverage, you would not be responsible for any of the bills. So you wouldn’t have to worry about any out-of-pocket costs. You’d have the freedom to choose any hospital. Many of us now have, particularly with private coverage, have plans that limit where we can go and that would be abolished and it would mean that there’d be no financial distinction among patients. For doctors, it would simplify our lives. It would say you don’t have to spend your time worrying about whether your patients can afford this. The amount of paperwork you have to do for billing and for the f inancial manipulations of your practice or your hospital would be tremendously cut and we’d be able to actually practice medicine without the ridiculous stuff that goes along with it today.

Q: Right. And just as doctors wouldn’t have to worry about whether their patients could afford the treatment, patients themselves also wouldn’t have to worry about that.

Himmelstein: Absolutely.

Q: And how would this affect the hospitals?

Himmelstein: Well, I would say to hospitals, first of all, you would need to transition many people in your staff who are doing useless and maybe even harmful things to doing useful work. So our estimate is that there are several hundred thousand people doing useless paperwork in hospitals today and we’d need to find different and hopefully useful work for them. And many of them could surely be deployed within hospitals to fill in the gaps that we have now andthe personnel shortages. So that’s one thing that would affect hospitals. And one of the other pieces for hospitals is that the lump sum payment, that monthly payment you get from the National Health Insurance plan, that would be to cover your work today and whatever you don’t spend on your patients that you would have to give back. So you wouldn’t be accumulating any surpluses or profits. You wouldn’t have an incentive for playing the kinds of games you have today.

Instead, if you want a new building or an upgrade of your facilities, you would apply for a grant from the National Health Insurance Program and they would judge the needs of the communities and see, you know, is this the biggest need for the billions and billions of dollars? This year some, I think $150 billion we’re going to spend on new what’s called capital investments in health care. Instead of that money being allocated based on which hospitals are profitable or not, it would go into a fund and there’d be a regional organization that would evaluate where the investments are most needed.

And again, to give you an example, you know, we have parts of New York that are really medical deserts at this point and where the hospitals are kind of run down and I said before the roofs are leaking. And those hospitals obviously ought to be at the front of the line for the new investments. On the other hand, Mass General, which is already kind of a medical palace, is building a new $2 billion building up in Boston. I’m not sure that would’ve been the highest priority in that city. So it would change hospitals’ behavior by saying to them, you’re not actually going to be run as a business because your goal is not going to be having a profit at the end of the year because you won’t be able to have a profit one way or the other.

Thank you, Dr. David Himmelstein.

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.

Don’t forget to subscribe to Code WACK! wherever you find your podcasts. You can also find us on ProgressiveVoices.com and on Nurse Talk Media.

Code WACK! 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…

By Brenda Gazzar
Code Wack Podcast, March 6, 2023

What’s the story behind the EMTALA patient protection law of 1986, which requires hospitals to stabilize or treat patients who are in a health emergency regardless of their insurance status or ability to pay? What has this law done for patients and what does it mean for hospitals?

How does the current way hospitals are paid incentivize them to pass the buck on uninsured patients?

To find out, we spoke to Dr. David Himmelstein, a distinguished professor of public health at CUNY’s Hunter College and a lecturer in medicine at Harvard Medical School. He also serves as a staff physician at Montefiore Medical Center in the Bronx and is the co-founder of Physicians for a National Health Program. This is the first of a two-part series with Dr. Himmelstein.

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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! What’s the story behind the EMTALA patient protection law of 1986, which requires hospitals to stabilize or treat patients who are in a health emergency regardless of their insurance status or ability to pay. What has this law done for patients and what does it mean for hospitals? To find out, we spoke to Dr. David Himmelstein, a distinguished professor of public health at CUNY’s Hunter College and a lecturer in medicine at Harvard Medical School. He also serves as a staff physician at Montefiore Medical Center in the Bronx and is the co-founder of Physicians for a National Health Program. This is the first of a two-part series with Dr. Himmelstein.

Q: Welcome to Code WACK!, Dr. Himmelstein. Tell us a little bit about yourself and how you became a Medicare for All supporter.

Himmelstein: I’m a doctor. I grew up in New York and really intended to be a doctor, taking care of poor people and contributing to the care of oppressed communities and found that the healthcare system wouldn’t let me. There were so many barriers to the adequate care of people in need that it just became impossible to do my job well under the healthcare system as it is. So I got involved in what would we need to do to fix the healthcare system.

Q: Thank you for that. We’re going to talk about hospital financing today, but we’d like to start with your 1984 study “Patient Transfers: Medical Practice as Social Triage.” It highlighted how transferring patients from private to public hospital emergency rooms can negatively affect their health and outcomes. Can you briefly tell us about that?

Himmelstein: Well, I was a resident at the public hospital in Oakland, California along with many other residents. We were disgusted at the mistreatment of our patients by private hospitals that were afraid they were going to lose money if they took care of uninsured people. So they routinely shoved patients who were coming to their emergency rooms who didn’t have insurance into ambulances to send them to us at the public hospitals and many of them were clearly worse off because of often long ambulance rides when they were gravely ill. So the group of us at the public hospital at that time decided to document what we were seeing on a routine basis and really found that there was, when we looked at it systematically, a lot of harm being done to our patients.

Q: You mentioned that many of them were uninsured. What other demographic did these patients have?

Himmelstein: Because lack of insurance is much more common among people of color, many were people of color, so a lot of them were Black people, particularly because Oakland at that time had a very large Black population and not very many Latinx folks and so they were by and large poor people, people of color, uninsured people.

Q: Wow. And so did you find that one of the main reasons that they were being transferred was because they were uninsured?

Himmelstein: Well, occasionally they would say that in the medical record openly, but more often they wouldn’t say it openly. But it was pretty obvious they were coming from fully equipped private hospitals that had doctors who were perfectly capable of caring for these patients, but they weren’t going to get paid or were afraid they weren’t going to get paid and that was the motivation.

Q: Mmm-hmmm and I imagine some of them had Medicaid as well?

Himmelstein: Some had Medicaid but far more were uninsured than had Medicaid because at that point in California, Medicaid wasn’t that bad a payer. So they would take care of Medicaid patients more readily than the uninsured.

Q: Oh, got it. Okay. Thank you. Did you come across a specific patient whose story moved you while doing this research or even before you launched the study?

Himmelstein: Well, there were a whole avalanche of patients. I guess really two come to mind. One was a young woman who was hit by a truck and taken to a fully equipped private hospital where they did x-rays and found she had multiple broken bones and a chest x-ray that showed that likely her aorta, the largest artery in the body was damaged. And they shipped her, I think it was about 30 miles across the county to us where we confirmed that in fact she did have a grave injury to that blood vessel and we didn’t actually have the capability of performing the surgery she needed because the surgical program, the specialized surgical program that could do that had been closed at our public hospital because it was a lucrative service and the private hospitals basically wanted that and didn’t want to leave it to our public hospital. So we very urgently transferred that young woman to a nearby public hospital that could do the surgery that she needed and then it would be paid for at the county’s expense.

Oh, wow.

Himmelstein: I guess another was a gentleman who was taken after an automobile accident to a hospital owned by the Kaiser Health Plan and he was apparently thought to be uninsured. That’s what the note said from Kaiser and transferred to us at Highland fairly nearby actually and when he arrived he had bone and brain literally showing through a wound in his head and we found he also had a broken neck. He miraculously was not quadriplegic but underwent emergency surgery to stabilize his head wound and his broken neck. And apparently did okay. It turned out he actually was a Kaiser member, but they hadn’t initially found him in their files when he was taken there and when they found out that he was a Kaiser member, they demanded that he be transferred back to Kaiser immediately because they didn’t want to pay for his care at the public hospital. So I guess those two cases kind of stick out in my mind.

Oh my gosh, they both sound so extreme. I’m sure these kinds of things happen much more than the general public realizes.

Himmelstein: Well we found quite a number of people who were admitted straight to the operating room or to the ICU so these were many of them very sick people.

Q: Right, right. The woman that was hit by the truck. So she was transferred two different times?

Himmelstein: Yeah, both of these were transferred two different times. Yeah.

Q: Wow. And do you happen to know how the woman who was hit by a truck fared?

Himmelstein: We were told that she did live. I don’t know more than that.

Q: Okay. Wow. Really powerful stories. Your study resulted in new legislation to protect emergency room patients who couldn’t pay for their care. Is that right?

Himmelstein: Our study and it was done again with a number of colleagues and similar studies from other public hospitals around the country – so the public hospital in Chicago and one of the public hospitals in Tennessee. The doctors there found similar things going on and we later learned that Senator Kennedy’s office became aware of these studies and was the motivation for him to propose this law that requires hospitals to stabilize patients before refusing them care. So they can still refuse care, but if you’re in a life-threatening condition or in active labor, they have to take care of you.

Q: Wow. Has that happened where they’ve actually transferred people in the midst of labor?

Himmelstein: Oh I’m sure it did.

Q: Unbelievable. And what is the name of that law?

Himmelstein: It’s the Emergency Medical Treatment and Active Labor Act. EMTALA. It’s known as E-M-T-A-L-A.

Q: Thank you for that. So let’s connect the dots to hospital financing. The EMTALA law has been controversial in part because of the cost to hospitals of caring for the uninsured. What can you tell us about that?

Himmelstein: Well, what it says to a hospital is you actually have to take care of someone if they’re in a life-threatening condition, even if you may not be getting paid for it. And some hospitals say, well that’s a money loser and it’s going to put us in financial straits. And probably they’re right for some hospitals there are grave financial problems that they’re under and caring for uninsured patients makes things worse. So on the one hand, they want to do something terrible and on the other hand, one can see why they would want to.

Q: Hmmm. Got it. Let’s shift forward and look at how hospitals fared during the COVID pandemic. We know as an NPR headline pointed out that hospitals serving the poor struggled during COVID and wealthy hospitals made millions. Why is this?

Himmelstein: Well, the hospitals got huge federal bailouts from the federal government. So they stopped – by and large – doing a lot of the elective care that’s most profitable for them. So things like joint replacements and elective surgeries of other kinds and those are the things that are most profitable and the federal government stepped in and said, well, we’ll make up the losses for you. We’ll give you what turned out to be hundreds of billions of dollars to bail you out. But most of that money went to the hospitals that were losing their lucrative business and it was not the safety net hospitals that were losing most of the lucrative business. They were already not getting a lot of that money making stuff. So less of the federal bailout money went to them and at the same time they were the ones who were most inundated with COVID patients and serving the greatest needs.

Q: Right. did the hospitals that were serving significant numbers of COVID patients, did they get funding for that?

Himmelstein: They got some, but generally not up to what was actually needed to keep them fully solvent.

Q: Oh, okay. Have you heard of any hospitals going bankrupt or having financial issues because of the COVID influx of patients?

Himmelstein: You know, it’s hard to separate the COVID influx from other causes of hospital distress, but certainly there are hundreds of hospitals around the country that are in financial distress and much of it worsened during the COVID pandemic. I mean the other thing going on frankly was there was a shortage particularly of nurses and other frontline personnel and to make up for nurses who were out because they had COVID or resigned because they didn’t want to take care of patients in that situation. Hospitals turn to what’s called registries. So these are companies that sign up nurses and say we’ll get you a temporary assignment at a hospital, but at much higher daily pay than the hospitals normally pay their nurses, so many hospitals really suffered financially because in order to take care of patients they had to rent nurses essentially at a much higher price.

Q: Wow. That’s true. How are safety net and non-safety net hospitals funded differently?

Himmelstein: Well there are a number of funding streams that come to any hospital so the backbones of hospital financing are insurance programs. So Medicare patients account for a very large share of the patients who are at any hospital because the oldest pay people who tend to be the ones most in need of hospital care are mostly covered by Medicare. So Medicare is a big payer for hospital care. Private insurance generally pays the best so hospitals that attract more privately insured patients generally fare the best because a bigger share of their patients are privately insured bringing in the biggest payments. Medicaid often pays less, it depends, varies from state to state, but Medicaid generally pays less than Medicare and certainly less than private insurance.

So hospitals that care for a lot of Medicaid patients are getting paid less per patient than those that care for Medicare and much less per patient than those that care for privately insured. And finally the uninsured and whether hospitals get paid for them or not really depends on local circumstances. So in some cities, there’s some government funding that helps defray the costs of care for uninsured patients. In others it’s just the hospital that takes the loss and that really just varies from place to place.

Got it.

Himmelstein: So safety net hospitals are really the ones that care for the biggest share of Medicaid and uninsured patients and those are the patients who bring in the least money when hospitals care for them. And as a result those hospitals get less money on average per patient than those that are caring for mainly Medicare and especially privately insured patients. But the other thing is the way our f inancing system works, two other factors come into play. One is hospitals that have a powerful reputation or that control much of the market in their area when they negotiate with private insurers can get a much higher rate than weaker hospitals or hospitals where there’s huge amounts of competition. So just to give you an example, in Boston the biggest system there and the one with probably the best reputation is called Mass General Brigham. It’s the merger of Massachusetts General Hospital and the Brigham and Women’s Hospital, two well known Harvard hospitals, and they get paid about 20% more from private insurers than the safety net hospitals that have less market power have been able to negotiate. So even from private insurers, places like Cambridge Hospital, the public hospital where I worked for many years get paid something like 20% less than Massachusetts General Hospital does.

Interesting.

Himmelstein: And the other factor besides market power that plays in here is what’s the mix of services they’re doing. As I said earlier, hospitals get the most profit from doing elaborate surgeries and much less profit from caring for pneumonia or other kinds of routine illnesses and hospitals that do large volumes of that fancy stuff tend to be paid more. So all of those things factor into how much a hospital is getting paid, both by insurance and its payer. And I guess the last factor is for most patients there’s some out of pocket costs for co-payments and deductibles that they have to pay and if you have a lot of patients who are poor, you’re probably not going to get, be able to collect from those patients for the piece that they themselves would normally be responsible for.

Q: Right. So you may have already answered this question, but I’ll ask it. How does the funding source contribute or affect the financial stability of hospitals?

Himmelstein: Well, if you have more privately insured patients, you’re likely to be doing better. If you have more uninsured patients, you’re almost certain to be doing worse. And if you have more Medicaid patients, you’re more likely to be doing worse. And if you’re a big powerful hospital that’s able to negotiate from a strong position with insurers, you’re probably getting paid more. So all of those things, the sources of funding and your market power really contribute.

Q: Mm, right. And how does this affect patients and communities?

Himmelstein: Well the result is that hospitals that care for a lot of uninsured patients or patients covered by Medicaid are on average paid much less for their care than the richer hospitals – the hospitals caring for more privately insured and Medicare patients and what that means is that their buildings are not as nice because they can’t afford to upgrade them or build fancy new buildings. They may not be able to afford to upgrade their machinery and may not be able to afford the staffing levels that richer hospitals have. And that sorts pretty closely which hospitals are rich and which are poor with the kind of communities that they take care of. So hospitals that care for poor people, generally are poor hospitals and hospitals that care for rich people are generally rich hospitals. And that also goes along with the race and ethnicity of the patients. So hospitals that care for Black and Latinx patients generally are poorer hospitals and those that care for more White patients and White non-Hispanic patients are generally richer hospitals. So it’s a way of saying our payment system structures payment to incorporate racism and oppression of communities.

Thank you Dr. Himmelstein. Tune in next week when Dr. Himmelstein talks about how hospitals will get paid when everybody has Medicare for All.

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.

Don’t forget to subscribe to Code WACK! wherever you find your podcasts. You can also find us on ProgressiveVoices.com and on Nurse Talk Media.

Code WACK! 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…

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

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.

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

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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.

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

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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.

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(SOUNDBITE OF SOLANGE SONG, “WEARY”)

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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.

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