PNHP

Prior Authorization Scrutinized

Prior Authorization Scrutinized

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

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

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

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

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

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

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

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

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

What is Prior Authorization?

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

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

Comment:

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

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

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

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

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

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

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

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

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

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Medicare for All Explained Podcast: Episode 92

Interview with Dr. Ed Weisbart

February 15, 2023

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

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

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

https://medicareforallexplained.podbean.com

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

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

FOR IMMEDIATE RELEASE: February 13, 2022

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

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

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

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

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

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

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

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

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

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

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

By Brenda Gazzar
Code Wack Podcast, February 13, 2023

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

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

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

Transcript

Dispatcher: 911, what’s your emergency?

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

(ambulance siren)

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

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

Welcome back to Code WACK! Dr. Verhoef.

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

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

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

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

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

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

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

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

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

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

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

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

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

Got it. Thank you for explaining that.

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

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

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

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

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

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

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

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

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

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

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

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

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

Thank you Dr. Verhoef.

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

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Public Education Needed on the Advantages of Public Insurance

Summary: US adults are fed up with health insurance costs and coverage, eager for real reform. Most favor a government guarantee of coverage, and a plurality (38%) support single payer. Yet 53% prefer a system of private insurance, despite its failings. We need to further educate the public.

The Challenge of Healthcare Reform, Gallup, January 27, 2023, by Frank Newport

Gallup data show that Americans’ current ratings of their personal healthcare situations are on the positive side of the majority line, including a 72% excellent or good rating for personal healthcare quality, a 66% excellent or good rating for personal healthcare coverage, and 56% who are satisfied with personal healthcare costs.

Americans are clearly more negative when asked about healthcare “out there” across the country. For example, 76% of Americans are dissatisfied with the cost of healthcare in the U.S.; only 32% rate healthcare coverage in the U.S. as excellent or good; and the new low of 48% of Americans rate the quality of healthcare in the country positively.

One seemingly simple solution for healthcare problems is the single-payer, “Medicare for All” program advanced by such leaders as Sen. Bernie Sanders. We don’t find strong support for this remedy from the public, although the public’s attitudes are complex (and interesting to study).

A 57% majority of U.S. adults believe that the federal government should ensure all Americans have healthcare coverage. Yet nearly as many, 53%, prefer that the U.S. healthcare system be based on private insurance rather than run by the government.

Putting responses to these two questions together, we find that only 38% of Americans adopt the position Sanders espouses — that the government’s role is to ensure that everyone has healthcare coverage and that the government should run the system. Another 35% of Americans adopt the opposite views, believing both that the nation should use a private insurance system and that it is not the government’s role to ensure healthcare for all to begin with. And 18% of Americans believe that the government should ensure that everyone has insurance, but that this should be accomplished through private insurance, not a government-run system.

The takeaway here: The majority of Americans recognize that government has a role in expanding health insurance coverage, but many are ambivalent about fulfilling that role with a government-run system.

Comment:

By Don McCanne, M.D.

The Gallup data confirms that Americans are increasingly concerned with cost and coverage of healthcare in the nation, though they rate their own personal situation more positively than they do for the nation generally. This lack of pressing personal concern combined with everyone’s concern about taxes likely explains why many are reluctant to support comprehensive healthcare reform at this time.

Another important finding confirmed here is that there is a clear preference for the insurance system to be run by the private sector rather than by the government. This probably represents a relative satisfaction with employer-sponsored plans, contrasted with problems with Medicaid and some other safety net health programs, as well as other experiences with government bureaucracies. This is heavily reinforced with positive marketing campaigns from the private industry and negative propaganda campaigns from right-wing advocacy organizations.

This preference for private plans would be very unlikely if the public at large truly understood the clear advantages of a well-designed single payer system over a market of private plans: universal, comprehensive, accessible, affordable, equitable, high quality health care for everyone. Indeed poll questions that describe single payer’s universal comprehensive coverage with lower costs often yield 2/3 support.

We’ve long said that we need to educate the public on these advantages. We’ve also been trying to educate them on the deficiencies of the private plans (medical debt and bankruptcies are now growing rapidly amongst the privately insured!). Even our President doesn’t get the message. Frank Newport writes, “The Joe Biden administration certainly feels the ACA has been a success,” when we have the most expensive system that barely qualifies as being mediocre.

There is a message here. We have to become much more effective at delivering it.

Response:

By Kip Sullivan, J.D.

I want to call attention to bias in the question Gallup asked. Pollsters frequently confuse respondents by asking how they feel about “government-run health care” or similar, rather than a more accurate phrase such as “government insurance like Medicare.” I tried to download the questions Gallup asked and was allowed to see only one. Here it is:

Which of the following approaches for providing healthcare in the United States would you prefer?

  • Government-run health systems
  • System based mostly on private insurance

Single-payer bills would not, as we all know, require the “government to provide health care.”

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Severely understaffed hospitals shouldn’t be buying Super Bowl ads

By Farzon A. Nahvi, M.D.
The Washington Post, February 8, 2023

For many health-care workers watching the Super Bowl in recent years, the hardest hits have often come not during gameplay but in the commercial breaks. 

Emergency rooms across the country have become chronically overcrowded and understaffed. Hospitals often claim they don’t have the funds to hire more employees to meet the urgent needs of patients. Yet in between Super Bowl advertisements for Flamin’ Hot Cheetos and Bud Light Seltzer Hard Soda, it’s now commonplace to see commercials for institutions such as the University of Rochester Medical Center, NYU Langone Health and Inspira Health. 

To understand why this situation is so troublesome, we must first appreciate the stakes: Hospital crowding, which gets worse when institutions are understaffed, is a national problem — and a deadly one. Multiple studies have demonstrated that overcrowding is directly associated with an increase in patient mortality.

To make matters worse, a 2016 report by the American College of Emergency Physicians found that over 90 percent of American emergency rooms are routinely crowded; that number has only increased since then. If you’ve been to an emergency room recently, the overwhelming odds are that it was packed. As a result, your chances of dying were higher than they should have been. 

Given what’s at stake, one would assume that hospitals would invest in a solution: If they were to simply hire more staff, the ratio of patients to nurses and doctors would be lowered — and lives would be saved. 

But hospitals have been doing the opposite. 

A recent investigation by the New York Times revealed that many American hospitals have spent years pursuing an “industrywide movement” of keeping labor costs low by wringing “more work out of fewer employees.” Indeed, hospital administrators often measure success by determining how much they can lower operating expenses by reducing the number of “employees per occupied bed.” In other words, low staffing levels are not a result of the coronavirus pandemic, staff burnout or a tight labor market — they are a business model. 

Simultaneously, as hospitals save money by cutting staffing, hospital marketing budgets have skyrocketed. According to a report in the Journal of the American Medical Association, between 2004 and 2016, direct-to-consumer advertising by hospitals and health-care systems jumped 74 percent to $1.4 billion per year. 

A brief stroll through New York City reveals billboards in Times Square, posters on bus stops and in subway stations, illuminated signs on city taxis, and newsstands full of magazines flush with advertisements for local hospitals. Prime-time TV slots feature ads from cancer centers and children’s hospitals. And beyond simply advertising during the Super Bowl, health-care systems have become official corporate partners of the Super Bowl. 

As hospitals invest liberally in marketing while tightening their wallets when it comes to bedside patient care, it’s hard to view the billions spent on ads as anything other than waste. 

Many hospital executives would say that deciding whether to spend on advertising or patient care presents a false choice. They would insist that marketing is a necessary operating expense that a modern hospital must invest in to succeed. This argument is often referred to as “no margin, no mission” — a shorthand way of saying that for a hospital to perform good work, it must first generate the money with which to do so. 

On the surface, this argument seems reasonable. But when hospital wings are closing because of staffing shortages, nurses are being asked to attend to more than four to five times the patients they can safely care for, and firefighters and the National Guard are stepping in to provide what hospitals themselves are failing to, can it really be argued that spending on television commercials remains a necessity?

If spending on advertisements is nonnegotiable but hiring enough nurses to save patients’ lives isn’t, who is our health-care system truly serving? At what point can it be said that this system has lost its way and the margin has, in fact, become the mission? 

Legislators in several states, including Massachusetts, Oregon and Washington, are trying to rectify the situation by considering legislation that would mandate safe staffing ratios. Predictably, hospital lobbying organizations say they “strongly oppose” these legislative attempts, citing the “financial burden” of higher operating costs that such laws would impose. 

In light of these claims, these bills should go a step further. They should also ban hospitals from engaging in costly direct-to-consumer advertising. What better way to save billions of dollars to offset the “financial burden” of hiring more lifesaving medical personnel? 

The Super Bowl provides us with a clarifying lens. It is American television’s most watched event and its most expensive airtime, and the very idea of hospitals advertising during the game is symbolic. It heralds an era when it’s no longer unusual for enormous amounts of money to be frivolously spent faster than a single touchdown play, while at the same time nurses are going on strike to demand safe staffing levels for their patients. 

So when people see any TV commercial or billboard highlighting a hospital system’s quality of care, then walk into that same hospital system’s emergency room only to find it dangerously overcrowded and understaffed, it is worth connecting the dots. Imagine how many lives would be saved if only we were to take the bold step of demanding that our health-care dollars be spent on actual health care.

Dr. Farzon A. Nahvi is an emergency medicine physician, the author of “Code Gray: Death, Life, and Uncertainty in the ER,” and a member of Physicians for a National Health Program. 

https://www.washingtonpost.com…

Projected Savings from Hospital Global Budgets under Single Payer

Summary: A new study quantifies huge anticipated gains over 10 years – $2.5 trillion in financial savings alongside added resources for clinical care – by shifting hospital financing from today’s service-based payment and profit generation to global budgeting.

Hospital Expenditures Under Global Budgeting and Single-Payer Financing: An Economic Analysis, 2021–2030, International Journal of Social Determinants of Health and Health Services, February 2023, by Adam W. Gaffney, David U. Himmelstein, Steffie Woolhandler, and James G. Kahn

Abstract:

U.S. hospitals provide large amounts of low-value care and devote inordinate resources to administration, while some hospitals leverage market power to realize large profits. Meanwhile, many rural and safety net hospitals are financially distressed. The coexistence of waste and want suggests that U.S. hospital financing is neither efficient nor equitable.

We model the economic consequences of adopting the mode of hospital payment used in Canada and the U.S. Veterans Health Administration and proposed in the leading congressional single-payer Medicare-for-All bill: global budgeting. Our models assume increased utilization due to expanded and upgraded coverage; gradual reductions in administrative costs from simplified payment; and the elimination of hospital profits, with hospital capital expenditures funded by explicit grants rather than from profits or borrowing.

We estimate that non-federal hospital operating budgets will total $17.2 trillion between 2021 and 2030 under current law versus $14.7 trillion [14.5% lower] under single-payer with global budgeting. This difference of $2.5 trillion reflects $520 billion in foregone profits and $1,984 billion in reduced expenditures on hospital administration. Expenditures on clinical operating budgets, however, would be higher than under current law, funded out of profits.

Comment:

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

This economic analysis (full disclosure: HJM authors, including myself) quantifies the anticipated changes in hospital costs over 10 years with a shift to global budgeting. The cumulative savings are estimated at $2.5 trillion, nearly 15% of the total.

The chart conveys the key findings: Savings accrue most of all by simplifying administration, but also by eliminating profit and slowing the rate of growth. At year 10, when current law spending is projected at $2.2 trillion, single payer is $1.8 trillion. These analyses include an allowance for increased care and quality improvement. Global budgets would assure financial stability, protecting hospitals for rural areas and when medical care needs shift.

This funding mechanism echoes the approach used successfully in most other wealthy countries. And the hospital analysis illustrates the kinds of savings that single payer would offer across the health system.

Global budgeting of hospitals (and of the entire health system) would require a complete shift in how we pay for medical care. That’s what’s needed. Single payer, putting patients above profits.

http://healthjusticemonitor.org…

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

Corporate health care? It’s NOT what the doctor ordered!

By Brenda Gazzar
Code Wack Podcast, February 6, 2023

What say should doctors have in reforming America’s healthcare system? Are their decades-long efforts to stop the commercialization of medicine having an impact? How can health professionals, and students in the health sciences, get involved in the movement for single-payer health care?

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

Find out the main strategies, goals and challenges of PNHP, the only single-issue, physician-led organization advocating for Medicare for All in America. And learn about the growing influence of Students for a National Health Program (SNaHP) in the single-payer movement.

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 role do physicians and other healthcare professionals play when it comes to advocating for a single-payer healthcare system? What are the main goals of Physicians for a National Health Program, the only single-issue physician-led organization advocating for Medicare for All in America? To find out, we spoke to the new president of PNHP, Dr. Philip Verhoef. Verhoef is also an adult and pediatric intensivist and clinical associate professor of medicine at the John A. Burns School of Medicine at the University of Hawaii-Manoa.

So welcome to Code WACK!, Dr. Verhoef!

Verhoef: Thank you.

Q: Let’s talk about Physicians for a National Health Program. It was founded in 1987, and here we are 36 years later, still fighting the commercialization of health care. Would you say the prospects for PNHP’S vision of a truly equitable healthcare system for all have improved since then?

Verhoef: I wish I could say that we were closer now than we were then to achieving a universal healthcare system. If you look over these last 35 years or so, we’ve seen attempts at getting a universal system up and running only to be completely squashed by corporate interests. So you might recall Hillary Clinton actually pushed a universal healthcare system that was just squarely defeated by everyone at the time in the early 90s. We tried as an organization to get single payer, at least at the table for the talks around the ACA back when Obama got elected and we were roundly shut out.

You know, we’ve had a bill introduced in Congress now for every Congress for the last 20 years since Rep. (John) Conyers introduced the first one in 2003. That was a bill that we helped work with his office staff on to be the aspirational single-payer bill that we want to see and yet here we are, since PNHP’s forming, we’ve got more and more privatization of Medicare out there in the forms of Medicare Advantage and this upcoming ACO REACH program. These are all ways that the federal government is actually taking Medicare and putting it in the hands of private insurance companies without, you know, holding onto it themselves and so, in many ways, you might argue we’re in worse shape now than we were 35 years ago in spite of the efforts that we have made on this particular front.

Yes, that’s a little depressing.

Verhoef: <Laugh> It is totally depressing. But, you know what? We’re not going to stop fighting, right? We want what’s best for our patients. We want what’s best for our whole country. You know, it’s hard. Every year I update my slides for PNHP, for the talks that I give, and you just watch how much more we spend than other countries in the world and then you watch our inequities get worse and you watch our life expectancy go down year after year and you say, ‘golly, how is it that we just keep making things worse in spite of ourselves?’ But on the other hand, if we weren’t fighting this fight, I would hate to imagine where things might actually be if we didn’t have folks actually protesting and fighting some of these really awful moves that will only hurt our American citizens.

Q: Right. Good point. PNHP membership includes doctors, other health professionals, and even members of the public. How does PNHP recruit doctors?

Verhoef: So we spend a lot of time just trying to get the word out there about what PNHP is, who PNHP is, and what single payer is. And so I can talk about my own personal experience. You know, honestly, I started getting involved when I was a resident, and then as I continued my training and became a faculty member, I was frequently giving talks to physicians, right? To educate them about our American healthcare system and about ways that we could change it or make it better. I’ve worked with student groups. I’ve worked with community groups where I’ve gone out and talked about what this is because, you know, it’s interesting. In 2016, single payer actually made it onto the main stage, right, as Sen. (Bernie) Sanders was engaged in his presidential campaign, we started talking about it and a lot of people had no idea what it is.

And, you know, we at PNHP said, ‘hey, we’ve been talking about this for 25 years. Come to us, we will educate you.’ And so that’s a big part of what PNHP does. But I think one of the things that we see now is that we won’t achieve single payer unless we get more healthcare professionals, more people behind it and so a lot of the work that we’re doing now is really targeted at expanding our membership, expanding the knowledge base among professional organizations and state medical societies. So we’re making a real concerted effort to shore up our ranks a little bit to get the buzz out there when you actually poll physicians, the vast majority support single payer. So of those that are out there that know about it, they like the idea. We just need to basically get those folks motivated and marching and supporting and actively working with us to make this a reality for our country.

Q: What do you see as the organization’s biggest challenges today?

Verhoef: You know, our biggest challenge is the fact that the fight that we’re up against is a fight against resources and money that outnumber anything that we have by orders of magnitude. You know, the private insurance industry, the pharmaceutical industry, for-profit hospital corporations, they have pockets that are so, so deep, and they will use those resources to influence legislation, to influence legislators. It’s not that we’re not going to win, but we’re not going to win by outspending them, right? We’re not going to be able to spend more money trying to influence legislators, that’s not going to be how we get single payer. We have to get single payer by organizing all of the physicians out there to say, ‘look, we’re not going to participate in this system that actively hurts patients, that actively leads to thousands of deaths per year in this country, simply by virtue of not having health insurance.’

I mean, that’s crazy. We literally watch people die as a function of lack of healthcare coverage. And so we’re not going to get single payer, I think, until we can get the majority of physicians out there saying, ‘we’re not going to participate in this system.’ You know, I’m not advocating for people to strike because I think that hurts people too. But I think we have to use our power within physician organizations and taking a cue from some of the labor organizing that’s out there to say, look, we can’t do this anymore. This is killing people. It goes against what we all join this profession for. So our biggest challenge is that we’re fighting a beast that’s just so much stronger than we are. I think there’s still a lot of physicians that don’t know entirely what single payer is and how it could benefit them.

And so it’s really on us to try and spread this out there so that people really understand. But we welcome doing that. I’ll give a talk every day if folks want to hear it about, you know, why I think single payer is the solution. We just need to, to bring people in and get them listening and understanding what’s going on. But we have the army of folks to do that. But, you know, it’s combating some of the misinformation that’s out there and really trying to say, ‘look, we don’t want corporate interests involved in our healthcare anymore. We don’t want people profiteering off of us.’ And so that’s the battle that we’re, that we’re really up against.

Q: PNHP also sponsors a program for medical students called Students for a National Health Program or snap. How’s that going? And why do you think it’s important to include these students?

Verhoef: Oh, it’s going awesome. It’s been one of the most inspiring things that we’ve done in the organization over the last 10 years. And, you know, I was involved in some of the earliest SNaHP chapter formations when we were just building this thing out when I was in Chicago and it was really incredible to see the enthusiasm of medical students who want to do what’s right for patients and it’s kind of remarkable because most medical schools don’t teach a lot about what our healthcare system is, or what are the economics or the ways that coverage happens or any of these kinds of topics and yet at the same time, I want students to understand that this is the career that they’re getting into. And so as an organization, we committed to building up these student chapters, to supporting students learning about single payer themselves.

And honestly, it’s been tremendously exciting because students, they haven’t been influenced by whatever healthcare system they end up going to work in. You know, they’re still open books ready to learn about what’s out there, and I want to see them advocate. I believe that physicians have a duty to advocate for their patients. And so, you know, I often tell students, ‘look, I don’t care what you advocate for. I want you to advocate for something, right? Something that you believe in that will make patient care better.’ And you know, I often tell ’em, ‘but you should advocate for single payer, right? You should advocate for healthcare reform because you know, because of how hurt patients are by our American healthcare system.’ And so our ranks have grown by substantial numbers and when we were at our national meeting this last fall, our numbers of students were almost as great as the numbers of non-students.

And that’s really exciting, right? Because now we have students who know all about our healthcare system. They know about a potential solution. They take that into their residency training, they take that into their clinical practice, and they can continue to fight. I don’t have to educate them anymore about what the optimal solution is to our broken healthcare system. They already know they’re already bought in and so we look at this as part of the long game. Yeah, I don’t know when single payer’s going to happen in this country. I have faith that it will, and I’m going to continue to work to make it so, but the more students that we can bring into this, the more physicians we will have out there who support this as a solution, who can get behind it. And so they have brought an amazing energy to PNHP’S efforts. We have now SNaHP representatives serving on our national board. Several of them are serving on our board, so they’re literally influencing the direction that PNHP goes and I just couldn’t be more excited about the involvement of students in PNHP.

Q: So Dr. Verhoef, what do you hope to accomplish in your two-year term as president of PNHP?

Verhoef: So I’ll tell you what I don’t think we’re going to get, I don’t think we’re going to get single payer in these two years, but I want to see us move the needle substantially, right? And what does that look like to me? It means fighting off privatization at every opportunity, continuing to raise the specter of the harm that privatization does. So I think that’s the first thing. The second thing is let’s build our ranks much, much greater, right? So let’s reach out to medical societies, professional organizations. Let’s get the word of single payer out there to these physician groups. We know that there are folks out there that support this. Let’s make single payer a mainstream thing that the American College of Physicians says, ‘we’re going to actively support this.’ The American Academy of Pediatrics says, you know, ‘single payer is the best thing for our children’s health in this country,’ right?

We want to bring it up to that level and so we also want to work with state medical societies to really move the AMA on this, right? You know, every state medical society has a delegation to the American Medical Association. If we can change the AMA from within and use the AMA, which is the largest physician group in this country, if we can get the AMA to start advocating for single payer, I think that’s going to be a game changer.

I want to see us continue to work with our allies. So these are other political organizations, labor movements, anybody who feels like healthcare is an important part of what they advocate for, we want to support them and give them the tools to argue that single payer is critical for the labor movement, right? That it should be a critical part of the Green New Deal, right? Or that it should be part of any progressive agenda and so you know, building further those relationships I think is also really, really critical.

Q: So how likely is it that the AMA, or the American Medical Association, would support single payer anytime in the near future?

Verhoef: You know, we make progress every year, and a lot of that progress comes from the students. Every year, they introduce single-payer support sort of resolutions within the AMA, and they get further and further to those being adopted as part of AMA policy. It’s been a stunning thing to watch and a real, you know, the students are taking the bull by the horns here. They got remarkably close to a supportive vote on single payer at the last AMA meeting. And so we expect, you know, to continue to work within the student chapters or through people’s state and local medical societies, I think it’s possible.

You know, it’s funny, I personally stopped being a member of the AMA a number of years ago because I didn’t feel like they represented my interests. They were representing sort of corporate conservative interests and not my interests. But as I take on this role as PNHP president, I’m strongly considering reengaging with the AMA now that I can take some time to work from within, you know. Let’s change this organization. Let’s bring this narrative up. Let’s fight hard for this. And I think that that’s going to be key, you know, is for physicians to look at this as an opportunity and not as a barrier, you know?

Q: Wow, that’s great. Where would you like to see PNHP in five years?

Verhoef: Oh, in five years, I would love us to have four times as many members as we do. I would love our staff to be twice as big. I’d love to see us out there building new SNaHP chapters and creating the next wave of physician activists. I’d love to see us with a real consistent permanent presence in DC. We aren’t a big enough organization, and, and we’re a 501c3 so honestly, we’re not going to engage in a lot of aggressive lobbying, but there is so much education to be done and if we could begin to build that presence and work with, you know, legislators on Capitol Hill to help them understand why this is the solution, these are all directions that I’d love to see us be in five years, you know, so we’re going to work towards that.

It’s a bit of a cycle in a good way, a spiral in the sense that if we get more members, we get more resources. If we get more resources, we can build this and if we build this out further, we can bring in even more members and these kinds of things feed forward and that’s very much where I’d like to see us going is really expanding as an organization and then building the amount of power that we have to truly influence the direction of health care in this country.

Q: How many members does PNHP have right now?

Verhoef: So on the books, we say around 25,000 members, and that’s primarily physicians, although again, anyone can join.

Q: Is there anything else you want to mention, Dr. Verhoef, about PNHP?

Verhoef: You know, I’m really proud to be a part of PNHP because it represents, I think, what so many of us, we simply want the best care for our patients. We want them to be able to get what they need, and we want to see people healthy. Those of us that engage in this advocacy, it’s not stuff we do because we seek fame. It certainly doesn’t pay us anything. This is work that we do as physicians outside of our otherwise, you know, busy lives. But it’s because we believe in it and we really believe that this is the best solution to really help out patients in this country and so we’re going to keep fighting. If you meet a doc who’s an PNHP active member, they are fighting like crazy for what they think is right and I’m really proud of that.

Thank you, Dr Verhoef. Stay tuned. Next time we’ll talk to Dr. Verhoef about the privatization of Medicare.

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

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

https://heal-ca.org…

Profit Obsessed US Health System Drives Physician Burnout

Summary: A physician-anthropologist highlights the conflict plaguing today’s medical profession: the contradiction of medical values and a profit-focused health care system. He advocates collective action for universal health care following the single payer model.

Doctors Aren’t Burned Out From Overwork. We’re Demoralized by Our Health System., New York Times, February 5, 2023, by Eric Reinhart (political anthropologist and physician, Northwestern University)

The United States is the only large high-income nation that doesn’t provide universal health care to its citizens. Instead, it maintains a lucrative system of for-profit medicine. For decades, at least tens of thousands of preventable deaths have occurred each year because health care here is so expensive.

What’s burning out health care workers is less the grueling conditions we practice under, and more our dwindling faith in the systems for which we work. What has been identified as occupational burnout is a symptom of a deeper collapse. We are witnessing the slow death of American medical ideology.

During the pandemic, physicians have witnessed our hospitals nearly fall apart as a result of underinvestment in public health systems and uneven distribution of medical infrastructure. Long-ignored inequalities in the standard of care available to rich and poor Americans became front-page news.

According to an investigation in The New York Times, ostensibly nonprofit charity hospitals have illegally saddled poor patients with debt for receiving care to which they were entitled without cost and have exploited tax incentives meant to promote care for poor communities to turn large profits. Hospitals are deliberately understaffing themselves and undercutting patient care while sitting on billions of dollars in cash reserves. Little of this is new, but doctors’ sense of our complicity in putting profits over people has ‌grown more difficult to ignore.

From at least the 1930s through today, doctors have organized efforts to ward off the specter of “socialized medicine.” We have repeatedly defended health care as a business venture against the threat that it might become a public institution oriented around rights rather than revenue.

This is in part because doctors were told that if health care were made a public service, we would lose our professional autonomy and make less money. For a profession that had fought for more than a century to achieve elite status, this resonated.

For example, a system of billing codes invented by the American Medical Association as part of a political strategy to protect its vision of for-profit health care now dictates nearly every aspect of medical practice, producing not just endless administrative work, but also subtly shaping treatment choices.

Addressing the failures of the health care system will require uncomfortable reflection and bold action. Any illusion that medicine and politics are, or should be, separate spheres has been crushed under the weight of over 1.1 million Americans killed by a pandemic that was in many ways a preventable disaster. And many physicians are now finding it difficult to quash the suspicion that our institutions, and much of our work inside them, primarily serve a moneymaking machine.

Doctors can no longer be passive witnesses to these harms. We have a responsibility to use our collective power to insist on changes: for universal health care and paid sick leave but also investments in community health worker programs and essential housing and social welfare systems.

Neither major political party is making universal health care a priority right now, but doctors nonetheless hold considerable power to initiate reforms in health policy. If we can build an organizing network, then proposals to demand universal health care through use of collective civil disobedience via physicians’ control over health care documentation and billing, for example, could move from visions to genuinely actionable plans.

Regardless of whether we act through unions or other means, the fact remains that until doctors join together to call for a fundamental reorganization of our medical system, our work won’t do what we promised it would do, nor will it prioritize the people we claim to prioritize. To be able to build the systems we need, we must face an unpleasant truth: Our health care institutions as they exist today are part of the problem rather than the solution.

Comment:

By Don McCanne, M.D.

Eric Reinhart already said what I have to say, “Until doctors join together to call for a fundamental reorganization of our medical system, our work ‌won’t do what ‌we promised it would do, nor will it prioritize the people we claim to prioritize.”

Of course, the model on which we can all work together and which will prioritize all of the people is single payer.

The House of Representatives this month passed a ridiculous resolution condemning “socialism” when it should have passed a resolution supporting public policy while condemning divisive politics. This would have provided a bipartisan pathway to bring us single payer. I tell you, it would have cured my burnout.

http://healthjusticemonitor.org…

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

Doctors Aren’t Burned Out From Overwork. We’re Demoralized by Our Health System.

By Eric Reinhart, M.D., Ph.D.
The New York Times, February 5, 2023

Doctors have long diagnosed many of our sickest patients with “demoralization syndrome,” a condition commonly associated with terminal illness that’s characterized by a sense of helplessness and loss of purpose. American physicians are now increasingly suffering from a similar condition, except our demoralization is not a reaction to a medical condition, but rather to the diseased systems for which we work.

The United States is the only large high-income nation that doesn’t provide universal health care‌ to its citizens. Instead, it maintains a lucrative system of for-profit medicine. For decades, ‌at least tens of thousands of preventable deaths have occurred each year because health care here is so expensive.

During the Covid-19 pandemic, the consequences of this policy choice have intensified. One study estimates at least 338,000 Covid deaths in the United States could have been prevented by universal health care. In the wake of this generational catastrophe, many health care workers have been left shaken.

“For me, doctoring in a broken place required a sustaining belief that the place would become less broken as a result of my efforts,” wrote Dr. Rachael Bedard about her decision to quit her job at New York City’s Rikers Island prison complex during the pandemic. “I couldn’t sustain that belief any longer.”‌

Thousands of U.S. doctors‌‌, not just at jails but also at wealthy hospitals, now appear to feel similarly. One report estimated that in 2021 alone, about 117,000 physicians left the work force, while fewer than 40,000 joined it. This has worsened a chronic physician shortage, leaving many hospitals and clinics struggling. And the situation is set to get worse. One in five doctors says he or she plans to leave practice in the coming years‌.

To try to explain ‌‌this phenomenon, many people have leaned on a term ‌‌from pop psychology for the consequences of overwork: burnout. Nearly two-thirds of physicians report they are experiencing its symptoms.

But the burnout rhetoric misses the larger issue in this case: What’s burning out health care workers is less the grueling conditions we practice under, ‌and more our dwindling faith in the systems for which we work. What has been identified as occupational burnout is a symptom of a deeper ‌collapse. We are witnessing the slow death of American medical ideology.

‌It’s revealing to look at the crisis among health care workers as at least in part a crisis of ideology‌‌ — that is, a belief system made up of interlinking political, moral and cultural narratives upon which we depend to make sense of our social world. ‌Faith in the traditional stories American medicine has told about itself, stories that have long sustained what should have been an unsustainable system, is now dissolving.

During the pandemic, physicians have witnessed our hospitals nearly fall apart as a result of underinvestment in public health systems and uneven distribution of medical infrastructure. Long-ignored inequalities in the standard of care available to rich and poor Americans became front-page news as ‌bodies ‌were stacked in empty hospital rooms and makeshift morgues. Many health care workers have been traumatized by the futility of their attempts to stem recurrent waves of death, with nearly one-fifth of physicians reporting they knew a colleague who had considered, attempted‌‌ or died by suicide during the first year of the pandemic alone.

Although deaths from Covid have slowed, the ‌disillusionment among health workers has ‌only increased. Recent exposés have further laid bare the structural perversity of our institutions‌‌. For instance, according to an investigation in The New York Times, ostensibly nonprofit‌ charity hospitals have illegally saddl‌ed poor patients with debt for receiving‌‌ care to which they were entitled without cost and have exploited tax incentives meant to promote care for poor communities to turn ‌‌large profits. Hospitals are deliberately understaffing themselves and undercutting patient care while sitting on billions of dollars in cash reserves. Little of this is new, but doctors’ sense of our complicity in putting profits over people has ‌grown more difficult to ignore.

Resistance to self-criticism has long been a hallmark of U.S. medicine and the industry it has shaped. From at least the 1930s through today, doctors have organized efforts to ward off the specter of “socialized medicine.” We have repeatedly defended health care as a business venture against the threat that it might become a public institution oriented around rights rather than revenue.

This is in part because doctors were told that if health care were made a public service, we would lose our professional autonomy and make less money. For a profession that had fought for more than a century to achieve elite status, this resonated.

And so doctors learned to rationalize a deeply unequal health care system that emphasizes personal, rather than public, moral responsibility for protecting health. We sit ‌at our patients’ bed sides and counsel them on their duty to counteract the risks of obesity, heart disease and diabetes, for example, while largely ignoring how those diseases are tied to poor ‌access to quality food because of economic inequities. Or, more recently, we find ourselves advising patients on how to modulate their personal choices to reduce their Covid risk while working in jobs with dismal safety practices and labor protections.

Part of what draws us into this norm is that doctors learn by doing — that is, via apprenticeship — in which we repeat what’s modeled for us. This is, to a degree, a necessary aspect of training in an applied technical field. It is also a fundamentally conservative model for learning that teaches us to suppress critical thinking and trust the system, even with its perverse incentives.

It becomes difficult, then, to recognize the origins of much of what we do and whose interests it serves‌‌. For example, a system of billing codes invented by the American Medical Association as part of a political strategy to protect its vision of for-profit health care now dictates nearly every ‌aspect of medical practice, producing not just endless administrative work, but also subtly shaping treatment choices.

Addressing the failures of the health care system will require uncomfortable reflection and bold action. Any illusion that medicine and politics are, or should be, separate spheres has been crushed under the weight of over ‌‌1.1 million Americans killed by a pandemic that was in many ways a preventable disaster. And many physicians are now finding it difficult to quash the suspicion that our institutions, and much of our work inside them, primarily serve a moneymaking machine.

Doctors can no longer be passive witnesses to these harms. We have a responsibility to use our collective power to insist on changes: for universal health care and paid sick leave but also investments in community health worker programs and essential housing and social welfare systems.

Neither major political party ‌‌is making universal health care‌ a priority right now, but doctors nonetheless hold considerable power to initiate reforms in health policy. We can begin to exercise it by following the example of colleagues at Montefiore Medical Center in the Bronx who, like thousands of doctors before them, recently took steps‌ ‌ to unionize. If we can build an organizing network through doctors’ unions, then proposals to demand universal health care through use of collective civil disobedience via physicians’ control over health care documentation and billing, for example, could move from visions to genuinely actionable plans.

Regardless of whether we act through unions or other means, the fact remains that until doctors join together to call for a fundamental reorganization of our medical system, our work ‌won’t do what ‌we were promised it would do, nor will it prioritize the people we claim to prioritize. To be able to build the systems we need, we must face an unpleasant truth: Our health care institutions as they exist today are part of the problem rather than the solution.

Dr. Eric Reinhart (@_Eric_Reinhart) is a political anthropologist, psychoanalyst and physician at Northwestern University.

https://www.nytimes.com…

Shameless Business Tactics to Bilk Medicare and Medicaid

Summary: Two KHN stories illustrate how nursing homes and Medicare Advantage health plans share a business rapacity, using no-holds-barred tactics to funnel public health insurance funds to the pockets of shareholders.

Nursing Home Owners Drained Cash During Pandemic While Residents Deteriorated, KHN, February 1, 2023, by Jordan Rau

After the nursing home where Leann Sample worked was bought by private investors, it started falling apart. Literally.

Part of a ceiling collapsed on a nurse, the air conditioning conked out regularly, and a toilet once burst on Sample while she was helping a resident in the bathroom, she recalled in a court deposition.

“It’s a disgusting place,” Sample, a nurse aide, testified in 2021.

The decrepit conditions Sample described weren’t due to a lack of money. Over seven years, The Villages of Orleans Health & Rehabilitation Center, located in western New York near Lake Ontario, paid nearly $16 million in rent to its landlord — a company that was owned by the same investors who owned the nursing home, court records show. From those coffers, the owners paid themselves and family members nearly $10 million, while residents injured themselves falling, developed bedsores, missed medications, and stewed in their urine and feces because of a shortage of aides, New York authorities allege.

At the height of the pandemic, lavish payments flowed into real estate, management, and staffing companies financially linked to nursing home owners throughout New York, which requires facilities to file the nation’s most detailed financial reports. Nearly half the state’s 600-plus nursing homes hired companies run or controlled by their owners, frequently paying them well above the cost of services, a KHN analysis found, while the federal government was giving the facilities hundreds of millions in fiscal relief.

In 2020, these affiliated corporations collectively amassed profits of $269 million, yielding average margins of 27%, while the nursing homes that hired them were strained by staff shortages, harrowing injuries, and mounting covid deaths, state records reveal.

Government Lets Health Plans That Ripped Off Medicare Keep the Money, KHN, January 30, 2023, by Fred Schulte

Medicare Advantage plans for seniors dodged a major financial bullet Monday as government officials gave them a reprieve for returning hundreds of millions of dollars or more in government overpayments — some dating back a decade or more.

The health insurance industry had long feared the Centers for Medicare & Medicaid Services would demand repayment of billions of dollars in overcharges the popular health plans received as far back as 2011.

But in a surprise action, CMS announced it would require next to nothing from insurers for any excess payments they received from 2011 through 2017. CMS will not impose major penalties until audits for payment years 2018 and beyond are conducted, which have yet to be started.

While the decision could cost Medicare plans billions of dollars in the future, it will take years before any penalty comes due. And health plans will be allowed to pocket hundreds of millions of dollars in overcharges and possibly much more for audits before 2018.

Comment:

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

In these two stories, KHN highlights the aggressive tactics employed by recipients of Medicare and Medicaid funding to maximize profits without regard to effects on patients or taxpayers.

Nursing home owners create supplier companies which then charge the nursing homes inflated prices. This depletes the nursing home budgets and results in dangerous under-staffing and patient harm. The supplier companies are highly profitable, so the owners of these linked entities make out like bandits. Shareholders win, patients lose, Medicaid (and private) payers lose.

Meanwhile, Medicare Advantage plans threaten to sue CMS about an eminently fair rule that diagnostic upcoding and overcharges found in intensive audits should be extrapolated to all patients in that plan. After years of rule-making, CMS backs down, foregoing reimbursement of hundreds of millions or billions of dollars in excessive charges. Once again, the legal and political muscle of insurers enables massive larceny from taxpayers.

A health system based on inadequately regulated private for-profit corporations cannot work. See our recent discussion on the corrosive effects of profit in US health care.

Single payer would dump the private insurers and control the providers.

http://healthjusticemonitor.org…

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Medicare for All Explained Podcast: Episode 91

End ACO REACH

February 1, 2023

Podcast host Joe Sparks warns listeners about the recently launched ACO REACH program, which allows for-profit middlemen (including commercial health insurance companies) to “manage” the care of Traditional Medicare beneficiaries.

“It makes no sense to move [ seniors and people with disabilities ] to private health insurance,” he says, “when such a system has produced the worst overall health outcomes of any wealthy nation, and the most expensive health care system in the world.”

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

https://medicareforallexplained.podbean.com