PNHP

BlueCross Secret Memo Re: ‘Sicko’ … “You would have to be dead to be unaffected by Moore’s movie…”

BlueCross Secret Memo Re: ‘Sicko’ … “You would have to be dead to be unaffected by Moore’s movie…”

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Confidential Memo (from partner)

SiCKO – viewed on 6/26/2007

Takeaways

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

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

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

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

* The health insurers that get the most airtime are:

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

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

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

Further Notes

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

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

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

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

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

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

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

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

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

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

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

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

MichaelMooreTalkingPoints61807.doc

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

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

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

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

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

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

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

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

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

Dr. Oliver Fein Debating Dr. David Gratzer

The “Sicko” Case for Single Payer

David Gratzer, senior fellow at the Manhattan Institute and author of The Cure: How Capitalism Can Save American Health Care, and Dr. Oliver Fein, chair of the New York Metro chapter of Physicians for a National Health Program, debate the pros and cons of a single payer health care system.

Waiting Times for Care? Try Looking at the U.S.

Embargoed for Release
July 5, 2007

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Keep your insurance and lose your doctor

State steps in to defuse PacifiCare controversy

By Suzanne Bohan
San Mateo County Times
June 30, 2007

The California Department of Managed Health Care has reached a settlement with PacifiCare that ends, for now, a months-long quest for hundreds of Peninsula residents to find medical care after the insurer dropped physicians from its network.

Last week’s settlement follows the first cease-and-desist order the managed health care department has issued for deceptive marketing practices, said Lynne Randolph, spokeswoman for the state agency. The Department of Managed Health Care, which formed in 2000, serves as a watchdog for patients enrolled in HMO plans.

The May 17 cease-and-desist order found that more than 500 people enrolled with a small physicians’ group associated with Sequoia Hospital in Redwood City were “deceived, or otherwise misled” into believing their primary care doctor was still part of PacifiCare’s network when they enrolled or re-enrolled with the insurer last fall.

In fact, the order states, the insurer knew more than a year before the patients signed up that it planned to terminate its contract with the small physicians’ group.

The order requires that PacifiCare allow the patients to immediately return to their original physician until the next open enrollment period in the fall. At that point, they’ll still need to find either a new health plan or a new primary care physician.

An enforcement official with the managed care department said notification wasn’t the issue; the enforcement order was solely focused on the insurer’s failure to notify patients that their physicians were already dropped from the network when they signed up with PacifiCare.

http://www.insidebayarea.com/sanmateocountytimes/localnews/ci_6269556

Comment:

By Don McCanne, MD

Single payer opponents claim that the government would take away your choice of physician under a program of national health insurance. But do you lose your choice in the traditional, government-run Medicare program? Only if you sign up for a private insurance plan through Medicare Advantage are you limited in your choices of physicians.

Why do we continue to pay private insurers outrageous administrative fees for intrusive, wasteful services such as taking away our choice of physicians? A government program would never waste administrative funds on enforcing policies that serve to the detriment of patients.

(There will be a three week lapse in the Quote of the Day messages.)

Five Careers and Eight Airplanes: An Oral History of John Geyman, M.D.

By John J. Frey III, M.D.
Annals of Family Medicine, July 1, 2007

Abstract

Each generation has an obligation to remind succeeding ones about the people, ideas, and events that have gotten us to this point. This essay and an accompanying oral history trace the origins of family medicine through the life of someone who helped found it—John P. Geyman, M.D. He is one of the most published family physicians in the United States. In addition to being a rural family physician, he was one of the first residency directors in family medicine and the first editor of the discipline’s first academic journal. His career weaves four themes together in interesting and creative ways: commitment to the work of clinical practice, a sense of responsibility for strengthening clinical education, a belief that clinical care should be based on science and delivered within a rational system of health care, and a love of flying. His story also exemplifies the generation of general practitioners who started family medicine but who retained both a personal understanding of the complex nature of independent practice and a reliance on community.

Introduction

Occasionally, when I talk with younger colleagues about a person or article or an event that was formative in the academic discipline of family medicine, I can see in their faces that I am talking about something with which they have no personal experience. Each generation has an obligation to remind succeeding ones about the people, ideas, and events that have gotten us to this point. A quote attributed to Roger Shattuck Jr. in the New York Times stated, “Everything has been said. But nobody listens. Therefore, it has to be said all over again — only better. In order to say it better, we have to know how it was said before.”[1] This essay and the accompanying Supplemental Oral History (available online at http://www.annfammed.org/cgi/content/full/5/4/368/DC1) are about saying it all over again.

John P. Geyman, M.D., is one of the most published family physicians in the United States, having published more than 160 journal articles and 10 books, five since retiring as chair at the University of Washington Department of Family Medicine. He was graduated from medical school at the University of California, San Francisco, and began practice in Mount Shasta, a rural community in Northern California, after two years of general practice training in Santa Rosa, Calif. John was among the first residency directors in the discipline, beginning at Santa Rosa in 1969, when the first 16 residency programs were approved in family practice, and Santa Rosa, a converted general practice residency, became 1 of those 16.

In 1974 John became the first editor of the first academic journal in family medicine when he and a group of colleagues started The Journal of Family Practice (JFP). Before that time, there were no refereed journals with original research by family physicians. He continued as editor of JFP until 1990, when he became editor of the Journal of the American Board of Family Practice. In 2003 he stepped down as editor of that journal. During his 29 years as a journal editor, he had an influence on the published literature in an academic discipline that may be unequaled in U.S. history. Most active academic family physicians have had at least one rejection letter from John during our careers!

From 1971 to 1972, John spent time at the University of Utah in the Division of Family Practice; after 1972, at the University of California-Davis, he was in charge of developing a network of residency programs in Northern California. In 1976, he became chair of the University of Washington Department of Family Medicine after the founding chair, Ted Phillips, M.D., M.P.H., stepped down. The University of Washington expanded its educational activities through the WWAMI (Washington, Wyoming, Alaska, Montana, Idaho) program and grew its biomedical research as well, becoming the top-rated family medicine school, as well as one of the top 10 National Institutes of Health–funded medical schools. John left the chair at UW in 1990 and for the next seven years returned to rural practice on an island in Puget Sound. He retired from clinical practice when he was 66 years old. He and his wife, Gene, have been married for more than 50 years and have lived part or full time on San Juan Island in the Strait of Juan de Fuca since the late 1980s.

By 2000, John was increasing his involvement with Physicians for a National Health Program, a national organization of physicians working for comprehensive health care in the United States. He served as the president of that organization in 2005 and 2006, and he has published four books on the health system in the United States.[2-5] He was elected to the Institute of Medicine of the National Academy of Sciences and is a recipient of the F. Marian Bishop Award of the Society of Teachers of Family Medicine.

Four themes emerge from the interviews that comprise John’s online Supplemental Oral History: his commitment to the work of clinical practice, his sense of responsibility for strengthening clinical education, his belief that clinical care should be based on science and delivered within a rational system of health care, and his love of flying. His 46-year career weaves those themes together in interesting and creative ways.

For example, early in his career he saw that his small community needed a more organized way to do acute cardiac care. He flew to San Francisco to train to establish a coronary care unit in his community hospital, then implemented the unit and reported its effects in the medical literature.[6] Later in his career, when he realized the island where he worked needed an effective way of responding to emergency situations, he organized an emergency medical technician (EMT) program, which subsequently saved his own life. Of course, he wrote that up and published it as well.[7]

His story also exemplifies the generation of general practitioners who started family medicine but who retained both a personal understanding of the complex nature of independent practice and a reliance on community. Some who left practice in their late 30s and early 40s to become faculty members were fleeing what was for them a practice that was becoming increasingly impossible to manage. They felt they had to find a different way for general practice. Others, such as John, wanted to be a part of an untested idea they believed would transform medical education to be more relevant to the needs of society.

John never emotionally left the small town, and he used his rural practice experience as a personal benchmark for practice and scholarship that helped him explore general practice and family medicine at a deep and personal level. His family didn’t sell their house in Mount Shasta until 15 years after they had left, and they continued to get the weekly county newspaper for 20 years. Most revealing, perhaps, is that, after a 30-year career in academic leadership, he spent the last seven years of his practicing career again in a small community practice.

John has managed to squeeze, depending on how one counts, at least five careers and eight airplanes into his life so far. His books on flying and his books on family medicine and the health care system in the United States all have some of the same literary style: a personal voice that does not overwhelm the facts and ideas that he is trying to convey. He exercises a diligence in looking for information wherever and from whomever he can find it, and he analyzes and organizes that information in a way he thinks will be helpful to the reader. He also conveys the pleasure he gets both from writing the book and doing the work, be it family doctoring, critiquing the health care system in the United States, or flying a small plane.

In 2001, on his 70
th birthday, John had a myocardial infarction and cardiac arrest while swimming laps and was successfully resuscitated by the EMT group he had helped train. Nine months after surgery and cardiac rehabilitation, he was allowed to fly again, but the Federal Aviation Administration required follow-up tests every six months for three years. During that time of monitoring, he decided to find and purchase an open-cockpit biplane. He did find one and flew it, solo, home to Washington from central Texas. As he says: “Low and slow type flying has always been my goal — good old stick and rudder without too much gadgetry.” He, of course, wrote a book chronicling the story.[8]

I spent two days interviewing John at his home in June 2006 for the oral history. He had been kind enough to pick me up in his single engine “tail dragger” at the mainland airport nearest to his home on the San Juan Island and then flew me back the next day. After he dropped me off, I realized that I had forgotten my passport and some files at his house. I called and explained the situation apologetically. “No problem,” John said, “I’ll be right over.”

So when I heard the small plane circling to land, I suspected that John might have taken my forgetfulness as a chance to fly his biplane, and I was right. We spent another hour talking and then he headed back. He climbed into the cockpit, did his preflight check, started the engine, and taxied off, at the age of 75 years, to experience the wind and the sun over the Puget Sound. I looked out to see him, in his leather flight helmet, ear phones, and aviator glasses, taxiing toward the runway, waving and smiling, focusing on what was next, starting another chapter.

The story of John’s career, thus far (as he would put it) is garnered from a series of oral histories by William Ventres, M.D., in 1989, Fitzhugh Mullan, M.D., M.P.H., in 1996, my own conversations with him, and from the books and articles he has published over a 37-year academic career.

[PNHP note: The supplementary oral history of Dr. Geyman is available here and is highly recommended.]

Conflict of interest: none reported. Received for publication February 24, 2007.   Revision received March 30, 2007. Accepted for publication April 9, 2007.

© 2007 Annals of Family Medicine, Inc.

REFERENCES
1.  Martin D. Rogert Shattuck, scholar, is dead at 82. NY Times. December 10, 2005:A19.
2.  Geyman J. Health Care in America: Can Our Ailing System be Healed? Boston, Mass: Butterworth-Heineman Medical /Elsevier; 2001.
3.  Geyman J. Falling Through the Safety Net: Americans Without Health Insurance. Monroe, ME: Common Courage Press; 2003.
4.  Geyman J. The Corporate Transformation of Health Care: Can the Public Interest Still Be Served? New York, NY: Springer Publishing; 2004.
5.  Geyman J. Shredding the Social Contract: The Privatization of Medicare. Monroe, ME: Common Courage Press; 2006.
6.  Geyman JP. A coronary care unit in a 25-bed rural hospital. Calif Med. 1970;112(1):74–77.
7.  Killien SY, Geyman JP, Gossom JB, Gimlett D. Out-of-hospital cardiac arrest in a rural area: a 16-year experience with lessons learned and national comparisons. Ann Emerg Med. 1996;28(3):294–300.
8.  Geyman J. An Open Cockpit Biplane Dream: Honey Bee III. Friday Harbor, WA: Avian Ridge Books; 2005.

CORRESPONDING AUTHOR: John J. Frey III, MD, Department of Family Medicine, School of Medicine and Public Health, University of Wisconsin, 777 S. Mills St, Madison, WI 53715, jfrey@fammed.wisc.edu

http://www.annfammed.org/content/5/4/368.full

Assets, debts and health insurance for middle-income families

Thin Protections: High-Deductible Plans Provide Little Comfort for Asset Poor Middle-Income Families

Health Access
June 22, 2007

Our research shows that many middle-income families, some who are uninsured and earn too much to qualify for subsidized coverage, have few assets and significant debt.

In this paper, we show that forcing families to have a bare-bones, high-deductible health plan is of little comfort to the majority of middle-income families with few to no assets that need to be protected.

Middle income families — earning as much as $70,000 a year — are:

* Struggling to buy and hold onto a home,

* Saving few dollars in the bank and for retirement, and

* Tying up as much as one-third of their income in credit card debt.

An individual mandate would have the opposite of its intended effect — exposing middle-income families to even more financial burden.

…the high deductible plans would only add more stress to the thin financial resources of middle-income families and do little to protect families from significant medical debts of thousands of dollars. An individual mandate for a high-deductible plan would have a perverse result of bringing a middle-income family closer to bankruptcy, not protecting it.

http://www.health-access.org/Assets_Debt07.pdf

Comment:

By Don McCanne, MD

This paper is an important addition to the dialogue on health care reform. Its primary contribution is that it demonstrates that middle-income families now have too few assets and too much debt to be able to tolerate the additional financial burden of out-of-pocket costs that result from plans with high-deductibles and reduced benefits – plans that are designed to keep premiums affordable.

Plans that would be effective in preventing financial hardship for middle-income families with health care needs would have to charge much higher premiums that still would place an excessive financial burden on those families.

The point is that health care costs are now so high that private insurance plans are no longer capable of protecting the finances of middle-income families. Most reform proponents agree that, under our current system of financing health care, the poor must be subsidized if they are to have affordable access to health care. This study shows that a system of subsidies would also have to be applied to middle-income families as well. It defies logic to suggest that the complex process of providing the majority of Americans with variable tax-funded subsidies to purchase administratively-wasteful, over-priced private health plans is somehow an efficient method of financing care.

Rather than assessing the assets and debts of each individual and each family, it would be much more efficient, more effective, and less expensive to establish a single, universal risk pool and fund it through equitable tax policies. We already have the money. We just need to fix our financing system.

The future is specialists and in-store clinics?

Crossroads/Health Care is a forum on the future of health care posted on the sacbee.com website. Sacramento Bee columnist Daniel Weintraub is the moderator. Following are submissions from James Knight, M.D., CEO of Consumer Directed Health Care, Inc. in San Diego, and Don McCanne, M.D., Senior Health Policy Fellow of Physicians for a National Health Program.

June 27, 2007

James Knight on economical care

From James Knight, MD

Primary care has been the holy grail of health care for quite some time now. The prevailing notion has been that investing more scarce health care dollars in relatively inexpensive preventive care as opposed to high quality (read: expensive) management of manifest disease would save money over the long run. The belief that robust first dollar coverage that pays for day-to-day care (including preventive care) is cost effective over the long run has now been shown to be a myth. Moreover, robust first dollar coverage has incontrovertibly been shown to drive significant unnecessary health care spending (the Rand Health Insurance Experiment.

From a medical perspective, management of manifest disease by specialists in the field provides the most qualified person for the neediest patients. Doctors and other paraprofessionals are generally paid according to the Common Procedural Terminology (CPT codes, trademark American Medical Association) for the services rendered; same codes same payment. While specialists’ management of manifest disease often does costs more, that’s more a function of their training and thus their ability (and perhaps inclination) to provide more advance services, rather than some inherent excess cost. Of note, for more advanced services, specialist fees are generally only a small portion of the total cost as compared to the hospital and technological fees that represent the lion’s share of the cost of a major medical intervention, for example a coronary artery bypass procedure.

The Rand study clearly shows that folks who are financially responsible for the cost of their day-to-day care make very good decisions (on average get the same health care outcomes http://cdhcinc.com/HIE.htm#HealthOutcomes ) but reduce overall health care spending by as much as 40% or more. As consumer directed health care solutions become more common, putting more consumers in charge of purchasing day-to-day care, innovative solutions such as in-store clinics providing access to more affordable preventive and day-to-day care will ultimately drive down the cost of these services.

I believe the AMA’s distaste for this competition is largely economic. That being said, there is also clearly some potential risk to patients that could arise with lax supervision of these new health care venues. Patients must be protected from the snake-oil salesmen so prevalent in the past before physician quality initiatives such as standardized, broad based medical training, board certification and recertification, continuing education requirements and credentialing and re-credentialing.

As we enter a new world in the way people access and purchase day-to-day health care, everyone can expect change. For some physicians that may mean less importance in the new paradigm than they have historically enjoyed. Routine day-to-day care needn’t be delivered by the most expensive provider any more than everybody with a headache must have an MRI and a full evaluation by a neurologist.

In my humble opinion, the person best suited to make these kinds of decisions is the financially responsible patient working with a properly trained and credentialed health care provider of the patient’s choosing (in my view that also includes properly trained and credentialed paraprofessionals who are appropriately supervised by a responsible professional).

June 28, 2007

Public comment on primary care

From Don McCanne, M.D.

James Knight’s comments on “economical care” are puzzling. A strong primary care infrastructure has been proven repeatedly to provide higher quality care by ensuring better access to more appropriate care, and does so at a lower cost. Yet he cynically dismisses primary care as a “holy grail” and suggests using in-store clinics. In-store clinics provide only single-visit care for very minor problems and can’t possibly manage major acute or chronic problems. He apparently would abandon the benefit of coordinated, integrated care in a primary care medical home.

He then suggests that specialists are the “most qualified” physicians, but also defends their high fees. How does increasing the use of highly specialized services reduce health care spending? In fact, the Dartmouth studies have shown that in many areas of the country we spend too much on highly specialized services and often have worse outcomes as a result.

He repeats his oft-made assertion that the results of the Rand Health Insurance Experiment provide a basis for adopting consumer directed health care (i.e., requiring patients to pay cash for their care). He omits the fact that hypertensive patients in the study had a higher death rate when they were exposed to cost sharing. Death is hardly the same outcome as that of those who didn’t die.

The Rand HIE was a study of a healthy workforce and their healthy families during a few healthy years of their lives. It has intrinsic validity for a similar healthy population, but it has no extrinsic validity for our entire population, throughout life, with our full basket of health problems. About 80 percent of health spending is for the 20 percent of individuals with significant health problems. The RAND HIE does not apply to this 80 percent of spending, and can have very little impact on our overall health care costs. Pretending that wasteful patient spending is why we have high health care costs is totally off target.

We know how to reduce waste while improving the overall quality of our system. We can eliminate a tremendous amount of administrative waste, due to our fragmented system of financing care, by changing to a single, efficient insurance system. We can improve quality and reduce costs by realigning incentives to support our rapidly deteriorating primary care infrastructure. We can realign incentives to encourage appropriate use of high-tech specialized services while discouraging wasteful, detrimental excesses. We can negotiate prices and fees to pay for legitimate costs and fair profits, while eliminating payment for costs that do not benefit patients (such as DTC drug marketing).

This year Medicare identified excesses in spending on imaging. They responded by shifting funds from these excesses to improve reimbursement for primary care. The fragmented private insurance industry is not capable of providing the structural reforms in financing that we need. If we really want to contain costs and improve quality in a system that’s affordable for everyone, then we need to change to a single, equitably-funded risk pool with administrators dedicated to patients rather than to enterprises. An improved Medicare for all of us would accomplish that.

http://www.sacbee.com/static/weblogs/crossroads/healthcare/

Statement of Dr. Robert McMurtry of Ontario, Canada to Rep. John Conyers, Chair, Judiciary Committee, US House of Representatives, June 20, 2007

Testimony of Dr. Robert McMurtry of Ontario, Canada

Prepared for Rep. John Conyers, Chair, Judiciary Committee,
US House of Representatives

I am a grand-father of four, an orthopedic surgeon, former Dean of Medicine and former Assistant Deputy Minister of Health Canada.

I believe that people in need of care, the ill and the injured should receive care based on need not ability to pay.

I have lived long enough to recall what life was like before Medicare in Canada and what it meant to my family.

My father had rheumatic heart disease as a young man. He became a successful lawyer and father of four. At the age of 53 he was struck down by a severe stroke from which he never recovered. He had no insurance coverage for health care or disability having been denied coverage by private insurers.

A proud man who paid his bills was left with permanent disability and a loss of financial security.
Four years after his stroke hospital insurance came to Ontario, followed by Medicare in 1965 a year after my father’s early death at age 62.

When Medicare came I was a new medical school graduate. I witnessed first hand the transformation of the public, crowded wards into decent spaces. I heard all the claims of impending disaster by established medical practitioners and witnessed very few of the problems that concerned them. Healthcare flourished and became the most popular social program in Canada’s history.

Over the ensuing 40 years I have been privileged to serve in a number of roles in academic medicine, orthopedic practice and government. I continue to practice.

There has never been an occasion in those decades that I or any of my colleagues have had to get permission to deliver care. Decisions to treat or not to treat have always been between us and our patients. My colleagues and I would have it no other way.

Care is delivered based on need not ability to pay.

Recently I have lost my mother and one of my brothers. Another brother and my son were both very ill and are now recovered. Through it all I marveled at the quality state-of-the-art, yet sensitive care they received.

There were no bills to pay.

It is not surprising to me that studies demonstrate that healthcare and health outcomes in Canada compare favourably to those in the U.S.

Like any complex human system, Canada’s Medicare is not without its problems.

Wait times in our system have drawn a lot of attention and frankly some outlandish claims made in the media. Statistics Canada’s latest figures demonstrate that median wait times for Canadians to receive elective surgical care are just 4.3 weeks, for specialty care 4.0 weeks, and for non-emergency diagnostic tests 3.0 weeks While this data is encouraging, we can and are doing better every year [For more information on successful efforts in Canada to reduce wait times, see “Why Wait? Public Solutions to Cure Surgical Waitlists” Canadian Center for Policy Analysis and the BC Health Coalition, www.policyalternatives.ca] Over 85 percent of Canadians support Medicare. The publicly funded single payer system works. It is high quality, efficient and equitable.

R.Y. McMurtry MD, FRCSC, FACS
Orthopedic Consultant
St. Joseph’s Health Care
London Ontario Canada N6A 4L6
robert.mcmurtry@sjhc.london.on.ca

Professor Emeritus
University of Western Ontario School of Medicine

Councilor
Health Council of Canada

Former Dean, Faculty of Medicine & Dentistry
University of Western Ontario

Former Assistant Deputy Minister
Population and Public Health Branch
Health Canada

Imaging as a proxy for government cost control

MRI, X-ray firms fight Medicare cuts

By Matthew Perrone
Arizona Daily Star
June 26, 2007

Medical imaging equipment makers are lobbying to overturn Medicare cutbacks after weathering some of the worst sales numbers in recent memory.

The cuts took effect in January and reduce how much doctors are paid for running X-rays, medical resonance imaging and other tests on patients enrolled in the government-run health program for seniors. For example, nationwide reimbursements for MRI scans, one of the most commonly performed procedures, dropped 38 percent on average, with payments varying by county.

The Medicare payment changes, which are expected to save $2.8 billion over five years, sent sales of scanners made by GE, Siemens AG, Toshiba Corp. and others tumbling more than 20 percent last quarter, according to data provided by an industry group.

Medicare officials say they are monitoring whether patients are having trouble getting access to imaging. And they point out that payment reductions don’t affect hospitals, where the majority of imaging services are performed.

Washington’s unresponsiveness may reflect a more troubling trend for these and other medical technology companies: Health-care experts that advise lawmakers are not convinced that more medical technology translates into better health care.

“We have communities with half as many scanners as those in other parts of the country, and their outcomes are just as good, and in some cases better, than communities spending twice as much on imaging,” said Elliot Fisher, a professor at Dartmouth Medical School who consulted for government advisers on the imaging issue.

Research by Fisher and his colleagues found that patients live about the same length of time regardless of their access to imaging.

Imaging industry representatives counter that basing the technology’s value on whether the patient lives or dies isn’t valid.

http://www.azstarnet.com/allheadlines/189110

Comment:

By Don McCanne, MD

Currently the greatest increase in Medicare spending has been due to the increased use of medical imaging. Some of it is appropriate, and some of it is not. As stewards of our public funds, Medicare officials have an obligation to see that we are receiving appropriate value for our health care spending.

There have been some disturbing developments in medical imaging in recent years. There has been an increase in independent, entrepreneurial imaging centers which are not linked to hospitals. Specialty groups that order many scans frequently purchase their own units, providing physicians with even more incentives to order scans. This increased capacity has been demonstrated to increase the number of imaging procedures performed. Elliot Fisher and his Dartmouth colleagues have demonstrated that this increase in volume has not improved outcomes, yet it has decreased value of our Medicare purchasing. It is this over-utilization that is targeted by the reductions in Medicare rates for imaging services.

The opponents of government insurance programs will likely claim that Medicare’s reduction in payments for imaging services will reduce incentives to develop new innovative technology. No. Medicare continues to adequately fund appropriate imaging services.

The message is that Medicare will pay for beneficial technology, but it will not waste taxpayer funds on expensive technology that fails to provide health care value. It is a message to the technology industry that they should continue to provide us with new technology that provides health care value, but don’t sell us excesses that we don’t need and really can no longer afford. The tech industry will not go away. They will still want their portion of the $2.2 trillion that we are already spending on health care.

This important oversight function is an advantage of having a single government program that can identify deficiencies in our financing of health care, and then put in place policies that correct them. The thousands of private plans with their fragmented proprietary information have very little capability of identifying these problems, much less having a credible basis for putting in place global policies that would increase health care value.

Just think of how much more effective we could be in value purchasing of health care if all of us were covered by our own single payer program of national health insurance. That would be so much better than being controlled by an industry that declares “whether the patient lives or dies isn’t valid.”

How many are uninsured?

Early Release of Selected Estimates Based on Data From the 2006 National Health Interview Survey

CDC
June 2007

In 2006, the percentage uninsured at the time of interview was 14.8% (43.6 million), which was not significantly different from the 2005 estimate of 14.2% (41.1 million).

http://www.cdc.gov/nchs/data/nhis/earlyrelease/200706_01.pdf

CDC: About 2M More Americans Uninsured

Associated Press
June 26, 2007

The number of adults without health insurance jumped by 2 million from 2005 to 2006, according to a new federal report. Uninsured Americans numbered 43.6 million last year, a 6 percent increase from 2005, according to the U.S. Centers for Disease Control and Prevention.

http://www.nytimes.com/aponline/us/AP-Uninsured.html

US survey lowers uninsured numbers to 43.6 million

Reuters
June 25, 2007

Just under 44 million Americans had no health insurance in 2006, according to a survey by the U.S. Centers for Disease Control and Prevention released on Monday. Their survey of 100,000 Americans is lower than previous federal estimates of 46 million.

http://www.alertnet.org/thenews/newsdesk/N25234092.htm

Census Bureau Revises 2004 and 2005 Health Insurance Coverage Estimates

U.S. Census Bureau
March 23, 2007

The revised estimates show that, in 2005, 44.8 million people, 15.3 percent of the population, were without health insurance — about 1.8 million fewer than the Census Bureau reported in August 2006 (46.6 million, 15.9 percent).

The Census Bureau discovered the need for a revision during a conversion to a more accurate operating system for the Current Population Survey.

http://www.census.gov/Press-Release/www/releases/archives/health_care_insurance/009789.html

Comment:

By Don McCanne, MD

How many in the United States are uninsured? According to the 2006 National Health Interview Survey (NHIS) just released, 43.6 million are uninsured, an increase of 2.5 million from 2005. But the CDC states that the 2.5 million increase was “not statistically different” from 2005. The Associated Press reported this as an increase in the numbers of uninsured, and Reuters reported it as a decline. Even the U.S. Census Bureau has problems with its estimates, having recently revised the 2005 numbers from 46.6 million down to 44.8 million.

This does not stop others from manipulating these numbers further. Conservative groups have suggested that many of the uninsured should be ignored for various reasons, and that the uninsured status is only of concern for less than 10 million individuals. Progressive groups have suggested that these counts understate the severity of the problem in that, over a two year period, more than 80 million individuals are without insurance at some point during that time.

In a few weeks (August) the Census Bureau will release the Current Population Survey for 2006. For purposes of the reform dialogue, those will be the most reliable numbers.

The point is that we cannot let others change the debate by zeroing in on the problems with counting the numbers of uninsured. The real issue that needs to be addressed is that we have a health care financing system that is a disaster for the uninsured and for many of the the insured with health care needs.

We do not need to get into a food fight over the precise numbers of uninsured. There are a lot of them, and many are suffering physically and financially, and some are even dying. And a great many more of those who are victims actually have insurance. Do not let the opponents of reform divert you from this crucial message into a silly numbers game.

Health care film exposes sore issue

Whether for or against reform, industry experts are eager to watch 'Sicko'

By Daniel Lee and John Russell
The Indianapolis Star
June 27, 2007

When controversial filmmaker Michael Moore’s blistering critique of the U.S. health care system hits Indiana theaters Friday, a Hoosier group that supports a government-run health care system will be waiting outside in search of converts.

“For our point of view, the timing is terrific,” said Dr. Christopher Stack, a retired Indianapolis surgeon who co-founded Hoosiers for a Commonsense Health Plan, a group that advocates for government-run health care. “It will get people talking.”

The group couldn’t agree more with Moore’s prescription — a move that would guarantee coverage for every American and presumably put Indianapolis-based WellPoint and other health insurance companies out of business.

Members of Stack’s group — including health care workers who will be encouraged to wear their medical scrubs — plan to be at theaters in Bloomington and maybe Indianapolis handing out literature and chatting up moviegoers.

Stack hopes the movie generates broad public and political support for a government-run health care system. “It’s never been taken seriously by the powers that be,” he said.

Love him or hate him, Michael Moore is focusing debate about health care in the United States.

And the movie’s message is expected to stir emotions, especially in the Indianapolis area — home to the nation’s largest health insurer, WellPoint; pharmaceutical giant Eli Lilly and Co.; and thousands of other health-industry workers.

WellPoint and Lilly are not featured prominently, but their industries are portrayed as more focused on profits than patients.

The film features allegations that WellPoint’s Blue Cross of California subsidiary had a systematic practice of illegally canceling some members’ policies after they got sick. The company has denied any wrongdoing.

Lilly is not verbally mentioned in the film; the only reference is a fleeting image of a Lilly corporate building sign during a broad attack on the U.S. drug industry for its support of the Medicare prescription drug law of 2003.

Other insurers featured include Louisville, Ky.-based Humana and Philadelphia-based Cigna.

“Sicko” focuses on a string of health care horror stories from Americans, contrasted by idealized portraits of nationalized health care systems in Canada, France, Great Britain and even Cuba.

Critics slam Moore for his style of filmmaking, which they say is agenda-driven and based on carefully selected facts. America’s Health Insurance Plans, an industry trade group that represents WellPoint and others, said neither Moore nor his staff contacted any of the companies mentioned in the movie to get their side of the story.
But even some in health care who may not agree with Moore seem eager to see the film.

“I do look forward to seeing it. That’s what I do for a living,” said Matt Gutwein, chief executive of the Marion County Health and Hospital Corp., which runs Wishard Memorial Hospital. “I do think our system is broken. I think it’s unsustainable in its current course.”

However, Gutwein blames the structure of the U.S. health care system, not the health insurers themselves.

“The vast majority of insurance companies, they play by the rules,” he added. “And they’re not the ones who made those rules.”

WellPoint, in response to the movie, said any reform of the U.S. health care system should be based on consumer choice, not a “one-size-fits-all” system. “Given our millions of members, our trusted Blue and UniCare brands, and our interactions with patients and doctors, WellPoint is in a great position to help make the system work,” spokesman Jim Kappel said.

“Sicko,” however, portrays WellPoint in a different way. The company’s Blue Cross of California unit was accused of canceling some members’ policies after they got sick and ran up high medical bills. The company, which denied any wrongdoing, this year settled a class-action lawsuit stemming from the controversy.

The members had claimed that WellPoint would review members’ insurance applications after they got sick looking for any untruth or undisclosed medical condition to deny their claims.

“Sicko” portrays one woman who said her policy was canceled because she had not disclosed a prior yeast infection.

The drug industry also comes under attack from Moore when he compares prescription drug prices in the U.S. to those elsewhere. Moore discovers that an inhaler that would cost an American with a respiratory disease $120 in the U.S. is available in Cuba for about 5 cents, although he does not verify that the medicine is identical or even Food and Drug Administration-approved.

Eli Lilly, long known for supporting free-market health care, takes issue with Moore’s sweeping push for a government- managed health care system.

“These government systems have been given numerous chances to work in other nations, and evidence suggests they are far from ideal,” the company said in a statement. “A single-payer system eliminates competition and hinders quality improvements by slowing the pace of innovation.”

Regina Herzlinger, a professor at the Harvard Business School, said despite its shortcomings, “Sicko” taps into an issue that is ripe for debate.

“It’s disgusting that a country as rich as ours doesn’t have insurance for everybody,” said Herzlinger, also a senior fellow at the Manhattan Institute, a New York think tank.

But she has major disagreements with Moore’s promotion of a government takeover of health care. “I don’t want the government to run it. I want you and me to run it.”

Herzlinger advocates having employers no longer providing workers with health insurance as a benefit. Citizens would be required to buy insurance, with rates depending on a person’s age, sex and location, with no one excluded for a pre-existing condition. Subsidies would be available for the poor.

Local health reform advocate Stack envisions a Medicare-like insurance plan for all Americans.

That debate is likely to rage on long after “Sicko” has had its run.