Los Angeles Times
July 25, 2001
Commentary
by William W. Thomas, Chairman of the House Ways and Means Committee

“Let’s pause for a moment in the debate over a patients’ bill of rights and go back to the basic premise of health care. It’s about helping people. It’s about getting the best medical treatment. It’s about you and your doctor making decisions that affect your health, your family and your life. It’s not about a lawyer making those decisions.”

Comment: It is rare for me to agree with the man that would privatize Medicare, and to disagree with our great allies in the cause for health care justice for all. But we should pause and reflect on Rep. Thomas’ words.

Most patients that suffer medical injury do not sue and are not compensated for their losses. Most patients that do sue are not victims of malpractice but have suffered a medical maloccurance that is not the result of error in judgment but is merely an unfortunate, fortuitous outcome. The medical tort system is an extremely ineffective system, yet about 10 billion dollars per year are diverted from patient care into this system. Much of this is consumed by the plaintiff’s attorneys, defense attorneys, malpractice insurance companies, investigators, and court costs, not to mention the additional waste of unnecessary “defensive medicine.” Of the remaining portion that reaches the plaintiffs, a relatively insignificant amount is used to obtain medical care. That 10 billion dollars would be better spent on beneficent programs such as meeting the needs of the uninsured or providing prescription drug coverage for Medicare beneficiaries. Instead, under the cloak of a “patients’ bill of rights,” Congress continues to debate the expansion of a tort system designed to divert even more funds to this wasteful legal industry. These comments will be challenged by our friends and colleagues on the basis that we need “accountability,” but what we really need is an expedited appeals process to gain access to needed care.

Tragically, this ridiculous debate has diverted our national leaders away from the real problems in health care. We desperately need to provide coverage for everyone, and we need to assure that our resources are provided exclusively for the benefit of patients. We can do this best through a publicly administered, universal health insurance program. Let’s start the real debate – now!

http://www.latimes.com/news/opinion/commentary/la-000060494jul25.story?coll=la%2Dnews%2Dcomment

Kip Sullivan responds to the quote of Rep. William Thomas and to my comment:

Don,

I agree with portions of your commentary, but I disagree with your characterization of the malpractice that occurs in this country as “a medical maloccurrence that is not the result of error in judgment but is merely an unfortunate, fortuitous outcome.”

You are usually a very crisp and precise writer, but the quoted phrase is mushy and, to the extent that I can understand it, wrong. Your phrasing suggests that malpractice is nonexistent (your invented word “maloccurrence” strikes me as almost Orwellian), or, if malpractice is real, it’s like gravity — there’s nothing we can do about it and, therefore, there’s no point in debating why it happens.

I offer a different point of view. Malpractice is real, some of it is due to system failure, some of it is due to the failings of individuals, and both types of failings are less likely to happen if individuals and systems know they could lose money and reputations in a law suit.

I agree completely with you that the existing malpractice system is highly imperfect. Too many people who shouldn’t sue do, too many who should sue do not, and the overhead costs of the system are very high. But we currently have no other system that can deter malpractice, whether by individuals, hospitals, HMOs or any other system.

Overwhelming evidence exists indicating that a substantial portion of adverse outcomes in medicine are the result of malpractice, which the law defines to be the provision of services, or the failure to provide services, that violates a widely recognized standard of care due to negligence of the doc or other provider. (For the sake of simplicity, I’m leaving out a few other elements of the definition of malpractice.) It’s true that a substantial body of evidence indicates that many (but not all) of the acts of malpractice should be blamed on the systems in which health care professionals work. I include managed care insurers in my definitions of “systems,” something the Institute of Medicine seems incapable of recognizing. According to the IOH, “quality is the problem, not managed care.”

But not all plane crashes are due to system failures –some are caused by errors of judgment by individual pilots — and, similarly, not all medical malpractice can be blamed on the system.

Regardless of where blame should ultimately lie for a given adverse outcome — on the individual, several individuals, or a system –the threat of a lawsuit will have a deterrent effect on at least some types of negligence. We’re already seeing proof of this axiom in the announcements by several HMOs that they are going to back away from utilization review. The plans doing this are claiming they are dropping UR because it wasn’t cost effective, but the timing of these announcements robs them of their credibility. UR has been around for three decades. That’s plenty of time for the plans to figure out that UR wasn’t cost effective. It is the threat of class action suits filed in recent years, and the possibility of many more if the right to sue HMOs is established by Congress, that has caused some HMOs to back off of UR.

Even after we get a universal health insurance system, malpractice will remain a problem. The public needs to discuss both issues –malpractice and universal coverage. They are separate problems.

I just wrote a piece for In These Times asking the question, Is the patient protection debate a waste of time? I don’t think it is. I’ll email it to you if you’d like to see it.

Keep up your great work.

Kip

Kip’s excellent article, “Patients Losing Patience,” from In These Times, August 20, 2001, is available at: http://www.inthesetimes.com/web2519/sullivan2519.html

Victor Sidel, M.D., Distinguished University Professor of Social Medicine at Albert Einstein College of Medicine of Yeshiva University, responds to the quote of Rep. William Thomas and to my comment:

Dear Don:

I not only “rarely disagree” with you, but I believe this is the first time I have ever disagreed with you.

I believe you give Thomas too much credit. Of course, lawyers should not be making medical decisions. (Doctors shouldn’t be making most medical decisions either, except in rare circumstances, but that’s a different topic.) But when managed care or other forms of medical care organization deny needed care to patients, under current conditions in the United States lawsuits are often the only channel for redress. Is that an effective, just, or equitable method for oversight of the U.S.medical care system? Of course not. Does it lead to “defensive medicine”? Of course it does. But until the United States arrives at what we both view as the needed high quality, publicly administered, universal health care system with an expedited appeals process, the tort system may be the only way to force the industry to provide needed care. Is it a diversion? Of course it is. But is it a necessary stopgap while the needed system change is attained? It may be. Tort law has certainly been misused in many instances, but defenders of the environment and of civil rights would be weaker without it.

Thomas opposes the patients’ rights bill that includes strengthening tort law methods as one of its provisions because he seeks to prevent needed system change and he views opposition to that bill as a tactic for his purpose. The remainder of his opinion piece makes his tactic clear. He should not be praised for that tactic.

Warmly, Vic

The Henry J. Kaiser Family Foundation

Report prepared by Public Opinion Strategies and Peter D. Hart Research Associates
July 2001

“1. Overall, seniors are VERY satisfied with the Medicare system.” “They do not want structural reform that they perceive might jeopardize what they are already getting.”

“2. The generally high levels of satisfaction have a significant impact on the way in which respondents react to words used to describe proposed ‘changes’ to the Medicare system.” “Words like ‘strengthened and improved’ elicit overwhelming favorable reactions, while words that suggest a more significant departure from the current Medicare structure, such as ‘changed’ or ‘privatized’ are very negatively perceived.”

“3. Participants suffer a severe case of sticker shock when they consider the price tag of a drug benefit program for seniors.” “Overall, participants were much more concerned with the costs to seniors than they were with the cost to the government in providing the benefit.”

“4. The budget surplus and the recent tax cut strongly influence perceptions about the affordability of a generous drug benefit.” “Given the current environment, participants do not blink at the idea of allocating significant government resources to pay for a new benefit.”

“7. Given their quite favorable views of Medicare, participants both presume and prefer that a new drug benefit would be administered within the framework of the current program.”

http://www.kff.org/content/2001/6002/Medicare%20Focus%20Group%20Report.pdf

Comment: Americans do want a prescription benefit for Medicare. They believe that the government can afford to pay for it. But they do not believe that drug benefits should be linked to privatization schemes. The message is clear: reject the Breaux-Frist premium support proposal, and enact a bona fide, comprehensive prescription benefit. (Then we can do focus groups on providing public insurance for all of us.)

The Orange County Register
July 22, 2001
by Margie Mason, The Associated Press

“About 250 students with dependents received letters earlier this month informing them a new health-care plan would be offered, but a premium increase of as much as 60% was expected. Many students said they can’t afford those rates and were embarrassed by an accompanying flyer detailing public-assistance plans available for low- or middle-income families in Santa Clara County.”

Jeffrey Martin, an engineering doctoral student with a wife and five children:

“I feel appalled that a world-class university like Stanford would let a situation come about whereby implying students should get public assistance for their dependents.”

Comment: Really? The university of such notables as Alain Enthoven and Milton Friedman is endorsing public-assistance health plans for family members of their own students? Surely it must be a practicum in applied economics. They wouldn’t really…. Naw, it must be a joke. Some sense of humor!

Medical Economics
July 9, 2001

A roundtable discussion

Moderator: “What about the proposal that Medicare be used as a model for a new American system?”

George D. Lundberg, M.D., Editor-in-chief of Medscape and former editor of JAMA:

“Medicare could certainly serve as part of our model. It’s not a new idea. Some people have said that it should be extended to cover the whole population. Then they made the terrible mistake of calling that a ‘single-payer system.’ There will never be a single-payer system in this country, because that presupposes people can’t or won’t use their own money to buy whatever they want outside the system.”

http://me.pdr.net/me/public.htm?path=content/journals/m/data/2001/0709/round2.html

Comment: All health care systems, including single payer, allow people to use their own money to buy whatever they want outside of the system. It is long past time to end fighting against reform based on semantic or rhetorical issues, and to begin supporting reform based on sound policy. The words, “single payer,” are not the enemy, but reflexive, stilted thinking is. The issues are straight forward. We all agree on the goals of universal access and coverage, free choice, quality, and value in health care. The structural changes required to achieve those goals are simple. Even Dr. Lundberg recognizes that publicly administered insurance, such as Medicare, will provide the reform we need. Call reform single payer or don’t call it single payer, just do it!

Medical Economics
July 9, 2001

A roundtable discussion

Moderator: “What about the proposal that Medicare be used as a model for a new American system?”

George D. Lundberg, M.D., Editor-in-chief of Medscape and former editor of JAMA:

“Medicare could certainly serve as part of our model. It’s not a new idea. Some people have said that it should be extended to cover the whole population. Then they made the terrible mistake of calling that a ‘single-payer system.’ There will never be a single-payer system in this country, because that presupposes people can’t or won’t use their own money to buy whatever they want outside the system.”

http://me.pdr.net/me/public.htm?path=content/journals/m/data/2001/0709/round2.html

Comment: All health care systems, including single payer, allow people to use their own money to buy whatever they want outside of the system. It is long past time to end fighting against reform based on semantic or rhetorical issues, and to begin supporting reform based on sound policy. The words, “single payer,” are not the enemy, but reflexive, stilted thinking is. The issues are straight forward. We all agree on the goals of universal access and coverage, free choice, quality, and value in health care. The structural changes required to achieve those goals are simple. Even Dr. Lundberg recognizes that publicly administered insurance, such as Medicare, will provide the reform we need. Call reform single payer or don’t call it single payer, just do it!

Boston Globe
7/19/2001
by Benjamin Gedan

“The governor and state legislators will lose their publicly funded health care in 2004 if they do not provide the same coverage to all state residents – that is, if voters approve a ballot initiative to be unveiled today.”

Richard Lord, president of Associated Industries of Massachusetts:

“I think that it’s inappropriate to threaten the Legislature in that regard.”

Comment: Inappropriate? Why should the legislators be allowed to grant themselves publicly funded health care while denying the same to the voters? Is health care a right for all or only a right for elected officials?

Bush’s Pharmaceutical Cards
Institute for Public Accuracy Washington, D.C.
http://www.accuracy.org

Thursday, July 12, 2001

Responding to George W. Bush’s announcement today supporting discount cards for more Medicare recipients to use while buying pharmaceutical drugs, the following board members of Physicians for a National Health Program (www.pnhp.org) comment:

DON McCANNE, M.D. A retired family physician, McCanne said today: “White House spokesperson Ari Fleischer claims that ‘the president is committed to helping seniors get prescription drugs they need and deserve.’ But this plan is not a government program. It is merely a private, marketplace scheme that is receiving the personal endorsement of President Bush. The program will be administered by pharmacy benefit managers (PBMs), the prescription drug equivalent of managed care plans. These middleman businesses siphon off health care dollars that should be directed to patient care. The PBMs will sell memberships to Medicare beneficiaries. Providing everyone with a ‘discount’ is no discount at all. It is merely a price that is below an artificially inflated price set for the purpose of creating a fraudulent ‘discount’ price. If Mr. Bush really wants to help seniors ‘get prescription drugs they need and deserve,’ then he would support a bona fide Medicare prescription benefit that minimizes beneficiary cost sharing. Sadly, not even the leading congressional proposals would accomplish this goal.”

QUENTIN YOUNG, M.D. National coordinator of Physicians for a National Health Program, Young said today: “The pharmaceutical industry justifies its super profits by pointing to research and development costs, but it actually spends more on marketing than on R-and-D. Canada, Mexico and our own U.S. government Veteran’s Administration get deep discounts on pharmaceuticals by negotiating with manufacturers — up to 60 percent. The White House … could reduce costs sharply by allowing people in the U.S. to import pharmaceuticals from Canada, where they are substantially lower in cost, but this ‘free trade’ administration is suddenly for no trade and doesn’t want importing of low-cost pharmaceuticals when it curtails the drug companies’ profits.”

DAVID HIMMELSTEIN, M.D. Associate professor of medicine at Harvard Medical School, Himmelstein said today: “Medicare already covers some prescription drugs — those administered in a doctor’s office. And the Department of Defense, by law, gets the best prices from drug companies. If the administration were actually interested in covering people inexpensively, they could extend Medicare drug coverage to prescriptions administered outside a doctor’s office. If they, like the Defense Department, insisted on the lowest prices, this would cut drug prices dramatically. But instead, they are telling people they can go to private drug-buying firms, and these firms would negotiate prices with drug stores and distributors, not the drug manufacturers. This puts a squeeze on the retailers, but lets the big pharmaceutical companies off the hook. This is part of a pro-corporate agenda for health care that has no chance of actual progress. The thrust of where they are taking Medicare is to managed care, which has utterly failed in the Medicare program. Letting the HMOs into Medicare has actually cost money, between $2 billion and $3 billion per year according to the General Accounting Office. This is because the government gives HMOs 95 percent of the average cost for a Medicare recipient for each one an HMO signs up, but of course the HMOs cherry-pick the healthy ones; 18 percent of Medicare patients cost them nothing at all. Then, when HMO customers do get a major illness and start accruing serious bills, they’ve gone back to standard Medicare. Medicare is actually much more efficient than the HMOs — it has 2 percent overhead, whereas they have 15 percent overhead.”

Bush’s Pharmaceutical Cards
Institute for Public Accuracy Washington, D.C.
http://www.accuracy.org

Thursday, July 12, 2001

Responding to George W. Bush’s announcement today supporting discount cards for more Medicare recipients to use while buying pharmaceutical drugs, the following board members of Physicians for a National Health Program (www.pnhp.org) comment:

DON McCANNE, M.D. A retired family physician, McCanne said today: “White House spokesperson Ari Fleischer claims that ‘the president is committed to helping seniors get prescription drugs they need and deserve.’ But this plan is not a government program. It is merely a private, marketplace scheme that is receiving the personal endorsement of President Bush. The program will be administered by pharmacy benefit managers (PBMs), the prescription drug equivalent of managed care plans. These middleman businesses siphon off health care dollars that should be directed to patient care. The PBMs will sell memberships to Medicare beneficiaries. Providing everyone with a ‘discount’ is no discount at all. It is merely a price that is below an artificially inflated price set for the purpose of creating a fraudulent ‘discount’ price. If Mr. Bush really wants to help seniors ‘get prescription drugs they need and deserve,’ then he would support a bona fide Medicare prescription benefit that minimizes beneficiary cost sharing. Sadly, not even the leading congressional proposals would accomplish this goal.”

QUENTIN YOUNG, M.D. National coordinator of Physicians for a National Health Program, Young said today: “The pharmaceutical industry justifies its super profits by pointing to research and development costs, but it actually spends more on marketing than on R-and-D. Canada, Mexico and our own U.S. government Veteran’s Administration get deep discounts on pharmaceuticals by negotiating with manufacturers — up to 60 percent. The White House … could reduce costs sharply by allowing people in the U.S. to import pharmaceuticals from Canada, where they are substantially lower in cost, but this ‘free trade’ administration is suddenly for no trade and doesn’t want importing of low-cost pharmaceuticals when it curtails the drug companies’ profits.”

DAVID HIMMELSTEIN, M.D. Associate professor of medicine at Harvard Medical School, Himmelstein said today: “Medicare already covers some prescription drugs — those administered in a doctor’s office. And the Department of Defense, by law, gets the best prices from drug companies. If the administration were actually interested in covering people inexpensively, they could extend Medicare drug coverage to prescriptions administered outside a doctor’s office. If they, like the Defense Department, insisted on the lowest prices, this would cut drug prices dramatically. But instead, they are telling people they can go to private drug-buying firms, and these firms would negotiate prices with drug stores and distributors, not the drug manufacturers. This puts a squeeze on the retailers, but lets the big pharmaceutical companies off the hook. This is part of a pro-corporate agenda for health care that has no chance of actual progress. The thrust of where they are taking Medicare is to managed care, which has utterly failed in the Medicare program. Letting the HMOs into Medicare has actually cost money, between $2 billion and $3 billion per year according to the General Accounting Office. This is because the government gives HMOs 95 percent of the average cost for a Medicare recipient for each one an HMO signs up, but of course the HMOs cherry-pick the healthy ones; 18 percent of Medicare patients cost them nothing at all. Then, when HMO customers do get a major illness and start accruing serious bills, they’ve gone back to standard Medicare. Medicare is actually much more efficient than the HMOs — it has 2 percent overhead, whereas they have 15 percent overhead.”

The Associated Press
July 11, 2001
by Ron Fournier

“The plan relies on companies that manage drug benefits to buy prescription drugs in bulk. The companies would sell the cards to Medicare patients, who could use them at any pharmacy to purchase their medicine at a reduced rate.”

Ari Fleischer, White House spokesperson:

“The president is committed to helping seniors get prescription drugs they need and deserve.”

Comment: The reality:

** The fact that this plan “does not require congressional approval” confirms that this is not a government program. It is merely a private, marketplace scheme that is receiving the personal endorsement of President Bush.

** The plan will “not require federal money.” Without use of federal funds, the plan totally depends on the charity of the marketplace to reduce prescription drug costs, a principle based on a law of economics that does not exist.

** The program will be administered by pharmacy benefit managers (PBMs), the prescription drug equivalent of managed care plans. These middleman businesses siphon off health care dollars that should be directed to patient care.

** The PBMs will sell memberships to Medicare beneficiaries. Paying a fee for a “discount” card further strains the budgets of lower income beneficiaries. The Medicare card could be used to establish eligibility for the “discount,” without adding further administrative burdens and fees.

** Providing everyone with a “discount” is no discount at all. It is merely a price that is below an artificially inflated price created for the purpose creating a fraudulent “discount” price.

** Bulk purchasing is not unique to PBMs, but is characteristic of the industry. Only patients using the services of the small retailer pay inflated prices since those retailers are not allowed bulk rates. This is yet another example of unfair price discrimination characteristic of this industry.

** Many pharmacies are dependent on the PBM contracts. The PBMs are in a position to force the retailers, contractually, to honor the discount cards, while requiring them to accept the burden of the discounts, threatening the solvency of the retailers.

** Beneficiaries are to have choice between at least two PBMs in each region. Competition didn’t stop health care inflation under managed care plans; it won’t work for PBMs either.

“Discount” cards are a marketing scheme that have no beneficial impact on true costs. In fact, the administrative burden of these programs actually result in a modest increase in overall costs. Medicare beneficiaries need prescription drug coverage, and they need relief from ever-increasing out-of-pocket expenses that are impairing access to care. If Mr. Bush really wants to help seniors “get prescription drugs they need and deserve,” then he would support a bona fide Medicare prescription benefit that minimizes beneficiary cost sharing. Sadly, not even the leading congressional proposals would accomplish this goal.

http://www.washingtonpost.com/wp-dyn/articles/A42753-2001Jul10.html http://www.washingtonpost.com/wp-dyn/politics/news/latestap/A45734-2001Jul11.html

http://www.nytimes.com/2001/07/11/politics/11MEDI.html

Los Angeles Times
July 8, 2001
Commentary
by John Balzar

“I’ve been researching opinion polls. Nowhere do I see that Americans are clamoring for more courtroom tedium to heal what ails them. For that matter, nowhere do I see that they’re feeling healthier thanks to bewildering insurance paperwork. But in poll after poll, a Top 10 concern of Americans is health care, plain and simple.

“The fan dance now underway in the capital will do nothing except make worse what is already occurring in the nation. Employer-based health insurance plans are eroding. Premiums are soaring. The number of Americans without insurance is climbing, perhaps to 45 million of us. Many cannot afford their medicine.”

“Insurance companies do not deliver health care. They are profit-driven bureaucracies. If they had their way, they would insure only the healthy. As soon as we got unhealthy, we’d be uninsured.”

“I say, let’s collectively hire our own doctors and civil service health administrators. Private sector profits have no place in a business so important as life and death.

“Why are we so afraid of managing our own health care through our government, anyway? Because we don’t want heavy-handed, slow-moving decisions. Yet what could be more heavy-handed and slow-moving than the system we have?

“Actually, we are afraid of just the words: Socialized Medicine.

“So let’s start by changing terms. Let’s call it, American Health Care.”