PNHP

Med Students' Own Mental Health Care

Med Students' Own Mental Health Care

By Elizabeth Murphy
Inside Higher Ed, Sept. 7, 2011

A study published Tuesday paints a grim picture of America’s increasingly stressed medical students, in what researchers say they hope will be a “wake-up call” to the nation’s medical schools and health care policy makers.

The study, led by researchers at the Cambridge Health Alliance, a hospital system near Boston, includes data from 115 of the nation’s medical schools, looking specifically at what type of health insurance they offer to students with mental health and substance abuse problems.

“This is one small example of how the system is failing at-risk people,” said Rachel Nardin, chief of the neurology division at Cambridge Health Alliance and a co-author of the study, which was part of a special issue of the Journal of the American Medical Association on medical education. “The study is partly a wake-up call to look at the health insurance [the schools] offer. They are struggling in the face of a health care system that has unsustainable costs.”

Studies have shown medical students have higher rates of depression than their peers and are equally at risk for substance abuse issues, said Nardin, also an associate professor of neurology at Harvard.

The researchers looked at medical students’ annual maximum visit limits, co-pay amounts, dollar limits and co-insurance, which is the percentage of total costs paid by the patient. The study found that fewer than 22 percent of the medical schools provided mental health and substance abuse coverage without a cost-sharing requirement. What’s more, six of the 115 offered no coverage for in-patient mental health visits, substance abuse treatment or either.

“This is worrisome because of evidence that cost-sharing discourages students from seeking both [mental health treatment and substance abuse treatment],” the study says.

Researchers culled student insurance data from college websites and surveys. The study did not look at how many students use outside insurance or university-wide counseling services separate from the specific colleges. Those limitations were among several problems cited by medical school officials about the JAMA study.

The majority of medical schools are making a “valiant effort” to provide mental health coverage for their students that is affordable and cognizant of the societal stigma attached to such disorders, said Sam Parrish, associate dean of student affairs at Drexel University’s College of Medicine.

Parrish pointed to a 2009 survey conducted by the Association of American Medical Colleges, which indicated that 59 percent of schools reported that mental health services for students were available with no out-of-pocket costs associated. The survey did not separate out substance abuse care. Parrish, a member of the AAMC survey’s committee, said his college provides a psychologist and psychiatrist for its medical students at no cost. Communication between those professionals and their patients are kept confidential by several “firewalls” put in place by the college, he said.

This, however, does not fully address the issue of confidentiality, Nardin said. Some medical students fear that by seeking help for mental health or substance abuse issues, they will jeopardize future opportunities as doctors, especially if that help is from someone right in the college, she said.

Elizabeth Wiley, a fourth-year medical student at George Washington University, said access to services that entail seeing faculty members can be difficult for some medical students. At George Washington, the psychiatry faculty who oversee students in class are also oftentimes the doctors that treat students.

“The only option is to be seen by someone that will likely play a role in evaluating you,” Wiley, also a student member of the American Medical Student Association, said. “It creates a deterrent in seeking care.”

“My goal is not to demonize these schools that are struggling,” Nardin said. “Health care costs are just staggering for all types of institutions these days. Although it was bad, it’s not necessarily worse than private coverage in general. This is a particularly poignant example of this because we can see the consequence of this for these patients.”

At-risk medical students are an example of a larger systemic problem with a health care system that relies on a patchwork of private plans, Nardin said.

The real solution, Nardin believes, will not come from the schools themselves. It’s lawmakers on the national level who have to put in place more regulation to protect students, medical or otherwise.

Aaron Smith, co-founder and executive director of the health care advocacy group Young Invincibles, said the reality is that college health care plans vary widely.

Smith said it is a “weird contrast to have these medical students who are so passionate about helping others” be left in the lurch when it comes to mental health and substance abuse care from their schools.

“I think all schools, not just medical schools, should see this as an opportunity to provide decent health care for their students and improve it when it is not up to par,” he said.

But students can hopefully look forward to new proposed regulations for student health care, Smith said. Proposed federal regulations through the Department of Health and Human Services call for less cost-sharing, restrictions on benefits caps and free preventive care, among other policies. If approved, these regulations would tentatively take effect next academic year, Smith said.

Even so, Parrish said the mental health professionals at his school have been consistently busy for the 11 years he has held his position. If time is any marker, this is a problem that is unlikely to go away.

http://www.insidehighered.com/news/2011/09/07/study_finds_mental_health_care_coverage_for_medical_students_lacking

Single-payer works

Letter to the Editor
Helena (Mont.) Independent Record, September 5, 2011

The IR’s editorial of Aug. 28 suggests that the “state needs insurance competition, … giving Montanans … choice and competition for their health insurance dollars.”
I disagree. The notion that competition and choice between health plans will improve care or lower costs is a fantasy; it hasn’t worked for decades. Competing plans do little else than drive up administrative costs currently costing the public nearly one-third of every dollar spent on health care. Of the $6.2 billion Montana spent on health care in 2008, $1.922 billion went to administration, $1,980 per Montanan.

Health care reform could provide better care at less cost by replacing competing insurance companies with a single-payer health plan. An improved Medicare for All would reduce administrative costs leaving the state with enough funds to provide universal care. Vermont recently passed legislation to move in that direction and Montana would be wise to study this option.

Robert W. Putsch, MD, Canyon Creek
Member, Physicians for a National Health Program

Read more: http://helenair.com/news/opinion/readers_alley/single-payer-works/article_9f5cd6c8-d782-11e0-88e7-001cc4c03286.html#ixzz1XH8wmRyr

Sally Pipes threatens us with Medicare for All

Democrats' Plan B For Medicare: Medicare For All

By Sally Pipes
Forbes, September 6, 2011

Democrats know the individual mandate might go up in smoke. So they’ve started strategizing a constitutionally sound means of achieving the ever-elusive goal of “universal coverage.”

Their preferred remedy? “Medicare-for-All,” a term popularized by the late Senator Edward Kennedy (D-Mass.) who supported a single-payer, government run healthcare system.

Former Clinton labor secretary Robert Reich laid out the basic idea in a recent op-ed for the San Francisco Chronicle. “So what do Obama and the Democrats do if the individual mandate in the new health care law gets struck down by the Supreme Court?” Reich asked. “Immediately propose what they should have proposed right from the start — universal health care based on Medicare-for-All, financed by payroll taxes.”

This notion has been floated in progressive policy circles in the past. It’s a pure distillation of their government-heavy approach to health care reform. Typically, though, the idea’s been shelved out of fears of political blowback.

Today, when the government extracts Medicare taxes from people’s paychecks, it’s forcing them to assent to this deal: Hand over a slice of your paycheck now, and get government-sponsored health insurance in old age.

Of course, Americans are not allowed to opt out of that deal — just like they won’t be able to opt out of the individual mandate. But unlike the mandate, the taxes that finance Medicare are not in danger of being deemed unconstitutional.

If the individual mandate is actually struck down, Medicare-for-All may become the new rallying cry for progressive luminaries. And if President Obama wins a second term, he may look to heed that cry.

http://www.forbes.com/sites/sallypipes/2011/09/06/democrats-plan-b-for-medicare-medicare-for-all/

Comment: 

By Don McCanne, MD

As a Canadian libertarian now serving as President and CEO of the Pacific Research Institute, an organization advocating for free market solutions to America’s problems, Sally Pipes is issuing a warning that “Medicare-for-All may become the new rallying cry for progressive luminaries.” Further, “if President Obama wins a second term, he may look to heed that cry.” Don’t we wish!

Most Med Schools Offer Subpar Mental Health Coverage

By Deborah Brauser
Medscape News Today, Sept. 6, 2011

Most medical schools in the United States do not offer health insurance plans that sufficiently cover mental health or substance abuse treatment, new research suggests.

In fact, only around one third of the schools evaluated offered unlimited monetary and visit benefits.

“Visit and dollar limits are common features of medical student insurance coverage for [mental health treatment] and [substance abuse treatment],” write lead author Rachel Nardin, MD, assistant professor of neurology at Harvard Medical School in Cambridge, Massachusetts, and chief of neurology at Cambridge Health Alliance, and colleagues.

In addition, “fewer than 22% of the schools provide first-dollar coverage without cost sharing,” they add.

The investigators note that this is particularly “worrisome” because past research has shown that requiring copayments or coinsurance often discourages students from seeking help for their mental health or substance abuse problems.

They write that although these findings may not be any worse than those found for nonstudent populations, “this parity is not reassuring given the importance to the medical profession and patients of aggressively treating these disorders.”

The study results were reported in a Research Letter in the September 7 issue of the Journal of the American Medical Association.

Plans Vary Widely

In the study, the investigators evaluated data on health insurance plans offered by 115 of the 129 US medical schools.

Results showed that although some outpatient mental health coverage was provided through health plans from all of the schools assessed, 6 schools did not offer inpatient coverage of either mental health or substance abuse treatment.

Only 37.4% of the schools provided unlimited outpatient coverage for mental health treatment, and only 28.6% provided it for substance abuse treatment. Unlimited inpatient mental health or substance abuse treatment was provided by 43.2% and 36.4%, respectively.

In addition, only 13 of the schools offered complete outpatient mental health coverage without cost sharing, and 17 provided it for outpatient substance abuse treatment. A total of 22 and 23 schools provided complete inpatient mental health and substance abuse treatment coverage, respectively.

Finally, the median coinsurance rate to be paid by a student was 20% for all services.

Dr. Nardin noted in a release that the plans also varied greatly in terms of annual limits. “At least 1 plan limited annual coverage for outpatient substance abuse care to $800, while another covered the same services up to $200,000 per year.”

“Everyone, including medical students, deserves full access to all needed care,” she added.

Senior author J. Wesley Boyd, MD, assistant clinical professor of psychiatry at Harvard, said in the same release that these medical students experience higher levels of psychological distress including depression and suicidality, than their peers.

“Such distress correlates with decreases in empathy and altruism…and with increases in medical errors,” he reported.

Dr. Nardin said that the best solution for this situation is a national single-payer health insurance program that would offer comprehensivebenefits without copays or coinsurance.

“That message needs to be heard once again in Washington.”

The study was supported in part by an Institutional National Research Service Award. The study authors have disclosed no relevant financial relationships.

JAMA. 2011;306:931-933. Abstract

http://www.medscape.com/viewarticle/749182

Sally Pipes threatens us with Medicare for All

Democrats’ Plan B For Medicare: Medicare For All

By Sally Pipes
Forbes, September 6, 2011

Democrats know the individual mandate might go up in smoke. So they’ve started strategizing a constitutionally sound means of achieving the ever-elusive goal of “universal coverage.”

Their preferred remedy? “Medicare-for-All,” a term popularized by the late Senator Edward Kennedy (D-Mass.) who supported a single-payer, government run healthcare system.

Former Clinton labor secretary Robert Reich laid out the basic idea in a recent op-ed for the San Francisco Chronicle. “So what do Obama and the Democrats do if the individual mandate in the new health care law gets struck down by the Supreme Court?” Reich asked. “Immediately propose what they should have proposed right from the start — universal health care based on Medicare-for-All, financed by payroll taxes.”

This notion has been floated in progressive policy circles in the past. It’s a pure distillation of their government-heavy approach to health care reform. Typically, though, the idea’s been shelved out of fears of political blowback.

Today, when the government extracts Medicare taxes from people’s paychecks, it’s forcing them to assent to this deal: Hand over a slice of your paycheck now, and get government-sponsored health insurance in old age.

Of course, Americans are not allowed to opt out of that deal — just like they won’t be able to opt out of the individual mandate. But unlike the mandate, the taxes that finance Medicare are not in danger of being deemed unconstitutional.

If the individual mandate is actually struck down, Medicare-for-All may become the new rallying cry for progressive luminaries. And if President Obama wins a second term, he may look to heed that cry.

http://www.forbes.com/sites/sallypipes/2011/09/06/democrats-plan-b-for-medicare-medicare-for-all/

As a Canadian libertarian now serving as President and CEO of the Pacific Research Institute, an organization advocating for free market solutions to America’s problems, Sally Pipes is issuing a warning that “Medicare-for-All may become the new rallying cry for progressive luminaries.” Further, “if President Obama wins a second term, he may look to heed that cry.” Don’t we wish!

Most medical schools offer students poor coverage for mental health and substance abuse treatment, imperiling student and patient care: Harvard study

Nearly 4 of 5 student health insurance plans require co-pays or coinsurance, obstacles to getting needed care, and most impose visit and dollar limits

EMBARGOED until
Sept. 6, 2011, 4 p.m. Eastern time

Contacts:
Rachel Nardin, M.D.
J. Wesley Boyd, M.D., Ph.D.
Mark Almberg, Physicians for a National Health Program, (312) 782-6006, mark@pnhp.org

Most U.S. medical schools offer their students poor health insurance coverage for the treatment of mental health and substance abuse disorders, a practice that imperils the well-being of our nation’s future doctors and their patients, a group of Boston-area researchers report in JAMA today [Sept. 7].

In the first study of its kind, the researchers – most of whom are faculty physicians at the Harvard-affiliated Cambridge Health Alliance (CHA) – found that fewer than 22 percent of the 115 medical schools they studied provided their students with complete coverage, without co-pays or coinsurance, for mental health and substance abuse treatment.

Some student health plans require co-payments of $20-$25 per outpatient visit and up to $500 per inpatient stay. The median coinsurance rate (the percentage of total costs paid by the patient) was 20 percent, meaning that a single course of treatment might cost a medical student thousands of dollars out of pocket.

“Research shows out-of-pocket costs discourage patients from getting mental health and substance abuse treatment,” said Dr. Rachel Nardin, assistant professor of neurology at Harvard Medical School, chief of neurology at CHA and lead author of the study.

“Everyone, including medical students, deserves full access to all needed care,” she said. “As an aside, it’s worth noting that only single-payer health systems have been able to assure such unhampered access. Private-insurance-based systems fail miserably on this score, as we see in this instance.”

A majority of schools’ insurance plans had annual limits on visits and/or total expenditures for mental health and substance abuse treatment. The plans varied considerably in this regard, Nardin said. At least one plan limited annual coverage for outpatient substance abuse care to $800, while another covered the same services up to $200,000 per year.

“In many cases the maximum dollar benefits can be very low,” she said. The number of patient visits allowed by the plans was also quite variable, ranging from 8 visits to 150 visits annually.

Senior author Dr. J. Wesley Boyd, assistant clinical professor of psychiatry at Harvard Medical School, said: “Medical students experience higher levels of psychological distress than their peers, including depression and suicidality. Such distress correlates with decreases in empathy and altruism among medical students and with increases in medical errors in doctors in training.

“Given that medical students are often leery about seeking treatment in the first place, requiring students to pay huge co-payments or coinsurance for mental health or substance abuse treatment might foreclose obtaining needed psychiatric care,” he said. “This is bad for the students and bad for patients.”

Boyd noted that many ailments persist into later years, so ensuring the ability to receive early treatment is essential.

The authors urge U.S. medical schools to “move immediately to improve student insurance coverage for mental health and substance abuse disorders.” Nardin added: “The best remedy for this situation would be a national single-payer health insurance program, a program that would offer comprehensive benefits while requiring no co-pays or coinsurance. That message needs to be heard once again in Washington.”

*********

“United States medical students’ health insurance coverage for mental health and substance abuse treatment,”
Rachel Nardin, M.D.; Leah Zallman, M.D.; Cassie Frank, M.D., M.P.H.; Benjamin Day, M.A.; J. Wesley Boyd, M.D., Ph.D. JAMA, Sept. 7, 2011.

*********

Physicians for a National Health Program (www.pnhp.org) is an 18,000-member organization advocating a nonprofit, single-payer national health insurance program for the United States. PNHP had no role in funding the study mentioned above. To speak with a physician/spokesperson in your area, visit www.pnhp.org/stateactions or call (312) 782-6006.

The emergence of private insurance exchanges

Private exchanges offer yet another alternative to group health plans

By Emily Berry
American Medical News, September 5, 2011

With potentially more than 50 state-based versions of a public health insurance exchange set to emerge by 2014, another version of a post-health reform insurance market is emerging: the private exchange.

A private exchange is an existing concept taking on a new name. The idea also has been pitched as a “defined benefit” plan and has been part of a package with a health reimbursement account. Simply put, a private exchange is an alternative to a group health benefit plan. Rather than paying a portion or all of a premium, an employer pays each of its workers a flat amount and sends each to choose his or her plan.

Here’s how a private health exchange works:

An employer decides what it can afford to pay for health benefits — for example, $1,000 per employee per month. Rather than enrolling every employee in the same plan and using the $1,000 to pay for a portion of a premium, the employer puts $1,000 in an account for each worker.

Then one of two things happens: One, the employee works with a third party that acts as a clearinghouse. The worker chooses from any plan available in the individual market, with the clearinghouse administering the employee’s HRA, and helping connect brokers and health plans with the employees who want to buy coverage.

Under the second scenario, the employer sends the worker to a third party that gives him or her a limited set of choices, for instance a range of plans offered by the state’s Blues plan.

A private exchange would be a better deal for the employer than not offering health benefits, because the company can still reap the tax advantage of offering health benefits and avoid the penalty that would apply to companies with 50 or more employees if they decided not to offer benefits, analysts said.

http://www.ama-assn.org/amednews/2011/09/05/bisb0905.htm

Comment: 

By Don McCanne, MD

Employers who want to reduce their roles in providing health insurance for their employees, yet do not want to turn their employees over to the state insurance exchanges and pay penalties for doing so, seem to have another option – private exchanges.

One of the greatest benefits for the employer is that they can convert their health benefit programs from a defined benefit to a defined contribution. This shifts the burden of future health care cost increases onto their employees.

In the next couple of years we can anticipate seeing many other similar efforts to skirt the provisions of the Affordable Care Act. It is really tragic that we are going to have to wait until far too many more people are destitute and suffer and die before we are ready to enact the reform we really need – an improved Medicare for all.

The emergence of private insurance exchanges

Private exchanges offer yet another alternative to group health plans

By Emily Berry
American Medical News, September 5, 2011

With potentially more than 50 state-based versions of a public health insurance exchange set to emerge by 2014, another version of a post-health reform insurance market is emerging: the private exchange.

A private exchange is an existing concept taking on a new name. The idea also has been pitched as a “defined benefit” plan and has been part of a package with a health reimbursement account. Simply put, a private exchange is an alternative to a group health benefit plan. Rather than paying a portion or all of a premium, an employer pays each of its workers a flat amount and sends each to choose his or her plan.

Here’s how a private health exchange works:

An employer decides what it can afford to pay for health benefits — for example, $1,000 per employee per month. Rather than enrolling every employee in the same plan and using the $1,000 to pay for a portion of a premium, the employer puts $1,000 in an account for each worker.

Then one of two things happens: One, the employee works with a third party that acts as a clearinghouse. The worker chooses from any plan available in the individual market, with the clearinghouse administering the employee’s HRA, and helping connect brokers and health plans with the employees who want to buy coverage.

Under the second scenario, the employer sends the worker to a third party that gives him or her a limited set of choices, for instance a range of plans offered by the state’s Blues plan.

A private exchange would be a better deal for the employer than not offering health benefits, because the company can still reap the tax advantage of offering health benefits and avoid the penalty that would apply to companies with 50 or more employees if they decided not to offer benefits, analysts said.

http://www.ama-assn.org/amednews/2011/09/05/bisb0905.htm

Employers who want to reduce their roles in providing health insurance for their employees, yet do not want to turn their employees over to the state insurance exchanges and pay penalties for doing so, seem to have another option – private exchanges.

One of the greatest benefits for the employer is that they can convert their health benefit programs from a defined benefit to a defined contribution. This shifts the burden of future health care cost increases onto their employees.

In the next couple of years we can anticipate seeing many other similar efforts to skirt the provisions of the Affordable Care Act. It is really tragic that we are going to have to wait until far too many more people are destitute and suffer and die before we are ready to enact the reform we really need – an improved Medicare for all.

John Geyman's "Breaking Point"

Breaking Point: How the Primary Care Crisis Endangers the Lives of Americans

By John Geyman, M.D.

What are the dimensions of the crisis in primary care? How did we get here? How and why have past efforts to resolve it failed? And how can we succeed in rebuilding our crumbling foundation of health care in this country? In Part I, we will outline the dimensions of this crisis; its impacts on our system, patients and their families; and consider what we can learn from failed attempts to rebuild primary care. In Part II, we will look at various policy alternatives, summarize what can be learned from other countries, and propose a comprehensive agenda for rebuilding primary care.

This is admittedly a challenging problem that requires a long view, most likely over one or two generations. Present trends are very unfavorable, and a complete re-orientation of the goals of health care, the roles of physicians and other health care professionals, and fundamental changes in the way we finance health care will be required if we are to deal effectively with the primary care problem.

http://copernicus-healthcare.org/books-by-copernicus.html

Both the book and the Kindle ebook are available at Amazon.com:
http://www.amazon.com/Breaking-Point-Primary-Endangers-Americans/dp/0983773408

Comment: 

By Don McCanne, MD

In “Breaking Point,” John Geyman explains why it is crucial for us to rebuild our primary care infrastructure, and how we can do it. Highly recommended!

John Geyman’s “Breaking Point”

Breaking Point: How the Primary Care Crisis Endangers the Lives of Americans

By John Geyman, M.D.

What are the dimensions of the crisis in primary care? How did we get here? How and why have past efforts to resolve it failed? And how can we succeed in rebuilding our crumbling foundation of health care in this country? In Part I, we will outline the dimensions of this crisis; its impacts on our system, patients and their families; and consider what we can learn from failed attempts to rebuild primary care. In Part II, we will look at various policy alternatives, summarize what can be learned from other countries, and propose a comprehensive agenda for rebuilding primary care.

This is admittedly a challenging problem that requires a long view, most likely over one or two generations. Present trends are very unfavorable, and a complete re-orientation of the goals of health care, the roles of physicians and other health care professionals, and fundamental changes in the way we finance health care will be required if we are to deal effectively with the primary care problem.

http://copernicus-healthcare.org/books-by-copernicus.html

Both the book and the Kindle ebook are available at Amazon.com:
http://www.amazon.com/Breaking-Point-Primary-Endangers-Americans/dp/0983773408

In “Breaking Point,” John Geyman explains why it is crucial for us to rebuild our primary care infrastructure, and how we can do it. Highly recommended!

Defining success – UnitedHealth acquires Monarch HealthCare

UnitedHealth Buys California Group of 2,300 Doctors

By Anna Wilde Mathews
The Wall Street Journal, September 1, 2011

UnitedHealth Group Inc. will acquire the operations of a major southern California physician group, in the latest example of how lines are blurring between insurance companies and health-care providers.

The purchase of the management arm of Monarch HealthCare, an Irvine, Calif., association that includes approximately 2,300 physicians in a range of specialties, establishes United’s Optum health-services unit as a formidable presence in the region. Optum had previously taken over the management arms of two smaller southern California groups, AppleCare Medical Group and Memorial HealthCare Independent Practice Association.

In California, deals involving control of medical groups are structured to comply with rules that block most entities from directly employing practicing physicians. Typically, a company like Optum might buy non-clinical assets and sign a long-term management agreement with an independent practice association of physicians such as Monarch.

United has said in the past that providers acquired by Optum will not work exclusively with United’s health plan, and will continue to contract with an array of insurers. But in one sign of the potential complications that might ensue, Monarch is currently in an arrangement with United competitor WellPoint Inc. to create a cooperative “accountable-care organization” aimed at bringing down health-care costs and improving quality.

http://online.wsj.com/article/SB10001424053111903895904576542553422509280.html

Comment: 

By Don McCanne, MD

Consolidation is accelerating, and the largest insurers are positioning themselves to be at the top of the heap.

Excuse a personal note, but this particular merger is difficult for me to observe. Having practiced in Orange County, I watched the founding and expansion of Monarch HealthCare until they dominated health care in our region. As an early opponent of managed care as it was playing out, I certainly had no interest in joining them. Probably because my practice included large numbers of Medicaid, uninsured, and undocumented patients (so many that they crowded out my privately insured patients even though I worked extended hours), Monarch also never communicated an interest in including me in their panel.

What defines a successful health care system? It always seemed to me that success would be when everyone could receive quality health care that was appropriate and without financial barriers that would impair access. Yet The Wall Street Journal implies that success is when you can organize and control the delivery system and corner the portion of the market that has the highest monetary resources.

Although I was far busier than other primary care physicians in our region, I ended up retiring earlier than I intended because the composition of my practice eventually resulted in an unsustainable negative cash flow.

By most standards, at least by the dominant standards of today, I was unsuccessful, and Monarch HealthCare was highly successful. I’m not sure that my patients who couldn’t get past the appointment desks of Monarch physicians would agree when they had success in negotiating past my appointment desk.

Not to be defeated, I made a decision to devote my remaining productive years to promoting a concept of success that serves patients – all patients – without the intrusion of intermediaries such as UnitedHealth and Monarch HealthCare that glom onto the money and try to keep all that they can. Haven’t we had enough of Wall Street’s version of success?