Cross-border checkup: Dr. Danielle Martin defends Canada's single-payer system
Health-care advocate alumna takes fight to Washington
By Adela Talbot
Western (University) News, London, Ont., April 24, 2014
Danielle Martin sure can stand her ground.
Last month, the 2003 Schulich School of Medicine & Dentistry graduate spoke as part of an international panel presenting to the U.S. Senate’s Subcommittee on Primary Health and Aging. Invited alongside health-care professionals from Taiwan, France and Denmark to present a defense of a single-payer health-care system, Martin did just that.
And when conversation veered toward an attack of Canada’s health-care system, and its long wait times for certain procedures, Martin delivered a defense that has garnered much applause from fellow Canadians and national media.
“On average, how many Canadian patients on a waiting list die each year? Do you know?” asked U.S. Sen. Richard Burr, R-N.C., in Washington, D.C., last month.
“I don’t, sir, but I know there are 45,000 in America who die waiting because they don’t have insurance at all,” replied Martin, a family physician and vice-president of medical affairs and health systems solutions at Women’s College Hospital in Toronto.
And that’s just one snippet of her Senate exchange with the anti-Obamacare Republican.
After completing her undergraduate degree at McGill University, Martin first worked in health-care policy and politics. She applied to Schulich for medical school and arrived at Western in 1999. Having done her residency in family medicine in Toronto, she stayed put. She took on a Master’s of Public Policy at the University of Toronto and has since enjoyed a professional life as a doctor who gets things done – with and without her white coat.
“My area of interest has always been health-care systems and how can we construct health-care systems to best serve the needs of the population; that’s what drew me to medical school in the first place,” Martin said.
In 2006, along with colleagues across the country, she helped establish Canadian Doctors for Medicare, a national physician organization that does advocacy work around evidence relating to equity and access to health-care services.
“Unlike many other medical leaders who sort of start from a clinical interest and move into policy issues later in their careers, I started out with a policy interest and then developed a love of family medicine during my medical training at Western,” Martin continued.
“But my interest has really been in health-care systems, and my primary concern, until recently, has been around the preservation and enhancement of publically funded health care in Canada – trying to make sure that we construct an insurance model that makes sure that access to health care is based on need, rather than ability to pay.”
By Adela Talbot
Western (University) News, London, Ont., April 24, 2014
Western (University) News, London, Ont., April 24, 2014
Danielle Martin sure can stand her ground.
Last month, the 2003 Schulich School of Medicine & Dentistry graduate spoke as part of an international panel presenting to the U.S. Senate’s Subcommittee on Primary Health and Aging. Invited alongside health-care professionals from Taiwan, France and Denmark to present a defense of a single-payer health-care system, Martin did just that.
And when conversation veered toward an attack of Canada’s health-care system, and its long wait times for certain procedures, Martin delivered a defense that has garnered much applause from fellow Canadians and national media.
“On average, how many Canadian patients on a waiting list die each year? Do you know?” asked U.S. Sen. Richard Burr, R-N.C., in Washington, D.C., last month.
“I don’t, sir, but I know there are 45,000 in America who die waiting because they don’t have insurance at all,” replied Martin, a family physician and vice-president of medical affairs and health systems solutions at Women’s College Hospital in Toronto.
And that’s just one snippet of her Senate exchange with the anti-Obamacare Republican.
After completing her undergraduate degree at McGill University, Martin first worked in health-care policy and politics. She applied to Schulich for medical school and arrived at Western in 1999. Having done her residency in family medicine in Toronto, she stayed put. She took on a Master’s of Public Policy at the University of Toronto and has since enjoyed a professional life as a doctor who gets things done – with and without her white coat.
“My area of interest has always been health-care systems and how can we construct health-care systems to best serve the needs of the population; that’s what drew me to medical school in the first place,” Martin said.
In 2006, along with colleagues across the country, she helped establish Canadian Doctors for Medicare, a national physician organization that does advocacy work around evidence relating to equity and access to health-care services.
“Unlike many other medical leaders who sort of start from a clinical interest and move into policy issues later in their careers, I started out with a policy interest and then developed a love of family medicine during my medical training at Western,” Martin continued.
“But my interest has really been in health-care systems, and my primary concern, until recently, has been around the preservation and enhancement of publically funded health care in Canada – trying to make sure that we construct an insurance model that makes sure that access to health care is based on need, rather than ability to pay.”
A Deadly Fungus and Questions at a Hospital
By IAN URBINA and SHERI FINK
NEW ORLEANS — The first victim was a premature boy in the intensive care unit whose mother noticed a mysterious irritation in his groin; it grew into an open wound burrowing into the baby’s abdomen. The last patient to die was a 10-year-old girl, whose face was ravaged.
Three other patients at Children’s Hospital here were also stricken, including a 13-year-old boy who his parents said endured over 20 surgical procedures in 54 days in a futile effort to save him.
Like the others, Zachary Malik Tyler, the 13-year-old, arrived at Children’s Hospital battling a serious illness before being overwhelmed by an infection. “What haunts me more than anything is thinking about what he suffered,” said Stephen Tyler, his father.
The children died of various causes between August 2008 and July 2009 during an outbreak of a flesh-eating fungal infection, mucormycosis, most likely spread by bed linens, towels or gowns, according to a medical journal. The disclosure this month caused new pain for the families of the children and raised troubling questions about how the infections came about, why doctors did not connect the cases until more than 10 months after the first death, and what obligation the hospital had to inform parents — and the community — of the outbreak.
Those questions take on greater urgency, experts say, because deadly fungal infections, while still rare, appear to be on the rise nationwide.
That may be because of changes in the environment and a larger pool of vulnerable people with suppressed immune systems because patients are living longer with serious illnesses.
An estimated 75,000 patients with infections picked up in health care facilities die in hospitals each year, according to figures released last month by the Centers for Disease Control and Prevention.
The outbreak may have spread unchecked, at least in part, because of lapses in the hospital’s infection controls and sloppy handling of contaminated linens, according to a review of emails, patient records, legal testimony from hospital and laundry staff, and interviews with doctors, lawyers, federal health officials, hospital administrators and patients’ families.
Workers unloaded clean linens on the same dock where medical waste was removed, moved clean and soiled linens on the same carts, and stored linens in hospital hallways covered in dust from a nearby construction site, court records indicated.
C.D.C. investigators did not fault the hospital for failing to move more quickly to detect the outbreak, noting that the infections occurred weeks or months apart in different areas of the hospital. Still, there were problems, records and interviews showed. With one of the five children, a doctor allegedly agreed to biopsy an infected spot only after a nurse and the parents insisted. And the hospital’s infection investigators did not become involved for months because their threshold for reviewing cases excluded some of the five deaths.
In a city where so many institutions had failed its citizens — a former mayor convicted of bribery, a police department tainted by charges of brutality, schools where student performance was historically abysmal — Children’s Hospital was well respected. It cared for New Orleans’s sickest young patients, from those living in the poorest precincts like the Lower Ninth Ward to those from the hospital’s genteel neighborhood uptown.
http://www.nytimes.com/2014/04/29/us/a-deadly-fungus-and-questions-at-a-hospital.html?hp
How Congress Is Actually Holding Down Medicare Spending
It’s a rare health policy wonk who has a good word to say about Medicare’s Sustainable Growth Rate formula. That’s the formula created by Congress to govern the amount that Medicare pays to physicians for various treatments. It is supposed to adjust payments to meet an overall spending target tied to economic growth.
But it hardly ever works out this way. Congress routinely overrides the cuts that the formula would demand, and it did so again a few weeks ago. Health care experts often view such action as a failure of government to control health care costs. But that view is incomplete. Congressional overrides of the formula have been fiscally responsible for the most part. And, apart from one gimmick, the most recent “doc fix” — as changes to the formula are known — is as well.
Medical spending, including that by Medicare, typically grows faster than the economy, and often significantly faster. The formula, often called the S.G.R., is intended to bring Medicare spending and economic growth into alignment, which necessarily demands spending cuts. Congress, wary of making such cuts, overrides them year after year, creating an ever-growing gap between Medicare’s payments to physicians and the level dictated by the formula. The gap now stands at about 24 percent. Good luck getting physicians to keep Medicare patients if the payments are suddenly cut 24 percent.
However, from another point of view, the formula — as flawed as it is — has helped keep Medicare spending lower than it might otherwise have been. Instead of cutting physician payments by the large amount the S.G.R. demands, Congress has increased payment rates, but typically by only tiny amounts — at an annual rate of just 0.7 percent. That pace does not keep up with the typical cost of care.
The RUC, Health Care Finance’s Star Chamber, Remains Untouchable
Posted By Brian Klepper On February 1, 2013 @ 12:43 pm In All Categories,Health
Law,Medicare,Payment,Physicians,Primary Care,Workforce | 9 Comments
Law,Medicare,Payment,Physicians,Primary Care,Workforce | 9 Comments
On January 7, a federal appeals court rejected six Georgia primary care physicians’ (PCPs) challenge to the Centers for Medicare and Medicaid Services’ (CMS) 20-year, sole-source relationship with the secretive, specialist-dominated federal advisory committee that determines the relative value of medical services. The American Medical Association’s (AMA) Relative Value Scale Update Committee (RUC) is, in the court’s view, not subject to the public interest rules that govern other federal advisory groups. Like the district court ruling [1] before it, the decision dismissed [2] the plaintiffs’ claims out of hand and on procedural grounds, with almost no discussion of content or merit.
Thus ends the latest attempt to dislodge what is perhaps the most blatantly corrosive mechanism of US health care finance, a star-chamber of powerful interests that, complicit with federal regulators, spins Medicare reimbursement to the industry’s advantage and facilitates payment levels that are followed by much of health care’s commercial sector. Most important, this new legal opinion affirms that the health industry’s grip on US health care policy and practice is all but unshakable and unaccountable, and it appears to have co-opted the reach of law.
The RUC exerts its influence by rolling up the collective interests of the nation’s most powerful medical specialty societies and, indirectly, the drug and device firms that support and benefit from their activity. The RUC uses questionable “methodologies,” closed to public scrutiny, to value medical services. CMS has historically accepted nearly 90 percent of the RUC’s recommendations without further due diligence [3]. In a damning October 2010Wall Street Journal expose [4], former CMS Administrator Tom Scully described the RUC’s processes as “indefensible.”
The RUC’s distortion of America’s health care market, ramping up both care and cost, cannot be overstated. It has consistently over-valued specialty services and undervalued primary care services. Ophthalmologists performing cataract procedures are now paid 12.5 times the hourly rate of PCPs [5]involved in a moderately complex office visit, arguably a more complicated activity.
At the same time, the erosion in primary care reimbursement has reduced office visit durations and undermined primary care’s moderating influence over specialty care. These dynamics are almost certainly responsible for the doubling of specialty referrals over the past decade [6].
The RUC’s excessive valuations of certain procedures — e.g., cardiac stenting, colonoscopies, back surgeries — have created lucrative incentives for over-utilization. 2008 OECD health data showed that, for every inpatient percutaneous transluminal coronary angioplasty (PTCA) performed on patients in the United Kingdom, New Zealand or Switzerland, we do more than four in the US. Then there are data [7] showing a clinically inexplicable 15-fold increase in complex spinal fusions between 2002 and 2007, with adjusted mean hospital charges of $81,000.
http://healthaffairs.org/blog/2013/02/01/the-ruc-health-care-finances-star-chamber-remains-untouchable/print/
Tuesday, 29 April 2014 09:53By Mara Kardas-Nelson, Truthout | News Analysis
Thus ends the latest attempt to dislodge what is perhaps the most blatantly corrosive mechanism of US health care finance, a star-chamber of powerful interests that, complicit with federal regulators, spins Medicare reimbursement to the industry’s advantage and facilitates payment levels that are followed by much of health care’s commercial sector. Most important, this new legal opinion affirms that the health industry’s grip on US health care policy and practice is all but unshakable and unaccountable, and it appears to have co-opted the reach of law.
The RUC exerts its influence by rolling up the collective interests of the nation’s most powerful medical specialty societies and, indirectly, the drug and device firms that support and benefit from their activity. The RUC uses questionable “methodologies,” closed to public scrutiny, to value medical services. CMS has historically accepted nearly 90 percent of the RUC’s recommendations without further due diligence [3]. In a damning October 2010Wall Street Journal expose [4], former CMS Administrator Tom Scully described the RUC’s processes as “indefensible.”
The RUC’s distortion of America’s health care market, ramping up both care and cost, cannot be overstated. It has consistently over-valued specialty services and undervalued primary care services. Ophthalmologists performing cataract procedures are now paid 12.5 times the hourly rate of PCPs [5]involved in a moderately complex office visit, arguably a more complicated activity.
At the same time, the erosion in primary care reimbursement has reduced office visit durations and undermined primary care’s moderating influence over specialty care. These dynamics are almost certainly responsible for the doubling of specialty referrals over the past decade [6].
The RUC’s excessive valuations of certain procedures — e.g., cardiac stenting, colonoscopies, back surgeries — have created lucrative incentives for over-utilization. 2008 OECD health data showed that, for every inpatient percutaneous transluminal coronary angioplasty (PTCA) performed on patients in the United Kingdom, New Zealand or Switzerland, we do more than four in the US. Then there are data [7] showing a clinically inexplicable 15-fold increase in complex spinal fusions between 2002 and 2007, with adjusted mean hospital charges of $81,000.
http://healthaffairs.org/blog/2013/02/01/the-ruc-health-care-finances-star-chamber-remains-untouchable/print/
Hand in Hand With US Government, Big Pharma Pushes for More Profits
Tuesday, 29 April 2014 09:53By Mara Kardas-Nelson, Truthout | News Analysis
In January of this year, South African Minister of Health Aaron Motsoaledi cried foul: he was publicly pissed about a US-created astroturf campaign (a faux "grassroots movement" actually led by moneyed interests) meant to undermine the country's efforts to lower drug prices through amending its intellectual property (IP) legislation.
Labeling the plot as being of "satanic magnitude" and tantamount to "genocide," Motsoaledi slammed the creators of the campaign, a veritable who's who of pharmaceutical companies and conservative, pro-business groups. The tripartite alliance responsible for the plot consisted of Public Affairs Engagement (PAE), a DC-based PR firm headed by US Ambassador James Glassman, formerly the undersecretary of state for public diplomacy and public affairs in the George W. Bush administration; the Pharmaceutical Research and Manufacturers of America, or PhRMA, one of the most powerful drug industry bodies on the planet; and a local pharmaceutical body, Innovative Pharmaceutical Association of South Africa (IPASA).
The draft South African policy that the groups sought to undermine seeks to more strictly define how patents should be given, what is patentable and what measures the government can take if pharmaceutical patents negatively impact public health, all in an attempt to stem rising health costs. With its burgeoning middle class, "diseases of the rich" like diabetes, hypertension, obesity, heart disease and cancers are on the rise. This, matched with a high rate of HIV, TB, and other historically "poor" diseases, and coupled with the excessive cost of patented drugs, means that drugs are in high demand, but prices are sometimes inaccessibly high.
The astroturfing plot was simple: For just under half a million dollars, paid for in large part by PhRMA, the US public relations firm would support IPASA's efforts to stem South Africa's IP reform by setting up a puppet front group, to be named Forward South Africa and led from Washington DC. The group would seek to persuade the South African public that strong intellectual property policy is good for investment and that the country's health woes are a result of a failed public health system rather than patent laws and the price of medicines.
What's more, South Africa is trying to stem costs just as pharmaceutical companies want a bigger slice of its pie - with its growing wealth, its patent-friendly laws and its sick population, South Africa looks like a deliciously ripe, relatively untapped market. If South Africa pushes back, not only could current and future profits be reduced within the country, but also, and more importantly, other emerging economies that also appeal to pharma could follow suit, eliminating potential profits for companies hungry for new markets.
It's easy to see how multinational pharmaceutical companies would be scared of South Africa's potential reforms. The country currently offers IP protection beyond what is required under international law and does not review patents before they are granted. As a result, it hands out thousands of drug patents annually and readily gives out multiple patents on a singular medicine, offering monopoly protection on a single drug for decades. Nearly all of the country's pharmaceutical patents are granted to multinational firms, and the country's department of trade and industry cites drugs as a key reason for South Africa's trade deficit. The country is also a continental leader that other African countries and middle-income countries look to for general policy guidance.
Motsoaledi's harsh words in reaction to the PAE-led scandal represent anger, but not necessarily shock: After all, the country has dealt with US and industry meddling in its pharmaceutical policy before. In 1998, Nelson Mandela's administration was sued by dozens of pharmaceutical companies in reaction to the country's attempts to make minor amendments to its drug laws (the case was eventually dropped in 2001, after years of public pressure). The PAE-led astroturfing campaign, which has died in the wake of public outcry, is just one example of many in which US pharmaceutical companies, with the help of high-profile Americans connected to the US government, pressure poorer countries battling high rates of disease to ensure that the IP playing field is set as they like it.
Maine Voices: Pharmaceutical patent exemption points to power of money in politics
Maine needs a universally applied Clean Elections system that excludes thinly veiled PAC donations.
By Janice Cooper
YARMOUTH — I used to begin my talks to civic groups with a statement of faith in Maine politics: Having worked for Congress for many years, I was delighted that Augusta was not Washington.
Inside the Beltway, money drowns out the public’s voice. Politicians are inevitably swayed by the campaign contributions that they spend every day raising. While the Supreme Court says that without a quid pro quo, this is not “corruption,” I say that the bubble they live in mars their vision and common sense.
In Augusta, most legislators run as Clean Election candidates, which, I told listeners, means no begging for money from special interests. Not anymore. The other day, I saw the beginning of the end. I’m sure it’s happened before, but I was too naive to notice.
The eye-opener was a simple bill, sought by Maine credit unions and banks that have been harassed by “patent trolls” demanding settlements on dubious claims of patent infringement, often involving ATMs. The Judiciary Committee reported it favorably.
Then came trouble. Seeing an opening, the pharmaceutical industry, the nation’s most profitable industry and largest campaign donor, came forward with an amendment. Give us an exemption. Let us file frivolous patent claims without fear of being sued under this bill.
Why, you ask, did they need an exemption? Committee members said no explanation was given, and there is no testimony in the committee file on the subject. Indeed, if you look at the amendment, you’d have to be a lawyer to figure out whom it helps.
In the House, the amendment was easily defeated. Then came consideration in the Senate.
In the Legislature, the only number that matters is 18 – the majority vote in the Senate. As a House member, it is easy to forget this, since each chamber works separately, except on committees.
So imagine our surprise when the Senate, without a roll call to hold it accountable, adopted the pharmaceutical exemption, and insisted that its amended version of the bill prevail.
Why? I can only speculate, and it ain’t pretty.
By Janice Cooper
YARMOUTH — I used to begin my talks to civic groups with a statement of faith in Maine politics: Having worked for Congress for many years, I was delighted that Augusta was not Washington.
Inside the Beltway, money drowns out the public’s voice. Politicians are inevitably swayed by the campaign contributions that they spend every day raising. While the Supreme Court says that without a quid pro quo, this is not “corruption,” I say that the bubble they live in mars their vision and common sense.
In Augusta, most legislators run as Clean Election candidates, which, I told listeners, means no begging for money from special interests. Not anymore. The other day, I saw the beginning of the end. I’m sure it’s happened before, but I was too naive to notice.
The eye-opener was a simple bill, sought by Maine credit unions and banks that have been harassed by “patent trolls” demanding settlements on dubious claims of patent infringement, often involving ATMs. The Judiciary Committee reported it favorably.
Then came trouble. Seeing an opening, the pharmaceutical industry, the nation’s most profitable industry and largest campaign donor, came forward with an amendment. Give us an exemption. Let us file frivolous patent claims without fear of being sued under this bill.
Why, you ask, did they need an exemption? Committee members said no explanation was given, and there is no testimony in the committee file on the subject. Indeed, if you look at the amendment, you’d have to be a lawyer to figure out whom it helps.
In the House, the amendment was easily defeated. Then came consideration in the Senate.
In the Legislature, the only number that matters is 18 – the majority vote in the Senate. As a House member, it is easy to forget this, since each chamber works separately, except on committees.
So imagine our surprise when the Senate, without a roll call to hold it accountable, adopted the pharmaceutical exemption, and insisted that its amended version of the bill prevail.
Why? I can only speculate, and it ain’t pretty.
The Case for Disobedience
LONDON — A recent Reuters story on the sinking of the South Korean ferry, the Sewol, attributed the high death toll among high school students in part to cultural reasons: “Many of the children did not question their elders, as is customary in hierarchical Korean society. They paid for their obedience with their lives.”
It is tempting to think that American teenagers with their liberal educations and readiness to question authority would have reacted to orders to stay put below deck as a ship lurched and began to sink with a “Hell, no, I’m out of here.” Common sense would have trumped obedience. Personal initiative would have resisted what turned out to be a death sentence from members of the crew. More would have survived. The toll of dead and missing, most from a single school, would not have reached more than 300.
There may be some truth to such speculation. Questioning and discord are central to American vitality. But I wonder.
Certainly, South Korea is a society with strong vertical lines where respect for elders and for the teacher (the pronunciation of the words for “captain” and for “teacher” are similar in Korean) is a powerful social force. On the other hand, it is one of the more rambunctious of Asian societies, a vibrant, super-wired democracy with frequent student and street protests. It is not a place of meek obedience or across-the-board Confucian deference to authority.
I am more struck, in fact, by the troubling cultural similarities between West and East that emerged in the disaster than by the differences. When the Sewol’s captain, Lee Jun-seok, opted to be among the first off the doomed ship — like 14 other now arrested crew members responsible for the ferry who boarded the first two rescue boats — he followed the craven example of Italy’s Capt. Francesco Schettino, who abandoned the sinking cruise ship Costa Concordia after it hit a reef off the Italian coast in 2012. In that disaster 32 people were killed.
Captains, Western or Eastern, don’t put their passengers first any longer, it seems. Women and children first has become a quaint notion in a globalized world of moral relativism. To go down like Capt. Edward Smith on the Titanic — to choose duty over self-preservation — is just so 20th century: Lee knew he was leaving children below deck to their fate, just as Schettino knew tourists would perish.
Editor's Note:
What, you may very well ask, does a sinking ship abandoned by its captain have to do with the necessity for health care reform? Well, both are characterized by a failure of stewardship - a phenomenon that has become the norm rather than the exception in many professions and in many places, including health care. See the article above on the RUC.
Roger Cohen hits the nail on the head.
Roger Cohen hits the nail on the head.
-SPC
- From the American Academy of Pediatrics
Policy Statement
High-Deductible Health Plans
- COMMITTEE ON CHILD HEALTH FINANCING
ABSTRACT
High-deductible health plans (HDHPs) are insurance policies with higher deductibles than conventional plans. The Medicare Prescription Drug Improvement and Modernization Act of 2003 linked many HDHPs with tax-advantaged spending accounts. The 2010 Patient Protection and Affordable Care Act continues to provide for HDHPs in its lower-level plans on the health insurance marketplace and provides for them in employer-offered plans. HDHPs decrease the premium cost of insurance policies for purchasers and shift the risk of further payments to the individual subscriber. HDHPs reduce utilization and total medical costs, at least in the short term. Because HDHPs require out-of-pocket payment in the initial stages of care, primary care and other outpatient services as well as elective procedures are the services most affected, whereas higher-cost services in the health care system, incurred after the deductible is met, are unaffected. HDHPs promote adverse selection because healthier and wealthier patients tend to opt out of conventional plans in favor of HDHPs. Because the ill pay more than the healthy under HDHPs, families with children with special health care needs bear an increased cost burden in this model. HDHPs discourage use of nonpreventive primary care and thus are at odds with most recommendations for improving the organization of health care, which focus on strengthening primary care.
This policy statement provides background information on HDHPs, discusses the implications for families and pediatric care providers, and suggests courses of action.
Single-payer advocate makes pitch to doctor executives
By Andis Robeznieks
Modern Healthcare, Vital Signs blog, April 28, 2014
Modern Healthcare, Vital Signs blog, April 28, 2014
CHICAGO -- The American College of Physician Executives annual meeting drew a record 830 attendees, including one doctor whose presentation on the merits of a national single-payer system may have been something of a surprise.
Dr. Ed Weisbart described himself as a long-time ACPE member who is also a member of Physicians for a National Health Program and now serves as chairman of the single-payer advocacy group's Missouri chapter.
Weisbart, a family physician, had a table full of PNHP literature and a poster indicating that salaries for Canadian physicians are comparable or better than those earned by U.S. doctors. The poster also said that Canadian physicians pay lower malpractice insurance premiums.
His intent, Weisbart said, was to build bridges between the two organizations, and he left with “several pages” of new names to add to the PNHP mailing list. “I think it was time well-spent.”
One visitor to his table questioned whether the government could be trusted to run the nation's healthcare system. Weisbart replied that he agrees. PNHP's goal, he said, is to have a publicly funded, privately operated system.
“I think many people wouldn't want to see a government-delivered healthcare system with physicians employed by the federal government,” he said.
