Doctors, Revolt!
by Rich Joseph - NYT - February 24, 2018
Boston — The 96-year-old patient with pneumonia in Bed 11 was angry. “Do you really need to check my vital signs every four hours?” he asked.
Checking things like temperature, blood pressure and respiratory rate every four hours on hospitalized patients has been the standard of care since the 1890s, yet scant data indicates that it helps. In fact, data shows that close to half of patients are unnecessarily awakened for such checks, perhaps to the detriment of their recovery. My patient wanted to know how, with all that poking and prodding, he was supposed to rest and get better.
“I understand your frustration,” I replied, “and wish I could help to change the situation.”
I may have been a lowly intern, but it was a feeble reply. And he knew it. “Understanding is not enough,” he said. “You should be doing something to help fix this system.”
The hospital, he lamented, is more like a factory — “it tests every ache and treats every laboratory abnormality, but it does little to heal its patients.” Treating and healing are both necessary, but modern health care too often disregards the latter.
Few understand this better than the patient in Bed 11. He turned out to be Bernard Lown, emeritus professor of cardiology at Harvard, a senior physician at Brigham and Women’s Hospital in Boston, and the founder of the Lown Cardiovascular Group. He is celebrated for pioneering the use of the direct-current defibrillator for cardiac resuscitation and an implant called the cardioverter for correcting errant heart rhythms. He also co-founded the International Physicians for the Prevention of Nuclear War, which was awarded a Nobel Peace Prize and helped to educate millions on the medical consequences of nuclear war.
But Dr. Lown identifies first and foremost as a healer. In 1996, he published “The Lost Art of Healing,” an appeal to restore the “3,000-year tradition, which bonded doctor and patient in a special affinity of trust.” The biomedical sciences had begun to dominate our conception of health care, and he warned that “healing is replaced with treating, caring is supplanted by managing, and the art of listening is taken over by technological procedures.”
He called for a return to the fundamentals of doctoring — listening to know the patient behind the symptoms; carefully touching the patient during the physical exam to communicate caring; using words that affirm the patient’s vitality; and attending to the stresses and situations of his life circumstances.
This time he was the patient in need of healing. And I was the doctor, the product of a system that has, if anything, become even more impersonal and transactional since he first wrote those words.
Despite his reputation, Dr. Lown was treated like just another widget on the hospital’s conveyor belt. “Each day, one person on the medical team would say one thing in the morning, and by the afternoon the plan had changed,” he later told me. “I always was the last to know what exactly was going on, and my opinion hardly mattered.”
What he needed was “the feeling of being a major partner in this decision,” he said. “Even though I am a doctor, I am still a human with anxieties.”
The medical team was concerned that because Dr. Lown was having trouble swallowing, he was at risk for recurrent pneumonias. So we restricted his diet to purées. Soon the speech therapist recommended that we forbid him to ingest anything by mouth. Then the conversation spiraled into ideas for alternative feeding methods — a temporary tube through the nose followed, perhaps, by a feeding tube in the stomach.
“Doctors no longer minister to a distinctive person but concern themselves with fragmented, malfunctioning” body parts, Dr. Lown wrote in “The Lost Art of Healing.” Now, two decades later, he’d become a victim of exactly what he had warned against.
As the intern and the perpetrator of the orders, I felt impossibly torn and terribly guilty. So after Dr. Lown was discharged the next week, I kept in touch, hoping to continue this important conversation.
We have since spent time together at his home, where he is back to living peacefully and swallowing carefully (no alternative feeding methods necessary).
I had known Dr. Lown as a doctor and a patient; now I got to know him as an activist. We agreed that the health care system needed to change. To do that, Dr. Lown said, “doctors of conscience” have to “resist the industrialization of their profession.”
This begins with our own training. Certainly doctors must understand disease, but medical education is overly skewed toward the biomedical sciences and minutiae about esoteric and rare disease processes. Doctors also need time to engage with the humanities, because they are the gateway to the human experience.
To restore balance between the art and the science of medicine, we should curtail initial coursework in topics like genetics, developmental biology and biochemistry, making room for training in communication, interpersonal dynamics and leadership.
Such skills would not only help doctors care for our fellow human beings but would also strengthen our ability to advocate for health care as a human right and begin to rectify the broken economics and perverse incentives of the system.
Finally, hospitals should be a last resort, not the hallmark of the health care system. The bulk of health care resources should go instead into homes and communities. After all, a large majority of health problems are shaped by nonmedical factors like pollution and limited access to healthy food. Doctors must partner with public health and community development efforts to create a culture of health and well-being in patients’ daily lives.
As I navigate my professional journey, Dr. Lown’s example inspires me to go to work every day with the perspective of a patient, the spirit of an activist and the heart of a healer.
Editor's Note:
The following talk was delivered by Dr. Bernard Lown at the
Avoiding Avoidable Care Conference, sponsored by the Lown Institute on April 26, 2012
-SPC
Social Responsibility of Physicians
■ Introduction
Ever since starting clinical practice 62 years ago I have looked forward to this conference. Mercifully, good fortune and good genes enable me to attend. From my earliest days in medicine I have struggled against the prevailing model of healthcare. My opposition in part was provoked by the growing prevalence of overtreatment. Resort to excessive interventions seemed to be the illegitimate child of technology in the age of market medicine. If more than a half century ago overtreatment was at a trickle pace, it is now at flood tide. Reflecting back on early days, the first overtreatment I encountered was not related to technology. It involved keeping patients with acute MI’s at strict bed rest for 4 to 6 weeks. This was a form of medieval torture. It promoted depression, bed sores, intractable constipation, phlebitis, lethal pulmonary embolism and much else. Worse it augmented cardiac ischemia and predisposed to malignant arrhythmias. Physicians were aware of what was transpiring but felt it was necessary to protect patients against cardiac rupture which activity may provoke.
The great Brigham clinician, SA Levine, my teacher and mentor, believed that patients would fare better when nursed in comfortable chairs. Yet he was not ready to challenge established practice. With his backing I launched such a study in 1951. The house staff initially was vehemently opposed, even greeting me with Sig Heil Hitler
■ Introduction
Ever since starting clinical practice 62 years ago I have looked forward to this conference. Mercifully, good fortune and good genes enable me to attend. From my earliest days in medicine I have struggled against the prevailing model of healthcare. My opposition in part was provoked by the growing prevalence of overtreatment. Resort to excessive interventions seemed to be the illegitimate child of technology in the age of market medicine. If more than a half century ago overtreatment was at a trickle pace, it is now at flood tide. Reflecting back on early days, the first overtreatment I encountered was not related to technology. It involved keeping patients with acute MI’s at strict bed rest for 4 to 6 weeks. This was a form of medieval torture. It promoted depression, bed sores, intractable constipation, phlebitis, lethal pulmonary embolism and much else. Worse it augmented cardiac ischemia and predisposed to malignant arrhythmias. Physicians were aware of what was transpiring but felt it was necessary to protect patients against cardiac rupture which activity may provoke.
The great Brigham clinician, SA Levine, my teacher and mentor, believed that patients would fare better when nursed in comfortable chairs. Yet he was not ready to challenge established practice. With his backing I launched such a study in 1951. The house staff initially was vehemently opposed, even greeting me with Sig Heil Hitler
salutes. Soon they became avid supporters.
Patient improvement was striking. In fact, hospital mortality from acute MI’s more than halved, depression diminished, pulmonary emboli nearly vanished, hospitalization was markedly shortened, rehabilitation and resumption of work was hastened. I am not aware of a single cardiovascular measure since then that improved survival of CHD patients as much as this common sense change in medical management. We published two articles on our findings in 1952. They evoked no comments as though reflecting a shameful era best forgotten. One should mention, if only as a historical footnote, that there was not a scintilla of evidence supporting prolonged bed rest. While patients were harmed, doctors profited.
Recognition that new technologies were driving overtreatment became evident with introduction of implanted pacemakers in the 1960’s. Compared to colleagues I was implanting about a third as many and inactivating like numbers. Pacemakers though were small cost items compared to what soon followed.
■ Coronary disease
The problem of overtreatment grew exponentially after Favoloro at the Cleveland clinic opened an innovative terrain by introducing bypass vein grafting. This was followed by technical virtuosities involving angioplasty and later stenting. Within 30 years after Favoloro, the number of revascularizations exceeded a million. Presently a majority of newly minted cardiologists are adept interventionists.
At the same time significant developments were occurring in the medical management of coronary artery disease. These included effective anti hypertensive measures in the 1940’s, introduction of beta blockers in the early 1960’s, and ever more effective lipid lowering agents thereafter. A profound advance was the recognition that risk factors, largely tethered to life style, accounted for the progression of coronary artery disease (CAD). In a rational social order, preventive medicine would have been the focus of resource allocation and physician concentration. Instead, prodigious investments flowed to halfway technologies.
No robust clinical evidence guided the onrush of revascularizations . The Coronary Artery Surgery Study (CASS), the first randomized investigation, published 16 years after Favoloro, provided no comfort
Patient improvement was striking. In fact, hospital mortality from acute MI’s more than halved, depression diminished, pulmonary emboli nearly vanished, hospitalization was markedly shortened, rehabilitation and resumption of work was hastened. I am not aware of a single cardiovascular measure since then that improved survival of CHD patients as much as this common sense change in medical management. We published two articles on our findings in 1952. They evoked no comments as though reflecting a shameful era best forgotten. One should mention, if only as a historical footnote, that there was not a scintilla of evidence supporting prolonged bed rest. While patients were harmed, doctors profited.
Recognition that new technologies were driving overtreatment became evident with introduction of implanted pacemakers in the 1960’s. Compared to colleagues I was implanting about a third as many and inactivating like numbers. Pacemakers though were small cost items compared to what soon followed.
■ Coronary disease
The problem of overtreatment grew exponentially after Favoloro at the Cleveland clinic opened an innovative terrain by introducing bypass vein grafting. This was followed by technical virtuosities involving angioplasty and later stenting. Within 30 years after Favoloro, the number of revascularizations exceeded a million. Presently a majority of newly minted cardiologists are adept interventionists.
At the same time significant developments were occurring in the medical management of coronary artery disease. These included effective anti hypertensive measures in the 1940’s, introduction of beta blockers in the early 1960’s, and ever more effective lipid lowering agents thereafter. A profound advance was the recognition that risk factors, largely tethered to life style, accounted for the progression of coronary artery disease (CAD). In a rational social order, preventive medicine would have been the focus of resource allocation and physician concentration. Instead, prodigious investments flowed to halfway technologies.
No robust clinical evidence guided the onrush of revascularizations . The Coronary Artery Surgery Study (CASS), the first randomized investigation, published 16 years after Favoloro, provided no comfort
for those trumpeting interventions. Instead of being a wake up call
alerting to irresponsible overindulgence, coronary procedures
continued to escalate.
■ Lown Clinic
Justification for revascularization is based on claims of increased survival, reduced toll of myocardial infarction and improved quality of life. By the late 1960’s I learned that in a majority of patients, CHD was largely stable and did not demand a rush for or even need for revascularization. I was persuaded that investigating this problem would be difficult once patients were hospitalized. As a result I founded the Lown Clinic. Almost immediately we launched a study. We intended to randomize post angiography patients to either revascularization or medical therapy. The study aborted before it began. After patients were informed by interventionists and house staff of their coronary anatomy, coached in the lurid prose then and now in use, every patient opted for coronary artery bypass grafting (CABG).
Coronary angiography was a funnel for interventions. Its purpose was largely to guide the operator to the narrowed vessel. To diminish coronary procedures required bypassing coronary angiography. We decided to study patients with multivessel disease over a long time frame without resort to angiography.
During the ensuing 35 years we published four studies in high profile medical journals involving about one thousand patients. Outcome data were remarkably consistent. Cardiac events were extraordinarily low, about 1.0 percent annual mortality rates. Our referral for revascularization increased from 1.1 percent annually during the CABG era to around 5 percent during the stenting era. Since a majority were second opinion patients, nearly all would have been revascularized.
Let me repeat. Over any five year period we referred less than 30 percent of patients with multivessel coronary disease for revascularization.
Our medical management was individually tailored. We rigorously treated risk factors. We encouraged optimism. We addressed social and family problems.
We discussed significant psychosocial stresses. We minimized shuttling patients to other specialists. . Foremost, doctors spent much
■ Lown Clinic
Justification for revascularization is based on claims of increased survival, reduced toll of myocardial infarction and improved quality of life. By the late 1960’s I learned that in a majority of patients, CHD was largely stable and did not demand a rush for or even need for revascularization. I was persuaded that investigating this problem would be difficult once patients were hospitalized. As a result I founded the Lown Clinic. Almost immediately we launched a study. We intended to randomize post angiography patients to either revascularization or medical therapy. The study aborted before it began. After patients were informed by interventionists and house staff of their coronary anatomy, coached in the lurid prose then and now in use, every patient opted for coronary artery bypass grafting (CABG).
Coronary angiography was a funnel for interventions. Its purpose was largely to guide the operator to the narrowed vessel. To diminish coronary procedures required bypassing coronary angiography. We decided to study patients with multivessel disease over a long time frame without resort to angiography.
During the ensuing 35 years we published four studies in high profile medical journals involving about one thousand patients. Outcome data were remarkably consistent. Cardiac events were extraordinarily low, about 1.0 percent annual mortality rates. Our referral for revascularization increased from 1.1 percent annually during the CABG era to around 5 percent during the stenting era. Since a majority were second opinion patients, nearly all would have been revascularized.
Let me repeat. Over any five year period we referred less than 30 percent of patients with multivessel coronary disease for revascularization.
Our medical management was individually tailored. We rigorously treated risk factors. We encouraged optimism. We addressed social and family problems.
We discussed significant psychosocial stresses. We minimized shuttling patients to other specialists. . Foremost, doctors spent much
time listening, thereby fostering trust and adherence to prescribed
lifestyle changes. We did much for the patient and as little as possible
to the patient.
One commonly hears that fear of malpractice litigation is a significant reason for doctors resorting to overtreatment. The Lown Group, with its minimalist approach, should have been deluged with malpractice suits. After all, we deviated from community norms. We did not adhere to the standard of practice prevailing nationwide. Yet during the past forty years we have not had a single malpractice suit for denying a patient with coronary artery disease a revascularization procedure.
We remain a tiny minority voice. Our observations have been ignored by mainstream cardiology. This has not been due to an absence of randomization in our investigations. Large randomized studies from CASS to Courage likewise have had no impact on the scale of interventions.
■ Health Crisis
Experience of the Lown clinic speaks to the uniformly acknowledged crisis in American health care. Politicians and health policy experts relate the crisis largely to run away costs. In my mind the crisis is far more than fiscal, far deeper than economic. For the past half century doctors have been distancing from patients.
Four points, well known to you, deserve emphasis.
1. Outside the hospital environment one becomes aware that problems bringing someone to a doctor are mostly minor. They largely derive from the rough and tumble of living. They don’t augur far advanced disease. These are healed by the passage of time. This is largely the reason that Hippocratic medicine held sway for nearly 2000 yrs.
2. A carefully taken history and physical exam identify the underlying condition in the overwhelming majority of patients.
3. Much clinical information is epidemiological and statistical. But statistical fact is not the same as individual truth. Data, irrespective of how comprehensive, may not be relevant for the individual patient. Each person is not only different, but different in a unique way.
4. The more time invested by the doctor at the outset, the more cost effective is the encounter and the more satisfied the patient. The number of specialist referrals and requests for technologic procedures
One commonly hears that fear of malpractice litigation is a significant reason for doctors resorting to overtreatment. The Lown Group, with its minimalist approach, should have been deluged with malpractice suits. After all, we deviated from community norms. We did not adhere to the standard of practice prevailing nationwide. Yet during the past forty years we have not had a single malpractice suit for denying a patient with coronary artery disease a revascularization procedure.
We remain a tiny minority voice. Our observations have been ignored by mainstream cardiology. This has not been due to an absence of randomization in our investigations. Large randomized studies from CASS to Courage likewise have had no impact on the scale of interventions.
■ Health Crisis
Experience of the Lown clinic speaks to the uniformly acknowledged crisis in American health care. Politicians and health policy experts relate the crisis largely to run away costs. In my mind the crisis is far more than fiscal, far deeper than economic. For the past half century doctors have been distancing from patients.
Four points, well known to you, deserve emphasis.
1. Outside the hospital environment one becomes aware that problems bringing someone to a doctor are mostly minor. They largely derive from the rough and tumble of living. They don’t augur far advanced disease. These are healed by the passage of time. This is largely the reason that Hippocratic medicine held sway for nearly 2000 yrs.
2. A carefully taken history and physical exam identify the underlying condition in the overwhelming majority of patients.
3. Much clinical information is epidemiological and statistical. But statistical fact is not the same as individual truth. Data, irrespective of how comprehensive, may not be relevant for the individual patient. Each person is not only different, but different in a unique way.
4. The more time invested by the doctor at the outset, the more cost effective is the encounter and the more satisfied the patient. The number of specialist referrals and requests for technologic procedures
are inversely related to the time spent with a patient especially during
initial visits.
Sixty years of doctoring has taught me that taking a history, namely listening, is the
quintessential part of doctoring. Proper listening is a skill, an art and a core element of medical professionalism. History taking is far more than providing key elements for a diagnosis. It is the basis for nurturing trust. I am persuaded that nothing of science taught to medical students is as difficult to master as is the fine art of listening. Numerous adverse consequences follow if a doctor does not listen. If time is short shrifted, the doctor treats the chief complaint. But the chief complaint is merely an admission ticket and frequently has little to do with what is troubling a patient. If you were a theater critic, it would be foolhardy to write a comment about a play merely from the scanty information on an admission ticket. Yet that is what doctors far too frequently do.
Treating the chief complaint commonly leads to unnecessary and costly interventions. When the chief complaint is unrelated to what truly bothers a patient, whatever medication prescribed will prove ineffective. As a result polypharmacy multiplies as new complaints are assaulted with still more drugs.
When doctors do not spend enough time listening, they become triage officers for specialists, as the patient is reduced to an assemblage of dysfunctional parts each part being served by some expert. Interest in the patient is replaced by preoccupation with disease. The human dimension is leached out from the clinical encounter. Dissatisfaction by the patient with the visit aggravates symptoms and adversely affects outcome. It encourages internet foraging and second opinion shopping.
When a doctor doesn’t listen, the focus necessarily shifts to the acute and emergent. Since preventive medicine, though the most cost effective approach to illness, is time intensive, it is largely neglected.
■ Prevention
The small role allotted to primary prevention is a major deficiency of our dysfunctional health care. Community support for healthy life styles are vastly underfunded. The largest investment goes to chronic illness when manifesting as acute disease. Prevention, the foundation of a sound health system, though honored in preachment, commonly
Sixty years of doctoring has taught me that taking a history, namely listening, is the
quintessential part of doctoring. Proper listening is a skill, an art and a core element of medical professionalism. History taking is far more than providing key elements for a diagnosis. It is the basis for nurturing trust. I am persuaded that nothing of science taught to medical students is as difficult to master as is the fine art of listening. Numerous adverse consequences follow if a doctor does not listen. If time is short shrifted, the doctor treats the chief complaint. But the chief complaint is merely an admission ticket and frequently has little to do with what is troubling a patient. If you were a theater critic, it would be foolhardy to write a comment about a play merely from the scanty information on an admission ticket. Yet that is what doctors far too frequently do.
Treating the chief complaint commonly leads to unnecessary and costly interventions. When the chief complaint is unrelated to what truly bothers a patient, whatever medication prescribed will prove ineffective. As a result polypharmacy multiplies as new complaints are assaulted with still more drugs.
When doctors do not spend enough time listening, they become triage officers for specialists, as the patient is reduced to an assemblage of dysfunctional parts each part being served by some expert. Interest in the patient is replaced by preoccupation with disease. The human dimension is leached out from the clinical encounter. Dissatisfaction by the patient with the visit aggravates symptoms and adversely affects outcome. It encourages internet foraging and second opinion shopping.
When a doctor doesn’t listen, the focus necessarily shifts to the acute and emergent. Since preventive medicine, though the most cost effective approach to illness, is time intensive, it is largely neglected.
■ Prevention
The small role allotted to primary prevention is a major deficiency of our dysfunctional health care. Community support for healthy life styles are vastly underfunded. The largest investment goes to chronic illness when manifesting as acute disease. Prevention, the foundation of a sound health system, though honored in preachment, commonly
plays second fiddle to the loud drumbeat for hospital focused care.
This lacks medical rationale and is devoid of economic sense.
Looking around the globe there are numerous persuasive demonstrations of the effectiveness of government sponsored programs promoting community prevention of cardiovascular disease. In 1972 Finland had the highest CVD mortality rate in the world. The Finnish government sponsored large scale programs educating the public about risk factors. It promoted availability of low-fat dairy products, passed antismoking legislation, and improved nutritional quality of school meals. Within a quarter of a century, CVD mortality in Finland was reduced by 75 percent. Another striking example is what occurred in Poland. In 1990, as the iron curtain toppled, Poland opened trade with the West, increasing import of fruit and vegetables. The government also stopped promoting and subsidizing butter and lard consumption. Within less than a decade CVD mortality dropped by a third.
I am persuaded that doctors devoting time listening to patients and shifting medical traffic to the proven road of prevention would profoundly reduce health care costs. Yet these two measures are largely ignored in the ongoing national debate.
■ Marketization of Health Care
A major factor accounting for these neglects relates to the dominance of market
forces which favor and even compel the industrialization of health care delivery.
An essence of industrialization is reducing cost of production by increasing
efficiency, namely, lessening the time to make a widget. Productivity is increased by speeding up assembly lines and replacing costly human labor with technology, especially with robotics. The product, irrespective of how socially necessary or value laden, if not profitable, will not be produced.
Listening was an early casualty. Since listening consumes much time, but is minimally reimbursed, it grew cursory, circumscribed, and frequently completely bypassed. It left patients frustrated and doctors uninformed. The consequences for the health care system are ruinous. Aiming to foster increased productivity, industrialization shifted the focus of the debate to efficiency, to competition, to cost
Looking around the globe there are numerous persuasive demonstrations of the effectiveness of government sponsored programs promoting community prevention of cardiovascular disease. In 1972 Finland had the highest CVD mortality rate in the world. The Finnish government sponsored large scale programs educating the public about risk factors. It promoted availability of low-fat dairy products, passed antismoking legislation, and improved nutritional quality of school meals. Within a quarter of a century, CVD mortality in Finland was reduced by 75 percent. Another striking example is what occurred in Poland. In 1990, as the iron curtain toppled, Poland opened trade with the West, increasing import of fruit and vegetables. The government also stopped promoting and subsidizing butter and lard consumption. Within less than a decade CVD mortality dropped by a third.
I am persuaded that doctors devoting time listening to patients and shifting medical traffic to the proven road of prevention would profoundly reduce health care costs. Yet these two measures are largely ignored in the ongoing national debate.
■ Marketization of Health Care
A major factor accounting for these neglects relates to the dominance of market
forces which favor and even compel the industrialization of health care delivery.
An essence of industrialization is reducing cost of production by increasing
efficiency, namely, lessening the time to make a widget. Productivity is increased by speeding up assembly lines and replacing costly human labor with technology, especially with robotics. The product, irrespective of how socially necessary or value laden, if not profitable, will not be produced.
Listening was an early casualty. Since listening consumes much time, but is minimally reimbursed, it grew cursory, circumscribed, and frequently completely bypassed. It left patients frustrated and doctors uninformed. The consequences for the health care system are ruinous. Aiming to foster increased productivity, industrialization shifted the focus of the debate to efficiency, to competition, to cost
containment. Industrial efficiency is in part obtained by rapid patient
through-put during encounters with primary care physicians or
during specialist referrals. In such a model of health care doctors are
providers, patients are consumer/customers, hospitals are industrial
plants and major profit centers.
Medicalization, and overtreatment are an essential part of a market system. As a result patients are morphed into amalgams of dysfunctional parts, with the human dimension commonly shredded in the gears of innovative technologies. The more patients are reduced to widgets, the more amplified is the verbiage that the bed rock of the system is patient centered.
■ Limitations of Markets in Health Care
Market medicine is organized like any other business to generate profit. Withholding care for those who can not afford it, as well as overtreatment of those with means, are profit maximizers and therefore sound business policy. In order to survive the well intentioned must hew to the competitive pressures of the market or get out of business. This was spelled out by the panjandrum of market theory, the ultimate market triumphalist, Milton Friedman, ”Few trends could so thoroughly undermine the very foundations of our free society as the acceptance by corporate officials of a social responsibility other than to make as much money for their shareholders as possible.” In the business model, like any other business, the major goal is profitability. Good intentions and high sounding principles are incidental. I believe that the market is not a solution. Indeed it is a major part of the problem.
Moral Issues
My objection to market dominated health care is on deeper grounds than economic. In a democratic society health care must be a right, not a privilege. The underlying issues relate to essential moral principles. Medicine is a calling. At the core it is a moral enterprise grounded in a covenant of trust between health professionals and patients. The primary mission of a clinician is to heal, to care, to advocate for the sick and
Medicalization, and overtreatment are an essential part of a market system. As a result patients are morphed into amalgams of dysfunctional parts, with the human dimension commonly shredded in the gears of innovative technologies. The more patients are reduced to widgets, the more amplified is the verbiage that the bed rock of the system is patient centered.
■ Limitations of Markets in Health Care
Market medicine is organized like any other business to generate profit. Withholding care for those who can not afford it, as well as overtreatment of those with means, are profit maximizers and therefore sound business policy. In order to survive the well intentioned must hew to the competitive pressures of the market or get out of business. This was spelled out by the panjandrum of market theory, the ultimate market triumphalist, Milton Friedman, ”Few trends could so thoroughly undermine the very foundations of our free society as the acceptance by corporate officials of a social responsibility other than to make as much money for their shareholders as possible.” In the business model, like any other business, the major goal is profitability. Good intentions and high sounding principles are incidental. I believe that the market is not a solution. Indeed it is a major part of the problem.
Moral Issues
My objection to market dominated health care is on deeper grounds than economic. In a democratic society health care must be a right, not a privilege. The underlying issues relate to essential moral principles. Medicine is a calling. At the core it is a moral enterprise grounded in a covenant of trust between health professionals and patients. The primary mission of a clinician is to heal, to care, to advocate for the sick and
to work for the promotion of everyone’s health. Central
to the doctor patient relationship is the expectation that
patient’s needs will be placed first, over and beyond
personal interests or the interests of any third party.
There is a moral absolute in medicine to help and never to wrong the patient. No such moral absolute can be found in the marketplace. Caveat emptor, let the buyer beware, is its underlying admonition. The warm and fuzzy rhetoric that “patients come first” is a transparent marketing ploy. For-profit health care is essentially an oxymoron. The moment care is rendered for-profit it is emptied of genuine caring. This moral contradiction is irreparable by any conceivable palliative. We talk of overtreatment as though it was merely an improper financial transaction. Overtreatment harms patients thereby negating the first principle of doctoring, primum non nocere.
I am reminded in Herman Melville’s Moby Dick; Captain Ahab, experiencing a terrifying moment of illumination, cries out, “All my means are sane; my motives and object mad.”
■ Where do we go from here?
Any challenge becomes doable when it is shown to be possible. A four minute mile was deemed impossible until Dr. Roger Bannister broke the record. Now it is common-place. So first, the good news. In the present adverse health environment it is still possible to drastically circumscribe overtreatment. For more than 40 years the Lown Clinic has substantially curtailed cardiovascular interventions. The possibility is no longer in question. We have done it!
The bad news relates to the acrimonious partisan health debate now convulsing American politics. When I was in medical school, 70 years ago, universal health insurance seemed a certainty. The Wagner, Murray, Dingell Bill was assured passage through Congress and would have been enacted except for a misbegotten wartime compromise. To maintain a work force in the face of a national wage freeze, industry diverted some wages into health benefits. We are still afflicted with the unintended consequences of that Faustian bargain. We need to get back on the track of history. Medicare has proven to be a remarkable advance in improving health for the elderly. It grants dignity to old age. It operates at lower cost than market driven health
personal interests or the interests of any third party.
There is a moral absolute in medicine to help and never to wrong the patient. No such moral absolute can be found in the marketplace. Caveat emptor, let the buyer beware, is its underlying admonition. The warm and fuzzy rhetoric that “patients come first” is a transparent marketing ploy. For-profit health care is essentially an oxymoron. The moment care is rendered for-profit it is emptied of genuine caring. This moral contradiction is irreparable by any conceivable palliative. We talk of overtreatment as though it was merely an improper financial transaction. Overtreatment harms patients thereby negating the first principle of doctoring, primum non nocere.
I am reminded in Herman Melville’s Moby Dick; Captain Ahab, experiencing a terrifying moment of illumination, cries out, “All my means are sane; my motives and object mad.”
■ Where do we go from here?
Any challenge becomes doable when it is shown to be possible. A four minute mile was deemed impossible until Dr. Roger Bannister broke the record. Now it is common-place. So first, the good news. In the present adverse health environment it is still possible to drastically circumscribe overtreatment. For more than 40 years the Lown Clinic has substantially curtailed cardiovascular interventions. The possibility is no longer in question. We have done it!
The bad news relates to the acrimonious partisan health debate now convulsing American politics. When I was in medical school, 70 years ago, universal health insurance seemed a certainty. The Wagner, Murray, Dingell Bill was assured passage through Congress and would have been enacted except for a misbegotten wartime compromise. To maintain a work force in the face of a national wage freeze, industry diverted some wages into health benefits. We are still afflicted with the unintended consequences of that Faustian bargain. We need to get back on the track of history. Medicare has proven to be a remarkable advance in improving health for the elderly. It grants dignity to old age. It operates at lower cost than market driven health
systems. Everyone would be covered regardless of employment or
health status. It is constitutional.
Half measures will no longer suffice. A single payer health care embracing the model of Medicare for all deserves to be at the forefront of consideration in addressing what now constitutes close to a fifth of our economy. It would bind our nation, improve health care, contain costs, and lessen moral ambiguities for health workers.
A crisis affords an opportunity for deep changes. We should not demure by resorting to creeping partial measures. Self regulation, presumably works among saints. Appeals to our better nature is welcome. History teaches though that curtailing incentives for misdeeds and providing recognition for good outcomes proves far more effective.
Creating a more just health care delivery system will not solve a host of other vexingly difficult issues. Unless fee for service is replaced, we will not restore the centrality of the patient nor lessen reimbursement driven over treatment.
More is better, or less is better are improper catch phrases. The ultimate litmus is
what is best for the uniquely individual patient. In 55 years of practice I recall but a single patient who insisted on having coronary angiography. Fully informed patients, trusting their physicians, do not insist on tests or procedures. In overtreatment the patient is victim not instigator.
Health care with a human face requires drastic restructuring of medical education. Promotion of personal communication skills has to be part of a core curriculum during each of the four years. Furthermore medical education should be subsidized. Health security is integral to our national security. Among other gains it would reduce the pressure for specialization in order to cope with mammoth student debt.
Beyond the breakdown of health care is a far deeper phenomenon. It relates to the onrushing marketization of all human activities. The result is to denature fundamental human values and tear apart ties that promote communal life. We in the health field, who nurture science for the sake of human health and well being, need to be in the forefront in promoting respect for the dignity of human life. This has to begin with listening to the patient.
One final thought: about three decades ago a small band of doctors contributed to a historic transformation. They spoke out against the
Half measures will no longer suffice. A single payer health care embracing the model of Medicare for all deserves to be at the forefront of consideration in addressing what now constitutes close to a fifth of our economy. It would bind our nation, improve health care, contain costs, and lessen moral ambiguities for health workers.
A crisis affords an opportunity for deep changes. We should not demure by resorting to creeping partial measures. Self regulation, presumably works among saints. Appeals to our better nature is welcome. History teaches though that curtailing incentives for misdeeds and providing recognition for good outcomes proves far more effective.
Creating a more just health care delivery system will not solve a host of other vexingly difficult issues. Unless fee for service is replaced, we will not restore the centrality of the patient nor lessen reimbursement driven over treatment.
More is better, or less is better are improper catch phrases. The ultimate litmus is
what is best for the uniquely individual patient. In 55 years of practice I recall but a single patient who insisted on having coronary angiography. Fully informed patients, trusting their physicians, do not insist on tests or procedures. In overtreatment the patient is victim not instigator.
Health care with a human face requires drastic restructuring of medical education. Promotion of personal communication skills has to be part of a core curriculum during each of the four years. Furthermore medical education should be subsidized. Health security is integral to our national security. Among other gains it would reduce the pressure for specialization in order to cope with mammoth student debt.
Beyond the breakdown of health care is a far deeper phenomenon. It relates to the onrushing marketization of all human activities. The result is to denature fundamental human values and tear apart ties that promote communal life. We in the health field, who nurture science for the sake of human health and well being, need to be in the forefront in promoting respect for the dignity of human life. This has to begin with listening to the patient.
One final thought: about three decades ago a small band of doctors contributed to a historic transformation. They spoke out against the
stockpiling of nuclear weapons capable of destroying the world many
times over. They believed that there is no greater force in modern
society than an educated public, aroused and angered to effect
change. This Gideon army of passionately committed physicians
made millions aware that medicine had nothing to offer in case of
nuclear war. They maintained that the two super-powers either lived
together or died together. They offered humankind a prescription for
survival. The involvement of multitudes in the antinuclear movement
compelled governments to serious negotiations which ultimately
lifted the Damoclean sword.
At present we physicians are challenged on our home turf. We need to offer people a prescription for health. Each American deserves dignified, person centered, and affordable health care. At the same time we must convince a wide public that our principles embody responsible stewardship of finite national resources. I have always believed that those who see the invisible can do the impossible.
At present we physicians are challenged on our home turf. We need to offer people a prescription for health. Each American deserves dignified, person centered, and affordable health care. At the same time we must convince a wide public that our principles embody responsible stewardship of finite national resources. I have always believed that those who see the invisible can do the impossible.
Democrats are shifting toward single-payer. Here’s proof.
A key center-left think tank now leans toward Sanders on health care.
by Sarah Cliff - VOX - February 23, 2018
The architects of Hillary Clinton’s agenda are moving toward Bernie Sanders’s vision for universal health care — a step that shows how far the Democratic Party’s center has shifted on policy since the 2016 primary.
On Wednesday, the Center for American Progress released a detailed, universal coverage plan that would offer Medicare to all Americans, enrolling newborns right at birth and allowing the federal government to set health care prices across the country.
“After we defeated repeal, it became clear that there would be a debate on the path forward for our country on health care,” says Topher Spiro, CAP’s vice president for health policy. “The debate is only going to gain steam. We thought we had some interesting ideas to contribute to that debate.”
Democrats have been moving toward the idea of a single-payer health care system in the past year. Presidential frontrunners like Sen. Elizabeth Warren (D-MA) and Cory Booker (D-NJ) spent last fall lining up to endorse Sanders’s (I-VT) plan for a Canadian-style health care system in the United States.
The CAP plan doesn’t envision quite as large a role for government as the single-payer system Sanders outlined. It would allow employers to continue offering insurance to workers — although it includes some strong incentives to switch those workers over to the public plan instead.
Importantly, though, the CAP and Sanders plans are similar in that they envision the federal government guaranteeing health coverage to all Americans through one more centralized program. This is quite different from Obamacare, where tens of millions remain uninsured because they can’t afford the premiums or they live in states that have not expanded Medicaid.
The Medicare Extra for All Plan, explained
Sanders has long modeled his single-payer plans on the Canadian system, where the government operates one health insurance program for all citizens. Under this setup, Canadians get an insurance card from their province.
The CAP plan looks more to me like many European countries: a heavily regulated, universal coverage program where the government standardizes the coverage all citizens receive. Under this scheme, the government sets prices and mandates a specific set of benefits — but allows a variety of health insurers to sell this coverage.
The Medicare Extra plan mandates that all health insurance cover a robust set of benefits including prescription drugs, hospital visits, doctor trips, maternity services, dental, vision, and hearing services.
The government would set the prices paid for all these services — unlike our current system, where thousands of insurers and hospitals haggle over fees that can vary widely from one place to another.
Low-income Americans would be enrolled in this plan without any premiums. Higher-income Americans would be expected to pay a monthly premium (at most, 10 percent of their income) — and pay deductibles and copayments (the exact amount of these is not set in the CAP plan, although Spiro said he is working with a modeling firm on making estimates).
The CAP plan would begin automatically enrolling newborns, the uninsured, and those turning 65 into the Medicare Extra program. Those who currently get coverage through federal programs — current Medicare enrollees, for example, as well as military members on TRICARE and government employees on the Federal Employees Health Benefits Program — would also be rolled into Medicare Extra.
Medicare Extra wouldn’t be the only game in town
CAP envisions a parallel program called Medicare Choice: insurance that offers the same package of benefits, with the same premiums and cost-sharing, but run by private insurers. This is meant to be a new version of Medicare Advantage, privately run Medicare plans that currently cover 34 percent of seniors.
These plans could “offer the same benefits as Medicare Extra and could also integrate complementary benefits for an extra premium.” This reminds me of the heavily managed competition we often see in countries like Germany and Switzerland.
Citizens of those countries get their health insurance from a whole slew of different insurers — Germany, for example, has hundreds of “sickness funds.” But those plans are so tightly regulated that they often look quite similar to one another and often end up competing on their quality of service.
This is not what health wonks would call a single-payer system; instead, they fall into the multi-payer category. But these systems arguably achieve the same goals as a single-payer system: providing universal coverage at a reasonable price to all citizens.
“Bernie Sanders has laid out a vision, and I think the debate is around how to fulfill the vision,” Spiro says. “There are several objectives that progressives have in common: to guarantee coverage, to eliminate underinsurance, to restrain prices charged by prices, to allow any American to enroll in the same plan if they want. These are things we’re all working to achieve.”
The CAP plan would still let companies offer health insurance
One of the most controversial parts of the Sanders plan is the decision to eliminate employer-sponsored insurance, moving all Americans to the government-run plan.
Most Americans who do have insurance currently get it at work — and most people who get insurance at work say they like their coverage, making the prospect of eliminating employer-sponsored insurance altogether very disruptive.
The CAP plan takes a more moderate approach here, letting employers continue to offer coverage to their workers so long as it meets certain federal standards. At the same time, it would give employers an alluring, simpler option: stop offering coverage and instead pay a payroll tax roughly equivalent to what they currently spend on health coverage.
I have no idea what decision employers would make here. Many smart health care observers thought that large companies would dump their workers onto the Obamacare marketplaces, where the federal government would subsidize their premiums rather than the employer. But that didn’t happen, and we saw that employers were quite reticent to disrupt their workers’ coverage.
Would things be different under the CAP plan? I think they might be, mostly because the public Medicare Extra plan that CAP envisions is much more generous than current Obamacare plans. Workers may get just as good a deal, if not better, by switching to the government plan. But as we saw with Obamacare, employer-sponsored coverage is very sticky, and companies may be reticent to move employees onto a new plan.
Democrats are in the middle of a shift to the left on health care — thanks, in part, to Republicans
My colleague Dylan Matthews wrote a piece last year noting the remarkable shift in liberal health politics around single-payer:
When he ran for president last year, Bernie Sanders picked up basically zero support from the Democratic establishment. Only one fellow Senator endorsed him, and even his fellow Senator from Vermont endorsed Hillary Clinton.The Bernie Sanders single-payer health care plan, released on Wednesday, is a totally different story. First, Sen. Kamala Harris (D-CA) announced her plans to co-sponsor it; then Elizabeth Warren (D-MA) joined in. Then Cory Booker (D-NJ), Sheldon Whitehouse (D-RI), Ed Markey (D-MA), Brian Schatz (D-HI), and Jeff Merkley (D-OR) joined in. Kirsten Gillibrand (D-NY) will reportedly co-sponsor it as well, and Pat Leahy (D-VT), who bucked his colleague Sanders in last year’s primary, is reportedly a supporter too.Warren, Sanders, Harris, Booker, and Gillibrand are arguably the most famous and most-admired Democratic senators in the country among the party’s base; the betting markets give a 63 percent chance that one of them will be the 2020 nominee for president.
This CAP plan has some different ideas than the Sanders plan but generally aims in the same direction. And the fact that it even exists — that CAP didn’t present a less expansive plan, like a Medicare buy-in plan, for example — suggests that the consensus we saw emerging last fall is only getting stronger.
Part of this seems to have been catalyzed by the Republican attempts to repeal the Affordable Care Act and the party’s general refusal to work toward Obamacare’s implementation.
“The repeal debate and efforts to undermine the ACA have influenced me, and I think others, deeply,” Spiro says. “I don’t think we’ll get any cooperation in designing the current system to function optimally.”
As the Huffington Post’s Jonathan Cohn astutely tweeted, you probably wouldn’t see this push toward a more regulated, more comprehensive health care system if Obamacare were functioning as its drafters hoped.
But now you’re seeing a pretty clear signal that Democrats want to shift to the left on health care — and are starting to work through the nuts and bolts of what it would look like to take the rest of the country with them.
Universal home care proposal gets enough signatures to appear on Maine ballot
The proposal would pay for hiring a home health worker to care for an elderly or disabled loved one whose relatives work full time.
Associated Press - February 23, 2018
AUGUSTA — Supporters of a proposed tax on Maine high earners to pay for home care for elderly and disabled people collected enough signatures from voters to get the initiative on the November ballot if lawmakers don’t pass it first, Secretary of State Matt Dunlap said Friday.
The chance of lawmakers passing the proposal is unclear, however, with House Republicans and business groups already expressing strong opposition.
The proposal would increase taxes on high-earning Mainers to raise $310 million annually for so-called “universal home care” for the elderly and disabled.
If successful, Maine – the nation’s oldest state – could be among the first to pass universal home care.
Hawaii recently passed a law providing up to $70 a day worth of services for a caregiver who has a full-time job yet must assist a loved one who’s over age 60. The state of Washington is considering a law to increase payroll contributions to provide family caregivers with $100 a day for a year.
Maine People’s Alliance spokesman Mike Tipping has said there’s an appetite in Maine to make the wealthy contribute more as income inequality grows nationwide. The campaign has reported receiving a $350,000 boost from nonprofits linked to billionaire philanthropist George Soros.
Under the proposal, employers and employees would together face a new 3.8 percent tax on the portion of wages and income above the amount that’s subject to Social Security employment taxes. In-home care providers and other groups that receive funds from the universal home care program would have to spend at least 77 percent on “direct service worker costs,” according to the proposal.
Conservatives and business groups argue that the tax would be worse for small businesses than the voter-approved, 3 percent surtax for school funding that lawmakers ended up repealing last year.
“Here we go again with another proposal to slam small-business owners and self-employed people with even higher state taxes, making Maine one of the highest taxed states in the nation,” said David Clough, state director of the National Federation of Independent Business.
Maine Medical Center, ambulance provider to pay $1.4 million to settle claims of improper Medicare billing
The hospital will pay $600,000 and North East Mobile Health Services will pay $825,000 to resolve government allegations that the ambulance service billed for trips that were medically unnecessary.
by Matt Byrne - Portland Press Herald - February 23, 2018
Maine Medical Center in Portland and the state’s largest ambulance provider have agreed to pay $1.4 million to the federal government to settle allegations that the ambulance provider submitted reimbursement claims for ambulance rides that were not medically necessary, a violation of the federal False Claims Act.
North East Mobile Health Services of Scarborough will pay $825,000 to resolve allegations that between 2007 and 2015, it improperly billed Medicare for transporting an unspecified number of patients who it claimed were “bed-confined” or who were otherwise medically required to be transported by ambulance, the office of U.S. Attorney Halsey B. Frank said Friday.
Maine Medical Center, which has contracted with North East since 2007 as its favored provider for medical transport services, agreed to pay $600,000 to resolve allegations that hospital personnel provided North East with paperwork containing incomplete or inaccurate information about the medical necessity of an ambulance ride, Frank’s office said.
That paperwork was then used by North East to bill Medicare, according to federal prosecutors.
Both groups cooperated with the investigation, and because of the settlement, neither admits wrongdoing, according to court records. Prosecutors did not specify in their complaint the number of ambulance rides that may have been affected. North East is also accused of keeping money that Medicare had overpaid to the company – an allegation it also denies. North East’s alleged improper conduct spanned from October 2007 to December 2017, according to a settlement agreement with Frank’s office. Maine Medical Center’s alleged improper conduct occurred between October 2007 and March 2015, the agreement said.
LESS COSTLY THAN A LAWSUIT
A call to Butch Russell, the CEO at North East, was not returned Friday, but the company released a statement through a public relations firm reasserting that North East did nothing wrong. The ambulance company also contended that all transports it provided were requested by medical professionals who were “acting in the best medical interest of the patient.”
Both groups said repaying the claims is less costly than defending a lawsuit.
“At the request of medical personnel, North East Mobile Health Services transported Maine Medical Center patients via ambulance to hospitals, skilled nursing facilities and other locations,” the North East statement said. “In all instances, all providers were acting in the best medical interest of the patient and the required documentation from medical personnel certified the ambulance transports were medically necessary. As such, reimbursement claims were submitted to Medicare and processed. However, the medical necessity of some of these ambulance transports was subsequently contested.”
Maine Medical Center, in a statement, also reiterated that it admitted no fault or liability, and called the settlement “an unfortunate result of a legal process that at times penalizes hospitals for prioritizing patient care,” and said the settlement heads off protracted and costly litigation.
The hospital said an “independent reviewer” found that Maine Medical Center saw no financial gain or incentive from the result of the disputed Medicare charges, but the statement did not identify the reviewer.
“Each case examined was based on medical necessity determined by a qualified medical provider,” the hospital said. “At all times, MMC acted with the best interests of patients in mind, making sure they had safe and reliable transportation following their treatment. We will continue to prioritize safe patient care and ensure that patients who have medical necessity receive access to ambulance services in a way that fully complies with legal and regulatory standards.”
The allegations by the government include details about the ambulance company’s relationship with the hospital. Since 2007, North East has held a “preferred provider” contract with Maine Medical Center to transport routine and critical care patients 24 hours a day, seven days a week. North East would often transport patients being discharged from the hospital to a skilled nursing facility or other rehabilitation center.
STAFFERS SIGNED OFF
For Medicare to pay a portion of the ambulance cost, the patient must be bed-confined or otherwise medically required to be transported by ambulance. Medicare will not cover the cost of an ambulance if a patient is able to walk around or sit in a wheelchair, meaning he or she could be transported by car or wheelchair van – modes of transport that Medicare does not pay for.
For North East to be reimbursed, the company is required to submit paperwork to Medicare showing that the ride was medically necessary. That documentation included a template certification form that North East provided and that hospital staff filled out.
Although North East’s own records showed that numerous patients could sit upright, move around and were not confined to a hospital bed or otherwise required to be transported by ambulance, the paperwork that Maine Medical staffers signed off on showed the ambulance ride as medically necessary, prosecutors alleged.
“These certifications are contradicted not only by the contemporaneous narratives of (North East Mobile Health Services) personnel, but also by (Maine Medical Center’s) medical records,” prosecutors alleged in a complaint.
According to Maine Medical Center’s settlement agreement, the hospital began conducting an internal audit in March 2015 of every nonemergency ambulance transport to ensure the information it submitted was accurate and complete.
As part of the agreement, Maine Medical Center agreed to continue conducting the self-audit for 18 months after the agreement was signed, until August 2019, and that it would notify North East of any suspected error in the paperwork within a reasonable time frame.
Although there is no specific number of allegedly improper ambulance rides, prosecutors allege that the vast majority of 949 patients who underwent total knee replacement surgery between 2010 and 2012 did not meet the requirements for ambulance rides, and could have been taken by car or wheelchair van.
LISTED AS ‘BED-CONFINED’
In one case from July 2010, a woman who had a knee replaced at Maine Medical Center was able to walk the roughly 10 feet from her hospital chair to a stretcher.
A Maine Medical Center nurse said the patient was fine to walk, but she was nonetheless transferred by stretcher to an ambulance that took her to St. Joseph’s Manor in Portland, according to prosecutors. The certification offered by Maine Medical Center for her transport showed she was “bed-confined,” according to prosecutors, and North East was paid $201.56 by Medicare on a $424 claim.
A week later, North East was dispatched to pick up the same woman to transport her to Maine Medical Center to have her other knee replaced. When EMTs arrived, the woman was sitting on the edge of her bed and denied having any pain or discomfort. She was able to walk with a walker to the ambulance stretcher and then to her hospital bed, prosecutors alleged.
The woman was listed again as “bed-confined” when North East billed Medicare for the $389 trip, of which it was paid $185.06.
But North East had indicated in the forms that the service was “medically indicated and necessary for the health of the patient,” prosecutors wrote.
Patients Eagerly Awaited a Generic Drug. Then They Saw the Price.
by Katie Thomas - NYT - February 23, 2018
When Teva Pharmaceuticals announced recently that it would begin selling a copycat version of Syprine — an expensive drug invented in the 1960s — the news seemed like a welcome development for people taking old drugs that have skyrocketed in price.
Syprine, which treats a rare condition known as Wilson disease, gained notoriety after Valeant Pharmaceuticals International raised the price of the drug to $21,267 in 2015 from $652 just five years earlier. Along with similar practices by pharmaceutical executives like Martin Shkreli of Turing Pharmaceuticals and Heather Bresch of Mylan (the maker of the EpiPen), the story helped spark a national conversation about the high cost of prescription drugs, not to mention Congressional inquiries and federal investigations.
In promoting its “lower-cost” alternative to Syprine, a Teva executive boasted in a news release that the product “illustrates Teva’s commitment to serving patient populations in need.”
What the release didn’t mention was the price: Teva’s new generic will cost $18,375 for a bottle of 100 pills, according to Elsevier’s Gold Standard Drug Database. That’s 28 times what Syprine cost in 2010, and hardly the discount many patients were waiting for.
Nearly three years after Valeant’s egregious price increases ignited public outrage, the story of Syprine highlights just how hard it can be to bring down drug prices once they’ve been set at stratospheric levels.
Despite efforts by the Food and Drug Administration to encourage more competition for drugs that have no generic alternatives, companies like Teva will still charge as much as the market will bear as long as there is no significant competition. And even companies that come under intense criticism, like Valeant, can often neutralize consumer upset through assistance programs.
While those can lower out-of-pocket costs for patients, the programs stick insurers with the bulk of the bill, which in turn can be passed on to consumers through higher premiums and deductibles.
Jay Copeland, 59, has been taking Syprine for a decade to treat Wilson disease, a condition that causes copper to build up in the body, leading to organ and neurological damage if not treated.
Calling the generic price “incredibly punitive,” Mr. Copeland said his employer’s insurance shields him from most of the drug’s cost, but he worries what would happen if he were to lose his job. Teva’s slightly lower price, he said, “would make relatively little difference to me if I were put in the position to pay enormous out-of-pocket costs.”
To encourage more generic competition, the F.D.A. recently published a list of off-patent drugs that have no competition and cleared a backlog of generic applications. But as the Syprine case shows, it often isn’t as simple as adding a single generic competitor.
“By and large, generics work when there are multiple players,” said David Maris, an analyst at Wells Fargo who wrote this week about Teva’s generic Syprine price. “When there’s not, you get this.”
If there are just a few players and if the drug treats a small group of patients, as is the case with Wilson disease, the companies will try to make as much profit as they can. Just 5,226 prescriptions were filled for Syprine, also known as trientine hydrochloride, in the first three quarters of 2017, according to the data research firm IQVIA.
Wilson disease is believed to affect between 8,000 and 10,000 people in the United States, and some with the condition take other drugs, according to Mary Graper, the vice president of scientific affairs at the Wilson Disease Association, a patient group.
“Generic companies are for-profit companies, too, and so it’s not surprising to me that they price the product at what they think the market will bear,” said Dr. Aaron S. Kesselheim, an associate professor at Harvard Medical School who has studied drug prices.
A spokeswoman for Teva declined to comment on how it set its price, but said the company considers a range of factors. “If there is more competition and ample supply, pricing will continue to fall,” said the spokeswoman, Kaelan Hollon.
Teva, which calls itself the world’s leading manufacturer of generic drugs, has struggled in recent years with management turmoil, lost sales of a leading brand-name drug, and — in a twist — with the falling prices of many commonly used generic drugs. In December, it announced a major reshaping, including cutting 25 percent of its work force.
Patients with Wilson disease had been watching for the arrival of a generic Syprine, but Teva’s announcement took them by surprise, Ms. Graper said. "We had no idea what to expect, but I had personally hoped for more of a discount.”
Not to be outdone, Valeant followed Teva’s move with the release of its own “authorized” generic of Syprine. It’s a common tactic by brand-name drugmakers who want to compete directly with generic manufacturers without lowering the price of their brand-name product, which some patients continue to prefer. Valeant’s authorized generic sells for $19,119, according to Elsevier.
Lainie Keller, a spokeswoman for Valeant, said the list price for its generic did not reflect discounts the company negotiates with buyers, although she would not disclose those discounts.
She said Valeant’s patient assistance programs have recently been improved to ensure that privately insured patients only pay about $5 a month. Those without insurance can get the medication for free if they meet certain income requirements.
Valeant was once a Wall Street favorite that kept investors happy by buying up old, off-patent drugs like Syprine, sharply raising their prices, and investing little in research and development. That changed in 2015, when questions were raised about the impact this strategy was having on patients, and about the company’s financial practices and its ties to a mail-order pharmacy.
Congressional and federal investigations into the company’s practices followed, leading to a plummeting stock and the departure of the chief executive and major investors.
Ms. Graper, whose group accepts donations from Valeant and Teva, confirmed that Valeant’s patient assistance program has improved since members of her group testified before the Senate about how the company’s price increases led them to stop taking their drugs.
Such industry assistance programs have themselves come under scrutiny — including ones run by Valeant — because they have helped make high drug prices more palatable, easing patients’ out-of-pocket burdens while leaving insurers to pay the rest.
Ms. Graper expressed hope that if other generic competitors enter the market, the price will continue to fall. “I think we have to wait and see where these two land,” she said.
She and others said they were frustrated that despite a flurry of Congressional hearings, government investigations and promises by politicians, the price of many of the drugs that stoked the initial outrage remain as high as ever.
In addition to Syprine, Daraprim, an old drug used to treat a serious parasitic infection, is still $750 a pill more than two years after Mr. Shkreli became a social media villain for his role in raising the price overnight from $13.50.
The cost of the EpiPen is an exception to the trend. In response to the outcry over the EpiPen’s price, which reached about $600 at its height for a pack of two, Mylan came out with a cheaper, authorized generic. A pack of EpiPens can now be bought for about $300 at many pharmacies.
“I had hoped that something would come of it, that the politicians would take some action, but obviously not much has happened,” Mr. Copeland said. “It’s all disheartening.”
States focus on drug importation as way to rein in drug costs
by Diane Archer - JustCare - February 21, 2018
Shefali Luthra reports for Kaiser Health News that states are looking at drug importation as a way to rein in prescription drug costs and encourage Congress to act to bring down drug prices throughout the nation. Even some Republican lawmakers in red states recognize that government intervention is needed because there is no free market when it comes to drug prices. They see addressing the outrageous price of prescription drugs as a non-partisan issue.
One Utah legislator wants Utah to buy drugs for the state’s health system from wholesalers in Canada. Legislators in Vermont, West Virginia and Oklahoma also are looking to pass laws that would allow their states to import drugs from Canada. Today, some 11 million Americans import drugs from abroad. Although doing so is technically illegal, no American has ever been prosecuted for importing drugs for personal use.
With a waiver from the Trump administration, states could buy drugs wholesale from abroad and then resell them to pharmacies and hospitals. Such a waiver could help states to bring down the price of drugs for their residents considerably. The drugs would be as safe as drugs available in the US; indeed, many Canadian drugs are manufactured in the same facilities by the same manufacturers as US drugs.
A 2003 federal law grants the US Department of Health and Human Services authority to permit state drug importation when the evidence suggests importation will reduce costs without jeopardizing the public health. Because of pressure from Pharma, however, HHS has never approved a state’s drug importation program. But, given that addressing prescription drug prices is the top policy priority for Americans, there is more public pressure than ever for HHS to do so.
Undoubtedly, if HHS were to approve a state’s Canadian drug importation program, pharmaceutical companies would cut Canada’s supply of drugs or otherwise penalize Canadian suppliers of drugs to the state. But, then, Congress finally might step in to regulate the price of drugs for everyone in the US, much like it has done for Veterans, and every other developed country has done for its citizens.
If you want Congress to rein in drug prices, please sign this petition.
Anthem expands its policy of punishing patients for 'inappropriate' ER visits
by Michael Hiltzik - LA Times - January 24, 2018
Over the last few months, Anthem, the nation's biggest health insurer, has informed customers in several states that if they show up at the emergency room with a problem that later is deemed to have not been an emergency, their ER claim won't be paid.
The policy has generated protests from numerous physician groups, including ER doctors, as well as pointed questions on Capitol Hill and among state regulators. So Anthem has taken the obvious next step: This year, it's rolling out the policy in three additional states. Prior to Jan. 1, the policy was in effect in Georgia, Missouri and Kentucky. This year, it's adding New Hampshire, Indiana and Ohio. More states may follow.
Medical experts say the policy places an insupportable responsibility on ordinary customers to diagnose themselves before turning to the ER for treatment.
Some are also concerned that patients who have experienced claim rejections in the past might be discouraged from returning to the ER for a recurrent condition or a new one, a decision that could have life-threatening implications.
"Patients are not physicians," Sen. Claire McCaskill (D-Mo.) lectured Anthem CEO Joseph R. Swedish in a Dec. 20 letter seeking documentation of how the company arrived at its policy and how it is being applied. "Anthem's policies are discouraging individuals from receiving needed care and treatment out of fear they may personally be fully financially responsible," McCaskill wrote, "even though they have insurance." McCaskill asked for the material to be submitted by Jan. 19.
Anthem refused to say how it has responded to the letter, and McCaskill's office didn't respond to a question about whether the company met the deadline.
Anthem says its policy is designed to save money by reducing unnecessary ER care. The goal, it says, is "to reduce the trend in recent years of inappropriate use of ERs for non-emergencies."
A spokeswoman for Anthem's Georgia program told me last year that the policy wouldn't apply when the patient is 14 or younger, an urgent care clinic isn't located within 15 miles, or the visit occurs on a Sunday or holiday. She said it's aimed at manifestly minor ailments — "If you had cold symptoms; if you have a sore throat," she said. "Symptoms of potentially more serious conditions, such as chest pains, could be seen at the ER even if they turn out to be indigestion."
But that doesn't fit well with a policy that threatens patients with a big bill if they guess wrong. And many patients may not be aware of the exemptions for weekend visits, for younger patients, or for those not located near an urgent care clinic. They could be discouraged from visiting the ER, too.
What's especially unclear is how Anthem's policy is supposed to correspond to two important legal safeguards for patients. One is the Emergency Medical Treatment and Labor Act of 1986. EMTALA, as the act is known, requires emergency departments to screen, stabilize or treat anyone showing up at the ER, regardless of their ability to pay.
EMTALA was designed as an anti-dumping law to prevent for-profit hospitals from fobbing off indigent patients to public hospitals without treating them first. The rule imposes costs for care on hospitals that treat uninsured patients; hospitals justifiably are concerned that Anthem's policy could impose costs for insured patients, too.
"Anthem expects us to screen their patients in the ER," says Jonathan W. Heidt, an emergency physician in Columbia, Mo., and president of the state chapter of the American College of Emergency Physicians, "but won't guarantee they'll pay for the treatment."
The second safeguard is the "prudent layperson" rule, which requires insurers to cover ER visits made by a member who resorts to the ER for a condition that the average person would consider a possible emergency.
Anthem told me in an emailed statement that a company medical director will review suspect ER claims by applying the prudent layperson standard to "claim information and medical records" submitted by the hospital, but that leaves a lot of room for dickering, in a process in which the patient, facing an unpaid charge that could be thousands of dollars, is almost certain to be at a disadvantage.
In Missouri, according to Heidt, judgments on ER claims appear to be made by Anthem nurses or other medical professionals based on the diagnostic codes entered on claims documents. But that's insufficient to show whether an ER visit was appropriate. In one case Heidt reviewed for his medical group, a patient was hit by a car, transported by paramedics to the ER on a backboard and with a neck brace, given a CAT scan and X-rays, and eventually found not to have suffered a serious injury. The patient was discharged with a diagnosis of bruises and abrasions. Anthem denied the claim.
A list of conditions that Anthem warned Indiana hospitals might warrant claims rejections numbered more than 120, including bronchitis, contusions, sprains and low back pain, any of which might herald more serious conditions; a more detailed list reportedly obtained for Missouri by physicians in that state ran to more than 1,900 conditions, including sprains and injuries of limbs, bone and muscles.
Medical experts have found that ER discharge diagnoses can be virtually useless in determining whether an ER visit was made for a "non-emergency" reason. A 2013 study of nearly 35,000 ER visits found that the vast majority of patients appeared with complaints that could have warranted an ER examination.
"Patients present to the [emergency department] with … complaints, symptoms and signs," observed the authors, "but usually not with diagnoses." They found that those relying on final diagnoses are "unable to accurately identify 'non-emergency' ED visits."
That doesn't surprise Heidt. He says that in studying claims denied by Anthem for his ER medical group, he concluded that more than half of the visits were reasonable, about 45% "were in the gray zone," and fewer than 5% could have been treated outside the ER. "I'm a board-certified trained doctor of emergency medicine," he told me, "and I have trouble looking at the ER note and knowing what the patient was thinking at 3 o'clock in the morning, let alone trying to figure it out from a claim form."
None of these concerns has yet stayed Anthem from expanding a manifestly anti-consumer policy. Only state regulators can do that, and it's time they stepped in.
Are Hospitals Becoming Obsolete?
by Ezekiel J. Emanuel - NYT - February 25, 2018
ospitals are disappearing. While they may never completely go away, they will continue to shrink in number and importance. That is inevitable and good.
The reputation of hospitals has had its ups and downs. Benjamin Rush, a surgeon general of the Continental Army, called the hospitals of his day the “sinks of human life.” Through the 19th century, most Americans were treated in their homes. Hospitals were a last resort, places only the very poor or those with no family went. And they went mainly to die.
Then several innovations made hospitals more attractive. Anesthesia and sterile techniques made surgery less risky and traumatic, while the discovery of X-rays in 1895 enhanced the diagnostic powers of physicians. And the understanding of germ theory reduced the spread of infectious diseases.
Middle- and upper-class Americans increasingly turned to hospitals for treatment. Americans also strongly supported the expansion of hospitals through philanthropy and legislation.
Today, hospitals house M.R.I.s, surgical robots and other technological wonders, and at $1.1 trillion they account for about a third of all medical spending. That’s nearly the size of the Spanish economy.
And yet this enormous sector of the economy has actually been in decline for some time.
Consider this: What year saw the maximum number of hospitalizations in the United States? The answer is 1981.
That might surprise you. That year, there were over 39 million hospitalizations — 171 admissions per 1,000 Americans. Thirty-five years later, the population has increased by 40 percent, but hospitalizations have decreased by more than 10 percent. There is now a lower rate of hospitalizations than in 1946. As a result, the number of hospitals has declined to 5,534 this year from 6,933 in 1981.
This is because, in a throwback to the 19th century, hospitals now seem less therapeutic and more life-threatening. In 2002, researchers from the Centers for Disease Control and Prevention estimated that there were 1.7 million cases of hospital-acquired infections that caused nearly 100,000 deaths. Other problems — from falls to medical errors — seem too frequent. It is clear that a hospital admission is not a rejuvenating stay at a spa, but a trial to be endured. And those beeping machines and middle-of-the-night interruptions are not conducive to recovery.
The number of hospitals is also declining because more complex care can safely and effectively be provided elsewhere, and that’s good news.
When I was training to become an oncologist, most chemotherapy was administered in the hospital. Now much better anti-nausea medications and more tolerable oral instead of intravenous treatments have made a hospital admission for chemotherapy unusual. Similarly, hip and knee replacements once required days in the hospital; many can now be done overnight in ambulatory surgical centers. Births outside of hospitals are also increasing, as more women have babies at home or at birthing centers.
Studies have shown that patients with heart failure, pneumonia and some serious infections can be given intravenous antibiotics and other hospital-level treatments at home by visiting nurses. These “hospital at home” programs usually lead to more rapid recoveries, at a lower cost.
As these trends accelerate, many of today’s hospitals will downsize, merge or close. Others will convert to doctors’ offices or outpatient clinics. Those that remain will be devoted to emergency rooms, high-tech services for premature babies, patients requiring brain surgery and organ transplants, and the like. Meanwhile, the nearly one billion annual visits to physicians’ offices, imaging facilities, surgical centers, urgent-care centers and “doc in the box” clinics will grow.
Special interests in the hospital business aren’t going to like this. They will lobby for higher hospital payments from the government and insurers and for other preferential treatment, often arguing that we need to retain the “good” jobs hospitals offer. But this is disingenuous; the shift of medical services out of hospitals will create other good jobs — for home nurses, community health care workers and staff at outpatient centers.
Hospitals will also continue consolidating into huge, multihospital systems. They say that this will generate cost savings that can be passed along to patients, but in fact, the opposite happens. The mergers create local monopolies that raise prices to counter the decreased revenue from fewer occupied beds. Federal antitrust regulators must be more vigorous in opposing such mergers.
Instead of trying to forestall the inevitable, we should welcome the advances that are making hospitals less important. Any change in the health care system that saves money and makes patients healthier deserves to be celebrated.
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