Health Care Reform Articles - April 27, 2021

Biden faces pressure from Pelosi, Sanders over whether to double down on Obamacare or expand Medicare

House Democratic leadership and Sen. Bernie Sanders split as Biden administration sculpts next package

Sanders said in an interview that he is arguing for lowering the age of Medicare eligibility to 55 or 60 and expanding the program for seniors so it covers dental, vision and hearing care.

The contrasting visions for the next phase of President Biden’s legislative agenda reflect divisions within the Democratic Party about how Biden should further overhaul health insurance in the United States. Pelosi is looking to double down on the ACA, which has become more popular in recent years as it offers insurance subsidies to people well above the poverty line. Sanders, meanwhile, is looking for an opportunity to make progress on his longtime efforts to make government health insurance universal.

Either approach would offer more health insurance to lower-income Americans. But the choice facing Biden will allow him to decide whether he wants to continue to focus on the ACA, which operates largely through private insurers, or use political capital on a government-run program.

The pressure comes as the White House works to formulate what it is calling the American Families Plan, a sequel to the infrastructure and jobs plan announced last month. The new program, which is likely to be focused on child care, higher education, anti-poverty initiatives and health care, is expected to propose cutting spending on prescription drugs by as much as $450 billion over 10 years.

That money, in turn, could be used for the health insurance expansions. White House officials have not said which direction they will pursue. A White House spokesman declined to comment.

“We cannot continue to deal with millions and millions of seniors — primarily low-income seniors — who cannot afford to go to a dentist, so cannot ingest the food they eat, or the millions of seniors who live in isolation because they can’t hear,” because they cannot afford hearing aids, Sanders said in an interview. He declined to discuss the push from Pelosi, but he said, “It is fair to say there are differences of opinion as to how we prioritize health-care needs.”

The divergent paths charted by Pelosi and Sanders point to one of many underlying tensions within the Democratic Party that the White House is being forced to navigate as it figures out its next major agenda item.

The path to passing either plan remains steep. Congressional lawmakers are just now taking up Biden’s $2 trillion jobs and infrastructure plan, which has faced a barrage of criticism from congressional Republicans and some centrist Democrats. The appetite in Congress for yet another $1 trillion or $2 trillion effort on top of the infrastructure package is unclear, although liberals in the Congressional Progressive Caucus have called for trying to move the two plans in unison.

Congressional Progressive Caucus Chair Rep. Pramila Jayapal (D-Wash.) says the group's policies push the Democratic Party left, despite moderate power brokers. (Blair Guild/The Washington Post)

Still, the early jockeying reflects how Democrats are already looking to the next legislative fight, as well as friction within the party over how best to expand health care.

Democratic leaders have celebrated the durability of the ACA, which has withstood more than a decade of criticism from congressional Republicans and seen its popularity rebound. The White House also has trumpeted figures showing that as many as 500,000 Americans have enrolled in the ACA exchanges during a special enrollment period the Biden administration created.

Asked by a reporter on Thursday about making the ACA expansion permanent, Pelosi cited the Biden administration’s pending families plan and the $500 billion that could be saved for “further expanding access to health care.” She also kept the door open to other forms of health-care expansion, saying the savings “could be used for other purposes,” too.

For Sanders, however, Biden has a unique opportunity to expand on the $1.9 trillion stimulus plan by offering tangible economic benefits to millions of older voters. Sanders helped popularize the single-payer proposal that would enroll every American in Medicare, and lowering the eligibility threshold represents a step in the direction of universal government-provided insurance.

“Some Democrats are all in on solidifying the Affordable Care Act, while progressives want to use their majority to push the health agenda further in the direction of Medicare-for-all,” said Larry Levitt, executive vice president for health policy at the Kaiser Family Foundation, a nonprofit organization.

As a presidential candidate, Biden campaigned on introducing a public option through which Americans could enroll in a government health system, as well as making the ACA subsidies more generous.

But the “unity task force” between Sanders and Biden aides after the 2020 primary produced policy recommendations that included dropping the Medicare enrollment age from 65 to 60. The task force report also said that gaps in dental, vision and hearing services “can lead to severe health consequences for Medicare patients” and stressed that “Democrats are committed to finding financially sustainable policies” to close those gaps.

The expected White House support for the prescription drug effort has helped create an opening for debating how Democrats want to expand health care. As The Washington Post previously reported, the administration is planning to include a measure to force pharmaceutical companies to reduce their prices or pay a steep penalty. Those plans are likely to be similar to the prescription drug bill House Democrats introduced in 2019, although its exact scope remains unclear.

The nonpartisan Congressional Budget Office has estimated that the House Democrats’ bill would save the government about $450 billion over the next decade. It does so by lowering the cost of prescription drugs, which allows the government to spend significantly less on Medicare and other public health programs.

Under House Democrats’ proposal, these savings are redirected to expand Medicare to cover costs for dental, vision and hearing care through Medicare, while also limiting yearly out-of-pocket spending on prescriptions to $2,000, said Alex Lawson, executive director of the advocacy group Social Security Works, which supports the prescription drug reform.

Congressional aides say the savings may be smaller if Democrats, as expected, are forced to pass the measure through the parliamentary procedure known as budget reconciliation.

Conservatives said the United States should use any easily recouped savings to help pay down the existing federal debt. Even passing the measure may be difficult, given warnings from powerful pharmaceutical groups that it would stifle innovation around lifesaving drugs.

“Any low-hanging-fruit budget savings should go to addressing the baseline deficit of $15 trillion,” said Brian Riedl, senior fellow at the Manhattan Institute, a conservative-leaning think tank. “If there’s $500 billion in heath-care savings, shouldn’t we be using that to pay for the programs we already have?”

Others played down the extent of the divisions. The disagreement about the policy direction has not been described by aides as acrimonious, and there may be room for a compromise that incorporates elements of both plans.

“Either one would be a blessing. There’s good arguments for both,” said Harold Pollack, a public health researcher at the University of Chicago, of the bids by Sanders and Pelosi. “I hope Democrats coalesce around whichever is most politically feasible and get it done.”

Still, tensions persist.

Biden’s rescue plan included expanded subsidies for very poor Americans and also extended them to those whose income is above 400 percent of the federal poverty level. That cost about $45 billion for two years, according to the Committee for a Responsible Federal Budget, a nonpartisan group.

“There’s been a robust conversation in the health-care [space] about the best uses of the savings,” said Leslie Dach, an Obama administration health official who is now chair of Protect Our Care, which advocates ACA expansion.

Dach said focusing on expanding the ACA delivers “the most health care for the buck,” noting that having insurance throughout one’s life improves long-term health outcomes. “Getting those folks covered really delivers a lot of health care, particularly to communities of color. … There’s a sense the ACA and Medicaid, which get people in the program early, have a lot of benefits.” Dach said there is also agreement on limiting out-of-pocket drug costs for Medicare enrollees.

Still, some advocacy groups are adamant that Biden increase the scope of public health programs, rather than putting more funding into plans that run through private health insurers.

Lawson said it was a “no-brainer” for Biden to demonstrate to seniors, a crucial voting demographic, that he was working on their behalf.

About half of Americans ages 65 to 80 lack dental insurance, according to University of Michigan researchers. As many as 23 million Americans would newly qualify for health insurance if the Medicare enrollment age is lowered to 60, Sanders’s office said in a statement, adding that half of Medicare recipients have not seen a dentist over the past year.

“Before the next election, we need the American people — and particularly seniors, who have suffered so much during this pandemic — to see that this government is working for them,” Lawson said. “People would get hearing aids, get their teeth checked, before the next election. That will show them Biden is on their side. Democrats have to deliver for seniors if they are going to win.”

https://www.washingtonpost.com/us-policy/2021/04/12/sanders-pelosi-biden-obamacare-medicare/ 

 

Docs Suffer From Noncompete Clauses: Any Hope for Change?

by Shelly M. Reese - Medscape Internal Medicine -April 7, 2021

When Traci Purath, MD, a Wisconsin neurologist, decided to leave the health system where she worked and go into private practice in 2012, she faced a major stumbling block: the noncompete clause in her employment agreement precluded her practicing within a 15-mile radius of either of the health system's facilities for at least 18 months.

Purath's lawyer said fighting the contract would cost about $50,000, and she wouldn't be able to practice medicine until the case was settled. Undaunted, Purath opened a clinic in a small town about 30 miles away.

But because her noncompete agreement restricted her ability to advertise, her patients didn't know what had become of her. When they called her former employer, they were sometimes told that she had moved out of state or was no longer practicing.

Purath ultimately landed on her feet — thanks to Google, many of her patients eventually found her, and when her noncompete clause expired, she moved her practice closer to home.

Her struggle is far from unique. In a recent Medscape poll of 558 physicians, more than 9 out of 10 respondents said that they were either currently bound by a noncompete clause or that they had been bound by one in the past that had forced them to temporarily stop working, commute long distances, move to a different area, or switch fields.

Some healthcare executives debate whether noncompete agreements are good or bad. Despite the blistering anecdotes, there are some defenders.

The Good and the Bad

Over the last few decades, noncompete clauses have become ubiquitous. Often used by employers to protect intellectual property and proprietary information, consolidation in the healthcare industry has made them a common element in physician employment contracts. Having invested heavily in acquiring physicians' practices and in recruiting and training physicians, hospitals and health systems use them to prevent doctors from leaving after a short time and setting up a competing clinic down the street.

Getting out of a noncompete agreement can be difficult. Almost a quarter (23%) of survey respondents said that they were unsuccessful when they tried to negotiate their way out of a noncompete agreement. Another 30% did not even try.

As a result, many, such as Purath, are forced to make accommodations to abide by the terms of the contract. Forty-two percent of physicians who left a job while under the terms of a noncompete agreement found work similar to their previous work outside of the noncompete area. Six percent found work of a different type, and 4% did not work during the time in which the noncompete agreement was active.

"In my market, noncompete clauses are still very much respected," writes a family physician in Indiana who commutes 45 minutes daily to comply with the 25-mile noncompete radius stipulated in her previous employer's contract

.https://www.medscape.com/viewarticle/948871

 

Our View: Closing disparities in health care critical to Maine’s well-being

Mainers face health challenges based on race, gender and which part of the state they live in. A new office within the Mills administration can help.  

The Editorial Board - Portland Press Herald -  April 12, 2021

Mainers face health challenges based on race, gender and which part of the state they live in. A new office within the Mills administration can help.

When COVID-19 hit Maine early last year, it didn’t hit everyone the same — by June, Black residents represented 27 percent of all cases while making up just 1.4 percent of the general population, the biggest racial disparity in the country. Latino and Indigenous residents were disproportionately hurt, too.

But that was only a more dramatic and visible example of the disparities that exist in health care at all times, not just during a global pandemic. Factors specific to certain groups, often based in discrimination and bias, lead to problems with access and substandard care — for not only Mainers of color, but women, LGBTQ residents, rural Mainers and those with disabilities.

That’s why we support the new Office of Population Health Equity, established recently by the Mills administration within the Maine Center for Disease Control and Prevention.

The office’s job will be to monitor health inequities in the state and intervene to ensure all Mainers have access to the care they need. A similar office, under different names, existed within state government for years before then-Gov. Paul LePage dissolved it in 2015.

It would be ridiculous to think such a change by itself could solve the systemic racism and bias that limits health care access. But the office should play an important role in that effort.

The office’s very existence is a much-needed acknowledgement that the disparities are real and must be addressed in order for all Mainers to have the opportunity to improve their well-being and live healthy lives.

The problems are not hard to find if you look. The disparities in health for Black Mainers did not begin with COVID; they have existed for years, driven by bias and lack of economic opportunity. Black women in Maine are found to have much less access to prenatal care and higher rates of infant mortality. Across the U.S., minorities face higher rates of chronic disease and premature death.

Transgender and other LGBTQ residents face similar barriers. In a large state with little public transit, and a lot of infrastructure unfriendly to their needs, Mainers with disabilities can struggle to get around.

The loss of hospitals, and maternity clinics specifically, in rural parts of the state mean residents there are at a disadvantage compared to their urban counterparts, with women traveling hours to deliver a baby.

The fact is, the health care system was built, intentionally or not, by the majority for the majority; it just doesn’t account for everyone. Great organizations have come in to fill the cracks, to advocate and care for the populations that have to struggle to get what comes easily to others.

But what we are doing now clearly is not enough. Maine has to look harder at the places where access to care and positive health outcomes depends on where you were born or how you look.

As long as those disparities exist, Mainers won’t be as healthy as they can be — and neither will Maine.

https://www.pressherald.com/2021/04/12/our-view-closing-disparities-in-health-care-critical-to-maines-well-being/

Mainers implore lawmakers to pass drug pricing bills, saying it’s a matter of life or death

by Evan Popp - The Beacon - April 14, 2021

One simple slip of the hand. That was all it took to put Sarah Lukianov’s life at risk. 

Lukianov, a type 1 diabetic from Bath, said she relies on two different insulins to survive. When she accidentally dropped one of those supplies on the floor, shattering the vial, she begged her insurance company to send her an emergency supply. But the company said she should go to a pharmacy to buy insulin, which would have cost Lukianov over $300. 

She decided to ration her supply rather than pay that exorbitant cost. Within days, she started suffering symptoms of Diabetic ketoacidosis (DKA) as a result of going without insulin. She described the feeling as “both excruciating pain and absolute terror. You feel like you’re dying. And that’s because you are.”

Lukianov survived the experience. But for others, the story has ended differently. “I’m lucky that DKA didn’t kill me like so many others who had to ration insulin because of the cost,” she said. 

Lukianov’s story was told during a public hearing Tuesday before the Maine Legislature’s Health Coverage, Insurance and Financial Services Committee on a package of bills introduced by Democratic lawmakers to help rein in the cost of drugs like insulin — which is cheap for drug makers to produce but sold at an exorbitant cost — and ensure that Mainers have access to life-saving medication and affordable health care. 

Those bills come as big pharmaceutical companies continue to raise prices for life-saving treatments beyond what many can pay while raking in massive corporate profits, with a study by the nonpartisan research organization RAND Corporation finding that prescription drugs in the U.S. cost an average of 2.5 times more than the same drugs in other Western nations. 

The slate of legislation put forward by Maine lawmakers includes two measures introduced by Senate President Troy Jackson (D-Aroostook). One would prohibit “excessive price increases for generic and off-patent prescription drugs” sold in Maine and allow the state attorney general to pursue action against drug manufacturers that violate the law. The bill defines excessive as when a price increase exceeds 15% of the wholesale acquisition cost of the previous calendar year, 40% of the wholesale acquisition cost of three years prior or if the price increase exceeds $30 for a 30-day supply of the generic or off-patent drug for treatment that lasts less than 30 days. 

Jackson’s other bill would establish the Office of Affordable Health Care within the legislature, which would be tasked with making recommendations “on methods to improve the cost-efficient provision of high-quality health care to the residents” in Maine. 

Another bill, introduced by Sen. Ned Claxton (D-Androscoggin), would make prescription drug manufacturers subject to fines for selling drugs in Maine “identified as having an unsupported price increase.” Determining what amounts to an unsupported price increase would be “based on whether there was no, or inadequate, new clinical evidence to support the price increase” as demonstrated by the annual analysis of prescription drugs by the Institute for Clinical and Economic Review.

An additional measure, sponsored by Sen. Cathy Breen (D-Cumberland), would establish “an insulin safety net program” in Maine, modeled after a program in Minnesota created after 26-year-old Alec Smith died because he couldn’t afford the insulin he needed. The measure in Maine would require manufacturers of insulin to make the product available to pharmacies to dispense to people who are “in urgent need of insulin or who need access to an affordable insulin supply.” The bill would allow pharmacies to dispense a 30-day supply to eligible people and would cap the copay a pharmacy could collect at $35. 

The final bill, introduced by Sen. Eloise Vitelli (D-Sagadahoc), aims to increase transparency around drug pricing by requiring greater public notice when a manufacturer implements substantial increases to the price of a drug. 

In his testimony in support of his bills and the others in the package, Jackson told the story of a woman in his district who was diagnosed with cancer. When she found out what her treatment would cost, the woman’s first thought was that she was going to die because she couldn’t afford it. 

“There’s no reason why we shouldn’t have basic protections for Maine people when it comes to medication,” Jackson said. “Pharmaceutical companies shouldn’t be allowed to exploit Maine people, who rely on live-saving medication, to pad shareholders’ pockets.” 

‘We are human beings, not bank accounts’

Being able to access medication is a huge issue for many Mainers, with 219,000 people in the state unable to afford drugs or medicine that a doctor prescribed, according to a survey from October 2020. 

Many people spoke to that struggle during the public hearing Tuesday, urging the legislature to pass the group of bills. Bonnie Deane from Appleton told the committee about her son, who was diagnosed with severe Crohn’s Disease and juvenile arthritis when he was 14. To treat his conditions, he began receiving Remicade infusions every six to nine weeks, without which he would die, Deane said. Each infusion of Remicade costs $78,000, she said. But even after signing up for a discount program with the drug manufacturer, Deane said she and her husband have medical debt that has grown to six-figures. 

“If you’re really sick and you need a drug like Remicade to survive, you’re going to lose everything — and there’s something wrong with that. I don’t want anyone else to ever go through what we continue to go through,” Deane said during her testimony. 

The exploding cost of prescription drugs can sometimes have fatal consequences. Catherine Begin of Waterville told the committee about her son, who was diagnosed with type 1 diabetes and struggled to afford the insulin he needed because of the exorbitant cost, often rationing it as a result. In 2017, Begin’s son died. 

“It wasn’t his fault he couldn’t afford his insulin,” Begin said, noting its cheap cost of production and the expensive price paid by those who need it. She said a bill like Breen’s to create an insulin safety net program could have saved her son’s life.  

Another person who testified at the hearing was Patricia Taniashvili of Surry, who spoke on behalf of her husband. Taniashvili said her husband has type 2 diabetes. The best drug to treat his condition is a medication called Trulicity, she said. However, he has been without that drug for the last two years because it costs $600 a month, even with his health insurance plan through the Affordable Care Act marketplace. Taniashvili said her husband can’t afford that cost, as his only income is a once-a-month Social Security check for just over $1,000. 

The lack of the medication has had a dire impact on her husband’s health. His blood sugar is over 200 regularly, Taniashvili said, and he often doesn’t have the energy to get out of bed. 

Taniashvili urged the legislature to take action to address such situations, describing it as immoral for drug companies to jack up the prices of medication. 

“We feel like we are being squeezed,” she said. “If you as legislators have the capacity to control these drug prices in some way, which it appears you would with this package of bills, it is your duty. We are not the only ones suffering. There are children and adults with type 1 diabetes in the same dire situation and this is patently unfair to them and us. We are human beings, not bank accounts.”

https://mainebeacon.com/mainers-implore-lawmakers-to-pass-drug-pricing-bills-saying-its-a-matter-of-life-or-death/

 

Biden officials rescind Trump’s okay for Texas’s $100 billion-plus Medicaid plan

The decision is seen as an effort to push Texas officials toward expanding Medicaid under the Affordable Care Act to cover more low-income residents

by Dan Diamond - Washington Post - April 16, 2021

The Biden administration on Friday rescinded approval for changes to Texas’s Medicaid program granted by the Trump administration, saying that federal Medicaid officials “materially erred” by speeding approval for the state’s $100 billion-plus request in January.

The decision was characterized as an effort to push state officials toward accepting the Affordable Care Act’s Medicaid expansion, which would cover more low-income residents, said two federal health officials, who spoke on the condition of anonymity to discuss private conversations. Texas, which has more uninsured people than any other state, is one of 12 that have not expanded the program.

“[W]e are rescinding the approval issued on January 15, 2021,” because it did not go through the full federal rulemaking process, Liz Richter, the acting administrator of the Centers for Medicare and Medicaid Services, wrote in a letter to Texas officials obtained by The Washington Post.

In its final week, the Trump administration told Texas officials that it had approved a 10-year extension for its Medicaid plan, which was set to expire in 2022. The waiver provides more than $11 billion in federal funding per year to the state, meaning that the Biden administration’s decision puts billions of dollars in federal funding to Texas at risk.

Health advocates had described that waiver as an effort to work around the federal Medicaid expansion by setting up alternate funding to help cover the costs of uninsured patients.

In a statement Friday, Texas Gov. Greg Abbott (R) slammed the Biden administration decision, saying it was “obstructing health-care access for vulnerable Texans and taking away crucial resources for rural hospitals in Texas. … With this action, the Biden administration is deliberately betraying Texans who depend on the resources made possible through the waiver.”

The approval for Texas’s changes, known as a Medicaid 1115 waiver, was among a flurry of last-minute activities overseen by Trump health officials in the waning days of the administration. Public health advocates and researchers decried the moves as inappropriate attempts to grant GOP governors’ requests and lock in Trump-era changes. Trump officials said that they were moving to provide stability for health-care providers.

“The 10-year extension permits greater financial certainty for the state and its safety net providers that serve Medicaid populations,” Seema Verma, then-administrator for the Centers for Medicare and Medicaid Services, wrote in a Jan. 15 letter to Texas.

Verma also said there was no need for the approval to go through the standard public notice-and-comment process, citing the coronavirus pandemic. But the Biden administration concluded the decision was a mistake.

“Upon further review, we have determined that CMS materially erred in granting Texas’s request for an exemption from the normal public notice process,” Richter wrote in her letter Friday.

In a statement, CMS said the agency had “erred in exempting the state from the normal public notice process — a critical priority for soliciting stakeholder feedback and ensuring public awareness.”

The new Democrat-led administration has been unwinding a series of actions overseen by Trump officials, including the prior administration’s approval of Medicaid work requirements.

The Biden administration also has pushed a dozen holdout states to accept the federal Medicaid expansion. Medicaid officials said on a briefing call for state officials last month that if Texas opted in to the federal expansion, the state would get a $3.9 billion funding boost over two years and 2.06 million uninsured people would become eligible for Medicaid coverage, according to a presentation obtained by The Post.

The Texas Medicaid program has been the subject of political disputes across multiple administrations. Texas officials in 2011 excluded Planned Parenthood from its Healthy Texas Women program, prompting the Obama administration in 2012 to cut federal women’s health funding to the state. But the Trump administration in January 2020 restored the funds by approving Texas’s Medicaid waiver, which was originally set to run through December 2024.https://www.washingtonpost.com/health/2021/04/16/biden-rejects-texas-medicaid-plan/ 

 

Bill Would Extend MaineCare, CHIP Insurance Coverage To Immigrants 

by Patty Wight - Maine Public - April 15, 2021

The Legislature's Health and Human Services Committee is considering a bill on Thursday that would allow noncitizen immigrants — including asylum seekers — to get insurance coverage through MaineCare and the Children's Health Insurance Program, or CHIP.

Assistant House Majority leader Rachel Talbot Ross said that coverage was stripped away in 2011 under the LePage administration.

"Preventing a child, an adult, an older Mainer, from getting health care because of their immigration status is wrong. It is discriminatory. And it must end," she said.

Talbot Ross said immigrants contribute to the economy and should have access to health care. She said in 2018, noncitizen immigrant households paid $193 million in state taxes and more than double that in federal taxes.

During a virtual press conference on Thursday morning, Crystal Cron of Presente Maine said immigrants provide labor for some of the largest industries in Maine.

"Even when they have raked thousands of crates of blueberries, shucked hundreds of thousands of pounds of lobster, harvested broccoli, packed potatoes, washed our dishes, cooked our meals, built our houses and cleaned our toilets, they cannot afford to go to a single check up at the doctor," she said.

https://www.mainepublic.org/politics/2021-04-15/bill-would-extend-mainecare-insurance-coverage-to-immigrants 

 

Health Care Reform Articles - April 9, 2021

A Single Ohio Hospital Reveals All That’s Wrong With American Health Care

By Mona Hanna-Attisha - NYT - April 8, 2021

THE HOSPITAL
Life, Death, and Dollars in a Small American Town
By Brian Alexander

The business of sickness is perverse. In too many instances, medical interventions are ineffective Band-Aids. Other factors, like where you stand in the social, racial and economic pecking order — and what ZIP code you were born in — determine far more about your health. As Bertolt Brecht said so well, in his “Worker’s Speech to a Doctor”:

When we’re sick, we hear
You are the one who will heal us.
When we come to you
Our rags are torn off
And you tap around our naked bodies.
As to the cause of our sickness
A glance at our rags would
tell you more. It is the same cause that wears out
Our bodies and our clothes.

In “The Hospital: Life, Death, and Dollars in a Small American Town,” Brian Alexander shares this reality from the perch of a struggling rural hospital, known to its Bryan, Ohio, community as the “Band-Aid Station.” While the nonprofit hospital fights to stay solvent and independent, each day brings new gut-wrenching stories. From the C-suite’s tension-filled strategic planning meetings to life-or-death moments at the bedside, Alexander nimbly and grippingly translates the byzantine world of American health care into a real-life narrative with people you come to care about.

Reporting over a period of two years, which only ended this past August, Alexander went into exam rooms, patients’ homes and pathology labs, and rode along with ambulance crews. He provides a deep investigative account that chronicles the staff of nurses, doctors, technicians and administrators trying to keep the patients of northwest Ohio alive.

You will root for the hospital C.E.O. who is tiptoeing around minefields, and for the immigrant doctors who are decidedly unwelcome in Trump country, even as they try their best. But the work is grueling and the lives are almost impossibly hard to save. In sensitive portrayals, Alexander shares how patients become sicker as care is delayed, costs spiral out of control and all too often patients die from preventable deaths. The entire mess is plagued by a malignancy of despair. Everybody in this story is drowning.

Just as Brecht captured in 1938, what often makes patients sick are conditions we don’t see — or choose not to see. Alexander identifies them with surgical precision, the underlying pathogens of pernicious poverty and the widening chasm of income inequality. Add in systematic racism, early childhood trauma and inequitable access to healthy food, healthy air and high-quality health care, and you have a perfect storm.

What transpires in “The Hospital” isn’t an aberration, though, and it isn’t only small-town Ohio that Alexander is telling us about. Weaving in the power- and profit-driven history of American health care, he describes how “the system had grown by accident, by ad hoc ‘solutions’ over many years, decade upon decade.” Policies with unintended consequences dating back to postwar prosperity forced employers to offer health benefit packages as a way to entice workers and avoid wage controls, eventually leading to our tragically bad employer-based model of health care.

When the Reagan era brought a decline in union strength and workers’ rights, and greater economic inequality, things started falling apart. “Fewer people were able to stand on the shoulders of their parents to make the all-American climb,” Alexander tells us. And the system began its slide to perversity.

“The modern American version of capitalism encouraged — even demanded — that employers extract the value from their employees while returning scraps to them and their communities.” As the decades passed, employers offered less robust health care coverage. For most, it became a sort of game: how to whittle down the care being offered and make everything indecipherable so nobody would notice how little coverage there really was. Smaller local hospitals and individual practitioners joined chains to survive. Health care stopped being about those moments of healing that occur between a doctor and a patient. Far removed from the bedside, it became about big money run by monopolies and corporations.

“The Hospital” sometimes reads like postapocalyptic science fiction. Alexander pushes us to ask, How can citizens of the richest nation in history allow loved ones to die because we can’t afford lifesaving medication, like insulin, while C.E.O.s of for-profit hospitals earn millions per year?

Public health systems were eroding during the same time, he writes, “from inattention and financial starvation in the same way other public goods like bridges, water systems and education eroded, and so the health of Americans eroded, too.” Alexander’s book places a stethoscope on America — and the diagnosis is bleak. It wasn’t an epidemic of viruses, but an epidemic of greed, that corroded the social contract and public health. Our country’s promise has evolved from “an ongoing project to improve democratic society and live humanistic ideals to being a framework for fostering corporate profit.” We don’t need more biopsies or autopsies, or drugs that cost more than a mortgage. It is unchecked capitalism that is making us sick.

Alexander’s reporting takes us into the pandemic, our system’s biggest moment of reckoning, and suggests it could offer an unexpected opportunity. After half a million deaths, Covid has exposed two false narratives: individual behavior as the sole cause of poor health, and universal care as an “evil of socialized medicine.” Things don’t have to be this way; we can do more than hand out Band-Aids. If health care is a public good, then public institutions should replace the for-profit models and profit-motivated private systems, and it should finally be a universal right, untethered to employment.

By the end of “The Hospital,” you’ll be making signs to carry at the next Medicare for All march. With the stories of these characters — from patients and doctors to the C.E.O. — etched in your heart, Alexander will make you see that a healthier America will only be realized when we begin to look beyond the patients in front of us and prescribe solutions that lift people out of poverty, eliminate inequities and respect the dignity of all.

https://www.nytimes.com/2021/04/08/books/review/the-hospital-brian-alexander.html?

 

An Accidental Disclosure Exposes a $1 Billion Tax Fight With Bristol Myers

Jesse Drucker - NYT - April 1, 2021

Almost nine years ago, Bristol Myers Squibb filed paperwork in Ireland to create a new offshore subsidiary. By moving Bristol Myers’s profits through the subsidiary, the American drugmaker could substantially reduce its U.S. tax bill.

Years later, the Internal Revenue Service got wind of the arrangement, which it condemned as an “abusive” tax shelter. The move by Bristol Myers, the I.R.S. concluded, would cheat the United States out of about $1.4 billion in taxes.

That is a lot of money, even for a large company like Bristol Myers. But the dispute remained secret. The company, which denies wrongdoing, didn’t tell its investors that the U.S. government was claiming more than $1 billion in unpaid taxes. The I.R.S. didn’t make any public filings about it.

And then, ever so briefly last spring, the dispute became public. It was an accident, and almost no one noticed. The episode provided a fleeting glimpse into something that is common but rarely seen up close and that the Biden administration hopes to discourage: multinational companies, with the help of elite law and accounting firms and with only belated scrutiny from the I.R.S., dodging billions of dollars in taxes.

Then, in an instant, all traces of the fight — and of Bristol Myers’s allegedly abusive arrangement — vanished from public view.

The Tax Shelter

Like most big pharmaceutical companies, Bristol Myers, which is based in New York, reduces its U.S. taxes by holding patent rights to its most lucrative drugs in subsidiaries in countries with low tax rates. The result is that the company’s profits move from high-tax places like the United States to places like Ireland, which has a low corporate tax rate and makes it easy for companies to attribute profits to locales with no income taxes at all.

The $2 trillion infrastructure plan that the White House unveiled on Wednesday proposed increasing the minimum overseas tax on multinational corporations, which would reduce the appeal of such arrangements.

For the three years leading up to 2012, Bristol Myers’s tax rate was about 24 percent. The U.S. corporate income tax rate at the time was 35 percent. (It is now 21 percent.)

The company wanted to pay even less.

In 2012, it turned to PwC, the accounting, consulting and advisory firm, and a major law firm, White & Case, for help getting an elaborate tax-avoidance strategy off the ground. PwC had previously been Bristol Myers’s auditor, but it was dismissed in 2006 after an accounting scandal forced Bristol Myers to pay $150 million to the U.S. government. Now PwC, with a long history of setting up Irish tax shelters for multinational companies, returned to Bristol Myers’s good graces.

The plan hinged on a tax write-off known as amortization. It lets companies deduct from their taxable income a portion of the cost of things, like the value of a patent, over a period of years. (For physical assets like office buildings, the process is known as depreciation.)

In the United States, Bristol Myers held rights to patents on several drugs that it had already fully written off for tax purposes.

In Ireland, a Bristol Myers subsidiary held rights to patents that it had not yet fully written off.

That mismatch provided a lucrative opportunity. The company moved the patent rights from the U.S. and Irish subsidiaries into a new company. As the U.S. patents generated income, the Irish amortization deductions now helped offset U.S. taxes.

When a company deploys a complicated new arrangement like this, it will generally seek the imprimatur of law and accounting firms. If they vouch for the maneuver’s legitimacy, that can protect the company from accusations that it deliberately broke the law.

In fall 2012, after the new structure was set up, Bristol Myers asked PwC and White & Case to review the arrangement. Both firms provided the company with lengthy letters — each more than 100 pages — essentially signing off from a legal standpoint.

“Bristol Myers Squibb is in compliance with all applicable tax rules and regulations,” said Megan Morin, a company spokeswoman. “We work with leading experts in this area and will continue to work cooperatively with the I.R.S. to resolve this matter.”

A spokeswoman for PwC declined to comment. White & Case lawyers and a spokeswoman did not respond to a list of questions.

But there were ample signs that the I.R.S. would probably take a dim view of the arrangement. A few months earlier, a federal appeals court had sided with the agency after it challenged a similar maneuver by General Electric using an offshore subsidiary called Castle Harbour. The I.R.S. also contested comparable setups by Merck and Dow Chemical.

The Bristol Myers arrangement “appears to be essentially a copycat shelter,” said Karen Burke, a tax law professor at the University of Florida. Since the I.R.S. was already fighting similar high-profile transactions, she said, “Bristol Myers’s behavior seems particularly aggressive and risky.”

The next January, the company announced its 2012 results. Its tax rate had plunged from nearly 25 percent in 2011 to negative 7 percent.

On a call with investors, executives fielded repeated questions about the drop in its tax rate. “Presumably, all drug companies try to optimize their legal entities to take their tax rate as low as they can, yet your rate is markedly lower than any of the other companies,” said Tim Anderson, an analyst at Sanford C. Bernstein & Company. “So I’m wondering why your tax rate might be unique in that regard?”

Charlie Bancroft, the company’s chief financial officer, wouldn’t say.

The more than $1 billion in tax savings came at an opportune moment: Bristol Myers was in the midst of repurchasing $6 billion worth of its own shares, an effort to lift its stock price. By January 2013, it had spent $4.2 billion. The cash freed up by the tax maneuver was enough to cover most of the remainder.

The Botched Redaction

It is not clear when I.R.S. agents first learned about the arrangement. But by last spring, the I.R.S. chief counsel’s office had determined that it violated a provision of the tax law that targets abusive profit-shifting arrangements.

In a 20-page legal analysis, the I.R.S. calculated that the offshore setup was likely to save Bristol Myers up to $1.38 billion in federal taxes.

After a complex audit, the I.R.S. often circulates its analyses to agents nationwide in case they encounter similar situations. A redacted version of the report is also made public on the I.R.S. website, cleansed of basic information like the name of the company.

But when the I.R.S. posted its Bristol Myers report last April, it was not properly redacted. With tools available on most laptops, the redacted portions could be made visible.

The I.R.S. quickly removed the improperly redacted version from its website. But Tax Notes, a widely read trade publication, had also posted the document. When the I.R.S. provided a clean version, Tax Notes took down the original.

An I.R.S. spokesman declined to comment.

Cara Griffith, the chief executive of Tax Analysts, the publisher of Tax Notes, said the publication erred “on the side of not publishing confidential taxpayer information that was accidentally released through an error in redaction, unless it reaches a very high threshold of newsworthiness.”

In the intervening hours, though, some tax practitioners had downloaded the original version from Tax Notes. One of them shared it with The New York Times, which viewed the document without the redactions.

In addition to detailing the offshore structure, the I.R.S. report revealed the role of PwC and White & Case in reviewing the deal. While both firms assessed the arrangement’s compliance with various provisions of the tax law, neither firm offered an opinion on whether the deal violated the one portion of the tax law — an anti-abuse provision — that the I.R.S. later argued made the transaction invalid.

Tax experts said they doubted the omission was inadvertent. The I.R.S. can impose penalties on companies that knowingly skirt the law. By not addressing the most problematic portion of the law, Bristol Myers’s advisers might have given the company plausible deniability.

Both firms “appear to have carefully framed the issues so that they could write a clean opinion that potentially provided a penalty shield,” Professor Burke said.

David Weisbach, a former Treasury Department official who helped write the regulations governing the tax-code provision that Bristol Myers is accused of violating, agreed. PwC and White & Case “are giving you 138 pages of legalese that doesn’t address the core issue in the transaction,” he said. “But you can show the I.R.S. you got this big fat opinion letter, so it must be fancy and good.”

The current status of the tax dispute is not clear. Similar disputes have spent years winding through the I.R.S.’s appeals process before leading to settlements. Companies often agree to pay a small fraction of what the I.R.S. claims was owed.

“There is a real chance that a matter like this could be settled for as little as 30 percent” of the amount in dispute, said Bryan Skarlatos, a tax lawyer at Kostelanetz & Fink.

In that case, the allegedly abusive tax shelter would have saved Bristol Myers nearly $1 billion.

https://www.nytimes.com/2021/04/01/business/bristol-myers-taxes-irs.html?searchResultPosition=1 

 

Editor's Note -

 

The preceding story is not an April Fool's joke! 

Opinion: The health-care industry doesn’t want to talk about this single word

By Ron Wyatt - Washington Post - April 5, 2021

Ron Wyatt co-chairs the Institute for Healthcare Improvement’s equity advisory group and is faculty for the IHI Pursuing Equity Initiative. He was the first Black chief medical resident at the Saint Louis University School of Medicine.

When I write about health policy or speak with medical colleagues about barriers to care, there is one word — and one word only — that evokes a wide range of responses. Some respond with silence; others with avoidance. Some respond with anger and defensiveness.

The word appeared at the top of a paper I submitted to the Journal of the American Medical Association in 2015 with David R. Williams, a professor of public health and African American studies at Harvard University. The title: “Racism in Health and Healthcare: Challenges and Opportunities.”

The editor of the journal at that time, Howard Bauchner, advised us that the word could not be published and that “racial bias” would be substituted into the title before publication. Using “racism,” he said, would result in “losing readers.” As authors and scientists, we compromised. We agreed to the change, and the article was published.

Just a few weeks ago, six years after that decision to compromise, Bauchner and I spoke by phone. He apologized, saying that progress has been made since then.

Has progress been made? JAMA recently announced that following controversial comments on racism in medicine made by a deputy editor, Bauchner was placed on administrative leave on March 25 while an independent investigation is completed.

Entrenched systemic racism — and the deliberate omission of the word in patient safety circles — is the cause of an astonishing level of preventable harm and death among communities of color that have been devalued and discounted for more than 400 years.

The covid-19 pandemic has laid bare the racial inequities of the U.S. health-care system. Too many health-care executives still perpetuate the ahistoric perspective that our country’s model provides safe and equal care for all. Yet the disproportionate number of deaths to covid-19 among racial and ethnic minority groups exposes the systemic and lethal barriers to care.

Last month, a major health-care trade magazine accepted another article that I contributed to with three colleagues, once again with “racism” in the title. When our editor sent us the final authors’ agreement, we noticed the word had been removed from the title and replaced with “intolerance.” This time, we were not willing to compromise. Our editor later informed us that the article would not be published in the May/June issue as scheduled. We were not given a reason.

I have worked all over the United States and internationally as a champion of addressing health inequity. I can say without hesitation — both as a doctor and a citizen — that racism in the United States is a public health crisis.

Having lived in rural Alabama, my family experienced these inequities personally. When my great uncle, who was like a father to me, fell ill, he was taken to a clinic that was segregated by skin color, and was subsequently admitted to a hospital in Selma in 1973. He died one day later. In 2015, I learned he had a ruptured appendix and was never seen by a physician.

I have advised and worked with large, complex health-care systems in the United States, Britain, Australia and Africa. I have collaborated with organizations such as the American Medical Association, the American Hospital Association and the Joint Commission. I have even discussed race as a risk factor for death with White health leaders, such as former president of the Institute for Healthcare Improvement Don Berwick.

Yet, I still sometimes feel that survival mechanism kick in to compromise and veil the truth that structural and systemic racism is a root cause of preventable harm and death across U.S. health care. I have been warned that if I did not continue to compromise, I would be labeled an “angry Black man” and that colleagues would distance themselves from me.

The days of compromise are over.

Solving systemic racism in public health must start with naming it. We must publish the word. We must say the word. If health-care providers are to be competent in caring for communities that have been marginalized and oppressed for centuries, then they must understand the role racism plays in poor health. This includes chronic illness, delayed or denied care, barriers to access, condescension, assumptions, inadequate diagnoses and overt disregard.

But proactively addressing racism in health care requires much more than completing training modules, launching hollow PR campaigns, hosting inclusivity workshops, hiring diversity chiefs or donating to under-resourced clinics. As any doctor would attest, before a wound can heal, it must be cleansed. This can be a painful process.

The actions needed to improve health care include listening and learning with humility; acknowledging and addressing implicit bias within work cultures; and fostering environments where reporting unfair treatment, without fear of reprisal, is encouraged and celebrated.

Mid-pandemic, we have a once-in-a-lifetime opportunity to transform health care. That change begins with language and proceeds with authentic, deliberate and intentional changes to policy and practices. Specificity matters now more than ever.

The word “racism” must be spoken loudly in hospital hallways, in boardrooms, at kitchen tables, in editorial meetings and in all health professions schools. Racism is a public-health crisis. 

https://www.washingtonpost.com/opinions/2021/04/05/health-care-racism-medicine/ 

 

Physicians aren’t ‘burning out.’ They’re suffering from moral injury

By Simon G. Talbot and Wendy Dean - STAT - July 26, 2018

Physicians on the front lines of health care today are sometimes described as going to battle. It’s an apt metaphor. Physicians, like combat soldiers, often face a profound and unrecognized threat to their well-being: moral injury.

Moral injury is frequently mischaracterized. In combat veterans it is diagnosed as post-traumatic stress; among physicians it’s portrayed as burnout. But without understanding the critical difference between burnout and moral injury, the wounds will never heal and physicians and patients alike will continue to suffer the consequences.

Burnout is a constellation of symptoms that include exhaustion, cynicism, and decreased productivity. More than half of physicians report at least one of these. But the concept of burnout resonates poorly with physicians: it suggests a failure of resourcefulness and resilience, traits that most physicians have finely honed during decades of intense training and demanding work. Even at the Mayo Clinic, which has been tracking, investigating, and addressing burnout for more than a decade, one-third of physicians report its symptoms.

We believe that burnout is itself a symptom of something larger: our broken health care system. The increasingly complex web of providers’ highly conflicted allegiances — to patients, to self, and to employers — and its attendant moral injury may be driving the health care ecosystem to a tipping point and causing the collapse of resilience.

The term “moral injury” was first used to describe soldiers’ responses to their actions in war. It represents “perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations.” Journalist Diane Silver describes it as “a deep soul wound that pierces a person’s identity, sense of morality, and relationship to society.”

The moral injury of health care is not the offense of killing another human in the context of war. It is being unable to provide high-quality care and healing in the context of health care.

Most physicians enter medicine following a calling rather than a career path. They go into the field with a desire to help people. Many approach it with almost religious zeal, enduring lost sleep, lost years of young adulthood, huge opportunity costs, family strain, financial instability, disregard for personal health, and a multitude of other challenges. Each hurdle offers a lesson in endurance in the service of one’s goal which, starting in the third year of medical school, is sharply focused on ensuring the best care for one’s patients. Failing to consistently meet patients’ needs has a profound impact on physician wellbeing — this is the crux of consequent moral injury.

Physicians are smart, tough, durable, resourceful people. If there was a way to MacGyver themselves out of this situation by working harder, smarter, or differently, they would have done it already.

In an increasingly business-oriented and profit-driven health care environment, physicians must consider a multitude of factors other than their patients’ best interests when deciding on treatment. Financial considerations — of hospitals, health care systems, insurers, patients, and sometimes of the physician himself or herself — lead to conflicts of interest. Electronic health records, which distract from patient encounters and fragment care but which are extraordinarily effective at tracking productivity and other business metrics, overwhelm busy physicians with tasks unrelated to providing outstanding face-to-face interactions. The constant specter of litigation drives physicians to over-test, over-read, and over-react to results — at times actively harming patients to avoid lawsuits.

Patient satisfaction scores and provider rating and review sites can give patients more information about choosing a physician, a hospital, or a health care system. But they can also silence physicians from providing necessary but unwelcome advice to patients, and can lead to over-treatment to keep some patients satisfied. Business practices may drive providers to refer patients within their own systems, even knowing that doing so will delay care or that their equipment or staffing is sub-optimal.

Navigating an ethical path among such intensely competing drivers is emotionally and morally exhausting. Continually being caught between the Hippocratic oath, a decade of training, and the realities of making a profit from people at their sickest and most vulnerable is an untenable and unreasonable demand. Routinely experiencing the suffering, anguish, and loss of being unable to deliver the care that patients need is deeply painful. These routine, incessant betrayals of patient care and trust are examples of “death by a thousand cuts.” Any one of them, delivered alone, might heal. But repeated on a daily basis, they coalesce into the moral injury of health care.

Physicians are smart, tough, durable, resourceful people. If there was a way to MacGyver themselves out of this situation by working harder, smarter, or differently, they would have done it already. Many physicians contemplate leaving heath care altogether, but most do not for a variety of reasons: little cross-training for alternative careers, debt, and a commitment to their calling. And so they stay — wounded, disengaged, and increasingly hopeless.

In order to ensure that compassionate, engaged, highly skilled physicians are leading patient care, executives in the health care system must recognize and then acknowledge that this is not physician burnout. Physicians are the canaries in the health care coalmine, and they are killing themselves at alarming rates (twice that of active duty military members) signaling something is desperately wrong with the system.

The simple solution of establishing physician wellness programs or hiring corporate wellness officers won’t solve the problem. Nor will pushing the solution onto providers by switching them to team-based care; creating flexible schedules and float pools for provider emergencies; getting physicians to practice mindfulness, meditation, and relaxation techniques or participate in cognitive-behavior therapy and resilience training. We do not need a Code Lavender team that dispenses “information on preventive and ongoing support and hands out things such as aromatherapy inhalers, healthy snacks, and water” in response to emotional distress crises. Such teams provide the same support that first responders provide in disaster zones, but the “disaster zones” where they work are the everyday operations in many of the country’s major medical centers. None of these measures is geared to change the institutional patterns that inflict moral injuries.

What we need is leadership willing to acknowledge the human costs and moral injury of multiple competing allegiances. We need leadership that has the courage to confront and minimize those competing demands. Physicians must be treated with respect, autonomy, and the authority to make rational, safe, evidence-based, and financially responsible decisions. Top-down authoritarian mandates on medical practice are degrading and ultimately ineffective.

We need leaders who recognize that caring for their physicians results in thoughtful, compassionate care for patients, which ultimately is good business. Senior doctors whose knowledge and skills transcend the next business cycle should be treated with loyalty and not as a replaceable, depreciating asset.

We also need patients to ask what is best for their care and then to demand that their insurer or hospital or health care system provide it — the digital mammogram, the experienced surgeon, the timely transfer, the visit without the distraction of the electronic health record — without the best interest of the business entity (insurer, hospital, health care system, or physician) overriding what is best for the patient.

A truly free market of insurers and providers, one without financial obligations being pushed to providers, would allow for self-regulation and patient-driven care. These goals should be aimed at creating a win-win where the wellness of patients correlates with the wellness of providers. In this way we can avoid the ongoing moral injury associated with the business of health care.

Simon G. Talbot, M.D., is a reconstructive plastic surgeon at Brigham and Women’s Hospital and associate professor of surgery at Harvard Medical School. Wendy Dean, M.D., is a psychiatrist, vice president of business development, and senior medical officer at the Henry M. Jackson Foundation for the Advancement of 

https://www.statnews.com/2018/07/26/physicians-not-burning-out-they-are-suffering-moral-injury/ 

 

With Hippocratic Oath, doctors pledge allegiance to patients, not profits

By Dr. Philip Caper, - Special to the BDN - Posted March 20, 2014,

The Maine Medical Association recently updated a 2008 poll of their members that asked the question, “When considering the topic of health care reform, would you prefer to make improvements in the current public/private system (or) a single-payer system, such as a ‘Medicare-for-all’ approach?” In 2008, 52.3 percent favored the Medicare-for-all approach. In the updated poll, released last week, that number had risen to 64.3 percent.

It’s pretty unusual for two-thirds of a group of doctors to agree on something as controversial as a single-payer health care system. Until recently, doctors formed the core resistance to “government-run” health insurance in the U.S.

A number of factors account for this impressive change, but the huge administrative burden on practicing physicians created by our plethora of private insurance schemes is certainly near the top of the list.

The other day, I spoke with a Maine physician nearing retirement and looking forward to it. She was recently returning home after a long day in her practice, carrying her “homework,” a pile of administrative paperwork several inches high. Her husband asked her how she got so far behind in her paperwork. “I wasn’t behind at all,” she replied. She did this much paperwork, mostly insurance forms, at least twice a week.

American physicians spend at least three times as much time, money and effort on administrative work related to payment and insurance coverage as our Canadian brethren, with their single-payer system. Administrative hassle is a major factor driving more and more American doctors to sell our practices to large corporations that take care of the back-office work. The Affordable Care Act has only added to that burden. Sixty percent of doctors now work for corporations, and that number is growing.

Working for a corporate provider of health care services is a mixed bag. He who pays the piper calls the tune. As both for-profit and nonprofit health care corporations have become increasingly focused on the bottom line, doctors working for them have come under increasingly subtle and not-so-subtle pressures to generate revenue for their employers.

Some tests and procedures are more profitable than others. Increasingly, doctors’ “productivity” is measured by the amount of profitable revenue we produce rather than by the results we get for our patients. But in health care, profitability is a very unreliable measure of value because doctors’ fees and other health care prices are often set arbitrarily.

When we graduate from medical school, most of us take the Hippocratic Oath, swearing our primary allegiance to our patients. Young doctors tend to take their oath very seriously. Most doctors truly want to do what’s best for patients, not their insurance company or our employers’ bottom line.

But in today’s corporatized and increasingly monetized health care environment, the demands for generation of profit often directly conflict with our clinical judgment. The belief that doctors and other healers act as stewards for our patients’ welfare has long earned us a special place in society and the trust of our patients. That position

and that trust, so critical to healing, is now threatened.

This conflict has made many doctors very angry. Practicing a profession that has traditionally been a calling has become a business. Doctors today are caught in a system corrupted by an excessive focus on money that is forcing us to behave in ways that conflict with our professional ethics. We are growing very tired of being told how to practice medicine by insurance company bureaucrats and corporate MBAs.

This is another major cause of the burnout experienced by increasing numbers of doctors. Many older doctors are now simply looking for a way out. Others are calling for systemwide reforms that will allow them to return to focusing on the welfare of their patients. Hence the results of the recent MMA poll.

In an excellent new book called “What Matters In Medicine”, longtime Maine family doctor David Loxterkamp points out that medical care, while often using scientific jargon, methods and tools, is at its core a profession about relationships, not profits. That’s something the bean-counters and policy wonks who have become increasingly influential in determining the nature of our corporatized health care system seem unable to understand.

It’s time to remove corporate profit from the financing of health care, and perverse financial incentives from the direct provision of services. It’s time for improved Medicare-for-all.

http://bangordailynews.com/2014/03/20/health/with-hippocratic-oath-doctors-pledge-allegiance-to-patients- not-profits/

 

How Health Care Became the Big Industry in Steel City

By Jennifer Szalai - NYT - March 31, 2021

Bad times for American labor have also meant boom times for a certain strain of American nostalgia. According to a well-worn narrative, the postwar era was an idyll of heavy industry and stable union jobs; a family with 2.5 children could get by with just one breadwinner — the archetypical working-class man, who toiled in a sooty industrial plant before coming home to a house that was impeccably maintained by his doting wife.

Decades after the collapse of its steel industry, Pittsburgh exemplifies how the trace memory of an old identity can live on in a football team (the Steelers), a nickname (Steel City) and even a local beer (Iron City), while the industry that actually flourishes there now — health care — garners no such reverence or recognition. The fastest growth in the sector isn’t for anesthetists or X-ray technicians but for poorly paid caregiving jobs; most of these care workers are women, and many of them are Black.

During the pandemic, these workers have been called “essential” — but as the historian Gabriel Winant explains in “The Next Shift,” remuneration and job protections haven’t kept up. “Care workers are at once everywhere and nowhere,” Winant writes. “They are responsible for everyone, but no one is responsible for them.”

The replacement of blue-collar work by pink-collar work has been much discussed, but what makes this book stand out is Winant’s argument that two seemingly distinct phenomena are in fact inextricably connected: “It was not a coincidence that care labor grew as industrial employment declined.” In the 1970s, deindustrialization pushed an ailing and aging population into unemployment, toward the welfare state — always tentative, in the American case — for their survival. Unlike other social institutions, which buckled under political pressure and austerity cuts, the American health care system flourished, having grown already in response to the rise of collectively bargained health insurance during the flush postwar years.

Winant traces the surprising story of how this happened, taking Pittsburgh as his focus. The city and its surrounding county offer one of the starkest examples of a local economy not simply shaped but warped by the steel industry, whose reach extended through the entire social fabric, right down to the level of family relationships. Winant, who teaches at the University of Chicago, consulted the archives, examined the data and conducted his own interviews to glean an intimate look at how a city of steel became a city of health care aides.

“The Next Shift” is an original work of serious scholarship, but it’s also vivid and readable; Winant has an eye for the telling, and occasionally crushing, detail. One ambivalent steelworker recalled that he always brought his lunch in a brown paper bag that consistently failed to protect his sandwich from hungry rats; he resisted getting a proper lunch pail like the others because it would mean that he was resigning himself to staying put. A woman remembered growing up amid the hushed silence of a house that had to be kept quiet and dark so that the father she barely saw, who worked night shifts, could get some sleep during the day. Households had to organize themselves around the needs of the industry. Each family became “a little factory.”

Despite the sentimentality that has attached to the steel mill, the work it generated was not only dangerous, it was also unpredictable and not infrequently alienating. Winant describes how a coke shoveler working night shifts lost “control over his body’s rhythms — eating, sleeping, toiling,” which in turn made it harder to maintain the performance of masculinity that was so central to his identity. Not to mention that the job security afforded by the union’s collective bargaining wasn’t evenly distributed. In the 1950s, as the demand for steel slackened with the end of the Korean War, layoffs hit Black workers first — they tended to be marginalized within the union, and kept in the worst positions at the mill.

For a time, steelworker unions obtained higher wages, outstripping inflation; then, responding to government pressure to keep wages down, they bargained for better health insurance, which generated its own inflationary dynamic in the health care system. Winant offers a lucid explanation of how the peculiarities of this system developed into what he calls the “public-private welfare state” — a dysfunctional realm of escalating health care costs and entrenched and entangled interests that no one seems capable of replacing.

This public-private welfare state was what awaited the workers cast off by a collapsing industry. Winant notes that the two social institutions that have prospered since the 1980s have been prisons and health care delivery: “Like the expansion of the prison system in the final decades of the 20th century, the rise of the health care industry afforded an economic fix to the social crisis brought about by deindustrialization.”

Hospital work was labor intensive, and it opened a job market for those Black Americans, including domestic workers, who were the first to be displaced by automation and industrial decline. Their exploitation, Winant says, “formed the basis of the bonanza for everyone else.” This work force was largely excluded from the midcentury prosperity and security it helped to create, and the ensuing cycle was vicious: “Caregiving could be offered at large volume to the insured fractions of the working class because its costs were passed on in such significant proportion to hospital employees via low wages.”

This system, as depicted in Winant’s eye-opening book, is not only inhumane but unsustainable. Toward the end of “The Next Shift,” he introduces us to Nila Payton, a medical secretary who takes calls all day from patients with mesothelioma and black lung at the pathology office where she works. The place is part of Pittsburgh’s enormous hospital complex, but her office is so understaffed that it’s sometimes hard to find someone to cover the phone when she needs to use the bathroom. She says this has damaged her bladder, and in nine years of working there she has never received more than a 15 cent raise.

“Like many patients,” Winant writes, “Payton is now in medical debt — though in her case it is to her own employer.”

https://www.nytimes.com/2021/03/31/books/review-next-shift-health-care-gabriel-winant.html?

 

‘There is a solution’: a Covid survivor’s life-or-death battle for Medicare for All

Mariana Pineda was hospitalized with Covid-19 and pneumonia last April and can only afford treatment via GoFundMe. Now she’s using her energy to fight for healthcare programs

by Amanda Holpuch - The Guardian - April 5, 2021

 

Few things in Mariana Pineda’s body have worked properly since she was hospitalized with Covid-19 and pneumonia last April. One day she is seeing a specialist to get nodules on her thyroid biopsied, another day it is a trip to the emergency room after her hands swell and turn red, symptoms of yet another high blood pressure crisis.

She pays $3,062.48 a month for health insurance to cover this constant stream of treatment, which she can only afford with the help of a GoFundMe online fundraiser. She is too sick to work and is a single mother – her only income is child support payments.

Amid all of this, when Pineda’s finished with doctors’ appointments for the day and her four-year-old is asleep, she uses her last stores of energy to fight for the government-run healthcare program Medicare for All and its New York state equivalent.

“This is my gift from the universe,” Pineda told the Guardian. “If nothing else, the fact that I didn’t die from Covid just ramped up my overwhelming desire to get Medicare for All and the New York Health Act.”

Pineda is one of the many activists, and lawmakers, making Covid-19 part of their calls to reshape the US healthcare system to provide universal coverage. In mid-March, Democratic representatives Pramila Jayapal and Debbie Dingell reintroduced the Medicare for All act on the anniversary of Covid-19 being confirmed in all 50 states and Washington DC.

“There is a solution to this health crisis – a popular one that guarantees health care to every person as a human right and finally puts people over profits and care over corporations,” Jayapal said in a statement. “That solution is Medicare for All.”

The bill has the support of more than half the Democrats, but it is unlikely to pass the House. In the Senate, several Democrats instead are pushing for the public option, a government-run health insurance to exist alongside private health insurance.

Both reforms seek to make health insurance more affordable, easier to access and less costly and are being weighed by several state governments.

The hurdles, however, are immense.

Partnership for America’s Health Care Future, a lobby which represents hospitals, pharmaceutical companies and health insurers, is already spending millions to campaign against reform. In Colorado, the group bought $1m in TV ads to run this spring before a bill was even introduced.

These ads, which warn of politicians having more control over people’s healthcare, have been effective against health reform for decades, explained health policy expert Colleen Grogan. “The evidence from the past suggests that those advertisements really work and that’s why they keep doing them,” said Grogan, professor at the University of Chicago’s Crown Family School of Social Work, Policy and Practice.

Americans for Prosperity, a group with financial backing from the conservative Koch brothers network, is also stepping in. The group spent millions to fight the ACA, and told CNBC in March that that campaign failed in part because they didn’t present an alternative. This time, the group is showcasing a “personal option” plan which would slash regulations and is pitched toward the private sector.

Activists must also contend with the more moderate wing of the Democratic party. Joe Biden has not endorsed Medicare for All and his healthcare efforts have so far been focused on expanding the Affordable Care Act (ACA).

The president has already had success: the last stimulus package included $61.3bn to expand insurance subsidies and coverage under the ACA and other federal programs for two years. More than four out of 10 people without health insurance are now eligible for a free or nearly free health plan, according to a Kaiser Family Foundation analysis.

Pineda is set to benefit from one of the changes: people who have recently lost work must be covered for up to six months under the usually costly Cobra program. That’s the insurance Pineda pays $3,000 a month for now and she’s waiting to hear from her employer or the government about the subsidy.

These efforts improve access and affordability, but also direct public money to the private healthcare industry. “So the American public benefits but the American public also loses because it ends up having to pay a lot more than a more rational system should really pay for,” Grogan said.

Should Biden attempt to make these changes permanent, as is expected, discussions about public spending on private healthcare could be more prominent, a useful tool for reform activists. In 2019, federal, state and local governments accounted for 45% of the country’s $3.8tn in healthcare spending.

“The interest in containing healthcare spending is not going away,” said Katherine Hempstead, senior policy adviser at the Robert Wood Johnson Foundation. “I don’t think we’re going to hear the end of that at all.”

And Pineda will do what she can to ensure that.

The mother of four posts pictures of her vital signs and medical bills on social media, providing an intimate look at the long-term symptoms some people experience after Covid-19 infections and the costs of trying to stay alive.

“I’ve done panels from hospital beds, I’ve gone on Facebook Live from the emergency room,” Pineda said. “Yes, it sucks that I am sick, but it gives me a unique insight and gives me access to all kinds of things that we might not necessarily know about.”

Pineda is energetic and quick to laugh, but she is experiencing a nightmare. Her symptoms include headaches that make her feel like someone is shaking a can of coins in her head, vomiting multiple times a week, emphysema, lesions on her kidneys, incontinence and anemia. Her period hasn’t stopped since she had a miscarriage in July. Doctors are monitoring an air sack in her lungs because if it grows much more it will need to be surgically removed.

She goes to the emergency room almost every month and in September had emergency surgery to remove six blood clots in her lungs, including one blocking her pulmonary artery – the respiratory therapist told her 99% of the people in her position don’t survive.

She is seeing a urologist, pulmonologist, endocrinologist, hematologist, gastroenterologist, neurologist and cardiologist. A quirk of her insurance, familiar to many Americans, is that her appointments with specialists are only covered if her primary care physician gives the referral – an added layer of bureaucracy.

“I’ve actually had to myself call up specialists, get their tax ID number, get the diagnosis code, get all of the codes,” Pineda said. “So I spend hours a day on the phone with specialists and the insurance company … if we had the NY Health Act or Medicare for All, it would all be one system and I wouldn’t have to do this while I’m home recuperating and a single parent with an autistic four-year-old.”

Pineda’s passion for Medicare for All formed when she was volunteering for Bernie Sanders’ 2016 presidential bid, knocking on hundreds of doors while pregnant. She cast her ballot in the New York primary while 4cm dilated and gave birth the next day.

Five years later, Pineda vowed to keep pushing politicians for health reform. Pineda said: “I am going to harass them until I drop dead and I hope I drop dead on their door stop for a good photo op.”

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ACP: Time to 'Re-Emphasize Ethical Foundation of Medicine'

— Guidance on navigating challenges of private equity, value-based care, and more

by Jennifer Henderson - Medpage Today - March 15, 2021

As more private equity firms acquire physician practices and healthcare moves from a fee-for-service system to value-based care, potential ethical implications of both are important for physicians to consider in prioritizing their duty to patients, according to the American College of Physicians.

The organization outlined recommendations for doing so in a position paper published in the Annals of Internal Medicine.

"Today, changing practice dynamics place greater focus on the business aspects of medicine," the authors wrote. "Although employment or consolidation within larger organizations may not be problematic per se, physicians, regardless of practice setting, should challenge business concerns that are placed above the best interests of patients."

Due to financial strain from the COVID-19 crisis, changing dynamics may include an uptick in the already increasing number of physician practices being acquired by private equity firms, according to the paper. Private equity firms typically take a large stake in the practice, invest in it to increase market share and revenue, take actions to decrease costs, and sell the practice within a few years to generate returns for investors. Those buyers include other private equity firms, large corporations, the public via an initial public offering, and insurance companies.

"This desire to sell the practice soon after acquisition can create the incentive to sell off parts of the practice or undertake drastic short-term cost-cutting measures, including staff layoffs, to make a potential sale more attractive," the authors wrote. "Insurance companies may further narrow their networks or restrict patient access to only their employed physicians."

"Because of their current value, relatively limited supply, and perceived future earning potential, dermatology, radiology, and ophthalmology practices particularly interest private equity firms," they added.

Though private equity can provide resources to maintain solvency and promote innovation, it can also limit physician control, the authors wrote. The need to generate returns quickly can also compete with other interests, such as long-term investments in safety and quality.

The authors cited the example of Hahnemann University Hospital in Philadelphia, which was bought by a for-profit corporation and shuttered just a year later.

Patients were left without access to care, the authors noted, and hundreds of medical residents and fellows were left in limbo, MedPage Today previously reported.

Additional concerns are that private equity firms may limit Medicaid and Medicare patients due to lower rates of reimbursement and more complex medical needs, the authors added. Physician practices owned by private equity firms have also been accused of aggressive or surprise out-of-network billing practices.

"Physicians who sell to a private equity firm must assess doing so with attention to potential effects on ethics and professionalism," the authors wrote. "At present, there is insufficient evidence comparing the clinical performance and ethical implications of private equity ownership versus other practice arrangements (partly because of nondisclosure agreements in some private equity agreements)."

Put simply, "Caution is needed," they wrote.

As for value-based payment, it's designed to promote high-quality care. However, the authors wrote, concerns include inappropriately influencing patient or physician choice, failing to account for complex medical illnesses, and creating access-to-care barriers for disadvantaged patient groups.

"A fundamental concern is whether the use of extrinsic incentives -- financial or nonfinancial -- actually undermines the intrinsic motivation of physicians (a phenomenon known as 'motivational crowding')," they wrote. "Paying physicians incentives could reduce intrinsic reasons or motivations of professionalism, clinical integrity, and the sense of medicine as a calling."

The authors added that similar concerns exist for referral-based incentives. They can be efficient and benefit coordinated care, but also restrict patient choice. Incentives for referrals must be transparent, they wrote.

The authors' recommendations about contract clauses included that confidentiality clauses should not interfere with patient well-being or physician responsibility to promote community health and quality improvement.

Another recommendation in the paper was that organizations should value time when it comes to patients' appointments with physicians. Time is needed for effective communication, counseling and physical examination as well as expressing compassion, the authors wrote.

New physicians as well as those with decades of experience have a role to play in being aware of how business practices and employment terms can affect ethics and professionalism, they concluded.

"The challenges to care and medical practice during and after the COVID-19 pandemic underscore the need to reemphasize the ethical foundation of medicine," the authors wrote. "Looking anew at the environment in which care is delivered, physicians should lead in ensuring that business relationships explicitly recognize and support the fundamental and timeless commitments of physicians and medicine to patients."

As more private equity firms acquire physician practices and healthcare moves from a fee-for-service system to value-based care, potential ethical implications of both are important for physicians to consider in prioritizing their duty to patients, according to the American College of Physicians.

The organization outlined recommendations for doing so in a position paper published in the Annals of Internal Medicine.

"Today, changing practice dynamics place greater focus on the business aspects of medicine," the authors wrote. "Although employment or consolidation within larger organizations may not be problematic per se, physicians, regardless of practice setting, should challenge business concerns that are placed above the best interests of patients."

Due to financial strain from the COVID-19 crisis, changing dynamics may include an uptick in the already increasing number of physician practices being acquired by private equity firms, according to the paper. Private equity firms typically take a large stake in the practice, invest in it to increase market share and revenue, take actions to decrease costs, and sell the practice within a few years to generate returns for investors. Those buyers include other private equity firms, large corporations, the public via an initial public offering, and insurance companies.

"This desire to sell the practice soon after acquisition can create the incentive to sell off parts of the practice or undertake drastic short-term cost-cutting measures, including staff layoffs, to make a potential sale more attractive," the authors wrote. "Insurance companies may further narrow their networks or restrict patient access to only their employed physicians."

"Because of their current value, relatively limited supply, and perceived future earning potential, dermatology, radiology, and ophthalmology practices particularly interest private equity firms," they added.

Though private equity can provide resources to maintain solvency and promote innovation, it can also limit physician control, the authors wrote. The need to generate returns quickly can also compete with other interests, such as long-term investments in safety and quality.

The authors cited the example of Hahnemann University Hospital in Philadelphia, which was bought by a for-profit corporation and shuttered just a year later.

Patients were left without access to care, the authors noted, and hundreds of medical residents and fellows were left in limbo, MedPage Today previously reported.

Additional concerns are that private equity firms may limit Medicaid and Medicare patients due to lower rates of reimbursement and more complex medical needs, the authors added. Physician practices owned by private equity firms have also been accused of aggressive or surprise out-of-network billing practices.

"Physicians who sell to a private equity firm must assess doing so with attention to potential effects on ethics and professionalism," the authors wrote. "At present, there is insufficient evidence comparing the clinical performance and ethical implications of private equity ownership versus other practice arrangements (partly because of nondisclosure agreements in some private equity agreements)."

Put simply, "Caution is needed," they wrote.

As for value-based payment, it's designed to promote high-quality care. However, the authors wrote, concerns include inappropriately influencing patient or physician choice, failing to account for complex medical illnesses, and creating access-to-care barriers for disadvantaged patient groups.

"A fundamental concern is whether the use of extrinsic incentives -- financial or nonfinancial -- actually undermines the intrinsic motivation of physicians (a phenomenon known as 'motivational crowding')," they wrote. "Paying physicians incentives could reduce intrinsic reasons or motivations of professionalism, clinical integrity, and the sense of medicine as a calling."

The authors added that similar concerns exist for referral-based incentives. They can be efficient and benefit coordinated care, but also restrict patient choice. Incentives for referrals must be transparent, they wrote.

The authors' recommendations about contract clauses included that confidentiality clauses should not interfere with patient well-being or physician responsibility to promote community health and quality improvement.

Another recommendation in the paper was that organizations should value time when it comes to patients' appointments with physicians. Time is needed for effective communication, counseling and physical examination as well as expressing compassion, the authors wrote.

New physicians as well as those with decades of experience have a role to play in being aware of how business practices and employment terms can affect ethics and professionalism, they concluded.

"The challenges to care and medical practice during and after the COVID-19 pandemic underscore the need to reemphasize the ethical foundation of medicine," the authors wrote. "Looking anew at the environment in which care is delivered, physicians should lead in ensuring that business relationships explicitly recognize and support the fundamental and timeless commitments of physicians and medicine to patients."

https://www.medpagetoday.com/special-reports/exclusives/91639

Wisconsin Hospital Replaces All Anesthesiologists With CRNAs

by Tinker Ready - Medscape.com - April 5, 2021

Watertown Regional Medical Center in Wisconsin has replaced all of its anesthesiologists with certified registered nurse anesthetists (CRNAs), sparking outrage on social media and reigniting debate about the role of advanced practice nurses.

On March 28, an undated letter was posted on Twitter announcing that the anesthesiology staff at the small Midwestern hospital would be replaced by CRNAs. The letter migrated to Facebook and several doctors used it as an opportunity to express concern.

"This is not good news for the residents of Watertown, WI. Watertown Regional Medical Center (courtesy of the private equity-backed, contract medical group Envision) removed all of its anesthesiologists for a 100% CRNA model. In a nutshell, they replaced physicians with nurses," the tweet with the letter reads.

The letter was posted by an unnamed doctor described as an Emergency Physician/Army Vet/Patient-Physician Advocate. The person responding to a direct message sent to the owner of the Twitter account declined to identify himself or herself or to speak to Medscape Medical News.

Over at Watertown Regional Medical Center, a Wisconsin community hospital that sits between Madison and Milwaukee, no one was available to talk officially about the letter. Several requests for comment also went unanswered at Envision, a large medical staffing agency that works with the hospital and will oversee the anesthesiology team.

Adam Dachman, MD, a surgeon at the hospital, speaking for himself, said he has no problem using nurse anesthetists.

"It's a misconception that physicians are required to administer anesthesia," he told Medscape Medical News.

Beyond the hospital, the tweet triggered a conversation on a closed Facebook group linked to Physicians for Patient Protection. That nonprofit group supports "physician-led care." Robert McNamara, MD, saw both the tweet and the Facebook post. He is the chair of emergency medicine at the Lewis Katz School of Medicine at Temple University in Philadelphia, and head of Temple's physician group. He said the move, and others like it, are being driven by cost-cutting.

"The root cause is that private-equity-backed corporations are taking over anesthesia services, and they are deciding to increase profits by replacing the most expensive thing in their equation — that's the anesthesiologist," he told Medscape Medical News.

Envision Physician Services advertises for both anesthesiologist and CRNA positions, and both are featured in a company video promoting its services. The company describes itself as "the largest anesthesiology provider in the country."

The long-running battle over physician supervision of nurse anesthetists is also being fought in the courts and at the Department of Health and Human Services (HHS).

https://www.medscape.com/viewarticle/948723