A Single Ohio Hospital Reveals All That’s Wrong With American Health Care
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
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.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 and - 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.
How Health Care Became the Big Industry in Steel City
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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https://www.theguardian.com/us-news/2021/apr/05/us-medicare-for-all-covid-survivor-treatment
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, 2021As 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
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
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