Health Care Reform Articles - October 30, 2022

Few Places Have More Medical Debt Than Dallas-Fort Worth, but Hospitals There Are Thriving

by Noam Levey - Kaiser Health News - September 28, 2022

PROSPER, Texas — Almost everything about the opening of the 2019 Prosper High School Eagles’ football season was big.

The game in this Dallas-Fort Worth suburb began with fireworks and a four-airplane flyover. A trained eagle soared over the field. And some 12,000 fans filled the team’s new stadium, a $53 million colossus with the largest video screen of any high school venue in Texas. Atop the stadium was also a big name: Children’s Health.

Business has been good for the billion-dollar pediatric hospital system, which agreed to pay $2.5 million to put its name on the Prosper stadium. Other Dallas-Fort Worth medical systems have also thrived. Though exempt from taxes as nonprofit institutions, several, including Children’s, notched double-digit margins in recent years, outperforming many of the area’s Fortune 500 companies.

But patients aren’t sharing in the good times. Of the nation’s 20 most populous counties, none has a higher concentration of medical debt than Tarrant County, home to Fort Worth. Second is Dallas County, credit bureau data shows.

The mismatched fortunes of hospitals and their patients reach well beyond this corner of Texas. Nationwide, many hospitals have grown wealthy, spending lavishly on advertising, team sponsorships, and even spas, while patients are squeezed by skyrocketing medical prices and rising deductibles.

A KHN review of hospital finances in the country’s 306 hospital markets found that several of the most profitable markets also have some of the highest levels of patient debt.

Overall, about a third of the 100 million adults in the U.S. with health care debt owe money for a hospitalization, according to a poll conducted by KFF for this project. Close to half of those owe at least $5,000. About a quarter owe $10,000 or more.

Many are pursued by collectors when they can’t pay their bills or hospitals sell the debt.

“The fact is, if you walk into a hospital today, chances are you are going to walk out with debt, even if you have insurance,” said Allison Sesso, chief executive of RIP Medical Debt, a nonprofit that buys debt from hospitals and debt collectors so patients won’t have to pay it.

Community Shadowed by Debt

Across the Dallas-Fort Worth metro area — the nation’s fourth-largest — the impact has been devastating. 

“Medical debt is forcing people here to make incredibly agonizing choices,” said Toby Savitz, programs director at Pathfinders, a Fort Worth nonprofit that assists people with credit problems. Savitz estimated that at least half their clients have medical debt. Many are scrimping on food, neglecting rent, even ending up homeless, she said, “and this is not just low-income people.” 

David Zipprich, a Fort Worth businessman and grandfather, was forced out of retirement after hospitalizations left him owing more than $200,000.

Zipprich, 64, had spent a career in financial consulting. He owned a small bungalow in a historical neighborhood near the Fort Worth rail yards. His daughters, both teachers, and his four grandchildren lived nearby. He had health insurance and some savings, and he’d paid off his mortgage.

Then in early 2020, Zipprich landed in the hospital. While driving, his blood sugar dropped precipitously, causing him to black out and crash his car.

Three months later, after he was diagnosed with diabetes, another complication led to another hospitalization. In December 2020, covid-19 put him there yet again. “I look back at that year and feel lucky I even survived,” Zipprich said.

But even with insurance, Zipprich was inundated with debt notices and calls from collectors. His credit score plummeted below 600, and he had to refinance his home. “My stress was off the charts,” he said, sitting in his neatly kept living room with his Shih Tzu, Murphy.

Overall in Tarrant County, 27% of residents with credit reports have medical debt on their records, credit bureau data analyzed by KHN and the nonprofit Urban Institute shows. In Dallas County, it’s 22.5%.

That’s more than five times the rate in the largest counties in New York, data shows. The Texans also owe a lot more — the median amount of medical debt on credit records in Tarrant and Dallas counties is nearly $1,000, compared with $400 or less in New York.

Last year, Zipprich returned to work, taking a job in New Jersey that required he commute back and forth to Texas. He recently quit, citing the strain of so much travel. He’s now job hunting again. “I never thought this would happen to me,” he said.

Who Is Responsible?

Even small debts can have potentially dangerous consequences, discouraging patients from seeking needed care. Angie Johnson, a 28-year-old schoolteacher, cut short her honeymoon so she and her husband could pay off more than $1,100 she owed a physical therapy center owned by Baylor Scott & White, a mammoth Dallas-based hospital system.

Johnson said the center, where she’d gone after a knee injury, initially said her visits would cost $60. “Then they billed me hundreds,” she said. “I don’t go to the doctor unless I absolutely have to because it’s so expensive.”

Who Is Responsible?

Even small debts can have potentially dangerous consequences, discouraging patients from seeking needed care. Angie Johnson, a 28-year-old schoolteacher, cut short her honeymoon so she and her husband could pay off more than $1,100 she owed a physical therapy center owned by Baylor Scott & White, a mammoth Dallas-based hospital system.

Johnson said the center, where she’d gone after a knee injury, initially said her visits would cost $60. “Then they billed me hundreds,” she said. “I don’t go to the doctor unless I absolutely have to because it’s so expensive.”

Angie Johnson of Waxahachie, Texas, cut short her honeymoon so that she and her husband could pay off more than $1,100 she owed a physical therapy center owned by a Dallas-based hospital system. (Laura Buckman for KHN and NPR)

Hospital industry leaders blame the patient debt on health insurers, citing the rise of high-deductible plans and other efforts that limit coverage. “The last thing that hospitals want is for their patients to face financial barriers,” said Molly Smith who leads public policy at the American Hospital Association. “Hospitals are in there trying to work on behalf of patients.”

Despite repeated requests from KHN, none of the medical systems around Dallas-Fort Worth would discuss their finances or the debt carried by patients.

But Smith and other hospital leaders point to billions of dollars of free or discounted care that hospitals nationwide provide every year. “Hospitals have been pretty darn generous,” said Stephen Love, president of the Dallas-Fort Worth Hospital Council. “If other parts of the community did as much as hospitals, we wouldn’t be in this problem.”

Unlike drug companies, device makers, and many physician practices, most U.S. hospitals are nonprofit and must provide charity care as a condition of their tax-exempt status.

Regardless of tax status, medical centers in markets with high medical debt do provide more charity care, according to an analysis by KHN and the Urban Institute, a Washington think tank. That’s important, said Dr. Vikas Saini, president of the Lown Institute, a nonprofit that grades hospitals on their quality and community benefits. But he asked: “Is a hospital truly serving its community if it’s pushing so many into debt?”

Around Dallas-Fort Worth, major medical systems frequently tout their commitment to the region and its patients.

When Texas Health Resources, a Dallas-based nonprofit system with more than $5 billion in annual revenue, opened a new hospital tower in Fort Worth earlier this year, Barclay Berdan, the system’s chief executive, said the building “reinforces Texas Health’s long-standing commitment to the Fort Worth community.” The nine-story, $300 million tower is one of more than a half-dozen new hospitals and major expansions around the Dallas-Fort Worth area since 2018.

The big building spree has been accompanied by big bottom lines.

From 2018 to 2021, Texas Health, which owns hospitals in North Texas, had an average operating margin of almost 6%, according to a KHN analysis of publicly available financial reports.

Other major systems in the area, including Baylor, Children’s Health, and HCA, the nation’s largest for-profit hospital company, did even better, KHN found. Cook Children’s, the region’s second major pediatric system, had an average operating margin of nearly 12%.

By comparison, profits at most of the 25 Fortune 500 companies based around Dallas-Fort Worth, such as ExxonMobil, were less than 6% in 2019, according to Fortune data.

Approaching a Tipping Point

Hospitals have thrived in other markets with high patient debt, KHN found.

In Charlotte, North Carolina, where a quarter of residents have medical debt on their credit reports, hospitals recorded an average operating margin of 13.6% from 2017 to 2019.

The average margin at hospitals in and around Gainesville and Lakeland, two central Florida markets where a quarter of residents also carry medical debt, topped 9%. In Tulsa, Oklahoma, which has the same level of debt, margins have averaged 8.5%.

Overall, U.S. hospitals recorded their most profitable year on record in 2019, with an aggregate operating margin of 6.5%, according to the federal Medicare Payment Advisory Commission. Total margins, which include income from investments, were even higher.

“You might think that hospitals in communities where patients have a lot of debt would be less profitable, but that doesn’t seem to be the case,” said Anuj Gangopadhyaya, a senior Urban Institute researcher who worked with KHN on an analysis of hospital finance and consumer debt data in U.S. hospital markets.

In fact, the analysis found, there is no apparent relationship between the profits of hospitals in a market and how much medical debt residents have. So while hospitals in places like Charlotte and Tulsa may be comfortably in the black, in other places with high patient debt such as Amarillo, Texas, and Columbia, South Carolina, hospitals are struggling, data shows.

Industry experts say the most profitable medical centers — like those around Dallas-Fort Worth — have developed business models that allow them to prosper even if their patients can’t pay.

One key is prices. These hospitals maximize what they charge for everything from a complex surgery to a dose of aspirin. Most of those charges are picked up by health insurers, which still pay a much larger share of hospital bills than patients do, even those with the highest deductibles.

Across the country, many medical systems have strengthened their market power in recent years by consolidating, buying up smaller hospitals and physician practices, which enables the hospital systems to charge even more.

Dallas-Fort Worth has the highest medical prices in Texas, according to the Health Care Cost Institute, a nonprofit that tracks costs nationwide. And in a state where most markets have relatively low medical prices, in-patient care at Dallas-Fort Worth hospitals was 13% more expensive than the national median in 2020.

In addition to charging more, the most profitable hospitals frequently squeeze more savings from their operations, holding down what they pay workers, for example, and securing better contracts from suppliers. “Hospitals have had to get leaner and meaner,” said Kevin Holloran, a senior director at Fitch Ratings who tracks nonprofit health systems for the bond rating firm.

It’s unclear how much longer this business model can endure.

Across the country, many small and rural hospitals have closed in recent years. Even some larger systems are now losing money, as inflation and rising labor costs put new pressure on bottom lines.

As bills rise, hospitals are having a harder time collecting. Last year, nearly 1 in 5 patient bills generated by hospitals for people with insurance topped $7,500, according to an analysis of hospital billing records by Crowe LLP, a Chicago-based accounting and consulting firm. That was more than triple the rate in 2018.

“These are bills that fewer and fewer patients out there can afford,” said Brian Sanderson, a senior Crowe health care consultant and former hospital executive. Indeed, hospitals manage to collect less than 17% of patient balances that exceed $7,500, according to Crowe’s analysis.

“The rates at which patient balances are growing is just unsustainable for our health systems,” Sanderson said, predicting that most will never be able to collect bills of this size. “It’s trending to the ridiculous.”

Robert Earley, a former Texas state legislator who used to head Fort Worth’s public health system, compared today’s hospitals to shrimpers in the Gulf Coast district he once represented.  

“They wanted to pull so much shrimp out of the bay that they didn’t think about whether there’d be any there long term,” Earley said, recalling his constituents’ struggles. “I worry that those of us in health care aren’t asking ourselves enough if this system is sustainable.”

To explore connections between hospital profits and patient debt, KHN and the Urban Institute examined data from each of the nation’s 306 hospital markets, also known as hospital referral regions.

Researchers calculated medical debt in each hospital referral region using 2019 credit bureau data maintained by the Urban Institute. They then compared the debt load in each market to the average operating margin for hospitals in that market over three years from 2017 to 2019, weighting each hospital’s margin by the number of adjusted admissions.

The margins data comes from hospital cost reports that hospitals file annually with the federal Centers for Medicare & Medicaid Services. These reports are aggregated by the nonprofit Rand Corp., which supplied the data to KHN and the Urban Institute.

https://khn.org/news/article/medical-debt-hospitals-dallas-fort-worth/?utm_campaign=KFF-2022-The-Latest&utm_medium 

 

As Hospitals Close Children’s Units, Where Does That Leave Lachlan?

Adult beds are more lucrative than children’s beds. So as institutions look to boost profit margins, pediatrics is often among the first services to be cut.

by Emily Baumgaertner - NYT - October 11, 2022

 

Adult beds are more lucrative than children’s beds. So as institutions look to boost profit margins, pediatrics is often among the first services to be cut.

Lachlan Rutledge, 6, has a connective tissue disorder, severe allergies and asthma, which have landed him repeatedly in pediatric intensive care.Credit...Melissa Lukenbaugh for The New York Times

• Published Oct. 11, 2022Updated Oct. 12, 2022, 12:07 a.m. ET

BROKEN ARROW, Okla. — It was Lachlan Rutledge’s sixth birthday, but as he mustered a laborious breath and blew out one candle, it was his mother who made a wish: for a pediatric hospital bed in northeast Oklahoma.

The kindergartner has a connective tissue disorder, severe allergies and asthma. Those conditions repeatedly landed him in the pediatric intensive care unit at Ascension St. John Medical Center in Tulsa, with collapsed veins and oxygen levels so low, he was unresponsive to his mother’s voice.

But in April the hospital closed its children’s floor to make room for more adult beds. So on a September morning, after coming down with Covid for the fourth time and with what looked like bilateral pneumonia, Lachlan was struggling to breathe in an overcrowded emergency room at the Children’s Hospital at Saint Francis — the only remaining inpatient pediatric option in Tulsa.

“We’re always preparing for battle. It’s just a question of where we’re going to fight,” said his mother, Aurora Rutledge, looking frightened as she twisted the blond ringlets that poked out from under Lachlan’s Spider-Man headphones.

Hospitals around the country, from regional medical centers to smaller local facilities are closing down pediatric units. The reason is stark economics: Institutions make more money from adult patients.

In April, Henrico Doctors’ Hospital in Richmond, Va., ended its pediatric inpatient services. In July, Tufts Children’s Hospital in Boston followed suit. Shriners Children’s New England said it will close its inpatient unit by the end of the year. Pediatric units in Colorado Springs, Raleigh, N.C., and Doylestown, Pa., have closed as well.

“They’re asking: Should we take care of kids we don’t make any money off of, or use the bed for an adult who needs a bunch of expensive tests?” said Dr. Daniel Rauch, chief of pediatric hospital medicine for Tufts Medicine, who headed its general pediatric unit until it closed over the summer. “If you’re a hospital, that’s a no-brainer.”

Many hospitals have converted children’s beds to adult I.C.U. beds during the pandemic and are reluctant to change them back. Now, staff shortages, inflation — drug costs have increased 37 percent per patient compared to prepandemic levels — low Medicaid reimbursement and dwindling federal subsidies granted during the pandemic have left some health centers operating on negative margins and eager to prioritize the most profitable patients.

Young patients like Lachlan, who has private insurance, occupy beds to recover from infections or asthma attacks but don’t undergo lucrative, billable procedures — like joint or heart surgeries — that are more common among aging patients.

Physician reimbursement through Medicaid, the insurance program for low-income people, is often only about 70 percent of the amount reimbursed through Medicare, the insurance program for elderly people of all incomes. More than a third of children in the United States are enrolled in Medicaid.

There have been no aggressive legislative efforts to keep hospitals from closing or shrinking their pediatric units. Democratic senators introduced a bill last year to grant funding to specialized children’s hospitals to improve their infrastructure, but it has not moved past the assigned committee.

Health policy experts say an important solution would be to encourage hospitals to care for children by increasing Medicaid reimbursement rates. But even higher Medicaid and private rates wouldn’t come close to what hospitals can charge for remunerative adult procedures, and with many state budgets already strained, experts say the regulatory move is unrealistic.

Hospitals that no longer admit children rely on transferring them to pediatric units at other hospitals. But when even the largest pediatric floors in the country are at capacity, the pileup of critically ill children in E.R.s can cause patients’ conditions to worsen.

An E.R. crush

“Picu kids don’t belong here,” an overwhelmed E.R. doctor in a small Boston area hospital wrote two weeks ago to his hospital’s chief medical officer in an expletive-ridden text message reviewed by The Times. (P.I.C.U. is the acronym for pediatric I.C.U. The text message was shared on the condition that the hospital not be identified.)

Every I.C.U. for children in Boston was full at the time, and the nearest open beds were in New Haven, Conn., and Vermont. The doctor who sent the text message considered intubating the child in the E.R. while he waited for a closer bed to become available.

As children return to school, waves of illnesses are overrunning many of the units that remain.

“Forget the two-week January crush. We couldn’t find beds in May or August or September,” said Dr. Melissa Mauro-Small, the chief of pediatrics at Signature Healthcare Brockton Hospital, near Boston. “There is no more respiratory season. It’s respiratory season year-round.”

A hospital in Plymouth, Mass., that had not transferred a patient to Dr. Mauro-Small’s hospital in a decade did so six times in 10 days recently, she said. The E.R. staff at Lowell General Hospital outside Boston had to ask eight hospitals across New England whether they had room for an intubated 2-year-old, according to patient charts reviewed by The Times. It transferred another patient to the closest I.C.U. bed available — in Maine.

“At some point, this was going to become a crisis,” Dr. Mauro-Small said. “And here we are.”

St. John Medical Center in Tulsa had been a community treasure for almost a century when Ascension acquired it in 2013. The closure of the pediatric unit triggered opposition from both families and referring pediatricians.

Dr. Michael Stratton, a pediatrician in Muskogee, Okla., said Ascension St. John had been “the number one place to send a child,” and its pediatric unit closure had been “such a huge disservice to all of eastern Oklahoma.”

A spokeswoman for Ascension St. John, where Lachlan had been admitted to the I.C.U. three times before the closure, declined to be interviewed but said in an email that the closure was driven by a demand for more adult beds. She also pointed to past statements that said the Children’s Hospital at Saint Francis was “more than capable of picking up the slack.”

A spokeswoman for the Children’s Hospital at Saint Francis said that it had occasionally reached full capacity and that the staff transferred about 23 patients to other facilities, including in Arkansas, so far this year.

The E.R. “was busy even prior to the closure of the St. John’s pediatric unit,” she said. Still, she said the hospital had not become overburdened. “Volume is fairly consistent with what we usually see on a seasonal basis,” she said.

Some Oklahoman families with chronically ill children say they routinely drive to Memphis, St. Louis and Rochester, Minn., for care. The distances cause financial strain and, in the worst cases, cause them to forgo care, said Katy Kozhimannil, director of the University of Minnesota Rural Health Research Center.

For those in rural communities, pediatric closures have made travel to what Dr. Rauch calls “bread-and-butter pediatrics” untenable. Sixteen-year-old Johnny in Childress, Texas, had to be home-schooled so he could travel eight hours to Dallas for dialysis treatment three times a week, according to his doctor.

Jamaal Bets His Medicine, a 2-year-old with an autoimmune disease in Fort Kipp, Mont., routinely takes an 11-hour trip to Billings, Mont., to receive infusions, his mother, Patricia, said.

‘Children are not small adults’

The decline of local access to children’s inpatient care began over a decade ago and accelerated during the pandemic. Between 2008 and 2018 — the most recent national data available — pediatric inpatient units in the United States decreased almost 20 percent, and nearly a quarter of children found themselves farther from their nearest pediatric unit.

The steepest decline in pediatric inpatient beds was in rural regions, where large health systems acquired community hospitals and consolidated pediatrics to one campus.

Centering pediatric care in specialized centers can erode a local hospital’s ability to care for a critically ill child, doctors say.

“Children are not small adults,” said Dr. Meredith Volle, a pediatrician at Southern Illinois University School of Medicine in Springfield, Ill., who routinely sees patients who travel from two to three hours away. The number of pediatric beds in Illinois has declined, and 48 of its counties now have no pediatrician at all.

“When nurses and respiratory therapists become less comfortable with children’s cases, when the units don’t have child-sized equipment,” Dr. Volle said, “at a certain point, you really shouldn’t treat kids anymore because you don’t treat them often enough to be good at it.”

Critically ill children are four times as likely to die in hospitals and twice as likely to die in trauma centers that scored low on a “pediatric readiness” test, according to research. Only one-third of children in a national research survey had access to an emergency department deemed highly “pediatric-ready,” and of those, nine out of 10 lived closer to a less-prepared one.

A parent who is unaware of the wide variability, said Dr. Katherine Remick, the executive director of the National Pediatric Readiness Quality Initiative, “could make a split-second decision that changes their child’s fate.”

Lachlan’s life

The Rutledge family lives in Broken Arrow, a sunny Tulsa suburb with a frozen custard shop and a dentistry called Super Smiles. Their front porch is home to potted succulents, an abandoned scooter and a 140-pound Great Dane named Thor.

But their lives are far from ordinary. The last time Lachlan needed to see an allergy specialist, his mother packed the car with his nebulizer and medications for a 14-hour drive to Denver, leaving her husband, their two other sons and her mother, who was undergoing chemotherapy, for two weeks. Later, when doctors told her that Lachlan’s disorder appeared to be causing stomach ulcers — but that the sole pediatric gastroenterologist at Saint Francis wasn’t available for months — she began planning a journey to Dallas.

On the September morning that Lachlan was in St. Francis struggling to breathe, the E.R. was so busy that Ms. Rutledge hooked him up to a pulse oximeter herself, quieting the monitor’s settings so it wouldn’t frighten him every time his heart rate spiked.

Lachlan tugged at his collar bone, his chest looking retracted. Five hours later, he still hadn’t been admitted. Ms. Rutledge’s hands trembled and tears streamed down her face.

“I know you guys are exhausted at this hospital, and I get it,” she shouted, leaning over Lachlan’s bed to level her eyes with the attending physician on the other side. “But you will not send this child home so he can watch his own vitals drop.”

Lachlan was discharged from the E.R. after 10 hours with a course of steroids to fight the inflammation in his lungs. He sleeps in his parents’ bedroom so they can check his oxygen levels and administer nebulizer treatments every few hours throughout the night.

https://www.blogger.com/blog/post/edit/3936036848977011940/7450453546278410190 

 

A Crisis of Burnout Among Doctors

Oct. 17, 2022, 12:06 p.m. ET

 

To the Editor:

Re “New Survey Suggests an Alarming Increase in Physician Burnout” (news article, Sept. 30):

There is a crisis brewing within the health care industry. More than half the physicians in this country suffer from burnout, and roughly 300 to 400 die by suicide each year. Common causes of burnout include increased administrative tasks, long hours, frustration with the electronic health records system and insufficient compensation.

Interestingly, the burnout rate among independent physicians in New York City, at 13.5 percent, is dramatically lower than the national average of 54.4 percent.

However, there has been a significant decline in independent physicians because of the policies put in place by the Affordable Care Act that favor larger corporations and hospitals. As a result, independent medical practices are increasingly being acquired by hospitals and large corporations, which tend to put profits before patients and exercise absolute control.

While there’s little growth in the number of physicians entering the work force, there has been a more than 3,000 percent increase in health care administrators over the last four decades. Unless the increasing power of hospital and practice administrators is curtailed, the situation will only get worse.

Congress needs to act now.

Bhupendra O. Khatri
Milwaukee
The writer is a neurologist and the author of “Healthcare 911: How America’s Broken Healthcare System Is Driving Doctors to Despair, Depriving Patients of Care, and Destroying Our Reputation in the World.”

https://www.nytimes.com/2022/10/17/opinion/letters/doctors-mental-health.html 

 

Lessons From a ‘Difficult Patient’

Sal was the kind of patient that doctors strive to avoid. But for one medical student, he provided an education in compassion.

By Gina Siddiqui - NYT - October 18, 2022

Sal was 58 when I was assigned his case. Sal had been diagnosed with cystic fibrosis in the 1960s and was considered an old survivor; all his friends who had been diagnosed at the same time, including his younger brother, were dead.

I was 21, a few weeks out of college and one of the youngest students in my medical school class. Our assignment, to follow patients with chronic diseases to their clinic appointments, felt like a formality to my classmates whose parents were doctors and who already knew what went on in hospitals. But for me it was eye-opening.

On the day of our first appointment, I stood waiting for Sal on the freshly buffed floor of our hospital’s clinic lobby, fidgeting with my white coat and trying to hold my clipboard in a way that looked natural. The morning wave of physicians and researchers speed-walked past me to the elevators, coffee or cellphone in hand, eyebrows furrowed.

After 30 minutes passed with no sign of Sal, I called his cellphone. He wouldn’t be coming for his appointment today, he said, and would have to call back; he was on a call with the clinic receptionist, giving her a piece of his mind. Before I could respond, he hung up.

I looked up and saw, three cubicles away, a receptionist on the phone. She was red in the face; she kept starting to speak and then stopping, as if being interrupted. Eventually she hung up, sighed and walked over to a neighboring receptionist, gesturing back at her phone.

My phone buzzed in my pocket: Sal. This week was terrible, he said, because he had caught a cold. It was no use blowing a whole afternoon by going to a routine checkup. It was a waste of time, he said — time he didn’t have.

In the body shop

As we talked, I learned that colds are a major concern for people with cystic fibrosis; for many it is the cause of death. “I’m stressed out,” Sal said, adding an expletive. I asked if instead of trying to ride this out himself, he might let a doctor help him. He was reluctant but eventually agreed to come to the clinic. But when I asked to squeeze Sal into the afternoon schedule, the receptionist looked incredulous: Was I sure the doctor really wanted to see Sal?

Sal, I was learning, was what medical people call a “difficult patient,” one who doctors avoid. I watched him quiz his new doctors to see if they had read his chart carefully. How many of the bacteria species that colonize the lungs of cystic fibrosis patients could they name? He rewarded correct answers with even harder questions about local antibiotic resistance patterns. If the doctor said he or she didn’t know, Sal glared quietly; if they made up an answer, he was merciless.

After Sal’s appointments, I stayed behind with the doctors who were discussing his case. They set aside their medical differences of opinion and found solidarity in complaining about him: Did he have any idea that everyone else waited graciously for whoever was available, while he demanded a new doctor every other visit?

Sal’s pulmonologist of 30 years had retired, and the clinic had been struggling for months to figure out who would take on Sal’s case. Since not many cystic fibrosis patients had made it to Sal’s age, Sal suspected that many adult pulmonologists, especially the older ones, saw his ailment as a pediatric problem that they wouldn’t have to deal with, and ignored its nuances. In the case of several doctors I met, he was right.

The next year of medical school I went from being an observer to having patients of my own in the hospital. My job was to write medical to-do lists for each patient, covering every organ system. I learned a 21-point inspection of sorts to troubleshoot each malfunctioning part, as if my patients were machines in a body shop.

My supervising doctors showed me how to set the rates at which my patients’ kidneys produced urine and their lungs expelled carbon dioxide. They made these decisions quickly, with little self-doubt. Hormones, fluids, wires, tubes, sedatives, paralytics; the bone’s ability to remodel, the heart’s strength to contract — I was responsible for all of these things and had limited time to make all these plans. Don’t worry, I was told, we’ll start you with easy patients.

One such patient was a man who needed emergency surgery to remove an oxygen-starved section of his intestines. The remaining segment was brought through his skin and stitched beside his belly button, a plastic bag taped around the opening where stool now left his body.

When I woke him up before dawn to examine his wound, he did not resist or chide me for my cold hands, as Sal would have. He didn’t challenge the plan or ask follow-up questions. Rounds on him never took more time than I had allotted. My colleagues were right: He was an easy assignment for a medical student, because he was a shell of a person.

The nurses in the I.C.U. told me they had seen many patients like him — that critically ill patients often detach themselves from what they must endure. They asked me to imagine waking up defecating out of my abdominal wall and if it would change who I thought I was. Patients on the brink of death are not demanding and inquisitive like Sal. They are formless putty in the hospital’s hands.

A year and a half on the wards and a few hundred patients later, I had become better at breaking people down into their medical machine parts. My evaluators judged this skill during medical rounds, when we distilled patients’ histories into a single sentence, a feat made easier with patients like the man with bowel surgery. These patients succinctly told me what would fill in the blanks of my medical one-liner and didn’t cloud the picture with any personal thoughts of their own.

Passive patients were “easy” because we doctors could efficiently take total control. But once patients left the clinic we could promptly absolve ourselves of that responsibility. I had no idea what happened, for instance, when my patient with bowel surgery had to figure out how to do groceries and clean his bag of stool himself.

A three-ring history

That summer, I visited Sal’s house in South Philly, and he took me for a drive in his yellow Viper. “The great thing about not having kids is all the disposable income my wife and I have for fast cars,” Sal said. (Male cystic fibrosis patients lose the ducts that enable sperm to be ejaculated, rendering them infertile.) We sped along back roads to his favorite Italian restaurant.

On the mantel of Sal’s home were photos of him and his younger brother. Next to these was a pile of medical binders. Sal kept daily records of his lung function, his muscle strength and his respiratory symptoms, compiling statistics monthly and yearly. He did this manually, before the advent of FitBits and Apple Watches. He also collected clinical trials and review articles on cystic fibrosis. Sal was on his third five-inch binder.

The doctors made fun of Sal’s tomes and took bets on who would catch the hot potato next month and be expected to wade through his thousands of pages in 30 minutes. I thought of the meticulous attention to his disease that these binders embodied. How absurd that this asset was perceived as an albatross.

It was my first lesson in recognizing patient qualities that benefited their health but not the doctor’s workflow. Doctors did not commend patients who expected to understand all their test results, or who pushed back against treatments that were only weakly supported by evidence, or who wanted to talk to a doctor on the phone instead of waiting a week and missing a half-day of work for an in-person appointment.

The only patients deemed more difficult than insistent patients like Sal were his opposites: patients so overwhelmed that they stopped wanting to pay any attention to their illnesses at all. They are well known to every doctor: a dialysis patient, gray from uremia, eyes glazed over when asked why she missed her last session; a double amputee now bed-bound, refusing home visits; a boy with severe food allergies who won’t carry his EpiPen with him.

Sal did not bring his binders to his next appointment. They were becoming too cumbersome, he said, so he had started to simply jot down any crucial notes. These all had the same upshot: Sal was growing sicker and weaker. During one appointment I sat in on, Sal complained that he could not lift as much as he could the previous year: Why was that? And what could he do about it?

The doctor pointed to his own gray hairs — advancing age, nothing to be done about it. I expected Sal to press the doctor to back up this proclamation with numbers and parameters for lung function, or to demand a new doctor. Instead, he was quiet for the rest of the appointment and seemed to shrink into himself on the examining table.

Later that week Sal wrote me an email: Prepare a speech for those moments, like the one that week, when patients come to you at the end of their rope, and you have no more solutions to offer, he said. I think I was studying for an exam, and brushed off the message.

Cultivating distance

By now I was almost done with medical school. As we neared the end of our rotations, actors were hired to play patients and give us feedback on our bedside manner. They said things like, “It made me feel better when you looked me in the eye to break bad news.” We laughed, half-insulted, half-guilty.

I practiced “therapeutic distancing” to make decisions about patients coolly and unemotionally. I didn’t share much about myself or display vulnerability or uncertainty. I practiced not thinking about my patients once I got home.

With Sal I maintained none of these conventions. He and I continued to email back and forth. I sent updates about medical school, vacation travels, relationships and my plans for the future; Sal updated me on his declining health. Then one day my email to Sal bounced back, because he had died.

Years later in my training, on a late night home from the hospital, I reread Sal’s emails. Bathed in the blue light of my laptop screen, his advice about preparing a speech spoke to me as if from a ghost. I now had a command of anatomy, pathophysiology and pharmacology. I had impressed my supervisors and diligently maintained therapeutic distance. I was finally starting to become confident as a doctor. Why, then, did I feel so empty?

At first, the speech I wrote was for him. I told Sal that he should not blame himself any longer for growing weaker. He had fought his ailment valiantly, and his brother’s photo could occupy that space on the mantel alone now, without the binders. For a while I wished I had given him this speech, but I knew why I didn’t: I wasn’t his doctor.

Sal did not seem to want speeches of that sort from his actual doctors. He had become unpleasant toward members of the clinic staff, distrustful of everyone before his appointment even started. If Sal was told there were no prescriptions or procedures to fix the problem he was describing, he would condemn his team’s command of medicine and declare the appointment a waste of time.

It was not just we who had mechanized Sal; he had mechanized us, too. He expected near-infinite knowledge from his doctors on technical matters but dismissed their opinions as individuals. Sal had come to expect only a machinist’s answers from doctors, and at some point that became all he would accept.

The weight of knowledge

Now I am the speed-walking supervisor asking my medical students to provide a one-line simplification of a person’s suffering. My focus is on which diagnoses would be most dangerous to miss and how behind I am with my other patients. I often tune out the personal stuff.

Modern medicine has trained me and my fellow doctors to pin patients down, like beetles to be examined on a bulletin board. Their free motion impairs our efficient taxonomy of them. Unsurprisingly, patients do not feel well understood while pinned on the paper roll of an exam table. But how else can we cover everything we must in an appointment lasting 30 minutes or less?

To its credit, medicine has tried to shift further toward seeing patients on their terms, with telehealth visits, open notes and hospital services at home. But even with these, the titanic burden of medical knowledge to which doctors must do justice can crush opportunities for intimate conversation.

I know none of my patients today as I knew Sal, and none of them know me as Sal knew me. Even if I had infinite time for them, patients treat me differently as a full-blown doctor. I carry responsibilities — to be knowledgeable, skilled, punctual — that Sal did not hold me to when he took me under his wing.

Now the speech that Sal inspired is directed inward. I tell myself that patients reach the end of their ropes for medical reasons, personal reasons and often a mix of the two. Sometimes just managing the medical reasons is challenge enough for me, and that’s OK. But when I’m the “patient” at a bank or courtroom or post office, I’m reminded of what competency feels like without humanity. That helps me summon that timid young woman on the buffed lobby floor, who knew nothing about medicine but earned her first patient’s trust by being kind and sincere. She has started seeing patients again.

A version of this article appears in print on Oct. 18, 2022, Section D, Page 8 of the New York edition with the headline: Learning to Really See ‘Difficult’ Patients.

https://www.nytimes.com/2022/10/18/health/doctor-patient-medical-school.html

 

To the Editor:

While we appreciate the attention to the issue of physician burnout in light of the Covid-19 pandemic, we wish to highlight a critical part of this story: The survey discussed in the article demonstrated that female physicians were twice as likely to report burnout.

As physicians, we are no different from the public. We have children, parents and loved ones who depend on us. In the pandemic, female physicians disproportionately took on child care, schooling, household and work-from-home tasks compared with male counterparts. Larger studies show how work-life interference — worse for those with caregiving responsibilities — contributed to burnout.

Repairing physician burnout requires looking beyond patient encounters to examine policies and resources that support caregiving and address the burdens that female physicians face. Programs like the Covid-19 Fund to Retain Clinical Scientists are concrete ways to systematically counteract burnout and support retention of women and caregivers in our work force. It’s imperative to act.

Anna Volerman
Bree Andrews
Vineet Arora
Chicago

Dr. Volerman is an associate professor of medicine and pediatrics, Dr. Andrews is a chief wellness and vitality officer and Dr. Arora is the dean for medical education at University of Chicago Medicine.

The Rise of Despair and Conservative Politics Health Justice Monitor -  October 19, 2022

Summary: Anne Case & Angus Deaton are leaders in defining the links between rising hopelessness, declining health, and political division. A linchpin is the growing economic penalty from lacking a college degree; another is increasingly unaffordable healthcare. Single payer is harder to achieve in this polarized context, but more needed to overcome our political disarray.

There Are Two Americas Now: One With a B.A. and One Without   By Thomas Edsall - NYT - October 8, 2022   The Republican Party has become crucially dependent on a segment of white voters suffering what analysts call a “mortality penalty.”   This penalty encompasses not only disproportionately high levels of so-called deaths of despair — suicide, drug overdoses and alcohol abuse — but also across-the-board increases in several categories of disease, injury and emotional disorder.   “Red states are now less healthy than blue states, a reversal of what was once the case,” Anne Case and Angus Deaton, economists at Princeton, argue in a paper they published in April, “The Great Divide: Education, Despair, and Death.”   … the correlation between Republican voting and life expectancy “goes from plus 0.42 when Gerald Ford was the Republican candidate — healthier states voted for Ford and against Carter — to minus 0.69 in 2016 and minus 0.64 in 2020. States classified as the least healthy voted for Trump and against Biden.”   … the ballots cast for Donald Trump by members of the white working class “are surely not for a president who will dismantle safety nets but against a Democratic Party that represents an alliance between minorities — whom working-class whites see as displacing them and challenging their once solid if unperceived privilege — and an educated elite that has benefited from globalization and from a soaring stock market, which was fueled by the rising profitability of those same firms that were increasingly denying jobs to the working class.”   The Great Divide: Education, Despair, and Death Annual Review of Economics April 2022 By Anne Case and Angus Deaton   Abstract  Deaths of despair, morbidity, and emotional distress continue to rise in the United States, largely borne by those without a college degree—the majority of American adults—for many of whom the economy and society are no longer delivering. Concurrently, all-cause mortality in the United States is diverging by education in a way not seen in other rich countries. We review the rising prevalence of pain, despair, and suicide among those without a bachelor’s degree. Pain and despair created a baseline demand for opioids, but the escalation of addiction came from pharma and its political enablers. We examine the politics of despair, or how less-educated people have abandoned and been abandoned by the Democratic Party. Whereas healthier states once voted Republican in presidential elections, now the less-healthy states do. We review deaths during COVID-19, finding that mortality in 2020 maintained or exacerbated existing relative mortality differences between those with and without college degrees.   Excerpts   [T]he economy has increasingly come to serve some, but not all, Americans, and where a central division is between those who do and those who do not have a 4-year college degree. While the college wage premium has soared to unprecedented levels, the inequality between these two groups involves much more than money. The college degree has now become “a condition of dignified work and of social esteem” as well as a matter of life and death, with adult life expectancy rising for the college educated and falling for the rest.   In our book [2020], we developed an account of the rising tide of despair, focusing on declining employment opportunities for those without a BA, especially the fall in good jobs, those that offer a sense of belonging, meaning, and purpose and prospects for advancement. This was aggravated by an ever more expensive health care system—more than twice as expensive as in other rich countries—a fifth of which is financed by an approximately flat tax on workers in amounts that often make low-skilled workers unemployable. An employer-sponsored individual (family) health plan cost $7,470 ($21,342) in 2020, $3.73 ($10.67) per hour for a 2,000-hour year, money that comes out of wages and take-home pay (KFF 2020). We also noted the lack of a comprehensive safety net in the United States for those who are neither elderly nor children … Both the safety net and the financing of health care are radically different in other rich countries where—with a few exceptions—there are few deaths of despair. …[W]e emphasized the corrosive effects of American meritocracy on the unsuccessful, on Young’s “populists” who have to live with the meritocratic hubris of the well-credentialed … and who, as they strive not to blame themselves, believe—with much justification— that society is rigged against them. …   Deaths of despair among Blacks and among Hispanics began to rise after 2010; like those for Whites, the increases are largely confined to those without a 4-year college degree. About three-quarters of the increase for Blacks and Hispanics without a BA is accounted for by drug overdoses.   A Politics of Despair   If the majority of Americans are failing to thrive while a minority prospers, why does the democratic process not work to improve their material and health outcomes? … [L]iving in a functioning democracy is good in and of itself, and the lack of effective political voice is one reason to despair. Woolhandler et al. (2021) in a Lancet Commission report on public policy and health in the Trump era … describe a negative feedback loop in which “the neoliberal policies that inflicted economic hardship and worsened health” did not, as might have been expected in a well-functioning democratic state, generate a political demand for better safety nets and health provision, because less-educated whites see such policies as favoring minorities at their expense. … Blacks and more educated whites react in the opposite direction, widening political polarization, which on net favors the right and provides an opening for populist politicians such as Donald Trump. …   [A]fter the US presidential election of 2016, several studies noted correlations between deaths of despair, changes in life expectancy, and the Republican share of the vote (Monnat 2016, Bor 2017). Bor (2017) finds a correlation of −0.67 across counties between changes in life expectancy from 1980 and 2014 and the share of each county’s vote going to Trump. There is a similar cross-county correlation of Trump’s vote share with the fraction of each county’s White population without a college degree …   The economy began to turn against the white working class around 1970. Real wages began to decline for workers without a BA, and there was a long, slow decline—interrupted but never fully restored during economic booms—in job opportunities for less-educated men, much of which was driven by the decline in employment in American manufacturing. Globalization was important, though less important than automation, as was the relentless increase in the cost of health care, much of which is paid for through what is essentially a head tax on wages. …   Since the 1970s, there has been a slow-rolling and still ongoing divorce between Democrats and the white working class, a divorce that is central to the politics of despair. Especially after the catastrophic 1968 Democratic National Convention, the party slowly oriented itself away from its traditional working-class and union base toward what it is today, a coalition of minorities and educated professionals. …  https://www.nytimes.com/2022/10/05/opinion/mortality-penalty-inhttps://www.nytimes.com/2022/10/05/opinion/mortality-penalty-inequality-education.htmlequality-education.html

Comment by: Don McCanne & Jim Kahn The political realignment that has taken place has racial minorities joining the better educated professionals, improving their own educational levels and their own health status, whereas less educated largely white populations have aligned with the Republicans as their despair and sense of being abandoned has risen. Hence worse health and rising drugs, depression, and suicide in GOP-dominated states. With the conservatives more volubly exploiting these issues, our hopes for reaching social solidarity on a universal health care system diminish. Is there pride in being uneducated? In being at high risk of those factors that lead to deaths of despair? Of having a shorter life expectancy? Of being used by the conservative political forces to impede social progress in our nation? If these concepts were better understood, we could raise social solidarity and accomplish goals such as health care justice for all. Providing universal, stable, affordable, high-quality care would sharply decrease political alienation and hopelessness, and tangibly convey the virtues of a community orientation over private profit. No wOonder single payer is so frightening to the conservative purveyors of political schism. Halloween is coming, time to embrace our worse fears.     Ruralist Lament: The King is dead – Long live The King by Richard Rhames - Portland Press Herald - October 27, 2022 Having been dirt farmers over the last 40 years, my wife and I have tended to live simply. We did take a couple perhaps extravagant “vacation trips” decades ago. Two years running we both went to Augusta (Maine) for the annual Agricultural Trade Show — even staying overnight at the “Senator Inn” between the Tuesday and Wednesday sessions. Wednesday morning we’d “breakfast” at the McDonald’s on Western Avenue and watch the log trucks rumble past. Good times. Those were the days. We were less extravagant when it came to health insurance — just couldn’t afford it so we went without, finally “successfully aging” into Medicare coverage. Medicare and Medicaid were as close as we ever got to universal healthcare in this backward, barbaric land and then only because of social movements in those “turbulent” 1960s which all-too-briefly struck fear into the wizened heart of the Washington establishment. Since then it’s been a steady diet of propaganda and policy pushing the snake-oil that “markets” are The Only Way to provide for society’s needs: housing, health care, communications, energy, technical innovation, transportation. Public subsidy to private profit is the only (rigged) game in town. We pay more to get less than other countries. But such comparisons aren’t typically topics of conversation. Instead we are invited to gape at tawdry “stories” of furtive celebrity-groping, consume Smackdown TV, ruminate on whether Zappe- 1/3 Hour will reign in PatriotNation (or will Mac Be Back?): This, while sluicing billions to the bipartisan “Weakening Russia” project, inviting what Commander Biden has called “World War 3.” Oh dear. And so when today’s local paper reported (below the fold) (in the “Business” section) that the Pfizer corporation planned to charge $110 to $130 for Covid-19 vaccines the news was unsurprising. The AP reporting was a typically bland, Rip&Read stenography simply recasting a Pfizer press release as journalism. If there was any objection to the price inflation it went unreported here. Those who remembered that the federal government rolled well over a billion dollars into the development of such RNA vaccines through the NIH (National Institutes of Health), DARPA (Defense Advanced Research Projects Agency), and many other federal research entities doubtless rolled their eyes at such corporate gall. But for the AP it was just another Move- along/Nothing-to-see here report. When Dolly Parton donated a million bucks to Vanderbilt University to fund RNA vaccine research it was news (see New York Times, 3/2/21), but public investment goes typically unreported. Turns out that there was another way to look at Pfizer’s gambit. Though the AP didn’t mention it, the People’s Vaccine Alliance (PVA) released a statement last Friday announcing that the “planned price hike would amount to a 10,000 percent markup above the cost of producing the vaccine, which is estimated to be as low as $1.18 per dose.” (see Jake Johnson, Common Dreams) Julia Kosgei, policy advisor to the PVA described the move as a “shameless fleecing” of the public, calling it a “truly mask-off moment for one of the great profiteers of this pandemic.” Despite a chronic lack of real reporting, Americans apparently smell a rat. Gallup (and West Health) recently released a poll (10/6/22) which asked citizens to grade US health care by category: “Overall, Cost of Care, Equitable care, Access to care, Quality of care. “ Average grades ran from C to D-/F — consistently D/F, across all income brackets on the cost-of-care question. But so what? The American public has a better chance of reanimating Elvis Presley’s corpse than they do of installing a humane and just health care regime. Frankly, the premodern constitutional system still controlled by the dead hand of the 18th century powdered wig set will not allow it. And the new “Originalist” super majority on the Supreme Court insists that the judgements of the ZombieFramers must supersede the needs and judgements of today’s downwardly-mobile citizens. 2/3 Despite the current run of stories about Americans bemoaning a decline in “democracy” Republican congressional leaders are increasingly open in predicting a post-election “debt ceiling” crisis, aimed at finally taking down the hated “Entitlements” of Social Security, Medicare, and Medicaid. In “Triumph of Politics” (1986), Ronald Reagan’s budget director David Stockman describes the Great Communicator’s plans to cut taxes, increase military spending while “storming the twin citadels of the welfare state — Social Security and Medicare.” Then, Stockman laments, “politics” triumphed. Under Bill Clinton there was another privatization bipartisan push. Reportedly the “private account” Social Security cards were being prepared when the Monica Lewinsky tempest broke. Clinton had to fold. This time, they will claim again that the social insurance systems are “unsustainable.” In 2010, Alan Simpson, co-chair of Obama’s bipartisan Commission on Fiscal Responsibility and Reform decried Social Security as “a milk cow with 310 million tits.” We’ll likely hear that sentiment again, probably without the ruralist twang. Elvis reanimation anyone? https://www.pressherald.com/2022/10/27/ruralist-lament-the-king-is-dead-long-live-the-king/ The FTC and DOJ have vowed to scrutinize private equity deals. Here's what it means for healthcare By Anastassia Gliadkovskaya - Fierce Healthcare - October 21, 2022 The Biden administration has been keen to take on corporate consolidation, appointing a new generation of antitrust officials to the Department of Justice (DOJ), the Federal Trade Commission (FTC) and the White House that has promised to pay closer attention to private equity deals. One area of focus is healthcare. For years, PE firms have been buying up healthcare players. In 2018, for the first time, there were more physicians who were employees than owners of their practices. While PE can help drive operational efficiencies, there is growing concern—and evidence—that their motive for profit can conflict with maintaining quality care.  Recent studies and investigative reporting have found that after PE takes over a nursing home, patients die more often. PE firms have been investigated for their role in surprise bills and slashing benefits for emergency room doctors early in the pandemic; they have been known to push clinical staff out of important decisions. They are also linked to higher Medicare and private insurance spending.  While critics claim the DOJ and FTC are not following traditional interpretations of antitrust laws, the agencies argue there is a need to more closely scrutinize these deals and the impact they have on competition.    “Ripe for potential investigation”    The DOJ has recently indicated a particular focus on rollup transactions that consolidate market share and, with it, negotiating power. Payers and providers have been merging for years, even throughout the pandemic, spurring concerns about price gouging. The FTC’s own study has found that several recent hospital mergers have resulted in significant price hikes and reduced quality care.  The agency is also concerned about filing deficiencies and conflicts of interest related to board appointments of PE representatives at competing companies. In September, the DOJ began digging into antitrust concerns in the New England fishing industry. That’s an indicator that probe efforts are ramping up, Austin Ownbey, an antitrust attorney at D.C.-based law firm Foley Hoag, told Fierce Healthcare.  “Given the fact that they are obviously looking at corners of the market that they haven’t traditionally looked at,” Ownbey said, “my advice would be don’t assume that you can just look at the standard antitrust concerns you’ve looked at for years.” Any PE involvement, including in smaller markets, seems “ripe for potential investigation.” In particular, Ownbey suspects, those being targeted will include verticals with promising returns from consolidation, namely outpatient services like gastroenterology, ambulatory and wound care centers.  Or, regulators might target areas where the patient population is especially vulnerable, such as nursing homes, explained Arman Oruc, co-chair of Goodwin’s antitrust practice. Though there haven’t been any enforcement actions that he has seen so far, Oruc says parties need to be prepared to answer a lot of questions.  “It’s something that any healthcare executive should consider if they’re looking at any transactions,” Oruc said. Adjusting to enforcement   Funds will likely reconsider what companies they go after and in what order, according to Matt Simpson, an M&A lawyer at Mintz. They will be thinking of higher priority targets first, and likely those they have expertise in already.  Healthcare markets tend to be large, fragmented and localized—so “a lot of this comes down to how you define competition and where does the competition actually occur,” Simpson said. “It is a very fact-specific analysis in these transactions.” Though it is helpful to have a business run by someone with prior investments in the same space, “you’ve got to weigh the fact that we don’t want to see consolidation reach the point where prices are going up,” Ownbey explained. If investors decide to avoid scrutiny by sticking to one investment per market, “it makes capital more expensive.” A company may need to look for other sources of funding; if that fails, it may need to pull out altogether, which could harm competition. https://www.fiercehealthcare.com/regulatory/ftc-doj-promise-heavier-scrutiny-pe-deals-healthcare   FTC warns states against laws permitting hospital mergers under special conditions In Oruc’s view, PE provides needed capital to underfunded businesses; it doesn’t go in to crush them. If added regulatory scrutiny has a chilling effect on activity in the sector, “it’s only going to harm consumers and patients out there,” Oruc said.  Healthcare entities should be mindful of this shift in enforcement. “Even if the focus of the investigation is on the private equity fund,” Ownbey noted, “a DOJ investigation will be incredibly disruptive.” The agency might seek months' worth of documents and interviews —and ultimately, might not approve the deal. Investors might decide to scrap a deal themselves for the same reasons. It would be “way better” to avoid getting into a deal with a fund that will draw scrutiny, Ownbey added.  The safest path forward is to seek antitrust legal counsel and identify the risks ahead of time. Transaction costs may go up; prices may go down. But ultimately, Simpson believes dealmaking will adjust: “Innovation and regulation—they can coexist.” https://www.fiercehealthcare.com/regulatory/ftc-doj-promise-heavier-scrutiny-pe-deals-healthcare The future for practicing physicians in a corporate world By Jeff Goldsmith - Stat News - October 14, 2022 Forty years ago, in his Pulitzer Prize-winning history “The Social Transformation of American Medicine,”  sociologist Paul Starr predicted that independent physician practice, which had been a cornerstone of American medicine for most of the 20th century, would be eclipsed by the “coming of the corporation.” Starr forecast that the end of the century would not only be “a time of diminishing resources and autonomy” of this powerful profession, but also “greater disunity, inequality and conflict throughout the entire health system.” With the benefit of 40 years of hindsight, Starr’s was a remarkably prescient forecast. By 2020, for the first time, less than half of U.S. physicians worked in physician-owned settings: more than 300,000 U.S. practicing physicians were employed by hospitals, and another 122,000 were employed by corporations of various kinds — health insurers, pharmacy chains, private equity-backed companies. A single diversified health insurer, UnitedHealth Group, claims to employ or represent 60,000 physicians through its Optum Health subsidiary. Though Starr’s forecast rested upon a looming physician surplus beginning in the 1980s, compounded by the effect of pressures to contain medical expenses, three other factors contributed to the decline of independent practice. Many of the baby boom cohort of practitioners chose employment as a bridge to retirement, trading professional independence for income security and what they hoped was a saner work schedule. The rising number of women entering medicine traded independence for the work-life balance that enabled them to start and care for families. And the crushing burden of college and medical school debt made assuming the risks of independent practice a bridge too far for many physicians entering the workforce. In accepting employment, physicians old and young shifted their business risk to corporate enterprises, which absorbed the resultant decline in productivity and negative practice cash flows in exchange for achieving overarching corporate objectives: increased hospital admissions, imaging scans, and surgeries; the redirection of patient flows away from hospitals; or increased prescriptions or traffic in retail stores. Viewing employment as a solution to work-related stress and burnout has proven simplistic, and many of the clinicians seeking shelter from these problems have not found it. Several of the supply factors I mentioned earlier are temporally limited. Baby boom physicians will eventually retire — some reluctantly, but many gratefully. And younger physicians will eventually pay down their debts and be in positions to re-evaluate what they traded away when they joined large corporate enterprises. But as baby boomers encounter end-of-life medical problems, the U.S. will experience growing shortages of primary care physicians, geriatricians, psychiatrists, cardiologists, gastroenterologists, and others. These shortages will increase practice options and choices for many physicians, something that began happening during the pandemic due to burnout-related retirements. Given the macro trends, what will determine the future role and influence of practicing physicians in the care system? Here are a few questions that need answers: Will absorbing physicians’ costs as a “loss leader” generate sustainable economic returns for corporations where the main business purpose of employing them was not the actual delivery of medical care? For how long will physicians remain motivated to work for organizations where reducing medical expenses or redirecting patient trajectories after their visits — rather than achieving clinical excellence or meeting patients’ actual needs — is the main objective? Will physicians seeking influence over the conditions of medical practice eventually clash with corporate cultures, operational control, and human resource policies? These questions are not entirely rhetorical, and ultimately pertain to corporate culture and the values that underlie it. Medical education teaches physicians to put patients first, so they are not blindly deferential to authority or accepting of managerial control and do not make “go along to get along” employees. If physicians perceive daylight between their own professional values and the needs of their patients versus the goals of their employers, they will find an attractive array of choices in the coming decade, and see increasing job mobility and earning potential. Starr doubted that the coming of the corporation would mean the proletarianization of physicians. I agree. Physicians remain the nation’s highest paid profession. I doubt that the creeping unionization of interns and residents necessarily foretells unionization of employed practitioners. That would be a 19th century solution to a 21st century problem. Employed physicians will have a strong say regarding their professional futures. By exercising their growing market power, they will determine which potential employers deserve their loyalty. Physicians might not return to the position of commanding social and political authority they enjoyed for much of the 20th century, but I see the next decade as a period of reversal of the recent erosion in physicians’ economic power, and perhaps a rising influence of human values in medical care. Jeff Goldsmith is the president of Health Futures Inc., a strategy consultancy founded in 1982 that specializes in industry forecasting and trend analysis, and author of “Digital Medicine: Implications for Health Care Leaders” (Health Administration Press, 2003) and “The Sorcerer’s Apprentice: How Medical Imaging is Changing Health Care” (Oxford University Press, 2011) with Bruce Hillman. The author acknowledges helpful comments on this essay by Doctors Steve Motew and Megan Swanson, as well as by Kerry Shannon and Trevor Goldsmith. https://www.statnews.com/2022/10/14/future-practicing-physicians-corporate-world/?utm_source=STAT+Newsletters&utm_campaign=3264c1de16-Daily_Recap&utm_medium=email&utm_term=0_8cab1d7961-3264c1de16-152705913 Gaining Momentum in the National Single Payer Movement from Health Justice Monitor - October 28, 2022 Summary: This week three city councils in the Midwest, West, and Southeast passed resolutions backing nationwide single payer. This brings local endorsements to over 100. Combined with growing popular and physician support, are we approaching an irresistible force? Three Cities Pass Medicare for All Resolutions in Past Week October 26, 2022 Public Citizen   In a show of growing momentum behind passing Medicare for All legislation, Denver, Colorado, Gainesville, Florida, and Kent, Ohio all passed city council resolutions in recent days backing a nationwide universal healthcare program, sending a strong signal to Congress that their constituents care about ending for-profit healthcare.   The three cities join more than 100 localities that have endorsed Medicare for All.   During the pandemic, more than one million Coloradans – including 34% of those in Denver – saw their incomes reduced; many lost their job-based insurance, and people of color were hit hardest, according to the Colorado Health Institute’s 2021 Health Access Survey. In Denver County, the U.S. Census Bureau estimates that 12% of residents under 65 are uninsured.   In Ohio’s 13th district, where Kent is located, more than 43,000 people are uninsured, and over 117,000 people live below the poverty threshold. Kent Councilwoman Heidi Schaffer-Bish works with Coleman Health Services and encounters many people struggling to make ends meet when it comes to healthcare. “We’ve seen that government-based healthcare works, and private insurance through your employer does not,” said Shaffer-Bish.   In Alachua County, where Gainesville is located, the U.S. Census Bureau notes that 11.5% of people under the age of 65 are uninsured.   Brittany Shannahan, a Medicare For All organizer at Public Citizen, stated:“These resolutions, city-by-city, are helping to pressure our representatives to act to make guaranteed healthcare for all a reality. The chorus of voices is growing.” Comment by: Lily Meyersohn   Shannahan is correct in announcing that the “chorus of voices is growing” on a nationwide single payer healthcare program. This is not just three cities; this is a national movement. In recent years, support for the program has risen in the general public and among key stakeholder groups like physicians.   In Medicare for All: A Citizen’s Guide (2021), physicians and progressive activists Abdul-El Sayed and Micah Johnson write that “there is one stakeholder in American healthcare that matters most: the American public.” And “public support for M4A is high. A nationally representative Pew Research study [from 2019] found that most Americans agree “it is the responsibility of the federal government to make sure all Americans have health care coverage. And a majority of Americans support M4A as a way to achieve this goal.”   This is a sea change from prior decades: “From 1998 to 2008, the Kaiser Family Foundation conducted ten polls asking Americans whether they supported a single-payer national health insurance program. None found majority support. Between 2017 and May 2020, the same organization conducted fifteen similar polls. Every poll found majority support for M4A.”   Physicians, too, are shifting toward single payer. Sayed and Johnson note that the American Medical Association “played a central role in fighting previous attempts at national health insurance.” But now the organization’s membership is in steep decline. “Both physician preferences and power may be changing fast. Most individual physicians today support M4A.”   Recently we’ve experienced COVID fatigue: people fed up and tired of the pandemic. If the 100+ localities that have endorsed M4A – including the three cities that signed on this past week – can teach us anything, it is that people across the country are fed up and tired of our abominable health care system. Maybe we should call that “Mixed Insurance Plan Fatigue.” From fatigue comes a determination for change!   Lily Meyersohn is a researcher at the Institute for Public Accuracy, where she covers pandemic policy and American health care issues. She can be reached at lilymeyersohn@gmail.com. http://healthjusticemonitor.org/