Letter to the editor: Martin’s Point case shows need for Medicare for all
An excellent article by reporter Joe Lawlor was headlined “Martin’s Point fraud settlement highlights shortcomings in Medicare Advantage program” (Aug. 4). It might have said the settlement highlights shortcomings in “private, market-based insurance.” Over and over again, we bemoan the failings of treating health care as a business. Yet we are the only developed country in the world that keeps trying to do so.
There is a better way. The federal Medicare for All Act of 2023 (H.R. 3421) would build upon and expand Medicare to provide comprehensive benefits to every person in the United States. This includes primary care, vision, dental, prescription drugs, mental health, substance abuse, long-term services and supports, reproductive health care, and more.
Rep. Chellie Pingree, D-1st District, is a co-sponsor. We need the rest of Maine’s congressional delegation to get on board and take seriously the possibility that Medicare will be gutted by the private insurance market.
Karen Foster
Portland
Editor's Note -
Here's some good news for a change:
- SPC
Suddenly, It Looks Like We’re in a Golden Age for Medicine
We may be on the cusp of an era of astonishing innovation — the limits of which aren’t even clear yet.
by David Wallace-Wells - NYT = August 4, 2023
Hype springs eternal in medicine, but lately the horizon of new possibility seems almost blindingly bright. “I’ve been running my research lab for almost 30 years,” says Jennifer Doudna, a biochemist at the University of California, Berkeley. “And I can say that throughout that period of time, I’ve just never experienced what we’re seeing over just the last five years.”
A Nobel laureate, Doudna is known primarily for Crispr, the gene-editing Swiss Army knife that has been called “a word processor” for the human genome and that she herself describes as “a technology that literally enables the rewriting of the code of life.” The work for which Doudna shared the Nobel Prize was published more than a decade ago, in 2012, opening up what seemed like an almost limitless horizon for Crispr-powered therapies and cures. But surveying the recent landscape of scientific breakthroughs, she says the last half-decade has been more remarkable still: “I think we’re at an extraordinary time of accelerating discoveries.”
The pandemic has exhausted many Americans of medicine, and it has become common to process the last few years as a saga of defeat and failure. And yet these brutal years — which brought more than a million American deaths and probably 20 million deaths worldwide, and seemed to return even the hypermodern citadels of the wealthy West to something like the experience of premodern plague — might also represent an unprecedented watershed of medical innovation. Beyond Crispr and Covid vaccines, there are countless potential applications of mRNA tools for other diseases; a new frontier for immunotherapy and next-generation cancer treatment; a whole new world of weight-loss drugs; new insights and drug-development pathways to chase with the help of machine learning; and vaccines heralded as game-changing for some of the world’s most intractable infectious diseases.
“It’s stunning,” says the immunologist Barney Graham, the former deputy director of the Vaccine Research Center and a central figure in the development of mRNA vaccines, who has lately been writing about a “new era for vaccinology.” “You cannot imagine what you’re going to see over the next 30 years. The pace of advancement is in an exponential phase right now.”
‘World-changing’ innovations
It is sometimes hard to see the silver lining for the cloud, particularly when it’s as dark as the last three years have been. But at the very center of the American Covid experience, amid all the death and suffering and despite the dysfunction that midwifed it into being, sits what would have stood out, in any previous era, as an astonishing biomedical miracle: the coronavirus vaccines. Drug-development timelines in previous history had swallowed whole decades; experts warned not to expect a resolution for years. But the mRNA sequence of the first shot was designed in a weekend, and the finished vaccines arrived within months, an accelerated timeline that saved perhaps several million American lives and tens of millions worldwide — numbers that are probably larger than the cumulative global death toll of the disease.
The miracle of the vaccines wasn’t just about lives saved from Covid. As the first of their kind to be approved by the Food and Drug Administration, they brought with them a very long list of potential future mRNA applications: H.I.V., tuberculosis, Zika, respiratory syncytial virus (R.S.V.), cancers of various and brutal kinds. And the vaccine innovations stretch beyond mRNA: A “world-changing” vaccine for malaria, which kills 600,000 globally each year, is being rolled out in Ghana and Nigeria, and early trials for next-generation dengue vaccines suggest they may reduce symptomatic infection by 80 percent or more.
Not every innovation arriving now or soon to market comes from U.S. research or shares the same saga of development. But many of their back stories do rhyme, often stretching back several decades through the time of the Human Genome Project, which was completed in 2003, and the near-concurrent near-doubling of the National Institutes of Health’s budget, which helped unleash what Donna Shalala, President Bill Clinton’s secretary for health and human services, last year called “a golden age of biomedical research.”
Ozempic and Wegovy have already changed the landscape for obesity in America — a breakthrough that has been described and debated so much in terms of cosmetic benefits and medical moral hazard that it can be easy to forget that obesity is among the largest risk factors for preventable death in the United States. Next-generation alternatives may prove even more effective, and there are signs of huge off-label implications: At least anecdotally, in some patients the drugs appear to curb compulsive behavior across a range of hard-to-treat addictions.
A Revolution Is Coming to Medicine. Who Will It Leave Out?
by James Tabery - NYT - August 5, 2023
On Aug. 16, 2011, my father woke up and couldn’t get out of bed. Until then, he was an avid outdoorsman, who cast for trout on the Delaware River and trained German wirehaired pointers to track and point pheasant. So after an ambulance ride to the emergency room and then hours of tests, the diagnosis shook our family: Stage 4 non-small cell lung cancer.
Scans revealed tumors all over his body — brain, ribs, pelvis, spine. The tumors on his vertebrae quietly grew until they had cut off nerve signals to his legs.
More people die of lung cancer in the United States every year than from prostate, colon and breast cancers combined. Our family received hope, however, when a biopsy revealed that my dad’s cancerous cells had a molecular marker on their surface making them an ideal candidate for erlotinib, a drug that could disrupt their growth. Just weeks after he received his first dose, my mother phoned with tears of joy in her voice to tell me that the tumors were shrinking.
Erlotinib is a textbook example of what physicians call “personalized medicine,” or sometimes “precision medicine.” In contrast to traditional, one-size-fits-all health care, personalized medicine uses molecular-genetic information about patients to deliver the right treatment, to the right patient, at the right time. Prominent medical geneticists, influential federal scientists, hospital system executives and even elected officials foresee cancer treatments as the leading edge of a genomic revolution, ushering in a new era of miracle cures and biomedical magic bullets, and fundamentally transforming the care of desperate patients.
As health care costs skyrocket, some proponents of personalized medicine envision a more affordable alternative to traditional treatments, one that tailors interventions from the beginning of treatment rather than sending patients off on a trial-and-error odyssey. This approach, they say, could decrease waste while increasing the quality of care. Moreover, the claim is that personalized medicine research that prioritizes the participation of marginalized communities will ensure these breakthroughs extend to everyone, combating racial and sociodemographic health disparities.
It’s hard not to get excited about a future guided by this medical revolution. But a closer look at lung cancer, and at my father’s experience specifically, paints a far gloomier picture than what the personalized medicine champions would have you believe.
There are some diseases for which genetics is truly saving lives; in particular, patients with rare diseases like spinal muscular atrophy and certain cancers such as chronic myelogenous leukemia may now be prescribed personalized medicine treatments that simply didn’t exist a couple of decades ago. For most patients with most diseases, though, the lofty promises have failed to materialize. Even more dangerously, the hype has distracted from alternative approaches to health care that are better suited to improving health for all of us.
One problem with personalized medicine is the cost. As the bills for his biopsies, surgeries and radiation piled up, we started to call my father the “million-dollar man.” The real eyepopper was the erlotinib, priced at over $5,000 for a one-month supply of the tiny pills. A number of other drugs for lung cancer have emerged in the years since — osimertinib, crizotinib and sotorasib, to name a few — in the $10,000-to-$20,000-per-month range. These, in fact, are on the affordable end of the spectrum; $50,000-per-month list prices aren’t uncommon for personalized medicines.
There’s a straightforward biological explanation for this. Personalized medicine works by carving patient populations into subgroups based on their molecular-genetic profiles. For lung cancer, there are a number of biological distinctions made, and those distinctions result in smaller pools of potential users for any given drug, which incline the pharmaceutical companies to drastically increase prices.
There is thus an inherent tension at the heart of personalized medicine. It purports to both tailor health care and drive down costs, but the more it succeeds at individualization, the higher go the prices. Patients, as a result, can now face an agonizing decision: forgo treatment or suffer financial ruin.
Our family was fortunate. My parents were financially stable, and they had good health insurance that covered the expensive drug. They lived only an hour’s drive to a major hospital network. My father had another thing going for him: the color of his skin. White patients with lung cancer are far more likely than Black patients to receive a diagnostic test indicating whether or not a drug like erlotinib is a good match, and patients from richer neighborhoods are more likely to get access compared with those from poorer neighborhoods.
My dad was ultimately able to leave the hospital and go home, where he continued receiving care, undergoing physical therapy and tying flies in the hopes that he’d one day again wade into the chilly spring waters of the Delaware. The following summer, however, a round of tests revealed that his tumors were growing again. He never regained the ability to stand, let alone cast a fly. On Sept. 23, 2012, a little over a year after he woke up paralyzed, my father died.
Media reports surrounding personalized medicine often forecast a future of health care revolutionized by the arrival of medical magic bullets and biomedical breakthroughs. Erlotinib, though, generally doesn’t cure cancer; it puts it on pause, and when it comes back, it often comes back with a vengeance. Oncologists today can respond by prescribing one of the newer, more expensive drugs. Still, for patients with advanced lung cancer like my dad, the chances of being alive five years after initial diagnosis are terrifyingly small.
Genetic information about patients can result in clinical treatments for certain diseases that are known to be caused by a fairly straightforward genetic mechanism; that’s what made conditions like spinal muscular atrophy and chronic myelogenous leukemia such good candidates for intervention. But those cases are the exception in medicine, not the norm. When we move to common and complex diseases like hypertension, Parkinson’s, diabetes or asthma, where, for a vast majority of patients, there’s no single gene causing the disease, the opportunity for a personalized medicine revolution that can benefit most patients is severely limited.
Taking steps to prevent the development of illness is both more effective and more cost-efficient than trying to eliminate disease after it arrives. Lung cancer is a prime example. Even though there is still no cure for metastatic lung cancer, age-adjusted death rates from lung cancer in the United States have been dropping steadily because of public health research and programs aimed at making our environments more lung-friendly, with asbestos abatement programs, antismoking campaigns and other efforts to control harmful chemicals.
People of color and those living in poverty are particularly susceptible to the harms of unhealthy environments. They tend to be the ones who are living closest to factories and highways and farthest from green spaces and fresh produce. It is abundantly clear that health disparities along racial and economic lines are largely caused by differences in our environments, not differences in our genes. That’s why the health and economic impact of addressing unsafe drinking water, food insecurity, exposure to heavy metals and countless other things is so important: Everyone benefits, not just the people with the right genes, the right skin color or the right bank account balance.
It’s impossible to specify how much time erlotinib added to the end of my father’s life, but there’s every reason to believe that he lived longer because of the drug. I’ll always cherish that period, just as I’m certain that the family members of lung cancer patients battling the disease today soak up every moment with their loved ones. Erlotinib, however, didn’t save him. For a very high price, the drug slowed his terminal disease down for a short time, and even that limited benefit is not available to everyone.
Improving health for us all, driving down the costs of health care and making the world a more equitable place are all noble goals. The most direct route, though, isn’t by way of orienting health care around the genetic differences between us. It’s by focusing it on the environments we share.
https://www.nytimes.com/2023/08/05/opinion/personalized-medicine-genes.html
How former CMS head, Tom Scully, privatized and destroyed Medicare
by Diane Archer - Just Care - August 1, 2023
David Dayen reports on former Center for Medicare and Medicaid Services (CMS) head, Tom Scully, privatized and destroyed Medicare for The American Prospect.
Back in 2002, Scully, the administrator at CMS under President George W. Bush, attacked the incentives in the Medicare program. At the time, he was focused on hospital incentives to inflate patient costs, saying “People follow the money, and they’ll find the little niches in the program and they’ll game it, and that’s what happened here.”
Scully, himself, has taken advantage of these “niches” since leaving government in 2003 for private equity. Scully’s view about health care is Darwinian. People should pay out of pocket for their health care, as they do for their vegetables–survival of the fittest–with help only for the poor.
Scully doesn’t recognize the value of Medicare negotiating prices for physicians and hospitals. Of course, that’s what has kept Medicare spending down for older Americans and people with disabilities. It’s also one key way other countries get value from their health care systems. In Scully’s view, if you get sick, you should pay for it.
It’s thinking like Scully’s that has pretty much destroyed our health care system. Physicians and patients have suffered as private equity and big corporations have seen their profits soar. “Scully’s fear of big-government price-fixers has led to the triumph of big private profit-takers, at the cost of doctors, nurses, and patient care.”
The corporate takeover of health care has also made navigating the system challenging. It’s now so complex. Choice and competition are meaningless. They have not improved quality and they have only increased costs. Unlike with airline travel, restaurants, housing or automobiles, you have virtually no idea if the health plan you choose will deny and delay your care and endanger your health. All you know is that there’s a decent chance that your insurer will not cover your care.
Health care corporations are in business to help their investors first and foremost. And, in the health care space, they can do so pretty easily, with little accountability, by simply extracting money from the system. Scully knows this full well and helped conceive, design and implement the algorithms that now power NaviHealth–a software AI system that helps insurers to keep more of their government payments by denying or limiting home health, nursing and rehab coverage.
Scully sold NaviHealth before it was bought by Optum, a division of UnitedHealth. He then went on to push Congress to allow for-profit PACE programs and to invest in InnovAge, which was buying up PACE programs. Soon after, CMS addressed allegations that InnovAge was denying thousands of PACE patients medically necessary services and suspended enrollment in many of InnovAge PACE programs for a time.
As former head of the Center for Medicare and Medicaid Innovation at the Centers for Medicare and Medicaid Services, Rick Gilfillan, explains: “When you privatize social goods like health care, you end up getting the worst of both worlds. Because it’s seen as a public good, you can’t let the marketplace operate as it normally would … you get captured regulatory processes that end up facilitating the extraction of wealth by the private sector.”
How much money do doctors really make and why is it such a lot?
by Andrew Van Dam - Washington Post - August 4, 2023
The average U.S. physician earns $350,000 a year. Top doctors pull in 10 times that.
When those simple data points were first presented in 2020, a small subset of physicians came unglued on the microblogging site formerly known as Twitter, slinging personal insults and at least one deeply unflattering photo illustration of an economist.
We couldn’t understand why. The figures are nigh-on unimpeachable. They come from a working paper, newly updated, that analyzes more than 10 million tax records from 965,000 physicians over 13 years. The talented economist-authors also went to extreme lengths to protect filers’ privacy, as is standard for this type of research.
By accounting for all streams of income, they revealed that doctors make more than anyone thought — and more than any other occupation we’ve measured. In the prime earning years of 40 to 55, the average physician made $405,000 in 2017 — almost all of it (94 percent) from wages. Doctors in the top 10 percent averaged $1.3 million. And those in the top 1 percent averaged an astounding $4 million, though most of that (85 percent) came from business income or capital gains.
In certain specialties, doctors see substantially more in their peak earning years: Neurosurgeons (about $920,000), orthopedic surgeons ($789,000) and radiation oncologists ($709,000) all did especially well for themselves. Specialty incomes cover 2005 to 2017 and are expressed in 2017 dollars.
Not all doctors breathe that rarefied air. Even in these peak years, family-practice physicians made around $230,000 a year. General practice ($225,000) and preventive-medicine ($224,000) doctors earned even less — though that’s still enough to put them at the top of the heap among all U.S. earners.
So why did those figures ruffle so many physician feathers?
“A lot of students go into medicine because they want to help patients,” Stanford economist Maria Polyakova told us. Polyakova and economist Joshua Gottlieb of the University of Chicago spent the past five years working on this data in collaboration with Census Bureau economists Kevin Rinz and Victoria Udalova and the University of New Brunswick’s Hugh Shiplett.
She continued: “There is this sense of, well, if you show that physician incomes put them at the top of the income distribution, then you’re somehow implying that they’re instead going into medicine because they want to make money. And that narrative is uncomfortable to people.”
Added Gottlieb: “You can want to help people and you can simultaneously want to earn money and have a nicer lifestyle and demand compensation for long hours and long training. That’s totally normal behavior in the labor market.”
Yale University economist Jason Abaluck notes that when he asks the doctors and future doctors in his health economics classes why they earn so much, answers revolve around the brutal training required to enter the profession. “Until they finish their residency, they’re working an enormous number of hours and their lifestyle is not the lifestyle of a rich person,” Abaluck told us.
That is true. Our analysis of Census Bureau data shows that residents are in an exclusive class with oil field roughnecks when it comes to hours worked in their late 20s and early 30s; firefighting managers such as captains and lieutenants also come close. And those blue-collar jobs pay about as well as medical residencies — often a bit better. At least until the residents become physicians and settle into working fewer hours and earning, um, more.
Residency also extends your education into your late 20s and beyond, cutting into your lifetime earning potential. And, as Abaluck’s students often point out, that long medical education also leads to astonishingly high student debt — an average of $246,000 as of 2017. But that debt almost vanishes against a physician’s still more-than-robust expected $10 million in lifetime income.
So, why do physicians make that much?
One unfair, inflammatory and accurate answer would be that they like money.
On average, doctors — much like anyone else — behave in ways that just happen to drive up their income. For example, the economists found that graduates from the top medical schools, who can presumably write their own ticket to any field they want, tend to choose those that pay the most.
“Our analysis shows that certainly physicians respond to earnings when choosing specialties,” Polyakova told us. “And there’s nothing wrong with that, in my opinion.”
They also found that each 10 percent increase in the Medicare payment rate for a procedure causes a 4.4 percent increase in billing for the procedure — mostly because the doctor will work to find additional patients who could benefit from the now-more-profitable intervention.
“We can’t just sit back and say, ‘Oh doctors, they’re good people. They wouldn’t possibly do this,’” Gottlieb said. “They may be very good people, but that doesn’t mean that they don’t care about economics.”
And American physicians seem to be quite talented at caring about economics.
“In general, U.S. physicians are making about 50 percent more than German physicians and about more than twice as much as U.K. physicians,” internal medicine physician Atul Grover told us. Grover leads the Association of American Medical Colleges’ Research and Action Institute, teaches medicine at George Washington University and speaks with the easy authority and charisma of someone who probably deserves to be earning several times what we do.
Grover said the widest gaps were “really driven by surgeons and a handful of procedural specialties,” doctors who perform procedures with clear outcomes, rather than preventing disease or treating chronic conditions. In the United States, “we’re not about prevention, you know?” he said, noting that his own PhD is in public health. “I wish it was different, but it ain’t!”
Doctors do tend to be at the top of the earnings scale in every country, research shows. But their especially high incomes in the United States are undoubtedly related to America’s doctor shortage.
The United States has fewer doctors per person than 27 out of 31 member countries tracked by the Organization for Economic Cooperation and Development, a club of mostly economically advanced nations that supplies a surfeit of stats you can’t find almost anywhere else.
In 1970, based on a slightly different measure that’s been tracked for longer, America had more licensed physicians per person than all but two of the 10 countries for which we have data. What caused the collapse?
Casting about for an answer, we recalled a fascinating submission from reader Sonia Bisaccia in West Chester, Pa. She noted that the United States has far fewer residency slots than qualified med school graduates, which means thousands of qualified future physicians are annually shut out of the residency pipeline, denied their chosen career and stuck with no way to pay back those quarter-million-dollar loans.
“I’d like to see an in-depth analysis of the effect of the government capping the number of residency spots and how it’s created an artificial ‘physician shortage’ even though we have thousands of talented and graduated doctors that can’t practice due to not enough residency spots,” Bisaccia wrote.
What a tremendous suggestion! Such an analysis would begin with a deeply influential 1980 report, according to Robert Orr, who has untangled this history over at the Niskanen Center, a center-right but far-from-orthodox D.C. think tank. (Orr recently became a health-care-focused aide for freshman Republican Sen. J.D. Vance of Ohio.)
That report, by a federal advisory committee tasked with ensuring the nation had neither too few nor too many doctors, concluded that America was barreling toward a massive physician surplus. It came out just before President Ronald Reagan took office, and the new administration seemed only too eager to cut back on federal spending on doctor-training systems.
In response to the report and the end of some federal grant programs, the mighty Association of American Medical Colleges (AAMC), a coalition of MD-granting medical schools and affiliated teaching hospitals, slammed the brakes on a long expansion. From 1980 to around 2004, the number of medical grads flatlined, even as the American population rose 29 percent.
Federal support for residencies was also ratcheted down, making it expensive or impossible for hospitals to provide enough slots for all the medical school graduates hitting the market each year. That effort peaked with the 1997 Balanced Budget Act which, among other things, froze funding for residencies — partially under the flawed assumption that HMOs would forever reduce the need for medical care in America, Orr writes. That freeze has yet to fully unwind.
The idea that there could be too many doctors might sound ridiculous — especially these days, when a global pandemic, burnout and changing markets have reshaped the medical profession. In 2021, a large survey found that about 1 in 5 doctors intended to leave their current practice within two years, and the share of physicians in private practice fell from 56 percent in 2016 to 47 percent in 2022, according to the American Medical Association.
But for decades, many policymakers believed more doctors caused higher medical spending. Orr says that’s partly true, but “the early studies failed to differentiate between increased availability of valuable medical services and unnecessary treatment and services.”
“In reality, the greater utilization in places with more doctors represented greater availability, both in terms of expanded access to primary care and an ever-growing array of new and more advanced medical services,” he writes. “The impact of physician supply on levels of excessive treatment appears to be either small or nonexistent.”
If health costs keep you up at night, research suggests there are better ways to rein them in than what Orr would call rationing the supply of doctors. Polyakova and her collaborators find doctor pay consumes only 8.6 percent of overall health spending. It grew a bit faster than inflation over the time period studied, but much slower than overall health-care costs.
“People have a narrative that physician earnings is one of the main drivers of high health-care costs in the U.S.,” Polyakova told us. “It is kind of hard to support this narrative if ultimately physicians earn less than 10 percent of national health-care expenditures.”
Regardless, the dramatic limits on medical school enrollment and residencies enjoyed strong support from the AAMC and the AMA. We were surprised to hear both organizations now sound the alarm about a doctor shortage. MD-granting medical schools started expanding again in 2005.
Someone like Orr might say it’s because states have responded to the shortage by empowering nurse practitioners and physician assistants to perform tasks that once were the sole province of physicians. Over the past 20 years, the number of registered nurses grew almost twice as quickly as the number of doctors, and the number of physician assistants grew almost three times as rapidly, our analysis showed.
Osteopathic schools, which grant DO degrees, were also fast to respond to the physician shortage, doubling in number since the turn of the millennium, according to the American Association of Colleges of Osteopathic Medicine. DO is a legally equivalent medical degree that features additional training in hands-on, chiropractic-like treatment, and those who earn it are more likely to go into primary care.
While there still aren’t enough residency positions, we’re getting more thanks in part to recent federal spending bills that will fund 1,200 more slots over the next few years.
But that’s still well short of the 4,000 per year that Grover estimates will be needed to stem the shortage.
https://www.washingtonpost.com/business/2023/08/04/doctor-pay-shortage/
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