Nurses Playing Cards? Politicians Show Why They Can't Fix Healthcare.

Washington State Senator Maureen Walsh (R-Walla Walla), became a national headline this week for alleging that “[nurses] probably play cards for a considerable amount of the day” during debate on legislation mandating break periods.  Many nurses have mailed decks of cards to Senator Walsh and posted pictures of blood-spattered emergency department walls in order to call attention to “last night’s card game,” driving home the point that they aren’t “playing” anything at work. 

  

Senator Walsh has since apologized.  But the mistaken beliefs which underlie her statements should not be overlooked.  Many politicians are out of touch with everyday Americans.  This is not about one legislator, one legislative body, or even one political party. 

This is about the safety and protection of healthcare professionals and their patients. And it is time for the public to pay attention to the disrespect of nurses and other healthcare professionals. 

The purpose of Senate Bill 1155 was to guarantee uninterrupted meal and rest periods for nurses and medical technicians working in hospitals.  This piece of legislation was important and necessary, especially after the tidal wave of hospital consolidation that swept the nation over the past few years.  Senator Walsh believed this mandate was financially burdensome for rural hospitals so argued for exempting critical access hospitals with fewer than 25 beds.  While debating to include this amendment to the bill, she earned the contempt of every nurse and physician in the country. 

The viability of rural hospitals, fighting to remain financially solvent despite implementation of additional mandates, must be balanced with the need for nurses working 12-hour shifts to have protected time for meals or breaks.  Both are important and a viable resolution exists somewhere in between.   Sacrificing meals and breaks for nursing staff already dangerously spread thin is not the solution to keep rural hospitals afloat.   And indeed, Senate Bill 1155 passed with bipartisan support and will now head to the Governor’s desk for signing. 

The Senator’s condescending statements about the work ethic of nurses reveals that their role in healthcare is misunderstood and underappreciated.  Nurses have an impossible job.  They assume the primary responsibility for continuous care of the sick, the injured, the disabled, and the dying.  The nursing profession is quite literally, the “super glue” which holds the healthcare system together.  Every aspect of medical care depends upon collaboration with nurses. Nurses are among the hardest working healthcare professionals and deserve our reverence and gratitude.  Furthermore, nurses improve the health of individuals, families, and their communities.

Senator Walsh has exposed the fact that both federal and state legislators have become overconfident in their ability to reform healthcare.  In reality, it is an industry sector most politicians know little about.  In fact, Senator Kirsten Gillibrand (D-NY) and Senator Cory Gardner (R-CO) recently introduced legislation to limit the ability of doctors to prescribe opioid medications for more than seven days --even when deemed medically necessary. The hubris of this approach seems to be growing across the legislative branch while reasonable concerns voiced by front-line health professionals are largely ignored. 

Winston Churchill said, “You can always count on the Americans to do the right thing after they have tried everything else.” This sentiment echoes the tactics of lawmakers more so today than at any other time in our history.  Legislators--who have never attended nursing or medical school and have no training or competency—repeatedly attempt to influence healthcare policy without possessing an adequate knowledge base to know what is best.  At the same time, lawmakers appear to prioritize the needs of special interest groups over implementation of real, common-sense solutions. 

We will all be patients eventually.  Our lives will depend on the care provided by skilled and conscientious bedside nurses.  We should hold our elected officials accountable when they disparage the role of healthcare professionals in delivering high quality healthcare to the patients they serve.  But Senator Walsh is just a symptom of a larger problem.  There is no replacement for the real-life experience and expertise that front-line health care professionals can provide.  To repair the broken healthcare system, lawmakers should stop trash talking healthcare professionals and focus on representing the needs of their constituents.  Nurses save lives.  Nurses are irreplaceable.  And politicians would do well to remember that. 

The 'Hybrid' Approach to Universal Health Care

Recent polls show a majority of Americans support Medicare For All, but few seem to realize that no other system in the world operates like the current single-payer proposals in Congress.  A few weeks ago, I addressed the concept of single-payer healthcare, with Cuba’s system as an example.  Today I’m writing more about the ideas being discussed now in our country and how those compare to other nations that provide some type of universal care. 

There are four significant misconceptions about universal healthcare systems that should be addressed:

1)     Most universal health care systems are not highly centralized

2)     Most universal coverage systems offer narrow benefit packages and incorporate cost-sharing for patients,

3)     Private health insurance plays a major role in most developed countries with universal coverage, and

4)     Countries with universal coverage have strict immigration policies to control healthcare expenditures.

Bearing these differences in mind, the Commonwealth Fund recently compared universal healthcare systems found in other countries with the U.S. single-payer bills proposed in Congress. 

The country bearing the closest resemblance to the U.S. proposal, where decision-making is centralized, is France, where the government is responsible for 77% of total health expenditures.  There is an out-of-pocket cost share for patients though it is relatively low, at 7% annually.  The Netherlands, Singapore, and Taiwan are also highly centralized; however, they are smaller in scale–with populations similar to that of individual U.S. states – and their relative affluence allows them to sidestep long wait times. 

In reality, “hybrid” systems, where decision-making and financing are shared among federal, provincial/regional, or local governments, are the most cost-effective way to deliver universal healthcare coverage to a large population.  In Australia, Denmark, the U.K. and Norway, policymaking and resource allocation decisions remain centralized, yet there is flexibility within a region to distribute funds in a more individualized manner best suited to local needs.   

At the other end of the spectrum are Canada, Germany, Sweden, and Switzerland, which provide “decentralized” universal health coverage, whereby decision-making and resource allocation is regulated at the regional or provincial level.  In Canada, for example, each province receives per-capita block grants from the federal government.  A “block grant” is a fixed amount of money the Canadian government allocates to a province in advance.  Regions are usually held accountable through establishment of broad national guidelines to ensure fairness and service uniformity.

   

A second misnomer is that universal coverage can be delivered on a large scale with “no copays and no deductibles.”  All countries with universal coverage provide a publicly-funded, basic benefits package which includes physician and hospital services, as well as inpatient (in-hospital) pharmaceuticals.  However, these systems include a cost-share that patients pay out-of-pocket in order to control costs in the long-run.

  

Even those countries with the most comprehensive benefit plans, such as Denmark, the U.K. and Germany mandate copayments for outpatient pharmaceuticals and a cost-share for inpatient hospital stays.  Out-of-pocket costs for each country range from 15% of health expenditures for Canadians, to 28% for those in Switzerland, and as high as 61% of health expenditures in Singapore.  It is disingenuous for U.S. politicians to make empty promises, by promoting a system of “no copays and no deductibles” that does not exist anywhere else in the world. 

It is important to clarify that nearly every country with universal coverage in the developed world is actually a “hybrid” system, mixing private insurance with publicly covered benefits to ensure access to physicians and hospitals when necessary rather than being a true “single-payer.”  Canada, England, Germany, the Netherlands, Norway, Singapore, Sweden, and Taiwan all have supplementary private health insurance. France has complementary private health insurance and Australia and Denmark utilize both. 67% of Canadians purchase private insurance or have employer-based supplemental coverage for medications, mental health services, dental care, and other uncovered services.

 

Finally, the majority of universal health-care systems in the developed world are considerably less “universal” when covering immigrants, who are mostly excluded.  Some countries, like the U.K., insist new arrivals pay into their national system prior to obtaining health coverage.  In Denmark, undocumented immigrants and visitors are covered through a voluntary, privately funded initiative by Danish doctors, the Danish Red Cross and Danish Refugee Aid, who provide access to care. 

Newcomers to Canada face an uphill battle when applying for healthcare coverage. In a nutshell, emergency medical services for immigrants are free, but access to basic medical care services is restricted and if necessary, might require out-of-pocket payment for most treatments or insurance. Those wishing to settle in Canada must pass a thorough “health screening” prior to being eligible for “universal” healthcare coverage.  If the government cannot confirm that cost of a pre-existing condition will not exceed $20,000 in annual expenditures, then healthcare coverage will be denied permanently.

When it comes to healthcare reform, our politicians need to stop trying everything else, and just do the right thing the first time.  It is not Medicare For All.    

Physicians Are Eagles Who Believe They Are Chickens by Niran Al-Agba, MD and Westby G. Fisher, MD

There are 800,000 physicians in America and more than 65% believe the Maintenance of Certification process, known as MOC, has no clinical value for patients.  For the first time in the history of our profession, physicians have a fighting chance to topple a Goliath-esque organization, the American Board of Medical Specialties. 

In a 2018 survey conducted by Merritt-Hawkins, 78 percent of physicians said they experience some symptoms of professional burnout. Physician burnout is a public health crisis which threatens the health and well-being of all patients. 

A burned-out physician reminds us of the fable about an eagle who believed he was a chicken.  When the eagle was small, he fell from his nest.  A chicken farmer found the eagle, brought him to his farm, and raised him in the chicken coop with his chickens. The eagle grew up living like a chicken, doing what chickens do, and believing he was, indeed, a chicken. 

One day, a visitor came to the farm and was surprised to see an eagle --considered the king of the sky-- strutting around the chicken coop, pecking at the ground, and acting like a chicken. The farmer explained that this bird was no longer an eagle, instead he was a chicken because he was trained to be a chicken.

 

The man knew there was more to this great bird than “pretending” to be a chicken. He was born an eagle and had the heart of an eagle, and nothing could change that. The man lifted the eagle onto the fence surrounding the chicken coop and said, “Thou art an eagle. Stretch thy wings and fly.” The eagle looked at the man and glanced down at his home among the chickens in the chicken coop where he was comfortable.  He jumped down off the fence and did what chickens do.

The farmer shrugged and said, “I told you he is a chicken.”  The visitor returned the following day and tried again to convince the farmer and the eagle that he was not a chicken. He took the eagle to the top of the farmhouse and said: “Thou art an eagle. You belong to the sky and not to the earth. Stretch your wings and fly.” The large bird looked at the man and then glanced down at the chicken coop. He jumped onto the roof of the farmhouse and returned to the place where he felt safest. 

The visitor asked the farmer to let him try one last time.

The next morning, the visitor returned and took the eagle and the farmer to the foot of a high mountain. They could not see the farm nor the chicken coop from this new place. The man held the eagle on his arm and pointed into the sky where the bright sun beckoned and said: “Thou art an eagle! You belong to the sky and not to the earth. Stretch your wings and fly.” This time the eagle stared skyward into the bright sun, straightened his body, and stretched his powerful wings. His wings moved, slowly at first, then surely and confidently. With the mighty screech of an eagle, he flew.

Because he was an eagle.

 

This past February 2019, four brave internal medicine physicians --recognizing they are eagles-- filed a lawsuit against the American Board of Internal Medicine for harm they endured from the Maintenance of Certification process.  Practicing Physicians of America has set up a fund to support our colleagues who are fighting this battle and need the support of fellow physicians. 

Merely 1300 physicians, out of 800,000 in the US, have contributed to the legal fight against the onerous MOC process, despite the fact that it is reviled by the majority of doctors.  Physicians members of the American Board of Radiology and the American Board of Physical Medicine and Rehabilitation have filed lawsuits of their own regarding violation of anti-trust laws.

Why are so few of our fellow physicians standing up when given the chance?

Unfortunately, physicians often choose consistency over happiness. If you’re used to being abused, ignored, or exploited, it’s strangely comforting to remain in the chicken coop and peck at the ground. These physicians are just like the eagle who believed he was a chicken.

Maybe physicians prefer the devil they know to the devil they don’t know.  Maybe physicians are terribly uncomfortable at the prospect of failure.  Maybe physicians believe it is better to control failure than be blindsided by it.  Physicians are standing on the mountain and being asked to spread their wings and fly.  What is stopping us?

The possibilities for the future of our profession are endless if we can win against the American Board of Internal Medicine.  If there were ever a time to join the fight, it is now.  Surely $100, $200 or even $500 is not too much to contribute to support our talented physician colleagues who have been harmed by the onerous MOC process.

Now we are asking every physician in America, are you a chicken or are you an eagle? 

Please donate to help physicians fight to spend more time providing care to patients and less supporting the American Board of Internal Medicine fiscal greed.  https://www.gofundme.com/practicing-physicians-of-america

The B & O Tax Increase Harms The Independent Physician

In 2014, 67% of physicians in Kitsap County were independent. Today, fewer than 20% of physician practices are owned and operated independently. That may not matter to you, but it should if you believe that competition leads to better care and lower prices. 

If you have never read my column before, please read this one. Because a proposal included in the governor's state budget could drastically change things for independent physicians, like my practice, and lead to the complete monopolization of healthcare in markets across the state. 

In his 2019 budget proposal Gov. Jay Inslee increases the business and occupation (B&O) tax by 20%, from 1.5% to 1.8%, on service-oriented industry sectors, such as professional, engineering and technical occupations. This specifically places independent physicians at a competitive disadvantage against physicians employed by hospitals, because non-profit hospitals are tax-exempt, and therefore unaffected by this tax increase.

Here’s why that matters to a community's health care: independent physician practices lower healthcare costs for all consumers. They are, quite simply, the last barrier to complete monopolization of a health care market. 

Hospital-based clinics — known as hospital outpatient departments (HOPDs) — charge a “facility fee," or a bill in addition to the one levied for the doctors’ services. A hospital executive once told me to think of a facility fee like a “room rental” charge. Independent practices are forbidden from charging facility fees. For one 15-minute visit with your doctor, Medicare pays $124.40 if it takes place in a hospital-based outpatient department. Medicare reimburses only $68.97 for the exact same service delivered at an independent physician-owned clinic — an 80% difference!  

Over the past decade, this payment inequity forced physicians to close their doors and sell their practices to large hospital corporations. Prior to 2000, approximately 60% of physicians in the U.S. were “independent practice owners or partners” and by 2016 that number had fallen to less than one-third of physicians. Solo physicians – like myself — are predicted to become extinct, like the dinosaurs.

Locally the consolidation trend mirrored that of the nation, as I mentioned above, because most could not remain economically viable on their own. Currently, every neurologist, endocrinologist, cardiologist, pulmonologist, urologist, and vascular and orthopedic surgeon in Kitsap County is employed or contracted with CHI Franciscan.

The Wall Street Journal recently exposed a second reason hospital-employed physicians increase healthcare costs for consumers. The more primary-care doctors that work for hospitals, the more they are being pushed to keep lucrative specialty referrals in-house. In contrast, independent physicians are free to make referrals to those physicians they would choose for their own family members and themselves. 

Research shows that physician-owned practices provide better quality of care. For example, in comparison to organizations employing more than 100 physicians, practices with 3 to 9 physicians had 27% fewer preventable hospital admissions and those comprised of one or two physicians had 33% fewer preventable hospital admissions.  Fewer days spent in the hospital leads to fewer bills for consumers to pay.

There is no doubt that communities need hospitals — they provide essential emergency services 24 hours a day and a full spectrum of specialty care that would be unavailable otherwise. But certainly not at the expense of independently-owned and operated physician practices. 

It is understandable, due to the provision of charity care and other critical healthcare services, that nonprofit hospitals are tax-exempt. Private practices provide charity care too — albeit on a smaller scale than non-profit hospitals — yet are not afforded the same economic amnesty. At a bare minimum, those private practices treating Medicare and Medicaid patients should be allowed an exemption from this tax increase, if only to equalize the odds for their economic survival. 

A Democratic Presidential hopeful should not prioritize the needs of large corporations over small medical practices, which can deliver high quality care at a lower cost.  Otherwise, Gov. Inslee is showing the nation that he is no fan of providing affordable care to the masses. 

After making many phone calls to Olympia this past week, I have learned that Rep. Steve Tharinger (D-Port Townsend), chair of the Capital Budget Committee and a member of the Health and Wellness Committee, and Rep. Eileen Cody (D-West Seattle), chair of the Health and Wellness Committee, are the most important legislators with whom to voice your concerns. They can help create the exemption to lessen the pressure on independent doctors. 

If Washington legislators blindly vote to increase the B&O tax on the few independent medical practices struggling to survive, without realizing the detrimental impact of their decision, they are turning their backs on patients, independent physicians and our communities. Please call members of our state delegation as well, and let them know that you do not want independent practices, and the valuable services they provide, to disappear. 

Contact state legislators 

Rep. Tharinge: 360-786-7904, Steve.Tharinger@leg.wa.gov. 

Rep. Cody: 360-786-7978, Eileen.Cody@leg.wa.gov. 

23rd District: Rep, Sherry Appleton, 360-786-7934, sherry.appleton@leg.wa.gov; Rep. Drew Hansen, 360-786-7842, drew.hansen@leg.wa.gov; Sen. Christine Rolfes, 360-786-7644, christine.rolfes@leg.wa.gov

26th District: Rep. Michelle Caldier, 360-786-7802, michelle.caldier@leg.wa.gov; Rep. Jesse Young, 360-786-7964, jesse.young@leg.wa.gov; Sen. Emily Randall, 360-786-7650, emily.randall@leg.wa.gov 

35th District: Rep. Dan Griffey, 360-786-7966, dan.griffey@leg.wa.gov; Rep. Drew MacEwen, 360-786-7902, drew.macewen@leg.wa.gov; Sen. Tim Sheldon, 360-786-7668, timothy.sheldon@leg.wa.gov

Pitfalls of a "Medicare For All" Single-Payer System

The World Health Organization describes universal health coverage-- a system coupling health care access with financial protection for all residents-- as the “single most powerful concept that public health has to offer.” The goal of universal care is to give all people the equal opportunity to enjoy the best health possible. 

I wholeheartedly endorse universal health care, though not a single-payer system like “Medicare for All” because there is no provision for cost control in the legislation proposed by Representative Jayapal and others. 

Understanding the distinction between universal healthcare and a single-payer system is critical. 

There are two countries in this hemisphere with true single-payer healthcare systems:  Canada and Cuba. The pros and cons of the Canadian system are well known; Canada reigns in cost mostly through rationing. Cuba handles the cost conundrum by conscripting physicians and trading them to foreign countries for a price.  The export of medical personnel has surpassed tourism as the single largest source of income for the island country, generating nearly $11 billion annually for the Cuban government.  

In 1959, following the revolutionary promise to be more attentive to the disenfranchised, the Castro administration established healthcare access as a fundamental right of its citizens.   A true single-payer system was implemented, outlawing the private market, and the government assumed total fiscal and administrative responsibility for the provision of health care. Initially, Cuba made great strides:  life expectancy increased and infant mortality dropped; however, when more people live longer, the cost of maintaining health results in higher total expenditures. 

Ever since Cuba sent 56 of their physicians to Algeria for humanitarian purposes in 1963, physicians have been viewed as a commodity and a diplomatic tool.  Physicians in Cuba earn about $50 per month, so Cuban doctors are more than willing to sign contracts for foreign work.  Over time, exporting physicians became profitable and today, Cuba uses the revenue produced by their “army of white coats” to fund “free” healthcare for the nation.  

There are, of course, some drawbacks to international physician trafficking.  First, exporting doctors has left a domestic health system in tatters.  Wait times at clinics and hospitals have grown and resources and supplies are stretched exceedingly thin.  In rural areas, many physicians practice medicine in conditions without electricity or running water.  Second, a legalized system of physician trafficking is ripe for corruption.

In 2013, the Mais Medicos program – literally ‘More Doctors’ – was established by Dilma Rousseff, the former Brazilian President. Cuba and Brazil struck a deal to pay $4000 per doctor per month, netting $360 million annually for Cuba.  From that $4000, the Cuban government pays their physicians $400 monthly and withholds $600 in a “frozen” account which physicians may access only upon return to Cuba.  

The Cuban government keeps a tight leash on their doctors.  Cuba forbids physicians from bringing their families with them internationally, enforces a daily 6pm curfew for them, and requires they report to Cuban intelligence officers stationed in Brazil in order to keep watch over Cuba’s most valuable asset. 

In 2017, Cuba tightened restrictions further by compelling pregnant doctors to return to Cuba after 22 weeks gestation to preclude their offspring from gaining Brazilian citizenship after birth.  It was at this point Jair Bolsonaro, Brazil’s President-elect, denounced Mais Medicos, calling it “modern day slavery.”

Of course, the Cuban-Brazil quagmire would not be possible without assistance from the Washington DC -based Pan American Health Organization (PAHO), a specialized health agency affiliated with the World Health Organization and the United Nations, that strives to “improve and protect the health of people.”  PAHO generates income from “annual contributions from member governments.”

Brazil pays $1.5 billion to Pan American Health Organization (PAHO) annually for administering the Mais Medicos program plus operating expenses in addition.  PAHO paid $1.3 billion to Cuba, keeping $75 million (5% cut) for itself.  In November 2018, a group of courageous Cuban physicians filed a lawsuit against PAHO, alleging the organization “knowingly provided, obtained, and benefitted from the forced labor and trafficking of more than 10,000 Cuban Doctors in Brazil between 2013 and the present.”  

It is conceivable that a bonified UN agency may be running a legal for-profit slave trade.

Think this could not happen in the United States, the land of the free and home of the brave?  Think again.  Do you remember, “If you like your doctor, you can keep them?”  It was the battle cry of the Affordable Care Act.  It was not true.  Medicare for All holds the same empty promise. Except this time the system will be financed by taxpayers writing a blank check. 

In a socialist construct, one central power controls the means of production and the goods produced, goods which may someday include U.S. physicians.  The Cuban government generates $11 billion annually by “leasing” their physicians out to foreign countries, in order to fund the Cuban national health system, which is “free.”

Most politicians disagree there is a physician shortage, calling it instead, a problem of “physician distribution.” If the U.S. government is in control, physicians will no longer be free to “distribute” themselves.  If the government decides New England is oversaturated, physicians will be “incentivized” (by termination from employment) to practice in Wyoming, Idaho, or Nevada, states desperately short of physicians. 

Thomas Jefferson said it best, “I predict future happiness for Americans, if they can prevent the government from wasting the labors of the people under the pretense of taking care of them.”