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.”

In Defense of Pediatricians... (And a Few Words of Advice For Doctors and Other Public Health Types)

Allow me to share a few select comments from Twitter with you.

“You people are awful.”

“This is just sick,” wrote another.

“All this to enrich yourselves. DISGUSTING!!”

“You endanger KIDS LIVES for a $400,000 a year salary and a Lexus???”

Wow. What’s going on? What are these people talking about?

They’re taking me and my fellow pediatricians to task because of the perceived role pediatricians play in perpetuating the conspiracy that pediatricians, public health officials and greedy pharmaceutical companies encourage vaccinations in order to make money and are therefore willing to endanger the lives of children everywhere.

The anger toward pediatricians is real. How did things end up this way?

How did a medical specialty most people associate with sniffles and sore throats, reach the point where labels are thrown at us that are more commonly used to describe axe murderers and third world dictators?

Allow me to defend myself and my fellow pediatricians, most of whom are relatively reluctant to engage belligerent people on social media.

I do not have that problem.

In a way, I understand the anger. It makes sense to me.  I deal with parents every single day. These people are worried about the safety of their children. They’ve run across a very disturbing story on the internet and are worried by what they’re reading.

But these people do all seem to have one thing in common.

They seem to be operating with a mental image of doctors that got lodged in their brains about twenty- five years ago.  Or might they have acquired it by binge watching too many medical dramas on Netflix? (I prefer to blame Hollywood scriptwriters, whose portrayal of the glamorous lives doctors lead is equally detached from reality, however I will save that for another time.)

As for the idea that I’m living a life of luxury? I’ve heard this one enough times that the time has come to address it.

The financial windfall I am supposedly reaping by vaccinating the kiddos in my care? Let me break it down for you. For the last 15 years, I have been paid $6 per immunization by the various insurers. With the ushering in of “value-based care,” the reimbursement rate is up to a whopping $17-22 as of this year. This is the princely sum for which I am supposedly willing to sell out my principals and commit the crime of keeping a child healthy.

Let me point out one little detail many people may not be aware of. The vaccinations that people are getting so worked up about? Fifty years ago they were administered by physicians or nurses only. In recent years, thanks to structural and legislative changes in the healthcare system,  the vast majority of immunizations are being administered by medical assistants, pharmacists, and other healthcare workers, many of whom have completed a single 20-hour training course. Could playing it ‘fast and loose’ with vaccinations have something to do with some of the uptick in complication rates?

Hmmm.

 

Perhaps we should consult a statistician?

Here’s a study I’d like to see.  I’d like to see research that looks at the complication rates for vaccinations given by nonphysicians and compare them to the complication rates back in the days when pediatricians and nurses gave the immunizations.

I wouldn’t be surprised if the numbers tell a very interesting story.

Just ask Lou Ferrigno –otherwise known as “The Incredible Hulk”– about how he ended up in the hospital after receiving an immunization for pneumonia at his local pharmacy. His tweet said it all, “Went in for a pneumonia shot and landed up here [in the hospital] with fluid in my bicep.” He tells his followers that “it’s important you keep an eye on who’s giving the shot and make sure they not only swab the spot correctly but that you watch the needle come out of the package.”

The problem is that while pharmacists, medical assistants and health center employees are considered adequately qualified to roll up somebody’s shirt sleeve and jab a needle into their arm after a 20 hour crash course, they have little or no training to evaluate the health status of their patients. Many have never seen the patient before the day they walk through the door.

Which brings us back to those terrible stories on the Internet. 

It’s natural for parents to be upset. Especially when they raise their hands to ask questions and get shouted down by an angry mob. That’s because the stories they’re hearing sound plausible.  The vast majority of people who are being converted to the anti-vaxx camp are intelligent, rational people. Most are highly educated, and they are good parents. They are aware enough to search for scientific evidence to answer their questions after being dismissed by the CDC.

If you’re like me, you may have noticed that the conspiracy theories that are floating around keep gaining strength. These ideas incense public health officials and scientists, but it turns out that on social media, the more we try to suppress ideas we dislike, the more they spread.  At this point it’s become obvious that things aren’t getting better. They’re getting worse. Pretty soon, the entire system is going to break down.

And one day soon there may be a real epidemic. Not a flare up. Not a scare. A real epidemic that kills thousands of people and brings life as we know it in this country to a halt.

And I’ll tell you one thing. If it happens, it’s going to be our fault.

Yes, you read that correctly.

If you want to blame somebody for the vaccine crisis, blame the pediatricians. Why?

Because we know better. We let government bureaucrats and health insurance bean counters push us around, even though this puts the health and welfare of children at risk. We let others who are far less qualified than we are take the lead and take up the challenge of explaining the vaccine story to the world.

How did we let that happen? I’ll tell you what happened. We gave up.

We got sick and tired of beating our heads against a wall. Tired of explaining to public health officials that it’s a bad idea to tell people that vaccines just work. Period.  Tired of fighting with insurers and employers, who don’t see the value of paying twenty dollars more for a physician to administer immunizations directly. Tired of arguing with our government, which believes vaccinations are so ‘harmless’ that in 1993, U.S. Secretary of Health and Human Services Donna Shalala (currently serving in the US Congress) asked the American Pharmacists Association (APha) to help define the role of pharmacists in the national vaccine program for children.  They jumped at the opportunity when millions in revenue was at stake.

We’ve known since the beginning that vaccines have risk. All medicines have risks. They have trade offs and rewards. In an age when scientific information is widely available on the Internet, it makes absolutely no sense for public health officials and scientists to dodge the hard questions by telling people that “vaccines work”.

In a world where opinion is shaped through social media, a public health strategy based on trying to “educate people” by shoving “facts” in their face when the facts are in dispute is not going to work very well.  In reality, it may backfire and produce exactly the opposite result from the one you intended. And that is exactly what is happening here.

The people who are revolting and opting out of the vaccination system? They’re not going anywhere. They’re not going to be shamed into submission. They’re not going to sit back down and shut up. You can try to “educate them.” They’ll go out and get different books.  You can bar their kids from schools. They’ll build new schools.

It’s pretty clear that it’s time for a new approach.  We need to have a national conversation about the risks and benefits of vaccination. We need to respect the power of immunizations and their side effects.  And it’s time to take vaccinations out of the hands of people who know nothing about the risks involved and give them back to the physicians.

And lastly, it’s time for somebody to have a long hard talk with Big Pharma about the role they are playing here.  What data do they have? To quote one of Hollywood’s favorite conspiracy movies: What do they know and when did they first know it?

Many of the questions that are being raised by the people who are challenging the current system are fair.  Parents deserve answers to their questions and full disclosure. Then and only then, will the controversy subside and allow pediatricians to go back to the peace and quiet of their glamorous lives treating runny noses and all that other stuff.

In reality, physicians are the only group of healthcare professionals with the ability to turn the anti-immunization debacle on its head.  Pediatricians, especially, must reclaim the responsibility for talking openly and honestly with our patients about the risks, benefits, and alternatives of immunizations. After all, look at where relying on the CDC, WHO or even the US Government has gotten us?

Oh and one last thing? For the record.

$400,000 is a pipe dream and my Lexus is a minivan made by someone else.

Niran Al-Agba, MD is a pediatrician based in Washington State. She is an associate editor for The Deductible. Follow her on Twitter at @silverdalepeds

When Doctors Need Our Help: Do No Harm, A Film

In the United States, 400 physicians commit suicide annually – an average of one per day.  Physicians have the highest rate of suicide of any profession; almost double that of the general population.  While physician suicide has reached epidemic proportions, the general public is relatively unaware of this tragic phenomenon.  Robyn Simon has produced a documentary film, Do No Harm, to shed light on this taboo topic.  Common Spirit Health/Dignity Health/CHI/Fransciscan Hospital (formerly known as Harrison Memorial) is sponsoring a free screening of this movie in Kitsap County, scheduled for Friday March 22, 2019 at 6:00pm in the Bremerton High School Auditorium.  

“Do No Harm” chronicles the journey of two families – the Dietls and Mechams – which share common insurmountable challenges during medical training.  John and Michele Dietl lost their son Kevin to suicide 3 months before his graduation from medical school.  Feeling hopeless during his fourth year of residency, Hawkins Mecham, DO, tried to take his own life. 

Dr Mecham reached out to Dr. Pamela Wible, a friend and colleague who has focused her efforts on preventing physician suicide.  Dr. Wible connected Mecham with the Dietls.  John and Michelle were able to ask Mecham the questions that they could not ask their son and by sharing their story with Hawkins, he had more insight into those who are left behind after suicide. 

I was twelve years old when the first physician I knew in Kitsap County committed suicide. He was a colleague of my father’s in a local multispecialty physician group.  As a young girl, I went on occasional playdates with his children and attended birthday parties in their home. My father always described him as intelligent and kind.  At that age, I could not fathom the wear and tear this career has on the souls of all physicians.  

Physicians who die by suicide are struggling healers; they are mothers, fathers, sons, daughters, husbands, wives, colleagues, neighbors and friends.  As a community, we must embrace those who are struggling and erase the stigma associated with depression, anxiety and suicidality. Physicians are reticent to share their personal and professional struggles with others out of fear from being labeled as being weak.  This silence helps no one.

Like my esteemed colleagues, I have often felt overwhelmed by this challenging career, more so after the loss of my father and business partner eighteen months ago.  The heartfelt and valuable advice shared nearly twenty-five years ago by a local gastroenterologist – Dr. Pankaj Sharma – has helped me cope through it all. 

During my junior year in college, Dr. Sharma evaluated me for nonspecific abdominal pain with an upper endoscopy, a procedure where a thin scope with a light and camera at the tip is used to look inside the upper digestive tract, including the esophagus, stomach, and first part of the small intestine, known as the duodenum.  His evaluation yielded little in the way of a definitive medical condition. 

At my follow up appointment, a stack of Medical College Admission Test (MCAT) study books accompanied me, because I did not want to lose a moment preparing for this exam.  Dr. Sharma quickly realized my problem was more stress-related and shared some guidance: “The challenges you will face as a physician will be overwhelming.  You must find a way now to accept the crushing demands medicine places upon us. If you cannot, you will never survive a career as a doctor.” 

At nineteen, I did not fully grasp the significance of his words but after nearly two decades in this field, I know all-too-well how right Dr. Sharma was. Medicine is a science grounded in uncertainty; it is the weight of facing this ambiguity every day that exacts such a heavy toll.  When physicians cannot cope with such doubt, it can manifest as depression, anxiety, alcoholism, or even, suicide. 

The “Dr. Sharma talk” still resonates today.  Despite giving patients our best, sometimes the negative outcomes are beyond our control. Physicians must be careful not to lose themselves while helping others. Failure is a part of medicine because it is an inevitable part of life. Grieving, when necessary, is important; every physician is, first and foremost, a human being. 

Our nations healers --nurses, doctors and all of those working in healthcare -- are suffering, they need our support, appreciation, gratitude, and forgiveness.  Please know that when tucking our own children in at night, we are often thinking – and even dreaming – of yours.  Please join the community for a screening of this courageous film:  Do No Harm. Thank you to Common Spirit Health Hospital for bringing this film and filmmaker Robyn Simon to Kitsap County.

And I wish to thank Dr. Pankaj Sharma personally, for being the voice in my head whenever I struggle with the demands of a medical career.  I have followed your advice by exercising every day, enjoying close relationships with my patients, and writing openly about my frustrations working in a healthcare system that no longer makes sense.  Please know your work has made a world of difference.

Are Health Insurance Companies Practicing Medicine Without a License?

It’s no secret that in today’s health care market, insurance companies are calling the shots.  

As a pediatrician in private practice for almost two decades, I’ve seen insurance companies transform into perhaps the single most powerful player in today’s health care landscape—final arbiters whose decisions about which procedures or medications to authorize effectively end up determining the course of patient care. Decisions made by insurers, such as MassHealth, have literally killed patients.  But it was only when I got caught in the crosshairs of an insurance company auditor with a bone to pick that I fully appreciated their power to also destroy physicians’ careers.

My own nightmare began around two years ago, when my late father, also a physician with whom I was in practice, and I opened our Silverdale clinic on a Saturday. It was the start of flu season, and we’d just received 100 doses of that year’s flu shot. Anxiety about the flu was running high following the death of a local girl from a particular virulent strain of the virus a year before, and parents were eager to get their kids immunized as soon as possible.

Under Washington law, adults don’t even need to see their doctors to get flu shots. They can get them at Walgreens, directly from pharmacists. But because children under nine are more susceptible to rare but life-threatening allergic reactions, they must be immunized by a physician. This meant that, for convenience sake, parents often scheduled their kids’ annual checkup on flu shot day, thus allowing them to condense much of their routine care into a single visit.

That particular Saturday went off without a hitch, with my father and I seeing and immunizing around 60 patients between the two of us over a 12-hour day.

Three months later, a representative from Regence insurance company requested to see some of the patient charts from that flu clinic as part of an audit. Aimed at rooting out insurance fraud by cross checking doctors’ records, these audits have become a routine fixture in medical practices today. To incentivize their auditors to ferret out the greatest possible number of irregularities, and thus boost the corporate bottom line, auditors work on commission, being paid a percentage of the funds they recover.

The Regence auditor in charge of my case, Anke Menzer-Wallace, failed to turn up any irregularities in our documentation. But, still, Ms. Menzer-Wallace issued a stern admonition to my father and me, ordering us not to open our clinic on Saturdays to administer flu shots.

This struck me as an outrageous restriction, considering our clinic is a private entity where we set our own hours and schedule accordingly, and so I called Ms. Mezner-Wallace. But instead of backing down, she ratcheted up her rhetoric, saying she was also forbidding me from examining my patients before immunizing them—clearly, a bid to save her employer even more money. I was shocked. Ms. Mezner-Wallace’s directive amounted to practicing medicine without a medical license—which is of course illegal in the state of Washington and many other states across the nation.

I shot back that immunizing infants and small children is a serious undertaking, requiring proper caution and care, informed her there was no way I would be complying with her mandate. Following this brief exchange, Ms. Menzer-Wallace took it upon herself to report me to the Medical Quality Assurance Board–the government-backed body charged with shielding the public from unqualified or unfit doctors. The accusation levied against me? Not following an insurance company mandate—which, in her opinion, amounted to unprofessional conduct.

It didn’t matter that the charges against me were ludicrous. The potential consequences were only too real, and potentially catastrophic. Had the State Medical Board decided against me, I could have lost my license. I hired a lawyer, sinking more than $8,000 into legal fees. I was cleared last month by a unanimous committee vote. But other physicians facing similar situations may not be as lucky.

The 18 months of excruciating stress that followed my altercation with Ms. Menzer-Wallace made it patently clear that insurance companies wield far too much power. Bureaucrats are making life-and-death medical decisions without a single minute of medical training, and their auditors are terrorizing physicians, by coercing state medical boards to act as their henchman. Unfettered by any consequences for enforcing policies that fly in the face of rules protecting patient safety, insurance companies will continue to harm doctors and patients alike if no one can stop them.

 

Being a Woman Physician : The Blank Wall of Social and Professional Antagonism #NWPD2019

February 3^rd is designated National Women Physicians Day, in honor of Elizabeth Blackwell, the first woman in the U.S. to earn a medical degree.  Dr. Blackwell said, “a blank wall of social and professional antagonism faces the woman physician.” She was right. Recently, an 85-year old retired surgeon shared that my ‘antagonistic attitude’ is unbecoming; his unsolicited comment reminds me why celebrating this day is important for all women. 

Dr. Mary Edward Walker was a female physician who embodied “antagonism.”  She is the only female recipient of the Congressional Medal of Honor in U.S. history, cited for valor as a surgeon on the Civil War battlefield.  She was also an abolitionist, prisoner of war, suffragist, writer and speaker.  Two years before her death, the Army revoked her award yet she refused to comply.  Her life story is inspiring. 

Mary was raised by progressive, “freethinking” parents, who founded a schoolhouse to ensure their six daughters were as well-educated as their son.  In defiance of convention, her family shared work equally on their farm, encouraged independence and disregarded traditional gender roles.

Mary paid her way through Syracuse Medical College graduating with honors in 1855.  She married Albert Miller, a fellow medical student, yet removed “obey” from her vows and retained her last name, like many female physicians today.  Unfortunately, due to Albert’s philandering – he impregnated two patients – the couple divorced thereafter. 

At the start of the Civil War, she volunteered as a surgeon for the Army, but the Secretary of War refused to commission a woman as anything other than a nurse.  She could have posed as a man, like 400 other women that graced the battlefield, but felt obscuring her gender contradicted her primary goal, which was breaking the gender barrier.

Dr. J.N. Green, the lone surgeon at a temporary infirmary in the U.S. Patent Office, hired her as an assistant surgeon.  After her request for compensation was denied by the U.S Government, she accepted the position without pay.   

Over time, more surgeons began working at the infirmary and Dr. Walker became concerned some were amputating limbs—which was a controversial practice –unnecessarily for practice. The mortality rate for amputations at the knee was 60%, while those done at the hip were more than 80%.  Seeing injustice, Dr. Walker counseled soldiers against amputation when medically appropriate.  Her reputation for being bold, skilled and a friend to the soldiers grew and resulted in families seeking her out to treat their injured sons, brothers and husbands. 

The Army refused to commission Dr. Walker as a surgeon, until Assistant Surgeon General Robert Wood observed her work at the Battle of Chickamauga and broke precedent, offering her a paid position as assistant surgeon with 52^nd Ohio Infantry.  She crossed enemy lines as both spy and surgeon until Confederate troops captured her in 1864.  The notorious “female Yankee surgeon” was imprisoned at Castle Thunder, a Richmond prison known for its brutality.  The maltreatment and starvation she endured would haunt her for the rest of her life, but even after her release via prisoner exchange, she continued seeking a ‘retroactive commission’ as a medical officer. 

The Army Judge Advocate General determined that while there was no precedent to commission a female, a "commendatory acknowledgment" could be issued in lieu of the commission.  Generals William T. Sherman and George H. Thomas provided testimonials of her service and President Abraham Lincoln recommended her for the award shortly before his death for “untiring service on the field of duty.”  On November 11, 1865, President Andrew Johnson bestowed the Medal of Honor upon Dr. Mary Walker, citing her valor on the battlefield during the Civil War as worthy of receiving the nation’s highest civilian honor.  

After the war, she became a writer and speaker supporting the women’s suffrage movement.  In 1917, the Army reevaluated eligibility for the Medal of Honor and rescinded her award.  According to folklore, when federal marshals arrived to reclaim her medal, she met them at the door wearing her medal and brandishing a 12-gauge shotgun.  In defiance, Mary Walker continued wearing the medal every day until her death, at 86, on February 21, 1919, just four months before Congress passed the Nineteenth Amendment, granting women the right to vote.   

Fifty years later, Mrs. Anna Walker, a distant relative, lobbied the Army to reconsider the Medal of Honor revocation.  She said, “Dr. Mary lost the medal simply because she was a hundred years ahead of her time and no one could stomach it.”  Upon the Army’s recommendation, President Carter ordered restoration of the Congressional Medal of Honor to Dr. Mary E. Walker on June 19, 1977.  To this day, she remains the only female recipient of this award in U.S. history.  

May Drs. Walker and Blackwell inspire us to embrace antagonism and change the world. 

"Say on Pay" Legislation: Giving Patients a Say on CEO Pay

Warren Buffet once described the cost of health insurance mandates as "a hungry tapeworm on the American economy."  He was right.

Health care inflation continues to exceed the base inflation rate.  Health insurer CEO compensation has ballooned out of control --in 2017, Cigna CEO David Cordani took home $43.9 million, Humana CEO Bruce Broussard made $34.2 million, and Aetna CEO Mark Bertolini earned nearly $59 million. That’s approximately $162,000 per day.  Seven years after the Affordable Care Act created an insurance windfall, earnings at the 70 largest U.S. health care companies reached $9.8 billion cumulatively. 

When people like you and I are paying high insurance premiums, shouldn’t we get some say in how the money is spent?   

Local legislators, Michelle Caldier, a Port Orchard Republican, and Sherry Appleton, a Poulsbo Democrat, joined by Reps. Eileen Cody (D-West Seattle), Laurie Jinkins (D-Tacoma), Shelley Kloba (D-Kirkland), and Nicole Macri (D-Seattle) agree that people should have a voice in this process.  To that end, they have co-sponsored House Bill 1017, which is intended to regulate the salaries of nonprofit health carriers, defined as health maintenance organizations, insurers, health care service contractors, or other entities responsible for the provision of healthcare services. 

“Say on Pay” legislation would require any non-profit insurer to assemble a panel made up of 10 health plan enrollees chosen at random.  The enrollee panel would be tasked with setting the compensation and benefits package of the board of directors’ members and approving the salaries of those executive employees receiving the top five highest levels of pay and benefits.  Each enrollee on the taskforce would serve a one-year term with a two-term maximum.  

Inflated CEO compensation has many negative consequences for the typical American worker. According to the Economic Policy Institute (EPI), a non-profit economic think tank, the gap between CEO compensation and that of workers has never been greater than it is today.  In 1965, the CEO-to-worker compensation ratio was 20-to-1, by 1989, the CEO-to-worker compensation ratio had grown to 58-to-1 and in 2017, the CEO-to-worker compensation ratio is 312-to-1. 

Economists Josh Bivens and Lawrence Mishel, writing for the American Economics Association, found that the substantial income gains at the very top are a significant impediment to increases in the standard of living for low- and moderate-income households.  The Economic Policy Institute endorses reducing incentives for CEO’s and corporate executives to extract economic concessions while preserving the economy overall. 

The two best methods are by increasing taxes on CEO compensation and corporations with higher CEO-to-worker ratios or instituting a “say on pay” policy, allowing shareholders (or beneficiaries) to control compensation and benefits for the CEO and other top executives. 

“Say on Pay” legislation would empower beneficiaries and patients to hold their health carriers accountable for building and maintaining a “patient-centered” health organization more focused on value of the services provided than volume.   Patients would benefit from interventions that would reduce the price of care, limit unnecessary tests or procedures, and prioritize care coordination.  

Annual healthcare spending in the US reached $3.5 trillion last year – 17.9% of the GDP -- almost double per capita spending of other developed nations. According to the Kaiser Family Foundation, most recent growth in health expenditures is due to insurance program spending, both private and public. Private insurance expenditures represent 34% of total costs (up from 21% in 1970), and public insurance --including Medicare, Medicaid, CHIP, and the VA Health Systems – represent 41% of overall health spending in 2017 (up from 22% in 1970).  In comparison, hospital costs account for 33% and physicians’ services are only 8% of health care expenditures.

CEO compensation is closely tied to stock price; therefore, executives prefer focusing on methods to generate higher earnings per share.  Dr. J. Mario Molina, the CEO of Molina Healthcare – a Washington Apple Health Medicaid plan based in California-- was fired in May 2017 due to lackluster company performance, yet still pocketed $17 million that year and received almost $23 million in severance pay.  His brother John C. Molina, former CFO, also fired in May 2017, received $10.7 million in severance.  Despite coughing up $50 million, Molina had enough money to hire Joseph Zubretsky in November 2017 as CEO and pay him $19.7 million for two months’ work. 

Health care expenditures will continue to climb if pay packages for health insurance executives don’t provide incentives to control health care costs.   Health insurers should not be rewarded for higher stock prices and better profit margins.  Supporting HB 1017 will give consumers an opportunity to hold insurers accountable,  improving access to healthcare services for everyone.

Medicaid Expansion: Nothing But an Empty Promise for Children

Recently, a child was on a waitlist for five months to get into my practice. For this article, I will call him Tiny Tim.

Tiny Tim, now 5 years old, has a skin condition known as eczema or atopic dermatitis. When we first met, virtuously every area of his body was covered with wounds from constant scratching. Skin that breaks easily and heals poorly can give bacteria access to other parts of the body.  After our first visit his mother complied with all the necessary care and his condition was slowly improving.

But on a weekend day in December Tim was rushed to an urgent care center, with a fever and pain in his ankle. He had no history of injury and the blood work, at first glance, indicated only mild infection.  He was diagnosed with a virus and sent home.  Two days later his fever spiked to 103 degrees and he refused to walk, insisting on being carried everywhere, so his mother brought him to my office.

He looked sick. Here was a usually defiant boy whose expression telegraphed fear and pain. On examination, his ankle was warm and swollen; he nearly jumped off the table when I flexed his joint.  Having eczema increased his risk of developing a joint infection and additional bloodwork supported the presence of a serious bacterial infection. 

Today, despite advances in antibiotics and surgical treatment, significant joint destruction can occur in children if infection is not caught early. It can lead to life-threatening complications and even death.  Within hours, he was admitted to Seattle Children’s Hospital and operated on the following morning. By the end of the month, he was skipping into my office as if nothing ever happened, if not for the IV line in his arm delivering daily antibiotics at home. 

I remember wishing there had been space in my practice earlier than the five-month mark. But Tiny Tim is on the state’s Apple Health plan, which is Washington’s Medicaid option for children, and providers can realistically only accept a certain number of those patients. He faced a delay that points to a serious flaw in the good intentions of the Medicaid expansion for children.

For the first time in a decade, the number of uninsured children in the United States increased in 2018.  Apple Health seemed like the quintessential success story because it expanded Medicaid coverage for children — in Kitsap County alone, the number enrolled grew from 9,000 to over 21,000 in the last 10 years. However, Medicaid reimbursement also decreased by more than 35 percent, after a federal provision that kept Medicaid payments on par with Medicare expired in 2015.  Some states set aside funding to maintain rates equal to those of Medicare, but Washington was not one of them. 

Medicaid reimbursement is set at two-thirds the rate of Medicare, forcing many physicians to limit the number of children they treat on Medicaid to keep their doors open. Physician costs amount to just 8 percent of all healthcare expenditures, a small slice of the healthcare pie. Every day, physicians are retiring early or closing their doors; those who remain on the front lines have more patients than the capacity to manage. 

Sarah Rafton, the executive director of the Washington Chapter American Academy of Pediatrics (WCAAP), calls Medicaid expansion “a hollow promise.”  She told the Columbian newspaper of Vancouver, “This isn’t about doctors who… want to make a lot of money. If half of your potential patients are on Medicaid, it becomes difficult to sustain your practice.” To my dismay, I have to limit the number of Medicaid patients in my own practice. 

Tiny Tim received timely, high quality pediatric primary and specialty care. He deserved nothing less.  Children like him need health care funding parity so primary care physicians can afford to stay in business. But the Washington State Legislature has been loath to fund health care for children on Medicaid. Getting access to high quality healthcare can seem akin to winning the lottery. 

Last year, Rep. Monica Stonier (D-Vancouver) introduced a bill aimed at increasing reimbursement rates for treating children and pregnant women. Local Reps. Sherry Appleton (D) and Michelle Caldier (R) were co-sponsors. The bill got a hearing but died in committee. The “Medicaid parity bill” has been reintroduced for the session that opens this coming week, calling for $80 million in state funding to raise Medicaid reimbursement to that of Medicare, $30 million of which would be designated for pediatric primary care.

When Medicare rates are already considered the “bottom line,” why is Medicaid reimbursement below sustainability? Who will care for children like Tiny Tim if basic medical care for children remains underfunded? As we open a new year, please think about children like Tiny Tim and the 840,000 other children also enrolled in Apple Health of Washington. And then contact your local representatives and encourage them to support legislation to bring reimbursement up to the Medicare equivalent. 

Can CEO's Dean and Lofton Perform A Miracle through the CommonSpirit Health Merger?

Last week the community learned that exterior work on the Harrison Medical Center expansion project in Silverdale will slow down for an unspecified period of time and interior work will temporarily be deferred. In the face of reduced revenue due to increasing labor costs coupled with lower insurance reimbursement, CHI Franciscan likely had no other choice. The parent corporation, Colorado-based Catholic Health Initiatives, has made budget adjustments in order to remain financially solvent. 

CHI Franciscan is not alone in their struggle for solvency. Moody's Investors Service recently issued a negative outlook on the nonprofit healthcare and hospital sector for 2019. The change in rating from "stable" to "negative" reflects Moody's prediction that operating cash flow will either remain flat or decline by as much as 1 percent and bad debt will increase this year. Moody’s predicts expenses will outpace revenue due to workforce issues, including the ongoing need for temporary nurses and continued recruitment of employed physicians. 

Nonprofit hospitals, in general, are facing challenging times. And that challenge is going to reverberate through our county, whether that means a major facility on a new construction timeline or further corporate creativity to reduce health care costs.

To that end, a year ago Catholic Health Initiatives and Dignity Health signed a formal agreement to join “ministries” and create a $28 billion health system giant with more than 700 facilities across 28 states. The merger is expected to be finalized by the end of the year. After receiving approval from the Federal Trade Commission and the Vatican, the newly combined organization — which becomes the largest non-profit hospital system in the country — will be known as CommonSpirit Health.

The new moniker reflects both the entity’s faith-based mission and the essence of those providing care to patients. According to CHI CEO Kevin Lofton, “We appreciate how the manifestation of the Spirit is woven into so many messages – God’s gift of compassion, the calling to heal others and the serving the common good. Each comes together and is reflected in just one powerful word, CommonSpirit.” 

While “common” doesn’t seem all that powerful to me, the fundamental question is whether merging two non-profit healthcare giants will boost the financial outlook for the newly combined corporation. 

At one time, Dignity executives had expressed concern over CHI’s financial performance and heavy debt load. But there was little reticence in the remarks of CEO Lloyd Dean, who recently said, “we remain steadfast in the belief that we can deliver a bold new health care enterprise of the future through our alignment with Catholic Healthcare Initiatives.”

His confidence in mergers may be based on financial statements, though revenue and expense isn’t always a safe forecast of what’s coming next. 

For example, acute admissions and outpatient visits declined 5 percent from 2017 to 2018 for CHI, yet the company’s operating loss fell during that time period, from $593 million to $276 million. It stands to reason in the face of reduced revenue, they accomplished this feat by cutting costs, including labor, benefits, supplies and other overhead expenditures. 

Dignity Health, a San Francisco-based system, looks formidable on paper, posting a net income of $988 million in fiscal year 2018, up from $425 million in 2017.  However, these numbers were boosted by a backlog in the California Provider Fees, which generated $447 million for 2018 and an additional $217 million in “catch-up” revenue from 2017. A quirky twist via the U.S. HealthWorks merger, an urgent care and occupational medicine subsidiary, garnered a one-time cash influx of $500 million plus a $120 million bonus on top of that. 

Sounds like a solid financial base for the new company. However, the regulatory burden of hospital consolidation can be costly and can leave open questions like the one Kitsap consumers may rightfully be asking about Harrison’s future. 

The California Attorney General made merger approval contingent on a number of charity care requirements, including creation of a program for homeless healthcare initiative and implementing a 100 percent discount to patients who earn up to 250 percent of the federal poverty level. CommonSpirit Health will invest $20 million over six years toward the homeless healthcare program alone, that will serve 30 communities in California where Dignity Health operates hospitals. How will these financial commitments in California affect future decisions nationwide if expenses must be reduced? 

Loften, the CHI CEO, recently told the Denver Business Journal, “If we do our jobs right, we won’t look like a hospital company. We still will have hospitals, but there will be fewer people in them.” But CommonSpirit Health is a hospital company, at least, for now. 

There’s little doubt Harrison and CHI will retain their footprint in Kitsap, but hospital mergers around the country haven’t always demonstrated that having more facilities under a common name bolsters the bottom line. Who knows what that will mean for a patient’s healthcare options in Kitsap County into the future, and for the health of our lone hospital.

 

What Happens when Big Pharma "Exploits" the Opioid Epidemic for Financial Gain? Kaleo Is Doing It.

The opioid crisis has grown exponentially - ravaging communities and taking an estimated 64,000 lives each year – escalating into a public health epidemic. In response to the increased availability of synthetic opioids like oxycodone and fentanyl, the Surgeon General called for expanded access to the opioid overdose antidote, naloxone, by using the slogan:  Be Prepared. Get Naloxone. Save a life. 

Naloxone is a compound which can literally cheat death, however due to price increases of up to 600%, public agencies are unable to afford to supply their first responders despite a federal mandate to do so.  According to data collected by the FDA, the price of generic naloxone—made by Hospira -- jumped by 50% in January 2014.  Amphastar, the producer of a product that can be used intranasally, doubled their price recently.  And Kaleo, which developed an ingenious “talking” naloxone auto-injector, known as Evzio, increased their price from $575 at market entry to $4500 for a two-pack.

While the government could use existing legal authority to slash prices for the lifesaving naloxone, there is more to reducing drug costs than meets the eye.  Medicare is legally prohibited from negotiating prices with drug companies. By employing a sales force to encourage doctors to sign off on paperwork that Evzio was “medically necessary”, Kaleo forced insurers and the federal government to foot the bill–Medicare shelled out $142 million for Evzio over the last 4 years—due to exorbitant price increases.

Secretary Alex Azar is contemplating removing the “safe harbor” provision, which was added to the anti-kickback statute of the Social Security Act by Congress in 1987.  The provision was designed to support group purchasing organizations, or GPOs, which got their start at the turn of 20^th century as hospital cooperatives. GPOs, it was thought, could score better deals by buying medications in bulk, bringing down health care costs by negotiating discounts with drug manufacturers. 

But that’s not what happened.

Instead, the safe harbor provision led to an institutionalized system of “pay-to-play” corruption that would be illegal in any other industry. With only four GPOs supplying virtually all U.S. hospitals, the competition to secure the exclusive right to supply each of those hospitals with any given drug is fierce – and, thanks to the safe harbor provision – dirty. Under the provision, pharmaceutical companies are forced to pay what amounts to kickbacks to GPOs to win coveted supply contracts.

Drug shortages result because there’s little incentive for drug companies to continue producing a particular drug after their competitor wins the lucrative GPO supply contract. Relying on the lone contracted manufacturer then increases the chance of experiencing a dangerous drug shortage.

In 2005, a bipartisan bill to repeal this obscure provision was drafted by Senators Herb Kohl (D-WI) and Mike DeWine (R-OH), but the legislation died in Subcommittee and has not been resurrected.   Congress is well aware of the risk the safe harbor provision poses to the American people, yet have proven loathe to act.  Why?

The answer lies in the power of the pharmaceutical lobby, which spent $171.5 million in 2017 and boasts two lobbyists for every member of Congress. Nine out of 10 members in the House and 97 of 100 U.S. senators accepted campaign contributions from pharmaceutical companies seeking to impact legislation, including both senators from Washington State. (As the ranking member on the Senate’s committee on Health, Education, Labor and Pensions, Sen. Patty Murray has yet to formally weigh in on the issue safe harbor repeal).

Return on investment for big pharma lobbying efforts has resulted in nothing short of a windfall.  By ramping up lobbying in 2008, Mylan –of Epi-Pen autoinjector fame—garnered legislation mandating the placement of epinephrine autoinjectors in every school in America.   By the time President Obama signed the “EpiPen Law” in 2013, known as the School Access to Emergency Epinephrine Act, Mylan secured themselves a market monopoly.

Initially, Kaleo created an Epi-Pen alternative to compete with Mylan, but soon set their sights on a more lucrative, not-yet-exploited niche: the opioid crisis.  Company documents demonstrate the Kaleo business model was restructured to “capitalize on the opportunity” of “opioid overdose at epidemic levels.”  Naloxone --the lone antidote -- costs less than ten cents to produce, yet has become cost-prohibitive to public agencies.

Using the Mylan roadmap, Kaleo successfully lobbied the FDA for approval of their device for consumer use,  then increased the price substantially.  By the time fifty states enacted laws mandating law enforcement and first responders to carry naloxone to treat opioid overdoses, Kaleo secured a market monopoly of their own.   The drug supply landscape is more of a coercive monopoly: the fees “kicked-back” to the GPOs are based on a percentage of the charges; higher prices are in the best interest of the pharmaceutical companies and the GPOs alike. 

The bottom line is opioids are costing too many American lives. Congress has the power to alter the course of the worst public health crisis facing Americans by reigning in the pharmaceutical industry through legislative intervention.  Removing “safe harbor” provision of the Social Security Act could save up to $30 billion annually and save 47 Americans from opioid overdose deaths per day.  We must push lawmakers to close the pharmaceutical industry loophole before it is too late.