CHI Settlement Returns Some Balance to Market

The State Attorney General's office this week settled the antitrust lawsuit with CHI Franciscan, claiming the acquisition of WestSound Orthopedics and affiliation with The Doctors Clinic violated antitrust laws by reducing competition and resulting in higher prices.  As part of the settlement, CHI must divest their majority stake from the ambulatory surgery center in Silverdale and pay $2.5 million to the state.  That amount will be distributed to four entities in an effort “to increase access to health care on the Kitsap Peninsula” according to a recent press release.



It is a well-known fact that one of the largest obstacles to affordable health care is the high cost of American hospitals. In 2018, Americans spent nearly $1.2 trillion on hospital care and the average daily cost of a hospital stay in the U.S. was 2.6 times that of the average of other industrialized nations.



The single greatest driver of higher hospital prices is the rise of monopolies.  The ACA triggered an epic buying spree as hospitals acquired independent medical practices.  Since 2010, hospitals have merged into larger and larger conglomerates, which used their increased market power to extract higher reimbursements from the commercially-insured.



For instance, in August 2013, Harrison Hospital affiliated with the Franciscan Health System and shortly thereafter, Franciscan Health re-branded as CHI Franciscan.  In February 2019, CHI merged with Dignity Health to become Common Spirit, which is a colossal $29 billion health system comprising 142 hospitals and more than 700 care sites across 21 states. 

According to data from the Center for Medicare & Medicaid Services (CMS), hospital care in Kitsap County is 40% more expensive than in the surrounding communities.   In documents filed as part of the lawsuit, a former physician president at TDC summed up the affiliation with CHI best: “You can now get your outpatient care in a complex, relatively unsafe, and vastly more expensive location.”



What exactly does this settlement mean for Kitsap County residents?



While not perfect, the settlement goes a long way toward restoring balance to our one-hospital community.  The ambulatory surgery center (ASC) is simply a hidden gem, where same-day surgical, diagnostic, and preventive procedures can be performed for a fraction of the price of a hospital outpatient department (HOPD.) 



ASCs perform more than 7 million procedures for Medicare beneficiaries annually and cost Medicare just 53% of the amount paid to HOPDs for the same procedure.  For example, Medicare pays hospitals $1,745 for performing cataract surgery while paying ASCs $976 for the same procedure. In general, Medicare beneficiaries pay half as much out-of-pocket at an ASC compared to at a HOPD.



A second important settlement term requires CHI and TDC to inform patients of alternative imaging options to Harrison Medical Center. Kitsap has a freestanding imaging center, which offers high-quality care at a competitive price.  InHealth Imaging is another hidden gem, which in my personal and professional experience costs one-fifth the price of imaging at the hospital. 



Most importantly, this settlement signifies a symbolic change in the healthcare landscape as the consolidation trend appears to have played itself out. For the first time, the percentage of medical practices owned by hospitals has actually fallen, from a high of 32.6% in 2016 to 28% of the market in 2018.  Hopeful hospital administrators have now learned hospital-owned medical practices are not as profitable as once believed to be, despite the fact that facility fees boost reimbursement considerably.  One example is CHI’s CFO Mike Fitzgerald, who once wrote “I am all for taking advantage of hospital-based pricing… it would be great to drop a couple of million more to our bottom line.”  Unfortunately, the financial windfall has never materialized. 



I commend Attorney General Bob Ferguson for doing his part to improve access for patients to affordable healthcare and have come to believe the way to change the system is through the courts or legislation. 



To that end, Rep. David Cicilline (D-R.I.), who chairs the antitrust subcommittee of the House Judiciary Committee, has stated that hospital consolidation is one of his top priorities. Rep. Jim Banks (R-IN) has introduced the Hospital Competition Act of 2019. In the future, legislation like this would reduce cost of healthcare and protect small communities from hospital monopolization. 



This bill would:

1.      Approve a 400% increase in FTC staff to ensure hospital mergers do not increase costs,

2.      Reduce the incentive to merge by lowering Medicare reimbursement rates in monopolized markets,

3.      Provide grant funding for states trying to improve hospital competition,

4.      Eliminate the facility fee and reimbursing HOPDs at the same rate as independent physicians,

5.      Repeal incentives for accountable care organizations (which have not saved money),

6.      Repeal the ban on physician-owned hospitals, and

7.      Require hospitals to publish the cost of their 100 most common services

When healthcare prices increase, everyone pays, whether consumers realize it or not.  Higher insurance premiums are passed on by employers, the uninsured pay through bankruptcy proceedings, and the increased cost for Medicaid/Medicare patients is borne by the taxpayers.  Competition lowers prices.  And this settlement is a step in the right direction for patients in Kitsap County who value choice. 

There are Ways to Save -- and Expand -- Medicare

Medicare is a national health insurance program which provides health insurance for Americans aged 65 and older, and those who are disabled or have specific chronic conditions. Medicare covers 17 percent of the U.S. population, including the nation’s oldest, sickest, and most disabled citizens. Medicare has achieved two important goals: ensuring access to health care for elderly and disabled citizens, and protection from the financial risks associated with health care.  By ensuring access, Medicare has contributed to a five-year increase in life expectancy after age 65.

Before implementation of Medicare in 1966, 48 percent of Americans 65 and older had no insurance; today, that figure hovers at 2 percent. Older Americans used to cover 56% of their health care expenses directly out-of-pocket, today, they pay only 13 percent.  Medicare is funded through a combination of a payroll tax, beneficiary premiums, co-pays and deductibles, and U.S. Treasury revenue; it is administered by the Centers for Medicare and Medicaid Services (CMS.)

Medicare is divided into four Parts. Part A covers hospital costs, skilled nursing, and hospice services. Part B covers physician and other clinical outpatient services.  For both A and B, there are copays and deductibles, as well as gaps in insurance coverage.  There are no annual out-of-pocket spending limits for Parts A and B, therefore supplemental coverage, known as Part C, protects from financial hardship. 

Medicare has significantly improved the well-being of citizens over 65 years of age.  

The single greatest threat to long-term survival of the Medicare Program is runaway costs, an issue which must be addressed before expanding the program to all of us. Between 1970 and 2013, spending per Medicare beneficiary increased 500 percent from $385 to $12,210, or 0.7 to 3.5 percent of GDP.  Current projections predict that Medicare spending will make up 5.1 percent of GDP by 2030. 

At the same time, researchers at the Dartmouth Institute for Health Policy and Clinical Practice estimated 30 percent of all Medicare spending and could be avoided without worsening clinical outcomes. According to the Congressional Budget Office, eliminating this waste could save as much as $700 billion annually.

Some bipartisan measures that might contain costs include: funding additional primary care physician residency positions, eliminating accountable care organizations, and allowing Medicare to negotiate drug prices with pharmaceutical companies.

First, the Balanced Budget Act of 1997 capped the number of residency slots in teaching hospitals which were eligible for Medicare payments. This mistake has facilitated a shortage of primary care physicians across the country.  A larger supply of primary care physicians is associated with a lower mortality rate. In fact, adding 10 primary care physicians per 100 000 population increases life expectancy by nearly two months, whereas the same increase in specialty physicians only improves life expectancy by 19 days. U.S. Senators Bob Menendez (D-N.J.), John Boozman (R-Ark.) and Chuck Schumer (D-N.Y.) introduced the Physician Shortage Reduction Act of 2019 to increase Medicare-supported doctor training slots by 15,000.  Investing in primary care reduces overall expenditures by lessening morbidity and mortality; at the same time, this legislation would address the physician shortage and improve access to care for patients. 

Second, in 2008, the Congressional Budget Office (CBO) warned Congress that Accountable Care Organizations (ACO) would not save Medicare dollars, yet the Affordable Care Act required CMS to establish them within Medicare.  ACO’s—similar to HMO’s –use narrow networks in an attempt to control cost yet bear considerable financial risk, because pay is on a per-enrollee basis with the obligation to provide all medically necessary services for enrollees.

After nearly a decade, studies consistently demonstrate that ACOs fail to achieve cost reduction, just as predicted.  Universal care plans must strike a balance between a free market and government regulation necessary to protect patients.  By eliminating the ACO construct, patients and private businesses will flourish.

And finally, federal law prohibits Medicare from negotiating prices for prescription drugs with pharmaceutical companies in order to reduce costs for nearly 43 million seniors enrolled in Medicare Part D.  U.S. Senator Tammy Baldwin (D-WI) and Senator Amy Klobuchar (D-MN) have reintroduced the Empowering Medicare Seniors to Negotiate Drug Prices Act. Enabling the federal government to negotiate for reduced drug prices is a policy supported by a majority of Democrats (96%), Republicans (92%), and Independents (92%).

Over the last 50 years, Medicare has improved the delivery of healthcare services for nearly one-fifth of the U.S. population.  Cost containment must be coupled with implementation of Medicare For All.  Without it, universal access will be unsustainable.

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.”

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