April 29, 2014

How Being a Doctor Became the Most Miserable Profession

http://www.thedailybeast.com/articles/2014/04/14/how-being-a-doctor-became-the-most-miserable-profession.html

Nine of 10 doctors discourage others from joining the profession, and 300 physicians commit suicide every year. When did it get this bad?

By the end of this year, it’s estimated that 300 physicians will commit suicide. While depression amongst physicians is not new—a few years back, it was named the second-most suicidal occupation—the level of sheer unhappiness amongst physicians is on the rise.

Simply put, being a doctor has become amiserable and humiliating undertaking. Indeed, many doctors feel that America has declared war on physicians—and both physicians and patients are the losers.

Not surprisingly, many doctors want out. Medical students opt for high-paying specialties so they can retire as quickly as possible. Physician MBA programs—that promise doctors a way into management—are flourishing. The website known as the Drop-Out-Club—which hooks doctors up with jobs at hedge funds and venture capital firms—has a solid following. In fact, physicians are so bummed out that 9 out of 10 doctors would discourage anyone from entering the profession.

It’s hard for anyone outside the profession to understand just how rotten the job has become—and what bad news that is for America’s health care system. Perhaps that’s why author Malcolm Gladwell recently implied that to fix the healthcare crisis, the public needs to understand what it’s like to be a physician. Imagine, for things to get better for patients, they need to empathize withphysicians—that’s a tall order in our noxious and decidedly un-empathetic times.

After all, the public sees ophthalmologists and radiologists making out like bandits and wonder why they should feel anything but scorn for such doctors—especially when Americans haven’t gotten a raise in decades. But being a primary care physician is not like being, say, a plastic surgeon—a profession that garners both respect and retirement savings. Given that primary care doctors do the work that no one else is willing to do, being a primary care physician is more like being a janitor—but without the social status or union protections.

April 22, 2014

Single-Payer System Would Be a Boon to the Economy, Public Citizen Report Says

http://www.healthcare-now.org/single-payer-system-would-be-a-boon-to-economy-public-citizen-report-says

A publicly funded, universal health care system would aid businesses by engendering a more dynamic economy, taming costs and freeing businesses that provide health insurance of the costs of administering benefits and subsidizing the nation’s health care,a Public Citizen report released last week concludes.

“Small businesses have rated the cost of health insurance as their top concern for a quarter century, and large businesses struggle with health care obligations that their international competitors do not have to worry about,” said Taylor Lincoln, research director of Public Citizen’s Congress Watch division and author of the report. “If it weren’t for entrenched partisan alliances, business leaders would have demanded that Congress relieve them of health care burdens long ago.”

Publicly funded universal health care systems – such as the Canadian “single-payer” system, in which the government pays for all covered services – exist in nearly every developed country in the world. In the United States, universal care systems could be implemented either at the federal or state levels. The Affordable Care Act of 2010 includes language permitting states to apply for waivers that would enable them to institute universal care systems beginning in 2017. Vermont has passed legislation declaring an intention to do just that.

Public Citizen’s report, “Severing the Tie That Binds,” outlines three ways a universal health care system would benefit businesses.

April 19, 2014

US health care prices are NOT higher because we use more services

Comment by Don McCanne of PNHP: The International Federation of Health Plans represents private health insurers in 25 nations. Its members include several U.S. health insurers plus AHIP - the powerful insurance lobby in the United States. Although many would argue that it is this industry that is tasked with the responsibility of negotiating fair prices for health care services and products, in this release they contend that the very high prices in the United States “merely demonstrate the relative ability of providers to profiteer at the expense of patients, and in some cases reflect a damaging degree of market failure.”

What a remarkable statement. We are paying the insurers massive sums for their very expensive administrative services while they inflict tremendous administrative burdens on the health care delivery system, plus they take away from patients their choices in health care, especially choices of their health care professionals. They concede that they cannot control the “ability of providers to profiteer,” nor can they correct this market failure. They have become a profoundly expensive but useless appendage to the health care system - an appendage that should be severed.

Nevertheless, prices are still too high in the United States, so what can be done? Consolidation of hospitals and physicians has been anti-competitive, but prices were already high before the recent wave of consolidations began. Some providers offer services that make them “must have” participants in the insurer networks. They have a greater ability to stand firm on high prices, thus it is unlikely that antitrust enforcement could have more than a negligible impact on reducing prices.

Physicians seem to be more sensitive to cost barriers for their patients than do the hospitals and pharmaceutical firms, though both of the latter do have programs for selected indigent patients. The New York Times article describes how physician organizations are beginning to address the issue of high prices, though much of the effort seems to target the pharmaceutical firms rather than the physicians themselves. What is really remarkable though is that some physicians are now willing to look at assigning a monetary value to a quality-adjusted life-year (QALY).

Do physicians really want to assume the role of telling their patients that they will deny care that may be of some benefit but exceeds an arbitrary cost threshold assigned to a QALY? Physicians traditionally have not been the payers for their own patients’ health care. That is usually an insurer, the government, or the patient paying in cash. Shouldn’t the payer be making the spending decisions instead of the physician?

The insurers have a terrible track record - often paying too much, but also creating access barriers to care. The government has done a better job with Medicare, but with Medicaid they have often underfunded care which also creates financial barriers to care. With today’s very high health care costs, most patients are unable to pay cash if they face major medical expenses, so a third party payer is required.

Some models today would place the physician at least partially in the role of insurer. What is surprising is the relative silence on the ethical violation that such a role entails. The physician should never be placed in a position in which he profits by withholding beneficial health care. The MBAs in health care do not seem to understand the fundamental ethical compromise of such an arrangement.

The IFHP report on international health care prices does show that other nations are much more effective in controlling prices. They all have in common the fact that the government plays a major role in administering or tightly regulating prices. In general, governments seem to get it right. If we had a single payer system, we would get it right as well. In doing so we would also eliminate the profound waste caused by the private insurers, and we would ensure that financial barriers to care are removed for everyone.

What about defining the value of a QALY as ranging from $50,000 to $150,000? That should not be the role of the physician who should always be in a position to advocate for what is right for the patient. That should be the role of the public administrator who negotiates health care prices. A better term than negotiation would be price administration, implying that the government should have an “unfair” or unbalanced clout when it comes to getting prices right. Right prices means legitimate costs plus fair margins. No other country will be paying $84,000 for a twelve week course of Sovaldi to treat hepatitis C. We wouldn’t either if we had a single payer system.

April 2, 2014

Krugman vs conservative Douthat on ACA

Comment by Don McCanne of PNHP: There have been many isolated efforts to define the conservative, or Republican, or libertarian proposal to replace the Affordable Care Act (ACA or Obamacare), but there is no one model that the Republicans wish to advance in Congress at this time. The Republican controlled House of Representatives has voted fifty times to repeal ACA, but they have not voted on any substitute to address the widely acknowledged deficiencies in health care financing.

Conservative Ross Douthat and liberal Paul Krugman now provide us with a perspective on the conservative/Republican alternative for reform.

Douthat acknowledges that a conservative goal is to expand coverage (especially for the more vulnerable), whereas the current “tinkering-around-the-edges alternatives to Obamacare that many Republicans have supported to date would end up stripping coverage from millions of newly-insured Americans.” He suggests that the policy restraints of an ACA already in place would force Republicans “in a more serious direction.”

Krugman, on the other hand, writes, “Obamacare IS the conservative alternative.” Not only does it meet many of the conservative goals of insurance reform, it was even designed by the conservatives. The liberal position would have been to support a single payer model.

Single payer was abandoned in favor of the conservative model that would bring Republicans on board with a new, post-partisan president, while liberals would forfeit the single payer advantages in exchange for a politically feasible, bipartisan accord.

Think of where that puts us now. If the conservatives were to gain complete control, they would tweak ACA to loosen regulation of insurers, to reduce federal funding, and to place greater control within the states. If the liberals were to gain complete control, they would tweak ACA to correct many of the defects that were left in place when the negotiations refining the legislation were halted abruptly because of the Democrats having lost a filibuster-proof majority in the Senate (not to mention the sabotage of a former Democratic vice-presidential nominee).

The fact that further battles will all take place over on the right is a tragedy. The fundamental structure of ACA is irreparably flawed, as would be any modifications that the Republicans would make to move the insurance function further into the private marketplace. Already we have seen a great multitude of very serious flaws that scream out for remedial legislation. But each new patch creates more complexity. The fundamental infrastructure cannot be repaired by patches. We need a new infrastructure (and it would be better and cheaper!).

Krugman says, “in a better world I’d call for single-payer.” Let’s make this a better world.