The national debate on health reform has uncovered innumerable “health care horror stories” in which cancer patients worry more about their bills than their malignancy or where pregnant women are laid off and dropped from their insurance soon before their due date. These stories are tragic, and unconscionable for the richest country in the world, however, as a physician, this is not my typical experience. Instead, what I see every day is patients with private health insurance who cannot afford the copays for their medications, delays in treatment as I grovel for prior authorization with a non-physician utilization reviewer, and patients stuck with huge bills for routine services that they thought they were covered for.

In my practice, patients have a mix of private and public coverage. While I work with some extremely impoverished patients who qualify for public insurance through Medicaid, it is the people with employee sponsored private insurance who are most at risk for roadblocks to care. As a primary care physician, it is hard enough to fit all of the recommended screening, health education, and chronic disease management that complex patients need into a fifteen minute visit. When the burden of battling with insurance companies is added to the equation, there is no way that I can succeed. My patients, especially the ones with private insurance, are forced to deal with the high copays, denials of claims, and delays in care.

Reflecting on the past week, a bunch of cases come to mind. While these stories may lack drama, it is nonetheless troubling to me how frequently my treatment recommendations are impeded by difficulties with health insurance. And I am sure my patients are not alone in suffering the consequences:

Ms. D, came in Wednesday. She has high blood pressure and very high cholesterol. I had not seen her in over six months, but she works a demanding job, so I figured that she had just been busy. In the office, we did not talk about her blood pressure. We did not talk about diet and exercise. She had not followed up for so long because at the prior visit I had sent her for an echocardiogram of the heart and she was billed $800 for the test. Her insurance would only cover $200. We spent the entire visit talking about how she could not afford to pay this bill. I just don’t get it. She has private health insurance. She was having symptoms that had been worsening over several visits and needed further evaluation – exercise intolerance and palpitations. Now, she is receiving daily letters from a collections agency, and she is frightened to come to the doctor because of the bills that may show up in the mail.

Mr. D, a security guard with diabetes, hurt his knee while fishing and had severe pain and swelling. When I initially saw him a few weeks ago, there did not seem to be any major structural damage to the ligaments, so I recommended a conservative approach with rest, ice, and anti-inflammatory medications. Now, several weeks later, the pain and swelling had not subsided, so I ordered an MRI to evaluate for more subtle damage to the knee. After several attempts at prior authorization, the private insurance company refused to pay for the test. Baseball players get MRIs the same day for any bump or bruise, but even going through the appropriate prior authorization process, I could not order an MRI for my patient with private health insurance. I am not looking forward to all the phone calls that it will require to protest this denial of necessary diagnostic test.

On Thursday, Mr. F came in to have his blood checked. He requires blood thinners to prevent recurrence of blood clots which could be fatal. He has twice previously had clots in the blood vessels of his calves, and he once had a blood clot travel to his lungs. He has a clotting disorder that makes any break in treatment with the blood thinners extremely dangerous. Warfarin is an effective and inexpensive blood thinner, but it requires frequent monitoring because its activity is affected by numerous interactions with other medications and foods. His blood test showed that the warfarin was not doing its job, so I recommended an increased dose. It takes about three days for the dosage change to have a full effect, so I also recommended injectable blood thinners, which act more rapidly, until we could demonstrate that his warfarin had reached a therapeutic level. However, he could not afford the copay for the injectable blood thinner, so he must hope that he does not develop another blood clot as we wait for the higher dosage of warfarin to take effect.

Yesterday, I saw Ms. E for a follow up appointment. She is only in her 30s but has already had major back surgery for a disk problem. She stands for six hours a day at work and has recently had worsening of her back pain. Her spine specialist had recommended physical therapy, instead of a repeat operation, but she cannot go because her private insurance company requires a copay for every session. She has been unable to work because of the worsening pain, so she cannot afford these copays and has not been able to follow the treatment plan. I do not want her to become dependent on pain killers, but since the treatment recommended by her orthopedist is not a realistic possibility, we are running out of options.

I could fill many pages with stories like these of my patients whom are hard working, have private health insurance through an employer, but just cannot get the care that they need, because of unreliable coverage. It frustrates me that executives of health insurance companies spend millions on advertising to disparage public health insurance, and Republican politicians are stone walling meaningful health care reform because they are afraid that a public health insurance option would put private health insurance companies out of business. I do not care who provides health insurance for my patients. Whether they have public or private insurance, I just want them to get the best care possible. If private health insurance companies provide a high quality product, they will not be “forced” out of business by a public plan. It makes sense that competition between a public plan and private plans would lower costs, improve quality, and guarantee an option to those who do not have employer sponsored coverage. As a physician, I need to advocate for my patients. Private health insurance companies have thousand of lobbyists and millions of dollars to spend. So why do these companies need so many politicians, including Democrats, advocating for them as well? This is not about ideology. It’s about patients who cannot afford their medications or who face bankruptcy due to medical bills.  We need change, and this will only come with a guaranteed public health insurance option.

- Aaron Fox, MD

National Physicians Alliance

In an editorial titled, “Prognosis: Debt” Fred Hiatt of the Washington Post expresses concern over the (misleading) 1.6 trillion dollar price tag placed on health care reform, but in a way makes a compelling argument for including a public health insurance option in health reform.

He writes that President Obama (and others) have defined the major problem with our health care system as being unsustainable growth in costs, while congressional Democrats have primarily focused on expanding coverage to the uninsured:

congressional Democrats and the most involved interest groups behind them are far more passionate about universal coverage than about controlling costs. Thus Obama’s political calculation: Push for health-care reform that delivers universal coverage — and insist on as many levers to control costs going forward as possible.

He explains that this disconnect between the problem and proposed solution comes from the fact that it’s easy to expand coverage but hard to control costs. He states that proposed cost saving measures, such as focusing on prevention, shifting from specialist care to primary care, and changing provider payments from fee for service, all are unproven, and he implies that expanding coverage to include all Americans would inevitably lead to more debt. He gives several suggestions to the President on how to ensure that whatever “new burden” we take on with health care reform “is really paid for”.

As a physician, I do think universal coverage and equitability in our health care system is a “moral imperative” – I see patients without health insurance or with inadequate health insurance who have put off necessary care due to costs and suffered the consequences – but for the sake of argument, let us just talk about costs.

If we expand health insurance coverage without controlling costs, as outlined by Mr. Hiatt, we would have the equivalent of the Massachusetts plan. Their health exchange (”Commonwealth Connector Authority”) and individual mandate to purchase insurance (with subsidies for lower income individuals and families), along with Medicaid expansion and other measures, has achieved more than 97% health insurance coverage. This initially improved access to care (more individuals had a usual source of care besides the ER and a preventive care visit in the preceding 12 months), and decreased the financial burden of health care costs on some families (with fewer people spending more than 10% of their income on out of pocket costs). However, without a mechanism to control costs, there have been challenges in limiting increases in premiums and some of the gains in affordability have been lost.

This is where the public health insurance option comes in. Massachusetts does not have a true public health insurance option. The Congressional Budget Office’s $1.6 trillion estimate on the 10 year costs of the Senate Health, Education, Labor, and Pension committee’s health reform bill did not include evaluation of the public health insurance option. A proposal by the Commonwealth Fund for comprehensive health system reform including a public health insurance option, provider payment reform, and investment in public health infrastructure was estimated to have a net impact over ten years of $3 trillion in savings. While the upfront costs in expanding insurance coverage may appear daunting, as long as it is coupled with a mechanism to control costs, it will be a wise investment that improves access, quality, and slows growth in health expenditures.

And the cost savings are not just wishful thinking – lower administrative costs and the ability to negotiate lower rates from providers and pharmaceutical companies would allow a public plan to offer premiums at least 20% less than those of comparable plans in private individual or group markets. This expansion of coverage would not reduce overall health care costs, but these savings are not included in the 1.6 trillion dollar price tag for the HELP committee’s proposal. If employers or individuals previously with commercial insurance chose to buy into the public plan and its less expensive premiums, there could be significant savings overall.

A public health insurance plan would also likely reduce the costs of premiums of private health insurance through competition. 94% of health insurance markets are “highly concentrated” by FTC standards and most metro areas only have one or two options for consumers. This near monopoly is not good for costs or quality.

The effects of payment reform may be more difficult for the CBO to estimate, but a public plan would have a clear advantage over private insurers in shifting incentives toward prevention, care coordination, and evidence based medicine. Managed care was supposed achieve these goals in the private sector, but it has failed to control costs or improve quality. Medicare has begun to align payment with outcomes through pay for performance and nonpayment of care for preventable complications instead of simply reimbursing for the volume of care provided. A public plan would have the national scope to influence practice patterns across the country; a public plan would offer transparency and could be held accountable if cost or quality measures were not being reached; and a public plan would have the mission of disseminating effective payment innovations to other payers as a public good.

There are many other reasons why we need fundamental health care reform – most pressingly because it is unconscionable to deny sick patients necessary care because of inability to afford health care costs – but the realities of increasing health care expenditures do require a discussion of costs. While it is unfortunate that a misleading CBO estimate on the costs of one version of the health care bill have decreased momentum for reform, drawing on the lessons from Massachusetts, we can still use this information to promote meaningful change. Relying on the private health insurance industry to control costs would be a mistake. However, adding a public health insurance option is extremely popular, with 72% of Americans supporting a public plan in the most recent poll, and would provide several mechanisms to control costs. The American people are correct on this one, and our elected representatives better be listening.

Aaron Fox, MD
National Physicians Alliance
New York City – Local Action Network

A recent New York Times/CBS Poll found that a large majority of Americans support a government run insurance plan. Politicians not supporting a public-health insurance option, are truly out of touch with their constituents. The current draft in the senate promoting co-ops is frankly a bad idea and won’t really do anything to keep insurance companies in check, improve quality, and bring down costs. We need to demand from our congressmen and women to support a real and robust public health insurance option.  I’m not surprised by the results, we all have so many patients who are disgruntled with private insurance companies. Everyone, please call your congressmen and women and demand real reform which includes a public health insurance option and nothing less!

In Poll, Wide Support for Government-Run Health
By KEVIN SACK and MARJORIE CONNELLY

Americans favor a plan for government-run insurance to compete with private insurers, a Times/CBS poll found.

Our own Valerie Arkoosh, the president-elect of NPA, is featured here explaining why we need the choice of a public health insurance plan.

A little late but it too a while to get these pictures done (they are hand developed). As a strong group of NPA leaders, we had our the Monday after our National Meeting. What was remarkable? In 2007, the whole group fit on picture. Now? I count 24 people here (including me behind the lens) and that wasn’t even everybody! Next time in DC we need a bus!

A recent CNBC segment posed the question of whether healthcare is a right. They brought on commentators to argue in favor and against, one from the Cato Institute and one from the National Physicians Alliance. (you can see the clip at curethis.org)

The host started by posing the question to the conservative commentator, Michael Cannon. “I think it should be a right,” he replied. “And therefore I think physicians should work for nothing.” Sarcasm notwithstanding, his point was clear: healthcare cannot be a right because it involves payment. The exchange of goods and services for money equals capitalism, which puts healthcare squarely in the category of commodity.

Mr. Cannon backed up his point by contrasting healthcare with other things we commonly think of as human rights, like freedom of speech and religion. No one has to be paid in order to let us speak freely and worship freely, he implied, which is why they are rights and healthcare is not.

This argument is persuasive. We like to think that a human right is something you are born with, not something that has to be given. The very phrase ‘freedom of speech’ suggests its simplicity: just let people speak! It’s not that hard! Healthcare, on the other hand, is not accomplished by standing aside and letting citizens exercise their freedoms. For healthcare to be your human right, something has to actively be done to you.

But is it true that freedom of speech requires no involvement by the government? Let’s imagine taking a trip to place where there is very little government, for example Somalia. You might have the basic human right to freedom of speech there, but it’s not worth much. If you stand on a milk crate (assuming you can find one) and give a speech that others find disagreeable, those people may choose to gag you, stuff you in the trunk of a car, drive you 20 miles out of town, and perhaps kill you. The government has done nothing to take away your freedom of speech, but they haven’t done anything to protect it either.

We often ignore the role of infrastructure, such as our police force and civil and criminal court system, in allowing rights like freedom of speech and religion to flourish. The U.S. legal system is a highly complex bureaucracy, and it plays an important role in keeping the right to free speech alive.

The same principles apply in healthcare. We have a complex bureaucracy in place — doctors, nurses, hospitals — to protect our right to health. There’s no difference, in principle, between free speech and healthcare, so why is one an unquestioned human right while the other is relegated to a commodity?

In fact, no matter what human right you can name, there is an infrastructure in place to protect and defend it. And the professionals who manage that infrastructure need to get paid. So it’s foolish logic to argue that since doctors are paid a salary, healthcare cannot be a right.

Now, an opponent of the idea that healthcare is a right could argue that sure, the legal system keeps freedom of speech alive. But it also does other things. We would need cops and judges around to deal with violent crime, even if society had no right to free speech. So the added cost to society from having freedom of speech is pretty minimal.
But the same argument could be made for healthcare. The medical industry has to exist regardless of whether healthcare is a right or not. Once again we can see that healthcare and freedom of speech are identical.

Still, let’s be generous. Let’s say we do accept the distinction that Mr. Cannon was trying to make when he drew a bright line between healthcare and freedom of speech. I think what he was trying to get at was that there are two types of rights. And actually, he’s correct. Philosophers and ethicists commonly refer to them as “positive” rights and “negative” rights.

In the U.S., we are very comfortable with the latter category. Negative rights are when a person has the right not to have something done to him. For example, the right not to be tortured, not be persecuted for your religion, and not to be thrown in jail for disagreeing with the government.

Healthcare falls into the category of positive rights, for obvious reasons. (i realize, by the way, that i’m not using the strict philosophical definition of these terms. If you really care, check out Wikipedia.) We Americans, when polled on this subject, have always been uncomfortable with positive rights. Positive rights seem to imply whininess, laziness, petulantly asking others for help.

But positive rights are actually a strong part of our tradition. Universal public education was introduced in the U.S. in the late 1800s, and today it is as American as apple pie. Ask any fourth-grader if she has a right to go to high school, and you’ll get a quizzical look because the answer is so obvious. We still fight about ways to improve education in the U.S., but no one has seriously proposed abolishing the public school system. Why? Because we understand what an incredible boon to our country it has been to have a well-educated workforce.

So we’ve established that healthcare, from the standpoint of principles, is no different than other accepted human rights. And from a practical standpoint, we see that Americans already support rights that are very similar to healthcare, like education.

So it seems to me that healthcare is a right. Other people, of course, can disagree. What they can’t do is pretend that there are objective, empiric differences between healthcare and other accepted human rights.

The major battle lines in the upcoming debate about health care reform will likely be drawn around the idea of creating a choice of a public health insurance plan to compete in the market with regulated insurance companies. Republicans have made it clear they will not support such a plan, and many Democrats have announced they will oppose reform that lacks this option.

Compromise is as American as motherhood, apple pie and the creation of the US Senate. Undoubtably, our political leaders will attempt to find compromise on this issue as well. While it is less important for the House (where the majority party has near total control), it will be necessary to obtain the 60 votes that may be needed in the Senate. However, the two positions appear mutually exclusive at the moment.

But I think there will be proposals that will attempt to find a middle ground. I anticipate they will be focused on the area of competition, since that is a linch-pin of modern GOP talking points. In particular, they are many places in the country with only one or two private health insurance providers, so the creation of a public health insurance plan would engender competition in those markets. (These areas also tend to be rural, which may attract the votes of Senators from important states such as Iowa and Maine.)

One approach that has been suggested for similar debates in the past is to create a public plan only for people who live in areas that lack competition among private plans. Thus, the public health insurance option would create competition and choice for those who currently don’t have it.

Is this a compromise we could live with? Or should every American have the option of enrolling in a public-sponsored insurance plan, regardless of how many private options they also have?

Now, consider the alternative proposal that will be suggested to stimulate competition: allow Americans to purchase health insurance across state lines. Currently, health insurance is regulated at the state level. Some states have passed laws requiring health insurance to be quite comprehensive; other states have only minimal requirements. However, if people could choose insurance from any carrier in any state, it would create more options for everyone to choose from.

I would call this type of proposal the “UnderInsure America Act”. It would lead to many more people purchasing inexpensive and, too late for them to realize, inadequate coverage.

Now, how does that first compromise look in comparison? Maybe it is something worth considering … it would create public plans for some people, allow us to work out the details, have a model to expand to other markets as insurance companies exit, etc.

On the other hand, the public insurance plans would likely exist only in rural areas, which have a much different population than urban centers. It may be harder for those plans to build the numbers necessary to demonstrate efficiencies over private insurers.

Is this a compromise we could consider?

Last night, CNBC featured a segment on “Is Health care a right or a privilege?” and invited two speakers to debate the question. One of the speakers was Dr Mai Pham, senior policy advisor at the National Physicians Alliance (NPA). The NPA fimly believes that health care is a human right and our campaigns and mission speak directly to that. The other speaker was Michael Cannon, director of health policy at the CATO Institute, a free-market, libertarian organization.

We applaud Dr. Pham’s cool and collected manner and her ease at articulating her points under fire. We could learn some tips on how to stay on point and how to debate an issue, from her appearance on the debate.

In any case, it was a pleasant surprise to see this issue covered by CNBC, and a great thanks to them for asking us on the show; perhaps the station will cover such issues in the future!

Ok, eye catching title, but I admit this has nothing to do with Sex, Lies and Videotape, other than what we need for healthcare may be what this movie did for independent film (to revolutionize it).

Nor do I want to suggest any of the described below are lies…. this is for readers to decide….

This just in from the New York Times: Richard L. Scott, a conservative that ran a company convicted of defrauding the government of hundreds of millions of dollars in the 1990’s (yes, he is still filthy rich), and whose investment firm claims “integrity” as one of its principles, now is embarking on a campaign à la Swift Boat Veterans against the Obama health plan. Which health plan? The one currently being developed by Congress, aka The People?

Hard to believe that someone with such a history will be taken as credible, so many of us who want affordable health care for all may welcome his attempt to influence the public…. Richard Kirsch, campaign manger for HCAN, of which the NPA is a partner, is quoted as saying: “We cannot have a better first person to attack health care reform than someone who ran a company that ripped off the government of hundreds of millions of dollars.”
Scott’s mantra “Choice, Competition, Accountability and Personal Responsibility” hardly disguises his “businesslike approach to health care” which is “bottom-line-driven”, and has seems to have helped make him a very wealthy man. And calling his organization “CPR” just seems too corny.

It is easy to offer urgent care services for “respiratory illness, headaches, sore throats, sprains or fractures, cold or flu symptoms, burns, cuts, ear and eye infections, pulled or strained muscles, coughs, and childhood illnesses; and physicals, including school or sports, pre-op, and basic check-ups“, as Scott’s company Solantic does, and leave true, costly emergencies for hospitals to deal with. This will not fix our healthcare system, nor have choice and competition taken care of the 46 million uninsured and many more underinsured people stuck with high deductible plans so far (of course Scott is quick to tell you its the governments fault).

Rick, we all agree our healthcare system is too expensive and not sustainable. Other than that, you seem to have little in common with me. I would suggest we all work on a solution that puts more money in people’s pockets, not in yours or mine. Let other, more credible folks (patients, health care professionals and dedicated law makers such as Kennedy come to mind) worry about how to fix healthcare.

cross post from Question Everything

On February 26th a large, well designed trial comparing different weight loss diets was published in the New England Journal of Medicine. It was a good behavioral intervention over two years. They compared high and low protein, high and low fat, and different amounts of carbohydrates. The result: no difference in weight loss between any of the diets. Overall, the participants lost 6.5-9 pounds at the end of 2 years. This is a mild, but significant reduction.

We have now had a bunch of trials that show that many different diets “work”, but only modestly. If we try and take these interventions into the clinical (i.e. non-research) world, we will likely have even less success.

So what do we take out of this? The editorial by Martijn Katan (linked to below) says it best:

“We do not need another diet trial; we need a change of paradigm.”

He goes on to talk about how behavior change is hard, and we will only be effective if we work at a community level:

“Like cholera, obesity may be a problem that cannot be solved by individual persons but that requires community action. …the apparent success of such community interventions suggests that we may need a new approach to preventing and to treating obesity and that it must be a total-environment approach that involves and activates entire neighborhoods and communities.”

I have been advocating for this for some time. Obesity treatment (via dieting) is not the answer to this large public health problem. Obesity prevention through large scale public health research and interventions is the answer. Let’s start taking responsibility for our laws, policies, and community designs that contribute to obesity. Let’s all work together to make our communities healthy places for our children, spouses, friends, and parents to live in.

NEJM — Weight-Loss Diets for the Prevention and Treatment of Obesity