In 2013, Drs. Ubel, Abernethy, and Zafar published “Full Disclosure — Out-of-Pocket Costs as Side Effects” in the New England Journal of Medicine. In this essay, the authors grapple with the ethical responsibilities of physicians when it comes to the enormous cost of modern medicine. If a surgery or a course of chemotherapy is likely to bankrupt a patient, what is our duty to warn them, to ensure that they have considered both benefits and harms? A larger question, however, was left unasked: “How do we as physicians ethically operate within a medical system that forces people on a regular basis to choose between health and financial stability”
To grasp the extent of the issue, consider that even after the passage and defense of the Affordable Care Act, 27 million American remain uninsured. An additional 41 million Americans are underinsured which is to say that their out-of-pocket expenses (such as deductibles and copays) are enough to cause financial duress, despite having health insurance. And as health insurance deductibles increases faster than wages, the proportion of Americans who are underinsured continues to grow.
The consequences of this are grave. Three out of ten American adults report forgoing needed medical care due to cost concerns. One in four were unable to pay for basic necessities like food, heat, or rent because of medical bills. One third spent down all of their savings. Continue reading “Do No Harm: A Doctor’s Case For Single Payer”
The American medical system has long operated under a fee-for-service model in which only specific, narrowly-defined medical services qualify for reimbursement from insurance companies. This system is reasonably well-suited for procedure-oriented specialties in which services with clear indications, processes, and outcomes such as colonoscopy or knee replacement can be appropriately paid for.
In America’s fee-for-service system, reimbursement for primary care services is limited to short office visits and certain outpatient procedures (such as a joint injection). Many primary care doctors have felt that they could offer better care for their patients if the payment structure allowed for more flexibility in services offered, but opportunities to test this hypothesis have been limited.
Today, three groups in the Seattle area – Landmark, Concerto, and Iora – are independently demonstrating the value of flexibility in primary care to improve patient outcomes at overall lower cost. They’ve accomplished this by arranging for alternative payment models with local Medicare Advantage plans (private insurance plans who contract with Medicare to provide health insurance to seniors). Rather than operating under fee-for-service, these companies get a per-member, per-month payment. This payment structure provides a flexible budget with which they can offer services that don’t necessarily fit into the established fee-for-service structure. Continue reading “Innovations in Primary Care: Moving Beyond Fee-For-Service”
Yesterday I attended a meeting of Health Care for All Washington regarding single payer legislation in our state. The particular set of bills they are supporting are SB-5701 and HB-1026 which establish a trust fund (the Washington Health Security Trust or WHST) which would eventually act as a single payer for health care services in the state of Washington.
Specifically, this legislation creates the trust fund, establishes a board of trustees and guidance committees to run the Trust, and then lays out in very broad strokes what the Trust is meant to accomplish. As described in the legislation, the Trust is meant to pay for health care for Washington residents not otherwise covered by Medicaid, Medicare, or private insurance including dental and long term care (think nursing homes). Most likely the funds for the Trust would come from a combination of a payroll tax and a sliding-scale premium. Continue reading “Bringing Single Payer to Washington State”
As part of my family medicine residency training, I’m taking a month-long elective called Innovations in Primary Care. This month is an opportunity for primary care doctors from family medicine and internal medicine residency programs in Seattle to explore some of the different primary care models being trialed in the Seattle area and to use those experiences to fuel discussion about how primary care (and really, all medical care) can be improved in the United States.
Today was our first meeting, during which we gathered to collectively write an H&P for our current medical system. For those reading this who are not in medicine, the History and Physical or H&P is a semi-standardized note-writing structure that doctors use to describe the subjective and objective information about a patient’s health, assess why the patient is experiencing illness, and describe the next steps we need to take (diagnostic tests and/or treatments) going forward. It’s a structured way of thinking about a patient that helps us be rigorous and methodical.
It was a gratifying process because each of the doctors at the table shared a passion for making our health care system better, but brought a different set of experiences and priorities to the conversation.
Some of the take-aways I had from this conversation are as follows (in no particular order):
- The insurance framework for paying for health care, while originally conceived to improve access to surgical services which would otherwise be prohibitively expensive to most people, was quickly recognized by doctors as a way to extract larger fees for patient care. After all, when a third party (the insurance company) pays the bills, people tolerate much higher fees even if the end result is steady rise in out-of-pocket costs for everyone. Doctors, hospitals, and pharmaceutical companies have abused this system so greedily under the previous usual-and-customary payment system that increasingly rigid cost-containment measures have had to be implemented to control costs. We now live in a society where the average doctor makes $294,000 per year–more than 98.9% of Americans–while medical bills bankrupt patients and health insurance cost suppresses wage growth. Recognizing and holding ourselves accountable to how capitalism in medicine has brought out the worst in us is necessary before we can even begin to conceptualize a new system.
- The costs of most important and effective interventions to improve health, including primary care, are recurring and predictable costs that are best paid for through public health funding, NOT through health insurance. Access to clean water, nutritious food, safe housing, and preventive medical care is necessary for All People at All Times.
- America fails to invest in public welfare programs because of racism. The idea of the racialized-and-thus-undeserving Other benefiting from public welfare programs (e.g. the racist specter of the Welfare Queen that Reagan so infamously promoted) is fundamentally intolerable to White America. We are comfortable with 1 in 7 people in the United States facing food insecurity if it means we can prevent one person from buying steak with food stamps. There is no justice without racial justice.
- Many participants are needed to transform our medical care system into a true health care system. While there are only physicians in this particular group, the real work requires public health professionals, community health workers, housing experts, policy wonks, political activists, artists, chefs, personal trainers, behavioralists, and many others to both design an implement a better system.
I’m looking forward to the experiences and conversations this month will bring, and I hope to walk away with greater insight into how I can be a better advocate for effective and equitable health care in this country.
Shortly after Donald Trump nominated Dr. Tom Price to serve as Secretary of the Department of Health and Human Services, the American Medical Association, the Association of American Medical Colleges, and the American Academy of Family Physicians released statements supporting his nomination without reservation or qualification.
Many doctors were shocked to see these endorsements from their professional organizations knowing Dr. Price’s legislative track record as Representative from Georgia’s 6th district since 2005. As the New York Times editorial board describes in detail, Dr. Price has repeatedly acted against the interest of Americans’ health and well-being during his time in Congress. For example:
- He repeatedly voted for legislation to dismantle the Affordable Care Act, threatening to eliminate the health insurance of tens of millions of Americans.
- He introduced legislation to defund Medicaid for millions of low-income patients who rely on it for life saving medical care.
- He voted against expansion of the SCHIP program which provides health insurance coverage for children.
- He repeatedly voted for legislative interference in women’s medical decision-making around their reproductive health and is rated at 0% by the Planned Parenthood Action Fund.
In other words, although Dr. Price earned his MD from an accredited institution, his actions have demonstrated little respect for the Hippocratic oath.
The reaction of physicians was swift and fierce. Thousands of doctors publicly denounced the AMA. An equal contingent of medical students condemned the AAMC. The National Physicians Alliance joined the fray. In response, the AMA and AAFP privately sent emails to their members reassuring them that these organizations’ values remained unchanged, but without public advocacy for those values, what meaning do they have?
As physicians, doing everything in our power to promote the health and well-being of our patients is not a corny mission statement to copy-and-paste onto a website and ignore when it’s inconvenient. It is the driving force of our clinical, academic, and political practice.
In 2016, when there is so much at stake for our most vulnerable patients, it is a time for personal and professional courage. It is time to call upon our professional societies to stand with us in the fight to ensure that all Americans have access to high quality medical care without legislative interference in the doctor-patient relationship. It is time for these organizations to state clearly the patient-centered principles that they believe in most strongly, and to advocate for these principles on every level.
Opportunities for action (list will be updated)
- Call your congressional representatives and voice your support for the greater access to healthcare services and opposition to Tom Price’s nomination.
- Open letter to the AAFP from family doctors
- Open letter to the AMA from physicians
- Open letter to the AAMC from medical students
Since Donald Trump’s election on Tuesday, I have seen a renewed call to solidarity and resistance amongst my friends and colleagues in medicine. As I did with racial justice activism, I wanted to put together a post to consolidate the opportunities for action. This is both to help me clarify my own thoughts on action in the coming years, but also to help anyone else in medical professions who are trying to figure out how they can best work for a healthier and more just America in the coming years. This list is geared toward the particular expertise of medical professionals and is not meant to exclude work that the more general population needs to fight for such as the incredibly important work of dismantling White supremacy.
The Affordable Care Act
One of the more obvious threats of a Republican-dominated legislature is to Obama’s signature piece of legislation. Although it was developed as a near-duplicate of Republican Mitt Romney’s healthcare access effort in Massachusetts, Congressional Republicans decided that repeal of the ACA was the hill they wanted to die on and now that they actually have control of the legislature and the executive branches, they now have the power to follow through on their threat. There’s a lot of great writing on why complete Repeal and Replace would be incredibly difficult and likely extremely politically damaging, but if we’ve learned nothing from this election its that the predictions of experts should not let us become complacent. Here are something things you can do:
- Call (not write, not email…call) your congress people at their local offices and talk to their staff member in charge of health policy about what the coverage expansions under the ACA have meant for you and your patients. I’ve been in residency for 6 months and I already have about a half dozen powerful stories of people who only have access to life-saving care because of either Medicaid expansion or subsidized marketplace insurance. Use these anecdotes, This is doubly important if you are represented by Republicans who need to understand just how many people ACA repeal would hurt.
- Write op-eds the same and then shop them around and get them published in local or national newspapers. When they publish these letters, work your social media networks and make it go viral.
- Call up your professional organizations (AAFP, AMA, ACP, AAP, etc.) and make sure they are going to DC to keep pressure on the legislature to maintain the core benefits of the ACA. If you have time, travel with them to DC to speak to congress in person.
Another prominent goal of the Republican party is to make it more difficult for women, especially poor women, to have access to birth control and abortion. As physicians, we bear witness to the impact of unintended pregnancy and cannot stay silent on this issue.
- As above, call your congress people, write op-eds, and work with your professional organizations to keep pressure on the legislature to protect access to affordable birth control. A great talking point here is emphasizing that access to affordable birth control is the most effective way we know of to decrease the rate of abortion.
- Set up a recurring donation to Planned Parenthood. With public funding under threat, private financial support of Planned Parenthood is more important now than ever. This is a vital organization which provides
Social Determinants of Health
As much pride as we take in our work in the diagnosis and treatment of disease, when it comes to improving the quality and quantity of our patients’ lives, healthcare is a drop in the bucket. Directly addressing many of these social determinants of health may feel like it is outside your purview as a medical professional. However, we also have an obligation to Do No Harm and without an understanding of social determinants of health we can inadvertently counteract the health gains we make through our clinical work. Hopefully I can do more to flesh out this list over the next few weeks. Please send me items you think I should include here!
- As a society founded on the mythology of White supremacy, every one of us is socialized into White supremacist beliefs. This is not a question of being a Good or Bad person, but rather about the cognitive biases we can’t help but internalize. The first step in any anti-racist work is introspection into the ways in which we’ve been socialized into White supremacy and act on that socialization without realizing it.
- White Coats For Black Lives has put out a call for medical professionals to commit their time and energy to anti-racism. Answer that call here.
- Learn more about anti-racism efforts by following these people on Twitter.
- Wear a Black Lives Matter lapel pin. However, make sure that it’s not performative allyship but rather a constant reminder to demonstrate that Blacks Lives Matter through your clinical and public works.
- Immigrant Health and Rights
- Welfare programs and their beneficiaries are easy political targets. Using the above methods, speak up for high quality programs to promote economic safety net programs, especially cash assistance. A promising advocacy target here is cash assistance for all children which you can read about here.
- Housing is very much a hyper-local issue. Seek out housing-first programs in your city and advocate for them.
Get on Twitter
I know it’s fun to dismiss social media, but there are some amazing physician activists on there whose writing has been incredibly helpful in broadening my thinking about where healthcare fits into the larger goals of a just society. Here’s a follow list of medical activists to start with. While you’re at it, check out this list of great anti-racist writers.
I’ve been listening to The Uncertain Hour by Marketplace’s Wealth and Poverty Desk. This season, they’ve taken a deep dive into the United States’ welfare system and the consequences of welfare reform in the 90s.
The podcast provides a great introductory education about American poverty, a topic where opinions are strong and facts are frequently scarce. Interviews with families receiving cash welfare benefits reveal the daily compromises and anxieties which are the lived reality of America’s poor.
Equally disturbing, however, are the interviews with the middle and upper class people who maintain political control of America’s welfare system and the profound contempt for the poor which suffuses their conversations about poverty and welfare.
It’s easy to understand why we have failed to develop a coherent, evidence-based system for addressing poverty in America when you listen to these people and realize that their primary goals are to shame and punish the poor for daring to seek joy or create life, actions that lie at the core of our common humanity.
Two thousand years ago, Jesus of Nazareth pushed back on the prevailing idea that poverty was God’s punishment for sinfulness. Today, in a country where nearly half of the population claims loyalty to his Good News, we remain in this punitive mindset.
I am biased in this conversation because my daily work brings me face-to-face with the suffering that poverty creates, the shorter and sicker lives the poor live out in the midst of abundance. But I truly believe that if our anti-poverty initiatives were crafted by people with direct experience with poverty and designed specifically to promote joy and reduce suffering in our fellow human beings lives that they would be radically different than the systems we have today.