HealthCommentary

Exploring Human Potential

Is Tenet Healthcare Your Collection Agency?

Posted on | January 18, 2018 | No Comments

Mike Magee

When America’s politicians and business leaders elected to promote a free-enterprise approach to health delivery services in the immediate post-WWII period, they were choosing a course diametrically opposed to not only our Allies, but also our enemies at the time.

We rejected serious health care planning. Instead we chose to directly and indirectly infuse taxpayer dollars into the hands of entrepreneurs running research enterprises, hospitals, insurance companies, medical journals, medical schools, pharmaceutical companies and more. Remarkably, we did this while our own military leaders were simultaneously executing well-thought out implementation of national health delivery systems in Germany and Japan as part of rational nation building efforts.

Now, nearly three-quarters of a century later, we have stubbornly held on to the myth that “defeating disease” will leave health in its wake, and that “scientific progress” is synonymous with “human progress”. Course corrections, now in their third and fourth and fifth iterations have failed to correct for complexity, disparity, high cost, high variability, and poor outcomes including declining life expectancy.

Where simplicity and proper national planning are obviously called for, we instead are forced to witness ever expanding institutional gymnastics in the pursuit of compensating for the absence of appropriate “checks and balances” and the raw pursuit of profitability at the cost of our own mental and physical well-being.

Consider for example that medical debt is now a $75 billion affair spread over 43 million people, and that billing (including verifying coverage, eligibility, coding and documentation) is now a $24 billion market in the U.S.

Crazy, right?

But it gets worse. Case in point: Tenet, the Dallas-based for-profit hospital network that has “for-sale” signs up on many of its’ hospitals to get out from under $15 billion in debt. They have quietly shifted 5% of their assets to Conifer. That name may be unfamiliar to many, but the subsidiary names of Central Financial Control and Syndicated Office Systems LLC are all too familiar to many burdened with medical debt.

Tenet’s Conifer employs 15,570 people to harass Americans owing money to 77 Tenet hospitals. That’s bad enough. But the venture has been profitable enough, with profit margins double those in health care delivery, that they now contract services to  700 other hospital nationwide including many non-profit Catholic hospitals.

If harassing patients forced into debt by absent or skinny health plans with high deductibles and TSAs  isn’t your cup of tea, consider the joy of trying to run a hospital that routinely struggles to secure grey-market access to standard supplies like IV solutions or morphine. The Martin Shkreli’s of the generic world, working with entrepreneurial zeal in our Wild West version of a health care system, have finally caused traditional American health care leaders to go radical.

Consider the fact that Carolyn Clancy, now running Veterans Health Administration, and Don Berwick, along with former Senator Bob Kerrey, have signed on to a plan, led by the vaulted Intermountain Healthcare System based in Salt Lake City, to launch their own generic drug company. As the system’s CEO says, “We are not going to lay down. We are going to go ahead and try to fix it.”

Good luck with that – fixing complexity with one more step in the chain. Seems counterintuitive to a leader like Don Berwick who thirty years ago, channeling Deming, favored eliminating steps to improve quality and lower cost, rather than adding steps. It was Deming who famously said, “Quality begins with the intent, which is fixed by management.”

What is our intent?  To answer this, we need to do what all others did as their nations struggled under the chronic burden of disease returning after WW II. We need to ask the very basic question, “How do we make America and Americans healthy?” An honest response will require both universality and solidarity on a national scale.

Time For Americans To Speak on Health Care Priorities

Posted on | January 11, 2018 | No Comments

Cathy Caldwell, Alabama CHIP

Mike Magee

Of all the developed nations on earth, our’s is the only one with no cogent national plan to support our citizens’ health, productivity and well-being. What we have in its place is an opaque and deeply collusive system of discovery profiteering that has entangled not only industry, but also academic medicine, government agencies like the NIH and FDA, and our elective representatives.

To access profits and career advancement requires a blind eye to transgressions that are, at this point, so obvious and egregious that they carry us all beyond ludicrous. Together we pretend that “defeating disease” as we once defeated the Nazi’s is not only finally within the reach of our brilliant scientists, but an adequate substitution for say – insurance for an everyday kid with a raging ear infection.

If you are Cathy Caldwell, Alabama’s CHIP director, you know the difference. CHIP provides coverage for approximately 9 million kids in the U.S. at a cost of approximately $20 billion a year. It’s part of a patch-work of quick fixes, including the establishment of federal funded community health centers that provide service to 24 million citizens, that are made necessary by our nation’s unwillingness to act in solidarity with each other and embrace universal coverage for our citizens.

The CHIP quick-fix was a series of partial authorizations which have left states like Alabama increasingly in the lurch. For example, Congress’s last 2-year funding provided full funding the first year, but only $5.7 billion the second year. As Caldwell stated recently, “I just do not understand how they even call (the CHIP) patch a half-year of funding. I am trying to get my head around it.” Her program serves 85,000 kids and is administered in partnership with the states BC/BS plan. How are the families involved dealing with the possible near term closure of CHIP? From Caldwell: “I think most are freaked out.”

And yet, you’d never know that from the round of congratulatory back slapping among medical sciences top elite who’s careers are as far removed from the realities of Alabama’s under-class as is humanly possible. No, this week they were all high-fives as Congressional Republicans and Democrats, in overwhelming numbers approved their third consecutive $2 billion increase in the annual NIH budget.

The NIH annual budget now tops $34 billion, enough to keep some 300,000 academic scientists gainfully employed across America. This revenue stream is doubled or tripled or quadrupled by a wide range of contractual relationships with industry with the bounty of patents and royalties being the shared pot of gold at the end of the rainbow.

What does the American public receive in return? Well, that’s hard to say. We don’t even have full access to the results of the studies that our own NIH funded. In 2008, the NIH created the ClinicalTrials.gov database and, in a toothless demand, insisted that studies (positive and negative) be reported out on this open access site. The major academic journals made a great show at the time that they would no longer publish papers who’s results were not listed on ClinicalTrials.gov. But within a year, under the industry threat of lost journal ad revenue, they folded.

Where are we ten years into transparency? Well this week we had a round of congratulatory headlines. Our vaulted academic medical enterprises, self-proclaimed the best in the world, had managed a “C” – reporting out 72% of their trials, and 40% of these were posted years later than required by law. Our FDA and NIH pledge more aggressive oversight but neither have additional staff or funding to support good intentions.

Does reporting matter? Well it did in 2008 when academicians working with GlaxoSmithKline hid clinical evidence that Paxil use in teenagers increased suicidal thoughts and actions. And it did that same year when Dr. Joan Daughton at the U. of Nebraska refused to release results of a study on the use of stimulants in 4 and 5-year-olds who had been labeled by industry marketers and compliant physicians as having ADHD. Other researchers were already picking up permanent neurotransmitter abnormalities in the brains of adults treated with Ritalin in pre-school years. Yet a decade later, the funded results of Daughton’s work have not surfaced in print or online.

The absurdity of all this is why increasingly the elite of the MIC, and their Congressional enablers, find themselves out-of-step with an American public who prioritize universal health care at the top of their list, and not the latest potential yet still to be validated gene cure for inherited blindness in a handful of kids in the U.S. Even if they could come up with the $850,000 per treatment that the company (and its academic partner patent holders) intend to pocket, how does that possibly make up for Cathy Caldwell’s CHIP kids in Alabama?

A health care system built on “defeating disease” is largely fueled by the pursuit of profit, fame and academic power. It should never have been offered as a substitute for a well-planned, equitable, and efficient health delivery system. The time has come to finally get our priorities straight.

2018 – The Year of Dr. King.

Posted on | January 2, 2018 | No Comments

Mike Magee

We awaken this morning, on this sacred day that honors Martin Luther King Jr., to the continued reverberation of racist and profane commentary days ago from his polar opposite, a man who adds insult to injury by bragging that his vile actions will help him in the polls.

And yet 2018 has the potential to be a monumental turn-around year for America, a year when we stare our true culture in the face, and decide to embrace health and well-being.

Fifty years ago, Rev. Martin Luther King Jr. warned that excessive materialism, militarism, and racism were “inseparable triplets”, and that our nation required a “revolution of values…a restructuring of the very architecture of American society.” Recently, conservative columnist David Brooks said as much with these words, “The first step in launching our own revival is understanding that the problem is down in the roots.”

Our culture is so blatant in its disrespect for human and planetary health that it’s simply hard to ignore any longer. Dr. King recognized this core truth a half century ago when he said, “We are all caught in an inescapable network of mutuality tied into a single garment of destiny. Whatever affects one directly affects all indirectly. We are made to live together because of the interrelated structure of reality.”

With new leadership in 2018, we might begin the long transformative step toward a healthier culture.

On gun violence:

Our’s is a country that not only allows and promotes guns, but also now limits federally funded research on gun violence and has attempted to muzzle physicians who wish to discuss gun safety with their patients. There were 36,161 motor vehicle crash deaths in 2015. That’s bad, but it’s 91 fewer deaths than caused by guns that year. We’re killing 100 people a day with our guns, 60% of which are suicides – successful 90% of the time when a gun is the instrument.

On planetary health:

We just marked the 25th anniversary of the landmark “Warning to Humanity”, a consensus document filed by 1,700 scientists on global warming. Trump’s pull-out of the Paris Accord aside, the group now 15,000 scientists strong from 184 countries, just published an update in the journal BioScience. Lead scientist, Henry Kendall, states, “If not checked, many of our current practices put at serious risk the future that we wish for human society and the plant and animal kingdoms, and may so alter the living world that it will be unable to sustain life in the manner that we know.”

On childhood obesity:

Futurists now predict that the obesity rate in today’s children, when they hit adulthood, will be 57%. And with this, soaring rates of diabetes and heart disease surely follow, while health resources are diverted to elusive “scientific progress” as American “human progress” continues in steep decline.

On gender inequality and abuse:

Of course, the list goes on – consider the mind-boggling short and long-term implications of what appears endemic sexual abuse in and out of our workplaces. And that doesn’t even begin to address the fact that we seem to have managed to elect as our president a man who is a confessed serial sexual abuser.

Yet, to his credit, President Trump, with his vile labels, has done nothing more than force us to face, in sharp relief, our true selves and the “inseparable triplets” Dr. King described now 50 years ago. The time has come to fulfill his dream of a healthier America. 2018 is the year, and elections are just a few short months away.

Santa’s Message on Health

Posted on | December 25, 2017 | 8 Comments

Mike Magee

“Dear Quinn, Luca and Charlotte,
Thank you for believing in my magic. I hope you will always believe in magic. 
Believe in the magic of family. There are times you will stumble, but your family will always be by your side. 
Believe in the magic of laughter. It will keep you whole. 
Believe in yourselves because I believe in you. 
Take care of each other.
Love always,
Santa”

When I read this message to three of our ten grandchildren on this snowy Christmas morning in New England, it spoke to me of strength and resilience, of love and solidarity, of healthy minds and bodies and spirits.

This coming year will be a critical challenge for all Americans. How will the American family respond? How do we make America healthy again? I cling to Santa’s final words – “Take care of each other.”

 

The MIC Circular Firing Squad

Posted on | December 16, 2017 | No Comments

Mike Magee

If you want to see the Medical-Industrial Complex (MIC) in full “circular firing squad” mode, simply check out the recent Energy & Commerce Committee hearings on soaring drug prices hosted by chairman Rep. Greg Walden (R-OR). Delivering tough talk to committee members, he said, “Consider yourself on [the working group] if you’re on the healthcare subcommittee.”

All for one, one for all. But not so much inside the MIC and its purposefully complex supply chain where every participant gets a piece of the action, and the actions drain the consumer pocket book.

Check out the “dialogue”:

AMA seemed focused on complexity over cost. Board Chair Gerald Harmon, MD said, “Affordability and price can be a major barrier, but so are the hoops we have to jump through — prior authorization, changing drug formularies, step [regimens] — all put in by insurers to manage costs.”

Insurers say,  No way! They point to PhRMA. Their rep Matt Eyles says, “Any discussion of drug prices in the supply chain must start with the list price, which is set solely by drug companies and which acts as a starting point for plans and PBMs to negotiate lower prices for consumers. Out-of-control prices are the result of drug companies taking advantage of a market skewed in their favor.”

Fresh off the vertical integration startegies of CVS/Aetna and United Healthcare/Optum, the PBM’s piled on. Their trade leader Mark Merritt said, “Prices are set exclusively by drug companies with zero input from anybody else in the supply chain, including PBMs.”

PhRMA spokesperson Lori Reilly cried foul. She claimed the PBMs pull $100 billion out of the system each year, adding with a figurative “tear in her eye”, “Unfortunately, many times those discounts and rebates are captured by intermediaries and don’t make their way back to patients.” Doug Hoey, representing independent pharmacists agreed – and with more detail:  “Opaque PBM practices include PBM-retained rebates and spread pricing, generic drug reimbursement schemes, and direct and indirect remuneration (DIR) fees assessed on pharmacies months after a prescription is filed.”

Consumer group head David Mitchell didn’t pick an MIC loser from the above list. He simply said “We should allow Medicare to negotiate prices for patients.” But to do that we’d have to declare that the MIC back door collusion days are over, not just on drug pricing, but also on research, medical education, governmental advisory councils, peer review publications, patent profiteering, and academic career advancement.

The starting point for all of the above is universality and solidarity in health coverage. Beyond helping to correct income disparity and moving us together toward a more empathetic culture, it would also force planning, budgeting, and prioritization to address the critical question we as a nation have avoided for so long, “How do we make America (and all Americans) healthy again?”

Stains Outlast Gains as Industry Encroaches on Physician Prescribing Power

Posted on | December 15, 2017 | No Comments

 

Opioid Czar & Czarina

Mike Magee

When the AMA helped empower Purdue Pharma funded Pain Management by granting specialty status in its’ Federation in the 1980s– and with that legitimacy of pain as the “5th vital sign”; and when everyday physicians (especially primary care physicians who were targeted by Purdue Pharma) became easy marks in a deadly nationwide narcotics scam – the profession was unwittingly risking their primary differentiator and economic lever, prescribing power.

Now, some three decades later, the crow has come home to roost. And government under Trump will not come to the rescue. The White House Council of Economic Advisers has placed the cost per year of the epidemic at $500 billion. Chris Christie found a “life-after-Trump” with the issue. Now, following the lead of putting Jared in charge of Middle East peace, Trump has assigned opioids to an equally unprepared Kellyanne Conway who has created an “opioids cabinet” as the first, and likely the final contribution she’ll make to solving this crisis.

In the meantime, the insurance industry has taken a break from its’ latest land grab at vertical integration (looking at you Aetna-CVS and United Healthcare-DaVita), and is putting the breaks on MD prescribing.

Aetna is all in on cutting off the spigot, stating that “Aetna is committed to addressing the opioid crisis through prevention, intervention, and treatment.” As for the details, look to Cigna and Anthem. They have both set up restrictions on number, frequency and location of opioid prescribing intended to deliver near immediate 30% decreases in the pharmacy enabled narcotic trade.

Anthem marketers make the whole mess sound like a “win-win”. Commenting on an Anthem supported effort to use combined therapy for opioid addicts in Connecticut, Sherry Dubester, their VP of Behavioral Health, says, “I think that’s a great example of where the payer side can find providers doing interesting things and innovative approaches, and look to embrace that early.” Sounds wonderful!

As for prescribing leadership, PhRMA is ready to fill the void as well (as long as it doesn’t interrupt their current focus on price hikes and job cuts to enhance profitability. Their just released policy includes 1) Prescription limits of a 7 day opioid supply for acute pain and a 30 day supply for chronic pain, and 2) prohibition on opioid prescribing in an office setting.

Short-term thinking often has long-term implications. Whether it’s open-ended entry into the AMA Federation as a membership-enhancement strategy, MD’s fast-pen prescribing so easily manipulated by industry, or the support of physician politicians who are clearly ethically compromised, the stains last a great deal longer than the government relations gains.

Trust must always be earned. That takes time and consistency.

As CEO Profits Soar, Why Are More and More Of Their Employees Underinsured?

Posted on | December 7, 2017 | No Comments

Mike Magee

Employees across America are discovering that money is tight this Christmas, in large part because they are on the hook for rising out-of-pocket health care costs. But as the rising trend line above well-illustrates, their CEO’s pockets are overflowing with cash, and their health plans are Cadillac or better.

This is the season for gift-giving, family recipes, and quotes on the co-pays, deductibles, skinny coverage schemes, and employer Scrooginess that marks our uniquely American health care system.

216 million of us will be playing the game over the next few weeks. That’s how many Americans are covered by private, employer-sponsored or self-purchased plans. For the 119 million of you covered by Government plans, count your lucky stars – less double-talk and purposeful obfuscation. Less phones trees and knee-jerk claim rejections. Less hidden profiteering at your expense.

Based on the latest data, out-of-pocket costs and deductibles are now so inflated on the private side that one quarter of those insured on the employer or private rolls have earned the technical label “underinsured”.

One of the main champions of skinny plans backed by personal banker friendly Health Savings Accounts (HSAs), Grace-Marie Turner, recently trumpeted in Forbes, “One company found that consumer-directed plans saved employers $208 per member per year and that employees in these plans spent less on healthcare, while increasing their preventative care visits.”

Tell that to the 13% of employees whose deductibles now exceed 5% of their household income. That’s up from just 2% in 2003 when Grace-Marie began to campaign for financial sector enriching HSAs in earnest. All this while the Tiny Tim’s of America struggle in the shadow of a 1% that now controls 38.6% of our country’s wealth.

But time has a way of correcting poor policy. Increasing underinsurance is not only raising alarm bells among policy elites, it is also fueling a public shift in opinion. In a June, 2017 poll, Americans by a margin of 60% to 39% believe the “federal government bears a responsibility to ensure health care for all Americans”. One third of those in favor now support a single payer system, and that number is trending upward from just 12% in 2014.

Skinny plans and HSAs just add insult to the “income disparity” injury. Proper health care for all Americans would deliver three holiday gifts: 1) Better health delivery, 2) an equality and social justice line in the sand, and 3) an overall positive impact on a culture that has spun off its wheels.

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