HealthCommentary

Exploring Human Potential

The Roots of Compassion – Dr. Ralph Snyderman and The 14th Dalai Lama

Posted on | March 21, 2019 | No Comments

Ralph Synderman MD and 14th Dalai Lama

Mike Magee

The issue of “doctor burnout” is front and center at the moment. It’s not a particularly new issue. I grappled with it way back in 1980, with soul-searching sessions at the Massachusetts Medical Society at the time. The focus then was on inadequate reimbursement, but the real issues were fear, depression, and isolation.

At the core of these debates are three elements: the caring professionals, the patients, and the system within which they encounter each other.

In 1999, working with social scientists, I set out to define what this encounter entailed, labeled then the “patient-physician relationship”. In a three month structured survey of both doctors and patients in the U.S., Canada, U.K., Germany, South Africa and Japan, I discovered surprising unanimity across geographies and between those receiving care and those delivering it. More than 90% of individuals surveyed said that the patient-physician relationship was three things – compassion, understanding and partnership.

Defining what the relationship was proved easier than nailing down what ails it at any moment in history.

Ralph Snyderman MD, Past-President of the AAMC and Chancellor Emeritus of Duke Medical Center took the unusual step last year to visit the 14th Dalai Lama in India and explore what it takes to ignite compassion in health care. In a joint publication, Dr. Snyderman describes the Dalai Lama’s insights including:

1. “Compassion is a deep inborne emotion and the source of true happiness.”

2. “Compassion is an inherent trait, but it does not necessarily maintain its focus and intensity in a world with so many factors suppressing it.”

3. “An essential component of compassion is the feeling of interconnectedness with others, which naturally leads to engagement—a critical component of effective health care.”

Twenty years ago, I asked a simple question: “Are we choosing the right individuals for medical school – ones that could deliver compassion, understanding and partnership – along with knowledge, judgement, and required skills? We tested 188 physicians from across the nation that hospital CEO’s had identified as “role models” for physicians using a highly validated Psychological Profile tool called NEO-PIR to identify scores on 20 different personality traits. One of those traits was “arrogance”, scoring low in our “best doctors” but present in more than trace amounts in 1/3 of our incoming class of students.

So first insight: We could do better in our medical student selection process by deliberatly attempting to rejecting arrogant students and selecting compassionate ones.

 Our second insight: Repeat testing of medical students and residents appeared to indicate that their capacity for compassion began to decline in the third year of medical school and continued downward through their years of residency. Conclusion: We could do better in designing training that did not systematically dehumanize future physicians.

Our third insight: Engaged and informed patients make better doctors. Expanding the time and quality of interaction expanded physician responsiveness, engagement and resilience.

Our final insight: Health system design inequities matter. Physicians and nurses are trained to take all comers without prejudice, no questions asked. The fundamentals of compassion, understanding and partnership don’t function very well in a dog-eat-dog environment where substanial portions of our citizenry are uninsured or underinsured; where major social determinants of health are largely ignored; where time devoted to patients is less than time devoted to billers; and where focus on patient care is substantially undervalued compared to profiteering research.

Compassion takes time and focus. Health systems that are equitable, accessible, and above all simple give the patient-professional relationship the opportunity to advance understanding and true partnership. Universality, solidarity, and compassion are one in the same.

Dr. Snyderman and the 14th Dalai Lama, Tensin Gyato, leave us with this challenge: “We must focus not only on developing the best scientifically driven care but also on creating delivery models that facilitate compassion, making them more personalized to the needs and capabilities of the patient and, hence, more cost-effective and humane than our current fragmented approach to care.”

The (Opioid) Day of Reckoning Is Near.

Posted on | March 14, 2019 | No Comments

Jerome Powell with Scott Pelly on 60 Minutes.

Mike Magee

If you missed the “60 Minutes” interview of Federal Reserve Chairman Jerome Powell, he surprised many with his list of contributors to the risk of recession. Here’s his exchange with Scott Pelley:

Jerome Powell: We have an unusually large number of people in their prime working years who are not in the labor force. The United States has a lower labor force participation rate than almost every other advanced country. That is not our self-image as a country.

Scott Pelley: Where did these people go who are no longer looking for work?

Jerome Powell: Part of it is evolving technology. So as technology evolves, it requires rising skills on the part of the people. U.S. educational attainment has not moved up as rapidly as it has in other countries. Globalization’s also a factor. For many advanced economies, manufacturing to some extent, has moved into developing countries. So for whatever reason, and the opioid crisis is related to I think to those other factors.

Scott Pelley: The opioid crisis?

Jerome Powell: The opioid crisis is millions of people. They tend to be young males. And it’s a very significant problem. And it’s part of a larger picture.

Scott Pelley: you seem to be talking about part of this generation being lost.

Jerome Powell: That is the issue. When you have people who are not taking part in the economic life of a country in a meaningful way, who don’t have the skills and aptitudes to play a role or who are not doing so because of because they’re addicted to drugs, or in jail, then in a sense they are being left behind.

As if Princeton economists discovery that the manmade opioid epidemic had bent the US survival curve downward (notably for white males) wasn’t enough. Now we see the secondary impact of losing a generation of young workers on our economy overall.

For those responsible for igniting this disaster, a day of reckoning is fast approaching. Of course Pharma is in the cross-hairs – notably Purdue Pharma, Cephalon, J&J, Endo Health Solutions and Actavis. Then come the wholesale drug distributors including AmerisourceBergen Corporation (NYSE:ABC), Cardinal Health, Inc. (NYSE:CAH) and McKesson Corporation (NYSE:MCK). Giant retail conglomerates like CVS and Walgreen’s could also be caught in the snare.

There are also enablers like the AMA which accepted into its Federation a new Pharma-funded  pain society which convinced the nation’s doctors that pain was the “5th vital sign”. The AMA also sold its Physician Masterfile Database to data miner IMS Health which allowed the opioid companies to target physicians through prescription profiling who were already sloppy prescribers. AMA sales of the data in 2006 alone brought in $44.5 million.

And let’s not forget a range of bottom feeders like Rudy Giuliani and Bernard Kerik who Purdue Pharma hired to get Bush Administration officials to stand down in their planned prosecution of the company in 2004. Consider the lives that might have been saved had they failed.

But now, the sheer scale of the disaster has caught up with many, if not all of the Medical Industrial Complex offenders. Attorney Mike Moore is leading over 30 state attorney generals in litigation, as he did in the 90’s with tobacco companies. Purdue Pharma is exploring bankruptcy with states pursuing the kind of claw-back on hidden Purdue family money that is reminiscent of the Bernard Madoff affair.

Still and all, it’s pretty shocking that you can literally bring down your entire economy when a greedy profiteering group of health sectors decide to conspire and enable each other. No wonder a sizable portion of the nation is eyeing nationalizing of the health care system. They’re not voting for socialism, they’re voting against conspiracy, collusion, death and the destruction of America’s economy.

Why US Women Die in Childbirth

Posted on | March 14, 2019 | 1 Comment

Source: JAMA

Code Blue Receives Kirkus Star

Posted on | March 13, 2019 | No Comments

KIRKUS REVIEW

“A doctor and medical historian relies on his experience inside the medical establishment to offer a searing and persuasive exposé of the American health care system.

Magee, who is on the faculty of Presidents College at the University of Hartford, has worked as a doctor, a university medical school administrator, a hospital executive, and head of global medical affairs for Pfizer. About that last position, the author writes, “until I turned away in a kind of revulsion at the manipulation and well-financed maneuvering, I was right there, helping give moral cover and scientific legitimacy to the world’s largest drugmaker, which also happens to be an industry leader in penalty fees paid to the government for regulatory infractions.” Clearly, Magee understands that he has been complicit as an insider, and he issues mea culpas throughout the book. As part of his penance, he blows the whistle on guilty individuals involved with pharmaceutical companies, hospitals, health insurance corporations, the American Medical Association, medical schools, and all levels of U.S. government. Referring to this “network of mutually beneficial relationships” as the Medical Industrial Complex, he convincingly rails against an industry that consistently produces “outcomes that are, in general, truly dismal.” The inferiority of U.S. health care compared to dozens of other nations has been well-documented for several decades, and the author effectively builds on that documentation. He demonstrates how leaders of other nations have consciously decided that quality health care is a basic right for all citizens, in large part because a healthy citizenry is essential to economic well-being. However, decades ago, American leaders decided that quality health care was not a basic right of citizenship; instead, they chose to rely on market capitalism as the health care model, with disastrous results. Magee suggests multiple sensible reforms in the realms of medical education, clinical research, publication of medical trials, marketing by pharmaceutical companies, and politically driven interactions within the MIC.

Readers will hope that Magee’s knowledgeable, urgent indictment, following so many others in recent years, will lead to meaningful reforms.”

Partnership to Sustain America’s Health Care Past

Posted on | March 4, 2019 | No Comments

The Partnership for America’s Health Care Future – not.

Mike Magee

On the surface, there appears to be a fair amount of finger-pointing going on among and between members of the Medical Industrial Complex these days. But this circular firing squad has no bullets. Behind the scenes the founding MIC members are busy colluding,  sharing profits and defending the status quo.

Case in point: The Partnership for America’s Health Care Future. It is a faux-partnership whose real purpose is to preserve the past rather then chart a progressive future. 

The party line, voiced by the CEO of the for-profit hospital association (a member), is “We have a structure that frankly works for most Americans. Let’s make it work for all Americans. We reject the notion that we need to turn the whole apple cart over and start all over again.”

It’s a slippery coalition, but it’s main members pack a wallop. When you go to the website, its 27 members are represented by logos with no active links. It’s one of those lobbying efforts that’s intentionally on the “down-low”; a quasi-organization whose name may soon appear as a tag line on a third generation of  “Harry and Louise” ads.

In the interest of transparency, here’s a list of the 27, segregated into Leaders, Followers, and Facilitators.

Leaders:

1. American Medical Association (AMA) – the doctors

2. American Hospital Association (AHA) – the non-profit hospitals

3. Federation of American Hospitals (FAH) – the for-profit hospitals

3. America’s Health Insurance Plans (AHIP) – the major insurers

4. Pharmaceutical Research and Manufacturing Association (PhRMA) – the drug makers

5. Biotechnology Innovation Organization (Bio) – the biotechnology companies

6. Association for Accessible Medicines (aam) – the generic drug producers

7. Council of Insurance Agents and Brokers (The Council) – the health insurance brokers

8. Healthcare Leadership Council (HLC) – the coalition of MIC CEO’s

9. National Association of Insurance and Financial Advisers (NAIFA) -The financial/insurance industry 

10. National Association of Health Underwriters (NAHU)

Followers:

1. Blue Cross/Blue Shield

2. Hospital Corporation of America (HCA)

3. Ascension Health (largest Catholic HC System)

4. Ardent Health Services

5. Community Health Systems (CHS)

6. Life Point Health (Holding Company for 70 health care institutions)

7. Tenet Health

8. UHS (Universal Health Services) – manages 350 hospitals

9. Texas Health Resources (faith based 29 hospital system)

10. Premier Inc. (Health Data mining company)

11. Life Point Health (Holding Company for 70 health care institutions)

12. BC/BS of North Dakota

13. North Dakota Medical Association (NDMA)

14. American College of Radiology

Facilitators:

1. National Osteoporosis Association

2. Retire Safe

3. healthy women

The Facilitators are only three in number now, but are certain to grow. They have in common a heavy financial dependency (either as grantees or clients)  on and history with the Leaders. For example, the National Osteoporosis Foundation has been in the middle of the “Vitamin D for all” research controversy. Retire Safe is an industry dependent alternative to the AARP. And then there’s “healthy women” marketed as “the nation’s leading independent, nonprofit health information source for women.”

When you look under the hood of MIC facilitator organizations, you will find extensive lists of professional and corporate “advisers”. This helps reveal the association’s funding, and often the quid pro quo behind their financial survival. But for a look at daily operations and priorities, examine the affiliations of Board members.

For example, here are the Board members for healthy women: 

Violet Aldaia (Vice Chair), SVP Omnicom, former Viagra marketer for Pfizer

Julia M. Amadio, Chief Product Officer at TherapeuticsMD

Kristin Cahill, President GCI Health, North America

Nancy Glick, SVP MS&L

Amy Landucci, CIO of GSKs Consumer Health

Wes Metheny, former PhRMA SVP of Advocacy

Brian O’Connor, VP of Alliance Development for AdvaMed

Oxana K. Pickeral, Ph.D., MBA (Immediate Past Chair), President BioVenture LLC, former Booz Allen Life Sciences practice

Elisabeth Ritz, former Eli Lilly Global Communications, former consultant to Edelman, Hill&Knowlton and Ogilvy.

Kristina K. Saunders, CFP, CIMA, SVP Farr, Miller & Washington

Lynn A. Taylor, SVP Government Relations Merck KGaA, Germany

Tomeka Thomas, Director at Cigna/Bravo Health Springs, former UHC Evercare

Tamar R. Thompson (Chair), Exec. Dir. State Government Relations, Bristol Myers Squibb

Christine Verini (Treasurer), VP Corporate Communications and Advocacy Eisai Inc

They share in common health industry backgrounds, either as employees or clients, with a heavy emphasis on government relations and advocacy, PR communications and marketing. They are likely deeply involved in charting the communications and advocacy strategy for The Partnership for America’s Health Care Future.

Some of these vibrant and conflicted service organizations do great good. They are part of America’s “thousand points of light” – our nation’s answer to the lack of funding and support for national health planning, prevention, and social service integration seen in all other developed nations. This disintegrated health services network survives on the crumbs of a federally underwritten, profit seeking MIC.

Our facilitating “patient service” organizations like healthy women are charitably funded by MIC members, and in return are expected to defend their flanks against progressive reforms and appropriate checks and balances. 

Camouflaged as a “partnership for America’s health care future”, what this is in reality is a partnership to sustain America’s health care past.

“Where’s the Beef?” Water as Currency.

Posted on | March 1, 2019 | 3 Comments

Mike Magee

“They want to take your pickup truck. They want to rebuild your home. They want to take away your hamburgers. This is what Stalin dreamt about but never achieved”, screeched former White House aide Sebastian Gorka at the Conservative Political Action Conference this week.

His widely discredited remarks were called out by a range of environmental scientists who laid out the role of American’s dietary habits as contributors to carbon dioxide production and global warming. For me, it recalled the slide above, part of a year long speaking tour I conducted in 2006 in support of the publication of Healthy Waters. The slide demonstrates the relative consumption of water resources to produce 1 kg of grain, versus 1 kg of chicken or beef as food.

Remarkably, we Americans require approximately 3 liters of water a day for survival, but the average America diet (heavy in beef) requires an investment of 3000 liters of water a day.

As the slide above from the same presentation illustrated, 70% of our water consumption is in support of our dependence on meat-heavy agriculture in this country.

It’s easy to make the case, for human health reasons alone, to shift in the direction of a plant based diet. What is more easily overlooked is that Americans obsession with meat has threatened in equal measures the planetary patient through its contributions to global warming and water consumption.

The Road to Universal Coverage

Posted on | February 26, 2019 | 1 Comment

A View in the Mirror.

Mike Magee

New York Times columnists. Austin Frakt and Aaron Carroll, provided a genuine public service this week in offering an interactive exploration of universal health care. Readers were asked to react to the same questions presented to a bevy of health gurus.

Their 5 “Yes or No” questions were:

1. Do you support automatic enrollment in universal coverage?

2. Do you support ending employer-based private coverage?

3. Do you support replacing individually purchased private coverage, like Affordable Care Act plans or Medicare Advantage?

4. Do you support eliminating premiums and having the system financed exclusively by taxes?

5. Do you support eliminating cost sharing — meaning co-payments, coinsurance, deductibles — for everyone?

Following each vote, you are able to see the % who voted “yes” or “no”. Then there is commentary from health policy notables explaining why they voted the way they did. Spoiler alert – majorities are leaning toward big change.

The national scale is obviously tipping toward idealism and solidarity with significant push back from pragmatists/realists explaining – usually based on taxation/financing – why what logically should be done is just not politically feasible.

What is missing from the piece above, and from many others on the topic, is an obvious truism: Universality is dependent on two co-determinants – mandatory participation and transformational efficiencies.

In short, we can afford health care as a universal right for all only if we share the risk and halt profiteering collusion by the Medical-Industrial Complex.

Consider these two facts:

One in five American dollars now go to health care – we spend close to twice the amount of most other developed nations.

There are 16 health care employees for every one physician in America – and half of these 16 have absolutely no clinical purpose.

Stories of profiteering and financial abuse abound, and I review many of them in Code Blue: Inside The Medical Industrial Complex (Grove Atlantic) due out on May 7, 2019. But let me share just one recent case that illustrates the near racketeering level of absurd waste in our system as described in an investigative ProPublica piece last week.

It seems that nearly all the major health insurers have been secretly greasing the palms of the 100,000 plus U.S. local health insurance brokers to push their products on small and large employers nationwide. Secretly, the brokers have been collecting a 3 to 6% commission on every premium, which for a company of 100 people amounts to a $50,000 plus annual fee.  And that’s for the regular plans. If they sell you supplemental plans (for drugs, dental, optical etc.) the commissions are richer – much richer. 40% to 50% to be exact because the benefits often go unused.

Scaling that up, BC/BS’s service of 15 million employees in 5 states generated $816 million in broker bonuses in 2017. And they and other big players like Cigna, United Healthcare and Aetna offer no apologies. To them it’s the price we pay for good, clean competition.

And then there is Morris County, New Jersey, where one fast-talking broker convinced the county’s HR people to switch coverage to Cigna and effectively concealed the administrative charges for the switch – over $800,000. The county is now suing, and consuming more local taxpayer dollars in the process.

A significant and growing contingent of consumer advocates favor big change. Why? Because they realize that crooks thrive in the cracks of complexity. Simplify is their true rallying call, and eliminating steps and “non-real” work is the surest way to finance health care for all.

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