A Market for Compassion: Single-Payer Health Insurance

When the ethics and the economics of major public policy agree, we ought to pay attention. House Resolution 676 promises to create a single-payer health insurance system to provide expanded and improved Medicare for all Americans.[1] It will insure everyone, and unlike many competing proposals, it could actually work.

In a single-payer system, the government will fund health insurance, but private providers will continue to deliver care. Economies of scale will save the money to make this possible. Many Americans, including Democratic presidential nominee Barack Obama, concede that single-payer insurance is probably our most efficient option.[2] But they worry that it lacks the spirit of the American market. Nothing could be further from the truth.

A single-payer system will harness the market's strengths while addressing its limitations. The private health insurance market is inefficient, bloated by advertising, duplicated bureaucracies, dividends, and executive compensation. What's worse, insurance policies are so complex and individuals' future needs so unpredictable that consumers cannot make the informed selections that induce competition between insurers.

However, consumers can create competition among healthcare providers. This is paramount because patients need the best healthcare, not the best middlemen to pay for it. Currently, providers are insulated from competition because private insurers often restrict coverage to select physicians. In addition, the 47 million uninsured Americans[3] have little impact on the market. A single-payer system will give all consumers the power of choice and open all healthcare providers to the effects of consumer decisions.

Single-payer works because of the efficiency of specialization. The government will manage the paperwork and private entities will provide the care. Adam Smith would be proud.

So if you believe in the market, ask your congressman to support HR 676. Together, we can restore common sense and common decency to American healthcare.

Special thanks to Prajwal Ciryam, a second-year MD/PhD student in the Medical Scientist Training Program at Northwestern University and a Co-Founding Member of Health Care for All Illinois.

Citations:
1. House Resolution 676: To provide for comprehensive health insurance coverage for all United States residents, and for other purposes. Available at: http://thomas.loc.gov/cgi-bin/bdquery/z?d109:h.r.00676 Accessed August 20, 2008.
2. Macfarquhar L. The conciliator. New Yorker. May 7, 2007. Available at: http://www.newyorker.com/reporting/2007/05/07/070507fa_fact_macfarquhar?currentPage=1 Accessed August 20, 2008.
3. US Census Bureau. Income climbs, poverty stabilizes, uninsured rate increases. US Census Bureau News. August 29, 2006. Available at: http://www.census.gov/Press-Release/www/releases/archives/income_wealth/007419.html Accessed August 20, 2008.

The Dying American Health Insurance Industry

The health insurance industry in America is dying. How can that be -- such a powerful, $300 plus-billion industry with so many lobbyists? Here are some benchmarks of its death march:

* Growing unaffordability of premiums, which grew 87% between 2000 and 2006,[1] and are projected to consume one third of family income by 2010 and theoretically all of it by 2025.[2]
* Forty-six million Americans are without health insurance, and at least another 25 million are underinsured.[3]
* Four of 10 Americans are "somewhat" or "completely" unprepared to cope with a costly medical emergency in the coming year.[4]
* The private market now includes less than 60% of employers, and in 2005, only 6% of US employers covered the full cost of family coverage.[5]
* While the insurance market fell by 1% between 2000 and 2005, its work force grew by one third (mostly new employees involved with denial management).[6]
* Private insurers can't compete with public financing on a level playing field. For example, private Medicare Advantage plans require government overpayments of 112% to 119% compared to traditional Medicare.[7]

Fortunately, we have a solution -- strengthened Medicare for All (H.R. 676), coupled with a private delivery system. Reliable public financing and shared risk across all 300 million Americans creates a win-win for everyone except a failed insurance industry.[8] Physicians can rid themselves of the bureaucracy of 1300 private insurers and have more time and clinical autonomy for patient care. To learn more, read references 9 and 10.[9,10] We physicians need to join with patients in working toward real healthcare reform, thereby asserting the public interest over corporate self-interest.

Special thanks to Dr. John Geyman, Professor Emeritus of Family Medicine, University of Washington.

Citations:
1. Barry P, Basler B. Healing our system. AARP Bull. 2007;48:2.
2. Who will have health insurance in 2025? Am Fam Physician. 2005;72:1989.
3. Schoen C, Collins SR, Kriss JL, Doty MM. How many are underinsured? Trends among U.S. adults, 2003 and 2007. The Commonwealth Fund. June 2008. Available at: http://www.commonwealthfund.org/publications/publications_show.htm?doc_id=688615 Accessed October 14, 2008.
4. Consumer Reports. Are you really covered? Why 4 in 10 Americans can't depend on their health insurance. September 2007. Available at: http://www.consumerreports.org/cro/health-fitness/health-care/health-insurance-9-07/overview/0709_health_ov.htm Accessed October 14, 2008.
5. Freudenheim M. Fewer employers totally cover health premiums. New York Times. March 23, 2005.
6. Krugman P. The world of health care economics is downright scary. Seattle Post Intelligencer. September, 26, 2006:B1.
7. Medicare Rights Center. Medicare private plan overpayments: no bang for the buck. Asclepios. 2007;7(21).
8. Geyman JP. Do Not Resuscitate: Why the Health Insurance Industry Is Dying, and How We Must Replace It. Monroe, Me: Common Courage Press; 2008:185-214.
9. Physicians for a National Health Program. Available at: http://www.pnhp.org Accessed October 14, 2008.
10. Quote of the Day. Available at: http://two.pairlist.net/mailman/listinfo/quote-of-the-day Accessed October 14, 2008.

Reempowering Primary Care

Over the last couple decades, America's primary care physicians -- PCPs -- have been relegated to medicine's lowest caste.[1] But many employers, who pay for the waste that results from tying PCP's hands, now see them as healthcare's most probable saviors.

In 2008, cardiologists take home up to 4 times more than PCPs,[2] who often report they don't have time to properly talk with patients. Now just 7% of medical students enter office-based primary care.[3] Why not become a specialist and make more? Aging boomers will quickly outstrip our dwindling supply of PCPs.

PCP-specialist pay discrepancies are traceable to the AMA's secretive, specialist-dominated RVS Update Committee that has consistently advised Medicare to pay specialists more at PCPs' expense. Medicare heeded them and commercial plans followed, marginalizing PCPs and costs exploded.[4] Then employers noticed that more PCPs and fewer specialists produce more efficient healthcare.[5] America's PCP-specialist ratio is about 30/70, but in other developed countries it is 70/30; their costs are half ours; and their outcomes are often better.[6]

So how do we reempower our 250,000 community-based PCPs?

The Patient-Centered Primary Care Collaborative -- Fortune firms, business health coalitions, primary care associations, and health plans -- laid out steps[7] for leveraging primary care to change our larger health system.

Pay PCPs more to reduce their patient loads with more time for patients. Help them acquire patient management information technology tools. Update the PCP-specialist engagement rules to involve PCPs when their patients need advanced care.

Some will oppose these measures. Health plans are key, but if you're a PCP, show this to your community's business leaders. Suggest they pointedly ask their health plans, "What are you waiting for?"

Special thanks to Dr. Brian Klepper, a healthcare analyst from Atlantic Beach, Florida.

Citations:
1. Bodenheimer T, Berenson RA, Rudolf P. The primary care -- specialty income gap: why it matters. Ann Intern Med. 2007;146:301-306.
2. Merritt Hawkins & Associates. Summary Report: 2008 Review of Physician and CRNA Recruiting Incentives. Irving, Tex: Merritt Hawkins & Associates; 2008. Available at: http://www.merritthawkins.com/pdf/mha-2008-incentive-survey.pdf Accessed November 24, 2008.
3. Johnson CK. US medical students shunning primary care. Seattle Post-Intelligencer. September 9, 2008. Available at: http://seattlepi.nwsource.com/local/378492_fewerdocs10.html Accessed November 24, 2008.
4. Goodson JD. Unintended consequences of resource-based relative value scale reimbursement. JAMA. 2007;298:2308-2310.
5. Starfield B, Shi L, Grover A, Macinko J. The effects of specialist supply on populations' health: assessing the evidence. Health Aff (Millwood). 2005; (supplWebexclusives):W5-97-W5-107.
6. Macinko J, Starfield B, Shi L. Quantifying the health benefits of primary care physician supply in the United States. Int J Health Serv. 2007;37:111-126.
7. Patient-Centered Primary Care Collaborative. Joint Principles of the Patient Centered Medical Home. February 2007. Available at: http://www.pcpcc.net/node/14 Accessed November 24, 2008.

Teaching Moral Reasoning to the Next Generation of Doctors

Right now, the medical profession is on the ropes. The media and Congress continue to flail away at the unseemly relationship doctors have with drug companies and medical device makers.^[1] Accusations of kickbacks for product selection,^[2] unearned "consulting" fees, stock options tied to research results,^[3] and drug-rep supplied pizza for office staff^[4] all imply that our profession puts personal gain ahead of patient welfare.

In medical-legal arena, lawyers and judges realize that favorable testimony can be purchased in a marketplace replete with practitioners of questionable ethical standards.^[5]

Likewise, statisticians find that local and regional variation in treatment for common aliments, such as breast cancer and back pain,^[6,7] correlate with ownership of imaging equipment, testing devices, and ambulatory or in-patient treatment centers.^[8]

Rather than fighting the accusations of unethical conduct with self-righteous assertions by our professional associations, it would be more appropriate to train the next generation of doctors to incorporate high-level moral reasoning in their medical and professional decision making.

Surveys of medical school and residency training programs find that formal education in medical ethics and moral reasoning is sadly deficient,^[9] and no wonder: Discussing ethics in the abstract is both boring and ill-focused.

Since doctors in training have turned increasingly towards review articles (both print and Web-based) as sources of information, it occurred to me that such publications should shine a brighter light on ethics issues arising out of topics their authors cover. For instance, assume a submission reviews the treatment of carpal tunnel syndrome and notes that most workers' compensation patients with electrodiagnostically negative CTS do poorly after transverse carpal ligament release. I believe that manuscripts' authors should discuss whether it's ethical to perform surgery on a subset of patients prone to an unfavorable outcome. In this way, we'll incorporate ethical judgment into all facets of medical education.

I'm concerned that our profession, after repeated conflict-of-interest inquiries (whether appropriate or off target), won't be invited to the table when the final structure of America's new healthcare paradigm is considered. While it seems impossible that doctors wouldn't be involved, remember that Hillary Clinton's health plan was drafted without much physician input. Even more remarkably, when Gov. Schwarzenegger's staff crafted California's monumental Workers' Compensation Reform Act, neither doctors nor lawyers were consulted, only labor and business. Perhaps the governor suspected that workers' comp treaters and claimant attorneys milked the system for their own benefit and thus wouldn't serve either the employers' or the injured workers' future interests.

If we continue to burn through our good will by continuous acts perceived by the public as corrupt, we'll get what we deserve!

Special thanks to Dr. Stuart A. Green, Clinical Professor of Orthopaedic Surgery at the University of California, Irvine.

1. DeFazio P. H.R. 5605: Physician Payments Sunshine Act of 2008. 110th United States Congress. 2008. Available at: http://www.govtrack.us/congress/bill.xpd?bill=h110-5605 Accessed December 29, 2008.
2. Heckman JD. Patient care, professionalism, and relationships with industry. J Bone Joint Surg Am. 2008;90:225.
3. Angell M. Industry-sponsored clinical research: a broken system. JAMA. 2008;300:1069-1071.
4. Ehringhaus SH, Weissman JS, Sears JL, Goold SD, Feibelmann S, Campbell EG. Responses of medical schools to institutional conflicts of interest. JAMA. 2008;299:665-671.
5. Jack SG. In Re Silica Products Liability Litigation, MDL Docket Number 1553: Order #29: Addressing Subject-Matter Jurisdiction, Expert Testimony and Sanctions. US Federal District Court. 2005:150.
6. Sariego J. Regional variation in breast cancer treatment throughout the United States. Am J Surg. 2008;196:572-574.
7. Weinstein JN, Lurie JD, Olson PR, Bronner KK, Fisher ES. United States' trends and regional variations in lumbar spine surgery: 1992-2003. Spine. 2006;31:2707-2714.
8. Becker S, Walsh A. Orthopedic-driven ambulatory surgery centers and specialty hospitals -- a physician and hospital perspective. Health Care Law Mon. 2005:3-6.
9. Manson H. The need for medical ethics education in family medicine training. Fam Med. 2008;40:658-664.

Seven Bad Habits of Highly Effective People

During these tough financial times, many people feel they have to push themselves to unhealthy levels in order to succeed. But high-pressure jobs and long hours take a real toll on their immediate and future health. Whether running for president, moving up the corporate ladder, or juggling the family's activities, success may come at a hefty cost.

The 7 worst habits of these workaholics include:

1. Forgetting to relax: Some stress can be good because it keeps you alert and motivated; too much stress, however, will take its toll on your body.^[1]
   
   
2. Eating on the go: Who has time to sit down for a healthy lunch? But beware of frozen meals, fast, and processed food that can be high in sodium, calories, and fat.^[2]
   
   
3. Putting off sleep for work: Lack of sleep can cause irritability, difficulty concentrating, memory problems, poor judgment, and obesity.^[3]
   
   
4. Not making time for exercise: Humans were not designed to sit at desks for 8 hours a day. Exercise has been shown to reduce the risk for nearly every major disease and to help fight anxiety and depression.^[4]
   
   
5. Working when sick: 3 common-sense reasons to stay home: avoid spreading the infection, you'll be less productive, and you need your rest to get better.
   
   
6. Drinking (too much): Moderate alcohol consumption has some proven health benefits , but excessive drinking can lead to alcoholism, liver disease, and some forms of cancer.^[5]
   
   
7. Skipping annual medical checkups: Depending on age, family history, and lifestyle, a comprehensive medical checkup and special screenings is recommended every 1 to 5 years.^[6]

Eventually, something's going to give. If you patients keep burning the candle at both ends, the flame will burn out faster. But, if you maintain a healthy balance, you will be happier and healthier overall.

Special thanks to Dr George Griffing, Professor of Medicine at St. Louis University and Editor in Chief of Internal Medicine for eMedicine.

Citations:

1. Wilbert-Lampen U, Leistner D, Greven S, et al. Cardiovascular events during World Cup soccer. N Engl J Med. 2008;358:475-483.
2. McNaughton SA, Mishra GD, Brunner EJ. Dietary patterns, insulin resistance, and incidence of type 2 diabetes in the Whitehall II Study. Diabetes Care. 2008;31:1343-1348.
3. Knutson KL, Van Cauter E. Associations between sleep loss and increased risk of obesity and diabetes. Ann NY Acad Sci. 2008;1129:287-304.
4. Berlin AA, Kop WJ, Deuster PA. Depressive mood symptoms and fatigue after exercise withdrawal: the potential role of decreased fitness. Psychosom Med. 2006;68:224-230.
5. O'Keefe JH, Bybee KA, Lavie CJ. Alcohol and cardiovascular health: the razor-sharp double-edged sword. J Am Coll Cardiol. 2007;50:1009-1014.
6. Iglar K, Katyal S, Matthew R, Dubey V. Complete health checkup for adults: update on the Preventive Care Checklist form(C). Can Fam Physician. 2008;54:84-88.