Ethical Health Partnerships Blog

Reform: The Health Exchange Idea

dawn@relationshipjourney.com (Dawn L) — Sun, 27 Sep 2009 13:10:00 +0000

I am very curious about why, in all the media coverage of the health reform debate and drama, why aren't we hearing more about another significant part of most proposals -- the Health Exchange approach? This is was one of the key pieces of President Obama's campaign platform. Variations of it are in his proposal, the House proposal, the Senate Finance Committee proposal, and even the Former Majority Leaders (Senators Howard Baker, Tom Daschle and Bob Dole)

The essence of the Exchange is that private insurance companies would offer plans under the Exchange that were more affordable and more accountable in terms of premium rates, costs, pre-existing conditions and that they cannot drop you because you become ill. Accountability is one of the biggest needs in insurance reform, and the Exchange idea helps promote that and more affordability for middle-class individuals and families.

This is a supplement to a public option that allows private insurance companies to stay competitive, to be included in reform instead of shut out of it by solely a public option, and yet holds them significantly more accountable.

This makes sense to me.

For more information, go to http://www.kff.org/healthreform/7908.cfm and from there, you can download a PDF file of a Brief on the topic of Health Exchanges.

You can also go to their Side-by-Side Comparison of Proposals, select the proposals you want to compare, and then click on the issue of “changes to private insurance” to see at least some of what each proposal says.

Part 4 on Integrated Delivery Systems is up

dawn@relationshipjourney.com (Dawn L) — Sun, 27 Sep 2009 13:04:00 +0000

Just to let you know that Part 4 of the series on integrated delivery systems is back up on the website. This section is on Community Need vs. Revenue and Market Share as driving forces in hospital employment of physicians.

In the near future, I will add a final section on some of the things I think could bring such systems into more ethical alignment with core values, patients and physicians.

Next installment of series up

dawn@relationshipjourney.com (Dawn L) — Thu, 24 Sep 2009 20:09:00 +0000

For those of you wanting to read the series, Part 3 on some of the negative impacts on physicians and patients is back up and hopefully Part 4 will be back up by tomorrow -- or at least over the weekend.

Adventist Health/Integrated Delivery Series

dawn@relationshipjourney.com (Dawn L) — Thu, 24 Sep 2009 01:37:00 +0000

Part 2 of the series is now back up -- The Power of Patient Steering by a Large Hospital System The graphs alone are worth a thousand words!

Series on Adventist Health & Integrated Delivery

dawn@relationshipjourney.com (Dawn L) — Tue, 22 Sep 2009 15:35:00 +0000

For those of you searching for the series on integrated delivery systems like Adventist Health in Central Florida, I temporarily took down the pages to fix some formatting. They will be going up little by little this week. Right now, you can find the following sections:
Ethical Issues in Hospital Based Healthcare Delivery Systems (Intro to the series)
Part 1: Hidden Ownership/Employment of Physicians
Current Online List of Adventist Health/FPMG Physicians in Central Florida This has questions to ask to help you make more informed decisions when you seek a physician or are referred to another physician. I have also added in some from surrounding counties. (Updated 9-21-09)
Downloadable related items: Report for Physicians on the Impact of Adventist Hiring on Independent Practice and downloadable list of FPMG/Adventist Physicians (As of 9-21-09, does not yet include the updates I did yesterday to the online version. I will be working on that today.

NOTE: On the downloadable report, the front page incorrectly lists my e-mail as dawn@ethicalhealthpartnerships.com -- it should be dawn@ethicalhealthpartnerships.org I will correct that on the PDF this week as well.

Trying to Separate Fact from Fiction in Healthcare?

dawn@relationshipjourney.com (Dawn L) — Sat, 15 Aug 2009 20:49:00 +0000

Check out the Politifact.com truth ratings on healthcare reform statements. Because this is updated regularly, and not only about healthcare. Each healthcare statement is rated on the 'truth-o-meter' and by clicking on the meter, you can find a more in-depth review of the issue.

Another good one is Kaiser Family Foundation's site on reform, including a section where you can do a side-by-side comparison of major issues in different proposals.

Still another good site is Factcheck.org Several things on healthcare and more.

CNN is broadcasting as I am writing this about truth checking and answering questions on healthcare reform. Their new website checks some of the facts and also has links to download the bills.

Send these sites to your friends so that they too can find out more accurate answers to some of their questions. This debate is too important to resort to reactivity on either side.

The Fears about Ezekiel Emanuel, MD

dawn@relationshipjourney.com (Dawn L) — Sat, 15 Aug 2009 12:17:00 +0000

Some of the viral chain e-mails quote Rep. Michele Bachmann (MN) or Betsy McCaughey blasting Ezekiel I think misrepresent him, what he thinks, and how that effects healthcare reform.

First and foremost, neither Emanuel or Blumenthal will ‘decide’ what is in or out of a public plan option. It will be a group process as government always is. But I think it is still important to put Emanuel in perspective:

Ezekiel Emanual is a renowned bioethicist and oncologist. He has worked with sick and dying people for over 25 years, of all ages. Interestingly enough, while they portray him as someone who would kill off disabled people, he has a sister with cerebral palsy! He is known as a warm and compassionate physician. (Here is some about him )

And, ironically, Ezekiel Emanuel is actually opposed to euthanasia and forms of assisted suicide!!! In a case about assisted suicide that was going before the Supreme court in 1997, Emanuel wrote a piece in the Wall Street Journal opposing euthanasia. He said,

“For the vast majority of dying patients, legalizing euthanasia or physician-assisted suicide would be of no benefit. To the contrary, it would be a way of avoiding the complex and arduous efforts required of doctors and other health-care providers to ensure that dying patients receive humane, dignified care.”

He is furious about what is being said about him in these e-mails and the protrayal of him in these scare tactics is against what his whole life and career has been about. Here is his response to all the allegations flying around about him.

What I Have Read and Think:

The chain e-mail talks about Emanuel’s remark about changing how doctors think about their patients: "Doctors take the Hippocratic Oath too seriously as an imperative to do everything for the patient regardless of the cost or effects on others" and they cite the Journal of the American Medical Association, June 18, 2008).

In the entire article, he is talking about the factors that have led to overutilization of costly care. I have read numerous other articles that talk about some of the same things. Too many unnecessary tests are ordered – for a variety of reasons: 1) the patient demands it and the doctor is both worried about being sued, 2) It is easier to give in to a demanding patient --
even if the physician does refuse, the patient usually goes somewhere else and gets the test. 2) 3. Another reason they overutilize is that, according to one of my clients in healthcare, many physicians are now trained to rely on tests instead of learning how to really examine and explore for a good diagnosis. It also takes way less time, but significantly raises the cost of care. 4. Emanuel also talks about the way doctors are trained to be meticulous and do everything possible.

THAT is the kind of 'overutilization' that Emanuel was talking about in JAMA. (Read the article online(subscription or payment for the article required unless you access through a university or hospital) OR you can usually find a copy at your local hospital's library, so you can make up your own mind!) Overutilization has been written about extensively by economists, physicians, policy makers, etc in nearly all the major medical journals.

In both the Lancet article and the old Hastings Center Report, that the chain e-mail quotes, he is discussing bioethics and how we make tough decision in healthcare, especially in situations where there is scarcity of resources – vaccines, organs, etc. What he is talking about just happened this past week when the government decided who would get swine flu vaccine first because there is not enough for everyone – pregnant women first because they are high risk, healthcare workers and I forget who comes next – I think children and then the elderly, but I’m not sure. Kids are much more likely to get swine flu than adults.) There is no outcry about that even though the 'government' decided who would get what care and who would not.

Another example would be who gets an organ transplant -- if you have a 6 month old baby, a 21 year old college student, and my mother with dementia – all of whom would die within a week or two without a new liver – and you have only one liver available – who do you give it to? Currently we use a list – and probably other things. Emanuel’s writing about bioethics is primarily about exploring the PROCESS, the HOW of coming to those decisions and creating ways that are the best when none are perfect, as he consistently acknowledges.

In both articles that quote him, he explores different models and where they lead, and in both say that there is no one size fits all that does not raise moral and ethical questions that are extremely challenging. That's why we have a field called bioethics!

In the first article from the Hastings Center Reports (1996) in which he contrasts two constructs in making those kind of decisions and concludes that neither is adequate and that more public discussion would be needed to come up with how those decisions are made.

In the Lancet article (again you can usually read it for free at your local hospital library), he and the other authors look at 6 or 7 models of decision making for things like ‘who do you give the organ to’? He finds them all lacking in and of themselves and thinks it has to be multi-principled with flexibility and considering numerous factors. Even the combined model that uses several of the principles explored that he and the others think would be better than a single principle model, he acknowledges that it still raises important moral issues.

They are tough questions that patients don’t usually think about, unless you or someone you love needs what is in scarcity.

So if YOU had to decide TODAY about that one liver for 3 people who would die in 2 weeks dilemma, what criterion would YOU use to make that decision of who gets the liver? How do YOU think we should make those decisions?

I, personally, --this is just ME talking -- do not think that one liver is best used for my mother who is in her 80s and with dementia, even though I dearly love her and want to enjoy every moment I can with her. Even if I were 80 and with full mental faculties, in one way I would want the liver because I love life. And yet, on the other hand, I would think twice -- I would have lived a long and full life and my getting the liver instead of the 6 month old or the 21 year old, deprives them of that opportunity. I think and hope I would be big enough to give one of those others the chance to have what I have had.

But no matter what I think, someone else will be making those decisions -- whether or not there is healthcare reform. I would hope that they, like Ezekiel Emanuel, would have thought long and hard about how to make the best decision possible in very heart wrenching situations.

Whither Reform?

dawn@relationshipjourney.com (Dawn L) — Fri, 14 Aug 2009 03:17:00 +0000

Hopefully I will be in a different frame of mind tomorrow, but tonight, I am uncharacteristically disheartened. I am concerned that the dis-information, appeal to the dinosaur parts of brains, and too little too late response from the White House, will result in a very watered down proposal that won't upset anyone because it really won't contain much different than what we have. There are rumors (hopefully they are just rumors) that they may consider taking out the provision to actually pay doctors for their time if patients would like to discuss end-of-life issues, that we won't get the public option -- which I think (and hoped) would be the centerpiece. And now the news, that they copped out, caved in and are not requiring pharma companies to negotiate better prices for Medicare.

I was hoping for visionary, bold, a real improvement. I'm thinking we're getting more of the same old, same old of politics before the good of the people. I hope we don't get saddled with something in name only that costs a fortune and that simply maintains the status quo.

And I'm profoundly disappointed in politicians who engaged and continue to engage in fear-mongering, stirring hysteria and de-railing one of the most important issues of public policy, something that so profoundly affects so many of us. I love disagreement and debate, but that is not what this has been. It's been road rage screaming about 'death panels'. It has been inaccurate statements designed to scare -- like Sen. Grassley, "You have every right to fear." Give me a break! I think it is a sad commentary on what the once respected Republican Party has become. I'm furious with Sarah Palin. I can't help but wonder if her 'source' for her 'information' was a chain e-mail! She loved getting the crowds whipped up about Obama and terrorism. This is like more of the same. I'm disappointed in the media for not addressing the rumors swiftly and with their own fact-checking to put it out to the public. I'm disappointed in the level of non-thinking and effort to read for ourselves the sections people are concerned about.

Wow -- am I in a funk about this tonight! My hope is that I am completely wrong about everything I just said! THAT would make my day!

Viral E-Mail Myths on Healthcare Reform

dawn@relationshipjourney.com (Dawn L) — Sun, 09 Aug 2009 12:50:00 +0000

Whatever your opinion about the proposed healthcare reform bill, please make sure you check the facts you use to make your decisions AND check your facts before you forward e-mails to your whole address book. With the rapid spread of e-mails, we have an even greater ethical responsibility for what we put out and what we forward to our contacts.

Several people have forwarded me an e-mail by a man who lists numerous pages and states what horrible things will happen to all of us. Some are highlighted in red so people can be even more scared. I haven't yet gone through each statement this man made, but I did check a few statements related to end-of-life care because I heard fears from one of my dear friends and also read Sarah Palin's characterization of the proposals being 'downright evil' and involving 'death panels'. (Using that kind of language is an issue of it's own and you can read more at What World Do We Create with Our Words? )

Here is what the chain e-mail says (there are several similar versions):

• Page 425: Government provides approved list of end-of-life resources, guiding you in death.

• Page 427: Government mandates program that orders end-of-life treatment; government dictates how your life ends.

• Page 429: Advance Care Planning Consult will dictate treatment as patient’s health deteriorates. This can include a GOVERNMENT ORDER for end-of-life plans.

• Page 430: Government will decide what level of treatments you may have at end-of-life.

Another e-mail goes even further:

On Page 425 of Obama’s health care bill, the Federal Government will require EVERYONE who is on Social Security to undergo a counseling session every 5 years with the objective being that they will explain to them just how to end their own life earlier. Yes…They are going to push SUICIDE to cut medicare spending!!!

If you actually read page 425-430 (the PDF version) OR (the online version by section) (or check it out at FactCheck.org on this issue) you will see that it is listing what will be a reimbursible office visit -- and is now including discussions about end-of-life wishes. The section of the Social Security Act (section 1861(s)(2)) that it is modifying is listing of Miscellaneous Services and includes things like psychiatric care, home dialysis and more -- NONE of which are required. In terms of talking about living wills, health care proxy, etc., it is defining what can be part of one of these session that they will reimburse. It includes discussion of things like living wills, health proxy's so that people can choose to have advanced directives that will be honored in health settings -- or choose not to have them.

After the Terri Schiavo case hit the news, I went out the next week and met with an attorney to set up what I want done and not done if I am incapable of making decisions or if I am brain dead. Other people might make different choices, but I want my choices honored and I do NOT want to end up like she did. This part of the reform reimburses a physician for taking the time to sit down and talk with her or his patient about those things if they so choose. It is not mandated and the government does NOT decide for you. Other people WILL decide for you if you don't have advanced directives.

So my point is, as you decide what you agree or disagree with in this reform proposal, check out the facts for yourself rather than decide based on e-mails or pronouncements (even mine!). And certainly consider your own ethical responsibility to check this and anything else you send out or forward e-mails.

May we come to wise decisions on this very important issue that will affect all of us.

How We Talk About Healthcare Reforem

dawn@relationshipjourney.com (Dawn L) — Sat, 08 Aug 2009 14:18:00 +0000

After reading yesterday's statement by Sarah Palin on the proposed healthcare reform being 'downright evil" and having 'death panels' to decide whether you get healthcare based on your productivity in society, I wrote in my Build Better Relationships blog about how we use language. You can read it at What World Do We Create With Our Words? (Aug. 8th blog).

Stay Informed About Healthcare Reform

dawn@relationshipjourney.com (Dawn L) — Tue, 30 Jun 2009 13:21:00 +0000

With all the media coverage of healthcare reform, Kaiser Permanente, who does a great job of publishing daily healthcare news summaries as well as other in-depth reports, has 2 sites worth bookmarking.

The first is their Health Reform site that carries up-to-date news about the issues and resources.
The second is a section of that same site that allows you to perform Side-by-Side Comparisons of Reform Proposals put forth by the President, Congressional committees and individual Senators and Representatives. You can also take a particular element, such as financing, or approach to expanding coverage, and compare those across various proposals.

Well worth your time if you want to stay informed and make your voice heard!

It Keeps Going . . .

dawn@relationshipjourney.com (Dawn L) — Mon, 29 Jun 2009 00:21:00 +0000

As of past efforts to flood the market and bypass independent surgeons were not enough, FPMG Adventist Health has just hired another breast surgeon in May 2009 that we don't need, but that we will all pay for as we pay her malpractice, benefits and salary. Of course, since they are steering most of the referrals to their own surgeons to bypass independent physicians, it does make sense.

One definition of 'integrated delivery systems' was that they are ways to avoid redundancy. Adventist Health has hired at least 12-13 surgeons that are redundant when there is no wait for the best surgeons in this area. Maybe President Obama needs this information to help cut healthcare costs!

Integrated Delivery Systems - Ethical Issues

dawn@relationshipjourney.com (Dawn L) — Wed, 10 Jun 2009 15:23:00 +0000

I am finally back! I have spent most of the past year researching the impact of an integrated delivery system in my own community on local independent physicians and the on ethical concerns it raises. Both independent physicians and patients are negatively impacted. I am still in the process of submitting the information to the general council of Adventist Health, but will begin posting some of the issues and concerns online.

Part 1 looks at the practice of deliberately concealing the physician network of physicians employed or owned by Adventist Health/FPMG and the ethical concerns of concealment. Part 2 shows the incredible power to completely shift referral patterns to specialists within 3 months in such a massive system. Part 3 highlights how this way of doing business harms independent physicians and patients. Part 4 explores the stated reasons of 'community need' and the reasons that seem to be the motivating factors, market share and revenue. There is also a list of those physicians that are employed or owned by Adventist Health in Central Florida and questions patients should ask to keep THEIR welfare above corporate goals.

Adventist Health is by no means the only system involved in this type of behavior -- which is all the more reason some of these questions need to be raised and brought to light.

What has been YOUR experience in such a system -- whether you are a physician, healthcare professional, patient or other?

Health Insurance Confesses it Cares More about Itself than Patients

dawn@relationshipjourney.com (Dawn L) — Tue, 20 May 2008 02:10:00 +0000

American Medical News (May 19th) reports that major health insurance plans stated clearly that they do not care if they lose members by raising premiums, as long as they increase profits even more.

Financial data from the 1st quarter of 2008 (only 3 months) shows:

Aetna brought in over $7.5 billion in revenue with a 3 month profit of over $431 million. (But it was down $3 million from the first quarter of last year)
Humana brought in $6.9 billion in revenue and made $80 million profit (actually up from $71 million for the first 3 months of 2007)
UnitedHealth brought in $20.3 billion revenue with a $994 million profit (up from $927 million for 3 months of 2007)
Wellpoint brought in $15.5 billion with profit of $588 million (sadly it is down from $778 million from the first 3 months of 2007)

This is for THREE MONTHS!!!! January - March, 2008.

According to the article, the CEO of Wellpoint states: "We will not sacrifice profitability for membership".
They will give up members as they raise premium prices to perform better on Wall Street. Ironically they will be doing some of it around the time of Cover the Uninsured Week sponsored by the Robert Wood Foundation to bring attention to the problem of the uninsured -- clearly not a concern for insurance companies. Or UnitedHealth's CEO, Hemsley: "We continue to protect our margins. . . ."

Not only do they not care about patients, they don't care about doctors either. The same Wellpoint CEO, Angela Brady, assures investors that because Wellpoint has market power (mostly through gobbling up other companies), it gives Wellpoint "the ability to lean hard on its network doctors to accept lower reimbursement." (AMNews)

I guess it is business as usual -- massive insurance companies, protected by our elected leaders who fail to call them to task (or upset their apple carts) -- raising costs to patients and creating unfair pay reductions for physicians.

I am a self-employed individual who gets to pay high rates, with a high deductibles and who is often just priced out after a few years with a company because insurance decides as I get older I'm more of a risk -- whether or not I use the insurance! More and more companies are dropping benefits or raising the cost to employees.

Until we have leaders who have the guts and the smarts to address the excess of corporate health insurance greed, we will have growing numbers of uninsured -- not just college kids, not just those close to the poverty line, but middle class Americans -- all of us. And we won't have leaders who step up to the task until patients like you and me make noise and demand it.

Hospital (Dis)Honesty

dawn@relationshipjourney.com (Dawn L) — Mon, 31 Dec 2007 15:06:00 +0000

A recent article on a The Changing Business of Medicine still disturbs me (The Orlando Sentinel strangely requires that you pay for any article over a week old so I can only provide a link to the opening lines). The article is touted on the front cover of the business section as "a new model of medicine' and essentially introduces the Orlando community to some general surgeons now employed by Florida Hospital. Understandably the young surgeons like not having to deal with insurance, overhead, the investment of long hours and all the business-related matters that come with solo or group practice. Their malpractice insurance is paid by the hospitals – no small thing since Florida surgeons usually pay upward of $150,000/year.

One has to ask: why would a hospital pay $150,000 plus salary for 5 surgeons and pay for their office space and all administrative functions? Why would they undermine the surgeons who have loyally supported their hospital and outpatient surgery center?

I don’t think it is concern about patient care, especially when we have so many fine surgeons in the Central Florida area. We are a major city, not a rural area that has no surgeons.

I am concerned about 2 things:
1. that the action, for whatever reason they decided to hire their own surgeons, creates negative consequences for patients and their surgeons.
The general negative consequences are:
a) it undermines those surgeons who DO put up with the hassles of running a practice, dealing with long hours, and usually cannot afford full malpractice premiums – yet who stay in practice because they do care about patients. That includes my own surgeon. And it expects those same surgeons to continue bringing their patients to the hospital and outpatient surgery center while reducing the number of patients they see.

b) it reduces future access and choice for patients. Why would anyone go into surgery with not only the current challenges of malpractice risk and declining reimbursements, but now the fact that they would have to compete with hospitals? If this were the true reason, it reveals the band-aid approach to healthcare issues that tend to make the problems worse instead of better.

c) it creates an unfair competitive advantage for local surgeons since Florida Hospital has the marketing power of it’s 7 local hospitals and the resulting referral network. It also owns all the CentraCare 24 hour centers and major imaging centers. They can funnel patients to their practice.

d) it is potentially a conflict of interest. With a hospital signing a physician’s paycheck, realistically, who will the doctor be most loyal to in a situation where there is conflict between patient interest and hospital interest? What will it mean in terms of necessity and intensity of procedures for patients?

2. My second, and now larger concern is that, whether by deliberate intent or simply by effect, they are being dishonest with patients and the community.

Why would the hospital hire its own surgeons? I could understand it if it were for a very specific focus. For example, if surgeons no longer want to take on-call, or they need surgeons specifically for liver or other transplant teams, or more trauma surgeons for their ER. I could understand it if they needed a couple of surgeons to direct their general surgery residency program.

Yet, when I contacted the hospital, their spokesperson beat around the bush with reasons like “to provide critical services. . .residency . . .access for patients . . . a new blend of community and hospital employed staff . . . .blah, blah, blah -- but most of those reasons simply do not make sense.
• Access for patients is not an issue with so many good local surgeons of all ages and levels of experience.
• Hospital hiring undermines future access and choice for patients.
• Critical services would seem to imply things like on-call, ER, etc., yet I know someone who was referred to the group for a small melanoma, which any surgeon could do. I received a referral to the hospital employed group from one of the hospital’s local women’s centers for a biopsy. When I asked if there was someone in the group who specialized in breast health, I was told that any of them could do it. (By the way, there ARE surgeons in Orlando who specialize in breast care, some of whom are listed as part of the hospital’s own breast care team.)
• A new model of medicine. For what purpose? In the past, hospitals hiring physicians has been a costly enterprise for the hospital. Why is it being resurrected? One reason could be that with the power and size of a hospital, or hospital network, the hospital could negotiate higher reimbursement from insurance companies in ways that an individual doctor or even a small group could not begin to do. Yet it still seems the expenses would eliminate significant profit.

The only reason that makes sense is that they need patients for their residency program and the fact that all of the surgeons are listed as faculty supports that assumption. So, why doesn’t the hospital present the group to the public as the residency program?

My guess is that the ‘practice’ is set up to provide surgical cases for the residents to work with. I could be wrong, but I imagine most surgeons in private practice might be reluctant to have resident involvement with the increased malpractice risk. By the hospital having its own group, it can guarantee those cases and offset some of the expenses of providing supervising physicians for residents by income produced by the doctors in their office and in surgeries done at the hospital and its outpatient center.

And THAT disturbs me even more, not because they have a residency program, but because they are not upfront about it with potential patients in relation to this group of surgeons.

Part 2: Ethical conflict

Insurance Mergers Serve Profits, not Patients

dawn@relationshipjourney.com (Dawn L) — Mon, 29 Oct 2007 17:59:00 +0000

Insurance Merger Serves Profits, not Patients

I just read that insurance giant, WellPoint is aggressively seeking more insurance companies to absorb, further reducing health competition. Both in the past and for the future, their plans also include buying non-profit companies and turning them to for-profit companies. WellPoint’s spokesman, Jim Kappel, says that “We believe we are in an industry suitable for further consolidation."

According to AMNews that reviewed the transcript, Wayne DeVeydt, WellPoint's executive vice president and chief financial officer, stated at a recent conference.

"If you looked at us 10 years ago, the top 10 companies made up 27% [of the market]. Today the top 10 companies make up 54%. I would venture to say that in the next five to 10 years, the top 10 will make up 75% to 80%. So we are far from being done on consolidation.”

I don’t know about you, but I do not want the top 10 insurance companies, who are already squeezing both patients and physicians while they post record profits, controlling 80% of the whole health insurance industry.

This whole scenario only highlights the need for the federal government to change the historical anti-trust exemption given to insurance. Patients and their physicians become helpless against such giants when there is no competition to turn to if you don’t like how they do business. While insurance already controls so much of our healthcare experience, I don’t want to hand them more on a silver platter.

I understand people need to earn livings and create and maintain profitable companies, but it should not be done at the continued unjust expense and burden of patients and the physicians and other health professionals who provide their care. We keep losing the focus of healthcare – the well-being of the patients and the continued ability to provide quality care by professionals.

Start writing your federal senators and representatives to revoke the anti-trust exemption for insurance (, and in so doing take a step toward more ethical health care. (I’ll try to get more up on the website soon about this aspect of anti-trust laws affecting your healthcare.)

A few notes on Wellpoint:
• Former CEO, Larry Glasscock’s total compensation for 2006: $14.5 million (per Indianapolis Star)
• The company earned $868 million in the third quarter of 2007, and has earned a total of $2.9 billion for the first 9 months of 2007 (total revenue was $15.23 billion)
• At the end of the third quarter it has 34.8 million members (up 615,000 from the year before) (How is a private practice physician supposed to negotiate against THAT!
• In 2006 a federal judge approved a settlement of two lawsuits that alleged Wellpoint deliberately delayed and denied reimbursements for physician services. They were one of the last settlements in findings against several national insurance companies, pointing to industry wide problems in ethical practice.

• In 2005 WellPoint paid $6.5 billion to obtain the parent company of New York’s Empire Blue Cross Blue Shield

Other insurance profits:
** UnitedHealth’s 3rd quarter profit this year rose 26%
Humana’s 3rd quarter profit rose 90%

Personal Injury Litigation by Doctors Offensive

dawn@relationshipjourney.com (Dawn L) — Wed, 24 Oct 2007 23:55:00 +0000

This week a jury in Tampa, FL awarded a 16 year old boy $4 million because a boy in the private school who had harrassed Danny Heidenberg in the past fell on him during a football game at recess and broke Danny's arm. The offender had bullied Danny and others at school and during the game. The reasoning for the lawsuit and award was that his parents had complained before and the teachers had not supervised them enough. Danny has screws in his arm and his attorney claims there is permanent nerve damage in his forearm. And, he should get $4 million dollars because he wanted to be a surgeon when he grew up. Give me a break.

While it is sad that Danny has damage to his arm, in my opinion it does not come close to deserving $4 million. It is not like he just finished medical school and was about to start his career as a surgeon. His injury does not prevent him from working and probably does not prevent him from a career in medicine -- if he even really wanted or continues to want that career. He was 12 at the time of the injury (16 now). He has plenty of time to pursue his life path in a way that is fulfilling and productive for him.

What makes this case even more offensive to me is that both of his parents are physicians. His father is a DO urologist and his mother is an MD fertility specialist. I find it fascinating (and irritating) when physicians, who are always under the gun of malpractice lawsuits themselves, jump at the chance to file their own lawsuits for the ever vague "pain and suffering" theme. I hope neither of Danny's doctor parents have or ever will complain about medical liability.

I can understand wanting to prevent this from happening to anyone again at that school. I understand wanting accountability. I understand frustration and anger. I could understand mediation to facilitate a constructive process and plan of action for both the bully and the school, including restitution for medical expenses. I understand wanting to stand up for and protect your child. But to me, his parents become just like the personal injury lawyers who go for money or revenge. "Let me hurt you to make my point." Nothing constructive happens to change the situation and they have their $4 million award. Personally, I would never, as a potential patient, go to physicians who thought this was the only way they could make a point or seek justice, or who finally feel some satisfaction because they won.

It may not be the case at all, but it reminds me of people who are abused becoming abusive themselves, victims who become victimizers. Is this an example of how the oppression of the malpractice system for physicians creates a situation where those same people use the system to beat up someone else? It also strikes me that they use a system that by its very nature is bullying while presenting as victims of a bully.

The personal injury system is out of control. It is not constructive and only creates more harm. We just had a case in Orlando a few weeks ago of a police officer who responded to a 911 call of a toddler found in a pool suing the family because she slipped in a puddle of water in the house after the mother carried her unconscious child in to the bedroom where she called for help. Fortunately public outcry pressured the officer to drop the lawsuit. In personal injury cases (and in life), the only thing worse than people who exploit a bad situation, who go after personal gain at any means, or who are more interested in punishment and award than constructive change, are the attorneys who encourage them.

I keep thinking that maybe, out there somewhere, there are actually ethical personal injury attorneys. I have no idea where, but I do hold hope. I just wish they, and their associations would hold attorneys accountable for more ethical behavior. Just because their actions may not violate the letter of the law, does not mean they are ethical. We need a major attitude shift in this country -- and maybe in the world -- toward ethical standards of behavior that take into consideration the well-being of all parties involved, not just one. What is fair and just for all involved? I wish we could focus on justice AND a process that results in a better school, or a better medical system, how we use a bad situation to help create a better situation for personal and collective justice. That could create the protection and enhancement of others to come after them so that this kind of thing doesn't happen again.

Are Hospitals Betraying Community Surgeons?

dawn@relationshipjourney.com (Dawn L) — Thu, 18 Oct 2007 03:15:00 +0000

The Orlando Business Journal announced this week in its cover story a 'New Model of Medicine'. The new model means that hospitals are not only hiring more hospitalists, but also specialist. In the article, they featured 3 young general surgeons who are now employees of Florida Hospital in Orlando.

While the article explains the role of hospitalists, it did not really explain the general surgeons. Reference was made to a surgical residency when the new medical school opens within a year or two and an attempt to get a liver transplant program in the future. These 3 surgeons in their 30’s are part of the faculty of the residency program. Perhaps they are the best and brightest of their programs and have 5 years or so under their belts. However, since so much of surgical proficiency comes from hundreds of surgeries, I find it curious that they bring in such young surgeons for a brand new residency program.

My bigger concern is why and how the hospital is employing 3 new surgeons full time right now when those programs are off somewhere in the future. There was no mention in the article that they are trauma surgeons or surgeons to simply take call – which I would think would be a selling point to the public if that’s what they are doing.

I could be wrong, but my take is that they are beginning to set up a hospital based program of general surgery that eventually will pull in residents, but that right now involves these new surgeons. It appears to be a trend around the country. Are these departments doing breast biopsies, gallbladders, hernias – all those procedures that are the bread and butter for community surgeons in private practice? If so, it is a betrayal of those physicians who support the hospitals.

Combine that with the massive marketing and referral system of a large hospital network with satellite hospitals all over Central Florida and I imagine it will indeed impact surgeons in private practice. The article talks about the new surgeons not wanting to deal with the hassles of the business side of practice, reimbursement, malpractice premiums, etc. which is certainly understandable. But what about those excellent surgeons in the community who ARE dealing with all those hassles – and now having the hospital they help support undermine them by creating its own department in competition with them for patients and facility time? The hospitals should be actively finding ways to partner with and assist physicians ‘dealing with the hassles’. Hospital systems could use their size and power to push for insurance reform, standardization and other ways that would benefit their own bottom line as well as support private practice surgeons. Instead they undermine them. The surgeons here deserve better support.

As a patient who has benefited from a private practice surgeon, I am concerned and angered. If surgeons are struggling with declining reimbursements and the ‘hassles’ while trying to provide quality care, what is going to happen with a massive system sucking in referrals and perhaps having priority for facility time?

As a patient, I am also leery of surgeons who would have full responsibility for their patients and yet be beholden to their corporate employer. I want, and have, a surgeon who, if necessary, will stand up to policies, procedures or anything that prevents me and other patients from getting the care we need. Will an employee of the hospital be willing to take on the institution that pays their salary?

If the hospital creates this surgical department in direct competition to our community surgeons, not only surgeons will suffer, so will patients.

Health care multi-millionaire proposes ‘reform’

dawn@relationshipjourney.com (Dawn L) — Tue, 26 Jun 2007 01:03:00 +0000

Last week experts attended the National Institute of Health Policy meeting in Minneapolis and gave the usual dire warning that the healthcare system will face serious problems in the coming years unless Congress takes action now. Don’t we already have financial problems?

The Minneapolis Star Tribune quoted one of the ‘experts’, former WellPoint insurance Chair and CEO, Leonard Schaffer, who said that we have 8-10 years to avoid the trend of an exploding federal deficit because of an aging population.

And then, he gives his recommendations for change: base payments to physicians and hospitals on the quality of care, make sure that treatments are prescribed based on evidence that they work, and closely monitor technological devices. He said that “everybody is going to have to sacrifice a little bit.”

By their own admission, a big part of the problem is the growing aging population. Along with that population comes record numbers of chronic illnesses, including obesity and its consequences. There are problems of non-compliance with treatment and recommended medications to help control those conditions.

Instead of addressing the problem, Mr. Schaeffer’s approach, and that of the insurance industry and government is to focus instead on micromanaging physicians and trying to tell them how they should treat us. Case managers second guessed doctors decisions and treatment plans. They punish them if they go out of the cookbook guidelines for the welfare of their patient. They penalize physicians for giving what the insurance company decided was too much. You may remember that this was HMOs’ approach in the past. The ones who benefited were insurance companies and their shareholders. The ones who lost were patients and their physicians. The formula being proposed does the same.

In this case, what makes it all even more insulting to me as a patient, and to my physicians, is that the pontificating comes from Mr. Schaeffer whose total compensation in 2002 was over $19 million dollars that year, and who, in 2004, along with that level of compensation, was given $234 million dollars bonus for a merger when WellPoint bought Anthem insurance. “Sacrificing a little bit” has a very different impact for me as a patient, or for my physician than it does for Mr. Schaeffer.

People like Mr. Schaeffer have no credibility when they talk about how to curb health costs – and especially when they nickel and dime physicians while stuffing their own and their company’s pockets. Their purpose is to make money for themselves, the company and the shareholders. UnitedHealth Group publicly estimates earnings of $4.2 billion in 2007. That is over $1 billion in profits in one quarter!

As long as healthcare is run for the benefit of people like Mr. Schaeffer, UnitedHealth Group, and their shareholders, profit will always come first -- at the expense of patients and the physicians who care for them who are supposed to 'sacrifice'. And to me, that is unethical.

The HPV Vaccine controversy -- choice and responsibility

dawn@relationshipjourney.com (Dawn L) — Wed, 28 Mar 2007 01:48:00 +0000

This morning’s newspaper (Orlando Sentinel) had a column by Susan Reimer of The Baltimore Sun in which she discussed the arguments by some parents against mandatory vaccination for the HPV virus that can cause cervical cancer. Some states have considered making it a mandatory vaccination at 11 or 12 years old before they become sexually active. Groups of parents have protested, saying that it will encourage their children to have sex.

She quotes Sarah Brown of the National Campaign to Prevent Teenage Pregnancy who says that she can understand parents being concerned about their children being required to be vaccinated with a drug that is new and does not yet have long term data on its effects. But, she added that their argument that getting vaccinated will change a young woman’s thinking about whether or not to have sex strikes her as ‘intensely unreasonable.’

And, another part of the issue is that the vaccine does not prevent all cervical cancers, and not even all that are caused by HPV. (It is estimated that it can prevent half of those caused by HPV.)

So what do you do? Do you allow future generations of women to be exposed to a virus that half of men have and that contributes to 7500 cases of cervical cancer per year? She states that 40% of those who develop cervical cancer die of the disease. Do you force those who object because of their beliefs (no matter how you view those beliefs) to comply? Do you force parents who think their daughter will never have sex until a certain age or marriage? (I wonder if they plan to have her vaccinated at 15 or 18?) Do you force parents to take risks of unknown side effects or limited efficacy of a new drug? Do we force parents who wonder if it is just a ploy by pharmaceutical companies to make millions or billions more?

I don’t know that requiring vaccination is the answer. And yet, polio vaccine was required early on. Other vaccines are required for entry to school.

My first thought was ‘if parents choose to NOT have their child vaccinated, and that child later develops cervical cancer associated with that particular virus that the vaccine prevents, they should be required to pay for medical treatment of the cancer, or at least 50% of the cost. In spite of the attitude of entitlement in this country, I think patients bear certain financial responsibility for their decisions. Taxpayers, insured, businesses, hospitals, public health assistance programs should not be required to absorb the cost of something that can be prevented. (On the other hand, where would that lead us if we actually held people financially responsible for their lifestyle choices -- smoking, obesity, unprotected sex with multiple partners?)

Perhaps more importantly, parents have a responsibility to safeguard their children’s health. What will it be like for a child who becomes a young woman and develops cervical cancer when it could have been prevented? What will it be like for her parents, who remember they had a chance to provide some protection, but did not? I wouldn’t want to be either one of them.

Is justice a dream or can it be our vision?

dawn@relationshipjourney.com (Dawn L) — Fri, 23 Mar 2007 14:53:00 +0000

Democrats vs. Republicans, trial attorneys vs. physicians . . . they are like the fighting couples I see in my office, caught in the power struggle, so caught up in being right and pointing fingers, that they lose what they both most want. The Power Struggle becomes more important than the relationship, than their vision of what is possible. Actually, most of them were never clear about their dreams or discounted their own or their partner’s, which also fueled more of the conflict. Perhaps that’s what has happened between the players in healthcare, and the politicians who play the games of being right by making the other wrong.

What has happened to the dreams, to their vision of what is possible?

Today I discovered a proposed bill (HB 733) in the Florida House of Representatives trying to get around the abolishment of joint & several liability that the legislature voted on last year. The bill seeks to make the named party in the lawsuit responsible for all the damages, even if they were only minimally responsible. (See more on my Legislation page) It’s a great way to go after the most solvent, the deepest pockets and to justify once again the shotgun approach to malpractice claims – naming every possible person in the hopes someone can be found guilty of some responsibility and forced to bear the burden of all the expense. So in the name of justice, we make an unjust law??? It’s like a game to see who will win, no matter who you damage in the process.

It is easy for me to think of trial attorneys as greedy exploiters of misfortune, and some are – as are some doctors, therapists, insurance companies, politicians and even some patients or family members. But I also can’t help but imagine that there are actually some trial attorneys motivated by a sense of justice and fairness, and some who are ethical and some who hold a vision of a more just world.

As I was researching the Florida bill, I found that the Academy of Florida Trial Lawyers has changed its name to the Florida Justice Association, as has the national association (now the American Association for Justice). Wouldn’t it really get interesting if it were all actually about justice?. . .If we looked for ways to be just to both injured patients and physicians who provide care, yet as human beings are not perfect every minute of every working day? Clearly there are some unethical and incompetent doctors. But so many named in malpractice claims are not that. So much energy, time, money, resource is wasted in attacks and counter-attacks, going back and trying to undo the opponents win. And we all end up losing.

What if we all, lawyers, physicians, patients, Democrats, Republicans, insurance industry and others sought justice for all, instead of protection of profit or power or position, or reward for the few? What if we put our combined vision, intelligence, creativity and the best part of our desire for a better world at the service of creating a better way?

Doctors, patient, staff relationships and . . . .

dawn@relationshipjourney.com (Dawn L) — Wed, 21 Mar 2007 16:56:00 +0000

I received a comment from Tim Dawes on a recent post I did on corporatization of healthcare and it's effect both on physicians and on the physician-patient relationship. I signed up for 2 free e-mail mini-courses that Tim has: 7 Steps to Excellent Service for Patients of Any Culture and How to Uncover the Hidden Opportunities and Risks in Your Medical Group. They are free and just require an e-mail address sign-up. (The second one you receive when you sign up for the special report -- 7 Mistakes Medical Groups Make that Cost Patients & Money)

Needless to say, the two topics are intertwined. Dawes talks about the importance of communicating more effectively, expressing empathy, respect and valuing. As a relationship expert, I certainly agree. The power of relationship is a major factor for quality healthcare, for patient compliance with treatment, for accurate treatment planning and for healing itself. For example, research has shown that trusting one's surgeon can actually lead to less pain after surgery. (I'll plug in links to the studies when I find the articles on my hard drive!) And, on the flip side, when people feel devalued, discounted, disrespected, not cared about, anger increases. Research has also shown failures in relationship between doctor and patient to be a significant factor in patients' decisions to file a lawsuit. (A Mediation Skills Model to Manage Disclosure of Errors and Adverse Events to Patients Carol B. Liebman; Chris Stern Hyman Health Affairs 23(4):23-32, 2004. © 2004 Project HOPE)

I liked what I read and I'm going to order his Healing from the Heart: A Practical Guide to Creating Excellent Experiences for Patients and their Families,

Further Reading:
Why Do Patients Sue Doctors? by Richard J. Andolsen, MD in Sonoma Medicine
How plaintiffs' lawyers pick their targets by Berkley Rice in Medical Economics
Beckman, H.B. et al., The doctor-patient relationship and malpractice. Lessons from plaintiff depositions, Archives of Internal Medicine, Vol. 154 No. 12 (1994)
Hickson et al. Factors that Prompted Families to File Medical Malpractice Claims Following Perinatal Injuries, JAMA 1992; 267:1359.
Levinson, W. et al., “Physician-Patient Communication: The Relationship with Malpractice Claims among Primary Care Physicians and Surgeons,” Journal of the American Medical Association 277, no 7 (1997): 553-559
Young, VC M, Phillips A. Why do people sue doctors? A study of patients and relatives taking legal action. The Lancet. 1994;343:1609-1613
Huycle, K. Characteristics of potential plaintiffs in malpractice litigation. Ann Intern Med 1994; 120:792-798.
Mazor, Kathleen M., Steven R. Simon, and Jerry H. Gurwitz. 2004. Communicating With Patients About Medical Errors: A Review of the Literature. Archives of Internal Medicine 164:1690-1697.

Ethical conduct by US research in India?

dawn@relationshipjourney.com (Dawn L) — Wed, 21 Mar 2007 01:35:00 +0000

Some of the questions about pharma’s ethics with research in India involve informed consent. To what extent are the people being enrolled truly giving informed voluntary consent rather than just signing a paper. Some are poor, some are illiterate. Some are offered $100, a small fortune to the poor, and therefore possibly undue influence. Some see it as an opportunity to get some treatment when they normally cannot afford to seek treatment. Some point out cultural differences in which most patients blindly trust that anything a doctor gives them or asks them to do will make them better, the legacy of the caste system and more. Experiences of autonomy and freedom are very different in Western culture than they are for many in Indian culture. (Pharma giants risk reputation through clinical trial cost-cutting) Candice Player in her article, Outsourcing Clinical Trials to India, points out that for many women, their role is defined by their fathers, then by husbands, and/or wishes of parents and elders.

Another question is that after determining that a person has the target illness, medication or a placebo is given for the trial, and no attention given to follow-up treatment of the patient. The drug matters more than the patient. Ms. Player makes the point of distributive justice which would make it unethical for one group to bear all the risks and inconveniences of the research, while another group is the one who receives all the benefits. She cites The Belmont Report on ethical principles in human research and the Indian Council of Medical Research’s principles of ethical research. (Ethics in Human Experimentation)

It is not just India’s responsibility to create an ethical environment for research, it is also the responsibility of the leadership of America’s and Europe’s pharmaceutical companies. And it is our responsibility as human beings to call them to ethical relationship and behavior.

Related articles:
How informed are the country's clinical trial participants? In Applied Clinical Trials

India a hotbed for clinical trial (Times of India)

Drug trials outsourced to India BBC News

Fear, Pharma or Ethical Choice?

dawn@relationshipjourney.com (Dawn L) — Wed, 21 Mar 2007 01:31:00 +0000

Today I received a notice about a Forbes magazine article on the pharmaceutical industry’s plans to fight any moves by Democrats to push for federal negotiation on drug prices for Medicare and to limit direct-to-consumer advertising of drugs. (Democrats Bad News for Big Pharma).

Parmy Olson states that David Seemangul, an analyst with S&P Equity Research, sees A Democratic congress as detrimental to pharma. Price negotiation would put pricing pressure, but it would also increase volume and that could mean lower operating margins.

So, if I understand it correctly, he says if we lower health costs for Medicare patients, save the government and taxpayers money, and help people actually get more of the drugs they need, pharmaceutical companies will be upset because their profits won’t be as high.

And then, heaven forbid, we could also address the concerns about direct-to-consumer advertising that many times lead patients to demand drugs from their physicians that may not even be the treatment they need. Patients sometimes switch physicians to get what they want – or perhaps more accurately said, what pharma wants them to want, and continually influences them to want.

To me, drug price negotiation and some boundaries around direct-to-consumer advertising would be a more ethical approach. And yet, Seemungal pulls the fear card that we will lose pharmaceutical business as they look to markets like India and China if we don’t keep feeding their profit margins.

Actually pharma already outsources their research and more to China and India. Turning to India to conduct clinical trials has already saved them billions. Never mind, that ethical questions have been ever-present with the practices associated with those trials. Pharma claims that labor is cheaper and there is a large population of people with diseases and little or no previous treatment. (Watch for another story about some of the ethical concerns.)

To me, the question is what, or who, will make our healthcare decisions that will create our future – fear, pharma profits, or ethical choice?

Corporatization and Motives in Medicine

dawn@relationshipjourney.com (Dawn L) — Wed, 07 Mar 2007 13:12:00 +0000

In today's Medscape's General Surgery Medpulse news, there was a link to an article that discusses the corporatization of healthcare, the changing motives of physicians, the impact on physician self-esteem and satisfaction and why that should be part of the discussion on universal coverage. The article is:

Pay, Pride, and Public Purpose: Why America's Doctors Should Support Universal Healthcare

Posted 02/28/2007

One of the saddest parts tome was a comment with a physician who was building an oversized luxury home. As he was giving a tour of the construction he said, almost as an apology, that "it gives me a reason to keep working". While there have always been some doctors who have entered medicine for the income, most physicians have found their motivation and passion for medicine in their care of patients, in the service they provide, in their contributions to those patients who come to them for help. Most physicians enter medicine because they want to make a difference in people's lives. That is the core of satisfaction, motivation and continued energy for the profession -- even on difficult days. It is a sad day when the price of a procedure becomes more motivating and more important than the procedure and it's potential for healing the patient.

The article talks about some of the many ways that increasing commercialization and commodification of them and their care impacts not only their morale, but their decisions and motives and how that weakens professionalism and healthcare. Altom states:

But for professionals, the only god worthy of solemn devotion is signified in the etymology of 'profession,' viz., an avowal of service beyond self.^[10] Without this piety technical proficiency may remain intact, and financial rewards may remain plentiful, but professional identity cannot be sustained. As Arthur Okun has remarked, "everybody (but an economist) knows that that money shouldn't buy some things."^[11] Yet to be accurate we need to go beyond the moral realm indicated by "should." One of the things money can't buy is a professional identity; this means that every encroachment of commercialism into medicine makes professionalism more fragile.

She continues:
Whatever else it brings, universal access, even in a system with multiple tiers, is a great equalizing force. Commercialism plays upon, and profits from, disparities in health status and income, and as noted above, makes physicians active players in that collusion against the poor and the sick. It is very likely that any system of universal care, whatever the organization and delivery mechanisms, will promote an environment in which physicians can again take pride in recognizing the skillful execution of their unique abilities in serving, healing, and alleviating suffering. For most doctors, a rise in professional self-esteem will be the result.

One of the places the 'money as primary motive' is clearly evident is in large group practices. While there may be exceptions, the focus tends to be on the bottom line and physicians themselves are evaluated and measured by how much revenue they bring in. In my opinion, one of the minefields for ethical healthcare lies in large group practice. And, it is often one of the places where physicians themselves seem to feel the least satisfaction -- as it is for many patients. As a patient, if I have a choice between a physician or specialist in a solo or very small group practice, versus a large practice, I always go with the small practice. Large practices in so many instances have become like factories. That is not what I want in my healthcare. And I really don't think it is what most physicians want either.

We need to find passion, strategies and ways of galvinizing patients and physicians to demand that the essence and the core of healthcare -- the patient -- AND their physicians and other professionals who give the care are supported, not undermined, to create the environment for the quality care they deserve to receive and to be able to give.