Embed Size (px)
Citation preview
Cancer Investigation, I7(2), 164- I69 ( 1 999)
OP-ED i The War on Healthcare Professionals and Healthcare Delivery*
Peter H. Wiernik, M.D.
Our Lady of Mercy Medical Center New York Medical College Bronx, New York
The purpose of this article is to stimulate readers to become involved individually if not collectively in the most important debate of our professional lives concern- ing the future of healthcare research, practice, and con- sumption that has been brought to center stage by the proliferation of for-profit healthcare organizations and by the present administration. It is a debate of immense im- portance to all Americans because it is in reality a debate about the future relationship of government to all profes- sions and ultimately to all Americans.
According to the media and many high government officials, major changes in the healthcare system are re- quired because we spend too much money on health care, healthcare accessibility is inadequate, and fraud and mis- conduct among healthcare researchers and providers exist at unacceptable levels, to name a few.
With respect to the cost of health care, we have been told that it is too much, but we have not been told com- pared with what. Former Governor Richard D. Lamm of Colorado in an article published in Cancer Investigation (1) quotes George Schieber (2) as follows: “In compari- son with other major industrial countries, health care in the United States costs more per person and per unit of service, is less accessible to a larger portion of its citi- zens, is provided at a more intensive level and offers
comparatively poor gross outcomes.” Most of those who make these points ignore the fact that we spend more on government than any other major industrialized country and they offer as a solution to the healthcare problem that we spend even more on government. Health care in the United States is expensive because we have the most ad- vanced healthcare system in the world by most (but not all) measurements. Health care in this country is inexpen- sive compared with the national debt (even taking into account major recent reductions), national defense, the savings and loan debacle, the Housing and Urban Devel- opment scandal, the Gulf war, and the activities of vari- ous governmental regulatory agencies. The problem with the cost of health care is not that it is expensive but that it is expensive for individual citizens. Proposals to fix the system have ranged from a huge new bureaucracy to manage healthcare delivery to merely minor adjustments. Most are not expected to pay off for many years. What- ever plan is adopted, it must result in the greatest degree of governmental disengagement from the day to day run- ning of the healthcare system if the plan is to succeed in reducing costs to individuals and at the same time max- imize provider and beneficiary satisfaction. I believe the Government understands this and that is why the Clinton Plan excluded members of Congress and other federal
*Adapted from the Presidential Address to the American Radium Society, Hamilton, Bermuda, April 23, 1994.
164
Copyright 0 1999 by Marcel Dekker, Inc. www . dekker. corn
Can
cer
Inve
st D
ownl
oade
d fr
om in
form
ahea
lthca
re.c
om b
y M
cgill
Uni
vers
ity o
n 11
/04/
14Fo
r pe
rson
al u
se o
nly.
War on Healthcare Professionals and Delivery 165
employees, who would have been allowed to continue membership in the Federal Employees Health Benefits Program (FEHBP) had the Clinton Plan been enacted. The FEHBP is a program that Dr. David A. Jones, the CEO of Humana, believes could solve everything if ex- tended to the rest of us (3). There is no comparison be- tween the per capita costs of and beneficiary satisfaction with FEHBP and Medicare. The former is run for govern- ment, the latter by government.
Just as the government’s track record for running in- surance plans (Medicare, Medicaid) is less than satisfac- tory, so is its record for running hospitals. As Robert Bau- man, a former Congressman from Maryland and a former Veterans Administration (VA) attorney, pointed out (4), despite a budget of nearly $16 billion and approximately a quarter of a million employees, VA health services got very low marks after a study by the General Accounting Office, which found the following: 55% of patients with routine problems waited at least 3 hr, sometimes all day, to be seen for a few minutes by an overworked doctor struggling with increasing numbers of patients and piles of government forms, regulations, controls, and policy directives; one of nine emergency patients waited up to 3 hr to see a doctor; and because of lengthy waiting lists, patients in need of specialized care even at the system’s best facilities cannot be seen by a specialist for 60-90 days and wait months more if surgery or other special procedures are required. It is no wonder that of an esti- mated 26.7 million veterans eligible for VA medical care, fewer than 10% use the facilities. Incidentally, the Clin- ton Plan would have allowed the VA System to continue as is, outside of any reformed healthcare system.
One of the reasons healthcare costs have risen is that the cost of the administration of health care has risen dra- matically in recent years. According to the League of Women Voters (9, 24% of healthcare costs are for ad- ministration, a percentage dramatically higher than in any other country. The number of hospital-based adrninistra- tors has risen dramatically in recent years (6). Unfortu- nately, these administrators have been made necessary by the ever-increasing volume of local, state, and federal regulations with which physicians and hospitals must comply. These administrators are costly. They frequently are paid hundreds of thousands of dollars per year, and presidents of even so-called nonprofit institutions are fre- quently compensated at well over a half million dollars per year. This financial drain on the system is a disgrace, as is the fact that it takes so many administrators to run an American hospital.
Government solutions for the healthcare system
will only increase administrative costs. No government agency or program in history has cost less for administra- tion over time. In the present climate of escalating regula- tions and enforcement, one can safely say that a govern- ment-run universal healthcare system has all the potential for an administrative nightmare. In an editorial in Science by Philip H. Abelson (7), the author notes that the federal government employs at least 125,000 bureaucrats in the formulation alone of regulations by various governmental agencies. The direct annual cost of this work is estimated at $500 billion, and indirect additional costs to support that work are estimated at another $500 billion. Of course, enforcing the regulations costs additional federal dollars, and citizens must spend money to comply with the regulations. For instance, Abelson further writes, us- ing the Environmental Protection Agency (EPA) as an example, that agency estimates the costs to the public for meeting EPA regulations alone in 1990 was $ 1 15 billion, and its projection for the year 2000 is $180 billion. He also points out that municipalities have reported instances in which real costs for compliance exceeded EPA esti- mates by a factor of 20 or more.
What has all this to do with government-managed healthcare reform? We have all had experiences with Medicare. I remember, as an example of how the govern- ment currently deals with us, receiving a letter from Medicare stating that I must fill out and return an en- closed survey by a certain date or face $10,000 a day criminal penalties. Of course, the due date had passed before the postmark date on the envelope. Bradley A. Smith (8), an academic lawyer writing in the Wall Street Journal, appraised us of little known facts about the now defunct Clinton Plan. The Health Security Act, as it was called, federalized a broad range of routine crimes and torts now dealt with by the states. Healthcare fraud, which is broadly defined, is punishable under the Act by criminal penalties ranging up to life imprisonment. “The act makes it a federal health care offense to willfully falsify or conceal any material fact in any matter involv- ing a health plan.” To understand such language, imag- ine a situation in which a provider of janitorial services misrepresents that she is bonded when negotiating a con- tract to clean the offices of a health maintenance organi- zation (HMO). Today, this is no more than a state civil law contract claim, for which the HMO could recover any actual damages suffered in a civil lawsuit. However, under the Clinton Plan, the janitors would have commit- ted a federal crime punishable by fines and imprisonment for up to 5 years. This would be true even if no harm had ever come to the HMO because of the concealment of
Can
cer
Inve
st D
ownl
oade
d fr
om in
form
ahea
lthca
re.c
om b
y M
cgill
Uni
vers
ity o
n 11
/04/
14Fo
r pe
rson
al u
se o
nly.
166 Wiernik
a fact. The Clinton Plan may be dead, but the bureaucratic mentality that conceived it is characteristic of all too many federally proposed solutions.
Under that Act, whenever a person is convicted of a “federal healthcare offense” having a “significant detri- mental impact on the healthcare system” (a phrase never defined), “personal property must be confiscated. Pro- ceeds from confiscated property were to be deposited in an account controlled by the inspector general of the DHHS. Those funds were expected to be used to expand his investigative activities. Thus, the prosecutors would have had real incentives to bring marginal or even base- less charges in the hope of extracting quick settlements from defendants.” Smith goes on to note, “. . . An HMO or self-ensured employer that fails to pay claims promptly may be fined up to $1 million for repeat of- fenses.” Thus, a plan that delayed payment to investigate possible fraud would have found itself sued by the federal government. A self-ensured empIoyer could have been fined up to $1OO,OOO merely for failing to report financial information on a timely basis. The plan also contained antidiscrimination clauses that disallow any activity with a discriminating effect, whether or not the activity was even related to the provision of health care and whether or not the activity was intended to have a discriminating effect. Thus, trimming a payroll to reduce costs might have been prohibited income discrimination under the Act. The Clinton Plan is dead, but unless this pervasive thinking in the Federal Government that leads to the criminalization of American medicine can also be killed, federal solutions to healthcare problems, however well intentioned, will continue to have the potential for ruining our profession.
Turning to the problem of accessibility of health care, there is no doubt that in certain areas of the country, rural and urban, access to decent and effective health care is lacking for certain segments of the population. But things may not be as dismal as pictured (9). It seems to me that certain simple measures might go a long way to resolve a major portion of the problem. Current health insurance might be made more affordable for those who cannot afford it now if healthcare insurance premiums were regulated by a federal insurance agency rather than state agencies; malpractice reform, initially proposed by the Administration and subsequently blocked by the Ameri- can Trial Lawyers’ Association, would reduce medical costs and therefore reduce insurance premiums; and ev- ery medical, nursing, and physician assistant school grad- uate in the country, in exchange for full professional school tuition paid by the federal government, would be required to perform 2 years of national service after com-
pletion of basic postgraduate training. These individuals could be assigned to undeserved areas of the govern- ment’s choice. Incidentally, a similar program could be applied to law school graduates as well, as suggested by Harlan R. Ribinik, a Wyoming anesthesiologist (10). In addition, certain Republican suggestions enunciated by William Kristol (1 1) should be implemented: lower in- surance premiums by making them fully tax deductible; permit the establishment of medical savings accounts on the individual retirement account model; provide health insurance tax credits or vouchers to low-income families; reform insurance markets to make health insurance sta- ble, portable, and devoid of preexisting condition restric- tions; and require by law that every child without medical contraindication be immunized. Every dollar spent here will save $10 in future medical costs. About one third of U.S. children are currently not vaccinated, and these are not just poor kids. In recent months, some of these pro- posals have come to fruition in a token way.
Of course, there is not much point in enhancing access to health care if the qualtiy of health care deteriorates. As P.J. O’Rourke has written (12), “Federal health care reform will drive the best people out of the health care profession. What type of person is going to become a doctor, a nurse, or, for that matter, a health insurance executive just to wind up as a bureaucratic goat or gov- ernment hack? There will come a day when you’ll be wheeled in for heart bypass operation and the surgeon will be the same fellow who’s now behind the counter when you renew your car registration at the Departmetn of Motor Vehicles.”
The vacuum left by the defeat of the Clinton Plan for health care gave impetus to the Managed Care Concept that, in my opinion, has been a disaster for patient, physi- cian, and academic health center alike. The fundamental concept of Managed Care is that efficiencies can be achieved in the delivery of health care and the savings that result should be shared with investors. In reality, what has happened is that treatments and services poten- tially available to patients have been rationed irrationally and reductions in the cost of health care have largely been achieved by denial of treatments and services rather than by more efficient management. In addition, investiga- tional treatments have generally not been allowed based on the fact that they are unproven treatments. The nega- tive impact of managed care is nowhere more evident than in the practice of oncology. The disallowance of par- ticipation in clinical trials has had a major negative im- pact on academic medical centers and especially on aca- demic cancer centers, where accrual to clinical trials has dramatically fallen in recent years. In an editorial in Sci-
Can
cer
Inve
st D
ownl
oade
d fr
om in
form
ahea
lthca
re.c
om b
y M
cgill
Uni
vers
ity o
n 11
/04/
14Fo
r pe
rson
al u
se o
nly.
War on Healthcare Professionals and Delivery 167
ence (13), Robert T. Rubin laments that, “Medicine is big business in America. Health care is now a full-fledged industry: The actuary stands with the physician at the bedside. The coin is the capitation contract for ‘covered lives,’ and the health maintenance organization (HMO) is emerging as the main administrative structure. ‘Managed care’ is the catch phrase, but who does the managing (physician or actuary) and toward what end is often not clear. Not only are academic health centers ill-suited for this competition,” he says, “they are in grave danger of degrading or losing altogether their raison d’gtre- teaching and research-in the process.” Rubin warns that HMOs will provide only static health care if they do not facilitate the research and teaching responsibilities of academic health centers.
The problem is that to do so is unprofitable in the short and medium range, despite the obvious potential for new treatments and better trained physicians to reduce healthcare costs in the long term. Fortunately, cracks in the wall of this new monolith of managed care have be- gun to appear. In early December 1997, a group of Bos- ton physicians and nurses protested the growth of for- profit health care by throwing the annual reports of some for-profit hospitals and HMOs into the Boston Harbor. Physicians in Chicago, Albuquerque, and Toledo and nurses associations in six states endorsed their protest (14). Later in the month an imaginary letter from an imaginary HMO to its customers appeared as an Op-Art piece in the New York Times (15). It stated among other things, “To compensate for inevitable staff cutbacks, all office administrative personnel will now receive training in obstetrics and basic anesthesiology,” and that “Our new national director of gerontology . . . will be Dr. Jack Kevorkian.”
In the middle of the year, Columbia/HCA Healthcare Corporation was served with multiple federal criminal charges in the delivery of managed care and its CEO, Richard L. Scott, who will have to face much of the mu- sic himself, stepped down. This $20 billion concern, the world’s largest HMO, which was supposed to be one of the shining examples of the advantages and profitability of managed care, may have “stretched beyond the legal limits” in pursuing profits (16). And finally, this year as a result of constant consumer complaints about access, a special advisory committee to the Governor recom- mended that California (where it all began) establish a new governmental agency to oversee HMOs and enact new law to improve care and protect consumers (17). We will see whether things begin to turn around in 1998.
There are, of course, many potential sources of saved federal dollars that could be invested in health care now.
The cheapest way to reduce healthcare costs and thereby reduce insurance premiums and in turn increase access is to fully fund medical research. Imagine the effect on all three if we could learn to cure AIDS, or cure more cancer patients, or cure alcoholism and other maladies. Daniel E. Koshland, Jr., writing in Science (9), notes that, “A funny thing happened on the way to better health care: increases in research got left out of the picture.” He goes on to note that, “if lowering costs of existing treatments but not improving cures and vaccines for new scourges had been applied in the past, we might be subsi- dizing the oil to maintain iron lungs or creating incuba- tors to produce cheaper leeches.” The Administration has apparently listened and will soon propose, with the support of Congress, major budget increases for the Na- tional Institutes of Health (18). We must make certain that these new funds, if approved, actually go to investi- gator-initiated peer-review research and not simply to “new programs.”
And now I come to my last point, that we must fashion an acceptable response to fraud and misconduct among healthcare researchers. Such a response must allow for the rapid discovery of fraud or other misconduct; a rapid assessment of the impact of the misconduct on science, medicine, and society as a whole; and an appropriate re- sponse to the misconduct. The appropriateness of some current responses by government, academic institutions, and the public to misconduct on the part of healthcare professionals needs to be addressed. Craig Holden, a de- fense lawyer, has said (19) that, “the government has begun to really push the outside of the envelope to go after conduct that isn’t expressly forbidden anywhere.” Richard Brookhiser wrote in Time Magazine (20) about the “. . . arrogance of lawyers, . . . especially those work- ing inside the (Washington) Beltway,” and of “doctor resentment,” and he suggests that both have played a role in the formulation of healthcare policy. The doctor re- sentment, he claims, stems from the 1960s when right- thinking college students were much taken with the ro- mance of Cuban and Chinese barefoot doctors. He claims that, “the attitude may have been filed away in a foot- locker with the beads and the bongs, but its long arm strikes out at physicians today.” But Freeman J. Dyson, a professor at the Institute for Advanced Study in Princeton, writing in the Phi Beta Kappa publication, the American Scholar (21), suggests that the blame for over- reaction to misconduct that has not harmed science or the public rests squarely on our own shoulders. He writes concerning one case, “The greater evil was the American academic establishment, the university administrators and faculty committees who continued, through venality
Can
cer
Inve
st D
ownl
oade
d fr
om in
form
ahea
lthca
re.c
om b
y M
cgill
Uni
vers
ity o
n 11
/04/
14Fo
r pe
rson
al u
se o
nly.
I68 Wiemik
or cowardice, to discriminate against the inquisitors’ vic- tims long after the inquisition was over. The lasting and permanent damage was done by us, by the scientific com- munity to which we belong. . . . The forces now driving academic institutions to join the bandwagon of moral rec- titude are the same forces that drove academic institu- tions in the 1950s to join the bandwagon of spy mania. These forces are, now as then, cowardice and venality. If we bravely stand up for our colleagues who are under attack, we risk being attacked ourselves, and, even worse, we risk being deprived of funds on which we have come to rely.” Dyson asks, “Why should we impoverish our science by excluding those controversial spirits and dubi- ous characters that have so greatly enriched our music?” In my opinion, the punishments extracted by universities for trivial deeds of misconduct have become so severe and the zeal with which perpetrators of such deeds have been pursued has become so great that the conduct of science and medical practice has become dangerous for us all. The atmosphere about which Dyson writes now permeates undergraduate schools as well. Scott Gottlieb, the editor of the Wesleyan Review, wrote about stu- dent judicial boards (22), which he claims are examples of authorities that work outside the U.S. constitution, “much the way federal agencies work.” “The boards, often jointly run by students and a smattering of willing faculty members, are charged with meting out everything from whiny disputes between students and infraction of speech codes to allegations of criminal battery and date rape. They are given considerable license to determine guilt or innocence and have no obligation to recognize U.S. civil procedures or legal traditions. At Wesleyan University, for example, the board deliberates in secret, provides no explanation for why it reached a particular decision and doles out punishments ranging from letters of reprimand to expulsion. How college officials square all this absurdity with their claim to teach students about truth, freedom and justice should be an interesting revela- tion.”
Something has gone tembly wrong in American aca- demic circles and we must fix it. American universities have adopted a Neville Chamberlain approach to the reg- ulators-feed them more than they asked for in the hopes that they will leave you, the university, alone.
We must find ways of responding to the alleged mis- deeds of a Najarian (23), a Gallo (24), a Baltimore (25), a Fisher (26), and others without destroying them. De- stroying such great men only serves to deprive humanity of their science and their medicine. If this is going to be our approach, to destroy men and women who discover
causes and cures for diseases, we had better get to work on that incubator for better leeches.
Drs. Gallo, Najarian, and Fisher (27) have been com- pletely vindicated, and Dr. Baltimore was never actually charged with any wrong doing, and his associate has been completely vindicated. The methods by which these col- leagues were tortured have been called into serious ques- tion (28-30), and significant reform in those methods is likely (29).
Academia is still “plagued with federal and state regu- lations . . . most of which are . . . enforced with more zeal than common sense” (31). To my knowledge, the regulatory quagmire that impairs our creativity and pro- ductivity is not the subject of any Congressional investi- gation to date.
Address correspondence to: Peter H. Wiernik, M.D., Our Lady of Mercy Medical Center, Comprehensive Cancer Center, New York Medical College, 600 East 233rd St., Bronx, NY, 10466. Fax: 7 18-920- I 123.
REFERENCES
1.
2.
3.
4. 5.
6.
Lamm RD: Health care: economic cancer. Cancer Invest 12:225- 229, 1994. Schieber G: Health care systems in twenty-four countries. Health Affairs, Fall 1991, p. 23. Jones DA: Choice and competition: a prescription for affordable health care reform. Cancer Invest 12:230-234, 1994. Bauman RE: The VA’s war on health. Wall Street J, Dec 6, 1993. Facts about the U S health care system. League of Women Voters Education Fund (flyer). June 1993. Woolhandler S, Himmelstein DU: The deteriorating administra- tive efficiency of the U S . health care system. N Engl J Med 324: 1253-1258, 1991. Abelson PH: Pathological growth of regulations. Science 260: 1859, 1993. Smith BA: The health police are coming. Wall Street J, December 16, 1993. Koshland Jr DE: Health care: more access and more cures. Sci- ence 262:1495, 1993. Ribnik HR: Health reform? How about lawyers? New York Times, September 26, 1993. Kristol W: How to oppose the health plan-and why. Wall Street J, January 1 I , 1994. O’Rourke PJ: Health reform: license to kill. Wall Street J, Sep- tember 23, 1993. Rubin RT: Editorial: HMOs and AHCs-in defense of town and gown. Science 273:1153, 1996. Findlay S: HMO protest. USA Today, December 3, 1997. Krist G, Chwast: Op-Art piece. New York Times, December 12, 1997. Eichenwald K: 2 leaders are out at health giant as enquiry goes on. New York Times, July 26, 1997. Purdum TS: Panel seeks H.M.O. overseer for California, a bell- wether. New York Times, January 6, 1998.
7.
8.
9.
10.
1 I .
12.
13.
14. 15.
16.
17.
Can
cer
Inve
st D
ownl
oade
d fr
om in
form
ahea
lthca
re.c
om b
y M
cgill
Uni
vers
ity o
n 11
/04/
14Fo
r pe
rson
al u
se o
nly.
War on Healthcare Professionals and Delivery 169
18.
19.
20.
21.
22.
23.
24.
Pear R: New funds for research. New York Times, January 3, 1998. Rundle RL, Stevens A: Investigators intensify crackdown on fraud in the health industry. Wall Street J, August 16, 1993 (quotes Holden). Brookhiser R: Barefoot doctors vs. scroogecare. Time, January 10, 1994. Dyson FJ: Science in trouble. Amer Scholar, Autumn 1993, pp. 513-525. Gottlieb S: A mockery of justice on campus. Wall Street J, Sep- tember 27, 1993. Anderson C: Scandal scars Minnesota medical school. Science
Anderson C: ON drops Gallo case in legal dispute. Science 262: 1202-1203, 1993.
262: 18 12-18 13, 1993.
25.
26.
27.
Baltimore D: Shattuck lecture-misconduct in medical research. N Engl J Med 329:732-733, 1993. Altman LK: Ouster sought of lead doctor in cancer study. New York Times, March 29, 1994. Fisher B, Anderson S, Redmond CK, et al: Reanalysis and results after 12 years of follow-up in a randomized clinical trial comparing total mastectomy with lumpectomy with or without irradiation in thetreatmentofbreastcancer.NEng1 JMed333:1456-1461,1995. Editorial: The Baltimore vindication. Wall Street J, July 2, 1996. Kaiser K, Marshall E: Imanishi-Kari ruling slams ORI. Science 272: 1864-1865, 1996. Woodward J, Goodstein D: Conduct, misconduct and the structure of science. Am Scientist 84:479-490, 1996. Abelson PH: Impact of regulations on universities. Science 267: 1247, 1995.
28. 29.
30.
31.
Can
cer
Inve
st D
ownl
oade
d fr
om in
form
ahea
lthca
re.c
om b
y M
cgill
Uni
vers
ity o
n 11
/04/
14Fo
r pe
rson
al u
se o
nly.
