Viewer/DiscussionLeader Guide

Dear Viewer:

What happenswhen your mother suffersa stroke…your childcomes down withdiabetes…you getcancer…or your em-ployer unexpectedly cutsyour health coverage?Suddenly, you realizehow vulnerable you are.And you face the all-consuming question…Will the proper healthcare be there for me andmy family when we needit most?

After the revolution of managed care,health care weighs on the minds of Americansmore than ever before. In fact, coming into the2000 elections, one in four Americans identifiedhealth care as the most important issue indeciding their votes for President and Con-gress.

In a health care marketplace that is inconstant flux, people are uncertain about howto gain access to care and assure high qualitycare. They are uneasy that 44 million Ameri-cans have no health insurance at all, with thattotal rising by one million every year despitesteady economic growth. And they are deeplyworried about what might happen if a medicaldisaster strikes their families or they findthemselves facing a chronic illness.

Our special PBS broadcast, CRITICALCONDITION with Hedrick Smith, takes apenetrating look at why—despite the mostenormous health expenditures in the world—does our country still suffer tens of thousandsof deaths from medical errors? Why are we so

poorly informed asconsumers on quality ofcare? How well do wedo caring for thechronically ill? Howlarge is the quality gapin U.S. medicine?

By providing casestudies, expert adviceand patient experi-ences, CRITICALCONDITION seeks tohelp American patientsand their families learnhow to find better

health care and to become powerful advocatesfor gaining the care they need. For as wecrisscrossed America, we found that peoplewho were passive, tended to get shuntedtoward second-class care, and were less likelyto get the treatments that experts recommend.Those who were well informed and assertive indemanding the best quality care generallyreceived better care.

Because it touches all Americans, thisbroadcast may be the most important that Ihave undertaken over the past decade. It is nomere journalistic homily to say that we hopeCRITICAL CONDITION will inform, educateand empower average Americans. For inhealth care, ignorance can be fatal. Goodinformation can often save a life. Our programis designed to give you insights and experiencethat will enable you to enjoy the good healththat should be the birthright of all Americans.

Hedrick SmithCorrespondent and Executive Producer

(Photo credit: Susan Zox)

(Cover photo credit: Susan Zox)

How to Use This Guide

This viewer/discussion leader guide is de-signed to show people how to become their own bestadvocates when navigating their way through thecomplicated world of health care and health insur-ance. Today, you need to be assertive and askquestions when dealing with your family doctor, thespecialists taking care of your loved one, or yourhealth plan representative. This guide to CRITICALCONDITION with Hedrick Smith is designed to beused with VHS cassettes of the three-hour PBSspecial or with the video clip reel of excerpts from thespecial provided in the Patient Advocacy Kit, or byitself.

The guide is broken into several sections. Itopens with an essay that provides the user withbackground on how health care has changed in theUnited States over the last 25 years. Following thisessay are detailed descriptions of the four segmentsthat make up the three-hour PBS special CRITICALCONDITION and another program Hedrick SmithProductions produced last spring for the PBS seriesFRONTLINE entitled DR. SOLOMON’S DILEMMA.These descriptions are:

• THE QUALITY GAP – Medicine’s Secret Killer

• THE CHRONICALLY ILL – Pain, Profit andManaged Care

• THE IDEALISTIC HMO – Can Good Care Survivethe Market?

• THE UNINSURED – 44 Million ForgottenAmericans

• DR. SOLOMON’S DILEMMA – Cost vs. Care

The next section of the guide is made up ofnine case studies, which examine the challengesfacing those dealing with serious illness and healthinsurance plans. Each case study is taken from thethree-hour special or DR. SOLOMON’S DILEMMAand focuses on a particular topic—stroke, diabetes,the uninsured, etc. Look at the different case studiesand select the ones that you think your group wouldlike to discuss.

Use the VHS cassette from the Patient Advo-cacy Kit, or an appropriate video sequence fromCRITICAL CONDITION with Hedrick Smith, or DR.SOLOMON’S DILEMMA, to show the group the casestudy and then begin a discussion using the ques-tions in the guide. If you don’t have access to thevideo, each case study is described in enough detailin the guide to set the scene for the discussion.Share the case study description with the group andthen proceed to the questions.

If the group wants more information on aparticular topic, the resource list beginning on page20 and the CRITICAL CONDITION Web sitewww.pbs.org/criticalcondition are excellent sourcesfor further information.

And, finally, to help members of the group knowthe type of questions to ask when considering healthplans, give them copies of “Ten Questions to Con-sider Before Choosing a Health Plan,” found on page17. Even if you already have a health plan, this is anexcellent tool to use to determine whether yourcurrent health plan does all that you want it to do.Immediately following these questions are “TenQuestions to Ask Your Doctor about Financial Risk.”Share these with the group, too.

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The New England Journal of Medicine recentlylabeled the U.S. health care system “the mostexpensive and most inadequate in the developedworld.” Harsh language from a sober institutiondevoted to repairing a system that has spun out ofcontrol. Over the past decade, few American institu-tions have been more dramatically transformed thanthe nation’s $1 trillion health care system. Yet despiterevolutionary change, or perhaps because of it, mostAmericans are unhappy with the state of health care.

In a New York Times/CBS News survey, 55percent believed that “fundamental changes areneeded in our health care system,” and another 30percent made the sweeping judgment, “We need tocompletely rebuild it.” One in four Americans told apoll, done for this project by Princeton SurveyAssociates, that health care would be the mostimportant issue in deciding their votes in November2000.

Over the past decade our health care systemhas changed with lightning speed, leaving ordinarycitizens uncertain, worried and frustrated. Mostpeople don’t understand how health insurance planswork or how they influence health providers. Man-aged care remains a mystery. Critical questions gounanswered: What motivates hospitals and doctors inthe new health market environment? How do peoplewith chronic illnesses and conditions fare undervarious health plans? How good is the quality of carethat most Americans receive? How well does Americacare for the needy?

Whose Point of View?The answers to many health questions depend

on who is speaking and where they stand in thelandscape of the U.S. health care system. Differentgroups judge health care by different yardsticks. Theexperience of the hard-working poor is radicallydifferent from people who are employed by corpora-tions that offer a choice of health plans at subsidizedcosts. Likewise, the experience of chronic patientsdiffers from people who are generally healthy.

To the institutions that foot most of the healthcare bill—corporations, the federal government andcommercial health plans—cost is and has been theparamount issue. For the payers, the past decade ofexpanding managed care has brought relief from thespiraling health care costs of the 1980s. Fifteen yearsago, leading corporations such as General Motorsand Xerox protested that they could not compete inthe global economy carrying the burden of skyrocket-ing health costs. They demanded an overhaul ofAmerica’s “unmanaged” health care system. Corpo-rate America championed HMOs and promotedstrategies to cut waste, push standardization, forcehospital mergers, eliminate excess capacity, andimpose cost restrictions on doctors and patients.Managed care advocates claimed they could improvequality by cutting waste and offering preventive carethat would save money in the long run.

Without doubt, the new, more efficient,market-driven system has profoundly affected healthspending. Health inflation slowed down dramaticallyin the 1990s as our health system trimmed awayexcess costs and capacity. The average dailyoccupancy in America’s hospitals dropped from763,000 in 1981 to 531,000 in 1996. Between 1990and 1996, health plans claimed up to $181 billion innational health savings—savings that corporateAmerica claimed helped restore its global competi-tiveness and allowed some small and mid-sizedemployers to continue offering health benefits. Butnow, once again, health costs are on the rise.

The Chronically Ill and UninsuredBut many health consumers have a radically

different view, especially those who are heavy usersof health care either for serious emergency care orfor long-term care for chronic illnesses. With chronicpatients now amounting to roughly 100 millionpeople, or more than one-third of all Americans, theirplight and the cost of their care—$760 billion ayear—has become a central issue in any debateabout our health care system.

America’s Health Care DilemmaBy Hedrick Smith

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Many of the chronically ill and other heavyhealth consumers complain that while businessesand commercial health plans save money, they findthemselves in a “health care strait-jacket,” constantlyfighting to obtain needed care and often forced tocarry more of their own health care burden. In a 1998Kaiser Family Foundation survey, two-thirds ofrespondents reported some problems with the healthcare system—56 percent worried about not beingable to keep their current doctor, 58 percent feareddenial of some medical procedure, and 70 percentdreaded benefit reductions.

The American public has become so dis-gruntled that four out of fiveAmericans now support thepassage of a comprehensivePatients Bill of Rights to helpensure access to quality care,according to an opinion pollconducted for this project byPrinceton Survey ResearchAssociates in the spring of 2000.The survey found that only 33percent were “very satisfied” withthe quality of their medical care—down from 55 percent a decadeearlier. Nearly three out of fourpeople expressed the fear that the drive by managedcare companies and health insurers to save moneythreaten the quality of their health care.

Another public concern is the mounting millionsof uninsured. Despite nine years of economic growth,employers are cutting back in providing health care,increasing the number of uninsured. Census datashows that roughly 85 percent of America’s 44 millionuninsured come from working families. Nearly one inthree adults reports being uninsured during the past12 months. So concerned is the general public aboutthis problem that a surprising 53 percent of Ameri-cans questioned by Princeton Survey ResearchAssociates said they were willing to pay at least $360more in annual federal taxes to help insure allAmericans.

New Role for DoctorsFor most medical providers, the central issue in

the upheaval in American health care is regaining the

power of decision over what treatments are medicallynecessary for their patients. Many providers chafe atseeing their role usurped by health plan administra-tors. But as they fight to regain control over healthdecision-making, many doctors and hospitals arebeing forced to take on the financial responsibility tocontrol and cut costs. To their great discomfort, theysee their own earnings coming into conflict with theamount and quality of care they order for theirpatients.

Quality CareIn opinion surveys, the public sees quality as

the #1 health care issue and a growing body ofhealth experts asserts that thequality gap is the most seriousproblem in the American healthsystem. In late 1999, the Instituteof Medicine stunned the nationwith its report that up to 98,000Americans die unnecessarily eachyear in U.S. hospitals because ofmedical errors—mistaken proce-dures, wrong drug doses, fatalinfections and the like. Dr. RobertBrook, head of the Rand HealthStudy Group, bluntly asserted that“as many as twenty-five percent of

hospital deaths from pneumonia, heart attack andstroke could be prevented by better inpatient hospitalquality of care.”

A small body of quality crusaders havemounted what some call “a holy war” to radicallyimprove the actual performance of health care—notjust access to doctors and regular checkups andmammograms but to lower death rates. They point toNew York state’s dramatic improvement in thesurvival rates from open-heart surgery after publish-ing the actual records of individual hospitals andheart surgeons over the past decade and a similarlyeffective campaign in northern New England wheresix hospitals shared experiences as a way to savethe lives of heart patients. Despite these impressiveachievements, most of the medical profession stillstaunchly resists publishing quality report cards onactual operations and treatments, leaving healthconsumers knowing less about health safety than

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Doctors at northern New England’sDartmouth Hitchcock Medical Center preparefor rounds. (Photo credit: Susan Zox)

about their safety on airplanes, in cars or on trains.One thing is clear. In today’s confusing,

fragmented, and often adversarial health caresystem, patients must become far more activist.Patients and their families must understand the

system well and demand to know much more abouthow to find and judge the quality of care. For it is truethat ignorance about health plans, the performance ofhealth providers, and issues of patient rights, canquite literally stop a beating heart.

Is the trillion-dollar American health caresystem the best money can buy? Most Americansassume it is and that they are getting the finest carepossible. The painful truth is the system is plaguedwith an alarming number of failures. Last year thenational Institute of Medicine reported that up to98,000 Americans die each year as a result ofmedical errors. They are America’s eighth leadingcause of death, ahead of car accidents, breastcancer and AIDS. There is also the subtler and stilllethal problem of varying quality of care, becausemost medical practice does not match the bestpractice.

However, a new movement of quality crusadersaims to cure these ills and improve the quality ofAmerican health care.

In 1990, New York became the first state in thenation to rate the medical performance of hospitalsand doctors. When it released a “report card”showing patients’ chances of surviving heart surgerydiffered dramatically from hospital to hospital, anddoctor to doctor, it causedshockwaves. Publicly humili-ated, hospitals that performedpoorly worked to lower theirdeath rates by improvingteamwork, hiring bettersurgeons, offering moretraining and upgradingequipment. New York’s deathrate for heart surgery fell 41percent between 1989 and1992.

Equally impressive gainswere made, without public

The Quality Gap – Medicine’s Secret KillerBy Marc Shaffer

disclosure, with a breakthrough collaboration amongsix hospitals in northern New England. After aninternal study revealed dramatically different heartsurgery outcomes, the hospitals began to worktogether. They shared information and replaced theirsurgeon-centered, top-down culture with a morecooperative team approach. The result: a 24 percentmortality drop between 1990 and 1992.

Quality efforts are springing up outside theNortheast, too. At Intermountain Health Care (IHC), anetwork of 122 hospitals and clinics in Utah, dozensof innovations developed by front-line doctors haveresulted in better quality care and lives saved. Onesuch innovation was a protocol for treating pneumo-nia developed by IHC Doctor Kim Bateman. Aftersurveying doctors in 10 rural hospitals, Batemanfound chaos—dozens of different treatments and awide variation in how patients fared. Batemanconvinced his peers to simplify their choice ofantibiotics and streamline care. His protocol saved asmany as 50 lives a year at Intermountain Health Care.

That still leaves thevexing problem of medicalerrors: a bungled prescrip-tion, the slip of a scalpel, abotched lab test, or a misseddiagnosis. When suchsensational errors arepublicized, they grabheadlines and drive debate.The threat of malpracticelawsuits only reinforces theinstinct among doctors andhospitals to hide their errors.

But in one hospital, the

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Utah physician Kim Bateman (left) with Hedrick Smith.(Photo credit: Susan Zox)

veil of secrecy has lifted. The Lexington, Kentucky,Veterans Affairs Medical Center has instituted apolicy that when errors occur, the hospital comesclean to the victims and their families. So, whenClaudie Holbrook died in 1997 after receiving thewrong strength of blood thinning medication, thehospital’s attorney openly confessed that the hospitalhad caused Holbrook’s death. Hospital attorneyGinny Hamm told Holbrook’s family: “We were theones that killed your dad.” With honesty, staff say,

patients and their families are far less angry and lessin the mood for high-priced malpractice suits. And thehospital can correct the wrong procedures.

Other places have adopted quality reforms likeNew York’s public report cards, New England’scollaborative improvements, Utah’s new healthprotocols, and the Lexington VA hospital’s openadmission of errors. Quality crusaders believe suchsteps are the wave of the future—especially if thepublic demands higher quality care.

In today’s cost-driven health care market,caring for the chronically ill poses special challenges.Today, people with chronic conditions such as cancer,heart disease, diabetes, stroke or cerebral palsynumber over 100 million Americans—or someone inyour home or right next door. Their care costs $760billion a year, or roughly three-fourths of all U.S. health care dollars.With people living longer, thesenumbers are rising.

In Tampa, Florida, this pro-gram sees Mike and CrissMcConnell fighting to hang on tohome nursing care coverage for theirson Hart. Born with a hole in hisdiaphragm, Hart needed a machineto breathe, and 24-hour nursing carefor almost two years. When thefamily’s HMO, Humana, suddenlywithdrew all nursing care, despite a doctor’s ordersfor 16 hours of care daily, the family had to take onthe care burden. Criss McConnell admits, “I wasbeyond terrified.” Humana later offered eight hours ofnursing care.

The McConnell’s story reveals the tensionbetween commercial insurers like Humana andchronic patients. As University of California healtheconomist Hal Luft notes: “If you enroll a lot of peoplewho are very high cost, you can end up spendingmore than what you bring in … and you won’t be able

The Chronically Ill – Pain, Profit and Managed CareBy Ariadne Allan

to stay in business very long.”In a drive to cut costs for other chronic patients,

Humana has turned to a strategy called diseasemanagement for its congestive heart failure patients.This program, using nurses to keep track of patients’daily regimens, significantly reduces mortality,

hospital visits, and costs.But dealing with some other

patients, certain children withchronic conditions, Humana at onepoint dropped their special treat-ment coverage. In Palm Beach,sheriff deputy Mark Chipps, whosedaughter Caitlyn suffers fromcerebral palsy, lost extendedbenefits covering her specialtherapies. Humana’s actionprompted Chipps to charge that atrade-off was being made. “You

can’t get rid of these kids and just weed them out sothat you save money,” he complains, “at the sametime centering all your attention on these other folks.”Chipps filed suit against Humana and won. Humanais appealing.

In another interesting story, two Fort Myersarea seniors suffered strokes and followed twodifferent paths to recovery and rehabilitation as theysought to overcome paralyzing disabilities. Theprogram follows Marijane Schacherer, who enteredan acute inpatient rehabilitation hospital, and Anthony

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Caitlyn Chipps. (Photo credit: Bob Eyres)

Oczkowski, whose MedicareHMO, Humana, overruled hisdoctor and instead sent himto a less expensive skillednursing facility. Dr. AndyKramer of the University ofColorado Center on Aging,who has studied stroketreatment methods, explainsthat inpatient rehabilitationhas a much better improve-ment rate than skilled nursingfacilities.

Finally, this program addresses treatment forbreast cancer. In this case, two women are diag-nosed with breast cancer—37-year-old ValerieKennedy, a runner and vegetarian, and Helen Boone,a 75-year-old grandmother. Both quickly learned theimportance of access to high quality specialty care.Each wanted treatment at Tampa, Florida’s H. LeeMoffitt Cancer Center and Research Institute, the

state’s only NationalCancer Institute designatedcancer center. Kennedy,who has a special healthplan from Humana, whichis her employer, wastreated at Moffitt. Humana,however, would not coverMoffitt care for Boonebecause Moffitt was notincluded in her HumanaMedicare HMO.

From chronically illkids to cancer patients, the financial objectives ofcommercial health insurers like Humana sometimesput them at odds with the people who need themmost. When cost and quality of care collide, for-profithealth plans can block doctors’ orders and denycertain kinds of care, leaving patients scrambling forother ways to obtain and pay for the care theirdoctors prescribe.

Most managed care companies like Humanasell insurance. They don’t actually provide healthcare. That’s a far cry from the original non-profitHMOs like Kaiser Permanente, launched more than50 years ago. Kaiser still takes a pioneering ap-proach to health care, combining doctors, hospitalsand insurance in one plan with a social mission oflifetime care.

Our program focuses onthe original home to KaiserPermanente, the NorthernCalifornia region, where in 1995activists protested Kaiser’sapproach to treating AIDSpatients. Kaiser boldly made itsharshest critics the leaders of itsunique HIV advisory board.Despite the fact that people withHIV and AIDS are very costly

patients, Kaiser launched a public ad campaign for itsHIV program. “Most health plans would never do anadvertisement saying, ‘We take good care of HIV,’because they would then get HIV patients who areexpensive and they’d lose money on them,” sayshealth care analyst Dr. Tom Bodenheimer, anindependent San Francisco physician.

On another front, Kaiser’slong-term mentality may save68-year-old Vivian Hannawalt’slife. Since 1994 Kaiser hasbeen giving expensive coloncancer screening exams to low-risk patients over 50, onceevery ten years. Hannawalt, a15-year member of Kaiser, hadno symptoms. But the examrevealed she had cancer andthat it had spread. If she had

The Idealistic HMO – Can Good Care Survive the Market?By Marc Shaffer

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Helen Boone (right) with her daughter Betsy Willard. (Photocredit: David Brown)

Kaiser member Vivian Hannawalt. (Photo credit: JohnVan Amburg)

waited for symptoms to appear, as many Americansdo, her chances of survival would be dramaticallyworse. But for Kaiser, the high cost of the examswon’t pay off for 15 years.

Kaiser’s commitment tolong-term care and itsintegrated structure give theHMO a big advantage inhelping members managechronic illnesses—people like12-year-old diabetic DillonMoore. At Kaiser, Dillon seesa regular team of providersevery three months for as longas an hour or two. It’s awelcome change from thecare he received at a clinic inCleveland, where his mothersaid the care was more hurried and impersonal. “InCleveland we’d see a different resident every time wewent in,” says Debby Lyttle. “There wasn’t thecontinuity of care that there is here.”

Forty-one-year-old Kaiser diabetic RobertaKuhlman shares Lyttle’s enthusiasm. A life-longKaiser member, Kuhlman worked for seven yearswith a special team of Kaiser care providers tobecome pregnant. She stopped working to take careof her child full time and became a self-insuredindividual. She kept Kaiser as her health plan, eventhough she lost many benefits. Kuhlman must pay forall her drugs and pharmacy benefits out of pocket.

When her doctor recommended that she try aninsulin pump to manage her diabetes, a device thatwas fully covered for Dillon Moore, Kuhlman learned

that as a self-insuredindividual the pump wasn’tcovered and the $5,000 pricetag put it out of reach.

Kuhlman’s dilemma iswhat Kaiser CEO DavidLawrence says is thefundamental problem inAmerican health insurancecoverage—the cost of healthcare rises while employersand the government fight topay less and less of thoseexpenses.

In the early 1990sLawrence turned to high-priced business consultantsto reshape the HMO into a tough market player.Kaiser cut rates and sometimes abandoned its time-tested formula of integrated one-stop health careservices. The strategy was a bust. The HMO lostmore than half a billion dollars in 1997 and 1998.Now, Kaiser has dropped efforts to be the low-costHMO and is counting instead on beating other healthplans by emphasizing quality care. As Kaiser’s pricekeeps rising, its strengths as an integrated, coordi-nated, community HMO with long-term goals mayprove insignificant to health care consumers lookingfor lower cost plans.

At last count, 44 million Americans had nohealth insurance. About 85 percent of these camefrom working families. In most cases, their employersdidn’t provide health insurance.

A typical story can be found in the West Texascity of Abilene. Its once mighty oil industry has hithard times and now the economy depends on theservice sector. Service jobs don’t pay well and oftendon’t provide health insurance. Twenty-five percent ofAbilene’s population of 110,000 is uninsured. One of

these uninsured is Jody Beal, who spent a lifetime asa logging engineer for oil wells. When times gottough, Beal had to jump from job to job. He gambledthat he’d make it without insurance until he retired at65 and qualified for Medicare. At 62, he had a heartattack and now faces $125,000 in medical debts. Hiscase epitomizes the plight of many “near elderly”people—too young for Medicare, but too old or toosick to work, and uninsured when they need caremost.

The Uninsured – 44 Million Forgotten Americans

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Diabetes patient Dillon Moore with his pediatric diabetesspecialist Dr. Catherine Egli. (Photo credit: Bill McMillin)

Across town, 42-year-old Tom Phillips drives atruck in a stone quarry and makes $265 a week. Withthree children, Phillips can’t afford insurance eventhough he had a heart attack and bypass surgery in1997. Doctors told him to take regular medicationsand have regular checkups. But fearing big medicalbills, he did not get the care he needed. This year hewas back in the hospital being treated for chestpains. Doctors say his case isnot unusual for the uninsured.They put off care until anemergency hits, and then thecosts and the risks are steep.

States like Tennesseehave tried to cover some ofthe working poor (eg., afamily of four with an incomeup to $30,000) by expandingtheir Medicaid programs(which cover families withincomes at or below poverty).For children with chronicconditions, like nine-year-oldJoshua Mitchell, the TennCare program has beencrucial. It pays for Joshua’s care at VanderbiltUniversity Hospital which treats his painful attacks ofsickle cell anemia. Usually, he is admitted for severaldays. Although once, when his TennCare coveragelapsed briefly, Vanderbilt was less welcoming. At theER, he was given morphine and Gatorade and turnedaway. “With TennCare, you can get the care youneed,” says his mother. “Without it, you’re out ofluck.”

But TennCare is in constant financial troubleand has had to put severe limits on taking in newpeople. Also, Dr. John Morris, chief of Vanderbilt’strauma center, reports that TennCare often cannotpay for proper rehabilitation for accident victims,

leaving them disabled.In 1996, to try to cover three million of the

nation’s 10 million uninsured children, Congresspassed the Child Health Insurance Program (CHIP).In many states, however, CHIP has been slowed byred tape and difficulty getting the word out. Insouthern California, where many Latinos are unin-sured, an anti-immigrant political climate deters

people from signing up.Those who use CHIP(known in California asHealthy Families) report ithas changed their children’slives.

Thirty-four-year-oldMaria Gumaer is a singlemother of two daughters,one of which, Denica, 14,has severe asthma. Mrs.Gumaer makes $26,000 ayear working in the accountsdepartment at a flooringdistributor. She can’t afford a

$400 monthly family insurance policy; so she paidDenica’s medical bills from paycheck to paycheck.She did not even know how seriously ill Denica wasbecause she could not afford sufficient medical tests.Insufficient medical attention meant Denica’s asthmaperiodically was severely out of control.

Under Healthy Families (CHIP), Maria’s low co-payments enabled her to afford the low cost of abattery of tests. The doctor was shocked by theseriousness of Denica’s asthma. He gave her strongtreatment and her condition improved dramatically. “Ithurt me so much to know that my poor child had tostruggle for six years not being able to breathecorrectly,” said Maria Gumaer. “But now I feel soblessed.”

In the 1990s, as America’s HMOs cut costs bycontrolling patients’ care, they were reviled as theenemy of doctors and patients. Now, after fighting to

regain control of the medical process, doctors areonce again assuming responsibility for treatmentdecisions and for controlling costs.

Dr. Solomon’s Dilemma – Cost vs. Care

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Sickle cell patient Joshua Mitchell. (Photo credit: Susan Zox)

For people like Dr. MartinSolomon, this presents a problem. Arespected Boston physician withmore than 20 years experience,Solomon is now wrestling with morethan just medical treatment for hispatients—he is also worried aboutfinances. Caring for some of hispatients has become a threat to hismedical practice and his ownpocketbook.

Solomon has learned that taking control meansfinancial risk. The more care doctors give, the more itcan cost them directly. So the sickest patients canbecome money losers for doctors like Solomon, whois a respected primary care physician

In DR. SOLOMON’S DILEMMA correspondentHedrick Smith goes behind the scenes for a candidexamination of this new frontier in managed care.The cameras follow Dr. Solomon and his colleaguesas they are forced to weigh cost vs. care, patient bypatient. That’s because these patients are in what’scalled a capitated plan with a lid—each doctor getsjust so much compensation per year per patient,regardless of the amount of treatment provided. As aresult, the physicians’ own salaries are at stake if apatient’s treatment exceeds the setlimit. This report looks at howthousands of doctors are part ofthis new trend in managed care.

In 1998, Dr. Solomon soldhis practice to a company calledCareGroup, a network of sevenhospitals, 3,000 doctors and400,000 patients. In 1999,CareGroup lost $100 million.

In an effort to change that,CareGroup’s doctors, workingunder these capitated plans, havebeen made responsible for containing treatmentcosts and turning their practices into profit centers.CareGroup and other national health care systemshave organized doctors into small mutual-reviewgroups known as “Pods.” Each Pod must balance itsown books.

We follow Dr. Solomon into one of his Pod

meetings where the doctors areshown cost charts itemizing howmuch each spends on everythingfrom X-rays to prescriptions tosurgery. The doctors see whichmembers of their Pod are spend-ing more on patient care; therebydecreasing the group’s profits.

DR. SOLOMON’S DILEMMAalso interviews corporate costcutters who argue that doctors

should have a more direct role in monitoring costs;hospital administrators who are fighting red ink everyyear; and patients who, in this new culture of medi-cine, are called “units.”

Several stories of patients are interwoventhroughout the report: an open-heart surgery patient,a Medicare HMO patient, a young diabetic mother, allof whom have become money losers for CareGroup,and even the doctors who care for them. So theirhospital stays are being shortened or they are beingtold that they must get their care from withinCareGroup’s network of doctors and facilities, eventhough some outside doctor may have more experi-ence in treating their specific condition or illness.

As Dr. Solomon confesses, this new costconsciousness not only affects adoctor’s decisions in treating hisown patients, it also ultimatelytears apart the trust betweendoctors and patients. He admitspoint blank that he is troubledthat cost cutting now affectsquality of care.

Solomon recounts anexchange with a longtimepatient diagnosed with agynecological malignancy.Solomon refused to authorize

her request to see a doctor outside CareGroup. “Thepatient said to me, ‘So, you’re not letting me do thisbecause of money?’” Solomon tells Hedrick Smith hisresponse was “Of course—if it were just medicalcare, I’d let you go wherever you want. But this is acontract. I’m not in the business of subsidizing yourcare.”

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Dr. Martin Solomon. (Photo credit: StevenMcCarthy)

Dr. Martin Solomon worries that the need tobalance cost with care will damage the doctor-patient relationship. (Photo credit: David Murdock)

CASE STUDIES

Most Americans assume that our trillion dollarhealth care system is the best in the world and thatpatients can assume they are receiving the highestquality of care. Medical studies and a few specificreports, however, reveal a serious shortfall betweenbest practice and what most people get from theirown doctors and hospitals.

In 1990 New York became thefirst state in the nation to rate actualmedical performance of hospitalsand doctors. Following a successfullawsuit by the newspaper Newsday,the state released risk-adjustedmortality rates after heart by-passsurgery for each New York hospitaland cardiac surgeon. For the firsttime, patients could see real data onthe performance of their surgeon andtheir hospital, and the numbers weredeeply disturbing. The chance ofsurviving heart surgery differed dramatically fromhospital to hospital, and doctor to doctor.

The debate rages to this day as to whetherthe public release of data is good for patients, or hasbackfired by intimidating physicians into avoiding

tough cases. The proponents of openness can pointto one very compelling argument: Between 1989 and1992 the death rate from heart surgery in New Yorkfell 41 percent.

Even so, some doctors dispute the value ofpublishing report cards. Dr. Josh Burack speaks for

many New York surgeons when hecomplains that the data isn’t goodenough to be trusted.

“Medicine doesn’t lend itself tomeasurement as easy as appliancesdo,” says Burack. “I mean it’s mucheasier to turn on a washing machinefor a thousand hours and see whichone breaks than it is to evaluate howgood a doctor is at treating pneumo-nia.”

For Luca Fresiello, one NewYorker who came through open-heart surgery well, the report cards

could very well have made the difference. Thehospital where he had his surgery, Winthrop Univer-sity Hospital on Long Island, has cut the death rateby 400 percent in the last decade.

Discussion Questions

1. Should patients have access to information about how their doctors and hospitals measure up?Would you be likely to expect this data if you had a health care crisis?

2. How can the public learn more about quality efforts in general?

3. Would you change your doctor if you found out he didn’t perform as well as his colleagues?

Open-heart Surgery – Tracking Doctors’ Batting Averages

Last year the Institute of Medicine shook thenation with the news that up to 98,000 Americans dieeach year as a result of medical mistakes. That’smore than AIDS, breast cancer, or even car acci-

The High Cost of Medical Errors

dents. Outright errors in medical care include: givingthe wrong medication to a patient; failing to follow upwith a patient about a problem lab test; cutting off thewrong limb or removing the wrong kidney. These

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A heart by-pass operation at WinthropUniversity Hospital in Mineola, NY.(Photo credit: Susan Zox)

types of errors grab newspaper headlines and drivedebate.

Health providers react defensively, and thethreat of malpractice lawsuits only reinforces theinstinct among doctors and hospitals to hide theirerrors from patients or survivingfamily members.

A few hospitals are trying anew approach of openness. InFebruary 1997, Korean War veteranClaudie Holbrook entered theLexington, Kentucky, VeteransAdministration Medical Center for thelast time. He died days later of ablood clot in his lung. AlthoughHolbrook was quite ill, he did nothave to die. His death was caused by a medicalerror, when the VA pharmacy began sending homethe wrong strength of blood thinning medication.

Instead of waiting for the Holbrook family to filea claim, as is the customary practice in medical errorcases, the VA took a proactive approach. After aninternal investigation, VA Hospital attorney GinnyHamm met with the Holbrook family. She told

Holbrook’s daughter, “We were theones that killed your dad.” Accordingto Hamm and Steve Kraman, thehospital’s chief of staff, once theevasion and hostility so typical ofhospitals facing errors disappears,patients are far less angry andpunitive.

A recent paper by Kraman andHamm published in The Annals ofInternal Medicine showed that the

Lexington VA, even with its policy of full disclosure,had the seventh lowest malpractice payouts of 36 VAhospitals east of the Mississippi River.

Discussion Questions

1. Is the Lexington, Kentucky, VA hospital’s approach to dealing with medical mistakes byacknowledging its errors the right way to go? Is it a model for other hospitals to follow?

2. How can Americans get information about who is making medical mistakes, and who is working to fixthem? Do you think the public should have access to this information?

3. What do you think accounts for the medical community’s reluctance to be candid about errors andproblems with quality of care? Is the high number of lawsuits in the U.S. today part of the problem?

Protecting Children with Special Health Needs

Born with cerebral palsy,Caitlyn Chipps needs specialists,intensive therapies, and customizedfoot braces to function indepen-dently. When Caitlyn’s dad, MarkChipps, enrolled his family in aHumana health plan through hisemployer, he was promised enroll-ment for his daughter in a specialprogram with extended benefits.

Caitlyn received appropriatetherapy through Humana for two

years before being cut off fromthese special benefits. Facing billsof about $18,000 per year, thefinancially-strapped Chipps had toreduce Caitlyn’s therapies. Herparents said this set Caitlyn back.“She was having a lot of problemsjust walking. She was constantlyholding on to things for balance,falling into walls, falling down,”said Mark Chipps. “We noticed herstarting to crawl a lot more.”

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Hedrick Smith with Lexington VAattorney Ginny Hamm. (Photo credit: SusanZox)

Mark Chipps’ attorney Ted Leopold (left)with Hedrick Smith. (Photo credit: Susan Zox)

Frustrated by repeated failures to get Humanato pay for his daughter’s treatment, Chipps filed suitagainst Humana. His action led to a startling discov-ery—the health plan’s reductions in coverage thathappened to Caitlyn had happened to 14 otherchildren.

The Chipps’ attorney, Ted Leopold, says that“Humana has very specific guidelines to keep thesechildren in the medical case management programs.

Discussion Questions

1. Discuss how chronically ill patients are affected by the fact that commercial insurers make a profitwhen members stay healthy but lose money when patients need a lot of care.

2. Mark Chipps asked about coverage for Caitlyn’s needs when he enrolled in Humana’s plan. Do mostparents understand or ask about complex coverage issues such as comprehensive therapy or durablemedical equipment?

3. How can parents of children with special health care needs ensure that a health plan will meet theneeds of their child?

Congestive heart failure costs more than $17billion annually, making it the most common diagno-sis for Medicare patients. Through a program calledDisease Management,Humana has found aninexpensive way to improvehealth and cut emergencyroom visits and hospitaliza-tions for heart patients likeFlorida’s Jeanne Lange.

Under this approach,a disease manager callsMrs. Lange regularly,keeping track of her sixmedications, providing life-saving guidance onnutrition and weightmanagement, and monitor-ing Mrs. Lange’s mood and energy level. The nurses

Saving Lives through Disease Management

at Disease Management encourage patients like Mrs.Lange to seek care before a crisis erupts.

This innovative program has reduced emer-gency room visits andcut hospital costs by 60percent. Humana’s Dr.Jerry Reeves says, “If wecan make these peoplewell, and they don’t needas much services, theyare happy and we arehappy.”

Normally one infive congestive heartfailure patients dieswithin a year of diagno-sis. With DiseaseManagement, Humana

has cut their mortality rate in half to one in ten.

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Jeanne Lange. (Photo credit: Dennis Dillon)

The guidelines, the policies and procedures were notfollowed. They weren’t even reviewed.” Mark Chipps’strongly held opinion was that “It’s money. It’s costover care.”

Although Humana denied it was reducingcoverage for children to spend money on otherprograms, a Palm Beach jury awarded Chipps andhis family a record $78 million verdict againstHumana. Humana is appealing.

Discussion Questions

1. How did Disease Management improve Mrs. Lange’s life? What is the essence of DiseaseManagement?

2. Why don’t more health plans offer innovative programs such as Disease Management?

3. Which kind of health plans work best for patients with chronic conditions such as congestive heartfailure? How does Medicare compare to other health plans?

4. How will America’s aging population affect coverage for chronic conditions?

The quality of treatment and rehabilitationpatients receive right after a stroke is critical. Thiscase study of two elderly stroke victims in Floridademonstrates how acute rehabilitation services candramatically shorten the road to recovery.

Stroke victim MarijaneSchacherer was immediatelysent to a well-respected acuterehabilitation facility. Thanks toextensive, high-qualitytherapy, she was home andliving independently just 12weeks after her devastatingstroke. She is optimistic abouther future, stating with a smile,“I’ve come a long way.”

Like Mrs. Schacherer,Anthony Oczkowski alsosuffered a stroke. But his road to recovery took avery different path. Mr. Oczkowski’s doctor recom-mended an acute rehabilitation facility. His HMO,

Humana, denied coverage for acute care and he wassent instead to a skilled nursing facility. The HMO’sposition? That a less expensive nursing home facilityoffered appropriate care for Mr. Oczkowski. His wife,Sarah, complained that his therapy was limited and

that he found the settingdepressing and poorly suitedto his needs. Unlike Mrs.Schacherer, he has pro-gressed slowly.

Dr. Andy Kramer of theUniversity of Colorado Centeron Aging has studied strokeand treatment outcomes. Hisfindings are that the inpatientrehabilitation centers offermore intense environment forrehabilitation. “As a result,”

Kramer asserts, “during that very crucial intervalwhere people are trying to recover from the acuteevent, they have a much better improvement rate.”

Discussion Questions

1. How well do stroke patients and their families understand the difference in care between an acuterehabilitation facility and a sub-acute nursing home facility?

2. What questions should stroke patients ask to ensure quality care? How can they advocate for better care?

3. How can consumers ensure that specialty care will be available to them when they need it? Whatquestions should they ask when considering a health plan?

4. How does coverage by an HMO differ from traditional Medicare coverage in treating strokes?

Stroke – Comparing Two Paths to Recovery

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Stroke victim Marijane Schacherer with her neurologistDr. Chris Marino. (Photo credit: David Brown)

Getting Special Care for Cancer

Patients like 37-year-old Valerie Kennedy, arunner and vegetarian, and Helen Boone, a 75-year-old grandmother quickly learned how importantaccess to specialty care is afterbeing diagnosed with breast cancer.

As a Humana employee inTampa, Ms. Kennedy was coveredby a comprehensive employee plan.Her research on available treatmentled her to Tampa’s H. Lee MoffittCancer Center and ResearchInstitute, Florida’s only NationalCancer Institute designated cancercenter. There, she underwent twolumpectomies and sophisticated lymphatic mappingof her stage two cancer before starting chemotherapyand radiation treatments. Virtually all her expenseswere covered by Humana’s special employee plan.

Because they lived on a fixed-income, Mrs.

Boone and her husband had decided against a costlyMedicare supplement and instead chose Humana’sless expensive Medicare HMO. Under this plan,

Humana denied Mrs. Boone accessto Moffitt and coverage for thelymphatic mapping Ms. Kennedyhad received.

In fact Humana’s HMOs,covering most of Humana’s patientsin the Tampa-St. Petersburg area,did not list the Moffitt CancerCenter among Humana’s availablenetwork of health providers.

Mrs. Boone’s family decidednot to appeal Humana’s denial, fearing that any delaymight result in the spread of her stage one cancer.Instead, they began a frantic search that ended whenthey found AV-MED, a non-profit Florida-based HMOwilling to pay for Helen Boone’s cancer care at Moffitt.

Discussion Questions

1. What are the most common coverage options people want when “shopping” for a health care plan?Do most people ask about specialty care for chronic illness when they are choosing an insuranceplan? Why or why not?

2. What kind of health care plans are best for people with chronic ailments? How does traditionalMedicare compare to care offered by an HMO? Should plans offer access to the best qualityproviders?

3. How will America’s aging population affect coverage for chronic conditions?

4. Where can families find dependable information about care for loved ones with chronic conditions?

Diabetes – Group Plans vs. Individual Plans

Diabetes is a chronic illness that consumes 10percent of all U.S. health care dollars and plagues 16million Americans. One of them is 12-year-old DillonMoore, diagnosed four years ago with Type Onediabetes. Dillon’s family joined the HMO KaiserPermanente after moving to the San Francisco area

from Ohio.At Kaiser, Dillon sees a set team of a physician,

nurse and nutritionist, for as long as an hour or twoevery three months. This careful attention to continu-ity of care was a welcome change from his clinic inOhio, where Dillon’s mother says “we would see a

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Breast cancer patient Valerie Kennedywith Hedrick Smith. (Photo credit: AaronBritton)

different resident every time we went in.”Forty-one year old diabetic Roberta Kuhlman, a

lifelong Kaiser member, shares the Moores’ enthusi-asm. Kuhlman enjoyed excellentcoverage through her employerthat paid for seven years oftreatment to help her becomepregnant. After her daughter wasborn, Kuhlman chose to care forher daughter full-time, leavingbehind her employer’s coverage tobecome a self-insured individualwith Kaiser.

Now, Kuhlman must pay fordrugs and pharmacy benefitsaveraging $5,000 a year. And, even though her

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Discussion Questions

1. The long-term complications of diabetes can be devastating. Is an insurer being short sighted to denyfull coverage of comprehensive treatment for individual members or responding responsibly tobusiness pressures and challenges beyond the insurer’s control?

2. What are possible solutions to the problems that self-insured individuals face? Does an insurer havea responsibility to offer similar benefits to all members, regardless of employment status?

physician recommended it, she has been deniedcoverage for the insulin pump that is paid for byDillon’s parents’ group health plan. Nonetheless,

Kuhlman chooses to remain withKaiser.

Kaiser CEO David Lawrencecalls Kuhlman’s dilemma “thefundamental problem right now inAmerican health insurancecoverage.” He says that with thecost of care rising and employersand the government fighting to payless of those expenses, it isbecoming impossible for Kaiser tocover the costs of individuals with

income from large group plans.

Maria Gumaer is one of the 44 million Ameri-cans who don’t have health insurance. A singlemother with two daughters, Maria works in theaccounts department of a flooring distributor butdoesn’t make enough money to pay for insurance.Already suffering from too little income and too manyexpenses, Maria struggled to pay medical costs forher 14-year old daughter, Denica, who has asthma.Insufficient medical care meant Denica’s asthmasometimes surged out of control.

Concerned about children like Denica, Con-gress passed the Child Health Insurance Program(CHIP), in an effort to insure at least three million of

the nation’s 10 million plus children without insur-ance.

When Maria learned about CHIP, she signed upher daughter for coverage. When Denica was finallyable to access quality care through CHIP, her doctorwas shocked at her condition and immediatelyprovided comprehensive treatment that dramaticallyimproved her health.

Her mother was pleased but felt guilty. “It hurtme so much to know that my poor child had tostruggle for six years not being able to breathcorrectly.”

Discussion Questions

1. Maria was able to access CHIP coverage for Denica. In many states, families who qualify for CHIP

The Uninsured – One Mother’s Story

Roberta Kuhlman (right) with her diabetesspecialist Dr. Anne Regenstein. (Photo credit:Susan Zox)

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coverage may find it difficult to access care. Discuss existing roadblocks to coverage that mayinclude red tape, language and literacy barriers, and complex eligibility requirements. How shouldthese be addressed?

2. Some eligible families complain that information about programs such as CHIP isn’t always easy toget. Discuss communication barriers and solutions that will help ensure target families get theinformation necessary to access care through CHIP.

3. Many providers will treat young patients covered by programs such as CHIP. Some providers,however, complain that reimbursement rates are too low and that paper work requirements are toocomplicated. Is this true in your state? If so, how can you work to ensure more providers will treatCHIP patients?

Like many seniors, 84 year-old LillianHumphrys suffered from several conditions: coloncancer, heart disease and mild dementia. When herdaughter, Beverly, signed her up for aMedicare HMO called Secure Hori-zons, neither woman understood howthe plan worked financially. Under theplan’s global capitation, Mrs.Humphrys’ doctors receive $5,000 ayear for her total—or global—care plusanother $5,000 for her hospitalizationcosts. Beyond this amount, they were responsible forall costs of her care. In and out of the hospital threetimes in six months, Mrs. Humphrys quickly ex-ceeded her cap, or payment total.

Her physician, Dr. Martin Solomon, wrestled

A Medicare HMO – Pros and Cons

with the dilemma of cost versus care. He kept tryingto avoid or minimize Mrs. Humphrys’ hospitaliza-tions, by trying to get her shifted to a rehabilitation

program or an assisted living center. Thebottom line? Dr. Solomon’s physician groupwinds up paying for additional care forseniors like Lillian Humphrys, literallywriting their health plan a check for theircare above the allocated reimbursements.As a result, these doctors fear that theymay soon have to give up covering the

entire group of seniors in this Medicare HMO.Trained to care for patients no matter what the

cost, doctors like Martin Solomon are now being toldthey have to watch the bottom line in ways that canaffect care negatively and shift costs to the physician.

Discussion Questions

1. Managed care reduces costs by tracking health expenditures. Every day in the hospital, every pill ortest, every shot is transformed into a dollar figure and used to encourage doctors to minimize costs to theinsurer. What do you think of this approach? Is it necessary to control spiraling health care costs?

2. Do you think Dr. Solomon’s practice has a moral obligation to continue treating patients such as Mrs.Humphrys when costs for her care far outweigh her insurance reimbursement? Why or why not?

3. How will America’s aging population affect the health care system? How can seniors ensure thatlife-saving care will be there when they need it most?

4. How can older Americans get the information necessary to choose the best health plans for theirneeds? Why did Mrs. Humphrys and her daughter choose a plan that was ultimately not well-suitedto her needs?

Lillian Humphrys. (Photo credit:Brian Dowley)

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ADVOCACY SECTION

Choosing a health plan is simple if youremployer offers just one option. Or, you may have tochoose from many options. Because people aredifferent, there is no single, best choice for everyone.

Ten Questions to Consider Before Choosing a Health PlanBy Marc Shaffer

Your health, personal tastes and priorities, and yourability to pay, all affect your selection. Here are somebasic questions you should ask when choosing aplan and points to consider.

1. How important is access to special care?• If you are diabetic, have cancer or asthma, will your preferred medications and

medical supplies be covered?

• Are pre-existing conditions covered? How about experimental treatments?

• Is there a lifetime cap for expenditures for all your treatments?

• Are you guaranteed access to the best doctors and hospitals or does the health plan have alimited choice of providers?

• How are mental health services covered?

• How about things such as eye care or dentistry?

2. How important is the quality of a particular plan?

Quality is the fact most cited by Americans when choosing a health plan. Ask about thefollowing three components:

• Patient Service (convenience, access)

• Care Inputs (preventive measures such as annual physicals and mammograms)

• Patient Outcomes (medical performance measures such as number of patients who survivecertain surgeries)

3. How important are convenience and service?

• Are doctors and hospitals conveniently located?

• Can you get appointments quickly?

• Can you get through on the telephone?

• Are providers open after-hours or on weekends?

4. How accessible is care?

• Must the HMO pre-approve your request to see a specialist? Must your primary care providermake these referrals?

• Is your primary care provider’s income increased or decreased by the amount of care he orshe provides to you? By the number of specialists you see or the number of testsyou have?

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5. How important is choice of provider?

• If you have a personal physician you want to continue seeing, does the plan provide access tohim or her?

• Do you feel strongly that you must have a very wide selection of physicians to choose from?

• Are well-respected providers available to you?

• Do you understand the difference between “choice” and “quality”? Remember, some healthplans that get the highest quality ratings are those that limit your choice of providers to theirpre-screened, pre-selected panels of physicians and facilities.

6. How important is short-term and long-term cost?

• Does a low premium plan limit or deny you some of the most important coverage you willneed if you become seriously ill or injured?

• How can you balance a low monthly premium with high-deductible, high co-pay costs?

7. How reliable is the health plan?

• Has the plan been around for a long time?

• Does it rate high marks from doctors? Patients?

• Is there a large turnover among the plan’s membership, especially patients who need costly,long-term care?

8. How good is the appeals process in a plan?

• If there is a dispute over coverage or access, are there good avenues of recourse?

• Is there a clear time limit within which the health plan must respond to appeals?

• Does your state provide public oversight and review of health plan performance?

• Is there a consumer hotline or service to which you can make appeals if you have a disputewith your health plan or medical provider?

9. What are the emergency care provisions of the plan?

• Does the health plan permit you to be taken to any emergency room in any hospital or clinic inyour area?

• Is the hospital nearest you or the one you prefer on the approved list of facilities for the plan?

• Does the plan require prior approval before the emergency room provides you with specificemergency services? Before emergency room doctors admit you to the hospital?

10. How do you get care when you are traveling?

• Does the health plan cover your treatment in distant locations? If so, does it limit the care thatyou receive?

• Does the health plan require you to obtain pre-approval before getting care when you aretraveling outside of your home area?

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Ten Questions to Ask Your Doctor about Financial RiskBy David Murdock

It is very difficult to raise financial questionswith our doctors. Such questions have often beenconsidered rude and challenging. But all of thedoctors we spoke with in researching CRITICALCONDITION and DR. SOLOMON’S DILEMMA

stressed the importance of patients understandingthe financial incentives at work in their care. Here aresome basic questions you might raise with yourphysician.

1. Are you “at risk” financially for my care?

2. Do you get paid a bonus based on performance measures?

3. Are you penalized financially if your costs are too high?

4. Does your practice follow a drug formulary? (A drug formulary is a chart developed by a` practice or a health plan that encourages physicians to prescribe less expensive drugs.)

5. Is your practice owned by a larger conglomerate?

6. What specialists are you able to refer me to? (Often the answer will involve certain medicalcenters or clinics with which the physician has a contractual relationship.)

7. Are you restricted in any way from referring me to someone I want to go visit? (If yourphysician is and your specialist is important to you, you may want to consider choosing aprimary care physician who is not restricted from referring you to your specialist of choice.)

8. Does the cost of the care you give affect your colleagues’ income?

9. What emergency rooms can I go to without question?

10. Which rehabilitation/skilled nursing/hospice centers do you refer patients to?

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RESOURCES

General Consumer Public Policy and Patient Advocacy Groups

AARP601 E Street NWWashington, DC 200491-800-424-3410www.aarp.orgprovides information, education, advocacy and commu-nity services for people age 50 and over

Alpha Center1801 K Street NWSuite 701-LWashington, DC 200061-202-292-6700Fax 1-202-292-6800www.ac.orgnon-profit health policy center which helps public andprivate clients respond to health care challenges byproviding objective information and insightful analysis

American Medical Rehabilitation Providers Association1606 20th Street NW, Suite 300Washington, DC 200091-888-346-4624Fax 1-202-833-9168www.amrpa.orgadvocates for what people with disabilities need in theirmedical rehabilitation recovery

Asian and Pacific Islander American Health Forum942 Market Street, Suite 200San Francisco, CA 941021-415-954-9988Fax 1-415-954-9999www.apiahf.orgpromotes improvement of the health status of Asian andPacific Islanders in the U.S.; offers extensive health links

Center for Health Care Rights520 S. Lafayette Park Place, Suite 214Los Angeles, CA 900571-213-383-4519Fax 1-213-383-4598www.healthcarerights.orga consumer advocacy organization which conductsresearch and analysis to increase consumer health careprotections

Center for Health Care Strategies, Inc.353 Nassau StreetPrinceton, NJ 085401-609-279-0700Fax 1-609-279-0956www.chcs.orgnon-profit, non-partisan policy resource center whichpromotes the development and implementation ofeffective health and social policy for all Americans

Center on Budget and Policy Priorities820 First Street NE, Suite 510Washington, DC 200021-202-408-1080Fax 1-202-408-1056www.cbpp.orgnon-partisan research organization and policy institutethat conducts research and analysis on a range ofgovernment policies and programs, especially thoseaffecting low and moderate income people

The Center for Patient Advocacy1350 Beverly Road, Suite 108McLean, VA 221011-800-846-7444www.patientadvocacy.orgnon-profit grassroots organization which represents theinterests of patients nationwide

FACCT (The Foundation for Accountability)520 SW Sixth Avenue, Suite 700Portland, OR 972041-503-223-2228Fax 1-503-223-4336www.facct.orgnon-profit organization dedicated to helping Americansmake better health care decisions

Families USA1334 G Street NWWashington, DC 200051-202-628-3030www.familiesusa.orgnon-profit organization dedicated to achievement of highquality, affordable health and long term care for allAmericans

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Health Care Financing Administration InformationClearinghouse1-800-MEDICARE (633-4227)www.hcfa.govprovides information on Medicare, Medicaid, and ChildHealth insurance programs

Medicare Rights Center1460 Broadway, 11th FloorNew York, NY 100361-212-869-3850Fax 1-212-869-3532www.medicarerights.orgnon-profit organization devoted to insuring that seniorsand people with disabilities on Medicare have acess toquality, affordable health care

National Aging Information CenterU.S. Administration on Aging330 Independence Ave. SWWashington, DC 202011-202-619-07241-800-677-1116www.aoa.dhhs.govan elder care locator

National Association of Children’s Hospitals andRelated Institutions401 Wythe StreetAlexandria, VA 223141-703-684-1355Fax 1-703-684-1589www.childrenshospitals.net/nachri/not-for-profit organization of over 100 children’shospitals, pediatric centers and other related healthsystems working to ensure children’s access to healthcare and the continuing ability of children’s hospitals toprovide services needed by children

National Health Council1730 M Street NW, Suite 500Washington, DC 20036-45051-202-785-3910Fax 1-202-785-5923www.nhcouncil.orgreferrals to voluntary health agencies, patient rights andresponsibilities

National Coalition on Health Care1200 G Street NW, Suite 750Washington, DC 200051-202-638-7151Fax 1-202-638-7166www.nchc.orgnon-partisan coalition of businesses, labor unions,consumer and religious groups, and primary careproviders committed to improving health care by helpingthe public, opinion leaders and policymakers understandthe possibilities for improving our health care system

NHeLP (National Health Law Program)2639 S. La Cienega BoulevardLos Angeles, CA 900341-310-204-6010Fax 1-310-204-0891www.nhelp@healthlaw.orgnational public interest law firm seeking to improvehealth care for America’s working and unemployed poor,minorities, the elderly and people with disabilities byserving legal services programs, community-basedorganizations, the private bar, providers and groups whowork to preserve a health care safety net for theuninsured and underinsured low-income population

National Latina Health OrganizationPO Box 7567Oakland, CA 946011-510-534-1362http://clnet.ucr.edu/women/nlhoraises consciousness about Latina women’s health andhealth problems

Society for Health Care Consumer Advocacy of theAmerican Hospital Association1 N. Franklin, 31st FloorChicago, Il 606061-312-422-3774www.shca-aha.orgworks with those health care professionals who ensurethat patients and consumers receive the high-qualityhealth care they deserve

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Disease Organizations

Centers for Disease Control and PreventionNational AIDS Hotline1-800-342-AIDSwww.cdc.gov/hivconfidential, clear information and education; referrals;written free materials relating to HIV/AIDS, CDC alsooffers extensive information on other health issues

Juvenile Diabetes Foundation International120 Wall Street, 19th FloorNew York, NY 100051-212-785-9500www.jdf.orgnon-profit, non-governmental funder of diabetesresearch; mission is to find a cure for diabetes and itscomplications through the support of research

National Association of People with AIDS1413 K Street NW, 7th FloorWashington, DC 200051-202-898-0414Fax 1-202-898-0435www.napwa.orgpatient support and information

National Cancer Institute (CancerNet)NCI Public Inquiries OfficeBldg. 31 Room 10A0331 Center Drive MSC 2580Bethesda, MD 208921-800-422-6237http://cancernet.nci.nih.govcredible, current and comprehensive cancer informationfrom National Cancer Institute

National Stroke Association9797 E. Easter LaneEnglewood, CO 801121-800-787-6537www.stroke.orgpatient information on prevention, treatment, rehabilita-tion, survivor/caregiver resources

Sickle Cell Disease Association of America200 Corporate Pointe, Suite 495Culver City, CA 902301-310-216-6363www.sicklecelldisease.orgpatient information and support; education and advo-cacy through network of affiliated members

Alzheimer’s Association919 N. Michigan Avenue, Suite 1100Chicago, IL 60611-16761-800-272-3900www.alz.orgAlzheimer’s disease information and support

American Cancer Society: Colorectal and BreastCancer Information1-800-ACS-2345www3.cancer.org/cancerinfodisease information—causes, risk factors, prevention,new diagnostic techniques and treatment

American Cancer Society Online Resource Centerwww2.cancer.org/medical_resources/index.cfm

American Diabetes Association1701 N. Beauregard StreetAlexandria, VA 223111-800-342-2383www.diabetes.orginformation about diabetes, who’s at risk, complicationsor warning signs of diabetes

American Heart Association National Center7272 Greenville AvenueDallas, TX 75231-45961-800-AHA-USA1www.americanheart.orginformation about heart/stroke: disease, prevention,treatment, recovery

American Lung Association1740 BroadwayNew York, NY 100191-212-315-87001-800-LUNG-USAwww.lungusa.orginformation about programs and strategies for fightingall types of lung diseases

American Medical Association515 N. State StreetChicago, IL 606101-312-464-5000Fax 1-312-464-4184www.ama-assn.orginformation about health and fitness, journals/publica-tions, Doctor Finder

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Quality and Oversight Organizations

Agency for Healthcare Research and QualityExecutive Office Center, Suite 5012101 E. Jefferson StreetRockville, MD 208521-301-594-1364www.ahcpr.govprovides evidence-based information on health careoutcomes; quality and cost; use and access enablingpeople to make informed health care decisions

Consumer’s Union101 Truman AvenueYonkers, NY 10703-10571-914-378-2000www.consumersunion.orginformation and educational materials developed byConsumer’s Union, publisher of Consumer Reportsmagazine

HealthGrades.comwww.healthgrades.comInternet service which grades performance of U.S.health care providers, including hospitals, physicians,health plans

National Committee for Quality Assurance2000 L Street NW, Suite 500Washington, DC 200361-202-955-3500www.ncqa.orgnon-profit group dedicated to assessing and reportingthe quality of the nation’s managed health care plans

Other

Alliance for Health Reform1900 L Street NW, Suite 512Washington, DC 200361-202-466-5626Fax 1-202-466-6525www.allhealth.org/home.htmaims to be an unbiased source of information formembers of public and opinion leaders so they canunderstand the roots of the nation’s health careproblems

National Governors’ Association Center for BestPractices444 North Capitol Street NW, Suite 267Washington, DC 200011-202-624-5300Fax 1-202-624-5313www.nga.org/centerassists governors and key staff in developing the bestpolicies and programs for their states; health care is akey issue being explored by this group

The Commonwealth FundOne E. 75th StreetNew York, NY 10021-26921-212-606-3800Fax 1-212-606-3500www.commonwealthfund.orga philanthropic foundation which, through nationalprograms, seeks to improve health care services, betterthe health of minority Americans, advance the well-being of elderly people and develop the capacities ofchildren and young people

LCHC (The Latino Coalition for a Healthy California)1535 Mission StreetSan Francisco, CA 941031-415-431-7430Fax 1-415-431-1048www.lchc.orga coalition which seeks to develop, propose and supportpolicies in the public and private sectors of Californiathat support and advance wellness, health promotionand healthy behaviors within the Latino community

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American Diabetes AssociationNational Office1701 N. Beauregard StreetAlexandria, VA 223111-800-342-2383www.diabetes.org

American Medical Rehabilitation ProvidersAssociation1606 20th Street NWSuite 300Washington, DC 200091-888-346-4624www.amrpa.org

The Center for Patient Advocacy1350 Beverly RoadSuite 108McLean, VA 221011-800-846-7444www.patientadvocacy.org

Families USA1334 G Street NWWashington, DC 200051-202-628-3030www.familiesusa.org

South Carolina ETV thanks the following organizations for their invaluable assistance in alerting theiraudiences and the general public to CRITICAL CONDITION with Hedrick Smith. Use these organizations asa resource in your exploration of the complicated world of health care.

Outreach Partners

H. Lee Moffitt Cancer Center &Research Institute12902 Magnolia DriveTampa, FL 336121-813-972-4673www.moffitt.usf.edu

Medicare Rights Center1460 Broadway, 11th floorNew York, NY 100361-212-869-3850www.medicarerights.org

National Association of Children’s Hospitals andRelated Institutions401 Wythe StreetAlexandria, VA 223141-703-684-1355www.childrenshospitals.net/nachri/

Society for Healthcare Consumer Advocacy1 N. Franklin, 31st FloorChicago, IL 606061-312-422-3774www.shca-aha.org

Rights, Credits and Questions

Segment Producers—Ginny Durrinand Mort Silverstein

Field Producers—Tom Jennings,Catherine Sager andAnne Rosenbaum

Principal Camera—Keith Walker,David Brown and Bill McMillin

Principal Sound—Alan Chow andBill Ruth

Writers—Hedrick Smith,Ariadne Allan, David Murdockand Marc Shaffer

Associate Producers—Leora Broydo, Teresa Gionis,Maria Raquel-Bozzi andJeanette Woods

Senior Researcher for Guide andWeb—Tamara Neely

Production Associate—Joy Ardizzone

Production Assistants—Erin Essenmacher,Susan Kerin and Saidah Said

Assistant to Executive Producer—Janina Roncevic

Photo Coordinator—Susan Zox

Original Music—Eric Kaye

Graphic Opening—Jannis Productions

South Carolina ETV

SCETV Executive in Charge—Polly Kosko

Outreach Director—Pat Dressler

Assistant Director—Michele Reap

Consultant—Betsy Wolff, MPH

Design—Big M Design Group

Educational RightsInformation

Groups have the right to usethe CRITICAL CONDITION withHedrick Smith Viewer/DiscussionLeader Guide in perpetuity and toduplicate copies of the guide.

The segments on the VHScassette are only for educationaluse by groups and their memberswho received it directly from PBSstations. None of the videosegments may be used forbroadcast, reproduction ordissemination except withadvance written permission of—

Hedrick Smith Productions, Inc.4905 Del Ray AvenueSuite #400Bethesda, MD 20814301-654-9848Fax 301-654-9856e-mail: hsmithprod@aol.com

If you record the complete 3-hour PBS program or the FRONT-LINE program, DR. SOLOMON’SDILEMMA, when they are broad-cast for use with this guide,remember both carry the standardPBS one-year off-air record rightsand may not be duplicated forother groups.

How to Purchase

CRITICAL CONDITION withHedrick Smith and FRONTLINE’sDR. SOLOMON’S DILEMMA areavailable for purchase. Schools,public institutions and organizedgroups or their members who

would like to purchase a videocopy of CRITICAL CONDITION,please call toll-free 1-800-257-5126 or write Films for theHumanities & Sciences, PO Box2053, Princeton, NJ 08543-2053or visit their Web site atwww.films.com. Educationalvideotapes of DOCTORSOLOMON’S DILEMMA areavailable for purchase by schools,libraries and other educationalinstitutions through PBS Video,PO Box 791, Alexandria, VA22313-0791 or call toll-free 1-800-328-7271.

Questions or Comments

Please refer any questionsor comments about these educa-tional materials to:

Michele ReapSouth Carolina ETV OutreachPO Box 11000Columbia, SC 29211

CRITICAL CONDITION withHedrick Smith ProductionCredits

Executive Producer &Correspondent—Hedrick Smith

Producers—Ariadne Allan,David Murdock and Marc Shaffer

Editors—Bill Creed, Cliff Hackel,Carol Slatkin and Wendy Wank

Coordinating Producer &Production Manager—Sandra L. Udy

CRITICAL CONDITION with Hedrick Smithwas produced by Hedrick Smith Productions

in association with South Carolina ETV.

Principal funding was provided by

The Robert Wood Johnson FoundationMaking grants to improve the health and health care of all Americans

Major funding provided by the

California HealthCare Foundation

Additional funding provided by the

Rockefeller Brothers Fundand the

Charles E. Culpeper Foundation

SouthCarolinaSouthCarolina

Television That Teaches and InspiresTelevision That Teaches and Inspires

ETV