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The average doctor in the U.S. makes $350,000 a year. Why? - The Washington Post - 0 views

www.washingtonpost.com/...doctor-pay-shortage doctor pay international comparison economics
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  • The average U.S. physician earns $350,000 a year. Top doctors pull in 10 times that.
  • The figures are nigh-on unimpeachable. They come from a working paper, newly updated, that analyzes more than 10 million tax records from 965,000 physicians over 13 years. The talented economist-authors also went to extreme lengths to protect filers’ privacy, as is standard for this type of research.
  • By accounting for all streams of income, they revealed that doctors make more than anyone thought — and more than any other occupation we’ve measured. In the prime earning years of 40 to 55, the average physician made $405,000 in 2017 — almost all of it (94 percent) from wages
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  • Doctors in the top 10 percent averaged $1.3 million
  • And those in the top 1 percent averaged an astounding $4 million, though most of that (85 percent) came from business income or capital gains.
  • In certain specialties, doctors see substantially more in their peak earning years: Neurosurgeons (about $920,000), orthopedic surgeons ($789,000) and radiation oncologists ($709,000) all did especially well for themselves. Specialty incomes cover 2005 to 2017 and are expressed in 2017 dollars.
  • family-practice physicians made around $230,000 a year. General practice ($225,000) and preventive-medicine ($224,000) doctors earned even less — though that’s still enough to put them at the top of the heap among all U.S. earners.
  • “There is this sense of, well, if you show that physician incomes put them at the top of the income distribution, then you’re somehow implying that they’re instead going into medicine because they want to make money. And that narrative is uncomfortable to people.”
  • why did those figures ruffle so many physician feathers?
  • “You can want to help people and you can simultaneously want to earn money and have a nicer lifestyle and demand compensation for long hours and long training. That’s totally normal behavior in the labor market.”
  • Yale University economist Jason Abaluck notes that when he asks the doctors and future doctors in his health economics classes why they earn so much, answers revolve around the brutal training required to enter the profession. “Until they finish their residency, they’re working an enormous number of hours and their lifestyle is not the lifestyle of a rich person,” Abaluck told us.
  • why do physicians make that much?
  • On average, doctors — much like anyone else — behave in ways that just happen to drive up their income. For example, the economists found that graduates from the top medical schools, who can presumably write their own ticket to any field they want, tend to choose those that pay the most.
  • “Our analysis shows that certainly physicians respond to earnings when choosing specialties,” Polyakova told us. “And there’s nothing wrong with that, in my opinion.
  • “In general, U.S. physicians are making about 50 percent more than German physicians and about more than twice as much as U.K. physicians,
  • Grover said the widest gaps were “really driven by surgeons and a handful of procedural specialties,” doctors who perform procedures with clear outcomes, rather than preventing disease or treating chronic condition
  • “we’re not about prevention, you know?” he said, noting that his own PhD is in public health. “I wish it was different, but it ain’t!”
  • The United States has fewer doctors per person than 27 out of 31 member countries tracked by the Organization for Economic Cooperation and Development
  • In 1970, based on a slightly different measure that’s been tracked for longer, America had more licensed physicians per person than all but two of the 10 countries for which we have data. What caused the collapse?
  • the United States has far fewer residency slots than qualified med school graduates, which means thousands of qualified future physicians are annually shut out of the residency pipeline, denied their chosen career and stuck with no way to pay back those quarter-million-dollar loans.
  • “I’d like to see an in-depth analysis of the effect of the government capping the number of residency spots and how it’s created an artificial ‘physician shortage’ even though we have thousands of talented and graduated doctors that can’t practice due to not enough residency spots,”
  • Such an analysis would begin with a deeply influential 1980 report,
  • That report, by a federal advisory committee tasked with ensuring the nation had neither too few nor too many doctors, concluded that America was barreling toward a massive physician surplus. It came out just before President Ronald Reagan took office, and the new administration seemed only too eager to cut back on federal spending on doctor-training systems.
  • ssociation of American Medical Colleges (AAMC), a coalition of MD-granting medical schools and affiliated teaching hospitals, slammed the brakes on a long expansion. From 1980 to around 2004, the number of medical grads flatlined, even as the American population rose 29 percent.
  • Federal support for residencies was also ratcheted down, making it expensive or impossible for hospitals to provide enough slots for all the medical school graduates hitting the market each year. That effort peaked with the 1997 Balanced Budget Act which, among other things, froze funding for residencies — partially under the flawed assumption that HMOs would forever reduce the need for medical care in America, Orr writes. That freeze has yet to fully unwind.
  • or decades, many policymakers believed more doctors caused higher medical spending. Orr says that’s partly true, but “the early studies failed to differentiate between increased availability of valuable medical services and unnecessary treatment and services.”
  • “In reality, the greater utilization in places with more doctors represented greater availability, both in terms of expanded access to primary care and an ever-growing array of new and more advanced medical services,” he writes. “The impact of physician supply on levels of excessive treatment appears to be either small or nonexistent.”
  • “People have a narrative that physician earnings is one of the main drivers of high health-care costs in the U.S.,” Polyakova told us. “It is kind of hard to support this narrative if ultimately physicians earn less than 10 percent of national health-care expenditures.”
  • Polyakova and her collaborators find doctor pay consumes only 8.6 percent of overall health spending. It grew a bit faster than inflation over the time period studied, but much slower than overall health-care costs.
  • Regardless, the dramatic limits on medical school enrollment and residencies enjoyed strong support from the AAMC and the AMA. We were surprised to hear both organizations now sound the alarm about a doctor shortage. MD-granting medical schools started expanding again in 2005.
  • it’s because states have responded to the shortage by empowering nurse practitioners and physician assistants to perform tasks that once were the sole province of physicians. Over the past 20 years, the number of registered nurses grew almost twice as quickly as the number of doctors, and the number of physician assistants grew almost three times as rapidly, our analysis showed.
  • While there still aren’t enough residency positions, we’re getting more thanks in part to recent federal spending bills that will fund 1,200 more slots over the next few years.
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When Hospitals Buy Doctors' Offices, and Patient Fees Soar - NYTimes.com - 0 views

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  • Medicare, the government health insurance program for those 65 and over or the disabled, pays one price to independent doctors and another to doctors who work for large health systems — even if they are performing the exact same service in the exact same place.
  • This week, the Obama administration recommended a change to eliminate much of that gap. Despite expected protests from hospitals and doctors, the idea has a chance of being adopted because it would yield huge savings for Medicare and patients.
  • The heart doctors are a great example. In 2009, the federal government cut back on what it paid to cardiologists in private practice who offered certain tests to their patients. Medicare determined that the tests, which made up about 30 percent of a typical cardiologist’s revenue, cost more than was justified, and there was evidence that some doctors were overusing them. Suddenly, Medicare paid about a third less than it had before.But the government didn’t cut what it paid cardiologists who worked for a hospital and provided the same test. It actually paid those doctors more, because the payment systems were completely separate. In general, Medicare assumes that hospital care is by definition more expensive to provide than office-based care.
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  • Cardiologists are not the only doctors who have been migrating toward hospital practice. In the last few years, there have been increases in the number of doctors working for hospitals across the specialties. And spreads between fees for office services exist in an array of medical services, down to the basic office visit. The president's proposal would apply to all doctors working in off-campus, hospital-owned practices.
  • Like Medicare, most private insurers pay higher prices to hospitals than to independent doctors.Private insurers tend to copy many of Medicare’s payment policies. And, in general, large hospital groups tend to have more negotiating clout with insurers, meaning they can bargain for higher prices than smaller practices.
  • Hospitals don’t like the idea. Nearly all the money would come out of their pockets, and they argue that running a medical practice really does cost more for hospitals than it does for independent physician practices. Hospitals have to stay open at all hours, run emergency rooms and comply with an array of regulatory requirements that physician-owned practices don't need to worry about.
  • The Medicare Payment Advisory Committee, a group of experts that advises Congress, thinks that the pay differences should be narrowed, but only for a select set of medical services in which it’s really clear that there’s no difference between the care offered by a hospital and a physician office.
  • The pay differences, of course, are not the only reason that more doctors are going to work for hospitals. There are generational trends: Younger doctors are less interested in entrepreneurship and more interested in predictable hours and salary. And another Medicare program is trying to create financial incentives for health systems to manage patients’ entire health care experience, which many hospitals find easier to do if they employ the doctors.
  • in contrast to a lot of things in the president’s budget, it’s hard to dismiss this proposal as mere wishful thinking. Congress is often looking for places to save money in the Medicare budget, in part because it must find money every year to keep all doctors’ pay from declining precipitously — the result of a misguided payment formula passed in the 1990s.
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What American Healthcare Can Learn From Germany - Olga Khazan - The Atlantic - 0 views

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  • Every German resident must belong to a sickness fund, and in turn the funds must insure all comers. They’re also mandated to cover a standard set of benefits, which includes most procedures and medications. Workers pay half the cost of their sickness fund insurance, and employers pay the rest. The German government foots the bill for the unemployed and for children. There are also limits on out-of-pocket expenses, so it’s rare for a German to go into debt because of medical bills.
  • this is very similar to the health-insurance regime that Americans are now living under, now that the Affordable Care Act is four years old and a few days past its first enrollment deadline.
  • There are, of course, a few key differences. Co-pays in the German system are minuscule, about 10 euros per visit. Even those for hospital stays are laughably small by American standards: Sam payed 40 euro for a three-day stay for a minor operation a few years ago
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  • nearly five million Americans fall into what’s called the “Medicaid gap”
  • In Germany, employees' premiums are a percentage of their incomes, so low-wage workers simply pay rock-bottom insurance rates.
  • You can think of this setup as the Goldilocks option among all of the possible ways governments can insure health. It's not as radical as single-payer models like the U.K.’s, where the government covers everyone. And it's also not as brutal as the less-regulated version of the insurance market we had before the ACA.
  • Germany actually pioneered this type of insurance—it all started when Otto von Bismarck signed his Health Insurance Bill of 1883 into law. (It’s still known as the “Bismarck model” because of his legacy, and other parts of Europe and Asia have adopted it over the years.)
  • Since there are no provider networks in Germany, doctors don’t know what other providers patients have seen, so there are few ways to limit repeat procedures.
  • All things considered, it’s good to be a sick German. There are no network limitations, so people can see any doctor they want. There are no deductibles, so Germans have no fear of spending hundreds before their insurance ever kicks in.
  • There’s also no money that changes hands during a medical appointment. Patients show their insurance card at the doctor’s office, and the doctors' association pays the doctor using money from the sickness funds. "You don’t have to sit at home and sort through invoices or wonder if you overlooked fine print,”
  • That insurance card, by the way, is good for hospital visits anywhere in Europe.
  • of all of the countries studied, Germans were the most likely to be able to get a same-day or next-day appointment and to hear back from a doctor quickly if they had a question. They rarely use emergency rooms, and they can access doctors after-hours with ease.
  • And Germany manages to put its health-care dollars to relatively good use: For each $100 it spends on healthcare, it extends life by about four months, according to a recent analysis in the American Journal of Public Health. In the U.S., one of the worst-performing nations in the ranking, each $100 spent on healthcare resulted in only a couple of extra weeks of longevity.
  • those differences aside, it’s fair to say the U.S. is moving in the direction of systems like Germany’s—multi-payer, compulsory, employer-based, highly regulated, and fee-for-service.
  • The German government is similarly trying to push more people into “family physician” programs, in which just one doctor would serve as a gatekeeper.
  • like the U.S., Germany may see a shortage of primary-care doctors in the near future, both because primary-care doctors there don’t get paid as much as specialists, and because entrenched norms have prevented physician assistants from shouldering more responsibility
  • With limitations on how much they can charge, German doctors and hospitals instead try to pump up their earnings by performing as many procedures as possible, just like American providers do.
  • With few resource constraints, healthcare systems like America's and Germany's tend to go with the most expensive treatment option possible. An American might find himself in an MRI machine for a headache that a British doctor would have treated with an aspirin and a smile.
  • Similarly, “In Germany, it will always be an operation,” Göpffarth said. “Meanwhile, France and the U.K. tend to try drugs first and operations later.”
  • Perhaps the biggest difference between our two approaches is the extent to which Germany has managed to rein in the cost of healthcare for consumers. Prices for procedures there are lower and more uniform because doctors’ associations negotiate their fees directly with all of the sickness funds in each state. That's part of the reason why an appendectomy costs $3,093 in Germany, but $13,000 in the U.S.
  • “In Germany, there is a uniform fee schedule for all physicians that work under the social code,” Schlette said. “There’s a huge catalogue where they determine meticulously how much is billed for each procedure. That’s like the Bible.”
  • certain U.S. states have tried a more German strategy, attempting to keep costs low by setting prices across the board. Maryland, for example, has been regulating how much all of the state’s hospitals can charge since 1977. A 2009 study published in Health Affairs found that we would have saved $2 trillion if the entire country’s health costs had grown at the same rate as Maryland’s over the past three decades.
  • Now, Maryland is going a step further still, having just launched a plan to cap the amount each hospital can spend, total, each year. The state's hospital spending growth will be limited to 3.58 percent for the next five years. “We know that right now, the more [doctors] do, the more they get paid,” John Colmers, executive director of Maryland’s Health Services Cost Review Commission, told me. “We want to say, ‘The better you do, the better you get paid.’”
  • “The red states are unlikely to follow their lead. The notion that government may be a big part of the solution, instead of the problem, is anathema, and Republican controlled legislatures, and their governors, would find it too substantial a conflict to pursue with any vigor.”
  • no other state has Maryland’s uniform, German-style payment system in place, “so Maryland starts the race nine paces ahead of the other 46 states,” McDonough said.
  • the unique spirit of each country is what ultimately gets in its way. Germany’s more orderly system can be too rigid for experimentation. And America’s free-for-all, where hospitals and doctors all charge different amounts, is great for innovation but too chaotic to make payment reforms stick.
  • rising health costs will continue to be the main problem for Americans as we launch into our more Bismarckian system. “The main challenge you’ll have is price control,” he said. “You have subsidies in health exchanges now, so for the first time, the federal budget is really involved in health expenditure increases in the commercial market. In order to keep your federal budget under control, you’ll have to control prices.”
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Female Physicians Spend More Time With Patients Than Male Doctors Do, But Earn Less : S... - 0 views

www.npr.org/...s-but-earn-less-money-than-men politics pandemic economics US healthcare
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  • Allen recently read a study published in The New England Journal of Medicine that found female primary care physicians spend more time with their patients than male doctors — an average of 2.4 minutes per visit, to be specific. But female physicians still make less money
  • "The pay gap in medicine by gender is very well documented," Neprash says. "It's been written about for decades, but the understanding of what exactly drives that is pretty sparse."
  • The study's authors analyzed data from over 24 million primary care visits in 2017, digging deep into information from Athenahealth, an electronic medical records company that's widely used in primary care practices.
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  • Using "timestamps" that track when patients check in and out, Neprash and her team analyzed exactly how long primary care doctors spent with their patients. They compared male and female physicians not just throughout the country, but within the same practices, which helped control for regional variations in the number of patients doctors are expected to see in a day.
  • Female primary care physicians spent about 15% more time with patients in each visit compared to male primary care physicians. As a result, they saw fewer patients over the course of a year.
  • In the U.S. healthcare system where most insurance companies pay doctors based on the number of patients they see — not how much time they spend with them — this means that women physicians generated about 11% less annual revenue for their practices than their male colleagues.
  • This could account for why female physicians are paid less than men, Neprash argues: They actually spend more time with patients.
  • Often patients come in for a straightforward medical concern, and I find myself discussing how stressed out they are about child care, or how hard it's been to pay the bills on time during the COVID-19 crisis.
  • But by not getting down to business immediately, could I end getting paid less than male doctors?
  • In addition to their visits generally taking longer, women also go to the doctor more than men, and female physicians are more likely to see female patients.
  • In one 2016 study, researchers found that the median salary for male physicians in the United States was almost $86,000 more per year than the median salary for female physicians in the early 2010s.
  • Another study published earlier this year found that in their very first jobs after training, male physicians earned about $36,000 more, on average, than their female counterparts.
  • "When you look at how many minutes they are spending with their patients over a year, female physicians are spending 20 hours more — despite the fact that they're seeing fewer of them, and they're earning less money," Neprash says.
  • Some researchers say female doctors spend more time with their patients, because patients have higher expectations of them.
  • Allen says she feels it's important to ask about her patients' home lives. But that kind of small talk adds up. Many evenings she finds herself still working in the office, long after her male co-workers have gone home.
  • "I do wonder if some of our male colleagues second guess themselves, or go above and beyond in the ways some of us as women tend to do,"
  • "We know that women have longer visits in general. They're twice as likely to raise emotional content in their visits, which generally takes longer to manage."
  • That 2.4 minutes may seem inconsequential. But the New England Journal study authors argue that the extra time female physicians spend with their patients adds up quickly and has profound implications for the pay gap between women and men.
  • Research suggests that the extra time female doctors spend connecting with patients may have a positive impact. One study found significant differences in the practice style of female and male doctors, and found the patients of female physicians tend to be more satisfied with their care.
  • And a widely publicized 2016 study found that when elderly hospitalized patients are cared for by female physicians, they are less likely to die or return to the hospital compared to patients who have male doctors.
  • I became a primary care doctor because I like getting to know my patients as people, not just as a list of diseases. I truly believe it helps me provide better care. But getting to know them takes time, and that means squeezing fewer patients into each workday. That could mean less money for my practice. It seems to be a price that many female primary care physicians are willing to pay.
  • Mara Gordon is a family physician in Camden, N.J., and a contributor to NPR.
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The Moral Crisis of America's Doctors - The New York Times - 0 views

www.nytimes.com/...doctors-moral-crises.html moral crisis doctor medical profession US health care
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  • Some years ago, a psychiatrist named Wendy Dean read an article about a physician who died by suicide. Such deaths were distressingly common, she discovered. The suicide rate among doctors appeared to be even higher than the rate among active military members
  • Dean started asking the physicians she knew how they felt about their jobs, and many of them confided that they were struggling. Some complained that they didn’t have enough time to talk to their patients because they were too busy filling out electronic medical records. Others bemoaned having to fight with insurers about whether a person with a serious illness would be preapproved for medication. The doctors Dean surveyed were deeply committed to the medical profession. But many of them were frustrated and unhappy, she sensed, not because they were burned out from working too hard but because the health care system made it so difficult to care for their patients.
  • Doctors on the front lines of America’s profit-driven health care system were also susceptible to such wounds, Dean and Talbot submitted, as the demands of administrators, hospital executives and insurers forced them to stray from the ethical principles that were supposed to govern their profession. The pull of these forces left many doctors anguished and distraught, caught between the Hippocratic oath and “the realities of making a profit from people at their sickest and most vulnerable.”
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  • In July 2018, Dean published an essay with Simon G. Talbot, a plastic and reconstructive surgeon, that argued that many physicians were suffering from a condition known as moral injury. Military psychiatrists use the term to describe an emotional wound sustained when, in the course of fulfilling their duties, soldiers witnessed or committed acts — raiding a home, killing a noncombatant — that transgressed their core values.
  • By the time we met, the distress among medical professionals had reached alarming levels: One survey found that nearly one in five health care workers had quit their job since the start of the pandemic and that an additional 31 percent had considered leaving
  • the physicians I contacted were afraid to talk openly. “I have since reconsidered this and do not feel this is something I can do right now,” one doctor wrote to me. Another texted, “Will need to be anon.” Some sources I tried to reach had signed nondisclosure agreements that prohibited them from speaking to the media without permission. Others worried they could be disciplined or fired if they angered their employers, a concern that seems particularly well founded in the growing swath of the health care system that has been taken over by private-equity firms
  • Mona Masood, a psychiatrist who established a support line for doctors shortly after the pandemic began, recalls being struck by how clinicians reacted when she mentioned the term. “I remember all these physicians were like, Wow, that is what I was looking for,” she says. “This is it.”
  • I spent much of the previous few years reporting on moral injury, interviewing workers in menial occupations whose jobs were ethically compromising. I spoke to prison guards who patrolled the wards of violent
  • in recent years, despite the esteem associated with their profession, many physicians have found themselves subjected to practices more commonly associated with manual laborers in auto plants and Amazon warehouses, like having their productivity tracked on an hourly basis and being pressured by management to work faster.
  • it quickly went viral. Doctors and nurses started reaching out to Dean to tell her how much the article spoke to them. “It went everywhere,” Dean told me when I visited her last March in Carlisle, Pa., where she now lives
  • “I think a lot of doctors are feeling like something is troubling them, something deep in their core that they committed themselves to,” Dean says. She notes that the term moral injury was originally coined by the psychiatrist Jonathan Shay to describe the wound that forms when a person’s sense of what is right is betrayed by leaders in high-stakes situations. “Not only are clinicians feeling betrayed by their leadership,” she says, “but when they allow these barriers to get in the way, they are part of the betrayal. They’re the instruments of betrayal.”
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As Health Care Shifts, U.S. Doctors Switch to Salaried Jobs - NYTimes.com - 0 views

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  • Health economists are nearly unanimous that the United States should move away from fee-for-service payments to doctors, the traditional system where private physicians are paid for each procedure and test, because it drives up the nation’s $2.7 trillion health care bill by rewarding overuse
  • “In many places, the trend will almost certainly lead to more expensive care in the short run,”
  • When hospitals gather the right mix of salaried front-line doctors and specialists under one roof, it can yield cost-efficient and coordinated patient care, like the Kaiser system in California
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  • many of the new salaried arrangements have evolved from hospitals looking for new revenues, and could have the opposite effect. For example, when doctors’ practices are bought by a hospital, a colonoscopy or stress test performed in the office can suddenly cost far more because a hospital “facility fee” is tacked on. Likewise, Mr. Smith said, many doctors on salary are offered bonuses tied to how much billing they generate, which could encourage physicians to order more X-rays and tests.
  • “From the hospital end there’s a big feeding frenzy, a lot of bidding going on to bring in doctors,” Mr. Mechanic said. “And physicians are going in so they don’t have to worry
  • The base salaries of physicians who become employees are still related to the income they can generate, ranging from under $200,000 for primary care doctors to $575,000 in cardiology to $663,000 in neurosurgery,
  • Dr. Jacowitz said that the economics drove the choice and that the only other option would have been to bring in more revenue by practicing bad medicine — ordering more heart tests on patients who did not need them
  • “The question now is how to shift the compensation from a focus on volume to a focus on quality,” said Mr. Smith of Merritt Hawkins. He said that 35 percent of the jobs he recruits for currently have such incentives, “but it’s pennies, not enough to really influence behavior.”
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Attack on Jill Biden's 'Dr.' title is no surprise for women scholars -- and proof that ... - 0 views

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  • On Friday, The Wall Street Journal had the audacity to publish an op-ed arguing that incoming First Lady Jill Biden should not use the title "Dr." in the White House. The piece, written by Joseph Epstein, a man who has not earned an advanced degree (though he was given an honorary one), argues that it would be "fraudulent" and "comic" for Dr. Biden to use the Doctor of Education, or Ed.D., title that she has earned.
  • On Friday, The Wall Street Journal had the audacity to publish an op-ed arguing that incoming First Lady Jill Biden should not use the title "Dr." in the White House. The piece, written by Joseph Epstein, a man who has not earned an advanced degree (though he was given an honorary one), argues that it would be "fraudulent" and "comic" for Dr. Biden to use the Doctor of Education, or Ed.D., title that she has earned.
  • It's commonplace for women with expertise in this country to be expected to deny it -- which is exactly why it's so important that Dr. Biden use her "Dr." title in the White House, prominently and with pride.
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  • Epstein gives away his sexism immediately by opening his op-ed with the advice that "no one should call himself 'Dr.' unless he has delivered a child." In other words, part of his problem appears to be that Dr. Biden is not a man.
  • Epstein also argues that it has become easy to get a doctorate degree these days. He makes this inaccurate and offensive claim despite never having managed to earn one himself.
  • In 2018, when Dr. Julia Baird earned her Ph.D. and changed her title on Twitter, she ignited a firestorm of complaints -- mostly from men. The discussion that ensued among academics revealed that women are routinely ridiculed for using the titles they earn, while the expertise of men doesn't seem to meet with the same level of skepticism and censure. One man who holds a Ph.D. responded, "I had no idea doctorate-shaming was even a thing!"
  • A 2017 study found that when men introduced female medical doctors at a professional event, they used their titles 50 percent of the time -- but when men introduced fellow male doctors, they used their titles over 70 percent of the time.
  • As Cornell philosopher Kate Manne writes in her 2020 book "Entitled: How Male Privilege Hurts Women," when women make claims, their credibility is questioned much more than that of men. In fact, Rebecca Solnit wrote an entire book entitled "Men Explain Things to Me" after suffering through a man explaining one of her other books to her at a party. Scores of female academics have taken to Twitter to describe similar experiences of men explaining their own publications to them.
  • America needs to stop lecturing and start learning from women who have expertise. By using her "Dr." title in the White House, Dr. Biden would show by example that women shouldn't deny their rightful authority.
  • In 2017, Dr. Biden spoke at the commencement ceremony at Hofstra University, where I teach. The president of our university told her that one of my colleagues, a university administrator, had just earned her graduate degree but was not planning to walk in the ceremony. Dr. Biden insisted that my colleague put on a robe and go up to the stage with her classmates because it was important to recognize all the work that had gotten her there.
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How Insurers Exploited Medicare Advantage for Billions - The New York Times - 0 views

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  • The health system Kaiser Permanente called doctors in during lunch and after work and urged them to add additional illnesses to the medical records of patients they hadn’t seen in weeks. Doctors who found enough new diagnoses could earn bottles of Champagne, or a bonus in their paycheck.
  • Anthem, a large insurer now called Elevance Health, paid more to doctors who said their patients were sicker. And executives at UnitedHealth Group, the country’s largest insurer, told their workers to mine old medical records for more illnesses — and when they couldn’t find enough, sent them back to try again.
  • Each of the strategies — which were described by the Justice Department in lawsuits against the companies — led to diagnoses of serious diseases that might have never existed.
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  • But the diagnoses had a lucrative side effect: They let the insurers collect more money from the federal government’s Medicare Advantage program.
  • Medicare Advantage, a private-sector alternative to traditional Medicare, was designed by Congress two decades ago to encourage health insurers to find innovative ways to provide better care at lower cost.
  • by next year, more than half of Medicare recipients will be in a private plan.
  • a New York Times review of dozens of fraud lawsuits, inspector general audits and investigations by watchdogs shows how major health insurers exploited the program to inflate their profits by billions of dollars.
  • The government pays Medicare Advantage insurers a set amount for each person who enrolls, with higher rates for sicker patients. And the insurers, among the largest and most prosperous American companies, have developed elaborate systems to make their patients appear as sick as possible, often without providing additional treatment, according to the lawsuits.
  • As a result, a program devised to help lower health care spending has instead become substantially more costly than the traditional government program it was meant to improve.
  • Eight of the 10 biggest Medicare Advantage insurers — representing more than two-thirds of the market — have submitted inflated bills, according to the federal audits. And four of the five largest players — UnitedHealth, Humana, Elevance and Kaiser — have faced federal lawsuits alleging that efforts to overdiagnose their customers crossed the line into fraud.
  • The government now spends nearly as much on Medicare Advantage’s 29 million beneficiaries as on the Army and Navy combined. It’s enough money that even a small increase in the average patient’s bill adds up: The additional diagnoses led to $12 billion in overpayments in 2020, according to an estimate from the group that advises Medicare on payment policies — enough to cover hearing and vision care for every American over 65.
  • Another estimate, from a former top government health official, suggested the overpayments in 2020 were double that, more than $25 billion.
  • The increased privatization has come as Medicare’s finances have been strained by the aging of baby boomers
  • Medicare Advantage plans can limit patients’ choice of doctors, and sometimes require jumping through more hoops before getting certain types of expensive care.
  • At conferences, companies pitched digital services to analyze insurers’ medical records and suggest additional codes. Such consultants were often paid on commission; the more money the analysis turned up, the more the companies kept.
  • they often have lower premiums or perks like dental benefits — extras that draw beneficiaries to the programs. The more the plans are overpaid by Medicare, the more generous to customers they can afford to be.
  • Many of the fraud lawsuits were initially brought by former employees under a federal whistle-blower law that allows them to get a percentage of any money repaid to the government if their suits prevail. But most have been joined by the Justice Department, a step the government takes only if it believes the fraud allegations have merit. Last year, the department’s civil division listed Medicare Advantage as one of its top areas of fraud recovery.
  • In contrast, regulators overseeing the plans at the Centers for Medicare and Medicaid Services, or C.M.S., have been less aggressive, even as the overpayments have been described in inspector general investigations, academic research, Government Accountability Office studies, MedPAC reports and numerous news articles,
  • Congress gave the agency the power to reduce the insurers’ rates in response to evidence of systematic overbilling, but C.M.S. has never chosen to do so. A regulation proposed in the Trump administration to force the plans to refund the government for more of the incorrect payments has not been finalized four years later. Several top officials have swapped jobs between the industry and the agency.
  • The popularity of Medicare Advantage plans has helped them avoid legislative reforms. The plans have become popular in urban areas, and have been increasingly embraced by Democrats as well as Republicans.
  • “You have a powerful insurance lobby, and their lobbyists have built strong support for this in Congress,”
  • Some critics say the lack of oversight has encouraged the industry to compete over who can most effectively game the system rather than who can provide the best care.
  • But for insurers that already dominate health care for workers, the program is strikingly lucrative: A study from the Kaiser Family Foundation, a research group unaffiliated with the insurer Kaiser, found the companies typically earn twice as much gross profit from their Medicare Advantage plans as from other types of insurance.
  • In theory, if the insurers could do better than traditional Medicare — by better managing patients’ care, or otherwise improving their health — their patients would cost less and the insurers would make more money.
  • But some insurers engaged in strategies — like locating their enrollment offices upstairs, or offering gym memberships — to entice only the healthiest seniors, who would require less care, to join. To deter such tactics, Congress decided to pay more for sicker patients.
  • Almost immediately, companies saw ways to exploit that system. The traditional Medicare program provided no financial incentive to doctors to document every diagnosis, so many records were incomplete
  • Under the new program, insurers began rigorously documenting all of a patient’s health conditions — say depression, or a long-ago stroke — even when they had nothing to do with the patient’s current medical care.
  • “Even when they’re playing the game legally, we are lining the pockets of very wealthy corporations that are not improving patient care,”
  • The insurers also began hiring agencies that sent doctors or nurses to patients’ homes, where they could diagnose them with more diseases.
  • Cigna hired firms to perform similar at-home assessments that generated billions in extra payments, according to a 2017 whistle-blower lawsuit, which was recently joined by the Justice Department. The firms told nurses to document new diagnoses without adjusting medications, treating patients or sending them to a specialist
  • Nurses were told to especially look for patients with a history of diabetes because it was not “curable,” even if the patient now had normal lab findings or had undergone surgery to treat the condition.
  • Adding the code for a single diagnosis could yield a substantial payoff. In a 2020 lawsuit, the government said Anthem instructed programmers to scour patient charts for “revenue-generating” codes. One patient was diagnosed with bipolar disorder, although no other doctor reported the condition, and Anthem received an additional $2,693.27, the lawsuit said. Another patient was said to have been coded for “active lung cancer,” despite no evidence of the disease in other records; Anthem was paid an additional $7,080.74. The case is continuing.
  • The most common allegation against the companies was that they did not correct potentially invalid diagnoses after becoming aware of them. At Anthem, for example, the Justice Department said “thousands” of inaccurate diagnoses were not deleted. According to the lawsuit, a finance executive calculated that eliminating the inaccurate diagnoses would reduce the company’s 2017 earnings from reviewing medical charts by $86 million, or 72 percent.
  • Some of the companies took steps to ensure the extra diagnoses didn’t lead to expensive care. In an October 2021 lawsuit, the Justice Department estimated that Kaiser earned $1 billion between 2009 and 2018 from additional diagnoses, including roughly 100,000 findings of aortic atherosclerosis, or hardening of the arteries. But the plan stopped automatically enrolling those patients in a heart attack prevention program because doctors would be forced to follow up on too many people, the lawsuit said.
  • Kaiser, which both runs a health plan and provides medical care, is often seen as a model system. But its control over providers gave it additional leverage to demand additional diagnoses from the doctors themselves, according to the lawsuit.
  • At meetings with supervisors, he was instructed to find additional conditions worth tens of millions of dollars. “It was an actual agenda item and how could we get this,” Dr. Taylor said.
  • few analysts expect major legislative or regulatory changes to the program.
  • Even before the first lawsuits were filed, regulators and government watchdogs could see the number of profitable diagnoses escalating. But Medicare has done little to tamp down overcharging.
  • Several experts, including Medicare’s advisory commission, have recommended reducing all the plans’ payments.
  • Congress has ordered several rounds of cuts and gave C.M.S. the power to make additional reductions if the plans continued to overbill. The agency has not exercised that power.
  • The agency does periodically audit insurers by looking at a few hundred of their customers’ cases. But insurers are fined for billing mistakes found only in those specific patients. A rule proposed during the Trump administration to extrapolate the fines to the rest of the plan’s customers has not been finalized.
  • Ted Doolittle, who served as a senior official for the agency’s Center for Program Integrity from 2011 to 2014, said officials at Medicare seemed uninterested in confronting the industry over these practices. “It was clear that there was some resistance coming from inside” the agency, he said. “There was foot dragging.”
  • Last year, the inspector general’s office noted that one company “stood out” for collecting 40 percent of all Medicare Advantage’s payments from chart reviews and home assessments despite serving only 22 percent of the program’s beneficiaries. It recommended Medicare pay extra attention to the company, which it did not name, but the enrollment figure matched UnitedHealth’s.
  • “Medicare Advantage overpayments are a political third rail,” said Dr. Richard Gilfillan, a former hospital and insurance executive and a former top regulator at Medicare, in an email. “The big health care plans know it’s wrong, and they know how to fix it, but they’re making too much money to stop. Their C.E.O.s should come to the table with Medicare as they did for the Affordable Care Act, end the coding frenzy, and let providers focus on better care, not more dollars for plans.”
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The Fake Freedom of American Health Care - The New York Times - 0 views

www.nytimes.com/...m-of-american-health-care.html health-care finland government
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  • Republican leaders seem unfazed by this, perhaps because, in their minds, deciding not to have health care because it’s too expensive is an exercise of individual free will.
  • The idea is that buying health care is like buying anything else. The United States is home to some of the world’s best medical schools, doctors, research institutes and hospitals, and if you have the money for the coverage and procedures you want, you absolutely can get top-notch care.
  • This approach might result in extreme inequalities and it might be expensive, but it definitely buys you the best medical treatment anywhere. Such is the cost of freedom.
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  • In practice, though, this Republican notion is an awfully peculiar kind of freedom. It requires most Americans to spend not just money, but also time and energy agonizing over the bewildering logistics of coverage and treatment — confusing plans, exorbitant premiums and deductibles, exclusive networks, mysterious tests, outrageous drug prices.
  • I never had to worry whether I was covered. All Finns are covered for all essential medical care automatically, regardless of employment or income.
  • If you can’t afford it, not buying it is hardly a choice.
  • in Finland I never worried about where my medical care came from or whether I could afford it. I paid my income taxes — which, again despite the stereotypes, were about the same as what I pay in federal, state and local income taxes in New York City — and if I needed to see a doctor, I had several options.
  • And more often than not, individual choices are severely restricted by decisions made by employers, insurers, doctors, pharmaceutical companies and other private players. Those interest groups, not the consumer, decide which plans are available, what those plans cover, which doctors patients can see and how much it will cost.
  • Meanwhile, life expectancy at age 65 is higher in 24 other developed nations, including Canada, Britain and most European nations.
  • According to the latest report of the O.E.C.D. — an organization of mostly wealthy nations — the United States as a whole does not actually outshine other countries in the quality of care.
  • In fact, the United States has shorter life expectancy, higher infant mortality and fewer doctors per capita than most other developed countries.
  • When it comes to outcomes in some illnesses, including cancer, the United States does have some of the best survival rates in the world — but that’s barely ahead of, or even slightly behind, the equivalent survival rates in other developed countries.
  • the United States are South Korea, Israel, Australia, Sweden and Finland, all with some form of government-managed universal health care.
  • And when it comes to cervical cancer, American women are at a significant disadvantage: The United States comes in only 22nd
  • According to the Republican orthodoxy, government always takes away not only people’s freedom to choose their doctor, but also their doctor’s ability to choose the correct care for patients. People are at the mercy of bureaucrats. Waiting times are long. Quality of care is dismal.
  • Americans might still assume that long waits for care are inevitable in a health care system run by the government. But that’s not necessarily the case either.
  • A report in 2014 by the Commonwealth Fund, a private foundation specializing in health care research, ranked the United States third in the world in access to specialists. That’s a great achievement. But the Netherlands and Switzerland did better
  • When it comes to nonemergency and elective surgery, patients in several countries, including the Netherlands, Germany and Switzerland, all of which have universal, government-guided health care systems, have faster access than the United States.
  • in fact Americans who are getting a raw deal. Americans pay much more than people in other countries but do not get significantly better results.
  • The trouble with a free-market approach is that health care is an immensely complicated and expensive industry, in which the individual rarely has much actual market power
  • It is not like buying a consumer product, where choosing not to buy will not endanger one’s life. It’s also not like buying some other service tailored to individual demands, because for the most part we can’t predict our future health care needs.
  • The point of universal coverage is to pool risk, for the maximum benefit of the individual when he or she needs care
  • And the point of having the government manage this complicated service is not to take freedom away from the individual
  • The point is the opposite: to give people more freedom. Arranging health care is an overwhelming task, and having a specialized entity do the negotiating, regulating and perhaps even much of the providing is just vastly more efficient than forcing everyone to go it alone
  • What passes for an American health care system today certainly has not made me feel freer. Having to arrange so many aspects of care myself, while also having to navigate the ever-changing maze of plans, prices and the scarcity of appointments available with good doctors in my network, has thrown me, along with huge numbers of Americans, into a state of constant stress. And I haven’t even been seriously sick or injured yet.
  • As a United States citizen now, I wish Americans could experience the freedom of knowing that the health care system will always be there for us regardless of our employment status. I wish we were free to assume that our doctors get paid a salary to look after our best interests, not to profit by generating billable tests and procedures. I want the freedom to know that the system will automatically take me and my family in, without my having to battle for care in my moment of weakness and need. That is real freedom.
  • So is the freedom of knowing that none of it will bankrupt us. That is the freedom I had back in Finland.
  • It’s true that in countries with universal health care the cost of hiring a new employee can be significant, especially for a small employer. Yet these countries still have plenty of thriving businesses, with lower administrative burdens. It can be done.
  • in a nation that purports to champion freedom, the outdated disaster that is the United States health care system is taking that freedom away.
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If We Knew Then What We Know Now About Covid, What Would We Have Done Differently? - WSJ - 0 views

www.wsj.com/...covid-lessons-learned-9dd5566f politics us history crisis culture policy trump pandemic response
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  • A small cadre of aerosol scientists had a different theory. They suspected that Covid-19 was transmitted not so much by droplets but by smaller infectious aerosol particles that could travel on air currents way farther than 6 feet and linger in the air for hours. Some of the aerosol particles, they believed, were small enough to penetrate the cloth masks widely used at the time.
  • For much of 2020, doctors and public-health officials thought the virus was transmitted through droplets emitted from one person’s mouth and touched or inhaled by another person nearby. We were advised to stay at least 6 feet away from each other to avoid the droplets
  • The group had a hard time getting public-health officials to embrace their theory. For one thing, many of them were engineers, not doctors.
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  • “My first and biggest wish is that we had known early that Covid-19 was airborne,”
  • , “Once you’ve realized that, it informs an entirely different strategy for protection.” Masking, ventilation and air cleaning become key, as well as avoiding high-risk encounters with strangers, he says.
  • Instead of washing our produce and wearing hand-sewn cloth masks, we could have made sure to avoid superspreader events and worn more-effective N95 masks or their equivalent. “We could have made more of an effort to develop and distribute N95s to everyone,” says Dr. Volckens. “We could have had an Operation Warp Speed for masks.”
  • We didn’t realize how important clear, straight talk would be to maintaining public trust. If we had, we could have explained the biological nature of a virus and warned that Covid-19 would change in unpredictable ways.  
  • In the face of a pandemic, he says, the public needs an early basic and blunt lesson in virology
  • “The science is really important, but if you don’t get the trust and communication right, it can only take you so far,”
  • and mutates, and since we’ve never seen this particular virus before, we will need to take unprecedented actions and we will make mistakes, he says.
  • Since the public wasn’t prepared, “people weren’t able to pivot when the knowledge changed,”
  • By the time the vaccines became available, public trust had been eroded by myriad contradictory messages—about the usefulness of masks, the ways in which the virus could be spread, and whether the virus would have an end date.
  • , the absence of a single, trusted source of clear information meant that many people gave up on trying to stay current or dismissed the different points of advice as partisan and untrustworthy.
  • We didn’t know how difficult it would be to get the basic data needed to make good public-health and medical decisions. If we’d had the data, we could have more effectively allocated scarce resources
  • For much of the pandemic, doctors, epidemiologists, and state and local governments had no way to find out in real time how many people were contracting Covid-19, getting hospitalized and dying
  • Doctors didn’t know what medicines worked. Governors and mayors didn’t have the information they needed to know whether to require masks. School officials lacked the information needed to know whether it was safe to open schools.
  • people didn’t know whether it was OK to visit elderly relatives or go to a dinner party.
  • just months before the outbreak of the pandemic, the Council of State and Territorial Epidemiologists released a white paper detailing the urgent need to modernize the nation’s public-health system still reliant on manual data collection methods—paper records, phone calls, spreadsheets and faxes.
  • While the U.K. and Israel were collecting and disseminating Covid case data promptly, in the U.S. the CDC couldn’t. It didn’t have a centralized health-data collection system like those countries did, but rather relied on voluntary reporting by underfunded state and local public-health systems and hospitals.
  • doctors and scientists say they had to depend on information from Israel, the U.K. and South Africa to understand the nature of new variants and the effectiveness of treatments and vaccines. They relied heavily on private data collection efforts such as a dashboard at Johns Hopkins University’s Coronavirus Resource Center that tallied cases, deaths and vaccine rates globally.
  • With good data, Dr. Ranney says, she could have better managed staffing and taken steps to alleviate the strain on doctors and nurses by arranging child care for them.
  • To solve the data problem, Dr. Ranney says, we need to build a public-health system that can collect and disseminate data and acts like an electrical grid. The power company sees a storm coming and lines up repair crews.
  • If we’d known how damaging lockdowns would be to mental health, physical health and the economy, we could have taken a more strategic approach to closing businesses and keeping people at home.
  • t many doctors say they were crucial at the start of the pandemic to give doctors and hospitals a chance to figure out how to accommodate and treat the avalanche of very sick patients.
  • The measures reduced deaths, according to many studies—but at a steep cost.
  • The lockdowns didn’t have to be so harmful, some scientists say. They could have been more carefully tailored to protect the most vulnerable, such as those in nursing homes and retirement communities, and to minimize widespread disruption.
  • Lockdowns could, during Covid-19 surges, close places such as bars and restaurants where the virus is most likely to spread, while allowing other businesses to stay open with safety precautions like masking and ventilation in place.  
  • If England’s March 23, 2020, lockdown had begun one week earlier, the measure would have nearly halved the estimated 48,600 deaths in the first wave of England’s pandemic
  • If the lockdown had begun a week later, deaths in the same period would have more than doubled
  • The key isn’t to have the lockdowns last a long time, but that they are deployed earlier,
  • It is possible to avoid lockdowns altogether. Taiwan, South Korea and Hong Kong—all countries experienced at handling disease outbreaks such as SARS in 2003 and MERS—avoided lockdowns by widespread masking, tracking the spread of the virus through testing and contact tracing and quarantining infected individuals.
  • Had we known that even a mild case of Covid-19 could result in long Covid and other serious chronic health problems, we might have calculated our own personal risk differently and taken more care.
  • Early in the pandemic, public-health officials were clear: The people at increased risk for severe Covid-19 illness were older, immunocompromised, had chronic kidney disease, Type 2 diabetes or serious heart conditions
  • t had the unfortunate effect of giving a false sense of security to people who weren’t in those high-risk categories. Once case rates dropped, vaccines became available and fear of the virus wore off, many people let their guard down, ditching masks, spending time in crowded indoor places.
  • it has become clear that even people with mild cases of Covid-19 can develop long-term serious and debilitating diseases. Long Covid, whose symptoms include months of persistent fatigue, shortness of breath, muscle aches and brain fog, hasn’t been the virus’s only nasty surprise
  • In February 2022, a study found that, for at least a year, people who had Covid-19 had a substantially increased risk of heart disease—even people who were younger and had not been hospitalized
  • respiratory conditions.
  • Some scientists now suspect that Covid-19 might be capable of affecting nearly every organ system in the body. It may play a role in the activation of dormant viruses and latent autoimmune conditions people didn’t know they had
  •  A blood test, he says, would tell people if they are at higher risk of long Covid and whether they should have antivirals on hand to take right away should they contract Covid-19.
  • If the risks of long Covid had been known, would people have reacted differently, especially given the confusion over masks and lockdowns and variants? Perhaps. At the least, many people might not have assumed they were out of the woods just because they didn’t have any of the risk factors.
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Once-wealthy Syrian doctor works in exile to treat refugees, dreams of healing his coun... - 0 views

www.washingtonpost.com/...3-a0b9-249bbb34602c_story.html
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  • REYHANLI, Turkey — When the wounded arrived at the Red Crescent hospital in Idlib at the start of the Syrian uprising — opponents of President Bashar al-Assad who had been shot or beaten by government troops — military police ordered the doctors to just let them die.
  • Ammar Martini and his colleagues refused.
  • “This I could not do,” said Martini, a successful surgeon from an affluent family. “I treat all people, of any origin. They are human, and I am a doctor.”
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  • “They beat me. They did terrifying things,” he said quietly in a recent interview. “I don’t want to remember that day.”
  • Martini is, in some ways, typical: mostly apolitical but firmly opposed to Assad’s regime and to the Islamist groups that are vying with other armed opposition groups for control of rebel-held areas.
  • Now, he lives alone in makeshift quarters in the offices of the aid organization he helped found in this Turkish border town. He heads the group’s relief operations in northern Syria and the Turkish border regions, overseeing the delivery of medical care to hundreds of thousands of Syrian refugees.
  • Martini is deeply skeptical of peace talks scheduled for this month in Geneva, which are supposed to facilitate negotiations between Assad’s government and rebel groups.
  • “We must keep working. Whether the time is long or short, this regime will fall,” Martini said. “Then we must rebuild our country.”
  • . Then he crossed the border into Jordan, which aid agencies say shelters more than 563,000 refugees.
  • When he left Syria, Martini said, he lost everything. The government seized all nine of his houses, along with his bank accounts, a clinical laboratory and 2,000 olive trees. The loss of the olive grove seems to have stung particularly; Idlib is known for its production of the bitter fruit.
  • In Jordan, the doctor briefly treated patients in the Zaatari refugee camp. Then he fled the difficult conditions to join his wife and youngest child in the United Arab Emirates. His older children escaped Syria, too, and are studying medicine in the United States.
  • At first, the effort paid for treatment for Syrians in Turkish hospitals. Operations were soon expanded to include the building of a 144-bed medical unit in the city of Antakya, near the Syrian border. Then hostility from Antakya’s Alawites — many of whom support Assad, who is also Alawite — prompted Orient to move the facility to Reyhanli. Alawites are members of a Shiite-affiliated sect.
  • Orient’s medical ventures expanded into rebel-held areas of Syria, where it now runs 12 hospitals and several rehabilitation centers and employs more than 400 doctors. Facilities in Turkey include a day clinic, a school for displaced Syrians and a sewing workshop that trains and provides work for many Syrian women.
  • It is an unusual arrangement for an organization of Orient Humanitarian Relief’s size — staff members said Orient programs and facilities helped nearly 400,000 people last year. But the setup offers a strategic advantage. A member of an aid organization working with Orient said it is able to move faster than any of its peers, making quick decisions unhampered by complicated bureaucracies and approval processes.
  • The many doctors and surgeons in the Martini clan are scattered across Europe and the United States. One uncle founded Martini Hospital in the Syrian city of Aleppo, where fighting between rebels and government forces has been sustained and brutal. Ammar Martini worked at that hospital, now heavily damaged, for 10 years.
  • When his father died recently in Syria, Martini was not able to return home to attend the funeral.
23More

What Doctors on the Front Lines Wish They'd Known a Month Ago - The New York Times - 0 views

www.nytimes.com/...new-york-coronavirus.html Covid-19 treatment
shared by Javier E on 14 Apr 20 - No Cached
  • Doctors, if you could go back in time, what would you tell yourselves in early March?
  • “What we thought we knew, we don’t know,
  • For the disease that drives this pandemic, certain ironclad emergency medical practices have dissolved almost overnight.
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  • The biggest change: Instead of quickly sedating people who had shockingly low levels of oxygen and then putting them on mechanical ventilators, many doctors are now keeping patients conscious, having them roll over in bed, recline in chairs and continue to breathe on their own — with additional oxygen — for as long as possible.
  • The idea is to get them off their backs and thereby make more lung available.
  • Other doctors are rejiggering CPAP breathing machines, normally used to help people with sleep apnea, or they have hacked together valves and filters.
  • Then there is the space needed inside of buildings and people’s heads. In an instant, soaring atrium lobbies and cafeterias became hospital wards
  • rarely-used telemedicine technology has suddenly taken off, and doctors are holding virtual bedside conferences with scattered family members
  • The number of intubations in New York State has declined to 21 new ones a day, from about 300 per day at the end of March
  • “I’m confident that we will have a lot of answers in months,”
  • People who need breathing tubes, which connect to mechanical ventilators that assist or take over respiration, are rarely in any shape to be on the phone because the level of oxygen in their blood has declined precipitously.If conscious, they are often incoherent and are about to be sedated so they do not gag on the tubes. It is a drastic step.
  • Yet many Covid-19 patients remain alert, even when their oxygen has sharply fallen, for reasons health care workers can only guess.
  • Some patients, by taking oxygen and rolling onto their sides or on their bellies, have quickly returned to normal levels. The tactic is called proning.
  • Dr. Nicholas Caputo followed 50 patients who arrived with low oxygen levels between 69 and 85 percent (95 is normal). After five minutes of proning, they had improved to a mean of 94 percent. Over the next 24 hours, nearly three-quarters were able to avoid intubation;
  • No one knows yet if this will be a lasting remedy, Dr. Caputo said, but if he could go back to early March, he would advise himself and others: “Don’t jump to intubation.”
  • not enough time has passed to say if their improvisations will hold up,
  • One reason is that contrary to expectations, a number of doctors at New York hospitals believe intubation is helping fewer people with Covid-19 than other respiratory illnesses and that longer stays on the mechanical ventilators lead to other serious complications
  • “Intubated patients with Covid lung disease are doing very poorly, and while this may be the disease and not the mechanical ventilation, most of us believe that intubation is to be avoided until unequivocally required,”
  • This shift has lightened the load on nursing staffs and the rest of the hospital. “You put a tube into somebody,” Dr. Levitan said, “and the amount of work required not to kill that person goes up by a factor of 100,” creating a cascade that slows down laboratory results, X-rays and other care.
  • “Obesity is clearly a critical risk factor.”
  • The first patient to rest on it arrived with oxygen saturation in the 40s, breathing rapidly and with an abnormally fast heartbeat, he said. After the patient was given oxygen through a nasal cannula — clear plastic tubes that fit into the nostrils — Dr. Levitan helped her to lay face down on the massage table. The oxygen level in her blood climbed to the mid-90s, he said, her pulse slowed to under 100 and she was breathing at a more normal pace. “She slept for two hours,” he said.
  • For heavier patients, Dr. Levitan advocates combining breathing support from a CPAP machine or regular oxygen with comfortable positioning on a pregnancy massage mattress
  • doctors in the region have started sharing on medical grapevines what it has been like to re-engineer, on the fly, their health care systems, their practice of medicine, their personal lives.
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Why Lagging COVID Vaccine Rate At Rural Hospitals 'Needs To Be Fixed Now' : NPR - 0 views

www.npr.org/...ospitals-needs-to-be-fixed-now vaccine hospitals rural
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  • President Biden on Tuesday is set to announce new steps to reach rural Americans in the push to get as many people as possible vaccinated for the coronavirus
  • It has prioritized a list of doctors enrolled in the vaccine system based on a "social vulnerability index" used by the Centers for Disease Control and Prevention — including doctors in many rural communities — and has been asking state government to send vaccine doses to those doctors, the official said.
  • The administration also plans to work with states to enroll more pediatricians and family doctors in their vaccine systems so they can begin giving people vaccines, a step that becomes "particularly critical" if the Food and Drug Administration gives emergency authorization for adolescents ages 12-15 to start getting the Pfizer vaccine, the official said.
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  • "So if you've got a quarter of the nation's rural hospitals having less than 50% of their staff vaccinated, you have a problem that needs to be fixed now."
  • 30% of the 160 rural hospital executives who responded said less than half of their employees had been vaccinated — even though health care workers have been eligible for months now
  • The new steps come as some rural hospitals are finding that their own staff members are reluctant to get the shot.
  • The Washington Post that found 29% of health care workers in rural areas didn't plan to get the COVID-19 vaccine. That's a greater well of hesitancy than the poll found among health care workers in urban and suburban areas.
  • He cited studies showing vaccines were effective and that the worst side effects were comparable to the vaccine for shingles, which is widely used.
  • There were also Zoom sessions for staff, led by doctors, leaving plenty of time for questions. Having trusted doctors and nurses vaccinated has been reassuring to others in the broader community, said chief nursing officer Kris Dascoulias, whose roots in the community are so deep that she was born in Memorial Hospital, where she now works.
  • The White House knows that doctors and other trusted local leaders will be the way to break through pockets of hesitancy in rural communities, said Bechara Choucair, the White House vaccinations coordinator.
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Trump Administration Allows Doctors Flexibility To Prescribe Buprenorphine : NPR - 0 views

www.npr.org/...be-drug-to-fight-opioid-addict
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  • The Trump administration introduced new addiction treatment guidelines Thursday that give physicians more flexibility to prescribe a drug to patients struggling with opioid addiction.
  • "As emergency physicians, we see every day the devastating effects that the opioid crisis has had on the communities we serve—a crisis that has unfortunately only worsened during the COVID-19 pandemic,"
  • The obstacle discouraged doctors from pursing buprenorphine as an addiction treatment for patients, despite evidence it was highly effective in preventing a relapse,
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  • "The medical evidence is clear: access to medication-assisted treatment, including buprenorphine that can be prescribed in office-based settings, is the gold standard for treating individuals suffering from opioid use disorder,"
  • The administration's move comes at a time when the U.S. is again facing record levels of drug overdose deaths, according to the Centers for Disease Control and Prevention.
  • More than 83,000 people died of drug overdoses in the U.S. in the 12 months ending in June 2020, the CDC said.
  • The Department of Health and Human Services is eliminating the requirement that physicians obtain a special federal waiver in order to prescribe buprenorphine,
  • The American Medical Association also praised the move, saying it will allow earlier intervention by doctors treating patients suffering addiction.
  • "With this change, office-based physicians and physician-led teams working with patients to manage their other medical conditions can also treat them for their opioid use disorder,"
  • Harris also said allowing doctors to treat opioid addiction as they treat other medical conditions, without additional regulatory hurdles, will reduce the stigma that has often shaped the healthcare response to substance use disorders.
  • doctors who possess a Drug Enforcement Administration registration will still be limited to treating no more than 30 in-state patients with buprenorphine for addiction treatment at any one time.
  • The guidelines are not considered a new law or federal regulation, making it very easy for the President-elect Joe Biden administration to walk back this policy if so desired. Giroir told Stat News that he thinks that scenario is unlikely, saying, "I doubt it seriously."
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Kaiser Permanente Is Seen as Face of Future Health Care - NYTimes.com - 0 views

www.nytimes.com/...ace-of-future-health-care.html health care health system costs efficiency economics
shared by Javier E on 21 Mar 13 - No Cached
  • Kaiser has sophisticated electronic records and computer systems that — after 10 years and $30 billion in technology spending — have led to better-coordinated patient care, another goal of the president. And because the plan is paid a fixed amount for medical care per member, there is a strong financial incentive to keep people healthy and out of the hospital, the same goal of the hundreds of accountable care organizations now being created.
  • Kaiser has yet to achieve the holy grail of delivering that care at a low enough cost. He says he and other health systems must fundamentally rethink what they do or risk having cost controls imposed on them either by the government or by employers, who are absorbing the bulk of health insurance costs. “We think the future of health care is going to be rationing or re-engineering,”
  • the way to get costs lower is to move care farther and farther from the hospital setting — and even out of doctors’ offices. Kaiser is experimenting with ways to provide care at home or over the Internet, without the need for a physical office visit at all.
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  • lower costs are going to be about finding ways to get people to take more responsibility for their health — for losing weight, for example, or bringing their blood pressure down.
  • there are other concerns, such as whether an all-encompassing system like Kaiser’s can really be replicated and whether the limits it places on where patients can seek care will be accepted by enough people to make a difference.
  • Or whether, as the nation’s flirtation with health maintenance organizations, or H.M.O.’s, in the 1990s showed — people will balk at the concept of not being able to go to any doctor or hospital of their choice.
  • its integrated model is in favor again. Hospitals across the country are buying physician practices or partnering with doctors and health insurers to form accountable care organizations, or A. C.O.’s, as a way of controlling more aspects of patient care. Doctors are also creating so-called medical homes, where patient care is better coordinated.
  • The days when doctors, hospitals and other providers are paid separately for each procedure will disappear eventually, health experts say. Instead, providers will have financial incentives to encourage them to keep people healthy, including lump sums to care for patients or provide comprehensive care for a specific condition. “All of care is going to move down this path, and it has to,” Mr. Halvorson said. “Medical homes are doing it; the very best A. C.O’s are going to figure out how to do it.”
  • there are downsides to the creation of large health care systems that may be motivated by the desire to increase their clout in the market, making it easier to fill beds and charge the insurers more for care. “They become these huge local monopolies,”
  • “We have all the pieces,” said Philip Fasano, Kaiser’s chief information officer. “Anything a patient needs you get in the four walls of our offices,
  • its plans are typically at least 10 percent less expensive than others, especially where they control all the providers
  • Kaiser has also been using the information to identify those doctors or clinics that excel in certain areas, as well as those in need of improvement. The organization has also used the records to change how it delivers care, identifying patients at risk for developing bed sores in the hospital and then sending electronic alerts every two hours to remind the nurses to turn the patients. The percentage of patients with serious pressure ulcers, or bed sores, dropped to well under 1 percent from 3.5 percent.
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Opinion | 'I Do Fear for My Staff,' a Doctor Said. He Lost His Job. - The New York Times - 0 views

www.nytimes.com/...tors-protective-equipment.html medical staff role model pandemic job risk
shared by Javier E on 02 Apr 20 - No Cached
  • Doctors and nurses responding to the Covid-19 pandemic are the superheroes of our age, putting themselves at risk to save the lives of others.
  • At least 61 doctors and nurses have died from the coronavirus in Italy so far. Already, in New York City alone, two nurses have died and more than 200 health workers are reported sick at a single major hospital.
  • Tension arises not only because of shortages of P.P.E. but also because of uncertainty about how much protection is optimal. No one knows. The Centers for Disease Control and Prevention have given conflicting advice, and other countries have varying standards
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  • These superheroes are at risk partly because we sometimes send them into battle without adequate personal protective equipment, or P.P.E. This should be a national scandal, and now hospitals are compounding the outrage by punishing staff members who speak up or simply try to keep themselves safe.
  • It’s baffling that the richest country in the history of the world fails so abysmally at protecting its health workers, especially when it had two months’ lead time. And for hospitals now to retaliate against health workers who try to protect themselves — ousting them just when they are most needed — is both unconscionable and idiotic.
  • On websites like allnurses.com, nurses wonder aloud whether they can refuse to work because of inadequate P.P.E. or even whether they should quit the profession.
  • The doctors, nurses, technicians and cleaning staff members on the front of this pandemic deserve our eternal gratitude. Instead, we’re betraying them: They have our back, but we don’t have theirs.
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World's Wealthy Tap Personal Ventilators, On-Demand Doctors to Fight Coronavirus - WSJ - 0 views

www.wsj.com/...-fight-coronavirus-11586251553 rich inequality pandemic crisis
shared by Javier E on 07 Apr 20 - No Cached
  • Money can’t stop you from catching or dying from the new coronavirus. But it can buy you an attentive doctor, faster testing, a luxury spot for self-isolation and, in some parts of the world, an at-home intensive-care setup complete with a ventilator.
  • Wealthy Americans are turning to personal doctors for immediate consultations and swift testing, while rich Russians are building their own clinics and snapping up vital medical equipment.
  • And across the globe, the affluent are escaping to luxury bolt-holes to take the edge off their self-isolation.
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  • Coronavirus testing is also more straightforward for the wealthy. Lisa Benya, medical director of CURE Daily, a Malibu, Calif.-based medical and wellness practice, had one of her patients tested after hearing him cough over the phone.
  • “A lot are so grateful to be able to reach out in the middle of the night,” she said. “That relieves a lot of anxiety. If someone needs to be sent to the hospital, we get a way to get them in.”
  • Former White House doctor Connie Mariano said demand for her $15,000 a year “concierge doctor” service has risen in recent weeks, as more patients seek to navigate the outbreak
  • “In our area we have less of a restriction in testing,” she said. “Our labs have the capability to test, but it’s not unlimited.” She said interest from prospective new members has doubled in recent weeks, as the coronavirus crisis has taken hold.
  • In Russia, the wealthy are taking things a step further. No longer able to travel abroad for treatment, they are setting up makeshift clinics in their homes or office
  • Rich Russians have also been buying up ventilators, at a cost of more than $25,000, for use in their personal clinics.
  • For the rich, self-isolation needn’t be unpleasant. Luxury rental properties in the Caribbean, Hawaii and the Mediterranean have recently been in hot demand,
  • “They have the money and the means to get away,” said Ms. Mosgrove, who counts celebrities, entrepreneurs and financiers among her clients.
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The US doctors taking Trump's lead on hydroxychloroquine - despite mixed results | US n... - 0 views

www.theguardian.com/...e-trump-us-doctors-coronavirus crisis corona economics coronavirus
shared by andrespardo on 24 May 20 - No Cached
  • The US doctors taking Trump’s lead on hydroxychloroquine – despite mixed results
  • Among the most ardent proponents of these claims is the American Association of Physicians and Surgeons (AAPS), a fringe group of less than 5,000 doctors. The group was recently cited by Trump’s campaign manager, Brad Parscale, to explain the president’s stunning announcement that he is taking the drug hydroxychloroquine in an attempt to protect himself against Covid-19 despite a lack of evidence of its effectiveness.
  • Yet Dr Jane Orient, executive director of AAPS, told the Guardian she believed the drug “should be prescribed more often”, and in a statement based on a flawed database claimed the drug offered “about 90% chance of helping Covid-19 patients”.
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  • This group is lobbying on behalf of what they believe to be right, but invariably experts would disagree on their stance on hydroxychloroquine John Ayers
  • “They’re aligned with the Trump administration, that doesn’t believe in science, doesn’t believe in fact. They’re completely compatible with the Trump White House.”
  • “I don’t want to have a target put on my back … which could result in somebody wanting to scrutinize my entire practice,” Orient said.
  • As far as the president’s pronouncements, Ayers said: “We don’t know if he’s actually even taking it.” Even as Trump said he was tak
  • Massachusetts general hospital, another world-renowned academic medical center, is giving priority to remdesivir, a drug developed by Gilead, although hydroxychloroquine is provided on a case-by-case basis.
  • But Orient argued that masks “are not free of side-effects” and that they “retard oxygen” to the brain. She later added: “I think one jogger even dropped dead.” One man in China reportedly suffered a collapsed lung while wearing a mask, though a doctor in the report said there was “no clear evidence” the mask caused the injury.
  • Orient also voiced her support for lifting stay-at-home orders. “They are destroying the economy, they are destroying people’s lives, there is really no evidence they work,” she said. The economic and social impacts of the lockdowns have been devastating.
  • The view of AAPS, he added, is “that doctors should be basically free to do whatever they want to do, regardless of the level of evidence, and that’s a dangerous perspective for medical practitioners to have in the 21st century”.
  • Nevertheless, Orient argues hydroxychloroquine should be available over the counter. Concerns from scientists have “nothing to do with concerns about safety and concerns about science”, she argued. Her view that lockdowns are “despotic, tyrannical and completely unwarranted”, and will probably also cause consternation in many circles.
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When the Patient Is Your Commander in Chief, the Answer Is Usually 'Yes, Sir' - The New... - 0 views

www.nytimes.com/...trump-military-doctors.html politics US trump covid19
shared by yehbru on 06 Oct 20 - No Cached
  • Disobeying Mr. Trump’s wishes could be seen as tantamount to insubordination, among the military’s highest offenses.
  • Dr. Conley, who served as an emergency doctor in the U.S. Navy as a lieutenant commander, said on Monday that while the president was “not out of the woods,” he agreed with Mr. Trump’s decision to leave the military’s health center in Bethesda, Md.
  • “He has never once pushed us to do anything,” the doctor added.
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  • Mr. Trump appeared to pick a doctor who would maintain the narrative of his health status
  • “Presidents make these decision based on politics over medicine,” said Matthew Algeo, the author of “The President Is a Sick Man” and other books about the presidency. “And there is an inherent conflict between politics and medicine.”
  • “It was an election season for F.D.R., too, when his health worsened so dramatically. Perhaps Trump, like F.D.R., is also in denial about the seriousness of his illness.
  • “behaved irresponsibly and with willful ignorance about the gravity of the pandemic, a true public health crisis, and his insistence on leaving the hospital today only underscores his juvenile, self-interested behavior.”
  • So Mr. Trump’s doctor appears to have chosen another route, obfuscating details with vague timelines and imprecise language.
  • The net result of Mr. Trump’s hospitalization has been widespread confusion among those who may have been exposed by the president and others around him who have tested positive for the virus, and a general sense that his care is being coordinated less by medical professionals than the West Wing.
  • Mr. Trump’s insistence on trying to resume normal activities when he has a highly contagious and notably volatile illness
  • “But if there is a suspicion that a patient will knowingly and purposefully endanger others, there would need to be a discussion had about keeping that patient in the hospital against his will.”
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Trump Says He's Beaten Covid-19. Doctors Aren't So Sure. - The New York Times - 0 views

www.nytimes.com/...trump-virus-doctors.html trump pandemic crisis
shared by kaylynfreeman on 07 Oct 20 - No Cached
  • no fever, only slightly elevated blood pressure and a blood oxygen level in the healthy range.
  • But when reporters asked him for results of Mr. Trump’s chest X-rays and lung scans — crucial measures of how severely the president has been sickened by Covid-19 — Dr. Conley refused to answer, citing a federal law that restricts what doctors can share about patients.
  • it was premature to declare victory over an unpredictable, poorly understood virus that has killed more than 210,000 people in the United States.
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  • Far from having vanquished Covid-19, the outside doctors said, Mr. Trump is most likely still struggling with it and entering a pivotal phase — seven to 10 days after the onset of symptoms — in which he could rapidly take a turn for the worse. He’s 74, male and moderately obese, factors that put him at risk for severe disease.
  • For many, it was a political stunt. For Dr. King of UCSF, who was watching on C-SPAN, the return to the White House was an opportunity to observe how the president breathed.
  • Some experts said that the decision to give Mr. Trump dexamethasone could be a sign that he was struggling with more serious Covid-19 than his doctors were revealing, or that his doctors had inappropriately prescribed him the drug.
  • severe form of Covid-19, with impairment of the lungs and a blood oxygen level below 94 percent, which is a cutoff for severe disease.
  • paused twice while walking across the lawn — whether to wave to cameras or to catch his breath, he said was not clear — and then appeared to be gasping for breath at the top of the stairs. He and others said Mr. Trump used his neck muscles to help him breathe, a classic sign that someone’s lungs are not taking in enough oxygen.
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