Mr. Sanchez was my hospital roommate for three days
when I had to go and have my aortic valve replaced.
He was 83 years old, deaf in one ear,
and scheduled for a triple bypass.
He had near constant minor pains
and was always pressing the nurse call button
and describing his current level of discomfort:
It’s a one, now…or a two…wait…three…definitely a three…
A nurse would come and give him handfuls
of little pills that dissolved beneath his tongue.
Oh…it’s back down to a two, now…one…zero, it’s zero now, thank you…
The nurse would go away and within a few minutes
Mr. Sanchez would be pressing at the button again.
Nurse, it’s back to a two…maybe two and a half…
The nurse would return with more little pills
and it went on like this throughout the day.
Whenever the nurses changed shifts
the new nurse would have to check Mr. Sanchez’ vitals
and ask him the same series of questions:
Did you used to smoke, Mr. Sanchez?
Oh yes, too much.
For how many years did you smoke?
I started at 16, so about 60 years I guess. I usta smoke about 3 packs a day.
Oh yes, I was a merchant marine, and that’s what we did – smoke and drink, smoke and drink…
You have a tattoo, Mr. Sanchez?
I sure as hell do.
Mr. Sanchez pushed up the sleeve of his gown
to reveal the face of a pretty young woman
and a faded name scrawled beneath.
I got this in Okinawa in 1963.
Mr. Sanchez sat up and started
to tell the story of the woman’s face
upon his arm but the nurses only
wanted to know what color of jello
he preferred for lunch.
He always asked for red
but they only had yellow
About the Author:William Taylor Jr. lives and writes in the Tenderloin neighborhood of San Francisco. He is the author of numerous books of poetry, and a volume of fiction. His work has been published widely in journals across the globe, including Rattle, The New York Quarterly, and The American Journal of Poetry. He is a five time Pushcart Prize nominee and was a recipient of the 2013 Kathy Acker Award. Pretty Words to Say, (Six Ft. Swells Press, 2020) is his latest collection of poetry.
An Epidemic of Overtreatment
By John Unger Zussman
Last month, I previewed Roger Weisberg’s new documentary about medical overtreatment, Money and Medicine, which premiered on PBS on September 25. You can view the film in full on its PBS website. In this post, I’d like to continue the discussion of the issues raised by the film and by readers’ thoughtful comments on my earlier post, with special emphasis on the politics of overtreatment.
In a particularly poignant scene in Money and Medicine, Dywane Stonum shows his elderly mother, Willie Stonum, black-and-white photos of her younger self on an electronic viewer. In one, she holds her first baby while her husband holds her. In another, she smiles proudly, decked out in an elegant jacket, a scarf tied in a bow, and a filigreed hat. “Here’s your favorite picture,” he tells her.
Willie Stonum doesn’t stir, or blink, or even acknowledge his presence.
Ten months earlier, she suffered a massive stroke. Now she languishes in her bed at UCLA Medical Center, occasionally opening her eyes. She is on a ventilator, uses a feeding tube, relies on dialysis, and needs constant medical support to maintain her blood pressure and fight pneumonia and other infections. Her Medicare bills exceed $5 million.
Dywane Stonum is his mother’s proxy for medical decisions. “I feel like my mom is my baby,” he says. “If there’s something that can sustain her medically, she would want that. Miracles happen if you believe in miracles. You do everything you can to preserve life. That’s what my mother would want.”
After ten months, UCLA’s Ethics Committee has decided that, should Willie Stonum experience another crisis, no heroic efforts should be undertaken to save her life. Dywane Stonum is incensed. “They’re pulling the plug,” he protests. “I call it a medical execution. It is euthanasia.”
“We do not practice euthanasia under any circumstances,” says Dr. Neil Wenger, chair of the Ethics Committee. But “it’s possible to use these advanced tools not to help patients, but to prolong a death, or to produce more suffering or less comfort. And under those circumstances, physicians may well say no.”
Nine years ago, my wife and I stood by my brother-in-law’s ICU bedside with his wife, daughter, and son-in-law. At age 59, after living with kidney disease for years, he had passed out and fallen in his bedroom. Although his wife quickly called 911, he had lost brain function by the time the paramedics arrived. Now we held hands and cried softly as the nurse removed his breathing tube. Minutes later, he died peacefully.
Long before his ultimately fatal illness, my brother-in-law had made this decision easy on his wife. “No way I want to live like a vegetable,” he told her, and us, and anyone who would listen. “Pull the plug. Put me out of my misery.” When he died, we felt relieved, not guilty. We were absolutely certain that’s what he would have wanted.
Leaving aside the question of why Willie Stonum is occupying a bed at UCLA—at a cost of over $16,000 a day—rather than at a nursing home, it is impossible not to wonder if she would want this kind of prolonged death—and if she ever had that conversation with her doctor or her son.
Of course, a proposal to compensate physicians to counsel their Medicare patients about end-of-life care options was originally included in the Affordable Care Act, often known as Obamacare. But when Sarah Palin falsely branded it a “death panel”—a claim that merited PolitiFact’s Lie of the Year award in 2009—it was removed from the bill.
Money and Medicine shows us two patients having just this conversation with their doctors at Intermountain Health Care in Salt Lake City. One, Davis Sargent, is suffering from end-stage congestive heart and kidney failure. “When it’s time, it’s time,” he says. “Of course I don’t want to die, but going out kicking and screaming doesn’t change the going out.” Sargent makes it clear that, instead of rescue care in an ICU, he wants hospice care at home. “I’m only 6 feet from a nice place to sit in the sun in the front yard, and I love that more than anything else.”
After his discharge, Sargent received comfort care at home for ten days before he died—as he wished—surrounded by his loved ones.
The film argues that reducing overtreatment at the end of life is not simply a question of reducing costs—it’s also what patients want when given the choice. “To deny people an opportunity to talk about death, to discuss how they want to die, to be given choices about dying, I think is a really cruel thing,” says Shannon Brownlee, acting director of the Health Policy Program at the New America Foundation, and the author of Overtreated: Why too much medicine is making us sicker and poorer. “And we have to start being able to talk about it. And not just because we’re spending a huge amount of money on it, but because a medicalized death is not what most people want.”
That sentiment is echoed by Sir Thomas Hughes-Hallett, former CEO of Marie Curie Cancer Care in the UK. “It’s not about hastening death,” Hughes-Hallett said in a recent New York Times Op-Ed. “It’s about recognizing that someone is dying, and giving them choices. Do you want an oxygen mask over your face? Or would you like to kiss your wife?”
Money and Medicine shows us overtreatment in a variety of settings and contexts. Filmmaker Weisberg argues that overtesting, overtreatment, and waste are inherent in the way we provide health care in the U.S. Our whole system is geared toward doing something rather than nothing, even when it doesn’t help or causes harm.
But there are alternatives, even within the current health-care system. Money and Medicine profiles Intermountain Medical Center, where Sargent received end-of-life counseling, as a case study in designing the best available science into care. IMC takes time to educate patients in the real risks and probabilities of both disease and treatment. And it regularly reviews practices and metrics in light of medical evidence.
For example, “elective induction of birth” by cesarean section has proliferated in much of the U.S., not for any medical reason, but for the convenience of patient and/or doctor. When IMC realized that more than a quarter of obstetrician referrals for elective C-sections were poor candidates for the procedure, they instituted team reviews of the cases. “Maybe I need my counselor who advises the surgery to not be the surgeon,” reasons Brent James, IMC’s chief quality officer. This resulted in a dramatic drop in C-sections, fewer babies in need of neonatal intensive care, and a savings of $50 million. Ironically, IMC suffered financially by receiving lower reimbursements because it performed fewer expensive procedures.
And this upside-down system of reimbursements—fee-for-service medicine—is at the core of the problem. Money and Medicine demonstrates that overtesting and overtreatment are not isolated or accidental, but integral parts of the American medical system. Every decision, every incentive—for patient, doctor, hospital, pharmaceutical and device manufacturer, insurer, and politician—is weighted toward doing more rather than less, even if it causes harm.
Of course, it’s wasteful—it consumes, by one estimate, 30% of U.S. health care spending, or $800 billion a year. But, as IMC’s James puts it, “one person’s waste is nearly always another person’s income.” In fee-for-service medicine, no one gets paid unless the test is ordered, the medication is prescribed, or the procedure is performed.
It would be one thing if overspending and overtreatment resulted in positive patient outcomes. But the U.S. achieves, at best, middling results when compared to other Western countries, while outspending them significantly. The system’s defenders like to point to foreign “medical tourists” who come to the U.S. for treatment, and the Deloitte Center for Health Solutions estimated there were more than 400,000 of them in 2008. But that number is dwarfed by the 1.5 million Americans who sought health care abroad in the same year.
Stanford geriatrician Dr. Walter Bortz blames overtesting and overtreatment on the collision of biology and capitalism in fee-for-service medicine:
I’m a capitalist, I believe in capitalism; it’s the best social contract we have to make the gears of society work. But it’s selling the wrong product. Our capitalism sells disease. We want you to bleed. Or we want you to have a spot that we don’t know, and that will generate X-ray after X-ray after X-ray … Stanford, where I love my life, is a repair shop. You go there to get fixed. Why? Because we can send you a bill for that.
The emphasis on profit means that we haven’t even done enough research to know which of our current treatments are actually working. Pharmaceutical and device manufacturers, who underwrite clinical trials, have no incentive to finance research on drugs and devices that are already making them money. “Medical research is dominated by research on the new: new tests, new treatments, new disorders, new fads, and new markets,” says Dartmouth professor Dr. H. Gilbert Welch. “We have to start directing more money toward evaluating standard practices—all the tests and treatments that doctors are already providing.”
I wish Money and Medicine had the time to show in detail the harm that can be caused by excessive screening tests and treatments, since many patients (and even doctors) discount it. What’s the downside, they reason, in getting an annual PSA or mammogram, or in receiving chemotherapy that reduces your chance of recurrence by a couple more percent? But as James says, “treatments that are powerful enough to heal can also harm.” This was illustrated last June, when Good Morning, America co-anchor Robin Roberts, who had gone public with her successful battle with breast cancer in 2007, announced that she was diagnosed with myelodysplastic syndrome (MDS). MDS is a bone marrow disease often caused by chemotherapy and radiation received in an earlier cancer treatment. “We always think of the drug as a double-edged sword,” says Otis Brawley, chief medical officer of the American Cancer Society. “It’s one of the reasons why I’m outspoken about only using chemotherapy when we absolutely need chemotherapy.” Roberts received a bone marrow transplant earlier this month.
With health care a central issue in the current presidential election, I asked Weisberg how the Obama and Romney campaigns would address the overtreatment and waste issues raised in his film. He began with Obamacare:
The Affordable Care Act that the Supreme Court recently upheld extends health care coverage to over 30 million uninsured Americans but actually does very little to make health care more affordable. The main thrust of the legislation was to expand access, not to contain costs. However, there are a number of provisions that fund demonstration projects that attempt to alter the reimbursement system in order to reward value instead of volume—to reward the quality instead of the quantity of medical services. One of the best-known initiatives involves the creation of Accountable Care Organizations or ACOs.
If the Affordable Care Act doesn’t actually do enough to make health care affordable, it’s tempting to blame Republicans and their lies about death panels. But let’s remember that the Obama administration gave away much of the store before the debate actually began, in its attempt to win support from industry and Congress. For example, in exchange for support and cost concessions from the Pharmaceutical Researchers and Manufacturers Association (PhRMA), the White House agreed not to use government leverage to bargain for lower drug prices or to import drugs from Canada.
But at least the ACOs encouraged by Obamacare take a shot at overturning the overtreatment incentives of fee-for-service medicine. Romney’s plan—to the extent he has revealed it—aims to reduce government expenditures for health care, but not the costs or structure of health care itself. Weisberg’s take:
The Romney plan, like many of his policies, is not terribly fleshed out. His mantra is “repeal and replace.” What we do know is that he would make Medicaid a block grant program, leaving states to struggle with declining budgets and decide who gets what kind of care. He would also turn Medicare into a voucher program, with the result that over time the voucher would cover a smaller and smaller portion of the medical bills of seniors.
As I write this, shortly after the final presidential debate, the campaigns have not seriously discussed medical overtreatment or cost control. In fact, so far they have not progressed beyond a fight between siblings. “You want to destroy Medicare!” “No, you do!”
Faced with governmental inaction, hospitals and professional medical organizations have begun to take responsibility for reducing overtreatment and waste in their own domains. Memorial Sloan-Kettering Cancer Center and the Mutual Of Omaha Medicarerecently decided to drop an expensive new colorectal cancer drug (Zaltrap) from its formulary, despite the fact that Medicare would reimburse them for it. The reason: it works no better than a similar drug (Avastin), but costs more than twice as much.
Another ray of hope comes from the Choosing Wisely initiative, sponsored by the American Board of Internal Medicine Foundation. The initiative has recruited professional associations for major medical specialties, like the American Association of Cardiology and the American Society of Clinical Oncology. Each association has identified “Five Things Physicians and Patients Should Question”—common tests or treatments that are expensive, overused, and unsupported by medical evidence. Working with these professional societies, Consumer Reports has compiled clear and objective guidelines for patients on such topics as heartburn, Pap tests, and lower back pain. As the film suggests, when patients are informed about the choices available to them and their risks and benefits, they are less likely to choose overtreatment. (My thanks to Cameron Ward for alerting me to this site in a comment to my earlier post.)
Some commentators maintain that, to truly control health care spending in the U.S., we need to ration health care. “In the famous ‘third rails’ of American politics,” argues Steven Rattner, former counselor to President Obama’s treasury secretary, invoking the spectre of death panels, “none stands taller than overtly acknowledging that elderly Americans are not entitled to every conceivable medical procedure or pharmaceutical.”
In the long run, that’s probably true. But we’re not there yet—not even close. There’s plenty of low-hanging fruit to pick first. “It’s not rationing to get rid of stuff that’s bad for you,” says Brownlee, author of Overtreated. “It’s not rationing to get rid of care that won’t benefit you.” In the film, she cites a recent study of late-stage cancer patients that compared palliative care—making the patient comfortable without actively trying to combat the disease—to standard, aggressive treatment. The patients who received only palliative care actually lived longer than those who received the standard treatment.
“This isn’t withholding necessary care,” echoes IMC’s James. “It’s withholding unnecessary injuries.” Eliminating overtesting and overtreatment have little downside and great upside. But to do that, we need to rely on science to sort out which tests and treatments are medically warranted. And we need to eliminate the incentives of fee-for-service medicine and embrace an ACO model in which healthy outcomes, not tests and treatments, are rewarded.
It’s time to have that “adult conversation” our leaders keep promising—whether they choose to participate or not.
If you listen to the Republican talking heads on cable news, bipartisanship just died. But the end of bipartisanship wasn’t last Sunday, or last week, or last month, or even last year. It was in 1991.
“In the spring of 1991, more than a year before the Democrats nominated Clinton, [House minority leader Newt] Gingrich was discussing long-term political strategy with a friend as they strolled around the Washington Monument at about six o’clock one morning. In a moment that he recalled vividly, Gingrich was seized by the conviction that the ‘next great offensive of the Left,’ as he put it, would be ‘socializing health care,’ because the Left, as he put it, was ‘gradually losing power on all other fronts, and they had to have an increase in the resources they controlled. We had to position ourselves in the fight before they got there or they might win….’
“Killing the Clinton reform was a critical means to achieving [control of Congress]. Had any part of the Clinton plan passed that Congress in any form, Gingrich and his closest conservative allies believed, their dreams for forging a militantly conservative future would ‘have been cooked,’ as a key Gingrich strategist later explained.”
— Haynes Johnson & David S. Broder, The System: The American Way of Politics at the Breaking Point. Little, Brown, 1996.
In other words, Gingrich decided he was against the Clinton health care plan in 1991 — more than two years before he knew what it would contain, and 18 months before Clinton even became president. He foresaw that Clinton would be elected, that he would try to put forward a plan for reforming health care, and that, if passed, it would be popular enough to derail for years his goal of Republican control of government. And he set himself to defeat it on that day, whatever its actual policies, because of partisan politics.
Eight Single Payer activists were arrested in May for attempting to tell the truth about health care reform at the Senate Finance Committee meeting.
Corporate Dems, “Single Payer” Health Care, and Two Party System Failure–All Made Real Simple
It is only natural that so many people are talking about health care and health care reform these days. I cannot express how excited I am to see the grassroots effort that many of my friends and colleagues have participated in, finally get the national attention it deserves.
But I have to be honest here…
Most of the conversations I hear swirling in and out of coffee shop doors, hovering outside entrances of local pubs, and even those that have boldly entered the confining walls of academia are incredibly misinformed. In these conversations I hear people throwing around words like “single payer” and “universal” interchangeably… Using words they don’t even know the meaning of, like they coined the words themselves.
At a social networking website recently, I noted one person admitting in a comment thread that he knew nothing about Obama’s proposed health care plan, but acknowledging, in the same breath, that reform is needed. This person took the “I trust Obama, so just pass the bill through” stance. I navigated away from this site only to return to someone else grumbling about how he shouldn’t have to pay another dime to support the “deadbeat Americans who are too lazy too work”.
I looked down at my check stub for a moment and did some quick math. Then I decided to visit the World Health Organization’s (WHO) website to look at their health care rankings. France currently holds the number 1 ranking for the best health care system in the world. Their citizens pay about 10% of their income in taxes. This includes militia, health care, transportation, etc. I looked down at my check stub again, noting duly, that I pay roughly 23% more in taxes than the average French citizen, work more hours a week on average, and if I get sick, well… I’m fucked.
This past week the House Democrats presented their health care reform bill. While many people believe that a step in any direction, is a step forward regarding an issue that has been immobile for so long, Obama’s plan—even if it passes—it destined to fail.
Because it keeps the insurance industry in the game.
It will cost a trillion dollars over ten years.
It won’t cover tens of millions of Americans.
It won’t control costs.
And it’s a bailout for the insurance industry.
Only a single payer — everybody in, nobody out — national health insurance bill (co-sponsored by 85 members of the House — most recently by Congressman John Murtha (D-Pennsylvania) will hit the grand slam — cover everyone, save money, control costs, and fix a broken health care system.
But what struck me yesterday while watching the Democrats was the depth of their deception.
There was Speaker Nancy Pelosi and Majority Leader Steny Hoyer.
Both heaping praise upon and honoring Congressman John Dingell (D-Michigan).
And his father — John Dingell, Sr.
John Dingell, Sr. represented Michigan’s 15th district for 22 years until his death in 1955.
John Dingell, Jr. has represented the district ever since.
But not once during the press conference did anyone mention that it was John Dingell, Sr. who first introduced a single payer bill in Congress in 1943.
And it was Democratic leaders in Congress and President Barack Obama who took single payer off the table.
The Republicans will tell you straight up — we’re for big business.
Single payer is socialism.
And that’s why we’re against single payer.
When the Democrats are out of power, they will tell you what you want to hear — we’re for single payer.
They then take power, and all of a sudden, they are against single payer.
Take Henry Waxman (D-California) as a case in point.
For years, Henry Waxman was a co-sponsor of HR 676 — the single payer bill in the House.
Until earlier this year, when he became part of the leadership in the House.
Then Waxman took his name off the single payer bill.
In 2003, Barack Obama said he was for single payer.
Obama said at the time that we would have single payer in America only when the Democrats took back the White House and Congress.
Last year, Obama and the Democrats took back the White House and Congress.
And now President Obama is opposed to single payer.
The reality is that there is only one solution to the health care crisis — get the insurance companies out of health care.
The Democrats are now engaged in what Dr. Marcia Angell — former editor of the New England Journal of Medicine — calls “the futility of piecemeal tinkering.”
Angell and a majority of doctors in the United States — and a majority of the American people — believe that only a major single payer overhaul will get the job done.
That’s why we’re challenging the Democrats around the country.
And we will continue to challenge them, and the health insurance industry to whom they are beholden, until single payer becomes a reality in America.
Many health care reform advocates warn that we need to press for “single” payer” and not the “public option” for many reasons: the public option is NOT single payer, it does not confer the benefits of single payer, and is too expensive. The inevitable failure that will result from the “system” including the public option but which also preserves the insurance companies, will only serve to discredit the idea of single payer and set back present and future efforts.
So what’s the solution?
I believe Dennis Kucinich is headed in the right direction with HR676, which is explained in the following:
Healthcare: Change the Debate
Support a Real Public Option
In mid-May, in an effort to reach consensus, President Obama secured a deal with the health insurance companies to trim 1.5% of their costs each year for ten years saving a total of $2 trillion dollars, which would be reprogrammed into healthcare. Just two days after the announcement at the White House the insurance companies reneged on the deal which was designed to protect and increase their revenue at least 35%
The insurance companies reneged on the deal because they refuse any restraint on increasing premiums, copays and deductibles – core to their profits. No wonder a recent USA Today poll found that only four percent of Americans trust insurance companies. This is within the margin of error, which means it is possible that NO ONE TRUSTS insurance companies.
Then why does Congress trust the insurance companies? Yesterday HR 3200 “America’s Affordable Health Choices Act,” a 1000 page bill was delivered to members. The title of the bill raises a question: “Affordable” for whom?.
Of $2.4 trillion spent annually for health care in America, fully $800 billion goes for the activities of the for-profit insurer-based system. This means one of every three health care dollars is siphoned off for corporate profits, stock options, executive salaries, advertising, marketing and the cost of paper work, (which can be anywhere between 15 – 35% in the private sector as compared to Medicare, the single payer plan which has only 3% administrative costs).
50 million Americans are uninsured and another 50 million are under insured while for-profit insurance companies divert precious health care dollars to non-health care purposes. Eliminate the for-profit health care system and its extraordinary overhead, put the money into healthcare and everyone will be covered, everyone will be able to afford health care.
Today three committees will begin marking up and amending HR3200. In this, one of the most momentous public policy debates in the past 70 years, single payer, the only viable “public option,” the one that makes sound business sense, controls costs and covers everyone was taken off the table.
In contrast to HR3200 … HR676 calls for a universal single-payer health care system in the United States, Medicare for All. It has over 85 co-sponsors in Congress with the support of millions of Americans and countless physicians and nurses. How does HR-676 control costs and cover everyone? It cuts out the for-profit middle men and delivers care directly to consumers and Medicare acts as the single payer of bills. It also recognizes that under the current system for-profit insurance companies make money NOT providing health care.
This week is the time to break the hold which the insurance companies have on our political process. Tell Congress to stand up to the insurance companies. Ask members to sign on to the only real public option, HR 676, a single-payer healthcare system.
Hundreds of local labor unions, thousands of physicians and millions of Americans are standing behind us. With a draft of HR3200 now circulating, It is up to each and every one of us to organize and rally for the cause of single-payer healthcare. Change the debate. Now is the time.
There are approximately 200 countries that exist on our planet and each of these countries has devised its own plan to meet the health care needs of its citizens. When studying collectively the health care systems of the world, one will note that four patterns tend to emerge. Hence, health care systems can be divided, for the most part, into four basic models. A brief outline of the four health care models can be found at : http://www.pbs.org/wgbh/pages/frontline/sickaroundtheworld/countries/models.html.
The United States is unlike every other country because it maintains so many separate systems for separate classes of people. All the other countries have settled on one model for everybody. This is much simpler than the U.S. system; it’s fairer and cheaper, too. The time for health care reform in the United States has finally come. It is imperative that we educate ourselves and press our government to make the right decision. A weak foundation now, will be the cause of failure in the future. How much more failure can we afford?
Kara Allison is an academic librarian, freelance writer, and activist living in Cincinnati, Ohio.