PNHP members react to Time's ‘Bitter Pill’

PNHP note: In addition to longer commentaries by Dr. James Kahn and Dr. Don McCanne on Steven Brill’s special report in Time magazine titled “Bitter Pill: Why Medical Bills are Killing Us,” many members and supporters of Physicians for a National Health Program sent in letters to the editor of the magazine. We reprint here a selection of those letters, none of which have been among the 21 letters published to date.Bitter Pill

Accurate data, flawed conclusions

In “Bitter Pill,” a well-researched and in many ways thoughtful essay, Steven Brill gets all the data right, but then draws conclusions that are surprisingly off the mark.

After providing nearly 20 pages of damning evidence -- against both the excesses and inefficiencies of the private health insurance industry, and the runaway profiteering of hospitals, pharmaceutical and device manufacturers -- he arrives, or appears to arrive, at the obvious point: that is, “the best way both to lower the deficit and to help save money for people” is “the single payer approach favored by liberals and used by most developed nations.” Here he is right on the mark. But then abruptly, having just provided an argument that clearly supports it, he dismisses this conclusion. He provides two reasons for backing away from single payer: first, “no doctor could hope for anything approaching the income he or she deserves (and that will encourage future doctors to want to practice).” Second, “this kind of systemic overhaul ... seems unrealistic” given the extraordinary political power and influence of the health care industry.

The first assertion is factually incorrect. In fact, most doctors would earn the same under a single-payer system as they do now. The main difference in the professional life of myself and of tens of thousands of physicians like me would be freedom from the unimaginably exhausting and time-consuming demands of private insurance company rules and regulations. For those doctors whose high incomes ($1 million or more annually) result from billing for individual procedures like cardiac catheterization and joint replacements, incomes would likely suffer somewhat, but would certainly remain in the mid- to high-six figures. It’s hard to believe that as a nation, we would reject such urgently needed reforms simply to protect these multimillion-dollar salaries.

The second assertion -- that it “seems unrealistic” for Medicare to be improved and expanded to include comprehensive coverage for all Americans -- is logically flawed. Brill himself admits that the halfway measures he goes on to propose are similarly “unlikely to happen” given the current political power structure. Beyond this, if our society had followed his logic in 1917 or 1954, today we’d be living in a country where women were forbidden to vote and where schools were separated by race.

The injustice of our current health care system is a civil rights issue as urgent as women’s suffrage and desegregation. Now the oppressed are not only women or minorities, but all of us who find ourselves outside the 1 percent of wealth and influence. An improved and expanded Medicare for All would change this. Virtually all other developed countries know this. When will we wake up to this?

Jim Recht, M.D.
Cambridge, Mass.
The writer, a psychiatrist, is co-chair of Massachusetts PNHP.

Brill missed the elephant in the room

Mr. Brill focuses on eight hospital billing statements yet dismisses the American private insurance industry as “ho-hum.” He missed the biggest elephant in the room. The largest single expense in American medicine is the administrative costs of private insurance that would be recovered with a single payer financing plan – that’s $350 billion annually and rising. That $350 billion represents 40 percent of our premium dollars. Half are insurance industry administrative costs; the other half are physician and hospital costs to collect from insurance companies. Remember this industry denies 30 percent of all first claims, requiring physicians to spend $82,000 each to pay clerks to persist in second and third claims.

That $350 billion is more than the combined income of all American physicians; more than the nation spends on all medications; more than we spend on obesity and tobacco-related diseases – combined; and more than we need to expand care to provide complete coverage of everyone in the country.

Every other industrialized nation provides better care to more people for less money than we do, and none use a private insurance industry like ours. Replacing it with a national single payer financing agency, even with no change in hospital billing, will provide everyone in the U.S. with health care for less than spend now. Mr. Brill found the bitter pill but missed the elephant.

Samuel Metz, M.D.
Portland, Ore.
The writer, an anesthesiologist, is a member of the Oregon chapter of Physicians for a National Health Program.

Cure for ailing health system falls short

Mr. Brill’s excellent article does a wonderful job of showing just how expensive, chaotic, dysfunctional and inequitable our health care “non-system” is. However, his prescription for the cure for this “lethal” system leaves much to be desired.

As a physician for 40 years, a Medicare recipient, a patient and an advisor for Medicare Rights helping seniors navigate the complicated terrain of today’s Medicare, I have come to a see that there is a better way to reform. I believe that a single-payer, publicly funded, privately delivered, Medicare for All is the best solution to our health care problem. Treating health care as a social need and not as a commodity from which to make a profit is the only moral path to health justice. It is also the most fiscally conservative solution. All other industrialized nations have already figured this out.

We need to learn from them.

Elizabeth Rosenthal, M.D.
Larchmont, N.Y.
The writer, a dermatologist, is a board member of the N.Y. Metro Chapter of PNHP.

Medicare for All would drive down costs

As someone who has worked on all sides of the health care field (regulator, nonprofit, for-profit) for 30 years, I was intrigued by the Brill piece “Why Medical Bills Are Killing Us.” On the analysis of the problem, Brill was mainly on target, but he missed the mark on most of his proposed solutions. For example, hospital competition is not the answer to getting lower prices and never has been. Hospital coordination of services within a region via regulation is a far more cost effective way to minimize duplicative purchases of expensive technology, for instance. Furthermore, group purchasing of supplies, pharmaceuticals and capital equipment by large, strong hospital systems has been shown time and again to drive down vendor prices by up to 20 percent versus pricing given to small independent hospitals with no clout. I know: I supervised hundreds of these studies in every area of the country and with many providers, including Sloan-Kettering. He glosses over the real solution: a single-payer system which forces hospitals to be more efficient. Medicare for All, incorporating quality measures, would eliminate all the “chargemaster” game playing Brill decries. The inefficient providers would be paid the same as the effective ones. With higher costs, they would be driven out. Likewise for the ones with poor quality. Plus, the 20-plus percent administrative/marketing costs currently charged by private insurance companies, versus just 3 percent with Medicare, could be put back into direct care where it belongs.

Jack Bernard
Monticello, Ga.

Mere tweaks won’t solve the problem

Steven Brill, in his well-researched special report, “Bitter Pill,” built a definitive case for further improving Medicare and then providing it for everyone as a single-payer national health program. Citing the power of special interests, he then rejects that concept and leaves us with a recommendation for a few tired ideas that would only tweak our dysfunctional health care system. It is time for us to accept the fact that the only special interest that really matters is the patient.

Don McCanne, M.D.
San Juan Capistrano, Calif.
The writer is senior health policy fellow, Physicians for a National Health Program.

Medicare model points the way

Steven Brill rightly identifies the heart of our health care cost problem as wildly inflated charges as well as wasteful diversion of health care dollars to corporate profits enforced by governmental protections for corporate interests. He also rightly notes that LOWERING the age of eligibility for Medicare (making Medicare available to more people) would improve/reduce our health care costs. But then he waffles and says that he isn’t going to come right out and support “single payer,” when, of course, he has just made a case for the single-payer system we have right now that is working so well: Medicare. I’m not sure why he does this, but let me underscore again his observation that Medicare is functioning well, that it does not pay the wildly inflated charges, and that we should make the Medicare option available much more widely -- ideally available to all -- if we are to bring health care costs under control without simply requiring all patients to pay for everything out of pocket (as increased co-pays or as payment for coverage denied by corporate insurance plans).

Judy Bertelsen, M.D.
, Calif.
The writer practices geriatric medicine and is a member of PNHP California.

Why not turn to ‘most logical’ solution?

Steven Brill’s “Bitter Pill: Why Medical Bills are Killing Us” describes the irrationality of the health care market and underscores its gross unfairness toward our nation’s patients, be they insured, underinsured or uninsured. However, Mr. Brill’s remedies for this mess (“tax hospital profits at 75 percent and have a tax surcharge on all non-doctor hospital salaries that exceed, say, $750,000” and “outlaw the chargemaster”) seem more contorted and less workable than what Sloan-Kettering’s chief operating officer, John Gunn, called the “most logical solution” -- a single-payer system, an expanded and improved Medicare for all. The Medicare model is a much simpler, economical way of paying for care, and from the look of the shiny new hospitals in retiree-laden Florida, it’s clearly viable.

Roy Korn, M.D.
Middleburgh, N.Y.
The writer is an internist who specializes in geriatric medicine.