California Road Trip, Home in Oregon

Katie Ottaway in Chico

On the “long march” through California this fall (and across the country last fall), with surprising consistency, the size of our audience was inversely proportional to the size of the community.  Indeed, almost three hundred people greeted us for our last event in Chico, far surpassing any of our audiences in L.A.  Perhaps people in smaller towns feel more empowered.  Perhaps webs of relationships are more interconnected.  Who really knows?

During our long drive up I-5 to green Oregon, we pondered another question.  “Was the California Road Trip worth all the effort that went into it?”  The denominator is measurable in money, time, and a substantial carbon footprint.  Measuring the numerator is more elusive.   By most accounts, the MAHD Road Show was entertaining and many people deepened their understanding of why our sick care non-system remains profoundly broken.  We made new friends in every community.   We gained greater clarity.  We had fun and we consumed our share of margaritas.  But what energy did we leave in our wake as we moved to from town to town?  Is anybody we touched even reading this?   If so, please respond.  Your perspective is valuable.

I know it feels better to toil in futility than wallow in defeat.  I’d like to think we are tilting at windmills.  More accurately, we are storming the Bastille with rubber spears.   We aren’t going to make real progress until there are masses of people who understand the health care conundrum as we do.  How do we create a wider and wider web of relationships to make this happen?  How do we get the right kind of media attention, long enough, to explain the flavor and texture of the real health care debate that needs to progress beyond the sound bites that feed people’s fears?   Lots of questions.  Not many good answers.

In any case, it’s nice to be home with the family.

–paul hochfeld

California Road Trip, Day 20, Nevada City/Grass Valley

Cool Hand Yuke warming up the crowd at the Historic Nevada City Theater

On Monday evening, we spoke to a packed house of 270 people at the Historic Nevada Theater, where Samuel Clemens performed long ago.  No fooling.

As usual, it was an enthusiastic crowd of single payer supporters with scattered skeptics.  One of the local docs asked my favorite question, “Wait, if we spend twice as much as the rest of the world and we only waste 20-25% of our health care dollars servicing the insurance industry, what about the rest of it?”    The video Health, Money and Fear systematically illuminates the multitude of other perverse incentives that drive up cost.  They include the abuse and overuse of technology, fear of liability, pressures for profits, near-criminal behavior of Big Pharma, chaos in medical records, primary care shortage, and frequent poor choices near the end of life, when far too often we spend unimaginable amounts of money keeping people alive to suffer longer.   Until we understand that we are all paying for everybody, put everybody in the same risk pool and manage our health care money to maximize health, we are never going to be able to get a handle on all those other cost drivers.

Passed out in what used to be the Operating Room

Disallowing the insurance companies to reek havoc by segregating us into favorable and unfavorable risk pools is the first necessary, but not sufficient, step to creating a real health care system focused on earning real value for our health care dollars.

Last night, we lodged in the Swan Levine House in Grass Valley, formerly a hospital from 1906-1968.  My bed is in a quaint room that used to be the operating room.  No fooling.

California Road Trip, Day 19, Davis

Our Davis audience, listening to their Mayor

Fall is upon us and the OSU Beavers are now 2-0 in Pac-10 play.  Sitting at a coffee shop in Bike City, USA (Davis) with a leaf blower wailing in the background, I ponder how to present my thoughts without sounding overly judgmental…

Before our evening presentation, we dined with our hosts who had also invited a skeptical third year medical student.  Ryan seemed primarily concerned that the “single payer” would dictate reimbursement levels, leaving physicians with little recourse to find another payer.   Let’s bluntly talk about physician income.  Generalizations are dangerous, but by all accounts, using the metric of net income,  primary care providers in other countries do “better” and specialists do “worse” than ours.   That said, the foreign doctors have higher job satisfaction than in the USA.  Unarguably, without minimizing the stresses unique to each different specialty,  our committed primary care providers are significantly underpaid compared to a number of the specialists who expect to bring in net incomes well in excess of $400,000/year.

Without minimizing financial incentives, medical students gravitate to particular specialties largely to find a niche that meets their particular interest, skill sets and temperament.   Some fine orthopedic doctors and radiologists would be unhappy, marginal primary care doctors (and vice-versa).   For the extra training and on-call responsibilities, they should should receive extra reimbursement, but how much is enough?   It is important to note that primary care has its unique set of stressors that some specialists would find intolerable.  Dr. Mike Huntington has yet another aphorism to capture this conundrum.  “Maybe the extra training that specialist receive should be the cost they pay for NOT going into primary care.”   In any case, our dire and worsening primary care shortage substantially contributes to our poor health care outcomes.  If our goal to provide value for the all the money we are spending on health care,  we need more primary care providers.  Or is our goal to sustain high, sometimes obscenely high, physician income?  Ouch.

I am confident that whatever flavor of single payer health care we ultimately embrace will reimburse physicians fairly. We will never lack for bright, competent, motivated young people who are willing to work diligently for the privilege of becoming a physicians.

As we departed our evening venue, a primary care doctor, now working for UC Davis Student Health, asked, “How are you ever going to get the specialists to sign on to this?”   Indeed, the physician community has been sadly MIA (missing in action) during the great health care reform debate.  Primary care docs, who are predominantly supportive of a single payer solution,  are buried in patients and paperwork, struggling to pay for the health care benefits of their employees.  Specialist are, for the most part, making a pretty darn good living, working in the heart of our Health Care Dragon… that costs us twice as much as most of the rest of the industrialized world and, by almost any measure of community health, yields very poor results.

It’s a lot less painful to think about football.  Go Beaves!

–paul hochfeld

California Road Trip, Day 18, Stockton

Philip Kauffman, our road manager picnicking in Visalia, taking a break from herding butterflys.

Our organizers in Stockton have demonstrated spectacular hospitality, including providing us hotel rooms, where we found baskets with a cornucopia of gifts, mostly food, but also wine and a cork screw.  It was over the top but much appreciated.

Shortly after our arrival, I spoke briefly with the former Director of the “county hospital” San Joaquin General (SJGH), from which we were banned.  See yesterday’s post for details.   Once upon a time, SJGH was a vibrant, healthy hospital that required little subsidies from the county.  They offered a panoply of services including a neonatal intensive care unit which was quite profitable, subsidizing the care of those without resources.   We call that “cost shifting”.  Over time, other facilities, with deeper pockets, have invested in and offered redundant services focusing on those that are most profitable.   The cream is gone but SJGH’s mission remains… leaving it with a 10-20 million shortfall, subsidized by county taxpayers.  A local task force is being developed to investigate the situation.   Who’s on committee?  I am sure those whose livelihood depend on the “profitability” of the competing hospitals lust for a chair at the table.  Their agenda?  Continue to keep SJGH alive with a continued infusion of millions of dollars so that their facilities won’t have to care for many of those who are unable to pay their bills.

At the risk of getting wonky, again, remember how insurance companies thrive by avoiding “adverse selection?”   Competing hospitals thrive by avoiding “adverse market share.”   That’s what we are talking about!

Before heading up the road to Davis, I will interview the prior Director of San Joaquin General at greater length this morning.  More juicy details tomorrow.  I can hardly wait.

–paul hochfeld

California Road Trip, Day 17, Visalia


Happy to report, we had a large turnout for our event in Visalia, opened by an awesome  mariachi band.   One of the local speakers introduced himself as a “recovering hospital administrator turned single payer advocate.”

Speaking of administrators, our organizers in Stockton have been working for months to find a space in the local county hospital for an educational event. We were invited by the CNA representative as well as one of the nurses.   After an intitial postitive response, the Director stopped returning calls and emails.   Last week, after looking at our website, he stated unequivocally that the Mad As Hell Doctors are too political.  The “hospital”  has no desire to be embroiled in politics.  How about a gathering on the lawn outside the hospital?   “Nah,” he says and “if you do, security will escort you off the property.”   It mattered little that the hospital loses $10-20 million every year, subsidized by county taxpayers, because our sick care non-system victimizes those that serve Stockton-like communities.  It mattered little that our agenda is not political but social.  We support neither the Republicans nor the Democrats.  We advocate for a health care system that yields “value” for all the money we are spending.  Value, in this case, is measured by health and the alleviation of suffering.

As it turns out, the “Director” is not a county employee.  He works for the consulting corporation that has been hired to manage the hospital… the sort of corporation that profits by the chaos created when health care is considered a commodity.    After mulling over the ramification of all our options, the local organizers decided to respect the Director’s decision.   Subsequently, he (finally) returned my call, followed by a long respectful, amicable chat in which I bluntly stated my disappointment and, among other things, my concern about his conflict of interest.   He’s a gracious, articulate man with a tough job, wearing too many hats.  Dr. Mike Huntington frequently cites Upton Sinclair, “It is difficult to get a man to understand something when his salary depends upon his not understanding it.”

Frankly, one of our options was to gather for our picnic on hospital grounds despite the Director’s objection and threat.  We were prepared to get arrested.  Out of respect for our hosts, who will continue to work with hospital administration, we won’t be getting a tour of the police station.  Bummer.  Sounds like a great adventure.

–paul hochfeld

California Road Trip, Day 16, Still in Los Angeles

Our thoughts are mounting!

Our sick care non-system is far more broken and corrupt than you can even imagine.

We spent the evening with a dear old (like me) medical school friend Dr. Paul Papanek.  After the usual “catching up” and retelling of old stories, our talk turned to, of all things, health care.  As an Occupational Medicine physician, without equivocation he railed that for every dollar paid into the workers’ compensation system, only twenty cents goes to actual care!  Evidently workers compensation is a very lucrative niche for all involved, including carriers, independent medical examiners, and lawyers who seem to have a hand in everybody’s pocket.

He cited a 2008 study of 4,387 of low-wage industries in the three largest U.S. Cities.  Aside from finding rampant violations of minimum wage protections, overtime reimbursement, and food-break laws, of those workers “who experienced serious injury on the job, only 8 percent filed a workers’ compensation claim.”  Furthermore, “When workers told their employer about the injury, 50 percent experienced an illegal employer reaction—including firing the worker, calling immigration authorities, or instructing the worker not to file for workers’ compensation.”  And, “About half of workers injured on the job had to pay their bills out-of-pocket (33 percent) or use their health insurance to cover the expenses (22 percent). Workers’ compensation insurance paid medical expenses for only 6 percent of the injured workers in our sample.”  They concluded, “the workers’ compensation system is not functioning for workers in the low-wage labor market.”    Paul agrees then goes on to say that even those higher paid workers who do get into the system find it badly broken.  It is fraught with perverse incentives and, too often, economic entities profit when a worker doesn’t  return to work.  It’s insane.

Paul’s lovely, lady friend, Tracy is a nurse practitioner with her own story, which she has seen repeatedly.  After an expensive hospitalization, a stroke patient, is discharged with a two month’s supply of medications… intended to decrease the chances of another stroke.  Of course, he can’t afford to pay for them and there’s no systematic mechanism to supply it longer.  Many months later, he arrives in the ER with another stroke and another expensive hospitalization for which we all pay.  Sheesh.

Every week or two, I learn something more about our “system” that suggests it is even more broken and corrupt than I could possibly imagine two weeks ago.  And I keep being surprised by this?

–paul hochfeld

California Road Trip, Day 15, Claremont

Speaking with medical students

Full of fire and insights, Dr. Katie Ottaway, from Port Townsend, Washington, joined us for the duration of our Road Trip.   We’re  no longer  just a bunch of old white men.  Our daytime Claremont event was well attended.  In the evening, we met with some medical students… Pop Quiz! Do you agree or disagree with the following statement?   “If we can’t have Single Payer, the public option would at least be a step in the right direction.”

Yesterday, upon hearing someone say that Medicare is an example of a single payer, I had an epiphany, but not the kind that requires a change of shorts. Grab a cup of coffee and settle in for an important discussion that is key to understanding our health care conundrum.

“Single Payer” does not mean that only single people pay.  It means that we pool all the money we are spending,  put everybody in the same “risk pool” and prioritize our resources to maximize  “our” health and minimize “our” suffering.    If you have been reading these posts, you may remember that we are all paying for everybody anyway (through taxes, tax subsidies and cost shifting).   Truth be known, we waste 20-25% of all of our health care dollars servicing the insurance industry which prospers by carving us into risk pools. I’ve been told that for every dollar an insurance company spends figuring our who NOT to cover, they generate five dollars in profits.  Insurance companies are gamblers. They win by stacking the deck to avoid excess risk, aka adverse selection.

Albeit  publicly owned/operated and truly not-for-profit, the public option would be just another insurance company.  We would insist that it behave ethically and accept all applicants. Unfortunately, as Dr. Mike Huntington is fond of saying, it would be “like a baby swimming in shark infested waters”.   The other insurance companies will use every loophole in the law to legally (and illegally) ensure that all the sickest, most expensive patients gravitate to the public option… which will predictably struggle then fail, NOT because of inefficiency, but because it was designed to be subject to adverse selection.  What’s worse, sometime in the future, when Congress takes on substantive health care reform again (because they didn’t fix it this time),  the insurance industry will point to the failing public option and state clearly, “See! The Government can’t do health care.  Single payer would be a disaster.”  Wrong lesson.  Public option is a trap.

In reality, our senior citizens today already have a public option, Medicare.   So do poor and disable people who qualify Medicaid/MediCal.  Vets use the VA System.  They are all high risk, expensive “risk pools” financed by the taxpayer.  Meanwhile the insurance industry uses taxpayer subsidies to cover those who are least “at risk” (employed people and their children).   It’s insane.

Back to my epiphany.  Medicare is the epitome of a public option that is designed to fail. It’s no wonder Medicare pays providers so poorly and future deficits look so bleak.

Want to fix Medicare, stop wasting $400 Billion dollars, and accomplish true Universal Health with one swing?  Create a single risk pool.  Then expand Medicare’s sleek infrastructure and make it the single payer.   I guess that’s two swings.

Gotta go.  Running out of shorts.   Laundry, two week’s of it, needs my attention.

California Road Trip Day 14 San Clemente

Drs. Marc Sapir and Mike Huntington

Most of the Mad As Hell Doctors took the day off today to sleep in late (8 am), do laundry, and hit the beach.  I traveled back to UCSD, where I observed Molly Tavella, the California PNHP Fellow present the case for Single Payer to medical students in the same room as I digested medical school lectures.  I was reminded of the first lecture on the first day of medical school, when Dr Averill Liebow waited patiently for the nervous chatter to yield to dead quiet.  The first words out of his mouth?  “Compassion without competence is crap!”  Ouch.

A few posts ago, we learned that Insurance carriers are being granted “waivers” so their plans won’t have to comply with either the spirit or the language of  P-PACA. In particular McDonalds is seeking to sustain their feeble annual limits. After some research by our astute butterfly-herding road manager, Philip Kaufman, we have ascertained that 30,000 employees of McDonalds have chosen to enroll in McCrew Care.  For $56/mo, some of them enjoy a $150 deductible and 30% co-pay up to an annual limit of $2,000.   For families who desire the McCrew Cadallac Plan, the cost is $320/mo, for the same deductable and copay but with a whopping annual limit of $5,000.  Wow! Evidently they are quite proud of this perk.  I quote from the McMontana website, “This is truly a unique benefit that only McDonald’s can offer.  We will pay $10 per month towards your premium, which equates to 18% of the premium for Basic – Employee only cost.”

These 30,000 people are included in the ranks of the “insured” along with many others who technically have insurance but “enjoy” profoundly inadequate coverage.  Were he still alive, Dr. Liebow might say, “Health Insurance with inadequate coverage is crap.”

–paul hochfeld

California Road Trip Days 12 & 13: Irvine and San Diego

Dr. Ellen Beck & Dr. Paul Friedman

“We” awakened Sunday morning to light rain, with the hope “they” don’t blame the Mad As Hell Oregon Docs for bringing all that moisture from the North Left Coast.

Our mid-day event at a Mishkon Tephilo Synagogue in Venice was well attended by  well informed people, hungry to learn more.  As we were packing up and schmoozing, a very bright gentleman, slightly older than myself,  pulled me aside, stating, “I need to talk to you.”   By the fatherly tone, I guessed I was in trouble.  In no uncertain terms, he expressed dismay at the music, which for him was a distraction.  He came for information.  He still didn’t understand what single payer is and how it works.   Twice, as we spoke, people came up to us, to express appreciation for the quality of the presentation, how much they learned, and their commitment to talking to their friends about it.  I guess you can’t please everybody.

In the evening, we  gathered informally at the UC Irvine Medical School with a modest crowd of medical students and affiliates. Professor Mike Huntington used a power point presentation to elucidate the various aspects of our health care financing and delivery fiasco.   In the lively Q & A, a skeptical gentleman, of my generation, challenged us with difficult questions revealing his unwavering allegiance to the magic of the marketplace. Though bordering on disruptive, he gave us a valuable opportunity to demonstrate the art of speaking with those who aren’t in the choir.  I spent an extra 30 minutes with him, mono-a-mono, afterward.   The whole while I was thinking of the Twelfth Insight, first developed by my good friend Don Johnson on the 12thhole of Trysting Tree Golf Course.  It goes something like this:  “Resist the urge to change an opposing point of view.”  I had no fantasy that I was going to change the skeptic’s conclusions, either about single payer or the human contribution to global warming.  But, in regards to the former, he now has a deeper understanding of the complexity of the issue.  In the end, we both felt heard and respected.  He doesn’t trust the  government and I don’t think we have any choice.   In any case, I trust the United States more than I trust United Health Care.

On Monday afternoon, standing in the light rain at the Price Center at UCSD (my medical school Alma Mater), we met with Dr. Paul Friedman, Dr. Ellen Beck, Dr. Sunny Smith and a handful of medical students.  We gave our informal dog and pony show.  The local doctors lucidly contributed their perspectives and then the medical students eloquently and passionately told their stories.  I was stunned by their caring wisdom.  My eyes were moist and it wasn’t the rain.   Their passion and commitment created a moving moment gives me some hope

HOT OFF THE PRESS!!!  I am have happy to announce that another physician has officially come out of the closet to proclaim that he is also a Mad As Hell Doctor.  That would be Don McCanne, who, in today’s PNHP Quote of the Day, wrote what follows about insurance company behavior:

“Right now Sandy and I have the pleasure and honor of hosting some of the Mad as Hell Doctors at our home during their current California tour in support of single payer. At dinner last night, one of them asked me if, when I’m writing the Quote of the Day, aren’t there times that I want to say… like… Bullshit!!… or something like that.  Yes! Right now. Bullshit!! Today I’m also a Mad as Hell Doctor!”

Even the rain, illegally imported from the Northland, didn’t dampen my ensuing laughter that continued for minutes.  Welcome aboard, Don.

California Road Trip, Day 11, Orange County

Don McCanne

Our foray into So Cal is softened by the opportunity to lodge with one of the heros of the single payer movement, Don Mcanne and his domestic supervisor Sandy.  They are the real pros while the Mad As Hell Doctors are aspiring amateurs.

Our mid-day event in Pasadena was captured by numerous video cameras including community TV, who plan to edit then show the entire event to their 30,000 loyal viewers.  As for the live audience, we had stiff competition from the Bruins home game, whose fans we  could hear from the Rose Bowl Stadium down the street.  To that, I respond, “Go Beavers!!!”  The evening event at the First Congregation Church was well attended and spirited.

As for our cool comments about “Baucus Care” (aka Obama Care), we are sadly validated by the recent New York Times piece (here) that illuminates the multitude of ways in which PPACA is unraveling.  Insurance carriers are dropping coverage, no longer offering particular plans, and being granted dozens of “wavers”, such as the one that allows Macdonalds to continue with the $2,000 annual limit on benefits.  Furthermore, Principle Financial is getting out of the business altogether and United Health will gladly pick up another 840,000 victims, oops, I mean customers.  Robert Laszewski, a health policy consultant in Alexandria, Va. “is worried that the ensuing concentration is likely to lead to higher prices because large players will no longer face the competition from the smaller plans. ‘It’s just the UnitedHealthcare full employment act,’ he said.”

The good is that McCannes needn’t worry about running out of engaging project.  Don will remain fully employed (without pay) during his retirement as he works tirelessly to bring some sanity to our Sick Care Non-System.  Go Don and Sandy!!!!