West of the Rotunda

Getting the power of the marketplace to have some effect on health care costs has been the holy grail for years. The Trump administration just announced a major move. Let’s look at it.

In an announcement Friday, while many were watching impeachment hearings, Trump officials described new rules they hope will improve transparency in health costs.

One rule will require health insurance plans to provide “cost-sharing information, including an estimate of their cost-sharing liability for all covered healthcare items and services, through an online tool” (HHS.gov).

Further, insurers will be required to: “Disclose on a public website their negotiated rates for in-network providers and allowed amounts paid for out-of-network providers.”

Have you fallen asleep? I hope not because we haven’t come to the good part yet.

The proposed rule will also require hospitals “to provide patients with clear, accessible information about their “standard charges” for the items and services they provide” (HHS.gov).

So, insurance companies will let us know how much they expect we will have to pay should we have to file a claim, and also how much they will be paying the hospitals and doctors. And hospitals will broadcast their charges. This is a big deal.

Or is it? It’s been done in some states already. The longest running experiment on this is in New Hampshire where they established a cost comparison website in 2007. Over a five-year study period MRI costs decreased 1-2%. The overall savings for all outpatient radiology costs for people who used the tool was 3%. Not really big apples, I’ll agree. Especially if you realize imaging costs in the US are about twice what they are in other developed countries.

But this modest success hasn’t stopped other states from launching their own website comparison tools. Our neighbors Washington and Oregon have theirs running, as well as half a dozen others. Maybe the states that have chosen to experiment can find better solutions. I really don’t see Idaho investing in this soon.

Why hasn’t the all-powerful marketplace had more of an effect ratcheting down the cost of healthcare? Before we look in the mirror, let’s see who else we can blame.

If you ask Bernie Sanders or any other Democratic presidential candidate that raised their hand, the blame would go squarely on the health insurance industry and the profit driven Medical Industrial Complex. “Let’s eliminate all that” to quote Kamala Harris. Maybe that gets your base fired up, but it skips over the fact that every developed country with universal coverage has some form of private insurance. Israel and the Netherlands require insurance be purchased. Many countries require private insurance to supplement public health insurance. Others make it optional. None outlaw it.

How about we blame the lawyers? Sorry, it is a cost, but a small one. Medical malpractice may be a boogey man for nervous doctors and an easy target for politicians, but it represents less than 3% of all health care costs, even if you factor in defensive medicine. And defensive medicine costs 4X what the actual premiums and settlements run.

Should we blame the defensive doctors, or at least the highly paid ones? It is true, doctors in the United States are paid more than doctors around the world. In fact, it’s about twice as much. And we have an abundance of specialists here in the US who tend to be higher earners. But doctors’ income comprises a little less than 10% of the national total health care costs. Cutting their pay in half would save us some. I’d rather focus on getting better results out of them, er, I mean us, since once again medical mistakes have been found to be the third leading cause of death according to a Johns Hopkins study.

The US Medical Industrial Complex is huge and to quote our President “complicated”. We are going to have to do a lot of things to turn this ship around. Every little bit will help. Transparency will help. Who knows what we might see.

Alexander Hamilton was waiting for James Madison at the crowded sports bar. He sipped his pint and barely noted the many screens showing the many games. He frowned at the ring his glass had left on the counter, lost in thought.

Madison clapped him on the shoulder. “So, is it your turn or mine, Mr. Hamilton?”

“I suppose it is me, Mr. Madison, since Jay did the last one and yours was prior.”

Madison laughed. “No, Alexander, I meant who was to pay for the ale. Since you have offered, I’ll order two.” He motioned for the ale wench.

“Well aren’t you two a little late for Halloween?” she grinned at them, appreciating the white wigs and knee breeches. “What can I getcha?”

“Two pints of your best ale, ma’am. And see if you can lift this poor man’s spirits.” He again clapped Hamilton’s shoulder.

She frowned, “What is the problem, sweetheart?”

Hamilton sighed deeply. “Alas, I must convince the New Yorkers that the Senate is the proper body to judge impeachment.”

She wiped at Hamilton’s wet ring spot and asked, “So, what have you been watching, CNN or Fox?”

“Madam, I assure you, we have no time for the hunt or fishing. We are trying to save this Constitution we have fought so hard for.” He turned to Jimmy Madison. “So, will this be the 65^th?”

Madison mumbled “Thereabouts” and licked his dry lips.

“Oh, I get it!” she burst into laughter. “You guys are acting as if you’re Hamilton and Madison and you are worried over writing those Federalist Papers. What a hoot!” She bustled off for the ale.

Alex and Jimmy leaned toward each other. “How did she know we were Federalists? Don’t Republicans look the same?”

“Oh, forget it. We have work. How do you propose to convince?”

Hamilton adopted his oratorical posture. “The Senate will hold the mantle since it will be the most august body of learned men, sworn to protect the Constitution and defend the Republic. They will be appointed by the legislatures and each state’s properly elected body will only choose men of the highest character, not swayed by self-interest or subject to partisan influence.”

A bearded man with a MAGA hat looked over and laughed. “I sure as hell hope not.” He raised his glass to them. “We need our President defended from those lousy Democrats. They’ve sworn to spit him out ever since he was elected. It’s the Democrats who want to overthrow our duly-elected President. It’s a coup!”

His buddy with a Seahawks T-shirt added, “You guys never heard of the 17^th amendment?”

Jim and Alex shook their heads but smiled. “It gives me great comfort to know the Constitution might be so changed, tell me about it.”

“We dumped that legislative election of Senators way back. States couldn’t agree and seats sat vacant. Not to mention the rich guys buying their senate seats.” The two shared a laugh at the patriots.

The ale wench brought the two pints for Madison. “You figured it out yet? I read all those Papers in Law School.” she said with a twinkle, playing along.

Both the patriots laughed at her joke. “Ma’am, the law is no place for a woman. She is best suited for the house.”

“Or the Senate!” she laughed back at them. “You guys are a real hoot. You’ve sure got the costumes and the characters down.” Then she frowned. “Hey, why don’t you get a little relevant here? What would you guys say about universal healthcare or gun rights?”

MAGA hat and Seahawk jeered from the opposite table. “There you go with your Democrat commie talk!”

She smiled at the hecklers and asked, “Can I get you guys a refill?” Then she turned to the patriots and murmured under her breath, “Watch out for these Republicans. Alex, I mean it. Especially that Aaron Burr.” And she tilted her head back with a hearty laugh.

This last week I ran into a guy in clinic that made me thankful for Idaho voters. We were able to help him out. You should know about this. It’s not about politics or policy, just about how we were able to help out a hard-working guy.

He was in his work insulated coveralls since he had gotten in a couple hours on a chilly October morning before his appointment. He’d made an appointment with our clinic since he’d heard we offer a sliding scale fee structure.

About 16 months ago on a job he had been holding a board for a brace and another guy shot a nail into the two by four. The tip of the nail had come through the board and embedded into his left hand. He was able to wiggle his hand off the nail and it hurt like heck, but with a bandage in his glove he kept working. It got real swollen over the next week but never infected so he figured it would be ok. The swelling and pain went down, but over time the wound developed a small lump that kept getting bigger.

It was on his left hand on the thumb side of the junction of the pointer finger knuckle. It would hit on things when he grabbed them and it was now, when I saw it, the size of a marble. It felt really solid, not like a fluid-filled abscess or cyst. His finger moved just fine. He wanted it taken off. I didn’t blame him. I could see how it would get in his way and be a problem.

The trouble was, I am not the right doctor to take that lump off. Hands, especially fingers are tricky to work on. He needed to see an orthopedic doctor, maybe a hand surgeon.

“Do you have health insurance?”

He looked at me blankly, a young healthy working man. “No sir, that’s why I came to you guys (meaning the clinic with the sliding scale fees).”

“Did you file a workman’s comp claim?”

“Naw, I just kept working.”

I explained to him the delicacy of dealing with this part of his body. I could recommend a local orthopedic doctor that might see him for a reduced amount, but I expected the surgery would include hospital or operating room costs; probably thousands of dollars all added up.

The physician assistant was in the room with us looking at the bump. He asked, “Can you wait until January?”

The young man looked at him a bit confused.

“Next week you can sign up for Medicaid here in Idaho and coverage will begin in January. You’ll have health insurance.”

“Heck, I’ve lived with it this long.”

I warned him if it got red or painful or started swelling more he should come back in, but given his situation it was fine to wait.

Idaho voters did the right thing for this guy and their fellow citizens last November when they overwhelmingly passed Proposition 2, Medicaid expansion. The Idaho legislature did the right thing this last session when they were putting on all those waiver sideboards. They mandated that none of their sideboard waiver applications would delay the enrollment of those eligible under the Medicaid expansion initiative. The Idaho Department of Health and Welfare has been doing the right thing for the last ten months and preparing to enroll the newly eligible for Medicaid health insurance.

This isn’t the story of a life saved or a bankruptcy averted. It’s just a small story of how health care can be of service when a bump gets in the way. But it’s also a much bigger story of how we can make decisions to help out our fellow citizens. It made my day.

In the middle of my career I was given a gift. The nurse I had worked with for a long time told me she would need to be leaving the office at 4PM each day to deal with family issues. She said she could arrange for someone to cover for the last couple hours of the day. I thought about it long and hard and said, OK, I will see my last patient at 4, then with finishing dictation, paperwork and hospital rounds I could be home by 5-530. Prior to this I’d get home by 630-7 on days I wasn’t on call.

But with this new schedule I was able to get home and have dinner with my wife and four daughters most nights. It was a generous gift. It cost me money, but I gained in memories and time with my family.

My oldest daughter was by then in Junior Hi School, the youngest in grade school. It was expected that we all sit around the table, pass the food and have conversation. One prolonged conversation I remember had to do with one daughter reacting to another with the loud declaration, “I am offended that you would say that!” The conversation usually stopped for a while after such a declaration.

As the pattern kept being repeated I intervened. “Taking offense is something you have control over. You are not in control over what comes out of your sister’s mouth. If you want to have a conversation, it’s fine to feel offended, but you cannot expect the person you are conversing with to guess or know what might offend you. Take control of your own offense. Share your feelings if you chose, but when you take offense and react with anger, the conversation is probably over. We can do better.”

You can imagine with school-age daughters this took some practice.

This last week we had our President’s Chief of Staff tell us all to “Get over it!” when reporters questioned him on our president seeking aid from a foreign leader for his own political benefit. In fact, he acknowledged that the president withheld appropriated military aid to incentivize cooperation, though President Trump has declared, “No quid pro quo!”

The Chief of Staff’s “Get over it!” declaration sounded like we, or the reporter might have taken offense at a politically incorrect utterance. Indeed, the Trump for President campaign now has embraced the slogan “Get Over It” with a fund-raising t-shirt.

When a conversation is the goal, it is important to “get over” one’s strong feelings to further understanding. But when one needs to be making judgements about another person’s character or indeed actions, I think of another phrase I ran across in medical residency training. Residents are new medical school graduates. We had four years of medical school and limited patient care and management but now we staffed hospital wards, emergency rooms and clinics under the supervision of teaching attending physicians. The phrase I heard that stuck with me was from good teachers who ultimately would decide whether we residents would graduate to the position of practicing physicians. It was: “Forgive and Remember”. Mistakes occur, some can be severe; forgive those mistakes, but remember them and look for patterns, because some patterns can prove to be fatal for patients when a physician is independently practicing. If these patterns cannot be corrected, the resident should not be graduated.

My interpretation of “Get over it!” was our President’s chief of staff calling for us to either dismiss shaking down a foreign leader as unimportant, or just forget that it might be an illegal bribe.

I understand that many are offended by our President’s demeanor, his tweets, his untruths, his policy decisions and actions. We should “Get Over” our feelings of offense. But we should remember his actions, his cumulative behavior, his abuse of power and then make some judgement about his fitness.

It had been a long day for Brad and Teresa touring the noodle factories of Taiwan. He pulled off his cowboy boots in the Presidential Suite in Taipei wanting to take a break before the big dinner tonight. He clicked on the TV, searching for the Vandals game figuring the kickoff was soon. Instead the airwaves were full of the Ukrainian Trump telephone conversation. Brad skipped the Fox News analysis.

“What should I wear tonight?” Teresa called from the walk-in closet.

“The black and gold dress!” Brad yelled, hoping she’d bring good luck to his Alma Mater.

She gave him “the look” and he laughed. “Go Vandals!” he retorted.

They went down the stairs before halftime and the Vandals were ahead so Brad was in good spirits.

“Governor, your table is here.”

They were escorted to the head table in the large banquet hall. Brad took off his jacket and threw it on the back of the chair, his Black and Gold suspenders complementing his wife’s dress.

As the hall filled he chatted with the Taiwan Minister of Economics. The minister asked, “Do you anticipate any tariff issues?”

“Oh, I don’t think our government would want to obstruct the free trade of agricultural commodities with Taiwan.”

The minister frowned. “Taiwan will always be a good trader and Idaho offers good wheat. We have agreed to take more. We are always willing to do favors.”

Brad laughed and clapped his shoulder. “It’s no favor. We grow good wheat. You make good noodles. We all benefit.”

The minister looked down, his frown deeper. “But surely, we can do more.”

Brad swirled his wine glass. “Well, we’ll grow more wheat.” Then he turned away as the Taiwan Minister of Security touched his elbow.

“Governor, I hope the noodle plants were to your satisfaction today. The Vandals are now down by 4 points in the third quarter.”

Brad didn’t skip a beat. “We’ll come back.”

“Maybe so.” The Minister of Security offered with a soft smile. “We have connections everywhere, but we cannot influence football games in Moscow, Idaho.”

Brad looked off, troubled by the news of the Vandal deficit. “We’ll come back.” He said again but distracted.

The Minister of Security cleared his throat and nodded his head to the man next to him who quietly moved away. “Governor, I am here to tell you if you need any favors in your state, we are here to help.”

Brad sipped the Washington Merlot and nodded. “We really appreciate all the wheat you guys buy.” He looked over to where Teresa was chatting with the wife of some Minister of Something. “Can you get your people to like potatoes more?”

The Minister of Security laughed and Brad did too. But as he started to turn away, the minister touched his arm. “We have many resources that could be an advantage to you. We know the political landscape of your state. Your primary election was very close. We study and have information. Let us know if you have any need, any need for any favors.”

Brad bowed toward the minister and the minister bowed back and before they parted he leaned in and added, “The Vandals just scored.”

Teresa gladly introduced Brad to her chatty companion, the wife of the Minister of Political Affairs. After the smiles and chatting Teresa leaned in to Brad and whispered, “Why does she keep asking me if we need any flavors?”

Brad frowned. “Maybe she has some influence on what dessert we get.”

Teresa didn’t give him “the look”, but she gave him the public look. “I think they are trying to tell us something and I just don’t get it.”

Brad nodded.

Now that Purdue Pharma has filed for bankruptcy, I wonder if Idaho State Attorney General is smiling or wincing. Either way, he’s shown courage and conviction.

Purdue Pharma famously produced Oxycontin, a powerful controlled-release narcotic they marketed as a magic pain reliever that wouldn’t lead to addiction. At least that’s what I remember their well-dressed salesmen saying to me over an expensive catered lunch they provided for all our office staff. But that was in the mid 1990’s. As the body count started to climb in the early 2000’s they toned back their claims.

But this drug made a lot of money for the Sackler family who 100% own Purdue Pharma. The family net worth is estimated to be over $13 Billion. And surprise, surprise, recently discovered documents have shown they have hidden billions of assets in preparation for this planned bankruptcy.

Purdue/Sackler have already settled lawsuits with the federal government and states for hundreds of millions. Indeed, some executives plead guilty to criminal charges in federal court for misleading advertising. But a large group of states, municipalities, even tribal governments have signed onto a much larger suit that is pending.

Idaho AG Lawrence Wasden joined many other states just this last June in suing Purdue Pharma. It’s Wasden’s second dance with the drug company in court. He (representing Idaho) was a co-complainant when Purdue settled in 2007 for $19M.

Wasden isn’t just focused on Purdue. Idaho has filed lawsuits in Federal Court against many other opioid manufacturers.

But now Purdue is declaring bankruptcy. Before they filed Sunday night, they offered to settle with the long list of states and entities suing them. It is interesting who agreed to settle and who didn’t. One analyst painted a map of the states that agreed and who refused. Idaho stands out as the only Red (Republican) state that refused. I can hear the “RINO” howls already echoing against Wasden. It won’t be the first time. But Red- Blue is the wrong way to look at this.

The analyst had some interesting conjecture on the relationships between Republican AGs and a big-time lobbyist for Purdue. It seems Purdue contributed three times as much money to the national Republican AG Association ($680K) as they did the Dem AG Association ($210K). It’s hard for me to believe this colored their decisions.

Fundamentally, either Republican or Democratic, I believe an elected state Attorney General would want to pursue justice for their constituents; color me naive. Maybe the AG’s who settled were just being pragmatic and figuring the pot would be reduced dramatically when the imminent bankruptcy was filed.

So, what was Wasden thinking? His only public comment was that he did not believe the settlement was in the best interests of the people of the State of Idaho. Since we don’t know all the details of the offers, indeed, we probably don’t know where all the money is hidden, it’s hard to second guess his decision. But he didn’t take the easy off ramp. He’s got a lot of work ahead of him.

It’s tempting to look at the bottom line and just see what the dollars would have been if a settlement had been taken compared to the route AG Wasden has steered. “What’s in it for us?” Such thinking is driven by self-interest, not justice.

There is no doubt our state has suffered. Idaho’s accidental overdose death rate has tripled since Oxycontin was rolled out. And there is no doubt some people have profited greatly from that suffering.

I blame Purdue Pharma/ Sackler for misrepresenting their product. I blame my profession for falling for their lies. I blame patients for expecting life to be without pain. But all this blame gives me little sense of where justice lies. I believe Lawrence Wasden has that sense.