Category Archives: Quality

ACOs Do Not Improve Spending or Quality

Thank to Dr. McCanne, I am re-posting the following article from the Annals of Internal Medicine that was published Tuesday. I have written before about MSSPs, so I thought it would be a respite from talking about single payer.

Here is the article in its entirety:

Annals of Internal Medicine
June 18, 2019
Performance in the Medicare Shared Savings Program After Accounting for Nonrandom Exit: An Instrumental Variable Analysis
By Adam A. Markovitz, BS; John M. Hollingsworth, MD, MS; John Z. Ayanian, MD, MPP; Edward C. Norton, PhD; Phyllis L. Yan, MS; Andrew M. Ryan, PhD

Abstract

Background:
Accountable care organizations (ACOs) in the Medicare Shared Savings Program (MSSP) are associated with modest savings. However, prior research may overstate this effect if high-cost clinicians exit ACOs.

Objective:
To evaluate the effect of the MSSP on spending and quality while accounting for clinicians’ nonrandom exit.

Design:
Similar to prior MSSP analyses, this study compared MSSP ACO participants versus control beneficiaries using adjusted longitudinal models that accounted for secular trends, market factors, and beneficiary characteristics. To further account for selection effects, the share of nearby clinicians in the MSSP was used as an instrumental variable. Hip fracture served as a falsification outcome. The authors also tested for compositional changes among MSSP participants.

Setting:
Fee-for-service Medicare, 2008 through 2014.

Patients:
A 20% sample (97 204 192 beneficiary-quarters).

Measurements:
Total spending, 4 quality indicators, and hospitalization for hip fracture.

Results:
In adjusted longitudinal models, the MSSP was associated with spending reductions (change, −$118 [95% CI, −$151 to −$85] per beneficiary-quarter) and improvements in all 4 quality indicators. In instrumental variable models, the MSSP was not associated with spending (change, $5 [CI, −$51 to $62] per beneficiary-quarter) or quality. In falsification tests, the MSSP was associated with hip fracture in the adjusted model (−0.24 hospitalizations for hip fracture [CI, −0.32 to −0.16 hospitalizations] per 1000 beneficiary-quarters) but not in the instrumental variable model (0.05 hospitalizations [CI, −0.10 to 0.20 hospitalizations] per 1000 beneficiary-quarters). Compositional changes were driven by high-cost clinicians exiting ACOs: High-cost clinicians (99th percentile) had a 30.4% chance of exiting the MSSP, compared with a 13.8% chance among median-cost clinicians (50th percentile).

Limitation:
The study used an observational design and administrative data.

Conclusion:
After adjustment for clinicians’ nonrandom exit, the MSSP was not associated with improvements in spending or quality. Selection effects — including exit of high-cost clinicians — may drive estimates of savings in the MSSP.

Primary Funding Source:
Horowitz Foundation for Social Policy, Agency for Healthcare Research and Quality, and National Institute on Aging.

In addition, here is an article from The Incidental Economist of June 17th on the same subject:

The Incidental Economist
June 17, 2019
Spending Reductions in the Medicare Shared Savings Program: Selection or Savings?
By J. Michael McWilliams, MD, PhD, Alan M. Zaslavsky, PhD, Bruce E. Landon, MD, MBA, and Michael E. Chernew, PhD.

Prior studies suggest that accountable care organizations (ACOs) in the MSSP have achieved modest, growing savings. In a recent study in Annals of Internal Medicine, Markovitz et al. conclude that savings from the MSSP are illusory, an artifact of risk selection behaviors by ACOs such as “pruning” primary care physicians (PCPs) with high-cost patients. Their conclusions appear to contradict previous findings that characteristics of ACO patients changed minimally over time relative to local control groups.

Conclusion

Monitoring ACOs will be essential, particularly as incentives for selection are strengthened as regional spending rates become increasingly important in determining benchmarks. Although there has likely been some gaming, the evidence to date — including the study by Markovitz et al. — provides no clear evidence of a costly problem and suggests that ACOs have achieved very small, but real, savings. Causal inference is hard but necessary to inform policy. When conclusions differ, opportunities arise to understand methodological differences and to clarify their implications for policy.

And finally, Don McCanne’s comment:

This important study in the highly reputable Annals of Internal Medicine concludes that accountable care organizations (ACOs) participating in the Medicare Shared Savings Program (MSSP) did not show any improvement in spending or quality when adjustments were made for selection effects, especially the non-random exit of high-cost clinicians (“I’m worth the extra money, and if you’re gonna cut my fees, I’m outta here.”)

The conclusions were immediately challenged by others in the policy community who have previously published studies indicating that “ACOs have achieved very small, but real, savings,” albeit admitting that “there has likely been some gaming.” And the savings were, indeed, very small. Others have suggested that the very small savings did not take into consideration the significant increase in provider administrative costs for technological equipment and personnel to run the ACOs, and certainly did not consider other unintended consequences such as the tragic increase in physician burnout.

Another problem with the infatuation for ACOs is that politicians and the policy community are insisting that we continue with this experiment in spite of the disappointing results to date. That simply postpones the adoption of truly effective policies, such as those in a single payer Medicare for All program, that would actually improve quality while greatly reducing administrative waste. The tragedy is that this also perpetuates uninsurance, underinsurance, and personal financial hardship from medical bills.

People are suffering and dying while the policy community continues to diddle with ACOs and other injudicious policy inventions. Enough! It’s long past time to reduce suffering and save lives! Single Payer Medicare for All!

(Yes, I’m angry, but even more I’m terribly anguished over the health care injustices that we continue to tolerate through our collective inaction.)

See, we can’t get away from Medicare for All after all.

 

Gauze: A Film by Suzanne Garber

Nearly a year ago, while channel surfing, I came across a short film being shown on my local South Florida Public Broadcasting System (PBS) station.

As I missed most of it, I was able to learn the name of the filmmaker from the credits, and saw that she had interviewed some of the leading names in the medical travel space.

One individual I saw listed in the credits was Keith Pollard, with whom I was connected with on LinkedIn, and had communicated over the years since I began blogging about medical travel. I reached out to Keith to ask him to put me in touch with the filmmaker, Suzanne Garber.

I later learned from Keith that before she gave Keith her permission to forward her email address to me, she wanted to know if I was legitimate. Keith vouched for me without hesitation, and I reached out to Suzanne.

Unfortunately, due to ownership of the rights to the film by PBS, it has taken nearly a year for me to get to see it. What follows is my review of her film, “Gauze Unraveling Global Healthcare”.

The film is a personal account of Suzanne’s exploration into the difference between US healthcare, with its bureaucracy and lack of transparency regarding cost to patients; plus its affordability, accessibility, and quality — the three characteristics of healthcare, according to Suzanne.

Suzanne had gone through some personal medical issues, and the film begins with her discussing statements she received that were very expensive. At one point, she describes how she was forced to sign a form at a hospital in order to get service that said she was responsible for the full amount if her insurance company refused to pay.

She asked the woman at the desk who gave her the form if she knew what it would cost her, and the woman replied that she did not know, so Suzanne said that she was signing away her right to know how much it could cost her.

Then Suzanne asked some of her friends the following question: where is the best healthcare?

Having been an executive credentialing hospitals for a company she was working for, Suzanne had vast experience visiting hospitals, and had personal experience of being admitted to a hospital in Spain as a child. She decided to go and visit some of the hospitals that cater to medical travel patients.

From 2014- 2015, she visited 24 countries, 174 hospitals, and interviewed over five dozen international healthcare experts. She wanted to know the answer to the following questions: Where to go, and where not to go?

But it was when she had a medical diagnosis of cancer that she traveled thousands of miles, flying from Philadelphia to Chicago, to Tokyo, and then to Bangkok, where she went to Bumrungrad Hospital. By that time, her position had been eliminated, she was unemployed and uninsured, so she took the chance and went.

She traveled to Singapore to get a second opinion with an orthopedist. A doctor there wanted to perform a bone density scan, and even though she brought along all of her MRIs, CAT scans, etc., the doctor had her go downstairs, wait forty-five minutes, and then go back upstairs to see the doctor after the results were entered into the computer.

In all, it cost Suzanne $29 dollars, not the amount she was quoted back in the US. And all this took one day.

As part of her journey, she visited the UK, India, and visited several hospitals in France. And what she found was that there is no one way to improve our healthcare, but it is possible. We need to ask questions, we need to contact our elected representatives, and we need to take responsibility for our healthcare.

A personal note: This film when shown on PBS last year, had a long list of names Suzanne interviewed. In addition to Keith Pollard, one other person, Rajesh Rao of IndUSHealth, was someone I met in 2014 at the ProMed conference in Miami Beach. Some other names in that list were familiar to me, but as of this screening, does not appear. One more comment, I was able to view the film online, but am not able to provide readers with a copy of it in this post.

This is a very important and timely film that should be viewed by both the health care industry and those in the workers’ compensation industry who have panned the idea of medical travel. The mere fact that Suzanne paid only $29 for a bone density scan, when she was told it would be $7,300 in the US, is not only criminal, it is insane to keep insisting that medical travel for workers’ comp is a stupid and ridiculous idea, and a non-starter, as one so-called expert has written.

When are you people in work comp going to wake up? You and your insurance carriers are being ripped off by an expensive medical-industrial complex. But you just go on doing the same things over and over again, and expect different results, or you boast that frequency is going down, yet medical costs are still too high. The choice is yours, but don’t keep making the same mistake.

I want to thank Suzanne for her patience in bearing with my periodic emails regarding my viewing the film, and for being courageous enough to put her personal struggles with health and health care front and center, and comparing it to our so-called health care system. I hope that Gauze Unraveling Global Healthcare will be seen by all those interested in better health care for all Americans, workers or not.

 

Physician practices seek help in transition to value-based care | Healthcare Dive

Follow-up to the last post and yesterday’s regarding CMS’ initiative for quality reporting.

See the link:

The report also found physicians are moving more toward independent and physician-led group practices after a six-year trend of doctors moving to hospitals.

Source: Physician practices seek help in transition to value-based care | Healthcare Dive

CMS to consolidate Medicare quality reporting programs | Healthcare Dive

As readers of this blog have noticed in the past, I have been very critical of CMS’ introduction of myriads of models, programs, and schemes to improve quality reporting and physician performance, so it is no surprise that I look upon this new initiative with a bit of skepticism. But I’ll let you the reader decide if this is just another wasted effort by CMS or if it has a chance to actually work this time. After all, after forty years of tinkering, the American health care system is no better off than it was before CMS got involved.

One of the quality networks CMS wants to roll into a single contract concerns something your humble writer is going through, ESRD.

Here’s the article:

Quality Improvement Networks and Organizations, End Stage Renal Disease Networks and Hospital Improvement Innovation Networks are all being bundled into a single $25 billion contract.

Source: CMS to consolidate Medicare quality reporting programs | Healthcare Dive

ACO’s Across the Pond: What Some Believe the US and England Can Learn From Each Other

It is amazing how experts in the field of health care are so wedded to ideas that are, with greater scrutiny, the real cause of the dysfunction and failures of providing health care to the citizens of a nation.

Such is the case with an article I found from the Commonwealth Fund, a well-respected organization in health care research, yet doubles down on the root causes of the crisis faced by the health care system in the US.

Late last month, Briggs, Alderwick, Shortell, and Fisher published the article entitled, “What Can the U.S. and England Learn from Each Other’s Health Care Reforms?

The focus of the article was on the idea of Affordable Care Organizations (ACO’s), which in the US were established in 2010 under the ACA. According to the authors, both countries are currently working toward better integrating health services, improving population health, and managing health care costs. They also said that both countries are developing their own versions of ACO’s to achieve these aims.

However, the authors point out, by way of listing previous links to articles they wrote, that results so far have been mixed, patient experience (you mean like having a great time at Disney World, that sort of experience?) and some quality measures have improved.

Yet, financial savings, they report, have been modest and data on outcomes is limited.

On the other hand, across the pond, the English NHS recently created 44 Sustainability and Transformation Partnerships (STPs) [Isn’t that what one puts in a motor car to make it run better?]

These STPs cover the entire country and are “place-based” partnerships of all NHS organizations and local government departments that purchase and provide health and long-term care services for a geographically defined population. They believe that organizations in STPs will work together to improve care and manage local budgets. Some payers are even considering American-style ACO contracting models.

Wait, if we are not having success with ACOs, what makes the Brits think they will do better? Interestingly enough, Himmelstein and Woolhandler, in “Health Care Under the Knife”, chapter 4, page 61, said the following when they were involved with drafting an new proposal for the Physicians for a National Health Program (PNHP):

“Recently, the emergence of huge integrated health systems incorporating multiple hospitals and thousands of physicians (so-called Accountable Care Organizations or ACOs), which dominate the care of entire regions, is causing us to again to talk about NHS models.”

So let me get this straight. We are not having much success with ACOs, yet, the Brits are moving in that direction. And the physician-led advocacy group in this country, the PNHP, that is pushing for single-payer, has been forced to consider models employed by the British NHS.

If that isn’t the definition of insanity, I don’t know what is.

Of course, the move towards ACOs in this country is due to the ACA and to the resurgence of 19th century economic liberalism, also known as neoliberalism, and its impact over the past thirty years on the American health care system. But in the UK, the move away from Labour Party socialism to the Conservative Party’s neoliberalism, is the reason why Britain is exploring the ACO model.

Maybe one day, both Anglo-oriented nations will wake up and stop believing in the fairy tale that the free market works for health care. It does for cars and other consumer goods, but health care is not a consumer good. It is a necessity of life.

What’s Really Wrong With Health Care?

Book Review

Health Care Under the Knife: Moving Beyond Capitalism for Our Health

by Howard Waitzkin and the Working Group on Health Beyond Capitalism

Monthly Review Press
e-book: $18.00
Paperback: $27.00
Hard cover: $45.00

Americans commemorated the assassination of Martin Luther King fifty years ago on Wednesday. Two years earlier, Dr. King, in March 1966, said the following during a press conference in Chicago at the second convention of the Medical Committee for Human Rights (MCHR):

“…Of all the forms of inequality, injustice in health is the most shocking and the most inhuman because it often results in physical death.”

The part of the quote up to the word ‘inhuman’ begins the Introduction of a new book I just began reading called, Health Care Under the Knife: Moving Beyond Capitalism for Our Health by Howard Waitzkin and the Working Group on Health Beyond Capitalism, published by Monthly Review Press, the publishing arm of the Monthly Review, an Independent Socialist magazine.

Those of you who know me, and those of you who have read many of my previous posts, know that my educational background is in the Social Sciences, as my B.A, is in Political Science and History, with Sociology and African-American Studies thrown in, along with some Humanities coursework. My M.A. is in History, with emphasis on American Social History, especially post-Civil War until the mid to late 20th century. In addition, I also have a Master’s degree in Health Administration (MHA).

But what you may not know is that my leanings have been to the far left, and I am still proudly and defiantly so, even if I have tempered my views with age and new insights. I think that is called wisdom.

So, as I set out to read this book, much of the material presented in it will not be new to me, but will be perhaps new to many of you, especially those of you who got their education in business schools, and were fed bourgeois nonsense about marketing, branding, and other capitalist terms that are more apropos for selling automobiles and appliances and such, but not for health care, as this book will prove.

In this book, there will be terms that many of you will either find annoying, depending on your own personal political leanings, or that you are unfamiliar with. Words such as alienation of labor, commodification, imperialism, neoliberalism, and proletarianization may make some of you see red. So be it. Change will not occur until many of you are shaken out of your lethargy and develop your class consciousness.

“Capital is reckless of the health or length of life of the laborer, unless under compulsion from society.” Karl Marx

While the publisher of the book is an independent socialist foundation, it is no means a Marxist or Communist organization. And from my perusal of the names of the contributors to the chapters of the book, I have found that they are all health care professionals or academics, as well as activists.

Two of the contributors of one chapter, David Himmelstein and Steffie Woolhandler, are familiar to many in the health care industry, as they have co-authored many peer reviewed articles in health care journals that I have cited in my previous blog posts.

Be warned. This book may piss you off. Too bad. The future of health care is at stake, as is the health of every man, woman, and child in the U.S. and around the world.

This will probably be true no matter what part of the health care industry you work in. Physicians, insurance company personnel, pharmaceutical company executives, Wall Street investors and money managers, service providers, vendors, consultants and many others will discover inconvenient truths about the businesses that provide their livelihood. As stakeholders in the status quo, you will be resistant to the prescriptions the writers offer for correcting the mistakes of the past, and the recommendations they suggest for the future of health care.

This book will not only be relevant to the health care industry, but also to the workers’ compensation and medical travel industries, as each is a subset of health care.

And if you do get upset or angry at me for what I have to say about health care, then you are part of the problem as to why health care in the U.S. is broken. Those of you around the world will also learn that your own countries are moving in a direction that sooner or later will result in your health care system mirroring our own, as the authors will point out.

This is a book that will shake you to your core. So, sit back, relax, and keep an open mind. It’s about to be blown.

The book is divided into five parts, with each part containing at most five chapters, as in Part Five, or two chapters, as in Part Two. Parts Three and Four, each contain four chapters. Part One deals with Social Class and Medical Work, and focuses on doctors as workers, the deprofessionalization and emerging social class position of health professionals, the degradation of medical labor and the meaning of quality in health care, and finally, the political economy of health reform.

Throughout the book, they ask questions relating to the topics covered in each chapter, and in Part One, the following questions are asked:

  • How have the social-class positions of health workers, both professional and non-professional, changed along with changes in the capitalist global economy?
  • How has the process of health work transformed as control over the means of production and conditions of the workplace has shifted from professionals to corporations?

These questions are relevant since medicine has become more corporatized, privatized, and financialized. The author of the second chapter, Matt Anderson, analyzes the “sorry state of U.S. primary care” and critically examines such recently misleading innovations such as the “patient-centered medical home”, “pay for performance”, the electronic medical record, quantified metrics to measure quality including patient satisfaction (“we strive for five”), and conflicts of interest as professional associations and medical schools receive increasing financial support from for-profit corporations.

Part One is concludes with Himmelstein and Woolhandler responding to a series of questions put to them by Howard Waitzkin about the changing nature of medical work and how that relates to the struggle for a non-capitalist model of a national health program. Himmelstein and Woolhandler comment on the commodification of health care, the transformation that has occurred during the current stage of capitalism, the changing class position of health professionals, and the impact of computerization and electronic medical records.

Part Two focuses on the medical-industrial complex in the age of financialization. Previous posts of mine this year and last, reference the medical-industrial complex, so my readers will be familiar with its usage here. In this section, the authors tackle the following questions:

  • What are the characteristics of the current “medical industrial complex,” and how have these changed under financialization and deepening monopolization?

Two corollary questions are raised as follows:

  • Are such traditional categories as the private insurance industry and pharmaceutical industry separable from the financial sector?
  • How do the current operations of those industries reflect increasing financialization and investment practices?

Once again, Matt Anderson authors the first chapter in Part Two, this time with Robb Burlage, a political economist and activist. Anderson and Burlage analyze the growing similarities and overlaps between the for-profit and so-called not-for-profit sectors in health care, considering especially the conversion of previously not-for-profit corporations such as Blue Cross and Blue Shield to for-profit.

The second chapter in Part Two is authored by Joel Lexchin, an emergency care physician and health policy researcher in Canada and analyzes monopoly capital and the pharmaceutical industry from an international perspective.

Part Three looks at the relationships between neoliberalism, health care and health. Before I go any further, let me provide the reader with a definition of neoliberalism in case the authors assume that those who read this book understand what it is.

According to Wikipedia, Neoliberalism or neo-liberalism refers primarily to the 20th-century resurgence of 19th-century ideas associated with laissez-faire economic liberalism. Those ideas include economic liberalization policies such as privatization, austerity, deregulation, free trade and reductions in government spending in order to increase the role of the private sector in the economy and society. These market-based ideas and the policies they inspired constitute a paradigm shift away from the post-war Keynesian consensus which lasted from 1945 to 1980.

These neoliberal policies have been associated in the U.S. with the Republican Party and the Conservative movement since the election of Ronald Reagan. In the UK, the rise of Thatcherism ended the long dominance of the Labor Party’s left-wing until Tony Blair’s New Labor took over. Bill Clinton’s election in the U.S. in 1992, diminished some of these policies, and implemented others such as welfare reform, a goal Republicans had wanted to achieve for decades.

Returning to Part Three, the questions asked here are:

  • What is the impact of neoliberalism on health reforms, in the United States and in other countries?
  • What are the ideological assumptions of health reform proposals and how are they transmitted?
  • What are the effects of economic austerity policies on health reform and what are the eventual impacts on health outcomes?

In the next chapter, Howard Waitzkin and Ida Hellander, a leading health policy researcher and activist, trace the history of the Affordable Care Act initially developed by economists in the military during the Vietnam War. International financial institutions, the authors say, especially the World Bank, promoted a boilerplate for neoliberal health care reforms, which focused mainly on privatization of services previously based in the public sector and on shifting trust funds to private for-profit insurance companies.

Colombia’s health reform of 1994, Hillary Clinton’s in that year as well, Mitt Romney’s plan in Massachusetts in 2006, which led to the ACA, are examples cited by the authors. The chapter also clarifies the ideological underpinnings of the neoliberal model and shows that the model has failed to improve access and control costs, according to the authors.

Economic austerity is closely linked to neoliberalism and have led to drastic cutbacks in health services and public health infrastructure in many countries. As I have recently written in my post, Three Strategies for Improving Social Determinants of Health, economic austerity policies have also affected health outcomes through increased unemployment, food insecurity, unreliable water supplies (Flint, MI), and reduced educational opportunities. Recent teacher protests in West Virginia, Oklahoma and other states are examples of this.

In the second chapter in Part Three, Adam Gaffney and Carles Muntaner, focus on social epidemiology, especially the impacts of economic policies on health and mental health outcomes. They also document the devastating effects of austerity in Europe, focusing on Greece, Spain and England. The authors analyze four dimensions of austerity:

1) constriction of the public-sector health system, 2) retreat from universalism, 3) increased cost sharing, and 4) health system privatization.

This trend would seem to have a negative effect on medical travel from Europe and to Europe, as Europe’s health care systems, long touted as a less expensive alternative to medical care in the U.S., begins to suffer.

Part Four examines the connections between health and imperialism historically and as part of the current crises. The question in this part is:

  • What are the connections among health care, public health, and imperialism, and how have these connections changed as resistance to imperialism has grow in the Global South?

The authors are referring to those countries in the Southern hemisphere from Africa, Asia, and Latin America as the Global South. The Global North refers to Europe and North America, and some other industrialized and advanced countries in the Northern hemisphere.

The authors in Part Four focus on the forces and institutions that have imposed a top-down reform of health care in the Global South. Such organizations as the Carnegie, Rockefeller, and Gates foundations, the World Bank and International Monetary Fund, trade agreements such as NAFTA, CAFTA, TPP, TiSA, and health organizations as the World Health Organization (WHO) and the Pan American Health Organization (PAHO) are all termed “philanthrocapitalism” by the authors, and have implemented policies that have weakened public health standards and favored private corporations.

The final part, Part Five focuses on the road ahead, i.e., the contours of change the authors foresee and the concrete actions that can contribute to a progressive transformation of capitalist health care and society.

The authors address these questions:

  • What examples provide inspiration about resistance to neoliberalism and construction of positive alternative models in the Global South?
  • Because improvements in health do not necessarily follow from improvements in health care, how do we achieve change in the social and environmental determinants of health?
  • How does progressive health and mental health reform address the ambiguous role of the state?
  • What is to be done as Obamacare and its successor or lack of successor under Trump fail in the United States?

Howard Waitzkin and Rebeca Jasso-Aguilar analyze a series of popular struggles that focused on the privatization of health services in El Salvador, water in Bolivia, as well as the ongoing struggle to expand public health services in Mexico. These struggles are activities David and Rebeca participated in during the past decade.

These scenarios demonstrate an image of diminishing tolerance among the world’s people for the imperial public health policies of the Global North and a demand for public health systems grounded in solidarity rather than profit.

In the U.S., the road ahead will involve intensified organizing to achieve the single-payer model of a national health program, one that will provide universal access and control costs by eliminating or reducing administrative waste, profiteering, and corporate control.

Gaffney, Himmelstein, and Woolhandler present the most recent revision of the single-payer proposal developed by Physicians for a National Health Program (PNHP). They analyze the three main ways that the interests of capital have encroached on U.S. health care since the original proposal:

1) the rise of for-profit managed care organizations (MCOs); 2) the emergence of high-deductible (“consumer-directed”) health insurance, and 3) the entrenchment of corporate ownership.

The authors offer a critique of Obamacare, explain and demystify innovations as Accountable Care Organizations, the consolidation and integration of health systems, something yours truly has discussed in earlier posts as they relate to workers’ comp, and the increasing share of costs for patients.

The next two chapters concern overcoming pathological normalcy and confronting the social and environmental determinants of health, respectively. Carl Ratner argues, that mental health under capitalism entails “pathological normalcy.” Day-to-day economic insecurities, violence, and lack of social solidarity generates a kind of false consciousness in which disoriented mental processes become a necessary facet of survival, and emotional health becomes a deviant and marginalized condition.

Such conditions of life as a polluted natural environment, a corrupt political system, an unequal hierarchy of social stratification, an unjust criminal justice system, violent living conditions due to access of guns, dangerous working conditions, and so forth, Ratner dissects as the well-known crises of our age in terms of the pathologies that have become seen as normal conditions of life.

Next, Muntaner and evolutionary biologist Rob Wallace show how social and environmental conditions have become more important determinants of health than access to care. They emphasize struggles that confront social determinants through changes in broad societal polices, analyze some key environmental determinants of health including unsafe water (Flint again), capitalist agribusiness practices, and deforestation in addition to climate change. And they refer to the impact these have on emergent and re-emergent infectious diseases such as Ebola, Zika and yellow fever.

Lastly, Waitzkin and Gaffney try to tackle the question of “what is to be done.” They outline four main priorities for action in the U.S. and other countries affected by the neoliberal, corporatized, and commodified model of health care during the age of Trump:

  • a sustained, broad-based movement for a single-payer national health program that assures universal access to care and drastically reduces the role of corporations and private profit, 2) an activated labor movement that this time includes a well-organized sub-movement of health professionals such as physicians, whose deteriorated social-class position and proletarianized conditions of medical practice have made them ripe for activism and change, 3) more emphasis on local and regional organizing at the level of communal organizations…and attempted in multiple countries as a central component in the revolutionary process of moving “beyond capital”, and 4) carefully confronting the role of political parties while recognizing the importance of labor or otherwise leftist parties in every country that has constructed a national health program, and understanding that the importance of party building goes far beyond electoral campaigns to more fundamental social transformation.

In their book, the authors try to answer key and previously unresolved questions and to offer some guidance on strategy and political action in the years ahead. They aim to inform future struggles for the transformation of capitalist societies, as well as the progressive reconstruction of health services and public health systems in the post-capitalist world.

Throughout this review, I have attempted to highlight the strengths of the book by touching upon some of the key points in each chapter.

If there is a weakness to the book, it is that despite the impressive credentials of the authors, they like many other authors of left-of-center books, cling to an economic determinism as part of their analysis, which is based on theories that are more than one hundred years old.

As I stated in the beginning of this review, my views have been tempered by examining and incorporating other theories into my consciousness. One theory that is missing here is Spiral Dynamics.

Spiral Dynamics is a bio-psycho-social model of human and social development. It was developed by bringing together the field of developmental psychology with evolutionary psychology and combines them with biology and sociology.

In Spiral Dynamics, biology is concerned with the development of the pathways of the brain as the adult human moves from lower order thinking to higher order thinking. The social aspect is concerned with the organizational structure formed at each stage along the spiral. For example, when an individual or a society is at the Beige vMeme, or Archaic level, their organization structure is survival bands, as seen in the figure below.

At the Purple vMeme, or Mythic level, the organizational structure is tribal, and so on. There is, among the authors of the book, an evolutionary biologist, but it is not clear if he is familiar with this theory and what it can bring into the discussion at hand.

It would not only benefit the authors, but also the readers to acquaint themselves of this valuable theory which would present an even more cogent argument for better health care. As the book concludes with a look at the future of health care after capitalism, knowing the vMemes or levels beyond current levels will enhance the struggle.

As I continue reading the book, I hope to gain greater insight into the problems with privatized, corporatized, free-market capitalist health care. My writings to date in my blog has given me some understanding of the issues, but I hope that the authors will further my understanding.

I believe that anyone who truly wants to see the U.S. follow other Western nations who have created a national health program, whether they are politicians like Bernie Sanders, his supporters, progressives, liberals, and yes, even some conservatives who in light of the numerous attempts to repeal and replace the ACA, have recognized that the only option left is single-payer. Even some business leaders have come out and said so.

I recommend this book to all health care professionals, business persons, labor leaders, politicians, and voters interested in moving beyond capital and realizing truly universal health care and lower costs.

 

Foreign-born, US-trained Physicians in Medical Travel vs US-born, Foreign-trained Physicians Practicing in the US and Foreign-born, Foreign-trained Physicians Practicing in the US

Those of you in the Workers’ Comp space have probably read my earlier posts extolling the benefits of medical travel, and promoting its implementation into workers’ comp.

Yet, in all those posts, hard evidence of the quality of care provided by physicians in these destinations was not presented.

However,  there is evidence that foreign trained, US  born doctors practicing in the US, provide as good as or better care than that provided by graduates of US medical schools, according to a recent study mentioned over the weekend in a post by Peter Rousmaniere, in his blog, Working Immigrants.

From this data, it may be possible to suggest that foreign-born doctors, trained in US schools provide the same good or better care than their American-born classmates, when they return to their home countries and work in medical travel facilities.

Before beginning to write this post, I tried to research some data on this, but was unable to find any recent information. However, it is well known that there are considerable numbers of foreign-born, US trained and Western trained physicians in medical travel facilities, which is one key factor in choosing to go abroad for medical care.

As Peter reported, among the 12.4 million workers in the health care field in 2015, 2.1 million, or 17% were foreign born. Of these, the foreign born accounted for 28% of the 910,000 physicians and surgeons practicing in the US. 24% of that number are in nursing, psychiatric and home health care.

How many of the foreign-born physicians trained in the US return home is not certain, but given the fact that many foreign born, foreign trained physicians have a hard time gaining access to practice in the US, it is not difficult to ascertain that those who do not enter the US end up working in their home country. In order to practice in the US, they must pass tests by a special commission and enter a residency program, even if they have done them before.

How many foreign trained, US born physicians practice in the US? According to Peter, about 25% of practicing physicians graduated from foreign medical schools. About a third of them are Americans. They are more likely, Peter says, to practice in rural and poorer communities, and are overrepresented in primary care. Given the physician shortage that I and others have commented on, there will be a need for more foreign-born doctors, and perhaps, more US trained, foreign-born doctors to work in medical travel facilities.

The Education Commission for Foreign Medical Graduates (ECFMG) gave roughly 10,000 certifications in 2015. 30.9% were issued to US citizens, 18.9% were issued to citizens of India and Pakistan, and 7.9% from Canada.

The states with the highest percentage of practicing physicians who graduated from foreign medical schools are New Jersey (40%), New York (38%), and Florida (35%).

Most of the New Jersey physicians no doubt practice in the Metropolitan New York Area, given the state’s proximity to NYC. And Florida has a large percentage given the demographics of that state.

So, if foreign-born, US trained physicians are ok for treating injured workers here, why can’t their fellow countrymen do the same back home if an injured worker, or his employer choose that as an option to expensive surgery at an American hospital?

Don’t tell me there is a difference, because there isn’t. It is only ignorance and prejudice that prevents foreign-born, US trained physicians from treating injured workers in medical travel facilities. That is another problem our health care and workers’ comp systems need to deal with.