Doctors and Nurses
Barack Obama Is the Anti-Frank Luntz
Published June 15, 2009 @ 08:39PM PT
If this is what President Obama can do while barnstorming the country for health care, I say, “Yes please.”
The talk of the town is Obama’s speech to the American Medical Association. Much like Michael Jordan, another Chicago icon, Obama is known for rising to the challenge in big moments. This speech was no different, and also owns the odd distinction of being one of his longest. Yes, that’s right, Barack Obama used more words to pitch for fundamental change to our broken health care system than he did to spark new dialogue with the Muslim World in Cairo. Take that for what you will.
It’s a tremendous shame that so much attention has been focused like a laser on the issue of medical malpractice. Out of a 7,300 word speech, the president spent about 230 words on medical malpractice – about 3%, or only slightly more than the malpractice claims that actually make it to trial in this country. And you know, he really didn’t say anything at all about it. Yet if you looked at the commentary on CNN and MSNBC, you’d think that’s all he talked about. The news, man… those folks just aren’t like you and me.
But the real story is that Barack Obama is the anti-Frank Luntz on health care. (And in so being, he is also your new bicycle.) Much like the now-infamous memo by the famed Republican pollster on phrases and ideas to use to scaremonger and ultimate defeat the president’s push for health care for all led to an almost reflexive use of this language by anti-reform Republicans, let’s see how many pro-reform Democrats pick up the president’s myth-busting language. Here are the highlights that struck me:
On the incentives in our system for more expensive care rather than better care: “It's a model that has taken the pursuit of medicine from a profession -- a calling -- to a business. That's not why you became doctors. That's not why you put in all those hours in the Anatomy Suite or the O.R. That's not what brings you back to a patient's bedside to check in, or makes you call a loved one of a patient to say it will be fine. You didn't enter this profession to be bean-counters and paper-pushers. You entered this profession to be healers. And that's what our health care system should let you be.”
This isn’t just a big deal for doctors, by the way (although most doctors I know loved this section.) It’s a fundamental recognition that the free market approach to health care is a misdiagnosis. Unlike selling cars or computers or hedge funds, health care is not just about making a buck. It’s about healing the sick.
On the reasons to invest consistently in comparative effectiveness research: “Now, let me be clear -- I just want to clear something up here -- identifying what works is not about dictating what kind of care should be provided. It's about providing patients and doctors with the information they need to make the best medical decisions. See, I have the assumption that if you have good information about what makes your patients well, that's what you're going to do.” Obama has consistently explained comparative effectiveness research better than just about anyone else. This goes double who have to go to semi-paranoid lengths of stretching the truth in their arguments.
On the need for insurance regulation: “But what I refuse to do is simply create a system where insurance companies suddenly have a whole bunch of more customers on Uncle Sam's dime, but still fail to meet their responsibilities. We're not going to do that.” This is only specifically referencing dispensing with business practices like pre-existing conditions, but could just as easily have been about the public health insurance option. More to the point, in a country that’s already seen bailouts of Wall Street, bailouts of banks and bailouts of AIG with a dubious corresponding surge in those institutions responsiveness and patriotism, it’s encouraging to hear that health insurance companies aren’t next on the list.
On financing health care reform: “Now, there are already voices saying the numbers don't add up. They're wrong. Here's why. Making health care affordable for all Americans will cost somewhere on the order of $1 trillion over the next 10 years. That's real money, even in Washington. But remember, that's less than we are projected to have spent on the war in Iraq. And also remember, failing to reform our health care system in a way that genuinely reduces cost growth will cost us trillions of dollars more in lost economic growth and lower wages.” Obama has always been strong on the cost argument, in a way that I wish more Democrats were. How does an opposition party that left us on the hook for two wars, a fractured economy and billions upon billions for bailouts have any credibility in suggesting that we can’t spend $100 billion a year to fix our broken health care system?
The president covered a lot in one speech – from payment reform to medical school debt, from the public plan to pre-existing conditions, from big picture prevention to the nitty-gritty on cost savings in Medicare. If he just does that consistently on television and in person, we could well be on our way to re-establishing popular momentum that may even withstand the worst Frank Luntz-inspired commercial you can imagine.
Hitting the Road and Hitting the Fan
Published June 11, 2009 @ 05:55AM PT
Earlier this week, former Labor Secretary Robert Reich described the moment we’re in this way: “This is it, folks. The concrete is being mixed and about to be poured. And after it's poured and hardens, universal health care will be with us for years to come in whatever form it now takes.” If the legislative calendar that the Senate and House are publicly calling for is at all accurate, he’s right. At the end of the next four weeks, give or take, we’ll know what the consensus is in the House and Senate, and what’s still left to be decided. Gradually, the central question will shift towards whether to support the bill or not, and away from what’s in it. No wonder both sides are ramping up their outreach to influence what's in it while they still can.
The prime movers today are President Obama and the American Medical Association. If the AMA represents “the voice of physicians” in the minds of the general public, that’s only because of historical memory. The physician’s voice is hardly monolithic these days. Physicians for a National Health Program is one of the strongest groups advocating for a single-payer health care system, and the Health Care for America Now! coalition contains five different national progressive doctors organizations. Up until now, the AMA has largely kept quiet. They were part of the group that met with the president promising to find fat to trim in our health care system, but have been a far cry from the organization that single-handedly defeated Roosevelt and Truman’s health care aspirations, JFK’s national push for Medicare, and helped drown the Clinton effort of the 1990s.
It’s been disorienting to say the least. Today, we’re starting to see the AMA we all know and love.
In an article in the NY Times, they’ve made clear they find the public health insurance option to be a non-starter. Of course, they’re couching it in the popular “crowd out” argument: “The introduction of a new public plan threatens to restrict patient choice by driving out private insurers, which currently provide coverage for nearly 70 percent of Americans… [and] the corresponding surge in public plan participation would likely lead to an explosion of costs that would need to be absorbed by taxpayers.” So few words, and yet so many leaps of logic. Whether the public plan can dip into taxpayer funds at all is an open question (some, like Sen. Rockefeller in his new proposal, say it should be financed by premiums and subsidies from the Exchange alone - a viewpoint shared by Sen. Schumer and the drafters of the House Tri-Committee principles). There will be subsidies for those who can’t afford it, but customers who choose private insurance in a National Health Exchange will have access to the exact same subsidies. Moreover, the argument as always is that private insurance can’t adapt, and that they’re so inefficient that they’ll go out of business. This is a reason to keep them around?
But of course, the story behind the story, as revealed by Forbes, is that “Doctors and hospitals, which already get paid less by government programs like Medicaid and Medicare than they do by private insurance, do not want a bigger public payer in the market either. That's why the American Medical Association this week came out strongly against it.” Ah yes, those pesky Medicare rates – something the AMA has been complaining about since before Medicare existed. Cut our compensation, they warn, and you’ll have inferior care. But the truth is many doctors are making a killing off of Medicare, no matter the complaints. More to the point, “Two decades of research suggests that the higher spending does not produce better results for patients but may be evidence of inefficiency.” We’ve seen health care costs explode at double the rate of inflation. The result hasn’t been that we’re all a lot healthier – it’s that millions more of our fellow citizens are uninsured or underinsured.
But today is also the first of President Obama’s many public appearances on the road in support of passing a real health care reform bill this year, with a town hall event in Wisconsin. Yesterday, Organizing for America, the heirs to the Obama presidential campaign, launched their health care Web hub, with content and tools very familiar from the general election. For weeks, Obama has kept health care in the headlines even as Congress worked on the details. Now he takes the show on the road.
These two forces are set to collide Monday – when Obama addresses the AMA directly. On the campaign trail, candidate Obama took a number of opportunities to prove that he had the character to tell people what they needed to know, not what they wanted to here. Telling Detroit executives that they needed to stop blocking progress on improving car emission standards wasn’t popular; neither was talking about a more equitable economy in front of Wall Street executives. Will he have any trouble once again reiterating a strong belief in the public health insurance option?
So to sum up a wild week, there’s a bill in the Senate HELP Committee, hearings and debate in the House, and furious Twittering in Senate Finance. Conservatives are in lock-step with Frank Luntz, decrying the influence of a “Washington takeover” of health care – a takeover, incidentally, that would keep all of the delivery system and the majority of the financing private. Big Insurance, Big Pharma, and the AMA are all taking solid aim against the public health insurance option and, more particularly, the threat of a shrinking profit margin. And finally, a popular president is taking to the road to drum up a popular movement to get health care legislation across the finish line.
Health care doesn’t look like “Kumbaya” anymore. It looks like war.
(Disclaimer: I have no relationship with the AMA whatsoever, and views expressed are entirely my own. They do not reflect the views of any employer, past or present.)
Improving the Quality of Health Care: The Kennedy Bill
Published June 10, 2009 @ 03:40PM PT
It's one day after the dropping of the draft of the Senate Health, Education, Labor and Pensions Committee bill in advance of hearings and mark-up of the language. Most news stories have focused on the "placeholders" put into the bill for the contentious public health insurance option and the employer mandate (or "pay or play" - I guess we'll find out which it is soon). Far too many have focused on the Frank Luntz bingo of Republican talking points in reaction to the bill. These fall along the lines of an outraged, "I am shocked--shocked!-that Sen. Kennedy's bill contains what he said it would two weeks ago!" The 600 pages or so that aren't rhetoric and don't involve the public plan or the employer mandate have gone somewhat underrepresented.
So I want to dive in on two parts that aren't as flashy as how you expand access or how you control costs, but are just as important to the success of the bill: how do you improve the delivery of care, and how do you make health care better?
As you'll remember, I was particularly taken by Sen. Mikulski's quote from the press release: "Emphasizing quality improves lives, saves lives and helps pay for reform by saving money." That's not part of our conversation often enough. It's not enough to cut costs to a more politically manageable level if the quality of our health care suffers. And it's not enough to do what we've done so far, which is push every new treatment in the hopes of seeing a payoff in quality, if we're only going to come up with expensive treatments that drive up the cost past the point where most people can afford it. That creates the situation we're in now, where you can have heart surgery done using the latest high tech surgical arm to no better value if you can afford it. If you can't afford it, you can't even get reasonably-priced primary care or cholesterol-managing pills to prevent you from getting heart disease in the first place.
So what tools would the HELP Committee bill provide? (Those of you who want to follow along, start on page 245, section 211.):
- A new agency within HHS, the Patient Safety Research Center, devoted entirely to new research on best practices, specifically focusing on high quality providers who regularly exceed their peers in terms of efficiency and health outcomes (one of the obvious examples being the Mayo Clinic), and then blasting out the results of that research so more doctors can learn from the superstars in their field. You may think it's weird we don't have this already. You'd be right.
- More grant programs to establish medical homes, a model of care that yields better outcome, lower costs and, most important of all, better patient education
- Better reporting working towards the lowering of preventable hospital readmissions. There have been many reports of patients on Medicare who are released without proper training on how to care for their condition and without sufficient follow-up, either from their hospital or their primary care provider. This is one of the huge wastes of money in our system in that most cases are easily and cheaply preventable, but it's not a priority for the hospital releasing them. Guess what? It'd be a priority now.
- Funds to create more "patient decision aids" and ways for patients to be more active participants and make better decisions in conjunctions with their doctor. These are particularly important where we don't actually have good information on which treatment is better - how else are patients supposed to figure out what works best for them, and not just what their doctor really, really, really strongly recommends for them?
- Analysis of how we're packaging drug information, and whether there's a better way to get that information across to Jane Schmoe, who hasn't had 4 years of medical school plus X years of private practice as a doctor.
- And trial programs to make sure our provider workforce of tomorrow is learning about patient safety and how to improve quality and teamwork from day one of medical or nursing school.
Notice a common trend? It's about education. This point can't be stressed enough - we talk way too much about the sacrosanct nature of the decisions made by a doctor and a patient, and not enough about what we can do to learn to make better decisions. For something that's already been dubbed "the most liberal approach" to health reform, we're not talking about command and control, fiats and mandates here. We're talking about learning what works from people who are really, really good at what they do - and then giving us the tools to do more of that.
The only surprise is that we're not doing it already.
(Photo credit: KB35 on Flickr.)
The Patient-Centered Care of Tomorrow
Published June 07, 2009 @ 10:02PM PT
We spend a lot of time taking about the high costs of medicine as it relates to designer drugs, medical technology, and overtreatment in the name of defensive medicine. But we spend little time talking about how the incentives of our system have warped the way medicine is practiced. It’s no wonder that we’re seeing a poor response in the plans coming out of Washington to the question of how we prevent the shortage of primary care providers in this country, and next to no response to the way economic factors have changed medicine – and not for the better.
Starting with the basics, we know that the emergency room is the costliest place to receive care. We also know that if we’re serious about controlling costs, we need to move away from “disease care system” where the incentives are towards expensive interventions when the condition is already serious and towards a “health care system” where we prevent the condition from developing in the first place. But this isn’t going to happen just by giving everyone coverage. In Massachusetts, whose universal health care bill epitomized this rush to achieve universal access without looking at costs or improving quality, the crisis of being uninsured has been replace with the crisis of being unable to find a primary care doctor – because there just aren’t enough to go around. Medical blogger KevinMD cites a study that says, “One in five adults said they had been told in the last 12 months that a doctor or clinic was not accepting new patients or would not see patients with their type of insurance.” As a result, “there has been little change in the use of emergency rooms for non-emergency treatment.”
We also know that just creating new residency slots in primary care isn’t enough, as we already have more slots than we can fill with the graduating classes of medical students we produce each year. Finally, a measly 5% bonus for primary care providers, one of the proposals coming out of the Senate Finance Committee, will do little to change the economics of who goes into primary care. As an article in The New York Times today relates, “According to a 2008 survey of physician salaries by the American Medical Group Association, their average annual salary is $201,555, versus $356,166 for a general surgeon and $614,536 for a neurological surgeon.” The low end of this spectrum is primary care and family practice. 5% won’t do much to help that. We’re still waiting for a solution from Washington that will seriously tackle the economic factors yielding a primary care shortage.
But there’s a quality side to the primary care shortage as well. That NY Times article I just cited is the excellent “If All Doctors Had More Time to Listen,” and it profiles a number of doctors – some in practice for themselves, others as part of a new type of clinic in Seattle -- who are trying to break out of the box of economic pressures they’ve been put in. Under fee-for-service, the 15-minute patient consultation is the basis for compensation for primary care. Not emailing or calling a patient, not following up with specialists who are treating the same patient, not even spending a lot of time trying to get into the weeds of a patient’s case history. The focus is instead on churning through as many 15-minute appointments as possible – a pressure reinforced from residency onward. But in this rush to make a living, something gets lost. In conversations with doctors who have practiced over a number of decades, many of them have told me the focus of their medical training was conducting high-quality interviews. That was the best way to get the diagnosis right the first time. But that took time. Some patients need some coaxing in order to get their full medical history. What do doctors do now that their compensation or their bosses focuses them on not going over 15 minutes?
Dr. Lilli Sacks, one of the doctors interviewed for the piece, spells it out. She went from a big clinic where the 15-minute consultation was the practice’s bread and butter, to a new clinic that reimburses for 30-minute consultations, as well as following up with phone and email. “I had a disabled patient that I saw for 13 years. Until she came to my new clinic, I never had the time to learn the details of her accident and the resulting complications. I was always treating whatever the immediate concern was.” Not only are the interactions better, but it soon becomes clear that overtreatment isn’t only a protection against liability – it’s also a crutch to relieve the incredible time pressures of the current systems: “Scheduled to see as many as 25 patients a day at a large clinic, she lacked the time for thorough examinations and discussions. Because of this, she said, primary care doctors are often forced to order tests and send patients to specialists.” Other doctors in the article are finding Health IT to be a time-saver, and that spending more time on patient education and prevention by ignoring the push of the 15 minute constraint leads not just to reduced costs but also better quality.
The goal is a simple one – spend more time with patients and focus on quality interactions, not just quantity of interactions. But more time means more primary care doctors, and more primary care doctors means paying them better and giving them the resources we need. In this light, the half-measures coming out of Washington aren’t just insufficient – they are, themselves, a rushed diagnosis.
(Photo credit: Orcoo on Flickr.)
What if MedPAC Rules the World?
Published June 03, 2009 @ 08:19PM PT
President Obama today embraced the notion of giving the Medicare Payment Advisory Commission (MedPAC), the commission that advises Congress already on Medicare reforms, the power to make its recommendations reality. The president embraced the idea of bringing MedPAC’s recommendations each year into a single up-or-down vote in Congress that cannot be filibustered. Similar to the base closing commissions, doing this would shift the power for making decisions out of the political sphere and into the sphere of men and women intimately familiar with how our health care system works. If we're seriously thinking of giving them this power, it begs one big question: what would MedPAC do if they ruled the world?
Well, luckily MedPAC’s recommendations are all documented – the ones Congress follows and the ones Congress ignores. Based on MedPAC’s statement to the Senate Finance Committee from April, here are some of the changes they recommend right away:
- Use the payment system to create incentives for efficiency. This includes setting Medicare payments to Medicare Advantage plans to 100% of the cost of a beneficiary in regular Medicare, instead of the 114% they’re gobbling up now for not terribly different outcomes. This has become an annual recommendation from MedPAC. Although both the President and most members of Congress have spoken out against these overpayments in Medicare Advantage, no one has done anything yet.
- Increase payment for primary care providers by “improving the accuracy” of payment for specialized care. That means taking an ailment that’s not terribly severe but is currently being billed at super-high rates as though it were a difficult procedure, and decreasing the payments for it. It's one of many ways to curb the excesses of our fee for service system while simultaneously making the investments in primary care that we know are so desperately needed. This would have the added effect of discouraging doctors and hospitals who’d be tempted to only do these easy but lucrative procedures.
- Create a “quality incentive payment policy” that applies to everyone from doctors to dialysis facilities, from hospitals to Medicare Advantages plans where part of the payment is based on hitting measurable standards for quality of care.
- Require doctors using Medicare to report back on what resources they use in their treatments, compare doctors treating the same ailments, and facilitate discussions with those who use the most and those who use the least. Note: there’s no money involved in this one – it’s just creating dialogue and learning opportunities that could improve care for everyone.
- Fund more comparative effectiveness research to generate more “credible, empirically based information” so that doctors and patients could “make informed decisions about alternative services for diagnosing and treating most common clinical conditions.” This also doesn’t have any money attached to it, but would give more information to doctors and patients to make better decisions and have more productive visits. It’s also likely to bring costs down and decrease overtreatment.
And I’m only on page 4.
A refrain I hear too often is that health care is so complicated -- particularly the health care delivery system -- that we don’t know where to even start fixing it. Baloney. One thing that will strike you if you read the statement all the way through is that MedPAC has been making these same recommendations for years in multiple reports. Missing from the discussion is that the VA system uses a lot of the same techniques, which explains why their outcomes and costs are better even than Medicare.
We have the experts already. They’re making great recommendations. Some of them just involve communications and research – they don’t even involve money. But because Congress is bogged down in getting perpetually re-elected, they’re not implementing them. Medicare is a huge opportunity to start turning our health care system around – we just have to start listening.
(Photo credit: wauter de tuinkabouter on Flickr.)
We Need New Primary Care Incentives, Not Just Slots
Published May 31, 2009 @ 05:18PM PT
I didn’t comment much when the original “Resident Physician Shortage Reduction Act of 2009” was unveiled back at the beginning of May. Neither, apparently, did anyone else until AMA News published a brief new item on it on Thursday. The bill, which was proposed simultaneously in the House and Senate, would lift the cap on residency slots for new physicians that are funded through Medicare. It’s not a bad idea, but it’s not transformational and doesn’t move the chains much at all on the growing shortage of primary care physicians in this country.
Right now, about 100,000 residency slots are funded through Medicare each year. The bill would increase that by 15%, and would also seek to increase the residency slots in play by transferring those from hospitals that have closed to active hospitals. Right now, a resident physician working for a hospital that closes will be transferred to another hospital and continue being funded by Medicare, but the new hospital will lose that funding when that particular doctor leaves. Finally, the bill would increase residency slots in non-hospital environments (particularly community health clinics), and “The Secretary [of HHS] shall give preference to hospitals that submit applications for new primary care and general surgery residency positions.”
It’s a necessary step if our aim is to create more primary care physicians, given a mounting shortage already and a definite shortage if we create a health care delivery system where primary care is properly valued in compensation and by patients. But it’s not a particularly helpful step in and of itself. It doesn’t even address most of the issues that are creating our primary care shortage, specifically:
- Creating a new residency slot in primary care funded through Medicare has no impact on low reimbursement rates for primary care in general, which is a major reason why so many doctors lean towards specialty care.
- We already do not even come close to filling the primary care resident slots we already have. As I wrote when The Match results came out, “a little more than half (53.5%) of the available slots will be filled with American medical graduates this year. Even if every one of the 3,047 doctor applying for an IM slot had been matched, that would only account for 62% of the available slots.” Just adding more residency slots doesn’t address this problem at all.
- Just to mention it, there are larger ethical questions about what having so many open primary care slots – which then become filled by international medical graduates – does to those countries who lose their native doctors to our open slots.
- Finally, this does nothing about medical school debt, which has a dramatic effect on who decides to train to become a doctor in the first place as well as what specialty that doctor goes into. The New England Journal of Medicine reports that 23% of medical graduates have $200,000 in student loan debt when they graduate.
All of these are far more important factors to our primary care physician shortage than a lack of residency slots. This is a bit like responding to a taxi cab driver shortage by buying more cabs. Sure, you’ve increased capacity, but you’ll need human beings to drive those cabs – and you haven’t made the job any more attractive.
(Disclaimer: Although I work for a labor union for residents, the above represents only my own opinion, and not the official position of any organization I currently work for or have worked for.)
(Photo credit: kevy mckeverson on Flickr.)
Who Receives Unnecessary Health Care? "Not Me!"
Published April 22, 2009 @ 09:34PM PT
We know from a Dartmouth Atlas Project study that about $700 billion of our health care spending – nearly a third of the spending for the entire country – is spent on unnecessary care: unneeded tests, expensive prescribed treatments that are just as effective as less costly treatments, and care that does nothing to improve health outcomes but gets prescribed anyway. Who’s receiving all this unnecessary care? In the tradition of “Family Circus,” it’s Ida Know and Not Me.
Kaiser Family Foundation, NPR and Harvard Medical School released a poll today in which 49% of respondents say unnecessary care is a “major problem” and 39% say it’s a “minor problem.” Now granted, the poll question came right out and said these were “medical tests and treatments they don’t really need,” to which you would hope your answer would be, “Yep, that’s not good.” But what follows next is even more interesting: only 16% think they’ve received unnecessary tests or treatment themselves. We know it happens, we know it’s a problem, but it definitely isn’t happening to me. Instead, it’s Not Me.
Health care reform isn’t just about what the government can do to fix the situation. It’s also about becoming an involved and engaged patient and being aware that yes, sometimes we do waste health care. Part of the reason why the conservative notion that patients, treated as rational consumers and given more control, will make good decisions rings so hollow is, well, we’ve all been to the doctor. If it’s a non life-threatening situation and/or you don’t know that much about it, it’s hard to rebuff suggestions for a test or treatment from your doctor. Earlier this year, I had both unnecessary tests and an unnecessary treatment before my mono was diagnosed. While my doctor was eliminating other possibilities, she ordered lab work to screen me for hepatitis, lupus, and HIV. I didn’t have any reason to think I had any of the above – as indeed I didn’t. The tests didn't lead to me being healthier, but under what reasoning should I have declined them? Similarly, in that first week of my illness when I was still experiencing high fevers and before my first bloodwork had come back from the lab, my doctor prescribed me an antibiotic. It was generic, and didn’t cost all that much. It also had nothing to do with my actual problem (mono) and was care I didn’t need to get. But I took it without question. So yeah, part of the unnecessary care problem is me.
When we’re in pain, or even worse, a loved one is in pain, we’re far less rational consumers. I’ve mentioned before White Coats’ post on his own daily prompts to practice defensive medicine and provide care that he, as a doctor, thinks is likely unwarranted. The most obvious of these anecdotes:
“A nice little old lady slipped on the stairs on her house and scraped her leg on the edge of the stair, causing a deep “V” shaped skin laceration. The wound was bleeding, but most of the skin was not able to be sewn back together because of the way the skin had been torn. I removed the nonviable skin, put a dressing on it, and was going to send the patient home. Her daughter, whom I had been forewarned was a nurse and who had complained about care in the ED before, asked me why I wasn’t going to do an x-ray. When I explained that she did not have any signs of a break. After I left, she asked the nurse to call the hospital administrator. That got her mother the x-ray that she so desperately didn’t need. And no, there wasn’t a fracture.”
That’s dramatic, but it’s hardly a-typical. We feel entitled to immediate care and the latest care – even when immediate care is unnecessary and the latest care is no better than the cheaper alternative.
There’s simply no way to bring health care costs under control without everyone sacrificing something. Yes, pharma has to sacrifice its dedication to pushing the latest drugs over generics, and private insurance has to sacrifice its administrative waste and most inhumane business practices, and specialist doctors need to know they can’t charge the moon forever, etc. But we have to realize that when it comes to receiving care that doesn’t make us healthier, it’s not Ida Know’s problem – it’s ours.
(Photo credit: skidder on Flickr.)
