The Four Horsemen of U.S. Healthcare – Part 1

It’s difficult to completely separate the role that each of the Horsemen play in healthcare. Like all symbiotic systems each part affects the other but not in the same way. Money is often, but not always, the medium in which all the Horsemen express their influence. Power also finds itself in the workings of the U.S. Healthcare system. The four horsemen are trying to make money for themselves and often for one or more of the other horsemen. We all need allies and friends when it comes to making money and increasing our power. The four Horsemen of Healthcare understand this principle better than most.

This series discusses the horsemen individually but not separately. The four horsemen together create an environment for the unique system we call U.S. healthcare. Healthcare systems in other countries may not have all four horsemen. Some only have three. Or, the horsemen that do exist in any particular country may work differently than in the U.S. . How the horsemen more fully affect the other players will be discussed thoroughly in the last post of this series. In the last post, I connect them in a more integrated way in order to show the symbiosis involved in the total system called U.S. Healthcare. I also integrate the strategies in the last post.

The first Horseman – Politicians

Why don’t I use the more general term government instead of politicians? First, there are several government healthcare programs. In fact most people agree that there are six U.S. government healthcare programs. In addition to Medicare there are, Medicaid, SCHIP (State Children’s Health Insurance Program), DOD TRICARE, TRICARE for Life, VHA (Veterans Health Administration) and HIS (Indian Health Service). Rather than speak about government managed healthcare programs, I speak about politicians. The reason is that politician-driven healthcare funds and drives all U.S. healthcare. This includes government healthcare programs and privately insured programs.

Remember, Congressional politicians created their own government healthcare program that is never discussed as a government healthcare program. The U.S. Congress’ medical care, is managed separately from the other government healthcare programs and of course they pass their own laws to manage it without any external oversight. Finally, a government has no individual name or face. Politicians have names and faces. You see them every two, four or eight years when they want to be re-elected. No one has ever seen “the government”.

In the U.S., government parties are not voted into power as in some countries. We vote individuals into power. Enough individuals from one party may make that party a majority in running the government. Many politicians vote the way their party wants them to vote. However, no U.S. politician is put in prison if they oppose how their party wants them to vote.

Politicians Want To Be Elected, Not Parties

Party affiliation in the U.S. has had less meaning for voters since World War II. It was the Republican party and Abraham Lincoln who ended slavery in the U.S. I don’t think any voters are looking for a repeat of that liberalism anytime soon in today’s Republican party. Being a member of a party is now more a granfalloon than an actual identity. Politicians in the past have changed parties but in the last 25 years it’s like changing clothes for some politicians. Some have changed parties more than once. Here are the 22 most famous party-switchers of all time. With the current Presidential election we saw a party leave a candidate before an election.

I’m sure party platform and principles play a role in every politician’s decision-making. Or, I want to believe that. But, the number one concern of every politician is re-election. If you’re not an elected government official then are you really a politician? Getting elected is job one for politicians. Like salesman, once they win the current election (or sale) they begin working on winning the next election the next morning. This takes money and lots of it.

Payment for physician services using eggs, chickens and farm animals is no longer acceptable after the big breakthrough cancer drugs and other drugs were created. Until after World War II, when penicillin and sulfa medications were the high dollar drugs, little money flowed through healthcare raising prices. More importantly, there wasn’t much money for drug and medical device companies, hospitals or politicians. Nano tech companies didn’t exist. Insurance was becoming required and charity wards at hospitals began closing in major cities. If patients didn’t have private insurance, they were second-class citizens. Money flowing into healthcare and healthcare prices began taking steroids with the Prescription Drug User Fee Act (PDUFA) of 1992.

My Experience with the First Horseman

I had a conversation in the office of a South Carolina state legislator in the early 1990’s who questioned the representatives of one of the state medical schools with whom I was affiliated. The medical school representatives asked me to attend in order to represent the rural face of medical education to the legislator. I was responsible for physician internships in my rural nine counties.

I had been in my job for two months. From the Medical University of South Carolina flowed most of my AHEC’s money. This money came from state tax dollars appropriated by the state legislature for rural medical, nursing and allied health education. Despite my inexperience I knew that to withhold my support for the medical school’s argument with the legislator was to hurt my own AHEC’s money.

The stipends of hospital residents were the topic under discussion that morning. I had no residency programs in my counties but the counties that did were hardly rural by anyone’s definition. Many of them were located in a hospital in the largest city of what was otherwise a rural county. So, I was the relief batter in this verbal baseball game called a meeting. I had no graduate medical education in my rural area, so my support appeared to show that rural areas supported the existing graduate medical education locations.

What Is Graduate Medical Education

Let me explain a little about graduate medical education and residents before we get too far into discussing the meeting that morning. Residents are MDs studying to be a gastroenterologists, orthopedic surgeons, etc..  They have graduated medical school and are now receiving further training in a chosen specialty. At the time the average resident earned $35,000/year stipend from the hospital where they were training. There might have been housing allowances, relocation expense reimbursement, etc. involved in their support but the cash part was $35K. In 2016 dollars, that stipend would be $62,000 per year.

After the medical school representatives politely defended resident stipends, the legislator asked, “Do you know how much the people he helps make in that town?” The answer was somewhere around $20,000. The issue wasn’t so much the legitimacy of the resident’s stipend. It was about the perceived discrepancy between a student’s stipend in school and the salary of the average person they served. This is not unlike the issue being discussed in the media now regarding the disproportionate salaries of CEOs compared to the average salary of the employees who work for them.

No one questioned the residents weren’t worth what they made. This was an image or public relations issue to the legislator. However, this was simply the cover issue. The real issue was yet to be revealed in the discussion.

Votes for Dollars Means More Votes

In fact, the issue of medical student stipends is more personal to legislators than simply the public relations angle. This legislator was running for re-election soon. Healthcare costs for the residents of his voting district was going to be an issue. Voters who went to the local hospital didn’t like the rise in costs for their healthcare. Of course, increased healthcare costs was occurring everywhere in the U.S. and has ever since. The voters didn’t know or care that high healthcare costs was a national issue. It was a local issue to them because it hit the wallet in their back pocket.

So what did the South Carolina legislator really want by bringing up this issue? Well, he was a member of the appropriations committee that controlled how much the medical school received each year. In order for the medical school to get their money, the legislator wanted something in return in order to win his election. He wanted a quid pro quo, or a favor for a favor. Quickly, the conversation became a discussion about the legislator receiving another full-time physician for a town in one of his rural voting districts. This legislator had the leverage he needed by discussing the amount of state funds that went to a resident’s stipend.

Medicine and Politics

When a politician gets a physician to move into a rural area and open up a medical practice, he is almost always assured of a positive election result. When a physician opens up a practice in a rural area of a state, the whole town turns out for the ribbon cutting ceremony. State and local politicians make speeches praising the hard work and support of each other. Each takes credit for the increase in local healthcare services.

This is only one example of healthcare and politics coming together. The good thing is that in this particular process more people do end up with healthcare in their communities. Other processes that involve healthcare and politicians are not so mutually beneficial and we will discuss those in this series.

If you think this occurs only in rural Southern areas of the U.S. you are wrong. As the featured image of this post shows, politics, healthcare and medicine occur on every political level including national politics. The images of this post show graduate medical students (i.e. residents) in a Congressional office and on the steps of Capitol Hill. The students were brought into Washington, D.C by the American Medical Association to lobby Congress on the need for more money for graduate medical education.residents-meet-with-congresswoman

Obviously, the AMA felt that fresh-faced and young graduate medical students asking for more money would be more persuasive than lobbyists in business suits. The Congressional men and women would be looking the students in the eye and saying yea or nay to their educational money. Notice also how each resident is wearing his or her white lab coat. Do you suppose they came ready to administer medical attention to anyone who needed it in Congress that day? No, they were hacking the Congressional politicians they met. They wanted to make sure the politicians saw them as physicians and not just greedy students.

Politicians Are A Passive Horseman

Politicians don’t participate actively in your treatments so they are the only passive involved in your healthcare. However, they do have a huge effect on the medical care you ultimately receive. Therefore, there are some hacks you need to know how to use on politicians.

I mentioned in the first paragraph that a Horseman may also try to, “maximize their profits or profit from their influence in creating profits for one of the other players.” This is surely the case for politicians. We saw above how politicians profit from medicine in their voting districts. Politicians create laws that allow for pharmaceutical, medical device and nano tech companies to earn big profits. This gives more money to the companies and more money to incumbent politicians for re-election. It may surprise you to know that Congressional staff rarely, if ever, write any of the laws their congressmen and congresswomen propose in the House or Senate. In addition, the information supporting these laws is not always objective or researched independently.

In nearly every case, the information that influences congressional politicians to pass laws comes from lobbyists representing special interest groups. The American Medical Society also lobbies for laws friendly to the interests of their members, i.e. physicians. Drug companies lobby for laws to increase their companies’ profits through political contributions, advertising, marketing and other efforts.

These companies also write the laws they need passed by politicians. Members of Congress vote on these laws simply because lobbyists tell them to approve them. Lobbyists and the organizations they serve are the largest campaign contributors for re-election. And, they are the “experts” in their field, right? Who better to write a law on drug issues than a pharmaceutical drug manufacturer? There is also often not enough time for anyone to read the thousands of pages of law approved during the typical Congressional session. So, again, Congress relies on drug company lobbyists to explain new bills to them before voting them into law. One example of this process is described in a story, Negotiating for Lower Drug Costs in Medicare Part D.

Thus far in the 2016 U.S. presidential election alone, pharmaceutical companies have contributed nearly $1B to political candidates. That number does not include the individual contributions their executives and employees can make. The limit for individual political contributions to candidates is $2,700 per election. However, each primary, runoff and general election is a separate election. Therefore, the final dollar amount an individual medical association or company employee can make to a political candidate their company supports can be much larger. Also, an employee can also contribute $5,000 to a PAC (Political Action Committee) in their own name. Corporations, trade associations and labor organizations can all create PACs.

Politics, Profits and Treatments

I don’t find it funny that a U.S. voter cannot sell their vote. However, Congressional and state politicians are able to sell their vote on a per bill basis? If you think about, one voter makes little difference in the outcome of any election. Yes, I know you think we each make a difference with our one vote. However, an election and final passage of a bond or referendum occurs at the end of thousands of votes not just our one vote.

Although one person’s vote out of thousands of votes makes little difference in an election, a few Congressional politicians out of a few hundred voting to get your bill passed makes a real difference. It’s certainly cheaper than purchasing thousands of votes from individual voters. This is particularly true if you buy Congressional members who sit on the committees that approve the bills you need for your business to be profitable. The story Selling votes is common type of election fraud points out that vote buying occurs even in U.S. local politics.

Politicians also played a role in passing the Prescription Drug User Fee Act (PDUFA) of 1992. This bill requires “user fees” paid by the drug companies in order to speed up drug approvals. With the Food and Drug Administration (FDA) receiving a portion of its money from the very companies they inspect and regulate, could the FDA be influenced while examining the safety and efficacy of the drugs patients receive?

Hospitals Love Politicians Too

As I moved from a position as Director of Education for one hospital and began serving as a Director of an Area Health Education Center for nine hospitals, enterprising accountants were coming up with a new strategy using Medicaid dollars to support hospitals. It is called Disproportionate Share Hospitals. The simple explanation of this new strategy to finance hospital costs spent on Medicaid patients is this one.

Disproportionate Share Hospitals (DSH) serve a significantly disproportionate number of low-income patients and receive payments from the Centers for Medicaid and Medicare Services to cover the costs of providing care to uninsured patients.

The payment system is a bit more complex than just paying for low-income and uninsured patients. 1989 was the year hospitals began receiving windfall record profits if they qualified as a Disproportionate Share Hospital. You find detailed information at CMS.gov on the program, if you are interested. There are several ways for hospitals to qualify for these payments besides simply treating low-income or uninsured patients. The one that had the most impact from what I saw in my position at the time was the qualification allowing for additional money going to a hospital because of their graduate medical education residency programs.

Many large city/county hospitals were awash in money as a result of their disproportionate share. Poor rural hospitals that did not have graduate medical education programs received very little or none of the disproportionate share money. Many of the large teaching hospitals feared the federal government would want it back when they realized their error. Therefore, they only spent the interest on the money they earned from their share. If you think back to the 1990’s you probably realize this is also the time hospitals began adding marbled lobbies and elegant foyers to their hospital. We can thank DSH money for these upgrades. Of course the executive branch of the U.S. government never asked for the money to be returned. This surplus of funds allowed hospitals to purchase or build satellite hospitals in future years.

How did the larger hospitals who offered graduate medical education make so much money? Think about it. A resident is a student and often not a fully licensed M.D. He or she earns $35,000 a year (in the 90’s). The hospital charges the allowed 3 times the cost of the procedures the resident performs. It was assumed that the supervising physician would be reviewing his notes and available to step in to assist the resident, so that physician had to be paid also. This was the reality for DSH hospitals in the 1990’s. The 200% DSH markup is the percentage I heard from several hospital administrators I knew at the time. As the wikipedia DSH page states: Between 1990 and 1996, federal DSH payments ballooned from $1.4 billion to more than $15 billion annually. It’s easy to see why.

Physicians Love Politicians Too

As Disproportionate Share Funding was being changed, pressure on Medicare costs began to make headlines. Voters heard since the late 90’s that Medicare (and Social Security) are not sustainable. They will be bankrupt in just a few short years. Since 1997, the Executive branch of government and the Office of Budget and Management has been proposing Medicare budget cuts in physician reimbursements for services provided to Medicare patients.

For the previous 19 years, elected members of Congress passed laws overriding those Medicare cuts to physicians. With the Affordable Care Act (Obamacare) a new bill called “Doc Fix” was passed by Congress. The American Medical Society and other physician groups were happy since it now gives physicians an increase in reimbursements over the next few years. Congress praised themselves as having created a new plan for reimbursements. How it will be funded is still in question, however. The Congressional Budget Office states it will add $141 Billion to the federal deficit. However, everyone is happy, especially physicians.

What Happens to Healthcare When Politicians, Wealthy Parents and a Prestigious University Get Together?

Another example of politicians and healthcare influencing each other is the Princeton University meningitis outbreak in 2013. In a rare move, the FDA approved the use of drug not tested or approved in the U.S. to be used to treat Princeton University students. However, it was only approved for use at Princeton. As the story states: The CDC and FDA have approved the importing of the vaccine for use at Princeton under an ‘investigational new drug’ status.

This meningeal vaccine is beneficial to 25% of patients with exposure to meningitis in the U.S.. Yet, use of the vaccine remains unapproved for any patient with a risk of exposure to meningitis. Enroll in Princeton and you receive treatment. Are you in college at another school? Oh well, sorry. Did a few parents and campaign contributors call their Congressional Healthcare Horsemen and urge them to get FDA approval for the drug quickly? Well, Princeton did distribute the vaccine to its students in a matter of weeks after receiving special FDA status.

What Hacks Can We Use by Understanding this Horseman?

So, as a cancer patient what does all this mean to you? If you don’t have the money to purchase political favors then you need to leverage the other thing all politicians want – votes.

Is there an effective treatment for your cancer that is not approved in the U.S.? Is the treatment available but only for use in hospitals which you cannot access? You may want to consider contacting your Congressional representatives.

Have your friends and family call his office also. Call other state and local politicians, especially those on committees that can make the wheels turn in your favor. Mention the clubs, organizations and church to which you belong and how many members they have. Tell these politicians you will inform all of the people in those clubs and organizations who helped you to receive the treatment you received that saved your life and to make sure they remain elected to strengthen healthcare. Get the club president or church pastor to invite your state or Congressional representatives to speak to the group about healthcare funding. Tell them they will be invited back before the next election to speak again. In effect, be a mini AARP for your cause. Show you are connected in a large web of friends, acquaintances and groups.

If a Congressman or woman can get the vote of your church members or members of your club by only making a phone call or two they may be inclined to help. Those are easy votes compared to what he or she has to do for other votes.

Social Media

Don’t forget about using social media to further your cause. Ideally, you want to have a Facebook and Twitter account before you need anyone’s help. With those accounts,  you can tell your local politicians and Congressional representatives how many followers and friends you have. You can also tell them that you regularly share information on what you’re learning as you pursue treatment for your cancer.

Every politician has a Twitter account. Follow them. Always be careful of your privacy and security when using Facebook or Twitter. you may not want to share your medical information with strangers. However, you can talk about policies and rules that government agencies, insurers, etc. use to prevent patients from receiving needed treatment. Include the .@(name of the agency or insurer) in your tweets that object to their policy decisions. They may reach out to see if they can resolve an issue. Do the same with the hospitals you have had a problem with in receiving the treatments you need or who are demanding full payment from you rather than extended payments. My only caveat is to make sure that you complain on social media sparingly. You don’t want to be someone who is always negative and complaining.

I know people who express their displeasure with a company’s service on Twitter. The result is they often receive a reduced price for a service or coupons for future services. No one likes bad press or a negative image if they can prevent it.

Tell politicians by letter, email or phone that you are keeping your Facebook friends and Twitter followers informed on general issues regarding your treatments and who has been most helpful. Say you hope you can include them in an upcoming share or tweet and then ask for the favor you need from them. For an idea how other patients use Twitter, enter #cancer #(your specific cancer e.g. #lungcancer #pancreaticcancer #bladdercancer, etc.) and similar word on Facebook. Look for patients who post about their health and see what they say and how they say it. You may find a way that suits you.

Within a few days of creating your twitter account you will be hit with offers to increase your number of followers to over 100,000 for a mere $10. Your Congressional representative will never know how you got so many and may think they all read your shares and tweets.

If you are an employee of a company that self-funds their insurance, go to the Human Resources Department and tell them how upset you are that your treatments were rejected by their insurance administrator. If you are a supervisor or manager tell them you are concerned how other employees will feel when everyone learns your request for treatment was rejected or you have to pay for it out-of-pocket. Be sure to remind them that the information would never come from you but “things have a way of getting out”.

How One Patient Changed England’s NHS Policy

In 2009, Sarah Palin, the former Republican Governor of Alaska, coined the term “death panel“. Fear spread about the U.S. government taking control of healthcare and bureaucrats deciding who was worthy enough to receive medical treatment and who wasn’t. This is likely a meme spread by insurance companies, drug companies, medical device manufacturers and nano tech companies.

Why do I think the idea was supported by these companies? Well, with these companies providing U.S. healthcare services they can continue to purchase the votes they need in Congress to make their business grow without having to work directly with voters/patients. Elected politicians and government officials managing healthcare would place more power into hands of voter’s. (And, no Obamacare or the Affordable Care Act is not government managed healthcare. Private insurers manages the patient care Obamacare provides.) The United Kingdom is a good example of the power that voters and citizens have over their healthcare when a central or federal government is in charge.

You may not have read the story of Ashya King in U.S. news media channels. It’s a story worth knowing. After an operation received from a NHS (National Health Service) Trust to remove his medulloblastoma brain tumor, Ashya was unable to speak, or eat or drink on his own. In order to prevent a recurrence Ashya’s parents wanted him to receive proton beam radiation therapy. Proton beam therapy was not offered in England at the time so his parents took him to Prague, Czechoslovakia where it was offered. They were arrested and imprisoned in Spain.

After prosecutors dropped the charges against Ashya’s parents to have them extradited back to the U.K to stand trial, the NHS six months later reversed itself and agreed to pay for Ashya’s proton beam therapy. What caused the reversal? First, proton beam therapy was successful for Ashya. Second, the media coverage and public outcry over refusing a child treatment put enough pressure on the government, politicians and NHS Trust that they changed their ruling. In fact they paid for all of Ashya’s treatments “in accordance with relevant European cross-border arrangements” that pay for EU citizen medical treatments in other EU countries. In fact, NHS pays for treatment in the U.S. for patients who they feel will benefit from treatments not offered in the U.K.

Compare that type of healthcare with U.S. healthcare. No insurance company in the U.S. will pay for patient treatment outside the U.S.. You can purchase Travel Insurance, for more money, if you need medical treatment outside the U.S. . However, you have to be traveling and not going there for treatment. For major treatments covered under Travel Insurance, you will experience a delay in treatment because you are flown back to the U.S. to receive care. If you have Medicare insurance while traveling, you will be reimbursed for medical care occurring within 3 miles of a U.S. shoreline. Beyond 3 miles offshore or after crossing a border, you will have to pay for your own treatment. Of course some Medicare insurance supplemental policies don’t pay for care in other states or for care not pre-approved.

Ashya’s story occurs every day in the U.S. . Patients are routinely refused medical treatments by insurance companies recommended by their physician. You can appeal your insurer’s decision but it will likely be rejected. In the U.S. it’s difficult to get your rejection by an insurance company for a treatment you need into a newspaper or news media channel. The stories of patient’s not receiving recommended treatment based on insurance company decisions is so common in U.S. healthcare, no one is interested.

In fact, Hollywood makes money off of movies such as John Q showing how healthcare in general and hospitals and physicians specifically fail to treat for financial, insurance or policy reasons.

In Summary

Who receives treatment and what treatment is available gets changed quickly when healthcare, politics and money come together. For that reason, you should never feel bad about hacking the healthcare system with the ideas and tips shared in the posts you read here. Everyone hacks the world in their favor when they need an advantage. The more important the cause the more serious the hacking. And, what could be more important than money? Perhaps you thought healthcare was about promoting the health of citizens first and last. Now you know better. Yes, money in healthcare benefits patients a lot of the time but not always and certainly not all the money.

Politicians hack to be re-elected. Medical Residents hack to get more money for their medical education. University officials and parents of students hack to protect their students and to prevent bad press releases from keeping students away from their schools. Leveraging your strengths and advantages (e.g. friends, clubs, church, local news stories, local politicians, Facebook and Twitter followers) will help you receive treatment options you need. It will work for you, as it does the horsemen. They use many of those tools as well. You simply have different ones to leverage. Political pressure, media pressure, influential connections, etc. are the hacks you have to use with this horseman. Your money is no good here unless you have a lot of it. And, if you have that much money you can get the treatment you need anywhere you want without any further hacks. Money hacks everything in U.S. healthcare.

If you have not read the Intro and FAQs section for other hacks and tips, made sure you do. You will find more that will help you receive the treatment you need along with many other useful hack for situations you may be facing in the near future.

So, while you’re waiting for the second Horseman to be discussed in an upcoming post, give me your comments on this one.

© 2016, Vernon Carre. All rights reserved.

About Vernon Carre 2 Articles
Vernon Carré, B.A., M.Ed. Vernon lists six careers on his resume. The positions he held in these careers which lead to the creation of this website include: counselor, Manager of Professional Development for a Fortune 500 electrical utility company, Director of Education for a hospital and heart institute, website designer, IT system administrator and blogger. In his role as the Director of a rural S.C. AHEC (Area Health Education Center) he was a voting member on the Dean's Council of the Medical University of South Carolina (MUSC), Charleston, SC, 1991-1999. During that time he managed the creation of numerous physician rural internships, as well as nursing and allied health education for nine county hospitals in upstate South Carolina.

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