Physicians

PHYSICIANS: An Open Letter to Harvard Medical School By Dr. Terry Bennett

Doctor Terry Bennett
became the focus of national attention two years ago when he brusquely told an
overweight patient that she was fat, warning that unless she changed her
lifestyle she faced serious healthcare problems. The woman complained to the state Medical Board.  Last year, the New Hampshire
physician  fought off the attempt to punish him. The
experience convinced Bennett that the practice of medicine in America
must change.

Like many physicians he
believes that doctors are treated unfairly and that the healthcare system is on
the verge of collapse.  He argues that
out-of-control HMOs, high malpractice rates and the financial burden of earning
a medical education
are ruining the  practice of medicine, creating a generation of
young doctors that has forgotten what makes a doctor a doctor.

Instead of sitting in
his office in
Rochester, New Hampshire  and watching it happen, Dr.
Bennett has decided to do something about it by nominating himself for one of the highest profile jobs in
medicine. He recently launched a "write-in" campaign to interview for the Dean’s
job at Harvard Medical School, generally considered the cultural heart of
the medical profession in America.
What follows is his open letter to the Harvard
search committee requesting an interview.  For the record, THCB neither
endorses nor opposes his candidacy. We
believe, however, that the views Dr. Bennett expresses are important and worthy of very careful
examination. He also turns out to be a gifted writer, which makes this piece a very compelling read. An insider at Harvard Medical School who must remain anonymous calls Dr. Bennett’s letter "one of the most beautiful pieces of writing on medicine I have ever read." I fully agree. —  John Irvine

To the search committeeHarvard Medical School

I would not press for the job of Dean of Harvard Medical School, at my age, and at my station in life, if I did not think the Dean’s job did not need a rethink, a change from, an inarguably good man, the present Dean and most of his predecessors, to a zealot, of sorts, with a considered and announced, very public, totally non-secret, pro patient anti "money only" agenda, one which will change the life/lives of the man/people on the streets of America, and by extension, the world.

Humor me a little:

Ask the first one hundred people you meet on the streets of Boston if they know the name of the present Dean of Harvard Medical School, or what, if anything, has he stood for, while he has been Dean, and how has his tenure positively impacted/affected their lives and those of their families?

What has the Dean of Harvard Medical School caused in the way of useful change in their lives? What has he changed, for the better, or at all?

I will be surprised if one person in one hundred knows his name, or thinks his existence in any way affects their lives, and so will you.

It is my belief that so much has changed for the worse in American Medicine, that the HMS Dean’s name should be a byword, his/her positions clearly known, and the positions inarguably pro bono publicum, as he/she struggles publicly to change the status quo, tries get the 45 million uninsured into a universal healthcare program of some kind or another, tries publicly to get US drug prices within the reach of patients, tries to get American community hospitals to return to full and fully charitable services offered to their communities, and vows to be producing debt free zealot "gonna go out and change the world" physicians from HMS to go out and effect the necessary change(s), before all is lost, forever.

What is my own track record, and why should it commend itself to you? To HMS? i.e. Why do I think you should choose me, a doer, not a talker, nor a quiet Academic?

1. I   figured out how to "work my way" though HMS, so as to avoid debt, keeping my   dreams of adventure alive, in so doing. I sold blood and semen, then ran a   used car lot out of the Vanderbilt Hall parking lot, borrowed only $2800,   total, and, thus, preserved my dreams of adventure. The preservation of low   debt/no debt status cost me any chance of finishing in the top of my class,   but facilitated the furtherance of my dreams, my own "go out and change the   world" plans. There was nothing simple nor easy about it.

2. A   choice had to be made, big debt, and totally dead dreams, or small debt, and   dreams neverending. Next, as part of my plan for adventure/dream facilitation,   I arranged my training at LACGH, and my during Residency moonlighting jobs at   "battlefront ERs", so as to be prepared to meet anything, anywhere, anytime,   and never be unprepared/terrified again. You have no idea how many dead people   I carry with me, as I travel through this life, and of what I learned/had to   learn therefrom, about disaster prevention and critical timing, while trying   so desperately to stay the clock and save them, then. Some I did save. 

3.    Some I could not. The dead ,and the lessons they taught me, I carry still.

4.  I then took my   Harvard education and my LACGH, Pasadena Police Dept Ambulance Doc, Bon Air   Hospital in Watts, battlefield training first to the Peace Corps, which was   difficult enough, and then to some of the most difficult places imaginable,   where i delivered solace and care without any loss of quality, going,   defiantly, to prison, 7 times, in 5 years, ( overnight stays, then released   again, as some Prince or some Bin Ladin or some other well placed patient   intervened)I went voluntarily, to prevent a truly evil landlord from evicting   me from my clinic, while working in Saudi Arabia, so as to be able to continue   to deliver care by my own standards, to all comers. Show me another Western   physician who ever got a private license there, and you will begin to see what   I have gone through and made happen.

5.    Upon my return I   worked walkin clinics, prisons and insane asylums, precisely because I   believed ( and still do believe) that the indwellers and uninsured people   living near or in such places suffered from substandard/zerostandard care.   Their care is marginal even now.

  6.  I have been in Rochester, NH,for 18 years, now, running a walk in clinic,   where we accept all comers, insured, uninsured, unbathed, penniless, and treat   them all the same, to the best standards I can reach, and get them seen by the   best specialists, by begging on their behalf, when necessary. It is for that   reason that you have in the file a single letter of recommendation with over 100 signatures on it .They call themselves "the Havenots". They call me the "Havenot  from Harvard".

  7.    Part of the continuous pursuit of excellence, is to refuse to set any   artificial boundaries about access to your knowledge, or your person. In my  view a "complete physician" may not have preset notions of who may or may not   be let into their presence.

8.    Some of the most extraordinary experiences of my life as a physician   have occurred while taking care of the destitute, the marginalized. 

9.    In addition to the   clinic, I worked prisons…see attached story "Prendergast", and I demanded   decent care for the inmates.

10.    I have not won   each battle I chose to fight, no one can. Bet that nobody who was on my side,   or the other side ever forgot the battle, though. I have somewhere around 1 million patient visits behind me now. For 43 years I have done my work,   and done it with as much love and respect as I could muster.

I never set limits, except time, for anyone of any origin, any means or lack thereof, to gain access to me/my services.

I never cared about money.

I did care immensely about quality of care, and about being a complete   physician to my patients, which is why, at age 68, I still have over 10,000 active charts.

I could go on, but my CV speaks for itself, as do the letters written on my behalf. So does my 1991   multimillion dollar donation to HMS and HSPH so that the indebtedness of young   doctors at Harvard would cease ( It has Not)

If I am interviewed, as a serious Deanship candidate, I will   speak to the issues I feel most pressing. I look forward to it.  Conversely, if I am not   interviewed, that, too, will speak volumes.

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  3. We’re screwed. Seriously. We’re screwed. But in the meantime, I’ll take my 1M+ / yr and continue until they come for me. Because there IS NO ALTERNATIVE now is there?

  4. Pubished By Local Paper Rant: ( the devil made me do it)
    The Author , Terry Bennett MD MPH is the last remaining non employee physician in Primary Care Practice in Strafford County New Hampshire.
    Both his degrees are from Harvard, and he has written Healthcare Policy all over the world earlier in his career.
    UNIVERSAL HEALTHCARE DEMYSTIFIED
    Forty five Million or so Americans are, at this moment, without healthcare insurance.
    Already politicians of every stripe are proposing “Universal Healthcare” as part of their “VOTE FOR ME, YOU CAN TRUST ME” message.
    The actual take home message?
    Forget it !
    It ain’t gonna happen in this lifetime!
    How does one arrive at such a dismal viewpoint?
    Too much that is unwelcome has already changed in the USA,
    and the change is accelerating.
    There is big money at stake, huge sums in the pockets of those who have controlled/corrupted the system. They will not surrender easily if at all.
    It begins early and never stops:
    In the good old days young doctors graduated from medical school debt free, and could go to a bank, borrow money, set up a practice, open their doors, accept all comers at varying fees, depending on the ability of the patient to pay, and be granted enough time to establish a practice, before paying back the bank loan. Young docs could stay altruistic.
    That is all finished, now, because, in the USA, the average medical student graduates from medical school owing $300,000. No bank will ever lend that student more money, and the student must take a hospital or other employee job immediately upon end of training, because the bank that financed the education wants to be paid the microsecond after the student graduates his/her training. The doctor has no further say in whom he/she sees and treats
    No altruists can remain amongst the employed by large corporations/hospitals
    No other industrialized country does this to its young doctors.
    The second major corruption has occurred at the hospital level.
    Once hospitals came to own all or most of the practitioners in their area, they controlled how patients are seen, when, where, and most importantly, how much it costs.
    By simply diverting patients from outpatient care to the emergency room, a fee differential of $75 to about $1000 occurs. If you do this 100 times a day, you have more money than God. It is not good have more money than God, if you are a nonprofit, so the money is spent in extravagant construction schemes and new equipment acquisition, all done in order to bury huge profits being earned by what is, in principle, a nonprofit institution.
    If “nonprofits” are extracting unforeseen billions/millions from a finite budget, it does not take long to bankrupt that budget.
    Medicare and Medicaid are insolvent as I write.
    HMO/Health Insurance premiums are rising at 20% per year, all attributable to runaway profits at all levels.
    Many working Americans are one Healthcare Insurance rate hike from uninsured or even unemployed status.
    The third insurmountable obstruction/corruption unique to the United States is the extraordinary prescription drug prices which American patients are forced to pay. American consumers spend 5 to 50 times more for patented drugs than any other patients in the world.
    The intense and corrupting politicking that has led to this disaster reaches all way to the White House, where George W. Bush went public to assert that somehow Pfizer and Astra Zeneca could not control the quality of their drugs in the Mexican and Canadian markets, to the degree that it was in some way unsafe to import drugs from either of those countries, where the prices are five to 50 times less than United States prices.
    Such an assertion is, on the face of it, ridiculous, but Medicare Part D forces American consumers to pay retail (outrageous)US prices, no negotiating possible, producing a situation where very soon the extraordinary and non negotiable costs of Seniors’ medications will bankrupt all of Medicare.
    If the above were not enough, add in the HMOs, which have taken over the middleman position between consumers, providers, pharmaceutical companies, and hospitals. The original argument was that these astute and altruistic businessmen would straighten out all the inefficiencies existing amongst doctors, hospitals, and all these other entities, would thereby achieve huge savings which would then accrue to us all, reducing the overall cost of medical care, and benefit us, each and every one.
    In fact, the greediest people we have ever seen, are the people that introduced the HMO concept to the United States. They pocketed billions of our dollars, literally, then sold their HMOs to the very people they had depicted from the beginning as “the enemy”, “Big Insurance”, whose interests have never been the same as any consumers’ interests.
    It should be no surprise, that “Big Insurance’ has squeezed everybody, and raised rates extraordinarily, paid themselves immensely, tried to avoid paying anyone else for anything at all, and bought enough political support to get away with it.
    It does not matter what politician suggests what plan.
    Republican or Democratic, that plan will fail
    Unless and until these extraordinary costs, unique to the USA are squashed into manageability, there is too much greed and too little control of greed being exercised.
    So, short of a consumer/voter rebellion, Universal Health Care ain’t gonna happen.
    If I close by telling you that GM, Chrysler, and Ford are failing/going bankrupt precisely because they provide health insurance to their employees, and that the huge increase in health insurance premiums has raised the cost of a Ford or Chevrolet to about $2000 more than an equivalent Toyota or Honda costs, ( whose workers are NOT insured),and who have no agong retirees for whom they are responsible,now do you understand why it is important that we do something right away??

  5. Barry,
    It is an imperfect world, and doctors are no different than the rest of humanity. Some are greedy and unfeeling.
    Almost all of us came to Med School to “Do some good in the world, and take care of people”
    Debt takes most of that altruism away, and it is gone by first year’s end. It is for that reason that I wish Medical Student debt to vanish for Student Doctors.
    Maybe the Plastic Surgeons and Dermatologists-to-be, can borrow, because they are going to be working in lucrative areas all of their lives,but not the GPs
    We work the darkened streets, and the byways, at least I have.
    That said, there is more work to do…there are ways to minimize lawsuits and identify those few “Bad apple doctors”who repeatedly do bad medicine and overwork/bleed the system
    Overusing labs, overbilling etc etc is easily trackable via computerized billing systems, and that is happening now.
    Then, to get at and identify and retrain or retire the “bad doctors”..so that unacceptable and/or dangerous practices cease.
    Almost all billing is done on computers now, with most done by professional billers. It is not difficult to see who is working/gaming the system
    There is a really interesting Harvard School of Public Health Paper from about 15 years ago, where Case readers were sent to the hospital(s) in a region of upstate New York.
    They looked at every single “bad outcome”, and tried to break them down into “bad luck” versus “bad medicine”
    The “Bad Medicine” cases were awarded an imaginary Workman’s Comp level payout for whatever the injury was, and then the payouts were added up and were determined to be less than the total malpractice premiums paid in the same catchment area had added up to.
    Why is this of note?
    Because it was possible to address every single case of bad medicine,not just the truly egregious ones. It was thereby possible to see who the tortfeasors were ( about 6% of local doctors were responsible for nearly 60% of bad outcomes) All cases were addressed, giving injured patients a sense of closure.
    Lawyers were not required, and huge awards vanished, to be replaced by simple justice.
    What should we do, what would I demand from whatever “Bully Pulpit” was available? ( Harvard Deanship)
    I would try to get a consensus, starting now, by first
    getting after the Presidential wannabees to promise to correct Malpractice abuse(s)by legislating this type of comprehensive and evenhanded look at All bad outcomes, everywhere. If this were done, ( the Trial lawyers would fight it tooth and nail of course) reason would enter the field, replacing confrontation.
    Once done,
    Most, if not all defensive medicine stops, bad doctors get identified and retrained, or retired,and the whole practice of medicine becomes a more answerable system.
    That seem like a decent start towards answerabiity and equanimity?
    If I were HMS Dean you can bet I would be talking like this every day.
    What is an iconic School, like Harvard, doing remaining silent, or worse, fiddling, while the city around them burns?
    Terry Bennett MD MPH

  6. Dr. Bennett,
    How would you deal with doctors who consistently order too many tests, either due to defensive medicine and/or a desire to make money by maximizing utilization of doctor owned equipemnt and labs? I don’t believe that every test a doctor orders is medically necessary and insurance companies are always wrong to refuse to approve or pay for a test or procedure.

  7. And while I am on a Rant, here is the HMO Rant, another set of true stories:
    Greed is excessive or uncontrolled desire for or pursuit of money, wealth, food, or other possessions, especially when this denies the same goods to others.
    It is generally considered a vice, and is one of the seven deadly sins in Catholicism. (People who do not view unconstrained acquisitiveness as a vice will generally use a word other than greed, which has strong negative connotations.)
    Some desire to increase one’s wealth is nearly universal and acceptable in any culture, but this simple want is not considered greed.
    Greed is the extreme form of this desire, especially where one desires things simply for the sake of owning them.
    Greed may entail acquiring material possessions at the expense of another person’s welfare (for example, a father buying himself a new car rather than fix the roof of his family’s home) or otherwise reflect flawed priorities.
    ( Or, as in the following tale, an HMO CEO paying himself many millions of dollars while denying basic healthcare services to an insured person)
    “Health Maintenance” and Other Fictions
    The following are some accounts of “Health Maintenance Organization” Behavior, recounted to capture your attention….Ready??
    First, let me make a statement:
    Healthcare, as conceived by my father and all practicing physicians in preceding generations, was mostly a charitable enterprise, done on a semi-entrepreneurial basis by practitioners who had been very carefully selected by Medical Schools out of a large pool of applicants.
    Selection was first by intellectual skills, and then by attitude and temperament, so that medical Schools controlled, in a very large sense, the community behavior of physicians, first by selecting the best and the brightest, and then by working them to death treating the poor, during their training, so that most of them understood that their job was to do good in the community, take care of all comers, and remain answerable to themselves and to their peers on an ethical basis.
    Any physician could make a decent living by simply charging those who could pay a retail price for services, and scaling down from there for those who could not afford the retail scale.
    Doctors prided themselves on their charities.
    All of my father’s colleagues groused a lot about poor patients who drove them nuts, but they never refused to see them or treat them.
    Anyone who was seen to be selecting out the poor, at least in a primary care setting, was ostracized, castigated, for not playing by the rules.
    Hospitals were mostly run by physicians, themselves, and so the ethic of the Hospital reflected the combined community ethic of the doctors on the staff.
    Finally, physicians in training, although poorly paid, were not allowed to become overly indebted during their education , so there were not the huge debts of $200,000 or more that we see encumbering current medical graduates.
    To indebt someone, whom you wish to maintain as an altruist in the community, is an oxymoron, especially if you transfer the debt from the Medical School to a Bank, whose interest is not in community care, but in profit.
    In the 20th Century, Medicine went from a Charitable enterprise, run by physicians, who shared a background and an ethic, to a business, run by businessmen, for whom “Profitability” has always been the issue.
    Hospital Corporation of America came on the scene, introducing the concept of “profitable” Hospital Management.
    (the emergence of HCA also led to complaints, for the first time, of wholesale refusal to treat, and/or direct transfer of patients to non profit hospitals, some of them in extremis, because they were unable to pay for services)
    Shortly after HCA was founded, the first HEALTH Maintenance/Management Organizations were founded.
    Their public pronouncements, regarding their raison d’etre, were that the cost of medical care was escalating at about fifteen percent per year, whereas the economy was only inflating at about three percent. The business types who were trying to establish these Health Management Companies claimed that the medical cost inflation was due to unbusinesslike behavior by physicians who were clearly overordering costly treatments, costly medications, and costly Specialist referrals, all of which was causing the 14% per year cost escalation, which was far ahead of the inflation in the rest of the economy.
    HMO founders argued that medications, special high tech services and excessive Specialist referrals were the underlying cause of the escalation in costs.
    The HMO owners generously offered to step in , manage the “Business of Medicine” and the savings would be sudden, profound , and, most importantly, shared with all of us.
    The promise was that the achieved savings would be everyone’s profit, and would be shared, passed back to members, and to third party payors, the US Government included.
    Savings, huge savings, were in fact achieved, but there is no evidence that a penny of savings was ever passed back to either members or payors, and no evidence that the ripping out of the body medical of these “Management Fees” ever did anything to slow the inflation of health care costs.
    Due to retained and unreturned savings, which were held by the HMO’s, HMO’s became the darlings of Wall Street…because, for a brief moment in time, they were enormously profitable.
    Control of access to state of the art services and to prescriptions of the latest wonder drugs were the first items to be “managed”.
    Doctors had to plead, to beg, to get their patients seen by specialists, admitted to Hospital, treated with the latest wonder drugs granted access to expensive diagnostic and testing equipment…this was the deal, deny access, pocket the difference, pay the management huge salaries, with stock options added on for “profitable behavior”, and Katy bar the door.
    This worked for about ten years.
    Then the corner was turned, patients and doctors organized and began complaining to the press about abuses.
    There was no use complaining to the Politicians, they had been co-opted already via political contributions, and the complaints got a lot of lip service, but no actual redress, right up to the present, when the “Patient Bill of Rights” died in conference, and was threatened with veto by President Bush, a “poster child” for the effect of money in American politics. (Bush also weighed in on drug prices, denying Medicare the right to negotiate a price reduction with the drug industry)
    Even so, even before the Patient Bill of rights went down in flames, the Golden Days were over for the HMOs. Huge profits began to shrink about 5 years ago.
    The founders of HMOs who had loaded up their own portfolios with huge blocks of their own stock via complacent Boards of Directors, effectively owned and controlled the HMO organizations, and uniformly sold out to the very companies they had always painted as “The Enemy” , the large Insurance Companies.
    In so doing these CEOs disregarded the interests of anyone, any shareholder, any ratepayers, other than themselves, as it became clear that the HMOs they controlled were becoming unprofitable due to a number of factors including the aging of the population served.
    No consideration for the interests of the insured was ever exhibited, during the sale of these large HMOs,
    This was “Insider selling” of the worst order, because they had squeezed everything and cooked the books so as to look enormously profitable, and destined to remain so, (Sound familiar??) much as Enron WorldCom and Xerox have done a little later, bringing us to the present, where most HMOs are only marginally profitable, and the owners are trying to squeeze profit out of the policy holders via death spiral policies of upward pricing coverage and diminishing services available without special dispensation/preauthorization.
    THERE NEVER WAS a good logical, fact based argument for HMOs, ( other than pure greed) and certainly never a logical argument why Billions of dollars should be extracted from the Healthcare Budget and pocketed by a few greedy entrepreneurs, but that is precisely what happened.
    Dr Norman Payson, who founded Health Source, New Hampshire’s largest HMO, first succeeded in bamboozling an acquiescent Board of directors into “gifting” him huge amounts of stock in the HMO as a “reward for excellence in Management”, gained controlling interest via these “stock bonuses”, and sold out his shares and control of the HMO to Cigna Insurance Company, pocketing just under One Billion Dollars himself, personally.
    Dr Payson is now “reorganizing” Oxford Health Care, a failing HMO based in the New York area, and, if past performance is a model for the future, will probably divert another Billion dollars from the system into his pockets .
    Meantime, it is alleged that the THREE private pilots Dr. Payson retains to fly his personal private jet, an additional bonus from HealthSource years, are all maintained as “part time employees” and that Payson has denied them and their Families health care benefits as a result of this sham/scam.
    Dr. Payson’s behavior is not unique, no matter how greedy and unfeeling it may appear.
    It is “just business”.
    Payson’s behavior, the diversion of Health Care funds out of health care and into a CEO’s pockets has been totally ignored by the government, into whose campaign coffers/election funds millions of dollars of contributions have poured, helping to elect and keep in office people who would never seriously address truly outrageous and antisocial behavior, including refusal to treat, refusal to admit, refusal to serve any but the wealthy, the insured, the “MEMBERSHIP” whose membership fees, not coincidentally, have escalated annually at a faster rate than the previous and much lamented expenses had done, prior to Healthcare Management..
    The US Senate, The US Congress have done NOTHING to address any of these outrages.
    No laws worthy of the name “laws” have been passed to protect consumers.
    Laissez Faire is the rule of the day, the decade, the Millenium, to date.
    Dr. Payson is not a unique physician/Robber Baron.
    Another altruist, Dr. Leonard Abramson founded US Health Care, another large HMO.
    The business plan for US Healthcare was a little more transparent;
    First try to select only the very young and very healthy.
    Undercharge them slightly, sell a “discount HMO policy”
    Then block these healthy patients from getting anything expensive done, NO REFERRALS, NO CAT SCANS, NO SPECIALISTS, NOTHING, pocketing a large number of premiums with out rendering an iota of service.
    Once again, as the formula begins to become threadbare, sell out to an Insurance Company, in this case AETNA.
    Pocket nearly One Billion dollars of “retained profit”
    All of the foregoing may seem a digression, but I wished for the reader to understand the terrain in which I must run, on behalf of my patients, in the 21st Century.
    It is a cruel world…unforgiving.
    Most of the major HMOs in the USA have followed this business model, this behavioral formula, and most are now being operated by Major Insurance Companies, who are “losing money”, while paying senior executives seven figure salaries, and doing their level best to deny anything other than very basic services to policy holders
    This brings me to three actual, current, true tales of HMO behavior,
    not pretty, and absolutely not unique:
    Case number One:
    I have been treating since her childhood, an eighteen year old girl, who is very bright, but who became depressed, attempted suicide, was very nearly successful, was hospitalized for a long time, eventually treated successfully, discharged and is on a prescription antidepressant, Prozac.
    This young woman is in her last year of High School, back on the Dean’s List, and is thriving.
    I count her a great success, and am delighted.
    Into my Fax machine, without courtesy of advance warning nor rationale, arrives a notice, an order, really, not a suggestion, from her HMO that she is to be taken off Prozac and put on a different drug, Paxil, also an antidepressant.
    I Fax back “I am unwilling to make this change in a patient who was hospitalized following a nearly successful suicide attempt and who is now doing well on Prozac”.
    The HMO Faxes back “You will effect this prescription change”
    Several to and fro Faxes ensue:
    “You will”, “ I won’t”, etc,
    Never the courtesy of a phone call.
    Finally I call the 800 number displayed at the bottom of the multiple faxes, and insist on speaking to the human person responsible for this directive.
    I can hear the squeaks and squawks as I am patched through and finally a male voice answers the phone.
    I ask who is speaking, write down the name, ask where he is physically located, and am told I am speaking to a Pharmacist in Austin Texas.
    “You are not a physician.. Why am I speaking to you about the drug therapy for a New Hampshire patient??”
    “Because I am the expert person in charge of the Formulary for this HMO”
    “OK, so let me tell you why I am unwilling to change medications…and I reiterate the story, suicide attempt, doing well on Prozac, etc, etc”
    “I’m sorry, Doctor, you will have to change the medication, so as to be in compliance with the Formulary”.
    “You know what?,”
    “I refuse, but this is clearly a pricing issue, what are we talking about here, how much more does Prozac cost than Paxil??”
    “Twenty cents per capsule”
    “Let me see, Twenty cents per capsule, times thirty days, that’s six dollars a month, right?? —–“
    “And in order to save $6.00 a month you are suggesting that I should take a chance, on my license, and on my conscience, that a promising eighteen year old will kill herself… for $6.00 per month”
    “That’s not what I said”
    “Yeah, it is exactly what you said, and I’m going to give you thirty seconds to see this my way, and continue the Prozac, or I’m gonna make you famous…”
    “What do you mean famous??”
    “I’m sorry, your thirty seconds are up” , and I hang up.
    New Hampshire is a small State.
    I once ran for the US Senate, and every career News Reporter in the State knows me and vice versa.
    I follow through, dialing up the patient’s mother, and ask if I have her permission to tell this story to a Newspaper, or even better, would she/could she strike a blow for all of us…
    Would she and her daughter be willing to go public, themselves, and talk to the Newspaper, so this abuse will stop.
    They agree, and on Monday on the front page of the Manchester Union Leader appears the story.
    There is a small furor, letters to the editor, etc, etc
    Shortly thereafter our Governor begins talking about a “Patient Bill of Rights”.
    Shortly after that, A Political Action Group funded by the HMO industry makes a significant donation to the Governor’s reelection fund.
    No HMO Reform Bill, No Patient’s Bill of Right has ever been enacted in New Hampshire.
    The Governor is running for the US Senate, where “Patient Bill of Rights Bills have never reached the floor for a vote, presumably also due to large political contributions to re election funds.
    Isn’t this fun??
    Case number two:
    A thirty something young woman, also a patient for awhile comes into my office and tells me a new story, but of long standing..
    She has crescendoing headaches, followed by clear fluid running from her right nostril, whereupon the headaches abate.
    There is no history of trauma that she can recall, no other historic or medical reason that I can link to this phenomenon, but this is a very worrisome story.
    I order an MRI of her head, thinking to find a meningeal defect, with a leak.
    Her HMO refuses to authorize the study.
    A parade of phone calls begins, dealing with a nonmedical phone answerer whose sole job is to deny services.
    My patience is very quickly exhausted.
    I tell the nay sayer that “ we are going to have this study done, bank on it”
    “You will need to talk to the Medical Director to get authorization for this study”
    “ I know your Medical Director, worked with him long ago, and if he knew how to actually practice Medicine, he would not be working for you”…
    There is a moment of silence, as she digests just how furious I am…
    “I will put you on hold and speak with the Medical Director.”
    A few moments pass, and she speaks again…the study is authorized”
    The MR is done at our local Hospital, but is not diagnostic,(lousy quality) leading me to worry even more that there is something gravely amiss, and that time is against us.
    I call the HMO…same nay sayer..
    “We are going to have to send this patient to a consultant Neurologist at the Lahey Clinic, and get a better quality MRI”
    There is silence at the other end of the line… , then,
    “OK, I will authorize the consult”
    A few days later, I get a call from the Neurologist..
    “Great call, she had a meningeal cerebrospinal fluid leak, and was waiting to get a fatal or ruinous meningitis, had you not intervened”
    “In future, did you know that you can test the fluid with a urine sugar test tape?? If it tests positive for sugar it is cerebrospinal fluid , nasal secretions are sugarless.””
    Two surgeries later the leak is stopped, and the patient on with her life.
    She and her husband stop in to thank me, having observed me as I confronted the HMO to whom they send a large fee every month.
    They understand what has happened, and what I have had to do to get her the care she needed They watched me go to war for them, and know that nobody else would have done so. No battle, no diagnosis. No diagnosis equals dead or ruined, that simple…
    What if I were not an aggressive angry man, unbeholden to anyone ??
    Case number three is a similar case..
    This time the patient is a forty something woman with a 50 pack year smoking history.
    “Doctor, I have had horrible headaches for a couple of months.”
    “Yesterday my husband found me unconscious in the kitchen, on the floor.”
    Jesus!!
    I call the HMO, the same HMO as for the last case, Dr. Payson’s old HMO.
    “I need a CAT scan done on a young female patient with severe headaches and a loss of consciousness episode, I need it done ASAP, as in now, right away”
    “You will need a prior authorization from the Medical Director….”
    Then she realizes who it is…
    “Oh, OK Doctor, I will authorize the study”
    Bad thoughts are going through my head, while I wait,
    I am suspecting lung cancer with a cerebral metastasis in this heavy smoker.
    Once the CT is done, I am stunned to find an early pituitary adenoma, amenable to medical treatment.
    I have had a nose full of this gross interference in my work, which I hold to be important work, much more important than some CEO’s paycheck
    I call the HMO and demand to speak with the Medical Director.
    (There is no way in hell to call the CEO, he is insulated from the likes of me by 5 or 6 layers of impenetrable bureaucracy)
    Once speaking with the Medical Director, I ask him to check my record to see how frequently I order these studies, and what the recovery (positive versus negative study results) rate is on me, and if below normal or normal, to flag my record so that I will be left to practice careful efficient Medicine as I have for nearly forty years, unmolested.
    I have heard nothing back.
    No new godawfulness has presented….yet
    So ends this tale, for now

  8. And as a Post script.
    Jack Meyer and the greedy bastards he had with him at the Harvard Endowment took over a CHARITY of 400 years standing and converted it to a Piggy Bank for themselves. They spent it down at $575,000 per day. That continues even though they are gone.
    The Endowment could/can be put out to bid and it would cost about 20-25 basis points to get the whole deal done, essentially for bupkus,so long as the Contract Endowment managers had access to the 300,000 living Harvard Alums and could offer them retail sevices.
    I asked, and these are the facts.
    Brandes and several other firms with as good or better records than Meyer et al were interested, but Harvard is NOT INTERESTED. for reasons NEVER explained, not to this day
    Charities, which seek donations from people as motivated as myself, should have the charitably minded running them, doncha think?
    It is worse than a bait and switch to discover that 4000 kids could have had, and could still have, free tuition if the Endowment were managed by the less greedy, but just as good at the work
    Not every investment manager needs $100,000 per day, whether they show up for work or not.
    And Yale’s guys are highy paid, beat Harvard’s greedy guys by several percentage points this year,but were never paid anywhere near the Harvard guys’ unbelievable pay, or did you fail to read the Stephanie Strom/NY Times article up the chain from this post?
    If you skipped it go back and read it.
    Present Greed is, in every case, the Enemy of the Future, Our Future, and that of our kids.
    How long can we keep this up?
    No other industrial country allows any of this.
    “Nuff said” for now.
    Terry Bennett MD MPH

  9. Thanks for the commentary.
    I do not propose a “free lunch” for medical students,
    It is possible to “indebt” them in time served in underserved areas in return for their educations.
    I have worked prisons and Indian Reservations and I presently work in an underserved area, Rochester NH.
    All of it has been graceful work, and I have no regrets, nor should anyone else, who set out to be a “real doctor”
    If “Prevention” is a goal, then it cannot happen in ERs.
    Prevention really only happens in Primary Care Offices.
    Ergo, no Primary Care Office, no Prevention.
    If all Primary Care Providers, because of their school debt(s) are hired and then are “owned” by hospitals,as is increasingly the case, how many altruists do you think wil be seeing the marginalized?
    And, what Prevention do you think wil take place?
    There are fewer and fewer Med Students applying for Primary-Care Residencies and, as you would expect, a huge shortfall is predicted 7 to 10 years hence.
    Who would want the job? We are the whipping boys and girls for the HMOs and are poorly paid as well as devilled. That is why I think Harvard needs a Realist, not an Academic, and why I think all of the Presidential wannabees shoud have their feet held to the fire.
    No More Corporate Medicine. Medicne is either a Service in which we all have a stake, or it is a Business, and HMOs and Insurance Companies will set the rules, set the pay, set the obstacles to decent care,in which case God help us all!
    Any more questions?? Thanks Terry Bennett MD MPH

  10. A very interesting post with some interesting responses. Quite frankly, I don’t know what the chances are that Dr. Bennett will win an interview – let alone emerge as viable candidate for the job. (A polite way of saying the deck is not exactly stacked in his favor.) In many ways he is the antithesis of the sort of person picked for this kind of role in the American university system — call him an “anti-candidate.” That having been said, I have a sneaking suspicion that more than one medical student will be reading what he has to say in the future.
    I’m curious to know a little more about the sort of things that Dr. Bennett would do “if elected,” as it were. What changes would he make? What would he do with the curriculum? What would he do to encourage the kind of idealism he espouses in the next generation of doctors? How would he achieve the kind of “separation of church and state” between physicians and other healthcare system actors that appears to be a component of his platform?

  11. Dr. Bennett tells us that the average new doctor graduates from medical school with $300,000 in debt. I wonder how much less income per year he thinks doctors would be willing to accept if they graduated debt-free. If we assume an after tax opportunity cost of capital of about 8% on the $300K of debt (assuming it were invested 50% in high quality stocks and 50% in government and investment grade bonds) which is in line with the projected long term investment return used by most pension funds, the implication is that a new doctor with no debt should be willing to work for $24K less after taxes per year than a doctor who has $300K of debt. Assuming a total tax burden (federal, state and local) of 33% (probably a bit low), the doc should be willing to accept $36K less on a pretax basis.
    At the same time, taxpayers would, of course, be responsible for covering the entire cost of training new doctors. If we also provided each medical student with a stipend (as France does), the annual cost to train each new doctor could approach $150K. Since practice expenses for staff, equipment, office rent, malpractice insurance, etc. would not change as a result of financing medical education in a different way than we do now, it is far from clear to me that taxpayers would achieve any net savings in healthcare costs overall. If the objective is to make primary care more accessible and more affordable, I think the emergence of retail store based mini-clinics staffed by nurse practitioners offers more promise than relieving new doctors of debt that needs to be repaid.

  12. Jack Meyer, and several of his top money managers, have since left Harvard to form their own firm. Even though their compensation was, I believe, justified by the performance they achieved over both the short and long term, they got tired of dealing with the drumbeat of criticism. While Yale is extremely fortunate to have David Swensen and his team willing to work for far less than they could earn elsewhere in money management, talent of this caliber is rare and plenty of investors are more than willing to pay handsomely for access to it. Interestingly, Warren Buffett plans to use exactly this pay for performance model to compensate the person or people who ultimately replace him as Chief Investment Officer for Berkshire Hathaway.

  13. Doctor: Greed subverts health care
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    Dr. Terry M. Bennett, an independent family physician poses in his office at Clinic on the Common in Rochester. Rich Beauchesne photo 3-30-2007
    By Shir Haberman
    shaberman@seacoastonline.com
    March 31, 2007 8:05 AM
    PORTSMOUTH — Dr. Terry Bennett, the controversial and opinionated Rochester physician who has traveled the world practicing medicine — including a stint as physician to the Saudi royal family — does not have high hopes that a fix can be found for the country’s broken health care system.
    The reason, he contends, is that the amount of money involved in the system brings out one of the more negative human attributes — greed.
    “Unless and until these extraordinary costs unique to the United States are squashed into manageability, there is too much greed and too little control of greed being exercised,” said Bennett, a Harvard Medical School graduate, who operates a practice that bases its fees on the ability of his patients to pay. “It does not matter what politician suggests what plan —- Republican or Democratic, that plan will fail.”
    There are four primary reasons for Bennett’s pessimism: the educational debt carried by new doctors; the practice of hospitals “owning” the physicians who are affiliated with them; extraordinarily high prescription drug costs; and the advent of health management organizations, which have assumed a middleman position between patients, health care providers, pharmaceutical companies and hospitals.
    Bennett asserts that the debt carried by young doctors makes it virtually impossible to take into consideration the amount a patient can afford to pay for his or her medical treatment.
    “In the good old days, young doctors graduated from medical school debt free and could go to a bank, borrow money, set up a practice, open their doors, accept all comers at varying fees — depending on the ability of the patient to pay — and be granted enough time to establish a practice, before paying back the bank loan,” Bennett said. “That is all finished now, because, in the U.S.A., the average medical student graduates from medical school owing $300,000.”
    No bank will ever lend that student more money, and the student must take a hospital or other employee job immediately upon end of training, because the bank that financed the education wants to be paid, the Rochester physician said. Once the young doctor takes that job, he or she has no further say in who he or she sees and treats.
    The second issue involves the driving up of health care costs by what Bennett calls “corruption” at the hospital level.
    “Once hospitals came to own all or most of the practitioners in their area, they controlled how, when and where patients are seen, and, most importantly, how much it costs,” he said. “By simply diverting patients from outpatient care to the emergency room, a fee differential of $75 to about $1,000 occurs.”
    Bennett believes this is done hundreds of times a day in larger hospitals, generating hundreds of thousands of dollars for traditionally not-for-profit institutions. In order to utilize that revenue so as not to show a profit, hospitals spend it on extravagant construction schemes and new equipment acquisition.
    “It is all done in order to bury huge profits being earned by what is, in principle, a not-for-profit institution,” Bennett contended.
    He said the exorbitant cost of prescription drugs is another factor driving up costs and creating a situation where greed becomes a motivating factor.
    “The third insurmountable obstruction/corruption unique to the United States is the extraordinary prescription drug prices that American patients are forced to pay,” Bennett said. “American consumers spend five to 50 times more for patented drugs than any other patients in the world.”
    What the Rochester physician called “the intense and corrupting politicking that has led to this disaster” reached all way to the White House, where President Bush asserted that somehow Pfizer and Astra Zeneca could not control the quality of their drugs going to the Mexican and Canadian markets, making it unsafe to re-import them to the United States. Re-importation would have cut drug prices substantially for U.S. consumers, Bennett contended, leading to lower profits for pharmaceutical companies.
    The last corrupting influence Bennett pointed to is the advent of HMOs. Originally formed to bring common business sense to the health care industry, it became a spawning ground for those more interested in making money than correcting the ills of a system that failed to address the needs of consumers, he contended.
    “In fact, the greediest people we have ever seen are the people that introduced the HMO concept to the United States,” said Bennett. “They pocketed billions of our dollars, literally, then sold their HMOs to the very people they had depicted from the beginning as the enemy, ‘Big Insurance,’ whose interests have never been the same as any consumer’s interests.”
    All this has led to an untenable situation for health care consumers, said Bennett.
    “Medicare and Medicaid are insolvent, and HMO/health insurance premiums are rising at 20 percent per year, all attributable to runaway profits at all levels,” the Rochester doctor said. “Many working Americans are one health care insurance rate hike from being uninsured or even unemployed.”
    Unless and until these issues are addressed or there is a general “consumer/voter uprising,” there is little hope of seeing a system that supplies quality health care to all citizens ever being enacted, Bennett contended.
    log onto terrybennetttmdmph@wordpress.com for more info

  14. Some Alumni Balk Over Harvard’s Pay to Money Managers
    By STEPHANIE STROM
    Published: June 4, 2004
    Last year, Jack R. Meyer, who oversees Harvard University’s mighty endowment, the largest university endowment in the country, was paid $6.9 million.
    His counterpart at the University of Texas, Bob L. Boldt, was paid $743,316 for managing the second-largest university endowment, while David F. Swenson, who manages the third-largest, at Yale University, was paid $1,027,685.
    The disparity is even larger when looking at the five highest paid money managers at the Harvard Management Company, two of whom made more than $35 million last year. This has angered Dr. Terry M. Bennett, who graduated from Harvard Medical School in 1964 and later got a degree from its School of Public Health.
    “The managers of the endowment took home enough money last year to send more than 4,000 students to Harvard for a year,” Dr. Bennett said.
    Dr. Bennett, who gave some $4 million in proceeds from an antique car auction to Harvard in 1991, at the time the largest gift ever to the medical school, has sent e-mail messages to class members in advance of their reunion next week asking them to withhold donations until the university agrees to put management of the $19.3 billion endowment up for competitive bid. He also wants a promise of greater accountability in management of the endowment.
    “I am going to shut the money off,” Dr. Bennett said. “I am in the process of doing that, and I am good for my word.”
    University officials say they are not concerned about Dr. Bennett’s campaign, but it comes at a particularly inopportune time. The Internal Revenue Service recently announced that it would require hundreds of nonprofit organizations to justify their compensation levels.
    Congressional interest in nonprofit compensation practices has also increased. The Senate plans to hold a hearing on June 22 on the issue as well as a broad range of concerns it has about the nonprofit sector. The compensation Harvard pays its money managers has long raised eyebrows in the nonprofit sector, where pay packages exceeding $800,000 are considered exceptional, but Harvard’s alumni have barely blinked.
    “I’ve followed the issue over the years, and I’m fully comfortable with the compensation they receive,” said Kenneth V. Hachikian, a financial consultant and investment banker who graduated from Harvard in 1971. “The financial performance of the endowment has been considerably above what the average has been in the broad marketplace.” Even so, the university acknowledged that the size of the pay packages last year produced more letters of protest than letters of support, a deviation from the past. In March, it announced a cap on future compensation but did not provide specifics.
    Harvard has long contended that it is merely paying the going rate for top-flight money managers. “There is an economic market out there for these kinds of fund managers, and we do know that many of them who work other places are making more than the people we have in house,” said Donella Rapier, the university’s vice president for alumni affairs and development.
    The university follows Wall Street practice in paying its managers, so that the vast majority of their compensation is bonuses reflecting their performance as judged against benchmarks. Last year, the endowment’s managers greatly outperformed those benchmarks, producing a total return after fees and expenses of 12.5 percent, and thus their compensation was unusually high.
    Yale’s return on its $11 billion endowment was 8.8 percent, while the University of Texas saw a 12.8 percent return on the $14.8 billion under management through Aug. 31, $11.2 billion of which was endowment money.
    Even some supportive alumni say the pay issue has made Harvard vulnerable to criticism.
    “I serve on a number of alumni committees, and there has been astonishment at the fact that people working for an organization like Harvard could take away such large salaries,” said Dr. Joseph K. Hurd, who is the reunion treasurer for Dr. Bennett’s class. The five highest-paid managers at the Harvard Management Company, which controls the university’s $19.3 billion endowment, were paid a total of $107.5 million in the year that ended last June 30, a 43 percent increase over the previous fiscal year, when they were paid $75 million.

  15. The best physicians have always been those for whom medicine is a calling, not a job. Bennett reminds us we need to find ways to encourage talented persons so called to want to heed it.

  16. It is a fact of life that there are many people who take up medicine just for the remuneration they can get. Many parents too force their children to take up medicine for the same reason and also for the respect they get in the society. The so called doctors majority of them are only concerned with how much their colleages are making and finding out different means to make money. So naturally the patients might not get the right treatment and what they get will be clouded with greed.

  17. It is so refreshing to read this article. I personally (and luckily I am insured and have many resources) have seen the degeneration of health care through the years through both personal experience and my position in the community where I see many, many people not receiving the quality of care that every American deserves. I have found only a handfull of doctors that are still of this quality… putting their patients first, not money.

  18. This guy may be the next albert schweitzer of our times, but that does NOT mean he necessarily has the skills or leadership qualities to lead a multi-billion dollar system.
    Sorry charlie, but it was a nice article.

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