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Who Will Oppose American Apartheid?

By MIKE MAGEE

This past month Bishop Mariann E. Budde drew the Episcopal Church into the national spotlight through a single act of courage. She is not the first, nor likely the last from this denomination to do so. There is a history. More on that in a moment.

The Episcopal church is an offshoot of the Anglican Church of England which dates back to 1534 when King Henry VIII broke with the Catholic Pope who opposed his marriage to Anne Boleyn. Two-hundred and fifty four years later, in 1789, Anglican Church leaders who had helped settle colonies in North America, gathered to form a united Episcopal Church, revising their Book of Common Prayer to exclude its blessing to the English monarch.

Though declining in modern times, missionary minded Anglicans spread throughout the British empire and remain connected to the mother Church as members of the Anglican Communion. For example, British Anglican military chaplains were part of the force that occupied Cape Colony in South Africa in 1795. By 1821, they had established a formal religious foothold. Today, they claim 3.5 million members. In 2012, they elected their first female bishop, Ellinah Wamukoya of Swaziland. And yet, arguably the most influential female Anglican from South Africa is an immigrant to America, an emotional ally of Bishop Budde, and a retired Chief Justice of the Massachusetts Supreme Court.

Her name is Margaret Marshall, and her place in American history dates back to June 6, 1966. That was the date this then 20 year old student, who was vice-president of the National Union of South African Students, was asked to stand in for the organization’s president, Ian Robertson (who was under house arrest for speaking out about Apartheid). She met and transported Bobby Kennedy to speak to over 1000 university students packed into the college auditorium at their “Day of Affirmation.”

Much like Mariann Budde last week in Washington, Bobby Kennedy caught his hushed audience by surprise that evening with these opening remarks:

“I come here this evening because of my deep interest and affection for a land settled by the Dutch in the mid-seventeenth century, then taken over by the British, and at last independent; a land in which the native inhabitants were at first subdued, but relations with whom remain a problem to this day; a land which defined itself on a hostile frontier; a land which has tamed rich natural resources through the energetic application of modern technology; a land which was once the importer of slaves, and now must struggle to wipe out the last traces of that former bondage. I refer, of course, to the United States of America.”

Margaret Marshall, some six decades later, recalled that moment in a conversation with Doris Kearns Goodwin. She said, “There was great tension in the room. People were on edge…As soon as the audience realized what he said, there was laughter and a sense of total relief. It was simply fabulous.”

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How Did We End Up with a Broken Health Insurance System? 

By LEONARD D’ AVOLIO

The murder of UnitedHealthcare CEO Brian Thompson has drawn attention to Americans’ frustration with the for profit healthcare insurance industry. Change is possible but less likely if people don’t understand how we got here, the real issues, and how they might be fixed. 

Health insurance wasn’t always run by big for profit corporations 

According to Elizabeth Rosenthal’s book, An American Sickness (a must read), it all started in the 1920s when the Vice President of Baylor University Medical Center discovered that they were carrying a large number of unpaid bills. The goal wasn’t to make money. It was to keep sick people from going bankrupt while helping keep the lights on at not-for-profit hospitals. 

Baylor launched “Blue Cross” as a not-for-profit and it offered one-size-fits-all coverage, one-size-fits-all pricing, and all were welcome. By 1939, Blue Cross grew to 3 million subscribers and health insurance might have stayed this way if it wasn’t for two important innovations that would change healthcare and insurance as we know it.

Before the late 1930s, there wasn’t a heck of a lot we could do for sick people. That all changed with two innovations: 1) the ventilator and 2) the first intravenous anesthetic. The ability to put people to sleep and keep them breathing opened the door to a whole array of new surgical and intensive care interventions. More interventions meant more lives saved. It also meant longer hospital stays, more expensive equipment and care. Insurance would have to evolve to keep up with medical innovation.

We probably could have solved that problem with direct-to-consumer private insurance (like car or life insurance). But World War 2 introduced a creative workaround to a labor shortage that gave employers an outsized role in determining our health. 

Health insurance tied to employment

During World War 2, the National War Labor Board froze salaries and companies faced labor shortages. Employers figured out they could attract employees by offering health insurance. The government encourages this by giving a tax break to employers on health insurance spending.  

The number of Americans with health insurance skyrockets. Between 1940 and 1955, this number increased from 10% to over 60%, with the not-for-profit Blue Cross dominating. It’s hard to believe nowadays, but at the time, an insurance company was one of the most beloved brands in America.

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It’s Money That Changes Everything (Or Doesn’t) For Surgeons

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By MICHAEL MILLENSON

“Money changes everything,” Cyndi Lauper famously sang about love to a pulsating rock ‘n’ roll beat. So, too, when it comes to financial incentives for surgeons, two new studies suggest, although “How much money?” and “What do I have to do?” are the keys to unlocking monetary motivation.

The first study, a JAMA research letter, examined the impact of a new Medicare billing code for abdominal hernia repair that paid surgeons more if the hernia measured at least 3 centimeters in size. Previously, “size was not linked to hernia reimbursement,” noted University of Michigan researchers.

Surprise! The percentage of patients said to have smaller, lower-payment hernias dropped from 60% to 49% in just one year. Were “small hernia” patients being denied care? Nope. Were surgeons perhaps more precise in measuring hernia size? Maybe. Or possibly, wrote the researchers in careful academic language, “the coding change may have induced surgeons to overestimate hernia size.” Ambiguous tasks, they added, “can be conducive to perceptive [cq] bias and potentially even dishonest behavior, perhaps more so with financial incentives at play.”

This being an academic publication, two footnotes informed us that dangling money in front of our eyes can cause people to “see what you want to see” and come up with an “elastic justification” for truth.

If a simple coding change can apparently boost the number of large-hernia patients by 18% in just one year, what about a payment incentive meant to induce more urologists to follow the medical evidence on low-risk prostate cancer and adopt “active surveillance” (formerly known as “watchful waiting”), rather putting patients through a painful and expensive regimen of biopsies and surgery?

A second study, also in Michigan, involved commercial and Medicare-age members of the state’s Blue Cross and Blue Shield plan. However, after three years and more than 15,000 patients, “the payment incentive was not associated with increased surveillance use among patients with low-risk disease,” researchers concluded in a JAMA Network Open article.

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Doctors Must Fight the RFK Nomination

By DANIEL STONE

As a doctor, I consider Secretary Xavier Becerra and his Department of Health and Human Services (HHS) to be allies of practitioners like me. The behemoth federal agency administers Medicare and Medicaid, the Food and Drug Administration, and an army of public health workers. The Surgeon General, symbolic leader of the nation’s healthcare providers, reports to HHS. For decades, the Department has supported medical science in safeguarding the public’s health. Now that sacred trust faces the threat of Donald Trump’s nomination of Robert F. Kennedy Jr. to run HHS.

RFK’s first problem is a stunning lack of qualifications. After a laudable triumph over drug addiction, he used his legal background to work on environmental protection. Kennedy never held a federal government position nor administered any public agency. He now appears poised for on-the-job training at an agency with 80,000 employees and a $1.7 Trillion budget. In contrast, Becerra served for years in Congress and on its Health Sub-Committee. He also served as State Attorney General, managing 4,800 employees. The qualification issue is not political. During Trump’s first term, his last HHS secretary, Alex Azar, had served as HHS general counsel and president of pharmaceutical giant Eli Lilly. RFK has nothing remotely resembling his would-be predecessors’ qualifications.

Unfortunately, RFK’s shortcomings go well beyond mere lack of qualification. His distortions and public denials of established medical science infuriate practitioners like me. He casts baseless doubt on the well-established benefits of vaccines and on the polio vaccine in particular. Despite the seven decades since polio vaccine’s introduction, doctors still see patients who were infected before it was available. My patient Donna, born in 1955, counts herself among this group. She wears leg braces and often struggles with daily activities. For me, she symbolizes those who by accident of birth or happenstance missed the profound benefits of vaccines that RFK now disparages.

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Beyond Stigma: Why Addressing Maternal Mental Health Means Confronting Systemic Failures

By EMILY JOHNSON

Imagine you’re an executive at a large health system in a major metropolitan area. One morning, you wake up to a missed call and a voicemail from your PR leader. It’s urgent: one of your employees–who was also a patient and a member of the organization–has unexpectedly died by suicide.  Their family is furious.

You follow up and learn that this wasn’t just any employee. It was a young leader you had worked with only a few months ago. You had regular meetings with them and had been serving as a mentor. You had been impressed by this young person’s drive, enthusiasm, analytical skills, and ability to build relationships. You believed they were on the path to being a strong leader in health care. But not anymore. Now, seemingly out of nowhere, they are gone.

You’re shocked. You’re devastated. You’re confused. You demand an immediate safety review to understand what happened and why.

The patient safety team moves quickly to investigate, and they discover that the patient was a young woman who had given birth to her first child just two weeks ago at one of your hospitals.

During her pregnancy she had disclosed to her primary OB that she was beginning to have panic attacks. The OB offered to start her on an antidepressant, but the patient declined. No referrals were placed. Red flag.

She delivered her baby after a 30+ hour labor culminating in postpartum hemorrhage. Anxiety was noted several times throughout her hospital stay. Her notes from labor say “patient acutely anxious and requesting “to be done.” Her discharge notes state “Difficulty coping with anxiety for past 1-2 weeks. Has been affecting her ability to bond with baby.” Red flag.

She was seen by a social worker, who shared with her a packet of information about postpartum depression. This person recalls the patient asking her “which of the numbers should I call if I need help immediately?” Red flag.

She presented back at the ED the day after her initial discharge with additional hemorrhage concerns. Her notes say “Patient is anxious, tearful, arriving in the ED hypertensive at 140/90, tachycardic in the 120s.” She was discharged with blood pressure medication. Red flag.

You learn that her husband tried calling the behavioral health department to make his wife an appointment, only to be told that the soonest they could get her in would be 6 weeks. He pressed and asked if there were exceptions for urgent OB patients and was told no. Red flag.

In the week leading up to her death this patient had been in contact with 3 OBs, a pediatrician, and a lactation consultant, saying things like “I am afraid of everything” and “I can’t eat or drink.” She had a positive EPDS flagging thoughts of self-harm. Big, bright, unmistakable red flag.

Phone records show that one night she tried calling the behavioral health appointment scheduling line, which was given to her by multiple providers as a 24/7 crisis line, at 2am. Red flag.

Her notes from the last time she was seen in the clinic state “she is not eating, vomits any food she eats and has diarrhea. She reports sleeping at most 4 hours a day.” She walked out of that appointment with only a prescription for hydroxyzine, which is similar to Benadryl. Red flag.

At 5:30am the next morning, her husband woke up and found that she was not in the bed. He looked over and saw that the baby was still sleeping peacefully in the bassinet. He panicked. He knew in his gut that something was wrong.

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All The Way With LBJ – A Half Century After His Passing

By MIKE MAGEE

This is the 52nd anniversary of the death of Lyndon Baines Johnson from his 5th Heart Attack. And two days ago was the 39th anniversary of the first celebration of a new federal holiday, Martin Luther King Jr. Day. In signing that original proclamation in 1983, President Ronald Reagan said, “The majesty of his message, the dignity of his bearing, and the righteousness of his cause are a lasting legacy. In a few short years he changed America for all time.”

The MLK federal holiday was not so “Kum ba yah” (“Come by here”) this year. President Trump was in no mood to be tutored on this 60’s phrase derived from an African American spiritual made famous by Pete Seeger. Rather, he took advantage of the convergence of MLK’s day and his own coronation to trash all things DEI (Diversity, Equity, Inclusion).

Of those supporting the 2nd term President, from here and beyond, few could have had a broader smile on his face than dearly departed (July 4, 2008) former North Carolina Senator Jesse Helms. Helm led the opposition to the MLK bill, submitting a 300-page report that labelled King an “action-oriented Marxist” and a communist. Senator Daniel Patrick Moynihan (NY) was so enraged at the time that he declared the report a “packet of filth”, threw it on the Senate floor, and then unceremoniously repeatedly stomped on it.

So, as a nation, we have been down this road before.

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Maybe AI Doesn’t Read Blueprints

By KIM BELLARD

Gosh, who knew that Jan 13 would be an AI day, with at least three major announcements about “blueprints” for its development going forward? Of course, these days every day is an AI day; trying to take in all AI-related news can be overwhelming. But before some other AI news drowns them out, I wanted to at least outline today’s announcements.

The three I’m referring to are the Biden Administration’s Interim Final Rule on Artificial Intelligence Diffusion, OpenAI’s Economic Blueprint, and the UK’s AI-driven Plan for Change.  

The Biden Administration’s rules aim to preserve America’s lead in AI, stating: “it is essential that we do not offshore this critical technology and that the world’s AI runs on American rails.” It establishes who advanced chips can be sold to and how they can be used in other countries, with no restrictions on 18 key allies and partners.

It also sets limits on model weights for AI models, seeking to constrain non-preferred entities’ ability to train advanced AI models.

“The U.S. leads the world in AI now, both AI development and AI chip design, and it’s critical that we keep it that way,” Commerce Secretary Gina Raimondo said in a briefing with reporters ahead of Monday’s announcement

Not everyone is happy.

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Aneesh Chopra talks Cancer Navigation Challenge & more

Aneesh Chopra is the former CTO of the US under Obama. He’s now head of strategy at Arcadia, but this week is one of the driving forces behind the new challenge called “Transforming Cancer Navigation with Open Data & APIs” . I caught up with Aneesh about why the need for this type of data exchange and why caner, and also more generally about interoperability, data analysis (his day job) and the impact of AI. Aneesh is an optimist but also about the most articulate person in health care explaining what is going on the ground and in policy with the regulations and actions of data exchange, and its uses. Pay attention–Matthew Holt

Why Financial Incentives Oppose Quality Improvement Projects in Healthcare

By TAYLOR J. CHRISTENSEN

When I attended the Institute for Healthcare Improvement’s 2024 annual forum in Orlando, Florida, one of the best parts of the conference, as always, was talking to the other attendees. Every time I would sit down to eat a meal or sit down in a session, I would talk to the people around me. And I heard about so many different quality improvement (QI) projects!

After several conversations, I started to notice a pattern: Many of the projects were fighting an uphill battle because they were going against financial incentives. Or, at a minimum, they were not supported by financial incentives. All of this got me thinking about a new exhaustive, mutually exclusive categorization . . .

All QI projects can be divided into three categories:

Category 1: Supported by financial incentives

Category 2: Neutral to financial incentives

Category 3: Opposed by financial incentives

Determining which category a potential project will fall into is important for predicting how much support from hospital leadership a QI project will have.

So how do you determine which category a potential project is in?

Remember that seeking profit (or “surplus” if you’re a non-profit organization) is what drives most behavior in all organizations, even in healthcare. And whatever is profitable is what organizations have a financial incentive to do. Here’s a simple formula for profit:

Profit = Revenues – Costs

In most industries, providing a higher-value product or service (Value = Quality / Price) compared to competitors will earn that organization greater market power, which they can use to extract greater profits either by keeping prices the same and winning more market share or increasing prices while maintaining the same market share. Either way, that greater market power turns into greater profit.

In healthcare, however, higher value does not lead to greater market power. The reasons for this have been explained elsewhere, but it really comes down to patients not making value-sensitive decisions when they are choosing where they will receive care.

Thus, quality improvement efforts that result in a healthcare provider delivering higher-value care are not automatically financially incentivized. Instead, the only factor that matters from a financial incentives standpoint is whether the QI project increases revenue or decreases costs.

So, if a project will increase revenue and/or decrease costs, it’s in Category 1; if it will not have any net impact on profit because either it doesn’t change revenues or costs or it increases or decreases both of them equally, then it’s in Category 2; and if it increases costs or decreases revenues, it’s in Category 3.

This all probably seems heartless–we’re talking about quality improvements that can save lives and quality of life here, and all I’m focusing on is money?

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Past Presidents Posthumous Advice To Trump #47

By MIKE MAGEE

For those many, many millions of viewers who tuned in to the live coverage of former President Jimmy Carter’s funeral this week, they were rewarded with two hours of intriguing video images, and moving words and song, including a recounting of the beginnings of environmental advocacy as Los Angeles burns, and John Lennon’s “Imagine” performed by Garth Brooks and Trisha Yearwood.

Five former Presidents and four Vice-Presidents were in attendance. And there were notable firsts, like the first greeting and handshake between incoming President Trump and former VP Pence since January 6, 2021.

But perhaps the most striking events of this carefully staged national funeral were the  two especially haunting posthumous eulogies delivered by the sons of a former president and vice-president. Presented by Steven Ford, son of former President, Gerald Ford, and Ted Mondale, son of former Vice-President Walter “Fritz” Mondale, they appeared to be directed to America itself, and its’ soon-to-be 47th president.

As the speakers explained, Jimmy Carter, some years back, asked both Ford and Mondale if they would be willing to present eulogies at his funeral. Both agreed, and put pen to paper in anticipation. But as it became evident that Carter might very well outlive them, they each asked their sons, in that event, to read their remarks at his funeral. And today they did.

Both President Ford and Vice-President Mondale’s words (voiced by their sons) deserve a full viewing when time allows. But in the meantime, let me share the closing remarks of each, prescient and timely now, at American democracy’s hour of need.

Steven Ford, son of former President Gerald Ford (7/14/13 – 12/26/06), reciting the president’s written words posthumously:

“…Now is time to say goodbye, our grief comforted with the joy and the thanksgiving of knowing this man, this beloved man, this very special man. He was given the gift of years, and the American people and the people of the world will be forever blessed by his decades of good works. Jimmy Carter’s legacy of peace and compassion will remain unique as it is timeless…As for myself, Jimmy, I’m looking forward to our reunion. We have much to catch up on. Thank you, Mr. President. Welcome home, old friend.”

Ted Mondale, son of former Vice-President Walter “Fritz” Mondale (1/5/28 – 4/19/21) reciting the vice-president’s written words posthumously.

Ted prefaced his reading with this sentence – “My father wrote this in 2019, and clearly he edited it a number of times since then, but here we go.”

“…Two decades ago, President Carter said he believed income inequality was the biggest global issue. More recently, in a 2018 Commencement Address at Liberty University, I think now the largest global issue is the discrimination against women and girls in this world. He concluded that, ‘Until stubborn attitudes that foster discrimination against women change, the world cannot advance, and poverty and poverty and income equality cannot be solved.’ Towards the end of our time in the White House, the President and I were talking about how we might describe what we tried to accomplish in office. We came up with a sentence which remains an important summary of our work. ‘We told the truth. We obeyed the law. And we kept the peace.’ That we did, Mr. President. I will always be proud and grateful to have had the chance to work with you towards noble ends. It was then, and will always be, the most rewarding experience of my public career. Thank you.”

Mike Magee MD is a Medical Historian and regular contributor to THCB. He is the author of CODE BLUE: Inside America’s Medical Industrial Complex. (Grove/2020)