Essays : August 14, 1945 - V-J Day - the whole world celebrated, and Vineyarders joined the fun
Senior Harvard medical graduates speak out on health care reform
By James W. Prichard, West Tisbury, and Robert S. Blacklow, Oak Bluffs
We represent 59 members of Harvard Medical School's Class of 1959 who have signed the statement below. It advocates major reform of the American health care system, including a government-backed insurance option for those who need or want it. The signers are a majority of our 112 living classmates. We are from 24 states and the District of Columbia. We include clinicians, administrators, and researchers with long histories in development and delivery of patient care in all major parts of American medicine. The public insurance option is essential, because it confronts the private insurance industry with an immediate challenge to support best practices known to improve access and quality, while also lowering cost. As Atul Gawande, a more recent graduate of our medical school, described in The New Yorker of June 1, and a New York Times OpEd article of August 13, by Mr. Gawande, Donald Berwick, Elliott Fisher, and Mark Mcclellan, the Mayo Clinic, the medical community of Grand Junction CO, and several other health care entities around the country have shown that such practices work in a private setting. But few insurance companies chartered to maximize shareholder return will follow those examples without competition from a public insurance option.
We 1959ers have been around the track. We know the American medical system from the inside, as part of it, and we are appalled that it does not serve this great country as well as it could.
We also know the system like most people do, as patients, and nearly all of us have horror stories about something crazy that happened to us or members of our families in a time of medical crisis. That both appalls and scares us.
You often hear that American medicine is the best in the world. If you are very sick, it is. But if your life is not in immediate danger, you will often spend weeks waiting for an appointment to tell somebody about what's bothering you. Other advanced countries do better with less money, as many of us know from working and lecturing in their hospitals.
Lieutenant General Lewis "Chesty" Puller - the most highly decorated officer in Marine Corps history - is reputed to have said, "If the President tells us to fight, we fight. Doesn't matter who, doesn't matter where." American medicine ought to be somewhat like that. "If you're sick, we treat. Doesn't matter who, doesn't matter why."
But our current health care system too often fails to meet that uncompromised standard of professional responsibility. Too many people get short-changed, and too many others left out altogether. That's not right, in this country.The American medical system should not just match the best achievements of other countries, but exceed them; and it can.
Preventive measures to keep people from getting sick in the first place, reduction of administrative waste, more efficient medical information technology that is securely confidential, volume discounts on drugs, and quick introduction of effective new treatments are among goals within easy reach of a society ready to demand them.
Congress and the president can start on all of those things this year, but in our opinion, the most urgent single goal is a government-backed medical insurance option.
We hope that you agree with the principles of the statement below and will tell your Senators and Representatives that you do.
The Urgent Need for National Health Care Reform
Fifty-nine members of the Harvard Medical School Class of 1959 are convinced that reform of the American health care system is essential, must be substantial and carefully designed, and must include a public health insurance option.
We present our position in this statement, a result of intense discussions begun at our June reunion commemorating 50 years since graduation. We are a majority of our 112 living American classmates. Six declined to sign the statement because they disagree with it, three more because it is not detailed enough, and 44 expressed no opinion.
Each of the signers has 50 years of experience and leadership in clinical practice, medical education, administration, and/or research. Our collective careers cover a wide variety of primary care and specialty fields in a range of organizational settings, in both private practice and academia, across the United States.
We believe that our humane and enlightened country, committed to "life, liberty and the pursuit of happiness", has the obligation to provide everyone with the opportunity to obtain affordable insurance and quality health care.
We support President Obama's proposal that all citizens should be offered the option of a government-sponsored medical insurance plan, along with private options. In our opinion, health care reform will fail without the discipline of competition from a public option.
Excluding a public option would throw away a vital opportunity to test different ways to provide quality care for all. A public plan would help develop and evaluate new standards of practice, malpractice reform, and reimbursement of physicians, and would emphasize preventive care. To be affordable, it would have to avoid financial incentives for unnecessary services and contain measures that curb financial abuse and waste by some hospitals and, unfortunately, by some of our medical colleagues.
A public option would also identify and encourage use of demonstrated best practices shown to be effective at less cost, offer greater access, and provide higher quality of care. Administrative overhead, as now in Medicare, would be significantly lower without for-profit intermediaries. These innovations could help lift the competitive burden that health care places on American employers in the global marketplace, while also offering portability and continuity of coverage during job changes and illness.
Common sense demands a planned, full comparison of the relative benefits of public vs. private options. At the outset, there must be clear and uniform ground rules for measuring, reporting, and evaluating cost, access, and quality of care for all plans.
We urge Congress and the President to take this courageous step at a vital time in our nation's history.
The 59 signers' names are available here. This statement expresses only their opinions, not those of anyone else associated with Harvard Medical School.
Synergy in health care
By Edward Harris Jr.
Although Massachusetts made the decision to expand access to health care before attempting to contain its costs, one triad of arrangements has approached true synergism by increasing access at no increased cost. It is a fusion of interests of the Massachusetts Medical Society (MMS), a not-for-profit health care provider on Martha's Vineyard, and commitment by a senior volunteer physician to enhance the chronic care model for health care, including prevention.
The first step in what was to become a synergistic effort was the creation in 1992 by the MMS of the Committee on Senior Volunteer Physicians (CSVP). This was designed to enable senior physicians, most of whom had retired from active practice but who had maintained or acquired a license to practice in Massachusetts, the opportunity to provide health care to uninsured and under-insured populations within the state. The driving force for success of the CSVP was the provision of resources by the MMS to give these physicians professional liability (malpractice) insurance without cost once they had identified a practice site. The senior physicians have signed agreements not to receive any form of compensation for their efforts.
On Martha's Vineyard, the second piece of the effort was made possible by Island Health Care, Massachusetts' very first rural health clinic, established in July of 2004. During its nearly five years of operation in small quarters at the Edgartown triangle beside the Stop and Shop Pharmacy, the clinic and its staff have seen more than 6,000 patients in a total of more than 20,000 visits. Nurse practitioners (Carol Forgione, Nancy Phillips, Dagmar Dockery and Lin DeYoung), physicians assistants (Carol Anne Lindsey), a part-time family physician who serves as medical director (John Lamb), a practicing psychiatrist who volunteers considerable time (Dr. George Cohn) and supporting staff including a Portuguese/English interpreter, medical assistants, tobacco treatment specialist (Allyson Thornton), and clinic manager Penny Franklin, have all contributed to establishing this small health center into our community. Additionally, clinical clerks from the medical schools in Boston and Worcester have come to the Vineyard on electives to learn from the patients and practitioners at IHC.
The creation of IHC was not a casual process. Cynthia Mitchell, the executive director of Island Health Inc., the non-profit umbrella organization for IHC, has been the principal leader in creating a mission and guidelines for the clinic as well as integrating IHC's activities with other community-based health care programs in southeast Massachusetts, locally on the Vineyard and regionally on Cape Cod and Nantucket. Numerous federal, state and privately-funded grants have allowed the organization to thrive and grow.
The third component of the triad came about through informal conversations between a past-president of the MMS, Alan Harvey, M.D., and me, a five-month a year resident on the Vineyard. I learned about the senior volunteer physician program and the Island Health Care clinic, renewed my Massachusetts license first acquired during my training years in internal medicine and rheumatology at the Massachusetts General Hospital. I negotiated the opportunity with Cynthia Mitchell to work as a consultant for patients with musculoskeletal complaints with the IHC providers. I am the retired chairman of medicine at Stanford University Medical Center in Palo Alto, California, a past-president of the American College of Rheumatology, and recent recipient of the college's Presidential Gold Medal.
I am very impressed with the thorough and efficient care that patients receive at the clinic. Each referral has been carefully evaluated, and the questions asked about diagnosis or therapy are always appropriate. I also must add that my work would be impossible without Jakeline Oliveira, receptionist and medical interpreter, providing precise translation of Portuguese, often the only language spoken by many Brazilian patients.
My consultations are not limited to those under-insured patients, however. Any resident or visitor on the Island can be seen at the clinic, and their insurance programs are billed accordingly.
The challenges for Massachusetts are enormous, and the costs high, but I commend the Commonwealth's leadership in wanting to give high quality management of chronic disease and to emphasize preventive medicine to all populations.
Having been a long-time administrator in health affairs, I am deeply impressed with the size and continued expansion of IHC by the tireless efforts of Cynthia Mitchell. She is constantly writing grant applications to support and sustain the clinic and its programs, as well as other collaborative ventures and consortiums. A few of these are the Cape and Vineyard Community Health Center Network, the Cape and Island Diabetes and Disparities Collaborative, and the Small Rural Health Care Provider Quality Improvement Program. The Vineyard Health Care Access Program (VHCAP), with a core service of connecting the Island's lower-income residents with health insurance and health care, was founded in 1999 and is a partner with IHI in several ventures. VHCAP has become an indispensable resource following the establishment of the Massachusetts health care reform initiative. In 2008, VHCAP enrolled 2,524 people in MassHealth (Medicaid) or the new Commonwealth Care, or the Health Safety Net.
As residents of Martha's Vineyard and visitors to it have need for high quality health care, Island Health Care in Edgartown is open to provide it. And the Senior Physician Volunteer Program, IHI, and the interest and expertise of volunteers have made one component - musculoskeletal health care - more accessible and less costly.
Edward Harris Jr., a physician and seasonal resident, volunteers his services at Island Health Inc.'s Edgartown clinic.
Medicare cuts in health reform bills will harm VNA
By Bob Tonti
We are all aware that runaway national health care costs and the need to increase access to care are the main reasons for health reform. Martha's Vineyard health care providers are certainly feeling the effects of rising costs on a local level. We have read recently in the local papers about how expensive procedures are at Martha's Vineyard Hospital and how budget stressed the folks at Martha's Vineyard Community Services are.
However, running below the radar are the national health care reform proposals that would attempt to rein in overall health care costs at the expense of quality homecare. The House health care reform bill, Affordable Health Choices Act of 2009, is proposing $56.8 billion in Medicare home health reimbursement cuts over 10 years to help pay for reform. This level of cuts could cripple the Vineyard Nursing Association's (VNA) ability to delivery quality homecare to all Islanders deserving of homecare support.
Home health care is already facing a 2.75-percent reduction in reimbursement for 2010 - a revenue loss of $55,000 for the VNA. In the current health reform bill, Congress would increase the scheduled cut by another 2.71 percent or $54,200 for the VNA. This would total 5.46 percent or $109,200 in Medicare reimbursement cuts for the VNA in 2010 alone. Of course a reduction in revenues translates directly to a cut either in the free care we provide or force us to reduce the number of services we can provide. And the cuts don't end there. Starting in 2011, home healthcare agencies could face at least another five percent in reimbursement cuts
All these cuts fly in the face of studies showing that home healthcare is not only cost effective compared to institutional care, but is also the consumer preferred choice. Ask anyone if they would prefer care in the home versus in a nursing home or hospital, and they will tell you, without equivocation, that they want to spend as little time in a hospital as possible and want to grow old gracefully in their own homes.
The VNA's ability to keep patients home and families together could get more difficult if Congress passes these cuts, and the reality is that they don't make a whole lot of sense. Home health care comprises only 4.5 percent of total projected Medicare payments, and federal government data demonstrates that home health care is significantly more cost effective than other settings. Home health care has the potential to be a huge cost saver for Medicare by leveraging its ability to care for people in the home, making the proposed cuts to homecare very perplexing.
The VNA has grown to become a $3 million agency providing Medicare services, eldercare services, services for the disabled, public health services, private care services and soon hospice services. If reining in national health care costs and increasing access to care are two of the main goals for reform, then reducing Medicare home health reimbursement is counterproductive.
Raising more money for the VNA through fundraising to solve this problem seems like an unfair burden on the community, and a daunting challenge given the current climate. Needing to raise another $100,000 plus on top of the $300,000 we raise today to break even would be a band aid solution at best. We need to change the federal government's approach to cost cutting by reminding them of the critical services the VNA provides and the potential impact of the proposed cuts on the community.
Please consider writing your members of Congress and ask them to support health reform, but not at the expense of the Medicare home health program. You can do this easily by visiting www.VNAA.org and clicking on "Advocacy" and then "Take Action: Email Congress". You will be helping yourself, the community, and the VNA, a nonprofit organization and the Island's only homecare agency serving Martha's Vineyard for the past 25 years.
Thank you and please help.
Bob Tonti is chief executive officer of the Vineyard Nursing Association.