Sunday, November 14, 2010

Exposure of Dialysis Care in the United States

Recently, a dedicated and passionate investigative reporter released a series of articles focusing on dialysis facilities and the care, or lack thereof, that patients received. Here are the links:

(We have posted to our website - - the dialysis facility surveys (inspection reports) for California for 2009 and 2010

Friday, June 11, 2010

Five California Hospitals Fined for Patient Privacy Breaches

Date: 6/10/2010

Number: 10-039

Contact: Al Lundeen (916) 440-7259


The California Department of Public Health (CDPH) announced today that five California hospitals have been assessed administrative penalties and fines totaling $675,000 after a determination that the facilities failed to prevent unauthorized access to confidential patient medical information.

“Medical privacy is a fundamental right and a critical component of quality medical care in California,” said Dr. Mark Horton, director of CDPH. “We are very concerned with violations of patient confidentiality and their potential harm to the residents of California.”

The following hospitals received penalties:

1. Community Hospital of San Bernardino, San Bernardino, San Bernardino County: The hospital was assessed a $250,000 fine after the facility failed to prevent unauthorized access of 204 patients’ medical information by one employee.

2. Community Hospital of San Bernardino, San Bernardino, San Bernardino County: The hospital was assessed a $75,000 fine after the facility failed to prevent unauthorized access of three patients’ medical information by one employee.

3. Enloe Medical Center, Chico, Butte County: The hospital was assessed a $130,000 fine after the facility failed to prevent unauthorized access of one patient’s medical information by seven employees.

4. Rideout Memorial Hospital, Marysville, Yuba County: The hospital was assessed a $100,000 fine after the facility failed to prevent unauthorized access of 33 patients’ medical information by 17 employees.

5. Ronald Reagan UCLA Medical Center, Los Angeles, Los Angeles County: The hospital was assessed a $95,000 fine after the facility failed to prevent unauthorized access of one patient’s medical information by four employees.

6. San Joaquin Community Hospital, Bakersfield, Kern County: The hospital was assessed a $25,000 fine after the facility failed to prevent unauthorized access of three patients’ medical information by two employees.

CDPH has assessed the penalties to these facilities under new legislation intended to protect the confidentiality of medical records. CDPH has determined that the hospitals failed to prevent unauthorized access to patient medical information, as required by Section 1280.15 of the Health and Safety Code.

An administrative penalty of $25,000 may be assessed against a medical facility for the breach of each patient’s medical information. A penalty of up to $17,500 is added for each subsequent breach of each patient’s medical information.

Facilities are required to submit a plan of correction to CDPH within 10 working days and implement a plan of correction to prevent future incidents. Facilities can appeal an administrative penalty by requesting a hearing within 10 calendar days of notification. If a hearing is requested, the penalties are to be paid if upheld following appeal.

All hospitals in California are required to be in compliance with applicable state and federal laws and regulations governing general acute care hospitals. The hospitals are required to comply with these standards to ensure quality of care.

In 2008, Governor Arnold Schwarzenegger signed legislation, SB 541 and AB 211, to improve patient privacy laws and to address breaches of confidential information.

SB 541 by Senator Elaine Alquist (D-Santa Clara) sets health facility fines for privacy breaches and increases the fines for serious medical errors in hospitals. The new law ensured that health care providers face real consequences when they fail to protect patients. For facilities, fines for disclosing private medical information range up to $250,000 per reported event.

AB 211 by Assemblymember Dave Jones (D-Sacramento) requires health providers to prevent unlawful access, use or disclosure of patients' medical information and hold health care providers and other individuals accountable for ensuring the privacy of patients.

Sunday, June 6, 2010

Hospitals Fined in California

The following is a list of hospitals in California that have been cited for deficient practices that resulted in harm, including death. The California Department of Public Health (CDPH) has posted such information on their website. As a result of this posting, consumers become more aware of the delivery of health care in their hospital.

We caution viewers that because the hospital where you receive care has been cited does not necessarily mean that overall care is poor. We must keep in mind, preventable errors occur in all health care facilities.

However, knowing this information makes you, the consumer, more aware and supports the continuing process of educating yourself in order to be part of the health care team that will provide quality safe care.






Wednesday, December 16, 2009

Advocates4QualitySafeCare comments on ESRD PPS - Will this new payment system change patients lives?

Uncompensated advocates striving for quality safe care
for all patients - all health care settings
San Diego, California 92128

December 10, 2009

Ms. Charlene Frizzera
Acting Administrator
Centers for Medicare & Medicaid Services
Department of Health and Human Services
Attention: CMS-1418-P
Baltimore, MD 21244-8010

To Whom It May Concern:

My name is Roberta Mikles. I am a retired Registered Nurse, Patient Safety Advocate, daughter of a dialysis patient and spokesperson for other Advocates4QualitySafeCare. These advocates are patients, family members, health care professionals and concerned taxpayers that are all dedicated to working towards patients receiving quality safe care in all health care settings. Today, however, we are focused on dialysis care.

We appreciate the time, effort and research that CMS put forth in development of the ESRD PPS proposed rule. It is evident that CMS has, to a great extent, considered Medicare cost containment while attempting to maintain quality safe delivery of care. Three areas that we support are: (1) pay-per-treatment to allow improved quality of life for patients, (2) inclusion of Epogen in the bundle to prevent misuse, and (3) exclusion of nephrologists’ services. Although we support the aforementioned, and understand CMS’ challenge to preserve quality safe care, we have significant concerns that are focused on patients and how they will be affected (negatively) by this proposed rule. It appears that there is considerable potential for patients to be negatively affected as a result of increased administrative burdens. That additional use of patient staff time could result in possible cost-cutting in areas of delivery of care.

We do not believe that CMS had sufficient valid data when developing this proposed rule. If the bundled rate is not based on current and accurate costs, patients will suffer. There are enough delivery-of-care problems now as evidenced by Medicare survey findings, as well as providers identifying those patient safety areas (during the time frame of the patient safety coalition).

We strongly urge CMS to revise the proposed rule to prevent patients from experiencing negative outcomes and postpone the implementation date (2011) until current and accurate data is obtained and fully analyzed and studied.

Medicare should NOT reimburse providers for preventable errors that result in negative outcomes. As a result of this bundling, we might see an increase in negative outcomes.

We bring the following comments and recommendations to CMS. Some comments and recommendations might be conflicting, but we are looking at this proposed rule from different views, therefore, different recommendations providing various options to CMS.



We commend CMS on recognizing the importance of allowing payment for more than three treatments a week. We highly support Medical Education Institute’s comments and recommendations:
“Patients want to live as long and as well as possible. Some in the renal community have expressed concern that CMS has put cost before patient health and well-being by not routinely reimbursing for more frequent treatments until results of the $10 million Frequent Hemodialysis Network (FHN) studyare published (already delayed >1 year). We wonder how many patients would have kept their jobs, had fewer complications and hospitalizations, had better health-related quality of life, and survived instead of died had CMS accepted data from multiple clinical trials. and routinely reimbursed for 1-3 additional treatments per week during the study period. Even if the results of the FHN study confirm data from other studies, it appears from the rationale in the preamble that the ESRD PPS will continue to limit treatments to three times weekly unless medical necessity justifies extra treatments, placing an additional burden on already overstretched nephrologists.
Short, thrice-weekly hemodialysis treatments evolved from a historical accident,1 are not evidence-based, and should not remain the default treatment in the face of compelling evidence that the 2-day treatment gap contributes to thousands of needless deaths in the U.S. each year (sudden cardiac death rates soar to 50% higher than expected on the day after the 2-day no-treatment gap) 2 and triple in the 12 hours prior to the next treatment after that gap. (3) “


“State in this bundling policy that if FHN findings demonstrate that daily and/or nocturnal hemodialysis improves blood pressure, LVH, nutritional status, anemia, quality of life, and vascular access, reimbursement for >3 treatments per week will be allowed at the bundled rate plus any other adjustments provided in the final reimbursement policy, without additional medical justification”


Comment - EPOGEN (potential for under dosing)

We commend CMS and recognize the reasons for inclusion of Epogen in the bundled rate and trust that this will prevent the misuse and overuse which can be harmful for patients. Although we support this inclusion, we remind CMS that Epogen accounted for over 20% of (some) provider’s revenue; therefore, with the inclusion of Epogen, the following significant concerns arise that require CMS’ prudent review:

(1) Will providers administer minimum amounts of Epogen in order to meet their revenue projections? (1 a) Will these minimum doses result in patients requiring blood transfusions? (1 b) Will these minimum doses result in affecting (negatively) the patient’s well-being? It must be remembered that, for the most part, about 95% of delivered dialysis treatments are given by for-profit providers who are accountable to their shareholders. When revenue is potentially affected, providers might be tempted to administer less Epogen than they would have prior to the bundled payment.

Recommendation -

Develop patient-safeguards in order to prevent patients from being under dosed. With the collection of hemoglobin data from facilities, CMS should be able to determine if patients are being underdosed.

Comment - Epogen (consequences of minimum dosing)

Consequences of administration of minimum Epogen dosages will not only affect dialysis patients, but the community-at-large. A rise in the number of dialysis patients who will require blood transfusions will affect the already limited blood supply in many areas of the country, thereby affecting non-dialysis patients who might require needed blood. This situation then becomes a “community-problem”


(1) Patient-safeguards should be developed to ensure patients are not receiving minimum doses.
CMS has and will continue to have sufficient hemoglobin data from facilities to determine such.
(2) In addition, CMS should develop a tracking record for reporting those patients who required a blood transfusion. CMS needs to determine the numbers of patients requiring blood transfusions, to establish negative outcomes.
(3) Increase the penalty and develop a separate penalty if a patient is admitted to the hospital due to under treatment requiring a blood transfusion.
(4) Increase the penalty if a facility has an increase from their prior year in patients admitted to the hospital for a blood transfusion.

Note: # 3 and 4 --- Develop a grid with correlating penalties for hospital admissions. Medicare will NOT reimburse for preventable negative outcomes e.g. a patient who is hospitalized requiring a blood transfusion as a result of Epogen under dosing. The grid should include penalties for such as in #3 and 4.

Comment - Epogen - (hospitalization as result of low hemoglobin level)

We are aware of the 1999 Institute of Medicine report, “To Err is Human,“ which stated the high numbers of deaths as a result of preventable errors in hospitals. To date, the numbers have not significantly declined; therefore, do we need to unnecessarily expose this vulnerable population to further potential risk of harm? Further risk rises for this vulnerable population such as acquiring a preventable infection when hospitalized. Therefore, we must do everything possible to prevent hospitalizations especially since infection remains the number two killer of this already compromised group.


(1) Develop patient-safeguards, as above, to ensure that patients are not being under dosed.
(2) Medicare will not reimburse providers for preventable errors resulting in negative outcomes e.g. blood transfusions as a result of under dosing and low hemoglobin

Comment - Epogen - (higher hemoglobin levels required

Many patients who we have spoken to claim that they feel better and are able to function with a higher hemoglobin level, e.g. above 12. Many of these patients are employed.

In conclusion, we are surprised that even after the Congressional Hearings and investigations that there is only a “slap on the wrist,” (2% reimbursement decrease) for parameter compliance. This is insufficient to maintain compliance.


(1) Include hemoglobin levels to be higher than target maximum of 12 if there is medical justification.
(2) We urge CMS to look at further studies and research data related to higher hemoglobin levels in the dialysis patient population

Comment - Oral Medications

We oppose the inclusion of Part D oral medications in the bundled rate. We further believe that CMS did not have complete Part D data in order to determine the bundled rate for oral medications e.g. $14.00 per treatment. The amount that facilities will be receiving will not be sufficient revenue, resulting in cost-cutting in other areas e.g. dialysis supplies, staffing, etc. This will also prevent physicians from ordering, for many patients, the same medications they are presently taking. Administering less effective medications can result in negative outcomes. In addition, the inclusion of phosphate binders and calcimimetics allows and gives permission (by CMS) to providers to prescribe and administer drugs with lesser efficacy that will be provider cost effective but not patient-effective.

We remind CMS of the recent exposure of Quest subsidiary, Nichols Institute Diagnostics Inc. and problems with medical test kits. These test kits were sold to labs across the country from 2000 to 2006 in spite of inaccurate test results, thereby putting hundreds of thousands of dialysis patients at risk. Further, some dialysis patients underwent unnecessary surgery to remove their parathyroid and therefore were administered unnecessary treatment.
We do not need further negative consequences for dialysis patients. Not being able to take the most effective drugs might do harm.

We recognize that there are some patients who do not have supplemental insurance and have been paying out of pocket, large amounts, for their medications. The 20% coinsurance that they will have to pay now might be a decreased amount, thereby being better for them. On the other hand, those patients who have been covered by Part D will now have a coinsurance payment that might be larger. We ask CMS if data was obtained prior to this proposed rule that included information on patients who would benefit and those who would not? This could be a crucial determinant of how patients will be affected.

Medicare beneficiaries have a right to Medication Therapy Management. This can only be accomplished if patients have all their medications filled at the same pharmacy. Patients need to continue to have a choice of where to have their prescriptions filled. Many have long time patient-pharmacist relationships that they trust.

Inclusion of oral medications without appropriate oversight can lead to negative outcomes for patients. Granted that the ESRD Conditions mandate quality measures of bone and mineral metabolism to be included in the QI process; however, it is our experience, after facility survey reviews, that many facilities, although having a QI process required by their own facility policies/procedures, did not implement such. Therefore, we have grave concerns in spite of Condition mandates and urge CMS to address such. We are aware of the HR 3962 mandates (inclusion of binders and calcimimetics); however, we remind CMS that quality measures need to be included in order to ensure patient safety. We, further remind CMS, again, of the recent whistleblower case related to parathyroid testing problems that placed patients in harmful situations. We do not need more problems. e.g. additional unnecessary parathyroidectomies, therefore, oversight with quality measures is imperative.


(1) Exclude oral medications until complete data is obtained and analyzed to determine negative consequences for patients and providers
(1a) actual cost of medications that patients are presently prescribed
(1b) study and obtain data on the number of patients who will benefit versus the
number who will not (those with no insurance who pay out of pocket who will
have a lesser amount to pay versus those who have no copay
who will have a copay)
(2) If calcimimetics and phosphate binders remain in the bundle, data collection on parathyroidectomy surgery and vascular calcification levels.
(3) If calcimimetics and phosphate binders remain in the bundle, include quality measures of bone and mineral metabolism.
(4) If oral medications remain in the bundle CMS should include patient-safeguards so that all patients have the opportunity to receive the same drugs with the same efficacy.



CMS has included anemia management and dialysis adequacy in the QIP; however, is this enough to determine quality care? NO, it is not. It is fully understood the reasons for inclusion of these two, as well as further QIP development; however, we believe CMS has needed data readily available to them to include other quality measures. Being aware of the slowness of improving oversight of dialysis facilities, we urge CMS to include additional quality measures to ensure patient safety.

(1) Include additional quality measures to ensure patients are receiving quality safe care.


It is shameful that infection remains, after many years, the number two cause of death among this vulnerable population. We do not believe that preventable acquired infections have ever been sufficiently addressed in dialysis units. It is our understanding that under the new Conditions the most frequently cited deficiencies are related to ineffective infection control practices, e.g. the most basic practices of hand washing, changing gloves and surface cleaning between patients. These continued problems with staff not implementing correct practices to ensure safe care MUST be addressed. This is the time to do so to protect patients. We believe that CMS has sufficient data that inclusion of such will decrease infection rates. The question we must ask is, “How many patients would have not acquired an infection should there have been increased oversight in this area?” and “How many patients would not have died as the result of a preventable infection?”


(1) Include infection rates in the QIP
(2) Develop an incentive program for those facilities that decrease their infection rates
(3) Increase the 2% (decrease reimbursement) if facilities are cited for infection control deficiencies during surveys.
(4) Increase 2% if facility infection rates increase from prior year.
(5) Mandate facilities to participate in the CDC’s surveillance programs for infection prevention


The ESRD Conditions identify patient-level indicators that are to be included in the facility’s Quality Improvement Program of which Mineral Metabolism and Renal Bone Disease are included. However, although this has already been identified as mandated tracking, there is no way to know if facilities are in compliance due to the lack of timely inspections in many states. Additionally, in our review of many facility survey reports, deficiencies were cited for facilities not adhering to their own QI policies and procedures. Therefore, it is even more essential that Bone and Mineral quality measures be included in the proposed QIP. Renal bone disease is also included in the comprehensive assessment (ESRD Conditions). Therefore, we ask, “Is this not important enough to include in the QIP?“ There must be oversight to ensure patient safety.


(1) Include Bone and Mineral Metabolism quality measures in the QIP
(2) If calcimimetics and phosphate binders are left in the bundle, tracking of parathyroidectomies should be done.



We believe that CMS has sufficient hospitalization data to include such in the quality measures. Increasing oversight by inclusion of hospitalizations will result in increased patient safety and delivery of quality care. In review of some survey findings it was evident that hospitalizations were a result of preventable errors.


(1) Include quality measure of ‘hospitalization rates’ in QIP.
(2) Include tracking of reasons for hospitalizations

Patient Satisfaction


It is our belief that patients, as the complete their facility patient satisfaction survey, often do not identify those ‘real’ concerns regarding care. Many patients have told us that they are not comfortable completing the facility patient satisfaction survey. When asked ‘why’ their responses are as follows: (1) lack of confidentiality as a result of (a) not being able to send survey in sealed envelop to another location other than handing back to staff (b) upon completion placing survey in container within their facility (c) staff standing next to them as they fill out survey, (2) fear that there will be retaliation for stating their concerns regarding delivery of care as a result of (2a) bringing forth concerns with no facility action taken (2b) staff demonstrating either covert of overt behavior indicating that patient should not bring forth concerns.

It is important for patients to be able to bring forth concerns, especially in a survey and that this information be kept confidential.


(1) Include patient satisfaction in the quality indicators
(2) Standardize procedure for patient satisfaction surveys to ensure accuracy and consistency.


The 2% penalty is a “slap on the wrist“. Dialysis Facility Compare clearly shows that there are many facilities that were either lower or higher than state and/or national percentages. Dialysis facility survey findings have also indicated cited deficiencies for that related to anemia management. Therefore, does this area not warrant more concern?


(1) Increase the 2% penalty to a higher number when providers under-treat or do not treat a patient’s anemia, e.g. when hemoglobin levels are below 10 and remain under ten for specified time frame.
(2) Increase the 2% penalty when providers over-treat a patient’s anemia, e.g. when hemoglobin levels fall over the parameter unless there is medical justification e.g. post-hospitalization.



We oppose the inclusion of home dialysis training in the bundled payment. We fear the inclusion of home training will be a disservice to patients. Patients, being responsible for their own life, must be fully educated and trained. It is somewhat disappointing that home dialysis training is not considered to be that important, e.g. having an attached adjustor. When considering the time it takes to train a new dialysis technician in order to ensure that patients receive safe care, even more consideration should be given to those who take full charge of their own dialysis treatment administration. CMS has proposed that the bundled rate shall be increased for the first four months, some of this amount to cover home dialysis training. However, most patients do not start home dialysis within the first four months. The sad reality is that many units do not and with the proposed rule even more will not encourage home dialysis due to poor reimbursement. We remind CMS that longer and more frequent home dialysis has proved to give patients a better quality of life, reduce medication use, reduce hospitalizations and increase survival. Considering patient survival is one of the aspects of CMS’ Dialysis Facility Compare, it would be prudent to address home dialysis differently than is in the proposed rule. Home dialysis is cost saving for Medicare and has not been adequately addressed. It makes sense that if patients take fewer medications with less hospitalizations, that this in itself saves millions of dollars. Therefore, we strongly urge CMS to realize that home dialysis plays a major role in reducing Medicare costs while improving patient lives.


(1) Exclude home dialysis training from the bundled rate
(2) Add adjustor for home dialysis to include training at a rate that is equivalent to, for example, training/teaching of dialysis technicians
(3) Add adjustor for those facilities that maintain patients on home dialysis for six months
(4) Add adjustor for patient outcomes
(5) If home dialysis remains in the bundled rate for the first four months, CMS should implement immediately a formal plan to monitor, e.g. increased oversight to determine if the number of home patients is decreasing or increasing and to determine how patients are being affected by the bundled rate.



We oppose the inclusion of all lab tests in the bundled rate. It is our understanding, according to Section 623(E)(1)(B) of the MMA, that the intent was only to include lab tests directly related to the use of IV drugs, e.g. Epogen and Vitamin D. CMS has included all laboratory tests which we oppose. We appreciate the fact that CMS is charged with reducing Medicare costs, while preserving quality safe care, however, we strongly believe that the inclusion of lab tests will result in (1) needed lab tests not being ordered, (2) patients will experience negative outcomes as a result of not having needed lab work performed., (3) potential - treatment errors as a result of not ordering adequate tests, and (4) potential - patient complications as a result of inadequate testing. The inclusion of all lab tests places the physician in a constrained position to order needed labs especially if there is any type of pressure from profit-making providers, or those providers who are barely making ends meet. Medicare beneficiaries should be able to obtain the same services e.g. according to this proposed rule, Medicare beneficiaries with ESRD requiring dialysis will not be afforded the same ability to have needed labs as non-ESRD patients, thereby setting up a system of discrimination. Patients who before did not have a copay for lab tests will now be responsible for 20% which might result in financial burden for many patients who already might be on limited/fixed incomes. This penalizes patients who have an illness - ESRD.

The following was stated in the recent published Semiannual Report to Congress DHHS, OIG, April 1, 2009 - September 30, 2009 in regards to dialysis facilities incorrectly billing for lab tests.
“Based on our sample results, we estimated that the intermediary overpaid dialysis facilities $3.9 million for laboratory tests provided to ESRD beneficiaries during CYs 2004-2006” This is absolutely appalling. And, this is just another example of why there now needs to be Medicare cost containment.. The correction of this situation is going to place increased administrative burdens on facilities as related to training staff in correct procedures, hiring staff, etc., This is going to take away from patient care time. Are patients paying for someone else’s mistakes?

FACILITY-LEVEL ADJUSTMENTS - Determination of Small Volume Facilities


We oppose the number of treatments listed in the bundle to determine small volume facility. There are too many variables, e.g. patients hospitalized, patients who travel, patient-visitors (traveling), and missed treatments. Determination of small volume facilities by patient census is a more stable method. Providers, in order to maintain their small volume status and receive the 20% increase, might not offer more treatments, or may even offer fewer treatments than 3x/week. If the 20% is decreased to 10% there will be no incentive to decrease patient treatments.


(1) Determine small volume facilities by number of patients.
(2) If the determination remains based on number of treatments the 2% increase should be decreased to 10% (minimum required by law).



Medicare’s intent was not to show discrimination towards one group of beneficiaries versus another, e.g. patients with kidney failure versus those who do not have kidney failure. It appears that this proposed rule penalizes ESRD beneficiaries who have co morbid conditions, e.g. with increased bundled payments comes increased copayments. One question that must be asked is, “Do other non-ESRD beneficiaries with comorbid conditions have higher copays because of their comorbid conditions? NO. Some patients due to numerous adjusters will have large copayments that could result in financial devastation.

Further concern is that patients who are on limited/fixed incomes might not be able to pay this new copayment which would mean that they could be involuntarily discharged. CMS has, by this proposed rule, set the patient up to be involuntarily discharged. CMS wrote the language in the ESRD Conditions which clearly state that a patient can be involuntarily discharged for non-payment. This is frightening for many patients to think that CMS who is suppose to ensure quality safe care and protect beneficiaries is setting them up for discharge. The reality of continued involuntary discharges is alive within the community. A major problem that we foresee is the following. Again, a reality, but many facility staff and/or physicians have not taken a liking to those patients and/or family members who speak up, ask many questions regarding delivery of care, bring forth concerns related to delivery of incorrect practices, etc. These individuals, who just want to protect themselves from preventable errors, or become more educated (it is their life), or to work with staff as a team, are often labeled e.g. ‘troublemaker’, ‘problem patient’ or ‘problem family’, ‘challenging patient’, ‘annoying’, etc. They are not seen as part of the team to help staff prevent errors, or even to become involved in their own care. These patients and/or families, who especially have brought forth concerns related to delivery of care, have been negatively looked upon by staff. Therefore, if, for example, one of these aforementioned patients is unable to pay their bill, they are immediately set up for an involuntary discharge. This is a sad reality. This area, as others, must have prudent review otherwise patients lives are at stake.

Further concern surrounds such as a case-mix adjustor for recovering alcoholic when, in fact,
more care is needed post hospitalization e.g. paperwork (mandated assessement, etc by Conditions), assessment/evaluations, possible ongoing treatment changes involving staff time.

Facilities are going to encounter a huge administrative burden with this case-mix adjustment model. Staff training and education will have to take place in order to ensure accuracy in data. Computer programs to support such will add cost and training of staff as well. More administrative costs for CROWNWeb again using more administrative resources. This increase in staff time and administrative burden, might result in added costs for the facility. This could result and likely will in cutting corners in the area of delivery of care. There are already enough problems with the delivery of care system as evidenced by survey findings and identified problems (by providers) as a result of the safety coalition .Therefore, cutting corners in the area of delivery of care will place patients in an even more compromised situation with potential for negative outcomes.

The complexity of this case-mix model is based on data that we believe is not always correct. The end result of this case-mix model poses potential negative outcomes for patients from financial to physical, therefore, CMS needs to re-evaluate this model.
CMS has led us to believe that the data obtained on the form 2728 is obtained by a nephrologist. This form is more than likely completed by someone who is not medically trained. Therefore, the data provided to CMS could be inaccurate, missing or forms incompletely filled out. This data must be correct otherwise patients will be affected.

Another equivalent concern is that of facility staffing and patient selection. If facilities are able to choose which patients they admit this could result in only providing treatment for the sickest of patients, with more comorbid conditions in order to increase revenue. This is a potentially dangerous situation. With the limited number of Registered Nurses in each facility, some with minimal dialysis experience or even medical experience, with no on-site physician, and with dialysis technicians providing most of the treatments, often with no medical background, along with a ’cookie-cutter’ training, we can only expect negative outcomes. (we are aware of those deficiencies related to insufficient training and education, etc., therefore, do we need more problems?) We are treading thinly in this area as evidenced by many facility survey findings and situations patients are placed in. We urge CMS to reconsider this case-mix model as there appears to be more negative than positive when it comes to patients and their safety
If providers ‘cherry-pick’ the most profitable patients, then other patients stand to lose. We must be ensured that all patients have access to care.

More concern surrounds the 120 adjustor. At the beginning of dialysis patients are receiving more acute intensive care with more complications that could happen. This critical time affecst all patients, Medicare beneficiaries or not. The present proposed rule excludes more than half of these patients. This time period could mean a patient’s life. Further concern lies in the area of providers inappropriately placing patients in home treatment in order to be Medicare eligible. This inappropriate placement could also mean a patient’s life especially if they are not medically stable at initiation of treatment. This adjustor must include all patients and not just Medicare beneficiaries.


(1) Increase the bundled payment and decrease the case-mix adjustors (those that require additional administrative time e.g. documentation, etc. that will result in a more equal system.
(1a) Add those monies devoted to other case-mix adjustors in the bundled rate so that patient care will not be affected due to increased administrative burdens.. If CMS is not agreeable to this, we believe CMS should compromise and Increase the bundled payment and decrease case-mix adjustors to include only those that affect costs, thereby resulting in a more equal system.
(2) CMS should provide to all facilities an electronic calculator to ensure consistency among providers
(3) Before initiating this model (2011) a study should be conducted to determine who is completing these forms and their experience/training. Included in this study should be a random selection of forms, coinciding with interviewing patients/families, and physicians, along with medical records reviews.
(4) Remove the 120 case-mix adjustor and include these monies in the bundled rate.
(5) Develop a mechanism to ensure that all patients have access to care.

In conclusion, we do not believe that this proposed rule is in the best interest of those Medicare beneficiaries or others, as all patients will be affected by this rule, not only Medicare recipients. The increased administrative burden that will be place upon providers will result in less attention to the patient (ALL patients) which can result in increased negative outcomes. We remind CMS that the State Survey Agencies, many, are not able to not only survey timely, but investigate complaints timely. Therefore, this continues to place patients at risk. The Networks do not have the authority as do SSA which poses yet further problems. The bottom line is that CMS must include quality measures to protect patients because for years oversight has been ineffective e.g. lack of timely surveys, lack of timely complaint investigations and lack of adequate sanctions. We can no longer continue to place this vulnerable population at risk. This proposed rule is a major change that will affect lives and we must make sure that we get it right the first time. We encourage CMS to publish an Interim Final Rule to allow for further comments. Not knowing how our federal health care reform will affect this vulnerable population puts even more stress on the importance of getting this right ---- protecting patients while continuing to allow facilities to operate. We further request that CMS postpone the 2011 implementation date in order to ensure that patients are fully protected.

We, again, thank CMS for the opportunity to respond to this proposed rule and offer our help in continuing to revise same.

The following was sent in separately



We are deeply concerned about small dialysis providers and rural facilities and have good reason to think that closures could come sooner than later due to bundling. The administrative burden that will be encountered as a result of bundling will not be beneficial for patients. The need to hire more staff, train new staff and pay more in salaries because experienced staff are not available in the area will place undue hardships on this group of facilities. Small and rural facilities do not financially operate at the same level as do some MDOs or LDOs. Even some MDOs might have financial problems resulting in closure. Because of bundling, we believe that patients will be negatively affected e.g. having to drive longer distances e.g. over a couple of hours to obtain life-sustaining treatment due to closures. Even at present, some patients travel this distance. Closures could result in some patients not having access to treatment. Particular attention and greater consideration needs to be given to this new payment method.

Further, many of these facilities are in medically underserved areas, often with many of these patients having no insurance and being indigent. Many of these patients already travel hours just to be able to live. No one should have to go through that.

We urge CMS to pay close attention to that which Dr. Sumit Mohan stated (below).

Dr. Sumit Mohan, MD (Columbia University/Harlem Hospital) recently presented at the American Society of Nephrology’s 42nd Annual Meeting and Scientific Exposition in San Diego, CA the following “Our facility-level analysis suggests considerable geographic variation in the impact of bundled payments on dialysis centers across the country.” He further stated, “Dialysis centers in the east and southeast are particularly likely to feel an adverse financial impact.” Having heard this, we, Advocates4QualitySafeCare, are even more concerned that dialysis delivery of care will deteriorate. We further are concerned that patients will not have access to a facility where they will receive their life-sustaining treating. You, CMS, must not let this happen.

Dr. Mohan, also stated, “Our analysis suggested unanticipated geographic variation in facility reimbursement payments." “The percentage of dialysis centers likely to receive lower payments under the new plan varied widely between states. Estimates suggested that in several states, no dialysis centers would be at risk of receiving lower reimbursements. In contrast, in one state (Delaware), 100 percent of centers are likely to see an adverse financial impact.
The plan would have a greater financial impact on dialysis centers in some parts of the country, especially the south and east. On average, 59 percent of dialysis centers would be affected in states east of the Mississppi River, compared to 33 percent in states west of the Mississippi. "The impact appeared to disproportionately affect the South census region, which also has the highest intensity of poverty,"


(1) Revision of the bundled rate to ensure provider-equity

In conclusion, with the above stated by Dr. Mohan, we urge CMS to put themselves in the patient’s shoes and remember - lives are at stake here. Spend a week with an individual who does incenter dialysis and observe that which many patients experience. Please, CMS, walk with caution as one day it could be a loved one of yours at the end of this new payment method.


Roberta Mikles, RN BA
San Diego, CA


Roberta Mikles, RN BA
Patient Safety Advocate
San Diego, CA


1. Blagg CR. The early history of dialysis for chronic renal failure in the United States: a view from Seattle. Am J Kidney Dis. 2007 Mar;49(30:482-96
2. Bleyer AJ, Russell GB, Satko SG. Sudden and cardiac death rates in hemodialysis patients. Kidney Int. 1999 Apr;55(4):1553-9
3. Bleyer AJ, Hartman J, Brannon PC, Reeves-Daniel A, Satko SG, Russell G. Characteristics of sudden death in hemodialysis patients. Kidney Int. 2006 Jun;69(12):2268-73

Sunday, October 11, 2009

NEW - ESRD Prospective Payment System

We have been quite busy reviewing the proposed rule for the new payment system for those individuals who require dialysis treatments. For those of you who are not familiar with dialysis, this is a life-sustaining/life-saving treatment that can become life-threatening within a seconds time. Those who require dialysis need to be, more than, aware that this new rule might either affect them positively or negatively, therefore, it is important that dialyzors (individuals who receive dialysis treatments) pay close attention and understand that which is being proposed by our government. The proposed rule is open for public comment and we encourage all to state their opinions and what they want to see changed or remain the same. For more information on this go to

Sunday, September 13, 2009

Open Letter to Centers for Medicare and Medicaid Services Chief Medical Officer, Dr. Barry Straube

Advocates4QualitySafeCare wrote an 'open-letter' to Dr. Barry Straube, CMS Chief Medical Officer. To date, we have not received a response back.

Open Letter to Dr. Barry M. Straube, M.D.

CMS Chief Medical Officer

Director, Office of Clinical Standards and Quality

Centers for Medicare and Medicaid Services

Open Letter to Barry M. Straube, M.D.,
Centers for Medicare & Medicaid Services

September 1, 2009

Barry M. Straube, M.D.
CMS Chief Medical Officer
Director, Office of Clinical Standards and Quality
Centers for Medicare & Medicaid Services

Dear Dr. Straube:

I felt compelled to write after reading your response letter to Dr. Thomas' letter, regarding the summary and recommendations from the April 2009 conference, State of the Art and Charting the Challenges for the Future. Your statement, “Furthermore, there are many improvements that ESRD providers, patients and suppliers, as well as pharmaceutical and device manufacturers, might be able to achieve independent of statutory, regulatory, or administrative changes at the federal level, and are simply part of expected, “good” healthcare by providers and “responsibility” that patients should take.” made me stop and realize, even more, that this is what I, and other advocates, patients and families, have been trying to bring to the attention of providers for several years --Providers must deliver that care which patients expect - quality safe care, as well as demonstrating more accountability and responsibility for the care that is delivered and admitting when a mistake occurs regardless of the outcome. Patients can only be responsible when they have adequate information, at hand, in order to make informed, educated decisions about their care and treatment. Providers play a major role in educating patients and directing them to where they can obtain information about their disease process. Patients need to be included in all aspects of their care as well as to have whoever they want involved. Patients, and their loved ones, should be able to ask questions and question that which is being done without being negatively viewed by health care providers. It is about advocating for oneself or a loved one, not about being a 'problem' or being 'difficult'.

My candor, often met with resistance, is now supported by your (aforementioned) statement. Such things as not adhering to physician orders, not adhering to facility policies and procedures, not implementing correct practices, not including the patient in their treatment plan and allowing the patient and/or family to actively participate to the degree they desire, not fully educating patients and their families in all areas, including modalities, not encouraging patients and/or their families to bring forth observable concerns related to their delivery of care and not including patients (who else knows better about the care they receive, than the patient and/or family) and/or family members in ’advisory councils’ (or unit-based committees) as some hospitals do in order to improve care, enables a system to continue to provide unsafe care. If the aforementioned areas of care were put into practice, then perhaps these ‘improvements’ as you mentioned would support a system that delivers quality safe care. These areas that I have mentioned are a result of my review of hundreds of survey findings, speaking with patients and families from throughout the United States, as well as communicating with health care professional. I want to make it clear that I believe there are facilities that provide quality safe care and I, also, believe that there are those that do not. It is these facilities that I address.

It must be a team working together, patient/loved ones and providers. Otherwise, we will not see change. We must call upon providers to be open and honest when mistakes occur and to tell patients and their loved ones. This has proved to have positive outcomes for both the providers and those who have experienced (and their loved ones) a negative outcome. If hospitals can adopt this thinking and action, then why can't dialysis providers? As a member of a hospital advisory council, as well as a member of the World Patient Safety Day committee my goals are to strive for safe care to be delivered to all patients in all health care settings.

As you are aware, I have been attempting to bring forth, for many years, during open-door forums and through other communications, concerns related to patient safety. As a patient advocate, being involved with patient advocacy groups (non-supported by the health care industry---- dialysis and non-dialysis patient safety groups), as a family member of a dialysis patient, and retired Registered Nurse, it is my opinion that without an effective oversight and enforcement program, there will be continued practices that place patients in situations of potential or actual harm, including death. Even though there are CPMs in place that certainly concentrate on quality, there are critical aspects of delivery of care that are missing that should be concentrated on to ensure safe delivery of care - This is about ’patient safety’. It is these areas (mentioned in first paragraph) that are not included in the CPMs that need to be along side of the CPMs to truly ensure quality SAFE care. What difference does it make if a patient's anemia is being managed, or their blood is being adequately cleaned, if they end up in the hospital with a preventable infection that takes weeks or months to recover from? What difference does it make if a patient, again, has his/her anemia managed adequately, and has their blood cleaned adequately, if they end up in the hospital with a negative outcome because symptoms were not reported to the Registered Nurse for appropriate assessment and evaluation. The lack of reporting symptoms, to the Registered Nurse, for appropriate assessment has been identified in many surveys.

The Survey

It is well known that many states, for many years, have not been able to comply with CMS’ request for timely surveys in order to ensure compliance with Conditions. Then, the first question is why does CMS continue to use the state if many states are not meeting the timeframe for surveys? Why has this gone on for so many years? It is understood that CMS is responsible to ensure that beneficiaries receive quality safe care. Again, how can this be accomplished if facilities are not surveyed timely? CMS has often blamed the state, and the state has often blamed CMS, thereby, placing the patient in the middle. If this system is not working, then get rid of the state who acts as CMS’ agent. We are not doing justice to the patient when their facility is not timely inspected. Is that placing the patient as the priority? No. Beneficiaries must have some type of assurance that they are receiving quality care and safe care. The CPMs, by themselves, will not accomplish the goal of delivery of quality safe care. More is needed. It is evident that the conducted survey process identifies that which is unobserved by facility staff, e.g. the lack of implementation of effective infection controls, the lack of adherence to facility policies and procedures, and Condition compliance, etc. It is our group’s opinion, that in spite of having QI mandated, we will continue to have the same problems related to patient safety. Many believe that because facility staff do not identify (often, as evidenced in survey findings) that which causes a potential (or actual) negative outcome, that an existing problem within a facility will not be brought to the QI committee timely. It will only be addressed after a negative outcome, e.g. infection, wrong dialysate, etc. We urge CMS to address the fact that there is more to delivery of care than the CPMs when it comes to safe care and this translates into having an effective oversight and enforcement program that takes action when there are negative outcomes that patients experience, including death. Action that will translate into telling those delivering care that this is NOT acceptable delivery of care and it will not be tolerated. In fact, when I reviewed surveys I noted that some facilities that had a QI program in place, were cited for not implementing an effective process. We see providers reaching out to CMS to have their new facilities inspected timely, however, do we see providers telling CMS and/or the state that they want their facilities recertified timely? I don’t think so. Perhaps, the millions of dollars that go to lobbying could support an effective oversight and enforcement program. Perhaps, as hospitals pay JCAHO, dialysis providers should pay for recertification surveys. Something must be done. Afterall, providers want, (as do advocates, as myself), for their patients to receive quality safe care. It is not a ‘we against them’ situation, but one that all must work together. If the oversight and enforcement program (CMS) has no plans of changing, our suggestion would be to revisit the entire process of surveying and look at other avenues that will ensure there is compliance. The existing system is not working for many patients, especially those who are in facilities that have not been inspected timely. And, of course, we are all aware that without adequate sanctions, there will be continued deficiencies as noted in some surveys. I urge CMS and Congress to look at other possibilities to ensure the implementation of an effective oversight program. Again, do we really need the state, especially if some states are not able to comply with CMS’ request? Certainly, this needs to be revisited.

Infection Prevention

One must stop and ask why CMS, Congress, and others, have not taken more of a stance when it comes to infection prevention, knowing that infection continues to be the number two killer of this vulnerable population? Those who worked on the Conditions, did a great job, however, in all due respect, even though the Conditions now have a different mandated direction for infection prevention, without timely surveys being conducted, we can not be assured that facilities are implementing effective infection controls. In fact, in many surveys that I reviewed, prior to the revised Conditions, clearly stated was that some facilities had policies and procedures in line with CDC guidelines, but these practices were not being implemented. And, again, often staff do not identify incorrect practices, but the surveyor does. This is a matter of ‘prevention versus preventable negative outcome’.
We need to do more to prevent infections. Do we publicly report infection rates, type of infections, etc.? Do we mandate all facilities post their infection rates in public view in their facilities? Do we ask CMS to include infection data on the 'dialysis facility compare website'? Does Medicare withhold reimbursement for hospitalizations that are the result of a preventable acquired infection? Something needs to be done to hold providers more accountable.

Again, there is something drastically wrong when we see infection continuing to be the number two cause of death among this population. Is there effective unit-level supervision to ensure correct implementation of practices? Are new staff being adequately trained in infection prevention? Are staff being inserviced periodically? Is there a true understanding of the seriousness of not implementing correct practices? Are patients being educated on how staff will prevent an acquired infection? Are patients being educated on self-prevention of infection? Are patients encouraged to bring forth concerns related to their observations of staff, without fear of retaliation? Are patients included in unit committees focused on patient safety? And, finally, why do the CPMs not address this area of infection prevention?

If there were more effective oversight of this area we would, perhaps, see a decrease in the numbers of acquired infections, a decrease in costs related to hospitalizations, rehabilitation and medications. We could decrease costs if we only would seriously address these preventable errors that result in acquired infections. Again, should dialysis facilities be held to the same accountability standards as hospitals e.g. no reimbursement for certain preventable errors that result in negative outcomes? That is the question to be considered. But, the bottom line is 'the patient'. It is the patient who will have more quality in their life, it is the patient who will not have months of recovery and it is the patient's life we are talking about.

Optimal Dialysis

Our group supports Dr. Peter Laird’s statement, "Optimal Dialysis Deserves a Trial of Life in America. It is a matter of life and death.”

We urge CMS, congress and others to read that which Bill Peckham, Dr. Peter Laird, and others, have written about optimal dialysis ( and remember … this IS about life, quality of life and possibly premature death. Lives are at stake.
Posting of Surveys

When the proposed language was posted in the Federal Register, we recommended that surveys be posted in public view in dialysis facilities, as they are in nursing homes. This was not included in the final rule and we are wondering why? If providers are delivering quality safe care, as they profess, then one would expect the posting of surveys to be supported. Patients, and their loved ones, are not aware, for the most part, that they can obtain a copy of the survey from the state survey agency. Additionally, they are charged in many states by the page, which many can not afford. These are taxpayer dollars that support the surveys, therefore, patients should be able to obtain without cost. Patients have a right to know if their facility is providing quality safe care, or when selecting a facility, patients, and their loved ones, should have the right to visit and read, at the time of the visit, the facility's survey and ask any questions pertaining to such. Perhaps CMS' 'dialysis facility compare' website should include more information about the survey, similar to other health care facilities e.g. nursing homes, hospitals. Would this encourage providers to ensure quality safe care is being delivered. True transparency is needed to give the real picture of delivery of care. That which the 'dialysis facility compare' site provides, does not give the complete picture of care.

Dr. Straube, I would welcome the opportunity to be included in the stakeholder meetings representing the following: those who are not connected to an advocacy group that is supported by the industry or similar, those who have experienced a negative outcome, including death, as the result of a preventable error, those who have experienced retaliation, overt or covert, as a result of speaking out in order to receive safe care, those who have observed incorrect practices and behaviors, and those who are afraid to speak out.

Thank you for taking time to read the above. If you have questions, feel free to contact me.


Roberta Mikles, RN, Director
uncompensated advocates striving for quality safe care for all patients
San Diego, CA

World Patient Safety Day
annually - July 25th
Member - Legislative Action Committee

This is a must-share as many have been stating that which was presented on Bill Moyers, KPBS Public Television Station on August 28, 2009



August 28, 2009
BILL MOYERS: Welcome to the Journal.

The world of medicine has changed radically since I was a kid in East Texas. Back then, Dr. Sam Tenney made house calls for a couple of bucks a visit. Dr. Granbury raced to a patient's side with such speed you could hear his tires screeching around the courthouse square blocks away. And if you needed a prescription, Dr. Wyatt would offer to drop it off at your door on his way to the hospital - a non-profit community hospital, by the way, run by civic-minded citizens who counted every penny.

If any of them were around today, they would surely marvel at our high-tech medicine. But as prudent folks, they would also marvel - in a horrified way, I think - at the cost of it all. How did we get here?

Maggie Mahar wanted to find out. She's one of our best financial journalists - now, after years of research, she has written: MONEY-DRIVEN MEDICINE: THE REAL REASON HEALTH CARE COSTS SO MUCH. During their summer recess, if every member of the House and Senate would read it before returning to Washington, the outcome of the health care debate might be very different.

In this broadcast we will share with you a film based on Maggie Mahar's work. The book and the film couldn't be more timely as our country wrestles with what to do about money-driven medicine.

DR. NORFLEET: All right, I'm Dr. Norfleet. And Joel has been talking to you about the build-up pain you're having right now.

MR. WILLSMALL: Yes ma'am.

DR. NORFLEET: Is it the same kind of pain you've had before Mr. Willsmall?

MR. WILLSMALL: Uh, no. It started about a month ago.

DR. NORFLEET: The pain you are having now?


DR. NORFLEET: And who is your primary doctor?

MR. WILLSMALL: I don't have one right now.

DR. NORFLEET: Okay. You've been admitted to the hospital before though? You've been here before?

MR. WILLSMALL: I've been… I was admitted to the Centennial Hospital.


MR. WILLSMALL: I had chest pains and that's when they found the hepatitis.

DR. NORFLEET: Oh boy. Hepatitis B or C or both?


DR. NORFLEET: Wow! You have a history of ulcers or anything like that?

MR. WILLSMALL: No ma'am.

DR. NORFLEET: And you haven't seen anybody else about this, huh?

MR. WILLSMALL: No ma'am.


MR. WILLSMALL: I went to the downtown clinic cause when this happened I wasn't able to work. I lost my job. I lost my apartment.


MR. WILLSMALL: And so, I'm just trying to get help.

DR. NORFLEET: Yes, Sir. We are going help you, okay?

He's complaining of vomiting blood. It's been going on for a month so it's not really considered an emergency anymore. It's considered a chronic problem, but we get a lot of patients like that, that the emergency department is the only place they know they can go to, to maybe address their problem.

He didn't have the luxury of having a primary care provider, which is a luxury in this country, which is kind of sad. We're like the richest country, you know, and a lot of our people don't have doctors so they use the emergency department in order to see a physician.

NURSE: Say, "Ah." You've got a lot of congestion in the back of your throat. Do you feel like its kind of sitting there?

DENTIST: Well, that second to last tooth is infected and the very back tooth looks broken off.

PATIENT: All right.

MAGGIE MAHAR: Over the last 12 years a number of people visiting America's emergency rooms has soared. Yet here's what's surprising: The number of low-income people going to ERs has not increased. The increase has come almost entirely among middle-class people and many of them have insurance.

NURSE: Whose insurance do you have?

PATIENT: Blue Cross.

NURSE: Do you have your card with you?


MAGGIE MAHAR: So why do they go to the ER? Why aren't they seeing their own doctor? Many people think that they know what's wrong with the health care system in this country. Millions of people are uninsured. And sure, that's part of the problem. But that's not the whole problem. The whole problem is bigger than that.

DR. JOHN NIXON: I am on top here. Any problem up there? Any problem in the back?

DR NIXON: There're just not enough resources out there for, not only your uninsured patients, but also your insured patients. Insured patients have a problem also because their doctors, when they call their office and says, "I need to see…" … "We can't see you for three weeks." "Well, what am I going to do for three weeks?"

DOCTOR: Open your mouth.

Health care costs keep going up, up and up and up. But the access seems to be going down down down down.

All right. Do you need anything for pain right now? You do? Okay, we'll get you something all right? We've got to run some tests and we'll be back.

PATIENT: Okay, thank you.

I'm just glad, you know, that there's a place to come to, you know. I mean, dying is not no big deal to me, but you know, people have to go through a lot before they get there.

MAGGIE MAHAR: When I was a financial journalist at Barrens, I wrote many stories about health care. And what I learned was that much of what we think we know about health care isn't true. And much of what is true is counterintuitive. So eventually I decided to write a book about health care. And when I did I knew I wanted to talk to a lot of doctors. So I began putting out phone calls. I didn't know most of the doctors I was calling. I was hoping that maybe 20 percent of them would return my call. To my utter surprise 5 out of 6 of them called me back. And they talked. They talked for 30 minutes. They talked for longer than that. They said, "Please, we want someone to know. Please tell people." To a man and to a woman what they were most passion about was the declining quality of care in this country. Not about how much they were paid or how much they weren't paid. They were concerned about the quality of care, about what was happening to their profession and how little power they had to do anything about it.

DR. DONALD BERWICK: It is, I guess, politically correct, widely believed, that to say that American health care is the best in the world. It's not. There's a much more complicated story there. For some kinds of care my colleague Brent James calls it rescue care. Yes, we're the best in the world. If you need very complex cardiac surgery or very advanced chemotherapy for your cancer or some audacious intervention with organ transplantation, you're pretty lucky to be in America.

You'll get it faster and you'll probably get it better than in at least most other countries. Rescue care we're great. But most health care isn't that. Most health care is getting people with diabetes through their illness over years or controlling the pain of someone with arthritis or just answering a question for someone who is worried or preventing them from getting into trouble in the first place. And on those scores: Chronic disease care, community-based care, primary care, preventive care. No no, we're no where near the best. And it's reflected in our outcomes.

We're something like the… We're not the best health care system in the world in infant mortality rates. We're like number 23. There is an index that is used in rating health care systems, which is the rate of mortality that could have been prevented by health care. There are at least a dozen countries with lower rates of preventable mortalities than the United States and not one of those countries spends 60 percent of what we do on health care.

MAGGIE MAHAR: Dr. Donald Berwick is a pediatrician and a revolutionary, really. He wants to overthrow a health care system he sees shot through with waste, inefficiency, self- interest and disrespect for patients. Berwick believes that the people working in our health care system are by and large dedicated and caring people, but they're stuck in a stupid system. And he calls that a national tragedy.

DR. DONALD BERWICK: If you look at the way we pay for care in the country and say, "Well, what is the underlying theme here?" We pay for doing things. A piece of surgery, performing a test, doing a procedure. Even a visit is a thing. So specialties or medical practices that do a lot of things, a lot of tests, a lot of surgeries, a lot of procedures; They'll tend to be the higher income earning specialties.

Medical students leave medical school today with enormous debts. Primary care specialties are the lowest paying. If you have a choice between taking 15 years to pay off your debt or seven, you might decide on seven, and that means you can't be a primary care doctor.

DR. DAN LARSON: I wonder what your blood pressure is first thing in the morning.

MAGGIE MAHAR: What's interesting about the fee schedule is that it's all about what it costs the doctor to produce the service in terms of time and education. Never does anyone ask, "How much benefit is there for the patient?" This might be a service that, on average, lengthens the patient's life by 5 months, as opposed to having your diabetes controlled for 30 years, which means that you live a lot longer and you never have an amputation. And yet we would pay much more for that technically very skilled procedure that gave you another couple of months, because we look at it entirely in terms of the work on the part of the doctor rather than the benefit to the patient.

DR. DAN LARSON: He has a very soft, like maybe one or maybe two out of six systolic near the apex. Take a listen; let me see if we've ever evaluated that...

MAGGIE MAHAR: So we don't value primary care doctors, generalists, family doctors highly at all. The compensation is relatively low and that's why we have fewer and fewer of them.

DR. DAN LARSON: Albany Med's Internal Medicine residency this year, I believe, none of them are going to primary care. They're all going to sub specialize in cardiology, gastroenterology, endocrinology, etc. I believe it's none are going into primary care.

STUDENT: I think I can hear it. It's very soft.

DR: DAN LARSON: Yeah. It's very soft. It's a little mid-systolic thing. It's probably nothing.

KRYSTAL IRIZARRY: Finances does play into the decision. People say that going into primary care can be a burden compensation-wise and the worry about their future. What does the future hold in terms of health care? It's really hard to make a decision. I wish there was an easy way.

DR. DAN LARSON: If the dollars to dollars ratio were even vaguely similar to specialty and primary care, I'd choose it again every time. I like the variety. I like doing different things. I wouldn't like doing the same thing all day long. And I'm willing to take an income hit to be primary care, but it's affected the quality of primary… the ability to deliver quality primary care in this country, because not enough people are going into it and, makes it harder to put together an integrated system. And everyone pretty much acknowledges that if someone doesn't have a primary care doctor they go to multiple specialists, there is more duplication of services at higher total health care cost.

KRYSTAL IRIZARRY: Do you have any pain when I press in your stomach?

LARRY CHURCHILL: There are very few relationships in which we're asked to take off our clothes and be examined by people with the idea that it's going to be safe to do that and tell them about intimate parts of our history that we probably don't tell anyone else about. That makes it special. That's making oneself vulnerable and sometimes a fairly profound way. Or going under anesthesia for an operation. If someone says, "I'm going to put you to sleep and we're going to cut you open and do certain things to you and it is all going to be fine and good for you," that's a pretty big leap of faith.

MAGGIE MAHAR: Larry Churchill is a bio-ethicist and one of the heroes of his profession. A discipline that struggles with the hardest moral questions regarding medicine. He doesn't just ask his students to wrestle with end of life care or stem cell research. He takes a clear-eyed look at the most difficult ethical questions regarding how you deliver care in a profit driven system.

LARRY CHURCHILL: We're now treating medicine as if it were an industrial product. Through put. How many units of care can you deliver? The idea that you are going to see a patient on average for between 12 and 15 minutes, no matter what their condition or how many kinds of problems they have or how complicated their diagnoses or how much reassurance they might need is an idea that you can treat medicine like a production line product and you can turn out patients in the same way like we produce widgets. That's a commercialization and an industrialization of the relationship. So this is a system which is fundamentally broken in terms of the kind of conflicts it raises in the minds of physicians and, also, in the minds of the patients.

DR. ANDREY ESPINOZA: Hi. Dr. Espinoza, nice to meet you. How are you? Karen, daughter? Wonderful, pleasure. Okay. Dr. Lynn was kind enough to send you in my direction is that correct?

PATIENT: Yes it is.

DR. ANDREY ESPINOZA: Do you have an understanding of why you're here to see me?

You can't just fix things in medicine. Medicine is a process. It's a duration of treatments that occurs over the course of somebody's lifetime. Yeah, there are things that we do that are very systematic and very matter of fact, so to speak, where you fix and "boom" they're are on their way, but it's just not a good way to develop a relationship. You need a rapport, you need trust, you need that patient, you know, having the ability to say, you know, "Yeah, Dr. Espinoza, that's my doctor."

DR. ESPINOZA: How've you been?


DR. ESPINOZA: The thing I miss most is being able to sit in a room and talk to a patient for an hour. But, you know, we're so compressed with our time and the amount of patients we have to see, you know, 15 minutes is a long time these days. That's a long time. Basically, you know, you get on the assembly line.

DR. ANDREY ESPINOZA: Have we met before?

PATIENT: I think so.

DR. ANDREY ESPINOZA: Just get hooked up and the chain keeps moving.


It doesn't allow you to have an intimate relationship with somebody without someone else trying to always pry, you know, that relationship apart.

PATIENT: Because you had told me to go to White House, I think, and I couldn't get there because they told me my insurance wouldn't cover it.

DR. ESPINOZA: Ah, okay.

The insurance companies, you know, are clearly in the room with us. You know, employers are in the room with us. You know, you get into these issues of out of network, in network; we're only going to pay 20 percent of your hospital visit versus 50 percent if you go to this hospital. These are all brokered deals and negotiated contracts and things like that, that in larger insurance companies have with specific hospitals, which specific testing centers. You know, so you're dealing with a lot of things that, you know, this is not stuff that's taught at medical school, this is not stuff that, you know, your partners are familiar with other than being exposed to it. You know, and we've kind of turned the blind eye or done the ostrich thing with, you know, burying our heads in the sand saying, "You know what, we're just doctors we want to just deal with what we do." But all of those other entities now live in our bed, in our bedroom with us. You know, you can't just pay attention to your wife and go to sleep at night. You're sleeping with six or seven other people that are trying to break your marriage up. That's a big problem. That's a big problem.

DR. DONALD BERWICK: When you go see the doctor and the doctor listens to you and then sends you a bill, there's profit in that bill. That's the doctor's income after he or she has paid the receptionist and the lights and heat and the rent and the equipment. He keeps the rest. That's profit. Just as long as it's a human enterprise, yeah, at some level, someone's got to make some money or why would… they won't do it. So we're going to have profit even if you call it a non-profit system. What are the incentives? Right now the incentives in America are if you want profit, do more. You make money by doing stuff and there's no limit. So we do and do and do and we get this oversupply, this excess activity because that's how people, hospitals, doctors make money.

DR. ANDREY ESPINOZA: Carl, you gave him already a little cocktail from the bar. All righty. If you need anything more, just let us know. Right now you are going to get a little bit of a local anesthetic down here in your leg. Let's start with the right heart.

You know, if you're a hammer, everything looks like a nail. You know, I'm an interventional cardiologist and that's what I do for a living is I fix blockages.

Six front checks B35, please.

Does the hospital like you doing lots of procedures? Sure, you know, these procedures are reimbursed, fairly substantially. You know, even within your own group there is a component of productivity. You know, you wish things would just be about taking care of patients and doing the right things but, you know, are there external pressures? Absolutely. Absolutely.

PATIENT: Do you have to push the cath in or does it find its way just naturally?

DOCTOR: Um, all roads lead to Rome.

PATIENT: Terrific.

DR. ANDREY ESPINOZA: But, at the end of the day, if you just remember the fundamental principle that you have to have done something for that patient in order to make them feel better, live longer, you know, engage in a lifestyle that they weren't able to engage in before, and if you stick to those principles, it allows you not to, kind of, drift from what you know is right and fall in to this arena where, you know, you're just slamming a stint in every blockage that you see. Because if you did that, then clearly it becomes… I would hate to use the term immoral, but it becomes an issue where you are doing things just to do them, not because it's the right thing to do.

DR. LARRY CHURCHILL: There's an awful lot of technology involved even in ordinary outpatient kind of encounters now. We have been so good at finding new and innovative ways to treat illness, and we love this. The idea that technologies can be turned into cures is really a fundamental thing in our society.

DR. JIM WEINSTEIN: I'd like to suggest that if we looked at the population of people with a problem: Back pain. And said how many MRI's do you think we need to do as a nation? We could probably cut the number in half and not have hurt anybody. Yet we keep opening more and more MRI machines and do more and more pictures. They're beautiful, they're incredible- incredible technology. But then that causes somebody to have to make a decision about a back surgery that maybe they didn't need.

DR. DONALD BERWICK: I think the main driver, the difference between our costs and other countries costs that have health care systems as good or better than ours, is supply-driven care. It's this work that Elliot Fisher and Jack Wennberg have explored at Dartmouth. It's that we overbuild and, therefore, we use, and there's no limits, there's no cap, there's no control. And so we just spin the wheel.

MAGGIE MAHAR: What's truly staggering is how much waste there is in our health care system. Up to one out of every three of the more than two trillion dollars that we spend is wasted on ineffective, often unproven procedures, overpriced drugs and devices that are no better than the drugs and devices that they're replacing. Unnecessary hospitalizations, unnecessary tests. Now this may seem like an overstatement. I mean, how can it be that 1/3 of the money is wasted? We actually have close to three decades of research done by doctors at Dartmouth University proving how much waste there is in the system. What the Dartmouth research ended up doing was looking at health care all across the country and what they discovered is that in some high treatment states, like New Jersey, Medicare was spending 20 percent more per patient than the average. And in other low treatment states, like Iowa, Medicare was spending 25 percent less than average. They tended to focus in on what happened to patients during their final two years of life.

So in that way you're comparing apples to apples, pretty sick patients, and they began looking at sick patients who had the same disease etcetera- Finding these enormous differences in what Medicare spent. Some people said, "Well maybe patients in New Jersey are simply more demanding than the stoic citizens of Iowa." But, in fact, very few people demand a chance to spend more days in the hospital during their final two years of life. Very few people cry out for a chance to die in an ICU or to have that fourth procedure or to be poked and prodded by eleven or twelve specialists during your final six months of life. In the states where Medicare spends more, these are the things that happen to people.

They're getting more aggressive, intensive, and expensive care. And here's the stunner: The outcomes are no better. Often they are worse on average in states like New Jersey or New York or California than they are in low treating states like Iowa or North Dakota.

RASHI FEIN: You have a situation where the doctor provides a service, is paid for providing this service, and controls, to a significant extent, the demand for that service. It's not I saying, "I'm going to get a high definition television." This is a doctor saying, "You ought to have a high definition television." More correctly, "You ought to have an MRI or a cat scan. It's called for in this situation." Who in the world? I don't have the ability to say "Is this MRI necessary?"

MAGGIE MAHAR: The fact of the matter is that insurance companies tried saying no in the 90s, in that era of manage care, when the great many HMOs would say, "No, we're not going to pay for that." The problem is that HMOs made their decisions on what they are going to pay for based, too often, simply on cost. If something was too pricy, they would say no. But they weren't looking at the quality of the procedure. They weren't asking, "Well, would it really benefit the patient?" They were simply saying, "Well, where does it fit on our schedule of costs?" So, sometimes, they denied ineffective, unnecessary, expensive care and sometimes they denied very good, effective, expensive care.

There was a backlash, needless to say, in the media, on the part of patients, on the part of doctors, so by the late 90s HMOs began to say, "Okay, okay, we won't try to manage care. By and large, we will pay for whatever Medicare pays for. Medicare tends to pay for whatever the FDA approves. We'll just pass the cost along to you in the form of higher premiums." And that's why, since 1998-99, premiums have just skyrocketed.

REPORTER: In fact the average total premium for a family of four last year topped ten grand.

REPORTER 2: Doctors here in Boston say they're seeing an increasing number of patients who cannot afford the most basic preventative health measures, like a blood test.

REPORTER 3: 72 million Americans had trouble paying for medical care last year.

REPORTER 4: Hospital bills are now a leading cause of personal bankruptcy.

DR. JAMES WEINSTEIN: I think it's interesting that a country that has a 12-trillion dollar budget spends a sixth of it on health care. And our work would suggest that we're not spending it wisely.

The Dartmouth slogan is "Vox clamantis in deserto," which is that voice crying out in the wilderness, and I thought it was a good analogy for me because I came here because I heard another voice, Jack Lindberg, talking about the disparities in the delivery of our health care system and the irrationality of its utilization. And, now, having been here for 12 or so years, I realize it's an uphill battle. You can't fight city hall, but we're going to try.

MAGGIE MAHAR: In the early 1990s Dr. Jim Weinstein made a courageous decision. He decided to walk away from tenure and an endowed chair in the University of Iowa to go to Dartmouth, where he would participate in devising ways to help patients become involved in making decisions about their own care. As a surgeon, Weinstein had long felt that patients just weren't getting a fair shake, as he put it. They weren't getting the information they needed about the risks of treatments. Too often, informed consent was informed persuasion. Ultimately, illness in his own family would drive that lesson home.

DR. JAMES WEINSTEIN: My daughter's name is Brieanna. She had beautiful blue eyes, curly brown hair; your first child, the light of your life. 13 months later I get a call from our pediatrician saying, "Could you come over to the hospital?" And I walk into the pediatrics hospital and I ask my wife what's wrong and she says, "They won't tell me. They won't tell me." The doctor walks in with about, it seems like, 10 other people other people. Very intrusive. And said, "I think your daughter has leukemia and we need to treat her, immediately."

The protocol for a treatment was very intense chemotherapy. She would lose her hair quickly. She would be sick. She would develop sores in her mouth. She wouldn't be able to eat because of sores from the chemotherapy in her esophagus. She would have all kinds of rashes. Her blood counts would be almost zero so her risk of infection would be very high. We couldn't take her any place. She had to be protected. And it sounds, "Well, that's not so bad, we can do that for a week." But the protocol was for 3 years. She did pretty well for about, I think, 2 years and then the leukemia came back. And they said, "We need to re-induce her with the bad medicines again and we have to consider brain and spinal radiation.

So spinal taps every day for three weeks." I said, "I don't get it. I mean, you just told us if we followed this protocol, these are the results. We did everything you said and it is still not working. And now you want us to do something worse." "Well, you have no choice and if you don't do that we will sue you." I said, "What?" "If you don't do what we tell you, we'll sue you."

MAGGIE MAHAR: Why would doctors threaten to sue a parent whose child is dying? In all probability, the physicians were concerned that if they didn't followed the protocol and go on with the further treatment that they had planned to give her, they might be sued for malpractice. Even though the doctors couldn't explain the protocol or give them any assurance that they knew that the next treatments would do Brieanna any good.

In a way, I think it's a response to the uncertainty that they say, "We are the doctors. We know what we're doing and this is the way we do it and this is what we do next." And if anyone, whether it is a resident, a patient or a relative, says, "Well, why?" They say, "Because it's the way we do it. Period."

DR. JAMES WEINSTEIN: You know, doctors are trained, I hope, in every case to think about what's best for the person that they are taking care of. They're trained to give medications, to do operations, to measure different tests with blood sugars or blood pressures. They're not really trained well in this decision process of giving information to patients to empower them to make decisions. That is a big short fall in the American health care system.

DR. DONALD BERWICK: We have really good data that show when you take patients and you really inform them about their choices, patients make more frugal choices. They pick more efficient choices than the health care system does. Wonderful work of a researcher named Annette O'Connor studied patient shared decision-making with respect to surgery. What she found across a range of studies was when patients actually got to participate in the decision, surgery rates fell by almost 25 percent. And satisfaction in outcomes improved. So an activated patient really engaged. I'm not talking about payment here. I'm not talking about shifting burden of cost. Just engaged with knowledge and shared decision- making. Better outcomes, lower cost, higher satisfaction. You know, what more could you want?

COMMERCIAL: Intensive care requires a finely orchestrated team led by physicians and nurses passionate about patient care.

COMMERCIAL 2: Some of the world's finest…

MAGGIE MAHAR: It's interesting how hospitals advertise. Who would make a decision about where to have their baby or where to be treated for cancer based on an ad they saw on TV?

COMMERCIAL 3: Number one for heart surgery in New York State.

COMMERCIAL 4: A magnet hospital for nursing excellence.

MAGGIE MAHAR: Hospitals are not advertising to the patient. Hospitals are advertising to doctors. Hospitals don't have patients, doctors have patients. And hospitals want doctors to bring their well-healed, well-insured patients to that hospital.

COMMERCIAL 5: Our award winning full service cardiology department has been nationally recognized as the best in the region. And in the…

MAGGIE MAHAR: Hospitals have engaged in, what many call, a "medical arms race".

COMMERCIAL 6: Using advanced micro technology physicians determine…

MAGGIE MAHAR: Typically, 4 or 5 hospitals within a 5 mile, 10 mile, 15 mile radius will all buy the same technology because they're competing with each other.

COMMERCIAL 7: When you need us, rest assured, we will deliver an exceptional performance.

MAGGIE MAHAR: One time Dr. Donald Berwick called a hospital in Texas and said, "We've heard you have a very good procedure for treating a particular disease. We'd like to learn more about your protocol so other hospitals can use it." And the hospital said, "We can't tell you that. It's a competitive advantage in our market that we're better at treating this disease and it is very lucrative. So this is proprietary information."

DR. DONALD BERWICK: We believe in markets, right? Isn't that the American way? Well, markets mean competition. Isn't that the American way? Competition makes things come out right. Well, what does that mean in health care? More hospitals so they compete with each other. More doctors compete with each other. More pharmaceutical companies. We set up war. Wait a minute, let's talk about the patient. The patient doesn't need a war.

MAGGIE MAHAR: The patient isn't the center of a collaboration. The patient is the victim of a competition. There's a saying in Swahili, "When…" I can't remember this one… "When the elephants fight the grass is trampled." The patient is essentially the grass.

SONG: If you've got the money, honey, I've got the time. We'll go honky tonkin'. We're gonna have a time. We'll hit all the night spots, dance, drink beer and wine. If you got the money, honey, I've got the time.

DR. CLIFTON MEADOR: Somebody says, "Nobody in Nashville makes anything. We just do stuff and people send us money." I've been told they never had a recession in the history of the place. This is music row. Every one of these houses is now a recording studio. There's Love Monkey Music, Flashville, Sharp Objects Music, Seasac, whatever that is. This is the heart of "music city" USA.

Here's what a nurse told me. "Tell patients to remove the foil from a suppository before insertion."

MAGGIE MAHAR: Clifton Meador has had many careers. He's been an author, a family doctor, an epidemiologist, a health care administrator and the youngest ever Dean of the University of Alabama Medical School. Over the years, he's watched the business of health care turn into a driving force in the US economy. Much of it headquartered in Nashville.

DR. CLIFTON MEADOR: This is Marilyn Way. Marilyn Way is a center road of Marilyn Farms. Marilyn Farms is a huge complex. The predominant business in here is health care corporations of one sort or another. This goes on and on for over a mile here and this is not called for-profit hospital row, or anything like that, but this, this is the equivalent of the music row that we went down for the recording industry.

SONG: If you've got the money, honey, I've got the time. We'll go honky tonkin'. We're gonna have a time. But if you run short of money, I'll run short of time. 'Cause you with no more money, honey, I've no more time.

DR. CLIFTON MEADOR: This is titled "The Nashville Health Care Industry, The Family Tree 2006." Every little square here is a health care business industry or spin-off. We have 3 mother corporations here: HCA, which is the Hospital Corporation of America, spun off all of these. Hospital Affiliates, which is a spin-off of HCA, spun off all of these. And Health Trust, which is a spin of Hospital Affiliates and HCA, spun off all of these. So this is a massive, industrial health complex that's headquartered here in Nashville.

MAGGIE MAHAR: After World War II, while other countries let their government begin to intervene in health care to make sure everyone got care, to regulate it to make sure it was good care, in this country doctors very, very strongly opposed any government involvement or anyone being involved in telling a doctor what to do. After Medicare was passed in 1965, elderly patients were getting far more care than they had been before then.

Then that's when our industrial medical complex, I would say, took off. By the early 70s, there were so much money involved that suddenly people began to say, "You know what? Medicine is too important to be managed by doctors. We all know doctors are bad managers. What we need are businessmen managing health care." And that's when health care went from being physician centered and controlled, to a large degree, by doctors to being controlled by the corporation and the CEOs of those corporations.

And, over time, more and more the CEO of the Hospital would not even be somebody with a MD. He would be somebody with a MBA. And CEOs bent on growth, bent on higher quarterly earnings, quarter after quarter, and year after year, are always pushing for more sales, more revenues, more and more and more. It produces more. But more may not be better for our health.

DR. DONALD BERWICK: I've heard it said that the official bird of health care is a crane. Look around at any hospital in your community there's a crane on top adding rooms. You know, we just, we overbuilt it. And then, having overbuilt it, we use it and then we think using it is necessary. It's a spiral.

RASHI FEIN: The worst thing that could happen to a director of a hospital is that everybody, all of the sudden, would be healthy. I'm not saying that he's overjoyed when there's an epidemic. Clearly, he isn't. I'm not saying that he's overjoyed when people are sick. Clearly, they're decent folks. But they're running something where what they are selling is hospital beds.

MAGGIE MAHAR: If you can believe it, Rashi Fein has survived 5 decades of the battle for health care reform. In 1953 he served on President Truman's commission on the health needs of America at a time when Truman was pushing for universal coverage. Then he worked with JFK when he fought unsuccessfully for Medicare, a battle that LBJ would later win. As a professor of medical economics at Harvard, Fein has never given up. He firmly believes that medicine should not be all about money. As he puts it, "We live in a society not just in an economy."

RASHI FEIN: Well, we spend more than any other country and we spend a higher percentage of our gross domestic product and our gross domestic product is larger than most other countries'. So we are spending per capita one heck of a lot more than anybody else, which ought to be disturbing, if only because there are lots of other things we could be doing with money. We could have more money for education or more money for infrastructure or more money for bridges and transportation or we could put money into high- speed trains or we could have tax cuts.

On the other hand somebody could say, "Well, we have chosen to spend money on health care and that's also a good thing." True. But interestingly, disturbingly, frighteningly, pick your own word, we spend more money and we are not healthier. We don't live longer. We don't seem to be getting as much value for money.

LARRY CHURCHILL: It shouldn't be any surprise that there is a huge disconnect between the amount of dollars that actually poured into health care and the health indicators of a population because this system was not designed to serve this end. That's a fundamental realization that we need to come to. And until we do I think, you know, we'll still be trying to tinker with the market in some kind of funny way. Just a little tweak or adjustment to make it work better, but it was never designed, actually, to meet health care needs.

DR. JAMES WEINSTEIN: We got through and had a few weeks over the years of no treatment and everyday without a smile. Ever. She was a great big sister. They had a lot of fun together as sisters. I was in Germany giving a lecture and I could tell in my wife's voice something was wrong when I called home. Gone one day. And she wouldn't tell me that she'd had another relapse. I got home from Germany, and she said, you know, "Brieanna relapsed again." So I picked my daughter up and I hugged her.

You know, said, "This isn't possible. We've done everything." So back to the doctor. Another protocol. Radiation she has to be put to sleep for, she has to be taped down onto a table. Imagine the effects of radiation on your child's brain, on the spinal chord when it's developing. Will there be brain damage, doctor? "Oh, your daughter's so smart, there'll be no problem." Will she get a secondary tumor from the radiation? "Oh, it's possible, but it's twenty years away." "Oh, okay. I guess I'm supposed to just accept that." We take her for radiation.

She'd have to go for five days in a row. They'd put her to sleep. She'd come home and she, we couldn't comfort her. We had to put padding all around the room so she wouldn't hurt herself. It upset her so much and bothered her brain so much. Am I helping her? Am I hurting her? Is this barbaric? Is this treatment? Eventually, she had her final relapse when she was twelve. Her sister, Shelsey, is probably about eight at this time. And I said, "Shelsey, I think your sister's going to go to heaven soon."

And she grabbed my hand, and she said, "Daddy, that's okay." She said, "I always thought heaven is where life is and that life is just a dream." I said, "Shelsey, I hope you're right. I hope this is just a dream and that we're going to go some place where life really is." And I've always… that's such a profound statement, for anybody. It made such incredible sense to me. When Shelsey and I went for a walk, her sister died.

DR. KEITH JUNIOR: Good morning, Ms. Elma. How you doing?

ELMA: Hurting, right now.

DR. KEITH JUNIOR: You're hurting?

ELMA: I hurt real bad. My pain is from here all the way up.

DR. KEITH JUNIOR: I'm sorry. I'm sorry. I'm sorry. It hurts that bad?

ELMA: Yes.

DR. KEITH JUNIOR: When did this first start?

ELMA: Yesterday.

DR. KEITH JUNIOR: What time yesterday? That hurts just touching you? That hurts.

ELMA: Up here when you touch me.

DR. KEITH JUNIOR: This doesn't hurt?

ELMA: No. It's just uncomfortable, but it doesn't hurt.

DR. KEITH JUNIOR: Medicine is everything I thought it would be and a whole bunch of things I didn't put into the equation. But I just love doing what I do so much that it just doesn't bother me to do those extra things. I'm willing to go the extra mile, because, hey, this is somebody's mother, this is somebody's father, this is somebody's brother. And if I don't do right by them, just understand, people die in my profession. Unlike other professions where, oh, I get a recall, I'll tell you what, I'll give you a free sandwich… No. I can't get you a free momma. You can't have mine. Mine is good. And you just have to keep the one you've got and I'm going to help you do things to keep her around.

Does it hurt to lift your arm?


DR. KEITH JUNIOR: You don't have any problem combing your hair?


DR. KEITH JUNIOR: Has anyone ever told you that you have high blood pressure?

PATIENT: It just happened today?

DR. KEITH JUNIOR: No, no, no. I don't believe that.

PATIENT: I was upset, because I got here. I was supposed to see Dr. Knox or somebody, so she was not here.

DR. KEITH JUNIOR: Well, she's not here anymore.

PATIENT: Well I don't know. You can take it again because I never had high blood pressure.

DR. KEITH JUNIOR: What I try to do is to make sure that I inform my patients and get them to understand what's going on with them. Inform them of what's going on.

Yeah. She may not have got it right. It's even higher. You should have taken the one she gave you.

You know, let the patient know. You've got a stake in it. It's not something magical I'm going to do, you know, wave my wand and you're going to be better. I don't. I mean, you've got high blood pressure; you will have high blood pressure when you leave here. But I'm going to give you a way in which you can manage the problem. And, so, manage the problem. Just don't stand there. Do something.

Anything change about your family history?


DR. KEITH JUNIOR: No chest pain or shortness of breath?


DR. KEITH JUNIOR: Prevention is the key and we in this trench need to make sure we prevent certain things, rather than wait for certain things to happen.

PATIENT: No, I get headaches. I've been having them for years.

DR. KEITH JUNIOR: You'll always have a bill, but the thing is, you can't always have good health. That's a window, something you work on, and if you've got it, maybe you can keep it. And even that's not a promise. But, the thing is, if you ignore it and neglect it, we can expect to have more recs of people who want to end up in the emergency room and when they go to the emergency room, they find that they have metastatic cancer. That's just not the way it's supposed to work. You know, access to care, and someone who does care about what's going on, not the dollar that comes into your pocket, but actually cares about that person, what they represent, is what we need more of.

MAGGIE MAHAR: A physician takes an oath to put his patient's interests ahead of his own. A corporation is legally bound to put its shareholders' interests first. And this is part of the inherent conflict between health care as a business, part of our economy, and health care as a public good and part of our society. Health care has become a growth industry. That means higher health care bills. That means more and more middle class people cannot afford health care in this country.

LARRY CHURCHILL: For Americans right now I think the primary question is, "How vulnerable am I in terms of the current system? Am I just a pink slip away from being uninsured and potentially uninsurable?" And I think there's a very profound question about whether we are creating a health care system that is sustainable over time. Some people have suggested, and I agree with them, that, actually, the end product of all of this mess and confusion in technological innovation, is going to be a system that cannot be sustained, because it will be so expensive that only the extremely well to do, the elite, will have access to it.

DR. ANDREY ESPINOZA: When you have a system that's built around generation of revenue, when that revenue is going somewhere, and that money is not being put back into the system to help people, you've really kind of lost, you know, we've lost our way.

DR. DONALD BERWICK: I think that health care improvement at the systemic level has some of the properties of major social movements in this country: civil rights, environment. So many oxes to be gored, and a lot of people with oxen that won't get gored but think they will. And this, you know, the coalition of the people who would be better off and the people who are needlessly afraid of change, that is, they don't need to be afraid of change but they are, that's an immense coalition. That's eighty percent of America.

DR. JAMES WEINSTEIN: In my life my daughter caused me to change my life. And I said, "I don't want other people to have to do what she had to do." We have the compassion. We have some knowledge. We have technology, but we let so many things get in the way of the real ideals, the hippocratic principles, that we get lost in that system that Brieanna shouldn't have had to face and so many millions of other people shouldn't have to face.

DR. DONALD BERWICK: I think health care is more about love than about most other things. If there isn't at the core of this two human beings who have agreed to be in a relationship where one is trying to help relieve the suffering of another, which is love, you can't get to the right answer here. It begins so much for me in that relationship that everything that's built around that had better make damn sure that it's supporting them and not hurting it. And a lot of the structures that I am talking about-fragmented structures, transaction-oriented structures, competitive structures, forget that- forget that this is about two people meeting and that's all it's about.

BILL MOYERS: MONEY-DRIVEN MEDICINE, a film produced by Alex Gibney, Peter Bull and Chris Matonti; directed by Andy Fredericks; and based on Maggie Mahar's book of the same name.

Log on to and click on BILL MOYERS JOURNAL - Maggie Mahar will be there to answer your questions online. We'll link you to the Money-Driven Medicine website where there's more info about the book and the film. We'll also link you to some analysis of what advocates of reform are up against in taking on the health insurance industry, the drug lobby, and the Wall Street equity firms.

Take a look at this recent cover of BUSINESS WEEK. Reporters Chad Terhune and Keith Epstein write that the CEO's of the giant insurance companies should be smiling - their lobbyists have already won. Quote: "no matter what specifics emerge in the voluminous bill Congress may send to President Obama this fall, the insurance industry will emerge more profitable."

And remember that television ad Barack Obama made as a candidate for president?

BARACK OBAMA: The pharmaceutical industry wrote into the prescription drug plan that Medicare could not negotiate with drug companies. And you know what, the chairman of the committee who pushed the law through went to work for the pharmaceutical industry making $2 million a year. Imagine that. That's an example of the same old game-playing in Washington. I don't want to learn how to play the game better. I want to put an end to the game-playing.

BILL MOYERS: Now look at this recent story in the LOS ANGELES TIMES. Lo and behold, since the election, the pharmaceutical industry's $2 million dollars a year superstar lobbyist Billy Tauzin has morphed into President Obama's pal. Tauzin says the President has promised not to pressure the drug companies to negotiate with the government for lower drug prices and has agreed not to allow cheaper drugs to be imported from Canada or Europe - contrary to the position taken by candidate Obama…

Each of these stories illuminates the scarlet thread that runs through Maggie Mahar's book - the story of how today's market-driven medical system gives Wall Street investors life and death control over our health care, turning medicine into a profit machine instead of a social service to meet human need. That's the conflict at the heart of next month's showdown in Washington.

I'm Bill Moyers. See you next time.