Letters to the Editor is a periodic feature. We and will publish a selection. We edit for length and clarity and require full names.
U.S. Health Care Is Harmful to One鈥檚 Health
Thank you for publishing this research (鈥Hundreds of Hospitals Sue Patients or Threaten Their Credit, a KHN Investigation Finds. Does Yours?鈥 Dec. 21). I am a psychotherapist and have written about this problem in my blog. The mercenary American health care system is hypocritical in the stressful financial demands and threats it imposes on so many patients. Stress due to health care-related bankruptcy, or the threat of bankruptcy, is harmful to one’s health. A health care system that is supposed to treat illness and restore health can, in fact, cause serious illness and/or exacerbate existing medical problems. The higher levels of stress and the threat of bankruptcy that all too frequently follow needed medical care can be harmful to individuals with cardiovascular issues such as high blood pressure and heart arrhythmia, and can trigger panic attacks in those who suffer from anxiety disorders. There may be digestive issues associated with higher levels of stress, and the patient’s sleep may be adversely affected. The individual may have to cut back on essentials such as food and medications because of unpaid medical bills, aggressive calls from collection agencies, and the threat of bankruptcy.
All of this in the name of “health care” delivered by professions and organizations that proclaim the importance of beneficence, justice, and non-malfeasance within their respective codes of ethics. Curative stress? Therapeutic bankruptcy? The hypocrisy is palpable.
American history is replete with examples of discrimination against certain groups, including racial discrimination, the disenfranchisement of women, child labor, and others. Eventually, political measures were enacted to correct these injustices. It’s only a matter of time until the American health care system, including the pharmaceutical industry, is forced to reform itself for the sake of the men, women, and children in need of essential health care. It’s not a question of if, but when.
鈥 Fred Medinger, Parkton, Maryland
鈥 Jan Oldenburg, Richmond, Virginia
Thanks for the article about hospitals suing patients. I just switched health plans in New York state. Reasons: My previous insurer raised my premium over 90% last year, paid very little of my claims (leaving Medicare to pay most of the claims), and sent me to collections. This, even though I worked two full-time jobs for most of my 46 years of teaching. How do insurance companies and hospitals get away with this unethical and outrageous behavior?
鈥 George Deshaies, Buffalo, New York
鈥 Molly Work, Rochester, Minnesota
Unhappy New Year of Deductibles and Copays
Listened to between Noam N. Levey and NPR鈥檚 Ari Shapiro, regarding Levey鈥檚 article on Germany鈥檚 lack of medical debt (鈥What Germany鈥檚 Coal Miners Can Teach America About Medical Debt,鈥 Dec. 14). Levey passed along the tidbit that Affordable Care Act plans purchased through state exchanges would pay a maximum out-of-pocket amount of $9,000 a year. Likely Mr. Levey knows the actual details of the ACA at least as well as I, but I had well over $20,000 in out-of-pocket expenses for my own care last year (in addition to annual premiums of over $15,000). The deductible/copay aspect of health insurance is rigged against folks who actually use their insurance. The in-network and out-of-network provider scheme is likewise designed to benefit providers as opposed to patients.
I鈥檝e had health insurance for about 40 years, since I graduated from college. Always a plan paid for by myself, never through an employer. I鈥檝e had my first year of using a lot of heath care services (colon cancer surgery and chemo follow-up), and the bills are quite astronomical. Still awaiting the final negotiations between Stanford Hospital and Blue Shield of California for the $97,000 bill for services for the surgery and stay in the hospital. Though my surgery was in September, the two had not resolved the bill by year-end. Now all my copays and deductibles have reset, and I鈥檒l be back at the starting gate, dollar-wise.
We need health care payment reform.
鈥 George McCann, Half Moon Bay, California
鈥 Allison Sesso, president and CEO of RIP Medical Debt, Long Island City, New York
Greedy to the Bone?
In orthopedics, surgery is where the money is (鈥More Orthopedic Physicians Sell Out to Private Equity Firms, Raising Alarms About Costs and Quality,鈥 Jan. 6). Just as a private equity-controlled ophthalmology group tried to persuade me to have unnecessary cataract surgery (three other eye doctors agreed it wasn’t necessary), too many orthopedic patients can expect to be pushed to unnecessary surgeries.
鈥 Gloria Kohut, Grand Rapids, Michigan
鈥 Dr. Amit Jain, Baltimore
The Painful Truth of the Opioid Epidemic
In a recent article, Aneri Pattani and Rae Ellen Bichell discussed disparities in the distribution of settlement funds from lawsuits against major pharmaceutical companies, especially in rural areas (鈥In Rural America, Deadly Costs of Opioids Outweigh the Dollars Tagged to Address Them,鈥 Dec. 12).
We suggest that the merit of many of the lawsuits that led to these large settlements remains unproven. While Purdue Pharma clearly of prescription opioids in treating chronic pain, judges in two high-profile cases ruled in favor of the pharmaceutical companies stating that prosecutors and noted that opioids used per FDA guidelines are safe and effective, remaining a vital means to treat chronic pain. Also, many cases involving Purdue Pharma, Johnson & Johnson, and others were settled based on expediency, rather than merit. This may have been due to the reasoning that continuing their defense against prosecutors having access to limitless public funds would lead to bankruptcy.
The primary cause of America鈥檚 overdose crisis is not physicians鈥 鈥渙verprescribing鈥 opioids. Dr. Thomas Frieden, former head of the Centers for Disease Control and Prevention, noted that the rise in prescription opioids in opioid deaths up to 2010, leading the CDC to create guidelines in 2016 limiting opioid use to treat chronic pain. However, cause-and-effect relationships between the legitimate use of prescription opioids and opioid deaths remain unclear. For example, the National Institute on Drug Abuse noted in 2015 that since 2000, misuse of prescription drugs preceded the use of heroin in most cases. But legitimate prescriptions by physicians to patients with chronic pain constituted only 20% of the cases leading to heroin addiction. Prescription drugs used by heroin addicts were from family members or friends in leading to heroin use.
Since at least 2010, the volume of prescription opioids dropped by over 60% 鈥 yet overdose deaths have skyrocketed to over 100,000 cases in 2021. The opioid overdose death crisis is now driven mainly by illegally imported fentanyl and in part by a of the Drug Enforcement Administration against physicians who legitimately prescribe opioids to chronic pain patients, forcing them to seek out street drugs.
Statistics from Michigan indicate that nearly will no longer see new patients for pain management. The CDC, in its 2022 updated guidelines, attempted to clarify misunderstandings, including inappropriate rapid tapering and individualizing care. However, the public health crisis of undertreated pain remains. Some states have passed to restore access to opioids to chronic pain patients with a legitimate need, indicating the shortfalls of the CDC guidelines to treat pain.
鈥 Richard A. Lawhern, Fort Mill, South Carolina, and Dr. Keith Shulman, Skokie, Illinois
鈥 Dr. Joanne Conroy, Lebanon, New Hampshire
We鈥檙e fighting to hold accountable the companies that helped create and fuel the opioid crisis so we can help people struggling with opioid use disorder across North Carolina and the country get resources for treatment and recovery. We need this money now to save lives.
To that end, I wanted to flag one concern about the article on rural counties and opioid funding. It looks as if the comparison and the maps about North Carolina funding by county and overdose deaths may not correlate. The reporting seems to reflect overdose deaths on a per capita basis, but funding is indicated by total dollars received.
might be helpful. It ranks each North Carolina county by the amount of funds they will receive from the distributor and Johnson & Johnson settlements (as posted on ) per capita, using 2019 population figures. In per capita rankings, rural and/or less populous counties are typically receiving more funding per capita than larger counties. For example, the 10 counties receiving the most per capita funding are all rural and/or less populous counties (Wilkes, Cherokee, Burke, Columbus, Graham, Yancey, Mitchell, Clay, Swain, and Surry). Wake County, our most populous county, is ranked 80th.
It鈥檚 also important to note that the formula was developed by experts for counsel to local governments in the national opioid litigation, who represent and have duties of loyalty to both large urban and small rural local governments. It takes into account opioid use disorder in the county (the number of people with opioid use disorder divided by the total number of people nationwide with opioid use disorder), overdose deaths as a percentage of the nation鈥檚 opioid overdose deaths, and the number of opioids in the county. Click for more information.
Indeed, one of the special masters appointed by U.S. District Judge Dan Polster in the national opioid litigation found that the national allocation model 鈥渞eflects a serious effort on the part of the litigating entities that devised it to distribute the class鈥檚 recovery according to the driving force at the heart of the lawsuit 鈥 the devastation caused by this horrific epidemic.鈥 (See Page 5 of of Special Master Yanni.)
You鈥檙e absolutely right that rural counties were often the earliest and hardest hit by the opioid epidemic, and it鈥檚 critical that they receive funds to help get residents the treatment and recovery resources they need. We鈥檙e hopeful that these funds, whose allocation was determined in partnership by local government counsel, will help deliver those resources.
鈥 Nazneen Ahmed, North Carolina Attorney General鈥檚 Office, Raleigh, North Carolina
鈥 Kate Roberts, Durham, North Carolina
A Holistic Approach to Strengthening the Nursing Workforce Pipeline
As we face the nation鈥檚 worst nursing shortage in decades, some regions are adopting creative solutions to fill in the gaps (鈥Rural Colorado Tries to Fill Health Worker Gaps With Apprenticeships,鈥 Nov. 29). To truly solve the root of this crisis, we must look earlier in the workforce pipeline.
The entire nation currently sits in a dire situation when it comes to having an adequate number of nurses 鈥 especially rural communities. With the tripledemic of covid-19, influenza, and RSV tearing through hospitals, it鈥檚 never been more evident how vital nurses are to the functioning of our health care system. A found that we need to double the number of nurses entering the workforce every year for the next three years to meet anticipated demand. Without support from policymakers and health care leaders, we cannot meet that.
As a health care executive myself, I鈥檝e seen firsthand how impactful apprenticeships can be because they help sustain the health care workforce pipeline. From high school students to working adults, these 鈥渆arn while you learn鈥 apprenticeships allow students to make a living while working toward their degree, and my system鈥檚 apprenticeship program has even reduced our turnover by up to 50%. It provides a framework to support a competency-based education rooted in real-life skills and hands-on training for key nursing support roles, all while team members earn an income.
Education is key to developing competent, practice-ready nurses. Not just through apprenticeships but early on in students鈥 educational journey, too. According to the newest data from the , students in most states and most demographic groups experienced the steepest declines in math and reading ever recorded. As we continue to see the devastating impact the pandemic had on young learners, it鈥檚 crucial we invest more in remediation and support, so students graduate from secondary school with a deep understanding of these core competencies and are ready to pursue nursing. A of nearly 4,000 prospective nursing students from ATI Nursing Education found that a lack of academic preparedness was the top reason for delaying or forgoing nursing school.
Without intervention now, our nursing workforce shortage will only worsen in the future. We need our leaders to face these challenges head-on and invest in a holistic approach to strengthen our nursing pipeline. There鈥檚 no time to waste.
鈥 Natalie Jones, executive director of workforce development at WellStar Health System, Atlanta
鈥 Oklahoma Health Action Network, Oklahoma City
Planning Major Surgery? Plan Ahead
I read Judith Graham’s good article 鈥Weighing Risks of a Major Surgery: 7 Questions Older Americans Should Ask Their Surgeon鈥 (Jan. 3) . Thought I should add some personal experience. At age 78, my mother had back surgery in 2016. When she was getting prepped, she was given multiple documents to sign. Once signed, she was immediately taken to surgery. There was not enough time to read any of them. In hindsight, we are certain the documents were mostly for release of liability if something goes wrong. After surgery, she had 鈥渄rop foot鈥 鈥 total loss of use of her left foot. Never heard of it. She was told she would regain use in about six months. Never happened. She had to use a walker and still had numerous falls in which her head had hit the ground multiple times. She slowly slid into long-term 鈥渃onfusion鈥 that was attributed to her falls and passed away at age 84.
My story is about my abdominal aorta aneurysm surgery in 2022 at age 62. I did not have an overnight recovery 鈥 tube taken out of my throat, catheter removed, and was immediately transferred to a room. An IV pump of saline was left on and my arm swelled up 鈥 I thought my arm was going to burst. Five days later, I was discharged. Everything seemed rushed. The only postsurgical 鈥渋nstructions鈥 I received were to keep the incision clean and not to play golf, and I don’t even play golf. I recuperated at home, and after five months I still have abdominal pain that I’ll always have.
Both of our surgeries were done on a Friday. I’m certain our experiences were due to hospital staff wanting to leave early on Friday, and weekend staffers are mostly the 鈥淏鈥 team. So, my advice is to suggest to the elderly not to have surgery scheduled on a Friday unless there is absolute urgency in choosing the date.
鈥 Paul Lyon, Chesapeake, Virginia
鈥 Suzette Sommer, Seattle
I am writing to express my concerns over the significant misinformation in the article about what older Americans should ask their surgeon before major surgery.
Most abdominal aortic aneurysms are treated with endovascular methods. These minimally invasive procedures still require general anesthesia (with a breathing tube), but most patients have the tube removed before leaving the operating room, and many patients leave the hospital the next day with minimal functional limitations due to surgery being performed through half-inch incisions in each groin.
The “best case鈥 surgical scenario described in your article describes open abdominal aortic aneurysm repair, which is recommended for fewer than 20% of patients requiring aortic aneurysm repairs.
In essence, you’re threatening everyone who comes in for a tuneup with an engine rebuild.
Abdominal aortic aneurysms are still undertreated in the U.S., with many patients not receiving screening recommended by Medicare since 2006. Your article misrepresents the “best case鈥 scenario and may dissuade patients from receiving lifesaving care.
鈥 Dr. David Nabi, Newport Beach, California
I read, with interest, Judith Graham鈥檚 article about older Americans preparing for major surgery. But you failed to mention the life-altering effects of anesthesia. My independent 82-year-old mother had a minor fall in July and broke her hip. After undergoing anesthesia, she is required to have 24/7 care as her short-term memory has been forever altered. Was there a choice not to have hip surgery? I didn鈥檛 hear one. Did anyone explain the issues that could (and often do) occur with an elderly brain due to anesthesia? No. And now we are dealing with this consequence. And what happens when you don鈥檛 have money (like most people in the U.S.) for 24/7 care? I hope you鈥檒l consider writing about this.
鈥 Nancy Simpson, Scottsdale, Arizona
鈥 Dr. Madelaine Feldman, New Orleans
The High Bar of Medicare Advantage Transparency
Unfortunately, KHN鈥檚 article 鈥How Medicare Advantage Plans Dodged Auditors and Overcharged Taxpayers by Millions鈥 (Dec. 13) provided a misleading, incomplete depiction of Medicare Advantage payment.
This story focuses largely on audits that, in some cases, are more than a decade old. While KHN鈥檚 focus is on alleged 鈥渙verpayment,鈥 the same audits show that many plans were underpaid by as much as $773 per patient.
More recent research demonstrates Medicare Advantage鈥檚 affordability and responsible stewardship of Medicare dollars. For example, an October 2021 Milliman report concludes 鈥渢he federal government pays less and gets more for its dollar in MA than in FFS,鈥 while the Department of Health and Human Services鈥 fiscal year 2021 report shows that the net improper payment rate in Medicare Advantage was roughly half that of fee-for-service Medicare.
KHN鈥檚 article is right about one thing: Only a small fraction of Medicare Advantage plans are audited each year 鈥 denying policymakers and the public a fuller understanding of the program鈥檚 exceptional value to seniors and the health care system. That is why has called for regulators to conduct Risk Adjustment Data Validation (RADV) audits of every Medicare Advantage plan every year.
There are opportunities, as outlined in our recent policy recommendations, to further strengthen and improve Medicare Advantage鈥檚 high bar of transparency and accountability, but that effort is not well served by this misleading article.
鈥 Mary Beth Donahue, president and CEO of the , Chevy Chase, Maryland
Targeting Gun Violence
I’m curious why KHN neglected to actually get into all the “meat and potatoes” regarding its report on Colorado鈥檚 red flag law (鈥Colorado Considers Changing Its Red Flag Law After Mass Shooting at Nightclub,鈥 Dec. 23). Specifically, it failed to report that the suspect in this case used a “ghost gun” to execute the crime in Colorado Springs, and more importantly what impact any red flag law is going to have on a person who manufactures their own illegal firearm. Lastly, why is it the national conversation regarding the illegal use and possession of firearms curiously avoids any in-depth, substantive conversation of access to firearms by mentally ill people? Quite frankly, this is the underlying cause of illegal firearms use and no one wants to step up to the plate and address the issue at any in-depth level. It’s categorically embarrassing for American journalism.
鈥 Steve Smith, Carbondale, Colorado
