Letters to the Editor is a periodic feature. We welcome all comments and will publish a selection. We edit for length and clarity and require full names.
First Do No Harm: When Financing Health Care Becomes Unethical
We attribute the oldest text of ethics in Western medical practice to Hippocrates (460-370 A.D.), a Greek physician whose oath instructs, “I will use treatment to help the sick according to my ability and judgment, but never with a view to injury and wrong-doing.” Most doctors, having pledged that oath upon entering the profession, recall best its later paraphrasing primum non nocere, first do no harm.
As physicians at UVA Health and educators at the University of Virginia, we were appalled by the revelations of the aggressive, pitiless billing and collections practices, first reported in The Washington Post based on an investigation by Kaiser Health News (“‘UVA Has Ruined Us’: Health System Sues Thousands Of Patients, Seizing Paychecks And Claiming Homes,” Sept. 10). We felt betrayed and we had, by extension, betrayed those who had relied on us. We had harmed.
When we began our positions at UVA, we did so with the understanding that, as clinicians at a public institution, we were privileged to care for all people, including those with limited ability to pay. Many of us chose academic medicine, and UVA specifically, so that we could partner with our patients to improve health and well-being thanks to the social contract specific to tax-exempt hospitals to provide low-cost care to people of all incomes. As we have learned recently about UVA and from stories reported from other states and institutions for more than a decade, avaricious billing and collections practices have broken the spirit, if not the letter, of that social contract (“UVA Doctors Decry Aggressive Billing Practices By Their Own Hospital,” Nov. 23).
The individual stories are heart-rending, and the extent of the collective impact is staggering. Indeed, based on an analysis by the Consumer Financial Protection Bureau in 2014, over half of all collections items in credit reports are associated with medical debt. A recent study of people with new diagnoses of cancer and a representative insurance mix, including the uniquely American categorization of people underinsured, found 42% had depleted their life savings 2½ years after their diagnosis. To be sure, academic medical centers must function within the competitive and revenue-driven environment of our country’s approach to health care, and some, like Hahnemann Hospital in Pennsylvania, have not survived. However, the survival of not-for-profit hospitals cannot be assured by the relentless pursuit of debt from the very patients for whom we are expected to be the safety net.
Senate Finance Committee Chairman Chuck Grassley (R-Iowa) sent a letter on Oct. 17 to the UVA Health System’s acting executive vice president for Health Affairs that detailed questions about billing and collections practices at our institution. We have similar questions. While we applaud UVA for the rapidity with which it has announced reforms aimed at reducing the numbers of lawsuits and making more financial support available, we are uncertain how many future lawsuits will be prevented by restricting that punitive action to those with bills of more than $1,000, and why UVA cannot join other public hospitals that have effectively stopped suing patients altogether?
We simply cannot accept one-off solutions. Over half of all hospitals in the U.S. are not-for-profits, and the regulations that govern billing and collections practices vary by state and fail to offer adequate protection in most. Continued identification of egregious practices at individual institutions is essential, and we are grateful for the work of health care journalists and of members of Congress who have prioritized these issues in the national discourse. Public pressure placed on hospitals has frequently resulted in forgiveness of debt and, in some cases, changes in billing practices. Yet, until we achieve a truly universal health system modeled after other countries with similarly vast monetary wealth but more concrete social moorings, we must pursue an immediate solution to address health care pricing and billing. Such a solution must ensure transparency, as Sen. Grassley rightly highlights in his requests of UVA, and therefore allows for honest conversations about how we, as a country, hope to continue to provide excellent care to all Americans. The National Consumer Law Center’s Model Medical Debt Protection Act could serve as an important starting point.
To be clear, we are outraged. We stand with those that have been financially injured, whose bank accounts have been looted, whose homes have been swallowed as if they were built on quicksand, whose credit scores were ruined and whose mental health and energy were spent in a courtroom or in anxious conversations with lawyers — all as a result of having sought our care. We commit to working at UVA, our beloved professional home, to advocate for leaders of high moral integrity, to regain the trust of our patients and to repair to the greatest extent possible the damage that has been done. We call on our community, and especially our fellow clinicians, to demand that the precious resource of our public, not-for-profit hospitals protect our ethical responsibility to first do no harm.
— Drs. Scott K. Heysell, Michael D. Williams and Rebecca A. Dillingham, University of Virginia, Charlottesville, Va.

It’s good news that predatory hospital billing and collection practices are being questioned (this time at a location we get care from): https://t.co/rT2MlRdnZo
— Jan Oldenburg (@janoldenburg) October 18, 2019

— Jan Oldenburg, Richmond, Va.
The Slippery Slope Of Preventing Falls
I commend Kaiser Health News for shining a light on the dangers of senior falls ― the most common cause of nonfatal trauma-related hospital admissions (“‘Fear Of Falling’: How Hospitals Do Even More Harm By Keeping Patients In Bed,” Oct. 17).
Fears over patient falls are warranted; however, steps should be taken to provide patients with access to physical therapy while in the hospital to prevent loss of strength and mobility. Further, access to physical therapy can help reduce the steep costs associated with falls, which total roughly $50 billion annually.
In the outpatient setting, physical therapists are uniquely qualified to improve a patient’s functional ability and recommend the home modifications necessary to allow them to remain independent.
Whether inside the hospital or in the outpatient setting, patients need to be allowed and encouraged to move and walk under the supervision of a physical therapist. Promoting access to physical therapy will ultimately keep our seniors independent, prevent adverse events and drive down health care costs.
― Nikesh Patel, PT, DPT, executive director of the Alliance for Physical Therapy Quality & Innovation, Washington, D.C.

Another poorly thought through CMS regulation. Quality healthcare cannot be reduced to yes or no questions. ‘Fear Of Falling’: How Hospitals Do Even More Harm By Keeping Patients In Bed https://t.co/GTO1xLTDU6 via @khnews
— Cat Shah (@CatherineShah8) October 22, 2019

— Catherine Shah, Charlotte, N.C.
Kaiser Permanente Therapists Sing The Blues
I’ve been a Kaiser Permanente psychologist for over 25 years. I have seen many changes with Kaiser and I am tired of having to shortchange my patients of much-needed treatment services (“Bruising Labor Battles Put Kaiser Permanente’s Reputation On The Line,” Nov. 8). I wrote this song on behalf of my therapist colleagues in protest for better working conditions for patient care in the Department of Psychiatry at Kaiser. I recorded it with another colleague, Matt Torres, and two musician friends who are Kaiser members and sympathetic to the NUHW cause.
― Eugenie Hsu, Oakland, Calif.

Not Either/Or, But Sometimes Both
The article “Meth Trip Or Mental Illness? Police Who Need To Know Often Can’t Tell” (Nov. 1) failed to delve into how often individuals whom police interact with are experiencing mental health or behavioral problems in conjunction with substance use disorders.
The police in this article said they need to know whether they’re dealing with a mental health issue or drugs in order to respond appropriately. In Substance Abuse and Mental Health Services Administration’s 2018 report “Key Substance Use and Mental Health Indicators in the United States,” the percentages of adults who used illicit drugs in the past year were higher among those with serious mental illness (49.4%) and adults with any mental illness (36.7%), compared with those without any mental illness (15.7%).
Since there is such a high chance that people with mental illness are also using substances that can alter their clinical presentation, the police should be trained to prepare for modalities that can accommodate that, keeping themselves and those they serve safe.
― Xi Lucy Shi, Pittsburgh
Standing By Drug Treatment For ADHD
I am a child psychiatrist with a research and clinical focus on treatment of attention deficit hyperactivity disorder. I recently submitted a grant to the National Institute of Mental Health examining the evidence for and against stimulant treatment. The individuals quoted in the article “Pediatricians Stand By Meds For ADHD, But Some Say Therapy Should Come First” (Sept. 30), arguing that behavioral interventions are effective enough to be considered the first choice in ADHD treatment, aren’t correct.
Repeated, large-scale, well-controlled double-blind studies have shown that, with the exception of preschool/kindergarten children: (1) Medication for ADHD is shown to be significantly more effective than behavioral interventions, with behavioral treatments for ADHD only mildly effective or not effective at all. (2) Medication improves long-term outcomes, such as reduction of motor vehicle accidents, accidental physical injury and delayed educational progression. (3) Untreated ADHD is associated with increases in suicide risk, legal issues, divorce rate, job loss, substance use, motor vehicle accidents and self-esteem issues.
While the 6-year-old child in this article has tantrums (which might improve with only behavioral interventions), a school-aged or older child with ADHD would have problems with attention and concentration in school ― hurting his/her early learning. Symptoms of attention and concentration are particularly poorly responsive to behavioral interventions.
Behavioral treatment is not the first choice because delaying treatment can quickly have consequences, while medication treatment is very low-risk, yet dramatically effective.
― Dr. Ryan S. Sultan, New York City

Modifying classroom instruction and using behavioral supports should be first. Then meds if they are needed at the lowest effective dose along with modification and behavioral support.Jeez
— Terri Lewis, PhD 和平抵抗 (@tal7291) October 1, 2019

— Terri Lewis, Silver Point, Tenn.
On Astronomical Air Ambulance Costs
Your recent story about the cost of air ambulance services (“Bill of the Month: The Air Ambulance Billed More Than His Surgeon Did For A Lung Transplant,” Nov. 6) failed to paint the full picture. Recently, my wife had a Type A aortic dissection. She was transported to emergency surgery via helicopter air ambulance for a six-hour-long heart operation that saved her life. Our bill for the air ambulance was over $81,000 for the hour-long flight. What I learned from this incident is that there are only four hospitals in all of California where this operation is performed. Without the air ambulance, I would have likely been planning a funeral instead of dealing with over $750,000 in medical bills. The highly trained crews of these operations save lives every day. Most fly a helicopter, which costs $6,000,000 before it is equipped as a flying ICU. Most fly between one and three flights in a 24-hour period, on average. They are manned 24/7, equipped to fly in the clouds and equipped with night-vision capability. Nearly all are single-pilot crews (to keep costs lower) and have at least one flight nurse (most have two). All have training and qualification maintenance costs for the equipment and personnel. In consideration of all of these costs (note: I did not include facility or insurance costs), I think their cost to the patient is not out of line with other medical costs today.
I noted there was no talk of using a ground ambulance in the article. Was it time-critical for the patient? In other words, would it have had a similar outcome if a ground ambulance been used? In our case, the two extra hours a ground ambulance would have consumed would have likely concluded in a fatality.
The other side of this conversation revolves around how patients are billed and how our current system works to be the most expensive system in the world with only mediocre results. Nearly all billing is reduced by some amount by the insurance ― often called a discount. Because doctors and hospitals know they will receive only between half and three-quarters of what they bill, they inflate the billing so they get what the need to cover most costs. The big loser is the patient, who is underinsured or not insured at all.
The article as written is a very incomplete picture of the air ambulance world and a disservice to your readers.
― Dennis Lyons, Paso Robles, Calif.
Just read your article about helicopter charges. Why not educate the public that they can purchase helicopter insurance, which is very cheap? I highly recommend it to friends who live in rural areas with hospitals that do not offer a full range of services or who need transportation to receive a higher level of trauma care. A bigger problem: the huge health care systems ― whether privately managed or government-run ― that have associates with these rural hospitals or own them. They want patients to stay in their system and will bypass other hospitals that are closer and offer the same services. Choices of care are not always given to patients, or when they are given, they are brief and come in a moment of crisis when patients and families can’t take it all in. How about educating the public on what really is happening and how we continue to waste health care dollars and how they can protect themselves in advance? Call the air transport company and learn about their insurance.
― Nina Jeffords, Miramar Beach, Fla.

The associated “fact sheet” was equally bizarre and rather incoherent..this is a far cry from the normal professional and policy-oriented communications we expect from HHS.
— Dr. Cheryl Phillips (@phillic58) October 4, 2019

— Dr. Cheryl Phillips, Washington, D.C.
Don’t Let Fact Check Undermine Facts
Shefali Luthra did an excellent point-for-point takedown of President Donald Trump’s speech at a conservative retirement community in Florida, which amounted to a cynical gambit of frightening Caucasian seniors into believing that their long-cherished Medicare was under attack from the Democratic “socialist” and the freeloading communities they represent (“KHN & PolitiFact HealthCheck: Trump Speech Offers Dizzying Preview Of His Health Care Campaign Strategy,” Oct. 3).
One critical point that she and others, including the Democratic candidates for president, however, have failed to give sufficient emphasis to, is the degree that household income will actually increase in response to a “Medicare for All” plan. Trump stated in this speech, with no evidence, that household income will go down $17,000 a year with Medicare for all. Although there will be a tax increase to fund this program, the increase will pale in comparison to what we are already paying in premiums and deductibles to a predatory insurance industry. Ms. Luthra only went so far as to question the accuracy of that absurd assertion. Failure to drive this point home will invariably allow the masses to revert to the default mode of “socialized equals a tax increase ― end of story,” and put its long-overdue implementation at risk.
― Samantha Derrick, Berkeley, Calif.

Good, in-story fact check.But could context that current efforts aimed at serious reducing protections through ACA and #GOP has never offered any legitimate alternative > Trump Speech Offers Dizzying Preview Of His Health Care Campaign Strategy https://t.co/8waboBoT1B via @khnews
— jerrymberger (@jerrymberger) October 4, 2019

— Jerry M. Berger, Boston
Under Pressure To Treat Lymphedema
Great story about a little-known expense patients have for compression garments (“Compression Garments Can Ease Lymphedema. Covering Costs? Not So Easy,” Oct. 23). I had to purchase some to wear for a short time for lupus-related swelling and I was shocked at how much they cost. They definitely make a big difference in comfort, and I really think insurers should pay. As they also help to prevent infection, it may make coverage cost-effective in the long run. Is there a petition I can sign to support legislation? I will call my Congress members as well. Thanks for the article!
― Kristan Thompson, Savannah, Ga.
Penalties Run Afoul
In response to Jordan Rau’s article on Medscape.com (“New Round of Medicare Readmission Penalties Hits 2,583 Hospitals,” Oct. 1): If the hospital does not want to be penalized for readmission, well, the hospital staff can just let the patient die. On the contrary, the hospital should be rewarded for saving the life of the patient, and that is all that should concern Medicare. The hospital should be penalized for any patient deaths, period! Because the way around that penalty from Medicare is to just let the patient die in the hospital. It should be that the hospital is recognized for giving treatment to the best quality care that the hospital can provide! Someone should look into Medicare’s revolting penalty system.
― Lois Greene, Sacramento, Calif.

Wow! 2,583 hospitals were penalized for heart failure readmissions in 2020, including @BrighamWomens, @MassGeneralNews, and @BIDMChealth. If everyone is penalized, is the program actually effective? @kejoynt @rkwadhera https://t.co/KAIELu819A
— Aaron Paul Kithcart (@APKithcartMDPhD) October 2, 2019

— Dr. Aaron Paul Kithcart, Boston
Entrenched Stigma
The cumulative effect of “experts” telling the public there is a stigma to mental illnesses (“Taking The Cops Out Of Mental Health-Related 911 Rescues,” Oct. 11) ought to draw considerably more attention.
― Harold A. Maio, Fort Myers, Fla., former editor of Boston University’s Psychiatric Rehabilitation Journal

I had injured/panicked bipolar client strapped on board call me frm accident scene bc cops on the way. She was afraid they’d shoot her. I get there, find Fire Capt next 2 her ready 2 protect her. Taking The Cops Out Of Mental Health-Related 911 Rescues – https://t.co/6f7k9Ehdf7
— R. Ruth Linden, PhD (@TOLHlthAdvocate) October 21, 2019

― R. Ruth Linden, San Francisco
Nurse Practitioners Answer The Call
Your Oct. 9 article “They Enrolled In Medical School To Practice Rural Medicine. What Happened?” underscores the growing primary care provider crisis in rural America. Nationwide, the demand and need for primary care, especially in rural areas, leaves patients without care.
According to the U.S. Department of Health and Human Services, 80 million Americans lack access to primary care, with the most significant shortages in rural areas. By 2030, the country is expected to face shortages of more than 120,000 primary care physicians.
The nation’s 270,000 nurse practitioners (NPs) can address the shortage. In fact, a study in Health Affairs found NPs now represent 1 out of 4 health care providers in rural health practices. NPs assess patients, order and interpret tests, develop treatment plans and prescribe medications in all 50 states ― yet outdated state laws stand in the way.
Forty percent of states authorize full practice authority (FPA) for NPs, ensuring patients full and direct access to NP care. The remaining states limit NPs from practicing to the top of their education and training.
NPs can meet the demand for high-quality primary care nationwide. It’s time the remaining states update their laws so that all patients can access the care they deserve.
― Sophia L. Thomas, president of the American Association of Nurse Practitioners, Austin, Texas
The Plus Side Of 3D Mammograms
As a clinical researcher and diagnostic radiologist who reads thousands of mammograms each year, I was dismayed to read the KHN investigation “A Million-Dollar Marketing Juggernaut Pushes 3D Mammograms” (Oct. 22), which stated “there’s no evidence they are more effective than traditional screenings.” Hundreds of peer-reviewed scientific articles substantiate improved recall rates and cancer detection rates associated with 3D mammography. This article fails to present this information to readers and causes significant confusion in patients and physicians nationwide.
Recalls ― or “callbacks” — from screening mammography impose a tremendous psychosocial and economic burden on patients. Not only do patients and their families experience fear and anxiety due to a potential cancer diagnosis, but recalls also lead to downstream noncompliance with future screening recommendations and, on average, a 13-month delay to returning to screening mammography. Experiencing a recall or false positive increases the risk of late-stage diagnosis, when breast cancers are larger and harder to treat.
The experience of radiologists reading thousands of mammograms is not anecdotal. It is rooted in evidence-based medicine and data. These are not my opinions, they are facts.
― Dr. Nila H. Alsheik, chair of breast imaging, Advocate Aurora Health Care, Chicago
How High Is High?
The article “Employers Are Scaling Back Their Dependence On High-Deductible Health Plans” (Oct. 29) did not provide enough detail to confirm whether the cost to the employer of the PPO options was the same, more or less than the cost of the “high”-deductible health option. For example, it wasn’t clear whether the employer was making a contribution to the Health Savings Account or Health Reimbursement Account for the high-deductible health option.
Assuming the PPOs and the high-deductible health option all use an 80%-20% coinsurance formula after the deductible up to the same out-of-pocket expense maximum, the employee contributions you quoted give the appearance that the PPO options are much more attractive to almost every employee. For that result to occur, the cost to the employer for the PPO options would have to be substantially greater than the cost to the employer of the high-deductible health option.
― Jack Towarnicky, Powell, Ohio

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