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.
On ‘Physician Assistant’: Watch Your Language
I think this story left out a few critical pieces of information (“A Title Fight Pits Physician Assistants Against Doctors,” Dec. 3). The term “physician associate” is already used in Ireland and the United Kingdom, and Yale’s P.A. program has used the term for some time. A recent update to the U.S. Department of Education’s Classification of Instructional Programs changed the title of CIP Code 51.0912 from Physician Assistant to Physician Associate/Assistant. The slash indicates equivalent program titles. While the titles were not updated, residency and fellowship programs for P.A.s in Series 60 include “physician associate” as an illustrative example.
— Allan Joseph Medwick, Clinton Township, Michigan
— Charles Taylor, Muncie, Indiana
It is disturbing that the story did not spend much time discussing the difference in training and education. Of course, we are thankful for our midlevel providers, but there is a vast difference in the type of training received and the level of responsibility that physician assistants and nurse practitioners are lobbying for in many states. It is dangerous. The article made it seem like this boils down to money, and it does not. It is about education and training and the safety of our patients. The P.A. at the end of the story made a comment about changing tires on a car and not needing a jet engineer, but really it is about knowing the difference between a car and a jet.
— Dr. Sharita Trimuel, Columbus, Georgia
— AJ Kavanaugh, Fishers, Indiana
The health of the patient. This is and should remain the goal of all health care providers. Advanced practice providers (APPs) such as physician assistants and nurse practitioners help physicians fill this role. Most patients who see an APP feel that APPs add value to their care, help them to see a provider sooner and are trusted to care for their health. I understand the apprehension of physicians toward the title change from “physician assistant” to “physician associate” and advocate that every health care provider should practice within their scope of practice. The reality is that health care is a team sport. As a student earning dual master’s degrees in public health and physician assistant studies, I am passionate and excited about this. Efficient and effective collaboration between nurse practitioners, physician assistants, nurses, social workers, pharmacists, dietitians, public health workers and many others is necessary to care for the population of patients that we see.
I also understand the necessity for the title change. When I tell people or patients that I am a physician assistant student, rarely more than one or two will understand what my role will be unless they routinely see a P.A. Most believe a P.A. to be a personal assistant, scheduler or scribe to the physician in my experience. I believe that a title change to physician associate will foster trust from patients that the P.A. is an extension of the physician. All those involved in health care should remain acutely aware of their scope of practice, but the title of P.A.s should reflect the trust placed in them by the physicians they work with and the patients they see.
There seems to be a disconnect between physicians and physician assistants on an organizational level. It seems that collaboration and communication on titles and roles should reflect the amount of collaboration between physicians and advanced-practice providers in caring for patients daily. It is important to remember that we are all on the same team and should communicate as such.
Interprofessional collaboration is the future of medicine. I am proud to be part of a program that places such a high value on this and regularly allows us to grow these skills with students from other programs. No one role can fill every need of the patient. Open communication, collaboration, innovation and trust will help us work together as a health care community to meet the needs of the underinsured, underserved and those already facing an uphill health battle due to their determinants of health. We are all in this fight together. The fight for the health of the patient.
— Gabby Henshue, Madison, Wisconsin
Guarding the Medicare Brand
I wrote an op-ed article about this recently (“Readers and Tweeters Find Disadvantages in Medicare Advantage,” Nov. 12) arguing that it is fraudulent to permit private health insurance to use the name “Medicare” for any of its profit-making plans. Medicare is held in such high regard that private companies feel the need to steal its brand, but if we continue to permit them to do so, we may witness the end of Medicare.
— John Steen, South Burlington, Vermont
— David Howard, Decatur, Georgia
Gauging Medicare Advantage Costs: It’s Complicated
Please make the numbers a bit more understandable for individuals who may have difficulty grasping the magnitude of the problem (“Researcher: Medicare Advantage Plans Costing Billions More Than They Should,” Nov. 11). The average person may find it easier to understand the gravity of the issue if you told them that their Medicare Advantage insurance company is receiving $1,000 a month per person or $12,000 a year of their taxpayer dollars that would be better spent on providing regular or original Medicare recipients dental, vision and hearing and other beneficial coverage. People cannot relate to billions stolen by big corporations, but they can relate to thousands of dollars being stolen from each of them.
— Cheri Zao, Coeur d’Alene, Idaho
— Michael Bertaut, Galvez, Louisiana
It was disappointing to read KHN’s one-sided reporting of Medicare Advantage costs and spending, which omitted key information that would have helped to inform seniors.
For example, the article parrots previously debunked claims that “taxpayers pay much more for similar patients who join [Medicare Advantage] … than for those in original Medicare.”
The truth? A new actuarial analysis from Milliman found that total government payments to original Medicare are “slightly higher” than Medicare Advantage for beneficiaries of a similar health status.
The report goes on to explain that “[Medicare Advantage’s] lower cost of coverage in spite of providing more benefits than FFS [original] Medicare lowers total program costs … and increases the value for every healthcare dollar spent by the government and the beneficiary.”
This research was shared with the reporter prior to KHN’s publication of this article and was regrettably not included.
What’s more, the article casts doubt on Medicare Advantage’s risk adjustment process, the legal mechanism by which Medicare Advantage receives payment for beneficiaries’ care.
KHN’s reporting argues that average risk scores in Medicare Advantage have risen in recent years, without providing an explanation as to why.
Again, research from Milliman shows that, from 2013 to 2019 alone, enrollment in Medicare Advantage among dual-eligible beneficiaries — who often present more complex health needs and higher rates of social risk factors — increased by 125%, even as it dropped in fee-for-service Medicare.
Now, Medicare Advantage serves a greater proportion of minority and low-income beneficiaries, as well as a greater proportion of beneficiaries with three or more chronic conditions. This context is helpful in understanding risk scores in Medicare Advantage today.
Risk adjustment is critical to Medicare Advantage’s success in identifying unmet needs, coordinating earlier interventions, and driving better health outcomes for the 27 million seniors and Americans with disabilities who entrust this program with their care.
At a time when we need to increase understanding of risk adjustment and Medicare Advantage spending, this biased reporting unfortunately only added to the misinformation that faces seniors.
— Mary Beth Donahue, president and CEO of Better Medicare Alliance, Chevy Chase, Maryland
— U.S. Rep. Lloyd Doggett, Austin, Texas
With So Many ‘On the Take,’ Enrollment Help for the Taking
If the Centers for Medicare & Medicaid Services is so concerned, I don’t understand why it doesn’t tell the insurance companies to stop the barrage of ads on TV that are misleading (“Medicare’s Open Enrollment Is Open Season for Scammers,” Nov. 10). It’s not even clear that insurance salespeople are going to be on the phone lines or whether you need to have Medicaid to get a “deal.” And why, for heaven’s sake, don’t you inform the public that they can get free sign-up help from their local Area Agency on Aging office? As an elder law attorney in Texas, I am appalled at what I’m seeing going on — a free-for-all for the insurance companies that should simply be open enrollment for seniors. Right now, everyone is thrown into the arms of a greedy insurance company that doesn’t seem to care if they meet the public’s needs or not. (I have talked to far too many seniors who became homeless because they were given misinformation about getting Medicare and Medicaid.)
— Barbara Epstein, Austin, Texas
— Simon F. Haeder, Centre County (“Happy Valley”), Pennsylvania
Don’t Blame the Doctors
I recently read the article “Becerra Says Surprise Billing Rules Force Doctors Who Overcharge to Accept Fair Prices” (Nov. 22), written by Michael McAuliff. This article is very misleading to the public in regards to who actually controls medical care costs for most patients. Most patients receive their care in practices owned by large hospital systems. Hospital systems charge patients “X” dollars for care. The insurance company sets what they will reimburse the hospital system. The physician, in most contexts, has nothing to do with the price of care. Please note: Most hospitals are run by non-physicians. Therefore, the price gouging is not on the shoulders of physicians but in the arms of insurance companies and hospital administrators. Please place the blame where it truly belongs.
Physicians hate the lack of price transparency in our health care system. We don’t like the fact that we can’t say to a patient, “This visit will cost you ‘X’ number of dollars.” Why can’t we do that? Because we aren’t aware of the contract deals the hospital system has with a particular insurance company. So physicians often have little idea about the cost of a particular procedure, lab or office visit.
There seems to be an unfair attack on physicians when physicians are victims of for-profit “nonprofit” health care systems, venture capital firms and insurance companies. Most physicians literally have no say in the price or how care is delivered unless the physician is practicing in a private practice. The majority of physicians practice in non-private practice settings, which means they have no control over the prices patients are charged for care received.
If this attack against physicians continues, medicine will find itself with fewer people going into it because of the abuse in training in addition to physicians getting blamed for things they have no control over. The misrepresentation and propaganda must stop. Please get to the root cause of a problem rather than looking for an easy scapegoat (physician). If not, I’m afraid for future generations, because our best and brightest will refuse to enter the medical field, and I wouldn’t blame them.
— Dr. Dezmond Sumter, Columbia, South Carolina
— Joe Garbanzos, San Diego
Don’t Tie Physicians’ Hands on Off-Label Prescribing
This article amounts to an attack on off-label prescribing of the FDA-approved drugs ivermectin and hydroxychloroquine (“Hospitals Refused to Give Patients Ivermectin. Lockdowns and Political Pressure Followed,” Dec. 2). The article obscures plain facts of hospital practice. Physicians should have the right to prescribe any drug that is believed to be beneficial to their patients, subject to agreement with the medical staff director and pharmacy and therapeutics committee. To limit their authority to use FDA-approved drugs to approved indications only would deprive their patients of receiving many useful off-patent medications. Such old drugs have no sponsor willing to invest millions of dollars in getting new indications approved by the Food and Drug Administration.
As to what the article terms “harassment” of physicians, may I say that threats against physicians and care staff are never appropriate. But consider how you would feel if you were watching a family member in the intensive care unit “circle the drain” while drugs that have reasonable evidence of utility are withheld. Practicing physicians are not held to the same standards of data analysis as academics and FDA staff because patients’ lives are at stake right now. I have seen reports of the use of ivermectin and hydroxychloroquine being discouraged by bureaucratic claptrap while patients die, and I am fed up. As a pharmacist with 40 years of experience, I have reason to take a less rosy view of the FDA than medical residents and the author of this article.
— Brent Cornell, Boise, Idaho
— Kristi Arellano, Denver
Navigators Won’t Steer You Wrong
I was disappointed that podcaster Dan Weissmann, during his guest appearance to discuss shopping for health insurance on the “What the Health?” podcast, failed to mention free, accurate and unbiased assistance through the federally supported navigator system (“KHN’s ‘What the Health?’: Boosting Confusion,” Nov. 18). As a volunteer navigator, we assist consumers with health insurance literacy, application assistance, policy selection to best serve their interests, referral to appropriate agencies if necessary and post-enrollment issues. Since by law we can have no vested interest in which policy they choose, we can provide totally unbiased information. For Medicare open enrollment, the program is called SHIIP (Seniors’ Health Insurance Information Program). With the Affordable Care Act, for which I provide consultation, it is the Navigator program, which can be accessed for all states by clicking the button “find local help” on the first page of the healthcare.gov website. Providing this information to your readers will help us promote our reach and mission. Thank you.
— Dr. Robert Shapiro, Southport, North Carolina
— Harry Sit, Reno, Nevada
On the Hook for Stitches: A Workers’ Comp Loophole
I am a Kaiser Permanente physician who treats people hurt at work. The patient in your story got hurt at work (“The ER Charged Him $6,500 for Six Stitches. No Wonder His Critically Ill Wife Avoided the ER,” Nov. 19). Why didn’t Tennessee workers’ compensation cover his care? Why wasn’t this mentioned as an issue? Many states have very limited workers’ compensation coverage. Perhaps Tennessee is one such state. I practice in Washington state, which has a state-run workers’ comp system, but many individuals don’t know that their work injuries are covered and they hesitate to seek care due to fear of the cost of going to an ER.
— Dr. Janet E. Ploss, Seattle
[Editor’s note: Several readers wrote wondering the same thing. Workers’ compensation insurance wouldn’t cover the injury because Jason Dean was working for the company as an independent contractor — technically, a “1099” employee. This is a common employment situation that effectively bypasses workers’ compensation laws in some states, including Tennessee. The employee is treated as a subcontractor even though they function as an employee. The article has been updated to add this detail.]
— Tara Jordan, Hazleton, Pennsylvania
Dental Hygienists: A Follow-Up
I would like to address inaccuracies made by Illinois State Dental Society lobbyist Dave Marsh regarding why the ISDS killed legislation to allow Illinois public health dental hygienists to provide preventive dental services for patients in prisons, nursing homes and mobile dental vans without an initial dental exam (“Hygienists Brace for Pitched Battles With Dentists in Fights Over Practice Laws,” Oct. 19). The ISDS said it did not support the legislation for “patient safety reasons.”
1. There is no data to indicate hygienists initiating basic preventive services — which they are educated and licensed to perform — harm patients without a prior exam.
In his reference to hygienists providing preventive care for residents of nursing homes, Mr. Marsh said, “I just don’t feel anybody with a two-year associate’s degree is medically qualified to correct your health. They’re trained to clean teeth. They take a sharp little instrument and scrape your teeth. … That’s all they do.” He also cited a “scarcity of research” on the benefits of dental hygienists having more professional freedom.
2. Had Mr. Marsh looked, he would have found a plethora of data that supports fewer restrictions be placed on hygienists to provide services they are educated and licensed to perform. In 1986, a California demonstration project allowed hygienists to open independent practices and provide prophylaxis, fluoride, root planing and exams. Researchers compared the seven hygiene practices to six dentist-owned practices and found the hygienists provided equal or better care in most areas, including infection control. The hygienists kept more accurate medical records and also provided more services to Medicaid patients than the dentists.
3. What Mr. Marsh didn’t say was that in 2015, when the Illinois legislature was considering legislation to allow hygienists employed in public health settings to provide basic hygiene services for Medicaid and low-income patients before an exam by a dentist, the quid pro quo from ISDS for not killing the bill was a provision to allow dental assistants to provide “coronal scaling” for low-income patients up to age 12.
Although Mr. Marsh suggested a lack of research on the benefits of hygienists having more professional freedom, data indicating patient benefits from a superficial scaling above the gumline is nonexistent. Supragingival scaling is part of a complete prophylaxis, it does not replace it, nor does it increase access to care for underserved population groups, unlike the now-defunct Illinois hygiene legislation.
Dental Association PACs use their deep pockets to leverage legislators all the time, such as Illinois Sen. Dave Syverson, who is not only the first cousin of the ISDS’ past president, but, in an audio recording found by KHN on this issue, Syverson made it clear that when it comes to voting on dental issues that benefit Illinois’ underserved population, he will put his own interests of attending ISDS freebie dinners and receptions ahead of the public every time.
4. For the approximately 60 million Americans living in dental deserts, this situation is all too familiar.
In July 2017, The Washington Post reported on “the unexpected political power of dentists” and cited “a political force so unified, so relentless and so thoroughly woven into American communities that its clout rivals that of the gun lobby.”
5. For years, dental hygienists have advocated to fill a critical need most licensed dentists are unwilling to address: providing basic preventive and therapeutic dental hygiene services they are licensed and educated to provide for America’s underserved. It’s time for state political and professional leaders to step up to the plate and make decisions based on what is in the best interest of the public they serve instead of themselves.
— Suzanne Newkirk, Lakemont, Georgia