Progress Notes features doctors and medical students across the country on the frontlines of our health care system. Our views and experiences are diverse, but we share common goals and values. We speak up to move toward a future where everyone can have access to affordable, high-quality health care. Please share our posts, and follow us on Facebook and Twitter!
Carol Duh-Leong, MD, MPP and Laura Marcus, MD
This past summer in our primary care clinic in the South Bronx, the most important anticipatory guidance we gave was not to take a vitamin or to eat a new vegetable, but rather to read a new book. Studies show that achievement gaps in high school between students of high socioeconomic status and students of low socioeconomic status can be traced back to differential summer learning over the elementary school years.1 While this knowledge is discouraging, it also creates a potential point of intervention for pediatricians. Summer plans for our patients are often fraught with anxiety, due to the prohibitively expensive nature of camps, travel, or additional structured activities. However, reading year round, with the help of a library card and the encouragement of your pediatrician, has always been free. Books are the cheapest form of international travel, the easiest way to meet presidents and heroes, and the greatest innovation we have engineered for time travel. If Yeats is correct and learning is not the filling of a pail, but the lighting of a fire, books are the kindling. The value of reading and independent learning cannot be underestimated in a school system fraught with overcrowding and lack of resources.
The impact of literacy and education on health outcomes cannot be understated, nor can the effects of health on education. Asthma is the leading cause of absenteeism among elementary school children, and accounts for more than 14.7 million days of school missed in 2002 nationally.2 Additionally, a study undertaken in our state’s schools revealed that 51% of school nurses feel that asthma is more disruptive to school routines than any other chronic condition.2 However, in a family in which more basic needs, like food and security, are at stake, remembering to give your child a controller medication for asthma is often a much lower priority, and lower health literacy often compounds this problem. As doctors we see every day that insufficient education and poor health are intimately and inextricably linked, and that both are a symptom, as well as exacerbating factor, of poverty.
In the Bronx only 54.7% of students who started high school in the year 2010 graduated within 4 years, as compared to 64% in Brooklyn and 67% in Queens and Manhattan.3 In our clinic, there exists a harsh discrepancy between the answers to, “What do you want to be when you grow up?” and the actual outcomes we see. Every day we hear our patients say that they want to be doctors, nurses, social workers, teachers, criminologists, police officers, and business people. Many adolescents express interest in going to college. As pediatricians, we push our adolescents to dream. However, in order to land among the stars, rockets require the forethought, training, and focus, often extinguished by the crushing weight of scarcity. It is our job to utilize what resources we do have, one of which being public libraries filled with books, to help put our children on the path to success.
Alexander, Karl L., Doris R. Entwisle, and Linda Steffel Olson. 2007. “Lasting Consequences of the Summer Learning Gap.” American Sociological Review 72 (2): 167–80. doi:10.1177/000312240707200202.
“Asthma and the School Environment in New York State.” 2008. Center for Environmental Health at the New York State Department of Health. http://www.health.ny.gov/diseases/asthma/docs/asthma_in_schools.pdf.
"Graduation Results: Cohorts of 2001 through 2011 (Classes of 2005 through 2015) Graduation Outcomes." NYC Department of Education. NYC Department of Education, n.d. http://schools.nyc.gov/accountability/data/graduationdropoutreports/default.htm
This piece also appeared in the AAP FACE Poverty newsletter.
Thank you. I want to thank Representatives Doggett and Welch for their leadership on this issue and for the invitation. I also want to thank my colleague Bruce Rector from DFA, my co-chair and the energy behind much of the work we do.
To introduce myself, I currently serve as the Co-Chair for Doctors for America’s Drug Price, Value, and Affordability Working Group, and serve as the State Director for DFA in Maryland. I am currently a medical student in the joint MD/PhD program at the Johns Hopkins University School of Medicine, and was previously trained as a bioethics fellow in the Department of Bioethics at the National Institutes of Health.
I am here today representing Doctors for America, a nonpartisan nonprofit organization, with the combined voices of more than 18,000 physicians and medical trainees as well as others involved in providing health care to millions of Americans. Our members span the spectrum from rural primary care and family medicine physicians to those in tertiary care oncology and surgical subspecialty practices. We are all united in our mission to fight on behalf of the patients we serve, advocating for policy positions based on what we see and what we hear on the ground from our patients each and every day. This is why DFA was formed: to be a group of health care providers who advocate for their patients first.
It is because of our motivation to improve the quality, affordability, efficiency, and compassion of the health care systems our patients experience that we support the Part B Demonstration. This past spring, DFA leadership voted overwhelmingly to support the Demonstration because we have seen too often how meaningful and well-intentioned efforts at reforming our completely irrational drug pricing systems get derailed by theoretical concerns.
Meanwhile, there are hundreds of thousands of patients – by some estimates, up to 24% of Medicare beneficiaries – who at this very moment are having difficulty accessing the medications they need because of high and ever-rising drug prices. The current Part B reimbursement formula has unintended incentives that forces some physicians to sustain their practices through reimbursement for these higher-price medications rather than through fees that better reflect the care they give to patients. And the pharmaceutical industry retains the ability to utilize the perverse incentives that are currently embedded in the Part B reimbursement scheme to their advantage, using the high price of a drug as a tactic to encourage physicians to use their products.
Increasing prices for medications cause a spiral of unintended consequences where higher-priced medications are prescribed frequently - even when a comparable, cheaper alternative is available - leading to barriers being placed to reduce their use. With no restraints in place, drug companies raise prices further in order to increase profits. Such a system is unsustainable for the country. It is also actively harming real people – people like Heather Block - in that it often prevents those suffering from devastating cancers and disabling autoimmune conditions from accessing the very care that these systems are set up to support.
You may have heard of Heather Block’s story; if not, she is a patient with metastatic stage 4 breast cancer who is fast going through her savings trying to pay for her medications, which are billed through Part B and require her to pay 20% with no out-of-pocket-maximum. She has written and spoken out in support of this demonstration. And there are many more in the same situation.
We recognize the concerns raised by our colleagues in oncology, rheumatology, and elsewhere that these reforms risk adversely impacting their practices. Our membership includes many providers in these specialties and our goal is to enable our patients to access and be able to afford the care that they need and for physicians to maintain adequate financing for their practices. However, we feel strongly that the prudent path forward is to collaborate with CMS to strengthen the Demonstration before and during its implementation, NOT to prevent it from happening. In this vein, we are part of the previously-mentioned coalition who has proposed several modifications to the demonstration, and support the ideas of Dr. Bach and others regarding increasing the flat fee, for example.
It is possible to simultaneously focus on the needs of all our patients, while also making sure specialty patients maintain access and that physicians are protected. To say otherwise is a false choice. We have past experience with formula changes where there were dire warnings of patients not having access and physicians going bankrupt – both when the system transitioned to ASP as the reimbursement standard, and during the sequester. These warnings did not pan out, yet these threats continue to be raised, most often by those with a stake in the status quo. More than anything, our physicians want to be adequately paid for doing what they do best – doctoring – and do not want to worry about balancing their practice finances based on reimbursements from drugs.
We are confident that CMS can monitor the Demonstration to ensure that physician practices are not being unduly harmed by these reimbursement adjustments. We need to make sure specialty drugs are priced at reasonable levels, and that patients do not face unthinkable trade-offs between medications and other essentials. By changing reimbursement incentives, focusing on concepts of value, testing models such as reference-based pricing, and providing clinical decision-support tools – all of which, as you’ve heard, this Demonstration proposes to do – we can allow physicians to focus on providing the best care possible for their patients and limit the ability of drug companies to raise prices.
This demonstration could have real positive impact on patients like Heather Block, patients like those on expensive infusions for autoimmune diseases like Multiple Sclerosis, patients like the approximately 1 in 5 Medicare patients without supplemental coverage facing co-pays that are as much as 20% of the total Medicare payment amount for the drug, patients whose stories have been shared with us by dozens of our members (stories which I am happy to share with you). It is THESE patients that illustrate why the ideas embedded in the Part B demonstration must be implemented.
We know that several other physician groups have come out against this proposal, and those in oncology are particularly concerned. Thus, I want to share the perspective of a prominent practicing oncologist-hematologist, Dr. Vincent Rajkumar of the Mayo Clinic, who in August 2015 brought together a large coalition of oncologists in calling for efforts to lower the prices of cancer drugs. He shared with DFA his opinion on the CMS Part B Demonstration, writing: “I express my strong support for the proposed Medicare Part B changes. The current system rewards physicians for dispensing the more expensive drug when two equally good options are available. The push back against the proposals are coming from those who stand to lose revenue. This is to be expected. Thus, it is best to get feedback from those who don't have conflicts of interest. It is sad that what is good for patients does not have the support it deserves."
We believe the CMS Part B Demonstration Project represents an important step, and it is because of the thousands of patients that we see each day that we strongly support moving forward. We urge all of you to do the same. Please – please – be the ones who take a stand in support of the patients that are suffering now, the patients that we see each day. Give them the support they deserve. Thank you.
Justin Lowenthal an MD/PhD student at Johns Hopkins, a biomedical engineer, and a bioethicist with expertise in ethical issues at the intersection of emerging therapeutic technologies and health care systems.
Each of us knows that mental health is vitally important to the overall health of our patients. Yet, too many Americans do not have access to the mental healthcare they need. Many of us know how it feels when we are unable to find adequate help for those who are suffering from anxiety, depression, addictions or a serious mental illness. It's heartbreaking.
We know that change is needed to better address the complete emotional and physical well-being of our patients.
In our most recent membership survey you rated mental health as a top priority for our movement. We need your input to build a healthcare system that fully addresses the needs of our patients.
We will use this information to build Doctors for America's mental health platform, then submit these recommendations to the next Administration.
Together, we will help improve our healthcare system to ensure it works better for everyone.
Dora is the leader of DFA's new Mental Health Task Force. Dora is a telepsychiatrist with a specialty in anxiety and mood disorders. She is based in New Mexico, where she is Historian for the University of New Mexico School of Medicine and a Penguin Books author.
Did you know the price of the EpiPen skyrocketed 400% while Mylan executives gave themselves huge pay raises? Now millions of patients are scrambling to figure out how they can pay for this vital drug.
As doctors and medical students, we know access to an EpiPen can mean the difference between life and death.
Mylan is now saying it will offer an expanded coupon for commercially insured patients to help make the EpiPen more affordable. This move is nothing more than a bandaid that does nothing to help uninsured, Medicare or TriCare patients. That is why we are calling on Mylan to take robust action by lowering it's actual retail price to help truly remedy these exorbitant, cruel hikes.
How much longer must our patients suffer while pharmaceutical companies get rich?
Let's tell big pharma that doctors and medical students won't be silent while they price-gouge Americans. Join us in demanding patients over profits.
Yours in service,
Dennis Deruelle, MD - Justin Lowenthal - Bruce Rector, MD - Mark Rood, MD
Co-Leaders of the DFA Drug Price & Value Campaign
As the 51st anniversary of Medicaid approaches on July 30, we are reminded of the benefits this vital program has provided to millions of Americans. Doctors and medical students know Medicaid is a lifeline for many. Yet, it remains among one of the most hotly debated healthcare programs.
The Affordable Care Act has added 20 million Americans to the nation’s insurance rolls and lowered the percentage of uninsured to a historic low using the twin pillars of state/federal marketplaces and Medicaid expansion in 31 states plus the District of Columbia. However, governors and state legislative leaders in 19 states across the country have continued to refuse to expand Medicaid to millions in the coverage gap.
During this election season and at a time when the disadvantaged are at risk of being swept aside, we must take a personal stand and do something tangible. Together, let us make it clear to everyone that the future of Medicaid is strong when we all do our part.
Our patients who are eligible for Medicaid deserve care. Most are fully employed in jobs that, despite being low in pay, are essential for the safe, smooth and secure functioning of our society. They are the indispensable caretakers, often unpaid, of children, the disabled, and the frail elderly. They are students who will soon find public health insurance unnecessary as they move into jobs with full benefits. And some are our future colleagues, medical students who need some temporary assistance in their first years of training.
So please, whether you are self-employed, employed, a medical student, or already caring for this economically vulnerable population, take the pledge that will help strengthen this essential public health insurance program so that it is available to many generations to come.
Together, we will continue to:
- work to expand Medicaid to non-expansion states;
- encourage states who have established Medicaid reimbursement rates at parity with Medicare rates to maintain those rates and push to establish Medicaid/Medicare parity in all states;
- support innovations in Medicaid that promote access, quality, and high-value care and will ensure the program has long-term sustainability;
- advocate for these vital programs as our nation decides the priorities for the future.
Thank you for all you do for patients!
R. Scott Poppen, MD MPA
Scott is a retired internist, Utah State Director, and member of the Doctors for America Board of Directors.
As doctors and medical students and advocates, it can feel like there's never enough time to do all the things we want to do. Especially in times like these, it's incredibly important for us to take care of ourselves so we can take care of others.
As part of our continued focus on wellness, which began at our most recent conference, please join us for a conversation on sleep with sleep expert, and the author of The Sleep Revolution, Arianna Huffington.
Doctors for America Presentation on Physician Wellness and The Sleep Revolution
with Arianna Huffington
Wednesday, August 3
7 PM Eastern/ 4 PM Pacific
Have a question you want asked on the call? Enter it here.
Arianna is the co-founder, president, and editor-in-chief of the Huffington Post Media Group, and author of The Sleep Revolution.
Mona Mangat, MD
Mona is an allergist-immunologist and the Chair of Doctors for America
Sonia Vishin Compton, MD
Sonia is a practicing pulmonologist in Louisville Kentucky and is Board Certified in Pulmonary & Critical Care medicine.
The past couple of weeks have been a time of deep introspection and searching to make sense of what's happening in the world around us and what we can do to acknowledge the pain and fundamentally make things better. While words are far less adequate than action, we want to share a statement that we released to the press last week on behalf of the Doctors for America movement:
“This has been a challenging week for the nation. We have watched Alton Sterling shot to death while selling CD's outside a convenience store. We saw Philando Castile, a beloved school lunch supervisor, shot to death while driving home from the grocery store. We are witnesses to five police officers — Brent Thompson, Patrick Zamarripa, Lorne Ahrens, Michael Smith, and Michael Krol — shot to death and seven others wounded while doing their jobs and protecting a peaceful demonstration. These tragedies come on the heels of 49 people shot to death while dancing on a Saturday night in Orlando just one month ago.
“As doctors and medical students who have dedicated our careers to protecting health and saving lives, we mourn every loss. We call upon society to do everything we can to prevent tragic deaths from stealing the hopes, dreams, and futures of any person in America.
“That means affirming that Black lives matter. That means recognizing that every life is precious. That means taking a hard look at the prejudices and implicit biases that each of us carry and doing everything we can to remove those prejudices and biases. That means ensuring that law enforcement is well trained and well supported to de-escalate potential conflicts and eliminating racial bias from all aspects of our criminal justice system. That means passing common sense legislation to reduce gun violence including funding federal research on gun violence, investing in programs that reduce violence, and ensuring that no one who poses a likely threat to others or themselves can purchase a firearm. That means doing the hard work of building and strengthening trust and bonds between each of us and anyone who looks, talks, and thinks differently.
“Together, we can build a stronger and more cohesive society where everyone can live to their full potential.”
In times like this, it is easy to feel as though everything is going wrong. We cannot ignore the challenges and problems the nation faces. But we also cannot lose sight of the continued march of progress that every member of Doctors for America has been a part of in the past eight years since our movement first came together. Your voice, your stories, your participation in the actions and campaigns that we collectively take on are creating a better world for our patients, communities, and the nation.
In the face of pain and tragedy, it is up to each of us to find the courage and persistence to make ourselves be more honest and open about both what divides us and what brings us together, about the power and culpability that each of us has to bridge divides or deepen them, to bring more love and compassion or more fear and hatred into the world, to look to the light or focus on the darkness.
What gives me hope is seeing Doctors for America members continue marching forward. With your help and thoughtful input, we will gain better access to equitable, affordable, high quality health care for every person in America and ensure that everyone has the opportunity to live a life of health and vitality. We will expand Medicaid to the millions who need it in the remaining 19 states. We will make sure our patients can afford their medications. We will save lives from gun violence. We will tackle the challenge of bringing mental health disorders and substance use disorders out of the shadows of stigma and into the care people need. We will ensure that the color of your skin does not dictate whether violence will visit your family. We will not shy away from taking on longstanding and emerging threats to health so people can pursue their dreams.
Many of us are wondering what we can do. Here is an initial list of ways we can each do our part, but it is just the start of a conversation we want to continue with each person in the Doctors for America family. Tell us what you are doing and what else you think the Doctors for America movement can do to make tomorrow a better day.
- Building bridges in your own life: Each of us can make an extra effort to be aware of and challenge our own biases, prejudices, and blind spots. Proactively connect with and learn about people and communities that are outside your normal circles, especially those that are hurting and feeling marginalized. Ask your patients about their experiences and their communities. Host a dinner or brunch and create a safe space where people in your life from different backgrounds can openly share their perspectives, fears, and hopes.
- Sharing with the Doctors for America community: We would love to put together opportunities where Doctors for America members learn from members of our incredibly diverse community. Let us know if you're interested in participating and sharing.
- Doctors for America campaigns: Get involved in our campaigns and initiatives to take on barriers to health and opportunity. We are always seeking leaders for our active or planned campaigns and actions on many fronts including Medicaid expansion, mental health, affordable drugs, substance and opioid use, racial disparities, food insecurity, gun violence, and more. Even if you cannot lead, your participation at any level is the heart of this movement, including inviting others to join our movement and contributing financially.
- Additional organized efforts: A group of doctors and medical students has authored "A Letter to Our Patients" with commitments to address structural racism as health care professionals. There are many events happening to highlight the growing scourge of gun violence both in communities and a #DisarmHate rally in DC on August 13. There are many other efforts arising out of recent events, and we encourage you to participate in efforts that speak to you especially those that are happening in your own community.
One more important note. As doctors and medical students, we focus our lives on taking care of those around us. As advocates, we demand even more of ourselves after hours and on weekends. But we can only keep changing the world if we carve out the space to take care of ourselves. So please, take the time to take of yourself, and we will continue this march together long into the future.
Congress is back in Washington, DC for their last two weeks before summer recess. They are debating three major public health issues that Doctors for America members know are important for patients.
As doctors and medical students, we need to tell Congress that they need to take action NOW to address gun violence, combat Zika, and save lives from the rapid rise in opioid addition.
Join us in urging Congress to put patients over politics to protect the public health. Take five minutes to make your voice heard on one or all of the issues below.
GUN VIOLENCE PREVENTION - The shooting in Orlando happened less than a month ago, and 91 people continue to die every day from gun violence. The only way to get Congress to act is to show them we are serious. We must keep speaking out to demand a solution to the gun violence crisis, including an end to the ban on CDC gun violence research and funding for this important work.
ZIKA FUNDING - We know Zika is coming to the continental U.S. this summer. Despite rising temperatures and an emergency fund request months ago, Congress has still not approved funds to get ready for Zika and make sure we can detect, diagnose, and prevent Zika before it's too late. Urge Congress put patients over politics and approve the funding necessary to control this impending crisis.
OPIOID ABUSE & HEROIN EPIDEMIC - Over 2 million people in the U.S. are suffering from opioid use disorders and addiction. This number has skyrocketed in the past 20 years. Congress has approved a set of bills to address the problem but with one catch -- they have approved no funding. Doctors and medical students urge Congress to move quickly to commit the funding necessary to battle the opioid abuse and the heroin epidemic so we can begin healing patients and saving lives.
TAKE ACTION BY CALLING 202-224-3121
Thank you for speaking up for patients and communities. Together, we can make sure our nation puts patients over politics and makes health a priority.
Orlando. 49 dead. 53 injured. Most were in their 20's and 30's. Vibrant, healthy people who were in the right place at the right time - dancing and enjoying life with a community where they could be free. One angry person should not be able to kill and injure so many.
Some would prefer a moment of silence to address this tragedy. As doctors and medical students, we know silence is not the answer. We must raise our voices louder and honor the lives of those lost with action.
Even as we write, our colleagues in hospitals across Orlando are scrambling to treat and save those who were injured.
Our profession is doing our part. Congress needs to do theirs. Every year, for twenty years, they have voted to pass a federal budget that restricts the CDC from doing gun violence research. We won't let them do that again.
As early as today, we expect an amendment to be introduced in the House to end the ban on gun violence research.
It's time to flood Congress with calls from doctors and medical students EVERY DAY.
It's easy. Call the Capitol Switchboard now: 202-224-3121
Then email us at email@example.com to let us know what happened and tell your friends to call too.
Never called Congress before? You can bet the NRA will be calling them and telling them to hold strong. Here's what you can say:
"My name is [X]. I am a [Doctor or Medical Student] from [your city] with Doctors for America. I am outraged by what happened in Orlando. It is past time for us as a nation to see that gun violence is a public health crisis that we can no longer ignore. Will you vote to end the ban on CDC gun violence research and fund the CDC to do this important work?"
Every day, we mourn with the families of the 32,000 people every year who are killed by guns. We struggle to heal the 108,000 people every year who are injured - many of them permanently robbed of a fully functioning life.
Because of you, Doctors for America is leading the way on this critical issue. We delivered a petition to Congress from doctors and medical students in all 50 states. We have gathered a growing coalition of over 100 medical, public health, and science organizations who are taking a stand including the American Public Health Association, the American Medical Association, the American Association for the Advancement of Science, and many more. And we are working with champions in both the House and Senate to build support in Congress including organizing a bipartisan letter signed by 146 House members two weeks ago.
We can win this fight if all of us work together. In the days and weeks to come, your advocacy will make all the difference.
Many of you have been following the news of the the Zika virus, which is spread to people primarily through the bite of an infected Aedes species mosquito. Just last week doctors confirmed that a baby had been born with Zika-linked microcephaly at the Hackensack University Medical Centre in New Jersey. Zika has the potential to cause a lot of illness and suffering in the United States. We know that those of us living in the Gulf Coast states, like my home state of Florida, where the tropical climate is hospitable to mosquitoes, are most likely to be impacted by Zika. But, this public health crisis can be controlled -- if we act now.
Unfortunately, many members of Congress have opposed allocating the $1.9 billion in funding requested by the Obama administration. This funding is needed right now -- as we head into mosquito season -- and is vital to ramping up surveillance efforts, controlling the mosquitoes spreading Zika, accelerating research into new vaccines and diagnostic tests and helping countries already battling the virus.
As doctors and medical students, we know all too well that the lives of our most vulnerable patients are at stake. I hope you will join me in speaking up to make our voices heard.
Here’s what you can do:
- CONTACT CONGRESS - This is the time to call or email your local representatives to let them know you are concerned about the spread of Zika. Use this activation page to demand Congress put patients over politics and approve the funding necessary to control this impending crisis.
- GET INFORMED - No local mosquito-borne Zika cases have been reported in the U.S., but there have been travel-associated cases. With the recent outbreaks, the number of Zika cases among travelers visiting or returning to the US will likely increase. Use this site to get up to speed. And, watch this video from U.S. Surgeon General Vivek Murthy to learn three ways patients can protect themselves and their families.
- INFORM YOUR PATIENTS - Put up this poster in your clinic or office. Urge patients to take preventive measures to avoid mosquito bites. And, talk with pregnant women about whether they or their male sex partners have recently traveled to an area with Zika.
- PEN AN OP-ED OR LTE- Write an opinion piece or letter to the editor urging your member of Congress to put patients over politics and provide the funds needed to prevent the spread of the Zika virus.