Note that this is a two year old webpage fashioned by the Massachusetts CDHC. We plan to update and supplement this page soon with a guide to FAQs which exist at several state and national sites, for a more complete range of questions and answers. We hope to make this a useful cornerstone for the discussions in the bulletin board section during winter 2001.
Frequently Asked Questions
- What is the Ad Hoc Committee to Defend Health Care?
- What do you stand for? What is your solution to the problems with our health care system?
- Isn't the Ad Hoc Committee really just an attempt to protect doctors' and nurses' economic interest?
- You focus very specifically on for- profit health care. But
aren't you ignoring the fact that not-for-profit hospitals and
fee-for-service physicians helped to create the enormous rise in health care
costs that led to the introduction of market models as a solution?
- But for-profit corporations insist that they have a financial
interest in maintaining the health of their enrollees. They contend there
is no conflict between patients and profits because that putting money into
keeping people healthy is the way to financial success.
- What about quality assurance programs that measure the outcomes of managed care? Can't we trust these programs to protect against compromised
care in the for-profit sector?
- Is your group opposed to managed care?
- Is this why one of the major focuses of your group is on freedom of choice of clinician?
- Yes I understand that employees may not have much choice of
insurance plan but a great many doctors are now permitted to sign on with a
variety of plans. Doesn't this insure greater choice of physician?
- But doesn't restricting choice limit the kind of doctor shopping that escalates health care costs?
- Does this means you are against any effort to control clinician practice?
- How do current reimbursement mechanisms threaten
the access of care to people with insurance?
- We understand what is happening with physician care, but why does this movement also include nurses?
- Does your group have room for clinicians other than doctors and nurses?
- For the most part you have talked here about the problems of the insured. What the problems of the uninsured?
- The situation you paint is very bleak indeeed. What does your
group propose to do about it?
Question: What is the Ad Hoc Committee to Defend Health Care?
The Ad Hoc Committee began in the winter of 1996 when a small group of
physicians and nurses came together to write "For Our Patients, Not for
Profits: A Call To Action" (published in the Journal of the American Medical
Association, December 3rd, 1997). The Call articulates our deep concern
about the bottom-line, market-driven models that are invading all areas of
health care. As clinicians we have become increasingly alarmed at what is
happening to our patients and to the integrity of our practice. We believe
that the American public doesn't fully understand the vast transformations
that are sweeping over our health care system. We therefore feel an important
role for the Ad Hoc Committee is to encourage a broad public dialogue about
the structuring and financing of health care services that will influence
each and every one of us--not only as professionals but as patients, family
members and members of the human community.
Question: What do you stand for? What is your solution to the problems with our health care system?
Our fundamental orientation is stated in the five principles of the Call to
Action. As a diverse group with many different viewpoints, our aim is not to
propose any one solution. We do, however, agree the headlong rush to
market-driven health care threatens our ability to deliver good care to our
patients. Before we move further down this disasterous path, we believe
these issues merit serious debate.
Although we do not purport to have answers to the larger health care crisis,
we are adamantly opposed to the increasing take over of not-for-profit health
care institutions by their for-profit counterparts and call for an immediate
moratorium on such not-for-profit conversions.
Question: Isn't the Ad Hoc Committee really just an attempt to protect doctors' and nurses' economic interest?
There is no doubt that some doctors have abused reimbursement
arrangements for personal profit. While this behavior was never condoned and
was the subject of great debate within the medical community, it continued
unabated for many years. We recognize that the failure of the medical
profession to rein in these excesses created the opening which has allowed
cost-cutters to assert increasing control of the health care system.
Nurses too are being greatly affected by market driven imperatives that have
led to the downsizing of hospital staff and in all of the other institutions
in which they work.
Just as all of us want to protect our jobs and believe our work has moral
value, doctors and nurses as well as all others who work in health care
clearly have an economic stake in any changes made to the health care
system. But wanting to protect one's job does not preclude wanting to
protect one's patients and the integrity of one's profession. Our concern for
our patients and the quality of the care we can provide them is the
fundamental reason why so many physicians and nurses have put so much time and
energy into this action.
As clinicians who want to serve our patients, we simply have less and less
choice about what kinds of services we can offer. We are unable to base our
decisions on our clinical judgment and our concern for the good of the
patient. We are now asked to "align our incentives" with insurers and "share
the financial risk" of the cost of any care. Beyond the obfuscating rhetoric
of market-driven health care lies a frightening reality -- profiteering is
becoming the norm today and doctors and nurses are now asked to serve two
masters -- their patients and insurers who want to reduce costs and
employers who want to reduce premium payments.
Because the ethics of medicine and nursing are being sacrificed to the
ethics of the market place, patients are beginning to lose faith in us.
They are becoming aware it is not just the ethic of care that governs our
practice but the ethic of the marketplace. This perversion of the
caregiver-patient relationship itself is harmful to quality.
Question: You focus very specifically on for-profit health care. But aren't you ignoring the fact that not-for-profit hospitals and
fee-for-service physicians helped to create the enormous rise in health care
costs that led to the introduction of market models as a solution?
We agree that medicine's fee-for-service system and the practices of many
hospitals - both for-profit and not-for-profit -- resulted in escalating
health care costs. We are not apologists of past failures and nor do we want
to return to failed systems. We do not believe, however, that replacing the
excesses of the fee-for -service system with those of a fee-for-non-service
system represents a positive transformation.
We are similarly aware that today there is a diminishing difference between
the for-profit and not-for-profit sector in health care. Today too many for
profits and not-for-profits act almost identically. Too many are obsessed
with price-competition, emphasize the bottom line, and have top down
management styles. Like their for-profit counterparts, not-for-profit
hospitals dramatically reduce length of stay, waste millions in advertising
and marketing and pay CEOs exorbitant salaries.
Nonetheless, we know that for-profit corporations have been far less
responsive to community needs than their not-for-profit counterparts.
That's because for-profit corporations owe their fiduciary responsiblity
neither to their patients nor communities, but to their shareholders.
Their legal obligation is to maximize the return on their shareholders
investments. This means that if there is a conflict between quality care and
profit, CEOS and boards of directors are legally obligated to resolve that
conflict in favor of profit. This creates an inherent conflict of interest
between clinicians and those they care for.
Even so, the for-profit sector in health care has been expanding. In l994,
there were 750 for-profit acute care hospitals. As the number of
not-for-profit hospitals shrinks, for-profits make up a larger proportion of
surviving hospitals and more and more of them are controlled by a few large
Between 1990 and 1995, for profit-HMOs grew 15 fold in both market value
and overall membership. At the beginning of 1996, there were 630 HMOs in the
country and 459, or 72.8 percent were for-profit. In 1996 only 50 of the
630 HMOs in the nation were staff or group model HMOs.
Question: But for-profit corporations insist that they have a
financial interest in maintaining the health of their enrollees. They contend
there is no conflict between patients and profits because putting money
into keeping people healthy is the way to financial success. How do you respond to these claims?
While many HMOs have indeed invested in prevention and health promotion
programs, much of this investment has been in the not-for-profit sector
rather than the for-profit sector. Moreover, as price competition heats up
in the industry, fewer and fewer managed care organizations are willing to
put money into prevention and health promotion. These programs are very
labor intensive and therefore expensive. Moreover, in health care investment
in prevention only pays off in the long-term. And health care corporations
today are focused increasingly on the quarterly profit statement.
Given the frequency with which employers switch coverage, why should a
health care company invest in its enrollees' future health when the majority
of those enrollees won't be in the plan after a few years? And that is the
reality in health care today. For example, one recent study noted that 54%
of managed care enrollees had been in their plan for less than three years.
That same study reported that 41% of managed care members--in contrast
with 12% of fee-for-service enrollees--had to change doctors when their
plan was changed. In Massachusetts, only 82 of 100 original members remain
in the average HMO at the end of one year. After four years, a majority have
Question: What about quality assurance programs that measure the
outcomes of managed care? Can't we trust these programs to protect against
compromised care in the for-profit sector?
The concept of QA was lifted directly from industry. As applied to health
care it involves the development of clinical guidelines to describe standards
of care and to streamline the evaluation of medical problems. Such
guidelines can be useful in establishing appropriate standards of care.
However, in an environment of intense competition over cost--rather than
quality--clinical guidelines and critical pathways become straight-jackets
through which insurers try to mold the behavior of doctors and nurses in the
service of profit, not patient care. Rather than helping to educate
clinicians, they are used to punish clinicians who try deviate from these
pathways because of the inevitable variation between individual patients.
We have seen the result of applying assembly-line models of care in the
almost obsessive quest to reduce hospital length of stay. What began as
useful guidelines to prevent over use of hospital facilities has turned into
a requirement that force every patient fit a one-size-fits-all mold.
When clinical guidelines are used to determine a proportion of clinician
compensation, corruption of clinical judgment is highly likely. In this
setting, clinical guidelines become a pathway to the rationing of care, not
quality of care.
Question: Is the Ad Hoc Committee opposed to managed care?
We are not at all opposed to the management of care. Genuine management and
coordination of care has been much needed in our health care system. Under
fee-for-service, as we have said, too many specialist services were used,
there was too little emphasis on prevention and education, and care was
highly fragmented. Specialist physicians often failed to coordinate care
with primary care physicians. And there was far too little collaboration
between physicians and nurses, and physicians and other clinicians.
Unfortunately, we do not believe that large health care corporations are
interested in either managing, coordinating or integrating care. What they
are doing is damaging and disintegrating care as they manage money. In the
process care is being managed right out of the health care system.
Question: Is this why one of the major focuses of your
group is on freedom of choice of clinician?
Absolutely. We believe that choice is critical if we are to have quality in
health care. But today, choice is being severely restricted. We're not,
however, only concerned with choice of physician but also with people's
choice of hospital, nursing home, home care agency, hospice, and of other
clinicians such as nurse practitioners, primary nurses, psychologists and
social workers. Under market-driven models the patient is told which
hospital he or she may go to, what nursing home they can recover in, what
psychologist they can see, which home care agency they must sign up with and
so forth. The comfort and convenience of patients and families is sacrificed
to insurer's desire to cut better deals with clinicians and health care
facilities. What we are seeing is the replacement of medical paternalism
with managerial paternalism.
Consider how choice of insurer has been restricted. According to one of the
most recent studies, 91% of firms with fewer than ten employees, 80% of most
small firms and 47% of large firms offer only one plan. The
remainder may offer two or three. However, even when employees are
able to choose from several plans, this choice may be more apparent than real
because increased price competition has led health plans of all sorts to
reduce care to the lowest common denominator.
Question: Yes I understand that employees may not have much choice of insurance plan but a great many doctors are now permitted to sign on with a
variety of plans. Doesn't this insure greater choice of physician?
You may have a choice of several primary care doctors within any one
plan, but often the choice of specialists is severely limited. And just
because a specialist is listed in the book of participating physicians, does
not mean that a particular primary care physician will be allowed to refer to
this specialist. Similarly, HMOs may contract with a prestigious university
hospital, but then steer the vast majority of their patients to lower priced
Question: But doesn't restricting choice limit the kind of doctor shopping that escalates health care costs?
Actually, there is very little pathological doctor shopping going on in
health care. Some patients may go from physician to physician trying to find
someone to give them an MRI for a routine headache. But these people are
the exception, not the rule. When patients switch clinicians it's often not a
result of mental pathology but rather poor medical treatment and lack of
follow up care and support. In many cases, patients change clinicians
because they come up against a limitation in their clinician's knowledge and
ability, or because the personality fit between clinician and patient is a poor one.
We believe that patients must have the freedom to seek relief from pain and
suffering and better treatment and care. Patients--who are after all, far
more motivated than anyone else to seek effective relief of their problems--
must have the ability to find help and must be allowed to make use of the
full range of clinical services that might reasonably be felt to benefit them.
Any health care system must recognize that there are many conditions about
which we have limited scientific knowledge. That is one reason individuals
must have the freedom to seek a second or at times even third or fourth
opinions. Similarly, sometimes patients simply need a different clinician
because the chemistry is wrong. We know that trust is one of the most
effective healing agents. Patients need the freedom to form relationships
with clinicians they trust. For all these reasons, we believe choice is
essential to healing. And we must oppose a system which--in the name of
competition--makes it impossible for clinicians to compete around what really
counts: knowledge, quality, and compassion.
Question: Does this means you are against any effort to control
Not at all. What we and the public must ask is who controls clinicians, and
in whose interest they are controlled? Clinical practice must be guided so
that the most effective treatments are offered in an efficient manner. But
this guidance must be motivated by the desire to serve patients not profits.
Therefore, we believe that any savings generated from clinical and
technological innovation must be recycled into expanding access, and
encouraging innovation in practice to enhance overall quality.
This is not what is happening today. In fact, quite the opposite is
occuring. Access is not only shrinking for the uninsured, it is also
shrinking for those who are supposedly well insured. If that is, they have
the misfortune to get sick.
Question: How do current reimbursement mechanisms threaten the
access of care to people with insurance?
Physicians pay is increasingly tied to denial of treatment and care. Many
are offered bonuses based on how little they offer patients. Under
capitation, in which the doctor receives a fixed monthly payment for each
patient, the doctor's economic interest is directly pitted against his or her
patients. According to a report in the New England Journal of Medicine, in
some high-risk capitation arrangements a physician's income could vary
between nothing and $150,000 per year depending on how many services that
doctor provides, or more precisely, how many are denied. In other words, we
have replaced the excesses of fee-for service medicine with those of
Because a physician who has too many sick patients can literally go bankrupt,
more and more physicians are explicitly rewarded for avoiding the sick and
are equally explicitly advised to shun them. In July of 1996, for example,
University of California Irvine Medical Center chief Philip Di Saia, M.D.
sent a memo to his physicians stating that their HMO could "no longer
tolerate patients with complex and expensive to treat conditions being
encouraged to transfer to our group."
It is clear that in a system based on cost-competition, not only are the
sick uninsured a problem, but the sick insured are a problem that physicians,
health care institutions and insurers try to align their incentives to avoid.
Because of increasingly sophisticated physician practice profiles employed
by insurers and medical groups (often run by other physicians), those
physicians who continue to care for the sick and try to do what is right for
their patients risk deselection. And physicians who are deselected by one
plan may find their employment prospects with others severely limited.
Although fee-for-service medicine contained enormous incentives that
encouraged physicians to provide unnecessary treatment, the moral physician
could decide to make a living rather than a killing. Under new market-driven
models, the physician who tries to truly care for his or her patients can
actually become not only unemployed, but unemployable.
Question: We understand what is happening with physician care,
but why does this movement also include nurses?
The physicians in The Ad Hoc Committee realize that we can neither care for
our patients, nor create change without the collaboration of other health
care colleagues. That's because our ability to care for our patients depends
not only on our own practice, but on those of nurses and many others in
health care. Similarly, our ability to create a meaningful public dialogue
also depends on the political activity of others in health care. Our
decision to ask nurses to join us also stems from our great concern about
what is happening to the nursing profession and to our patient's ability to
get nursing care under market-driven models.
Here are some of the facts:
Over the past four years, the nation's hospitals have responded to insurers
efforts to wrest greater and greater discounts by laying off thousands of
registered nurses. Three -quarters of America's hospitals have engaged in
restructuring, which means many have significantly downsized nursing staffs,
often replacing them with aides or "patient care technicians." Nurses today
must deal with greater patient loads, of more--and more acutely
ill--patients. A day-shift nurse may care for seven or eight patients and,
at the same time, be responsible for supervising an aide assigned to care for
four or five others. This means that the nurse will be effectively in charge
of 12 patients.
Many nurse replacements are poorly trained to do the nursing work they are
asked to do. One 1994 study cited in an Institute of Medicine report "found
that 99 percent of the hospitals in California reported less than 120 hours
of on-the job training for newly hired ancillary nursing personnel. Only 20
percent of the hospitals required a high school diploma. The majority of
hospitals (59 percent) provided less than 20 hours of classroom instruction
and 88 percent provided 40 hours or less of instruction time." Yet, in many
hospitals, these workers now insert catheters, read EKGs, suction
tracheotomy tubes, change sterile dressings, and perform other traditional
This has produced hospitals that in the words of the American Hospital
Association itself--"are a nightmare to navigate." Last winter the AHA and
the Boston based Picker Institute released a study of the results of
questionnaires sent to 37,000 patients and comments made by patients who
attended 31 focus groups in 12 states. These patients cited a host of
specific problems related to their visits to doctors, clinics and or
hospitals. Almost 33 percent felt they were sent home from the hospital too
early. Thirty percent said that, when discharged, they were not warned about
possible danger signals related to their condition. Thirty-seven percent
were unsure about when they could resume daily normal activities. Between 23
and 29 percent reported problems with continuity of care or lack of
coordination between various providers. One quarter wanted more emotional
support. Twenty-three percent cited insufficient information and education
about their condition.
According to another study by the AHA, much of patient dissatisfaction with
hospital care comes from their sense that what they consider a "key component
of quality" is missing today--and that is the registered nurse."
Question: Does your group have room for clinicians other than
doctors and nurses?
Indeed it does. Although our group began with physicians and nurses,
recently we have been joined by many colleagues who are social workers,
psychologists, physical therapists, nutritionists and others in health care.
They are all concerned about the same problems. From hospital to hospice,
there seems to be no part of health care that is immune to market forces.
Mental health is an area, for example, that is particularly hard hit. In
spite of the fact that there can be no neat distinction between mind and body
in health care, patients are receiving fewer and fewer mental health services
n the new system. Patients who have emotional problems are given minimal
services, humiliated in the process of receiving what few services they're
allowed and their privacy is routinely violated by health plan utilization
reviewers demanding to know the most intimate details of their lives. To make
matters worse, this private information becomes a permanent part of their
computerized medical record available for non-clinicians to read. In spite
of the fact that we know that relationship between client and therapist is a
significant factor in the client's successful response to treatment, there is
even less choice and continuity of care in mental health than in other areas
of health care.
Question: For the most part you have talked here about the
problems of the insured. What the problems of the uninsured?
Concern for the fate of uninsured Americans is one of the primary reasons so
many of us have joined together in this movement. Corporate driven health
care has done nothing but exacerbate the chronic problem with access to
health care. Forty-one million Americans now lack any health insurance.
That's up some three million since the debate about the Clinton health care
plan. According to some figures we are adding one million people to the
roles of the uninsured every year. In a report released in February of l997,
The General Accounting Office said that the proportion of people under 65
with private insurance declined from 75 to 71 percent, while in children it
dropped from 73 to 66 percent during the same period.
The American health care system's ability to deal with providing care to the
uninsured has also eroded considerably. Because managed care companies have
extracted such deep discounts, it has become more and more difficult for
hospitals and doctors to provide uncompensated care, since traditionally the
revenues from insured patients helped subsidize the care of those who could
not pay. According to one study, for example, uncompensated care is being
reduced by as much as 36 percent in markets with high managed care
penetration. Patchwork solutions to the problem of lack of insurance--like
the Health Insurance Portability and Accountability Act--known as the
Kennedy-Kassebaum Bill--are also proving to be ineffective. Recent reports
document that insurers are raising premiums to such an exorbitant level that
people with preexisting conditions cannot afford them. To avoid the sick,
insurers are similarly denying commissions to those salespeople who sign on
Question: The situation you paint is very bleak indeed.
What does your group propose to do about it?
In our Call to Action, we have listed those initial steps we favor. We
believe it is essential to begin a broad public discussion about the
corporatization of health care so that we, as citizens, can begin to plan for
our long-term needs. In the short-term we believe we must act immediately
to stop future for-profit conversions and health care profiteering.
This discussion, we believe, must begin with the premise that patients'
needs take priority over profits. We want a health care system that allows
patients to get the services they need, when they need them and that gives
clinicians sufficient time to understand and work with their patients. We
understand full well that it is essential to deliver health care services
efficiently and economically. But we believe whatever savings are achieved
should be used to expand access to the uninsured and provide better care for
all, not to line the pockets of investors, executives and some unscrupulous
A health care system must be based on ideals and incentives that encourage
clinicians to rise above concerns for personal comfort and convenience and
economic self-interest so that they can respond to the urgent needs of human
suffering and help patients and families who are in extreme situations. Our
appeal is to the most noble tradtions of our professions. Those Samaritan
traditions led us to reject a market-driven system in which profits, not
patients, come first and in which health care is viewed as a commodity, not
an essential human service which should be the right of all.