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 firms.

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 left.

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 institutions.

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 clinician practice?

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 fee-for-non-service medicine.

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 nursing functions.

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 sick patients.

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 clinicians.

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.