Category Archives: Uncategorized

Changing the Focus of Healthcare: From Treatment to Prevention

Too often, the practice of medicine in the United States is focused on treatment. Doctors are taught to battle disease and treat chronic illness to the bitter end, and we have amazing technologies and treatments that have been proven to save lives, but our costs and health outcomes don’t seem to match what we pour into the system.

But what if we doctors changed how we think about battling disease? What if we focused on prevention, rather than treatment? What if our goal were to put ourselves out of business?

That’s where more of our health care tax dollars should be directed — and Dr. Tom Price, the Georgia congressman who was confirmed as secretary for health and human services last night, agrees.

Price, an orthopedic surgeon,  understands the relationships doctors and patients must develop. He’s experienced the frustrations of the current American health care system, and he knows patients are no longer the center of the health care debate.

He has fought on behalf of patients with insurers, taken care of those without insurance and seen firsthand the devastation preventable disease can have on patients and their families.

Under our health care system, government organizations such as the U.S. Preventative Task Force (USPTF) can set policy and greatly influence how physicians practice. Their recommendations directly affect reimbursement and help determine what tests and procedures CMS and Medicare will cover. Dr Price has been outspoken against their recommendations throughout his career—particularly when it comes to the latest recommendations for breast and prostate cancer screening.

For example, though screening for breast cancers clearly lowers risk for death, recent recommendations have made screenings optional for women under 50 and on an every-other-year basis for those between 50 and 74. These changes in recommendations will change the way physicians approach screening and may have long term affects on breast cancer survival rates—only time will tell. Dr Price has criticized the USPTF for not having enough expert specialists — particularly in the areas where they are making their more controversial recommendations.

Americans spend far more than any other country on medicine and treatment, yet we’re No. 42 in life expectancy and No. 56 in infant mortality. That’s because Americans generally don’t feel that health is an individual responsibility or that behavior modification is a way to prevent disease.

Fortunately, a large body of data supports the use of screening tests for chronic diseases, and we have reliable tests for prostate, lung, colon and breast cancers — just to name a few. But these tests are not without debate within the medical community. Some say widespread, population-based screening leads to more unnecessary tests and procedures, putting patients at undue risk. Others say doctors use screening tests to generate more patients and procedures.

Nothing could be further from the truth.

We must change the way doctors and health care systems think in the U.S. today. The Affordable Care Act — ObamaCare — was supposed to give patients access to more preventive care. But, in reality, all it did was provide emergency access to those who had urgent medical needs. Lack of accessibility, high costs and lack of timely availability of physicians who participated in the ACA exchanges limited patients from receiving preventive care.

We must reward physicians for preventing disease. We must hold patients individually accountable for behaviors that put them at higher risk for certain diseases. If we are to ever improve outcomes, increase life expectancy and improve infant mortality rates, it will be due to changing health and wellness behaviors, not from spending trillions of dollars on treating chronic preventable diseases.

Prevention also has long-term economic effects that reach far beyond direct medical costs. It can reduce absence from work — absenteeism resulted in nearly $85 billion in productivity losses last year alone — and improve worker and corporate productivity.

Good health affects us all. It affects our quality of life and the economy, as well. But prevention starts with you. It entails:

  1. Taking stock of your own health risks.

Understand your family history and how it affects your risk for disease. Know your numbers — BMI (body mass index), fasting blood sugar, blood pressure and cholesterol. If you know your individual risk, you can make changes to affect it.

  1. Making changes to modify risk.

Understand that exercise and diet are critical to reducing risk. Know that smoking is the No. 1 cause of preventable death in the U.S. today. Obtaining an ideal body weight or BMI reduces your risk for diabetes, high blood pressure and heart disease (the No. 1 killer in the U.S. today). We must address key indicators of health outcomes — smoking, physical activity levels and diet — to improve our health and reduce costs.

  1. Getting regular screenings

Work with your health care provider to make sure you know when and how to screen for cancers and other diseases. If you test positive, get multiple opinions before you do anything, so you can make the decision that’s right for you.

  1. Engaging with a health care provider/partner

 Developing a long-term relationship with a physician can make a big difference in your health status and outcomes.

Tom Price, as HHS secretary, will help us begin an important transition in American health care: focusing on the patient — not the politics — and making sure we prevent disease before too many lives are lost. Prevention must be our goal.

I challenge all my colleagues who treat terrible diseases … Let’s put ourselves out of business. Let’s work to make America healthier than ever

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Keeping Campaign Promises: Trump Issues First Executive Order to Repeal Obamacare AND a Call to Action for Congress

Throughout his campaign, Donald Trump was a vocal critic of the Affordable Care Act. Within hours of his swearing in, President Trump issued his first executive order aimed at dismantling Obamacare. In a meeting in the Oval office before he left for the Inaugural Ball, the President signed an order that aggressively begins the process of repealing the ACA. While the order itself cannot repeal the law, the document goes a long way toward eliminating key portions of Obama’s signature legislation.

Taking A Closer Look at the Executive Order—What’s In It?

In the one page order there are several important statements to note—powerful words that will effectively begin the dismantling of Obamacare even before Congress begins its debate in the coming weeks.

First of all, President Trump orders the immediate repeal of the Affordable Care Act and directs all agencies to “take all actions consistent with the law to minimize the unwarranted economic and regulatory burdens of the act and prepare to afford the States more flexibility and control”

In addition, the Order directs the heads of Federal agencies to “waive, defer, grant exemptions from or delay any provision…that would impose a fiscal burden on any Stat or a cost….on individuals, families insurers or makers of medical devices products or medications.”

Finally, President Trump orders all head of agencies to “encourage the development of a free and open market in interstate commerce for the offering of healthcare services and healthcare insurance”

What Will Be the Impact?

The most immediate result of Trump’s first executive order on healthcare is that he has now signaled both lawmakers and all Americans that he intends to make good on his promise to immediately begin work to repeal the ACA.

Using the words “to the maximum extent allowed by law” throughout the document also sends a message to all Federal agencies that they must move quickly and decisively to begin to dismantle certain provisions of the law. It is likely that a system will be developed to allow free competition of insurers for the individual market across state lines. IN addition, the move will likely result in less regulation and more flexibility for BOTH States and insurance companies—Something that had been requested and denied numerous times during the Obama administration.

While the order does not directly eliminate the individual mandate, it does substantially weaken the law by instructing government agencies to delay, or defer any tax penalties related to failure to purchase insurance. It is likely that no penalties will be levied going forward while Congress works to repeal the ACA.

While many insurers have pulled out of the ACA market due to high cost, high risk and low returns, President Trump’s orders may result in significant changes in the insurance market by providing more stability and predictability. By making the individual market more attractive to insurers through relaxing regulation and allowing for more inter state competition and business opportunities, it is likely that the Executive Order will result in more choices for consumers—whereas many Obamacare marketplaces currently have only one choice.

What Are the Next Steps?

The Executive Order sets the stage for the repeal of Obamacare. It is now incumbent on Congress and the likely head of HHS, Tom Price to move forward quickly. While repeal is vitally important, we MUST provide a simultaneous replacement. Uncertainty will undermine any efforts to revamp healthcare in the US and ensure coverage, access and affordability for all. A replacement plan must be produced and discussed openly in the coming weeks. I believe that Republicans in both the House and Senate have the scaffolding of a new healthcare law in place—now they must craft it into law. It is vital, however, that Republicans learn from the errors of their colleagues on the other side of the aisle—any legislation must be bipartisan—having one Party craft the law without ANY input from the other would be disastrous (just as the ACA turned out to be). A replacement healthcare law should address the shortcomings of the ACA and should keep the few things (such as protection for those with pre existing conditions) that actually worked.   We must continue to provide subsidies to those who cannot afford insurance in order to stabilize the market. We must, however, demand individual accountability from patients, doctors, insurers and government stakeholders. Patients MUST be engaged in their own care and take steps such as smoking cessation, diet and exercise, etc in order to improve their OWN health (in partnership with their doctors). Insurers must be allowed to compete across state lines and must be allowed to operate in ways that provide maximal access for patients but must be held accountable to control costs. Doctors must provide efficient, high quality care—and be allowed to do so without government interference.

There are many challenges ahead of Congress and President Trump in the coming weeks—none bigger than healthcare. The Executive Order issued on Inauguration Day has signaled that this administration will be one of action. Now it is time for Congress to do their part and provide a real, working replacement for the ACA that can be immediately implemented. We must remember that any new healthcare law must put #PatientsFirst and allow Medicine to return to its roots—Doctors and patients working together to improve health outcomes and ensure a long and happy life.

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Cyber Hacking and the Heart: How Science Fiction Becomes Science Fact, And How Profits Influence Policy

This week, the Food and Drug Administration (FDA) confirmed that pacemakers and implantable defibrillators (ICDs) manufactured by St Jude Medical are vulnerable to cyber hacking. This completes months of cooperative investigation and evaluation by the company and the FDA. An announcement was made on January 9, 2017 that Abbott—who recently acquired SJM in a deal reported to be worth 25 billion dollars—has provided a software patch as a “fix”. To date, the FDA has confirmed that no patients have been harmed by the vulnerabilities.

What Exactly IS the Security Issue?

Most implantable cardiac devices such as pacemakers and defibrillators (regardless of manufacturer) are now able to connect to home monitoring systems wirelessly so that physicians can monitor the devices remotely. These remote monitoring systems are essential in the long-term management of device patients. This technology allows healthcare providers to respond quickly to any device alerts, malfunctions or changes in a patient’s clinical status. All of these networks contain embedded computer systems that are connected to the internet and this makes them vulnerable to malicious cyber attacks and these vulnerabilities have been discussed since before 2013. All major manufacturers have these home transmitters and each differs in the exact frequency with which the transmitter communicates with the device. Previous research has shown that medical devices are vulnerable to hackers who were able to assume control of the device in a laboratory setting. In the case of the St Jude Medical devices, the FDA released their findings on security vulnerabilities in a safety report dated January 9, 2017. In the report, the FDA states that the agency “has reviewed information concerning potential cybersecurity vulnerabilities associated with St. Jude Medical’s Merlin@home Transmitter and has confirmed that these vulnerabilities, if exploited, could allow an unauthorized user, i.e., someone other than the patient’s physician, to remotely access a patient’s RF-enabled implanted cardiac device by altering the Merlin@home Transmitter.” According to the FDA, the issue at hand is that hackers could potentially access the Merlin@home transmitter and potentially reprogram the device or prematurely deplete the battery putting patients at significant risk. Based on the completed review, SJM (now Abbott) has released a software “patch” that was recently designed to address the vulnerabilites in the Merlin@home system. The patch will be automatically installed wirelessly over the internet in all home monitoring systems this week. The FDA will continue to monitor cyber security issues and advises both patients and physicians to continue to conduct home monitoring as per routine.

How and When Did This Come About? Follow the Money….

This story began in August 2016, when Muddy Waters Capital, a privately owned investment research firm, first suggested that these vulnerabilities existed and advised that they would be short selling the SJM stock. Muddy Waters, in turn, first learned about the cyber security issues concerning SJM devices from MedSec, an independent cyber security company. At the time, Med Sec claimed that their research suggested that St. Jude Medical was “by far the least secure” of the four largest implantable cardiac device makers in the United States. SJM responded by saying that the claims were “absolutely untrue” and that the Muddy Waters investigation was based entirely on “financial gain”.

In September public record indicated that SJM sued Muddy Waters—calling the short seller’s claims “irresponsible” in a press release—and ardently defended the safety and security of their devices.  The FDA acted immediately by beginning a joint investigation of the SJM device vulnerabilities in cooperation with the Department of Homeland Security. During the last year, SJM had been in the process of negotiating an acquisition deal with Abbott laboratories—the deal closed January 4, 2017.  Five days later, the FDA safety report was released.

Internet Connected Medical Devices Are At Risk: Guidance From The FDA

In December of 2016, (before the current SJM findings were released) the FDA published guidelines regarding cyber security issues and medical devices. As medicine becomes more digitally connected with patient devices being accessed via smartphones, tablets, doctor’s offices and hospital systems, security vulnerabilities are becoming more of a concern. In the document the FDA makes it clear that all medical devices are at risk and that more must be done in the pre market phase by industry to design more secure portals for data collection and device integration. I addition, more study is needed to identify potential risks and impact to patients. The guidance statement goes on to recommend a much more vigorous post market cyber security surveillance and suggests that all of the findings should be shared with the FDA. I expect that in the future, there will be a great deal more regulation involved for medical devices that are capable of wireless communication across the internet.

What Can We Learn from This? What’s Next?

Our lawmakers and the FDA must do more to regulate the medical device industry. We must do more to PUT PATIENTS FIRST. I am certain that SJM is not the only company with devices that are vulnerable to hacking—we have had reports of other devices—from MRI scanners, IV infusion pumps, personal insulin pumps and other connected devices that either have been compromised or have been identified as high risk. I think it is important for device makers to be proactive and tell us what we need to know now—What are they doing to do NOW to protect patients from cyber attacks? Outside research firms have suggested that most cyber security efforts related to medical devices and healthcare systems are lagging nearly a decade behind current technology. Many devices are still working on operating systems with known vulnerabilities such as Windows 7 and Windows XP.

I agree with the spirit of the FDA guidance statement from last month but I expect MORE. We must pursue post market cyber security issues aggressively. We must make every effort to identify and mitigate risk quickly. I would advocate for more cooperation between companies in cyber security efforts—by combining efforts to create more secure environments for medical devices and information, all parties will profit and ultimately patients and the healthcare system in general will benefit. . As a physician and a patient advocate, I am ready for change. While we must continue to promote free market competition and innovation, we MUST also protect the very people we are intending to serve—the patients who depend on us—and our devices—every single day.

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New Law Could Speed FDA Approvals: Will Patients Still Be Safe?

This past week, the US House of Representatives passed legislation that has become known as the CURES ACT. This is thought to be the largest and most powerful healthcare related law since the passage of the Affordable Care Act during Obama’s first term. The Cures act provides for a large increase in funds for boosting biomedical research and also takes aim at speeding up drug and medical device approvals through the Federal Drug Administration (FDA). As expected, other items are also placed inside this bill such as funding for Opioid abuse as well as a program to better treat mental illness—making it very likely that President Obama will sign the law once it is approved by the Senate.

Many medical researchers have worried about what may happen to important and essential research funding for the National Institutes of Health (NIH) under a Trump administration and this law provides for more that 4 billion dollars for the NIH over the next decade.

How Might This Law Affect the FDA Process?

Currently drug and device makers must present data obtained from rigorous randomized controlled clinical trials (RCTs). RCTs provide the best type of evidence for the safety and efficacy of a drug or device and can Under the new law, companies would be able to use “surrogate endpoints” rather than hard outcomes to obtain approvals—this would make it far less expensive and time consuming for pharmaceutical and device companies to move new products through the FDA at a much quicker pace. Company controlled registry data would be accepted as evidence and RTCs would not always be required.

What Could This Mean for HealthCare Consumers?

Proponents of the legislation argue that this will be a huge step forward in public health. By providing such a large amount of funding for biomedical research as well as funding for work on opioid addiction and mental health treatments, that are likely to provide better treatment options for millions of Americans. In addition, simplifying the FDA approval process is likely to spur innovation—companies will be able to devote more time to research and development and patients will be able to reap the benefits of new therapies much faster. The FDA process is currently weighed down with lots of rules and regulations—providing a more clear path to approval may encourage smaller innovators and entrepreneurs to produce new products.

Opponents to the law argue that removing the requirement for robust data with hard endpoints to support the safety and efficacy of new drugs and devices may place patients at risk. Consumer and public safety groups worry that the law may open the door to the approval of unsafe drug and device approvals. Using observational data and patient feedback rather than RTCs may allow unsafe drugs and devices to enter the market; Companies may be incentivized to rush drugs and devices to the market with only anecdotal evidence in support of their efficacy or safety. Some experts argue that the law will de-legitimize the FDA and lead to patient harm.

The CURES Act—A Physician Perspective

As a practicing cardiologist, I rely on robust data to help me decide how best to treat my patients every single day. I trained at Duke University where we have the largest and most prolific center for the conduct of cardiovascular clinical trials in the world—the Duke Clinical Research Institute (DCRI). I was taught to only use a drug or device that had been rigorously evaluated by RCTs and that all other data was insufficient to determine safety and efficacy. Observational studies can provide correlation but not establish a true “cause and effect” relationship. However, it is often frustrating when we hear about a potentially practice-changing drug or device that is available in Europe but NOT available in the US due to a protracted FDA process. The FDA is currently not adequately funded to handle the amount of regulatory and administrative work they must accomplish in order to efficiently evaluate drugs and devices in a way that still protects patients from harm. The Cures act does provide more funding to the FDA but it is far short of what the agency really needs. I do think that they agency can still ensure patient safety by shifting the way they look a drugs and devices—more needs to be done in the area of pharmacovigilence or post market drug and device monitoring. Possible novel mechanisms for this monitoring could be “social listening” where artificial intelligence (AI) programs are used to sift through social media posts by patients in order to identify possible adverse drug or device events that may warrant investigation. Currently, the agency relies on self-reporting of these events—leading to under-reporting and duplication of reports—making the data relatively unreliable.

We must remember that the pharmaceutical and device industries are ‘for profit” and that they pursue FDA approvals in order to sell their products—as with most businesses, when they can cut expenses (such as in research and development costs) they will do so. This law will certainly allow for more innovation at a lower cost but I worry that this law will do little to change the cost of drugs (think Mylan and EpiPen). Unless there is some provision for more Pharmaceutical regulation I suspect that this law will have little effect on drug costs—it will help the bottom line of industry executives.

The provision of the Cure act that ensures funding of the NIH is incredibly important to researchers in health and science at academic institutions throughout the US. Much of the most important research that is conducted by medical schools and universities will be funded by the NIH and directed at finding cures for cancer and heart disease (just to name a few) through cutting edge genetic medicine. This funding is essential to advance science and develop new and exciting treatments for chronic disease—without it, many projects will never come to fruition and many bright minds may leave institutions that are focused on research in science and medicine.

Ultimately, I am pleased with the Cures act. I think that it is important legislation that will help bring treatments to patients faster—saving lives and improving quality of life. We must, however, continue to balance promoting innovation with patient safety. We must also ensure that, as we move forward, that attention is given to monitoring the practices of the drug and medical device industries—we cannot allow price gauging and we must ensure that all patients have fair and affordable access to the latest and most effective therapies.

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Quit Beating A Dead Horse (and wasting money): The Day of the Pharma Rep is Done

As I sit behind a computer in my office today at the Physician’s “workstation”, I am baffled at the steady flow of Pharmaceutical representatives that flow into our office on a daily basis. Each rep comes in with a fancy glossy print detailing the data concerning their particular drug. My office is busy—patients are coming in and out and medical assistants are busy checking vitals and verifying medications (and of course, entering data into the computer system EMR). Yet the reps come in and stand at the workstation until someone acknowledges them. They stand, and stand—often distracting clinical staff. These reps are given a quota of “visits” they must make by their superiors. Many times they will arrive with their direct supervisor in tow—they are evaluated by the relationship they may (or may not have) with a group of physicians. But my time with each and every patient I see is limited due to the increased electronic medical record work that I must do—I feel bad for the reps (it is not their fault that they are placed in this role)—but Do I really have time to stop the endless flow of clinical work to speak to them? Does a Pharma rep actually provide any real value to me or to my patients? Would a “detail” presentation by any rep change my practice?

The Days of Yore

In the past, pharma reps were a source of “samples” that I could provide to my poorer patients who could not afford their meds. This was a real value—I depended on reps to provide these medications for my patients. In the days of print only access to journals, I may not have been as current with the medical literature. Reps would often come in and discuss breaking trial news that I had not yet had time to read about. Often they would discuss upcoming trials and plans for the future. We would have spirited “academic” debates over drugs, trial design and outcomes or endpoints. When you were unable to attend scientific meetings, the pharma rep would often be able to summarize the latest trials after they were released.

Now, my institution no longer allows “samples” to be left, and honestly, if I need a drug rep to share the latest data with me then I am not doing my job as a physician. Online access to immediate data from trials upon their release makes “keeping current” much easier. Social Media and other digital tools make it possible to attend national academic meetings such as the American Heart Association annual scientific session or the American College of Cardiology meetings allow everyone to be virtually present for ground breaking presentations of Late Breaking Clinical Trials.

Don’t get me wrong, there is nothing wrong with the people who choose to be pharma reps—many are smart, classy, well-meaning folks. However, there is a lot wrong with the antiquated pharma rep sales model in today’s world. Modern technology and easy access to data allows physicians to keep up with the latest clinical trials. Pharmaceutical detailing by reps is not very helpful—it is scripted and based solely on what the FDA allows them to say (think on label vs off label). Reps are not allowed to talk about upcoming trials or discuss any off label applications.

What’s the Answer?

Drug prices in the United States are far too high. Pharma will argue (rightfully so) that the costs of research and development (as well as marketing) drive those costs. However, I think that there are ways to lower costs without sacrificing R and D. I would argue that a restructuring of the pharma “sales force” would save significant dollars. I would also argue that making the FDA approval process more streamlined, faster and more agile would also lower costs. The current Congress is working on the “Cures Act” that will address some of the issues associated with the FDA process. Ultimately, I think that pharma must adjust to the way medicine is now practiced. There is no role for the pharmaceutical representative in the office or hospital. These individuals have absolutely no bearing on my choice to prescribe a particular drug and do not contribute to my continuing medical education. Nearly 75% of all Americans go to the internet after a doctor’s visit. Almost all physicians can access the internet immediately from a smartphone or tablet. Pharma should move their marketing and sales efforts to the digital space exclusively. There is no role for in person physician-pharma rep interaction in medicine today. Use these dollars in better ways—fund patient assistance programs, improve treatments and fund clinical trials. Stop spending money on lunches for the office staff and on fancy packaging. Glossy detail cards are simply tossed in the trash as soon as the representative leaves the building. Focus more on patients. The days of the drug rep have come to an end.

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A Battle is Brewing—Changing Medicare and The Impact on the US Healthcare System

For years, Paul Ryan and other Republican leaders have been touting a change to Medicare in order to safe money and increase benefits to Americans. Democrats have rigidly opposed ANY modifications to the Medicare system.

Republicans now support the idea of “premium support”. In this model, Medicare beneficiaries would purchase insurance from a group of selected plans. These plans would compete directly with traditional insurers such as Humana, United, BCBC and others. The government would contribute the same basic amount to all beneficiaries. If a individual selects a more expensive plan or a plan with a lower deductible, they would pay the difference between the premium they choose and the amount that Medicare provides. If a beneficiary chooses a less expensive option, they would receive a rebate or extra benefits from the government.

What Would This Mean for Medicare?

Competition and free market forces are likely to lower prices overall and improve the services that insurers provide—many private insurers will be competing to insure Medicare beneficiaries. Due to the sheer volume of customers, many private insurers would likely offer cheaper options and work to cash in on a “by volume” business. By providing vouchers for Medicare, Republicans argue that they are providing more choice. Currently, many physicians will not accept Medicare patients due to very poor rates of reimbursement and complex filing requirements. In addition, Medicare can refuse to pay claims for months at a time if they decide to make a rate change or computer system upgrade, for example. I believe that if there is competition among insurers, more physicians may be likely to accept Medicare patients. More physician choices will improve access to care for older Americans. In many geographies across the US, patients now have very limited choice.

What Are Democrats Saying?

Democrats are adamantly opposed to these changes. They argue that by effectively “privatizing” Medicare that individual costs for beneficiaries will rise. They worry that those with multiple chronic medical conditions will be given a fixed amount of healthcare money to work with that they will incur significant “overage” expenses. IN addition, those opposed to the “privatization” model also argue that those who are more affluent and those that have fewer medical problems will be more likely to purchase a private insurance plan with a voucher—leaving those who remain in traditional Medicare plans older, sicker and more expensive. Medicare has long been a traditional Democratic Party campaign issue—often using fear of loss of benefits as a way to sway older voters.

What’s Next?

Nearly one third of the 57 million Americans on Medicare are already on private Medicare Advantage plans. However, current Federal law limits the competition among more traditional insurers and there is no bidding against private plans. In the next Congress, I expect we will see more debate on this issue. At the current rate of spending and under its current structure, Medicare is not going to be a viable way to care for Americans. We must do something to modify the plan and provide CHOICE, ACCESS and HIGH QUALITY care to all Medicare eligible Americans. The current system provides physicians with very poor reimbursement and ultimately, many doctors will no longer be able to care for Medicare patients—simply from an economic viability standpoint.

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What Does a Trump Presidency Mean For Healthcare?

While much about a Trump Presidency remains relatively unclear, one thing is for certain—the way healthcare is handled in the US today will change.

One of Mr Trump’s biggest issues while on the campaign trail was his promise to “Repeal and Replace” Obamacare.

WILL PRESIDENT-ELECT TRUMP KEEP ANYTHING FROM OBAMACARE?

–Based on his most recent comments on 60 Minutes, it appears that Mr. Trump will keep a very important provision that ensures that those with pre existing conditions will remain insured. If we do not keep this provision, we will go back to the days when insurers could discriminate against individuals with chronic medical problems by either denying coverage or making coverage far too expensive. It is essential that this stay in place in order to make sure that ALL Americans are covered (in an affordable way)—regardless of what chronic medical problems they may have.

–Mr. Trump has also indicated that he will keep the provision that allows young adults to stay on their parent’s plans thru age 26. I think this too is vital. Young adults are building careers and often are scraping to get by from a financial standpoint while they complete higher education and low paying internship training programs. I think allowing these individuals to stay on their parent’s plans only makes sense. It alleviates a significant financial burden during the time in which they are developing careers and working towards education goals in order to make significant contributions to society.
WHAT IS LIKELY TO CHANGE IN HEALHTCARE?

This is where the water gets a little “murky”. Trump says that he will “Repeal and Replace” Obamacare—this may be difficult from a legislative standpoint unless the Republicans invoke the Harry Reid approach of the “nuclear option” in Congress. Currently it will take 61 votes in the Senate in order to repeal the legislation. Based on the partisan politics we are likely to see in Congress, this is unlikely to happen. Alternatively, Trump can “starve the ACA” by signing a bill similar to the one that was sent to Obama a few years ago that essentially defunded the ACA. (Obama of course vetoed that bill).

Over the last year, President Obama has been using Treasury monies that were meant for tax refunds to pay back insurers in the exchanges that have had high cost patients. While the ACA provided for these payments, Congress did not fund this provision so Obama has been re-appropriating money from other sources. There is a court case pending that is likely to stop this action. However, Trump can stop it immediately on Jan 20th. If this happens, I worry that more insurers are likely to pull out of the exchanges and the ACA will continue to slowly implode.

ARE THERE ANY SPECIFICS FROM TRUMP’S PLAN FOR HEALTHCARE?

While it is likely that any plan will involve the Republican/Ryan proposal that has been crafted for more than a year, Mr Trump has discussed a few specifics during the course of the campaign. It is unclear at this point just how much of this will be implemented.

  1. Allow insurers to sell insurance across state lines

–By allowing free market competition, Trump argues that competition for patients by insurance companies will lead to better service, lower prices and more patient satisfaction

  1. Allow individuals to deduct healthcare premiums from taxes

–By putting more $ in individual pockets, patients will be better able to afford healthcare

  1. Allow individuals to set up Healthcare savings accounts (HSAs) tax free money

—tax free accumulation for healthcare spending

  1. The individual and employer mandates will be eliminated 

—Allow individuals to CHOOSE if they wish to purchase health insurance

5.  Price transparency for doctors and hospitals

–Prices for common surgeries and services vary widely by geography and hospital. By requiring transparency, patients can shop around, using both quality and price data to determine the best place for them

–This will prevent gouging by certain hospital systems.

  1. Begin a Block grant to states to deal with Medicaid

— The federal government would send money to the states. It would then be up to the states as to how to use the money to cover the citizens.   This may not be good as in some states it is likely to lead to decrease payments to docs and hospitals and may leave more low income Americans without adequate care

  1. Streamline the FDA and allow Americans to purchase prescription drugs from other countries.

–Currently the US pays far too much for drugs that can be obtained in Canada and elsewhere for much less. Why should the US pay all of the R and D costs for the world?

  1. Privatize Medicare—Other Medicare changes

–Provide citizens with a choice—use medicare dollars to see a medicare doctor or use that money to pay for private doctor that does not take medicare. May result in more out of pocket expenses for seniors.

–Allow medicare to negotiate drug prices—lower costs to Federally sponsored healthcare plans

Ultimately we must put a healthcare plan in place that will cover all Americans and we must make sure that the plan allows for low costs and easy access. However, I do not think this will be a “quick fix”. If there is no good replacement plan I am concerned that there may be 25million new uninsured Americans. However, many of these while listed as insured, are currently functionally uninsured due to limited access, high copays and premiums and deductibles. It is my hope that Congress will work quickly to craft a fiscally responsible healthcare plan that works for ALL Americans—and allows doctors to be healers once again.

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