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.

images

 

 

 

 

 

‘The Rest of the Story’—SJM Leadership Explains the ICD Battery Advisory

After writing my opinion piece for Bold.Global two weeks ago, I have received many comments and I felt it necessary to produce a follow up article. Much of the buzz surrounding the advisory has had a lot to do with the timeline of events—what happened when and how the company responded to concerns over the current ICD battery issues. I obtained a copy of the SEC filing that is required during an acquisition such the Abbott Laboratories/SJM deal. I also reached out to the leadership at SJM. After speaking with St Jude Medial Chief Medical Officer Mark Carlson last week and reviewing the SEC filing, I wanted to provide a bit more information and share what I have learned. Dr Carlson agreed to allow me to quote him in the production of this piece.

The AdvisoryTimeline (as provided by Dr. Carlson from SJM):

–2010 SJM begins production of the FDA approved family of devices that are the subject of the current advisory

–Following an ongoing internal investigation of lithium deposits at SJM, by 2014, there were a small number of devices that were found to have a lithium deposit induced short associated with premature battery depletion

–The first report of a patient death associated with premature battery depletion was in June of 2014.  According to Dr Carlson, returned product analysis found no evidence of lithium cluster induced shorting

–November 11, 2014 SJM convened their Medical Advisory Board to discuss the premature battery depletion cases. SJM reported that the rate of battery depletion due to shorts was 0.004% of worldwide sales. MAB recommended continued monitoring rather than market withdrawal

–May 2015 SJM worked with battery manufacturer to produce a “design enhancement” in order to avoid further lithium deposit related shorts.

–August 25, 2016 SJM MAB reconvened to discuss the battery issue. Based on the recommendations from the MAB, SJM began the process of communicating an advisory with the FDA

–The second report of a patient death associated with premature battery depletion on March of 2016. The product analysis found no evidence of lithium cluster induced shorting.

–October 11, 2016 SJM issues an advisory due to the premature failure of batteries related to lithium deposits. At the time of the advisory there were 2 reported deaths, 46 confirmed shorts and 795 unconfirmed shorts (.21% of total sales).

 

The Acquisition Timeline (taken from the SEC filing on public record)

–On December 15, 2015, members of the respective managements of Abbott and St. Jude Medical met and that meeting also served as an introductory meeting between Miles D. White, chief executive officer of Abbott, and Michael T. Rousseau, the incoming chief executive officer of St. Jude Medical. During the course of the meeting Mr. White indicated to Mr. Rousseau an interest in discussing a potential business combination between Abbott and St. Jude Medical.

–During the first week of January 2016, Mr. White contacted Daniel J. Starks, former chief executive officer and current executive chairman of St. Jude Medical, regarding a possible business combination between Abbott and St. Jude Medical.

They agreed to meet in person later in the month.

–On January 23, 2016, White and Starks met in person and at this meeting, Mr. White indicated that Abbott expected to present St. Jude Medical with a proposal to acquire St. Jude Medical.

–On February 23, 2016, Mr. White called Mr. Starks to communicate a preliminary indication of interest for Abbott to acquire St. Jude Medical at an indicative value of $83.00 per St. Jude Medical share, with consideration consisting of 60% in cash and 40% in Abbott shares, subject to due diligence. On that date, the closing price of St. Jude Medical shares was approximately $53.99 per share.

–On February 29, 2016, members of management of Abbott and St. Jude Medical met. St. Jude Medical management delivered a presentation on the company’s businesses, financial information and operations. Abbott began a due diligence review of SJM

–On March 13, 2016, Abbott communicated an updated proposal for the acquisition of St. Jude Medical at an indicative value of $84.00 per St. Jude Medical share, with consideration consisting of 60% in cash and 40% in Abbott shares.

–On March 15, 2016, the St. Jude made a counterproposal for Abbott to acquire St. Jude Medical at value of $85.00 per St. Jude Medical share, based on a mix of cash and stock consideration. On March 16, 2016, the closing price of St. Jude Medical shares was approximately $54.50 per share.

–After agreeing to terms as outlined above, Abbott and St. Jude Medical executed the merger agreement after the closing of trading on the NYSE on April 27, 2016. Abbott and St. Jude Medical announced the transaction with a joint press release prior to the opening of trading on the NYSE on April 28, 2016.

 

Putting all of this In Perspective: Where Does this Leave Us?

It is clear that the timelines (as reported by SJM) that led up to the issuance of the battery advisory did overlap with the acquisition talks with Abbott during late 2015 and all of 2016. However, based on SEC filings, it appears that the initial investigation of the battery issues preceded the discussions with Abbott by more than a year. During this time, the SJM stock price fluctuated by nearly 20 points according to SEC documents. So, exactly how much did the acquisition proceedings influence the timing of the advisory for the current battery issue? We may never truly know—it is my hope that those who lead in the medical device industry will consider the enormous impact that their decisions have on patients—Both GOOD and BAD. I sincerely hope that senior leadership recognizes that the choices they make every day affects real human beings. In the interest of full disclosure, I must admit that I know many of these individuals at SJM personally and call many of them friends– and I have always had great respect for each of them. However, I have had no direct knowledge or involvement in the business dealings of SJM. I also have had no knowledge of any battery issues with SJM devices until the day before the advisory was released to the press in early October 2016. During the timeline of SJM internal investigations of the battery issues, I and all other physicians continued to implant these devices without any knowledge that there was a possible concern—only SJM and their medical advisory board were aware.

Based on the information provided to me by Dr. Mark Carlson, it does appear that SJM did have discussions with the Key Opinion Leaders (KOLs) on their Medical Advisory Board early on in the process. It also appears that SJM did pursue due diligence in the analysis of the behavior of lithium deposits in medical devices. From my research into the lithium issue it does appear that others in the market—including Medtronic as well as Boston Scientific—have also noted issues with deposits that may affect battery life. These reports indicate that these occurrences are quite low. However, many patients depend on these devices to have a ZERO failure rate (and yes, I realize this is not possible). In addition, I have learned that the lithium deposits have been found to be “fluid”—they may appear and disappear over time. After reviewing the available information, it does appear that the St. Jude Medical team did work in a systematic way to determine the root cause of premature battery depletion with a goal of balancing patient safety with business success. It does appear that the company did continue to sell the devices in question after the battery manufacturing process was altered and according to Dr Carlson this was due to the fact that (after discussions with the medical advisory board) the failure rate was very low and did not meet criteria to take action either internally or with the FDA .

Ultimately, more needs to be done in the Medical device AND pharmaceutical industries in order to protect patients. While under a certainly a completely different set of circumstances, recent well-publicized pharma company actions (such as Mylan and Epi Pen rate hikes) have reflected poorly upon the entire medical device and drug industry. Unfortunately, these activities have served to increase suspicion concerning the motives of industry leaders. As healthcare consumers, we must work to hold all in the industry accountable—However, we must also approach each situation with an open mind and evaluate each case individually. Time will tell just how significant the current SJM advisory truly is and if other companies have similar issues.  It is my hope that industry leaders will advocate not only for stockholders but for patients as well.

img_2299

Getting Successful with Social: Tips to Build a Digital Following

Social Media and the digital space is ubiquitous in today’s society. As consumers of media, we are constantly flooded with data—how can we best handle the influx of information, process it and engage others? Here are some of my TIPS for building a powerful digital following!

Social Media use among millennials is widespread and continues to grow. Believe it or not, the older Gen X-er’s and Baby Boomers are also jumping on board—IN fact the fastest growing demographic on twitter is the 55-65 year old set.

The widespread use of social media across generations provides us all with an enormous opportunity to engage with others and make a significant impact.

As a media personality and a physician, I use social media and the digital space in many different capacities—

–To Teach

–To Market

–To Brand

–To Engage

–To Collaborate

–To Become a KOL (Key Opinion Leader)

I believe that all digital users—regardless of background, goals and target audience should also be focusing on each of these areas.

Here are some key tips for success:

  1. KNOW your audience. Find out what they want and who they are. Understand what is important the THEM—remember it is “all about them, not all about YOU”
  2. Provide relevant, timely content. Consistently update your profile and always respond to inquiries and current events
  3. Engage in conversation with other Key Opinion Leaders (KOL’s) –follow them and respond to their content
  4. Create a buzz—Give your audience a reason to consistently come back to your social platforms and ultimately broaden your reach.

And don’t forget to Use technology to target your audience. My friends at MDDigital Life have developed amazing software that can actually “map” your digital reach. By examining the way in which you are connected you can better reach out to those you want to influence and engage. Just as in medicine, data provides you with the ability to develop a successful strategy. Here is my Twitter reach below.

social-engagement

Check out http://www.MDigitalLife.com to see how this map was created and how you can better engage your connections today!

screen-shot-2016-10-30-at-9-23-18-am

 

 

 

 

 

 

Illegal Use of Tax Dollars to Cover Insurance Company Shortfalls: Obama Bails Out Insurers

Recently, a Federal audit found that the Obama administration has illegally redirected funds related to collections from the Affordable Care Act that, by law, should have been deposited in the US Treasury. The President, under the guise of executive order, used these tax dollars to bail out insurance companies that have experienced hundreds of millions of dollars in losses due to their participation the Affordable Care Act (ACA) exchanges. In their report auditors state that the Obama administration “ignored the statutory requirement to collect funds for the Treasury,” As you might expect, President Obama defended his actions by arguing that it was necessary to direct these funds to insurers in order to offset the increasing costs (and rising premiums) of the Affordable Care Act. Unfortunately for taxpayers, the Government Accountability Office—who was responsible for this audit—has no legal authority to enforce its findings or legal opinions.

This latest report is just another example of how the President’s devotion to a failed policy continues to hurt the American people. Even with the diversion of tax dollars to insurance companies by Mr. Obama, premiums continue to rise an average of 25% with some states reporting nearly 50% increases for some plans. As these premiums rise, covered services and access to care have begin to dwindle.  Competition in the exchanges is nearly non-existent in some states—patients are beginning to realize that they have very little choice in insurance companies. Many shoppers are unable to compare prices due to the fact that only one company is represented in the exchange marketplace in their State.

This week, the New York Times FINALLY admits that unless changes are made, the ACA is unlikely to be sustainable unless changes are made. While neither candidate has spent very much time on discussing healthcare (no mention in the first debate), healthcare and the ACA will definitely change based on who becomes the next President. As mentioned before, Hillary Clinton wants to expand government involvement in healthcare—ultimately resulting in a single-payer system—Medicare for All. Mr Trump, by contrast suggests that less government involvement will be the answer. Mr Trump advocates for more free market competition—essentially allowing insurance companies to compete for subscribers across state lines.

When the marketplace opens for its fourth year of enrollment in November, consumers will be greeted with higher premiums and fewer choices. Major players such as United, Aetna and Humana have significantly limited their participation in the exchanges due to mounting financial losses. Many non-profit cooperatives have closed down. The basic premise of the ACA is that young and healthy enrollees would help pay for older, sicker enrollees who would require more care and more healthcare dollars. Unfortunately, for the President and his legacy, two things (that I and others predicted) happened:

  1. Older patients with multiple medical problems enrolled in the exchanges in record numbers. This has placed an enormous financial burden on the Federal government and the insurers that participated in the ACA.
  2. Fewer young healthy patients have enrolled in the ACA than originally expected. This has resulted in a premium shortfall in many cases—Many insurers are “upside down” in the ACA and are pulling out.

Ultimately, the ACA is a bad law. While insurance for all is a noble goal, it must be accomplished in a way that is fiscally responsible and in a way that allows doctors to practice responsible evidence based medicine. It is disturbing that our President has manipulated tax dollars (redirected them outside the law) in order to buffer his signature legislation rather than work with Congress to actively overhaul a broken law.

unknown

We are the “Kings of Pain” Pills: Addressing The Opioid Epidemic In the United States

Opioids are common pain medications that are used for the treatment for mild to moderate pain. These medications are highly addictive and bind to particular receptors in the brain and spinal column that produce a feeling of euphoria along with the relief of chronic pain. However, in the US they are becoming a leading cause of death due to overdoses. Opioids—such as oxydocodone, Percocet and others—are now gateway drugs to heroin and other narcotics. They are also becoming a drug of choice for those who have not abused drugs in the past. Now they are gaining increased in popularity due to ease of access– and their street value continues to grow. The sad fact is that in the last year, drug overdoses killed more people in the US than car crashes.

While some physicians are very diligent in the way in which they prescribe opioid type pain killers–others are not. Drug companies that make these compounds for profit have misled physicians with small studies touting opioid safety and many physicians have not done their due diligence in evaluating the addictive nature of pain medications. All of these factors have led to a practice of indiscriminate and irresponsible prescribing practices.

What are the Facts Regarding the Abuse of Opioids?

As a society, we are quick to accept a pharmacologic approach to treating any ailment. As a people we demand an immediate fix for any medical problem and often do not consider any other alternatives. Drugs are much cheaper way to treat chronic pain as opposed to a more comprehensive multi-disciplinary approach. Time with therapists, treatment plans involving meditation, yoga and exercise are not widely supported—it is simply easier to take a pill. Currently, the US accounts for over 75% of the world’s total opioid prescriptions. In the last year, over 260 million opioid prescriptions were written in the US alone according to the American Society of Addiction Medicine. Currently, drug overdose is the leading cause of accidental death in the US today. Of the nearly 50 thousand overdose related deaths in 2014, opioid overdoses accounted for over 18 thousand—only 10 thousand were due to heroin.   In the last decade, opioid overdose rates have risen more than six fold. Women tend to be more at risk than men with overdose rates from prescription pain relievers up 400% over the last decade (as compared to 230% for men).

What Role to Doctors Play?

Obviously, physicians and other healthcare professionals are the source of opioid prescriptions. Don’t get me wrong—opioids do in fact have an important role to play in medicine in the short term treatment of acute pain related to accident, injury, surgery or the like. However, chronic opioid use must be avoided. These medications have numerous side effects and can be highly addictive in some patients. As a physician, it is incumbent upon me and my prescribing colleagues to choose the best treatment for a particular patient. It is never OK to enable abuse through writing recurrent, long term narcotic prescriptions. Unfortunately, financial pressures in medicine have created situations in which physicians feel as though they MUST write prescriptions of this type or fear losing patients to another provider who will. In addition, many patients with chronic pain require a great deal of time and effort during the course of a busy office day. Rather than spend the necessary time to create a more holistic and multi-disciplinary treatment plan, many physicians find it easier to simply write a prescription and move on the the next patient—thus enabling addiction.

What Is Our Government Doing to Address Opioid Addiction?

In March 2016, President Obama announced a new initiative (and new funding ) to combat opioid abuse and addiction. Currently, the FDA and DEA is considering regulations that will require “retraining” of doctors who prescribe opioid medications. Healthcare providers may be required to undergo re education in order to maintain a particular DEA prescribing certification. Many state medical boards already track opioid prescribing patterns and will often reach out to physicians who have unusual prescribing practices or prescribe higher numbers than their peers. Many of these physicians may be subject to disciplinary action.

Research dollars are being spent to investigate new types of pain relievers with less abuse potential and greater efficacy. Other studies are being conducted that will help better understand this type of addiction and how best to treat it. In addition, government dollars will be allocated to improve access to addiction treatment programs and the FDA will require new labeling of opioid prescriptions that will make their abuse potential much more clear.

Finally, drugs that reverse narcotics overdoses, such as naloxone (also called Narcan), are making their ways to city streets. It is imperative that we provide first responders as well as others in areas of high abuse rates with easy access to this life saving antidote during an overdoes. IF we do not, many more will die before we can change the course of the opioid epidemic in the US today.

What’s Next?

While these proposed government sponsored initiatives do have some promise, it is unlikely that any of them will have an immediate impact. It is important that we continue to educate the public as well as healthcare providers to the risks associated with taking opioids. In addition, we must make it easier for physicians to develop a more comprehensive and multi-disciplinary approach to pain management. Those physicians who do not carefully prescribe narcotics and instead do so indiscriminately, must be sanctioned and must no longer be allowed to prescribe these medications. We must also address the behaviors of those who are addicted to these drugs—we must identify sources of these drugs in the community and eliminate them from circulation. We cannot wait for government to act FOR us and fix the problem through bureaucracy and legislation—as physicians and as citizens we must act on our own. While ultimately research into better ways to treat chronic pain and the management of addiction will produce new ways to treat our patients, we must all work together NOW in order to halt the alarmingly high rise in opioid use in our country today. Ask your physician for alternative ways to treat pain. If you are concerned you or your friends and loved ones are suffering from addiction—say something—get involved and help.

unknown

Doctors Glued to Computers—And Patients Left Out : The Impact of Electronic Medical Records (EMR)

In 2009 the Health Information Technology for Economic and Clinical Health Act (HITECH) was signed into law by President Obama and this law quickly changed the way medicine in the United Sates is practiced. The law was a first step in requiring all physicians to utilize electronic records. The President promised that creating and electronic record mandate for physicians would result in a national, universal electronic medical record system and improve care and communication. Ultimately, the legislation that required EMR implementation in 2009 began the process of penalizing physicians who do not use them and started a lucrative business for healthcare IT vendors such as Allscripts, EPIC, Cerner and many others. The requirements to implement EMR resulted in thousands of physician practices having to make harsh financially motivated decisions—either close the doors or sell out to larger healthcare systems.

What are the Benefits of EMR? What are the Practical Drawbacks?

Certainly, EMR systems do have their benefits—standardized documentation and portability all improve care. When a patient travels and has an illness care is improved when another hospital and provider can easily access long-term medical records. Communication between physicians of different specialties and organizations is significantly improved. However, EMR vendors have not yet created exchangeable, universal systems as Mr Obama promised they would. Each vendor creates their own platform and continues to compete with other EMR makers by creating different interfaces—Each EMR platform has its own idiosyncrasies and none is perfect. The Obama administration failed to put any mandates on EMR vendors—they were allowed to produce whatever they liked. The burden of integration has been dumped squarely in the laps of healthcare providers. In addition, EMR systems have been designed as billing tools and NOT for clinical documentation. Hospital systems are able to reduce billing and coding staff and now force physicians and other healthcare workers to perform this role as well. Because of the design focus of EMRs to capture maximal billing they are often clinically irrelevant and woefully inefficient in the clinical setting.

There is a significant learning curve for physicians and other healthcare workers when changing from one system to another. These transitions often bring operations to a crawl as productivity and efficiency decline for several weeks to months—ultimately negatively impacting patients.

How Has The EMR Requirement Affected Physicians and Patients in the Last decade?

This past week, a study published in the Annals of Internal Medicine found that physicians are spending twice as much time logging data into electronic medical patients as they are actually spending time interacting with patients. In the study, investigators observed nearly 480 hours of clinical time from the practice of 57 physicians across multiple specialties—including family medicine, internal medicine, cardiology and orthopedics. Investigators found that during a day in the office, physicians spent 27% of their time seeing patients and 49.2% of their time on the EMR or doing deskwork. In addition, these physicians also did 1-2 hours of EMR time at home during family time every single night. Ultimately the study found that for every hour physicians spend providing direct face to face patient care, they then spend TWO hours working on the EMR. Obviously, this type of scenario is unlikely to be sustainable. Physician burn-out and dissatisfaction with their job is at an all time high—more younger doctors are retiring early and looking for employment in other industries. More importantly, many patients are beginning to feel isolated and unable to develop any type of meaningful relationship with their physician.

What’s Next?

We must get back to a patient centered focus for the US healthcare system. We cannot allow a computer screen and government mandates to separate docrom patient. We must demand that physicians be given the time and space to interact with patients in a meaningful way that allows for a human connection. While documentation and EMR technology is an important part of clinical medicine, we must not allow the computer to be the focus of the clinical visit.

Here’s what I think needs to be done:

  1. Keep laptops out of a physicians hands in the exam room
  2. Require universal connectivity and easy interaction between different EMR platforms/vendors
  3. Reward physicians for quality CARE, not for quality EMR notes
  4. Make EMR interfaces more clinically relevant, easier to use, and more efficient (NOT AS BILLING TOOLS)

These are not easy goals to achieve. However, we must work diligently to make changes or patients will become more isolated and medicine will no longer be a human interaction between doctor and patient. These changes will only be possible if all of us work together—patients and doctors–to demand legislative reform.

 

{This blog was originally published in my column on Bold.Global on Monday September 12, 2016}

Major Insurers Bail on the ACA—Limited Choices and Patient Struggles Ahead

(This blog was originally published on September 5, 2016 on Bold.Global)

In the last several months three major players in the Obamacare exchanges have publicly  reported millions of dollars in losses and have made plans to either pull out completely (or significantly decrease participation) in the ACA insurance exchanges. Humana, United and Aetna account for the majority of the policies written under the affordable care act and will no longer be participating in open enrollment in 2017. All three insurers have cited overwhelming losses and a responsibility to their shareholders at the motivation for the change. The mass exodus of larger insurers has created a situation where nearly 1/3 of the individual counties in the United States will have only ONE choice in the exchange—effectively creating monopolies for these insurers. The insurers that remain are already asking for substantial premium increases—in some areas premiums may rise nearly 40%. In an effort to cut costs even further, those insurers that remain are negotiating contracts with healthcare systems that will accept rock bottom reimbursements. Many major healthcare systems are not able to participate in the exchanges. This has left many Obamacare participants with very narrow “in network” choices and some areas are faced with only ONE healthcare system and its affiliated physicians.   By limiting the network choices, the insurers are able to better control costs due to the fact that more expensive physicians and hospitals can be left out. When an insurer contracts with a particular hospital system and affiliated physicians, they are able to require referrals for specialists and the often offer incentives to primary care doctors for limiting costs (with no measure of quality).

What is the obvious Fallout from NO competition??

  1. Diminished Choice

As mentioned above, the remaining insurers must cut costs. The ACA exchanges have been flooded with older, sicker patients that require more care and create a higher cost burden. In order to manage these costs, insurers are negotiating contracts with single healthcare organizations in an effort to limit costs. These contracts will eliminate choice for most of those insured through the ACA. There is a shift towards HMO style plans and there are now fewer PPO (Preferred Provider Organization) options. PPOs allow patients to make choices in providers and HMOs typically have far fewer choices. In many states, there are no PPO choices—overall 15% of customers will have NO PPO to choose from. As you may expect, the profit margins for HMOs tend to be much higher for the insurers.   In 2016, HMOs represented 65% of all ACA plan choices. Non HMO plans tend to have higher premiums and are subject to more frequent and more significant premium increases as these insurers accumulate sicker, more expensive customers.

  1. Less Quality

Whenever there is a lack of competition, quality tends to suffer—no matter what the industry—and Medicine is not immune. Cost cutting measures and incentives for physicians to “do less” can result in a lower quality of care. For the most part, insurance companies are not concerned with the health of the insured—they are focused on the cost and the risk. In an ideal world, medicine would focus on prevention rather than treatment. However, many insurers do not cover important preventative tests and prescription drugs that are designed to modify risk.

  1. Increased Cost

Insurance companies are “for profit” businesses with shareholders to which they must answer. The job of the insurance executives is to maximize profits and minimize risk—Do not be fooled, insurance companies do not care about the well being of their customers. When insurance companies such as those who are taking losses in the exchanges find that their bottom line is negatively affected, they quickly raise rates, increase co-pays and raise deductibles.

  1. Less Access

As insurers limit their networks, patients will find that they have less access. When exchanges only offer one choice of hospital system and affiliated physician groups, patients will have difficulty finding a primary care doctor or may experience waiting lists to see specialists. Ultimately, patients will be separated from their long time physicians (unless they are lucky enough to find that they remain in network). Many physicians will ultimately retire or choose not to participate in the exchanges due to lower reimbursement rates—in some cases the exchanges reimburse at rates lower than Medicare and Medicaid—which are already 30% lower than private insurance rates. Major academic medical centers—such as UCLA and Northwestern for example—and countless others, are not participating in the exchanges due to reimbursement concerns. Academic centers often have cutting edge therapies and experimental protocols for cancer and other devastating diseases. Because of network and cost containment issues, those insured by the ACA will not have access to this type of care.

WHAT needs to be done?

It is clear that the ACA is NOT working. While we have millions of newly insured Americans, many of these newly insured remain effectively “uninsured” due to the inability to meet deductibles, and the limited access to care. It is vital that we insure all Americans—but we must do so in a way that preserves patient choice and helps improve quality of care—all while being fiscally responsible. We must work to better regulate insurers and make sure that the focus of care pivots to PREVENTION in the next decade. Physicians should be measured on how well they PREVENT disease as well as how well they TREAT disease with the highest quality care. We must also require individual accountability for patients. Those that make healthy lifestyle choices should be rewarded with lower premiums. Those that choose to continue high risk behaviors—smoking, poor diet, etc—should pay more.

Ultimately, Congress will have a choice in 2017. They can either bail out a broken ACA by pouring more good money after bad—OR—they can actually legislate and reform the law, making it more effective for all parties—insurers, patients and physicians.