Tag Archives: ACA

The Cost of a Cure: What’s the Right Price?

Recently, two significant pharmaceutical breakthroughs have resulted in a renewed debate about the costs of drug therapy. In the last year, a new drug class for the treatment of Hepatitis C has been released by two different manufacturers and has been found to cure a once incurable chronic liver disease for nearly 90% of patients who are treated with a full course of therapy. The drug appears to be safe and highly effective—however, the cost of a curative course of therapy is nearly 80K dollars. As you might imaging, there are already barriers to access for many patients including those treated in the Veterans’ Affairs (VA) system as well as those on government based insurance programs such as Medicaid.

In the last several months, another remarkable, potentially “game changing” drug has been approved and released into the market. These drugs, made by Regeneron and Sanofi, are intended for patients who do not achieve adequate cholesterol reduction with standard statin therapy (the current standard of care).   According to some analyses, these drugs, when used in the appropriate patient population, may result in the prevention of thousands of cardiovascular related deaths. However, just as seen with the new hepatitis C drugs, the price tag for therapy is exorbitant—nearly 15K dollars annually. With the Hepatitis C drug, therapy is only required for approximately 12 weeks and then is no longer needed—with the cholesterol drug, the therapy will most likely be lifelong.

This month a study examining the cost effectiveness of these new cholesterol drug has been published and concluded that the drugs are far over-priced (nearly 3 fold) for the benefit that they produce. Based on a pure economic analysis, researchers concluded that the drugs should actually cost between 3K and 4K dollars annually rather than the current 15K price tag.

Did Healthcare Reform Forget Big Pharma?

The purpose of the Affordable Care Act (ACA) (as touted by supporting politicians and its authors) is to make health care accessible and affordable to all Americans. Certainly this is a noble goal and one that we should continue to strive to achieve. However, the legislation has failed to meet this mark. While addressing physician reimbursement and clinical behaviors (and limiting choice and physician autonomy), the ACA has done nothing to regulate the high price of pharmaceuticals. Big pharma is allowed to charge exorbitant prices (whatever the market will bear) without regulation. It is clear that pharmaceuticals must reclaim their research and development investments and make a profit—however, many of these drugs are far overpriced and pricetags are simply designed to exploit the system and maximize corporate (and CEO profits). IN addition, many of the most expensive drugs in the US are sold overseas and in Canada at a fraction of the cost. This seems to me to be clear evidence of the pharmaceutical industry taking full advantage of the inherent wealth in the US today.

However, Would it not follow that if we placed limits on the prices of new drugs and paid “fair and equitable” charges, that healthcare costs would significantly decline?

It seems our politicians have sought to attack the problem from a few angles and have failed to address other significant sources of excessive healthcare spending. While reimbursement for physicians and physician groups are set clearly in the crosshairs of the ACA, it appears industry and litigators are not even on the radar. There is hope—legislation is being introduced that will allow legal purchase of drugs from Canada for Americans. In addition, pharmaceutical companies would be required to disclose what they charge for the same drugs in other countries. I believe this is a step in the right direction. Lets continue to innovate and provide new therapies for ALL Americans. But lets do it in a way that is cost effective. The latest studies make it clear that these drugs are overpriced. We must find a way to negotiate a fair and reasonable price that promotes and rewards innovation BUT also provides access to the newest and most effective therapies for all who need it.

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Sharing Bad News or Keeping Secrets—How Physician Communication Impacts Patients and Families

Doctors and Patients bond over time. Information exchange, education and sharing of expertise are critical activities that add to the effective practice of medicine. Delivering bad news is unfortunately an unpleasant part of a physician’s job. Honesty, empathy and clear communication are essential to delivering news to patients and their families—even when the news is unpleasant or unexpected. While communication is an integral part of the practice of medicine, not all healthcare providers are able to relay information or test results in a way that is easily digested and processed by patients. Some physicians may avoid delivering bad news altogether—often keeping patients in the dark. While a paternalistic approach to medicine was accepted as the status quo for physician behavior in the 1950s, patients now expect to play a more active role in their own care. Patients have a right to demand data and understand why their healthcare providers make particular diagnostic and treatment decisions.

Recently, a disturbing report indicated that in a database of Medicare patients who were newly diagnosed with Alzheimer’s disease, only 45% were informed of their diagnosis by their physician. While shocking, these statistics mirror the way in which cancer diagnoses were handled in the 1950s with many doctors choosing not to tell patients about a devastating health problem. With the advent of better cancer therapies and improved outcomes, now we see than nearly 95% of all patients are informed of their cancer diagnosis by their physician.

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How can this be? Why would a physician NOT tell a patient about a potentially life changing diagnosis?

I think that there are many reasons for this finding in Alzheimer’s disease and that we must address these issues in order to provide ethical and timely care to our patients.

  1. Time constraints: Electronic documentation requirements and non-clinical duties allow for less time spent with each patient. In order to deliver bad news such as a terminal diagnosis, a responsible physician must not only spend time carefully delivering a clear message but must also be available to handle the reaction and questions that will inevitably follow. Many physicians may avoid discussing difficult issues due to the lack of time available to help the patient and family process a diagnosis. We must create ways to diminish the administrative burden on physicians and free them up to do more of what they do best—care for patients. More reasonable and meaningful documentation requirements must be brought forward. Currently, many physicians spend far more time typing on a computer rather than interacting in a meaningful way with patients during their office visits. Eye contact, human interaction and empathy are becoming more of a rarity in the exam room. This certainly limits the effective delivery of bad (or good) news to patients. Priority MUST be placed on actual care rather than the computer mandated documentation of said “care”.
  2. Dwindling Long-Term Doctor Patient Relationships: Networks of hospitals, providers and healthcare systems have significantly disrupted traditional referral patterns and long-term care plans. Many patients who have been enrolled in the ACA exchanges are now being told that they cannot see their previous providers. Many physicians (even in states such as California) are opting out of the Obamacare insurances due to extremely low reimbursement rates. Patients may be diagnosed with a significant life changing illness such as Alzheimer’s disease early in their relationship with a brand new healthcare provider. When a new physician provides a patient with bad news—of a life-changing diagnosis that will severely limit their life expectancy as well as quality of life—patients often have difficulty interpreting these results. Healthcare providers that have no relationship with a patient or family are at an extreme disadvantage when delivering negative healthcare news. Long-term doctor patient relationships allow physicians to have a better understanding of the patient, their values and their family dynamics. This “insider knowledge” can help facilitate difficult discussions in the exam room.
  3. Lack of effective therapies to treat the disease: No physician likes to deliver bad news. No doctor wants to admit “defeat” at the hands of disease. It is often the case where some healthcare providers will not disclose some aspects of a diagnosis if there are no effective treatments. I firmly disagree with this practice of withholding relevant information as I believe that every patient has the right to know what they may be facing—many will make significant life choices if they know they have a progressively debilitating disease such as Alzheimer’s disease. In the 1950s, many patients were not told about terminal cancer diagnoses due to the lack of effective treatments. However, medicine is no longer paternalistic—we must engage and involve our patients in every decision.
  4. Lack of Physician communication education: As Medical Students we are often overwhelmed with facts to memorize and little attention is given to teaching students how to effectively interact with patients as well as colleagues. Mock interviews with post interview feedback should be a part of pre clinical training for physicians. We must incorporate lectures on grief and the grieving process into the first year of medical school. Making connections with patients must be a priority for physicians in the future—we must equip trainees with the tools they need for success.  Leaders distinguish themselves by the way in which they share bad news.  According to Forbes magazine the critical components of sharing bad news include–accuracy of communication, taking responsibility for the situation, listening, and telling people what you will do next.

What’s next?

As with most things in medicine, change often occurs “around” healthcare providers without direct physician input. Physicians are appropriately focused on providing excellent care and connecting with patients while politicians and economists craft the future of medicine. The issues with lack of communication of negative findings with patients MUST be addressed. Patients have a right to their own data and have a right to know both significant and insignificant findings. In order to avoid situations where patients are not fully informed about their medical condition, we must continue to remain focused on the patient—even if it means that other clerical obligations are left unattended.

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Buyer Beware: How Patients are Negatively Impacted by the Changing Landscape of the Affordable Care Act (ACA)

As the Obamacare machine continues to grind forward, many patients have re enrolled in a second year of coverage. While most have not had to use their insurance (the young and healthy crowd) others have found their newly minted coverage to be far less than promised. High deductibles, and up front out of pocket expenses, forced many covered by the exchanges to avoid seeking regular preventative care—Prevention was one of then tenets of the ACA plan. Many have found choices limited and have been forced into healthcare systems that are not their first choice.

Now, as the second year of enrollment (and re-enrollment) has concluded, many of us are concerned about the likelihood of rate hikes and changes in coverage. The Obama administration continues to tout the fact that enrollment numbers remain high and that there have been no substantial increases in premiums. However, this is not necessarily the case. Many exchange insurers have cleverly disguised rate hikes through changes in other aspects of the plans. While some advertise that there are absolutely no significant premium increases, customers who shopped carefully on the exchange site were able to find higher prices for Emergency Room visits, and higher charges for non generic drugs. For some plans this means that rather than pay a $250 co-pay for an Emergency Room visit, the customer must pay up to the yearly deductible for the same ER visit before the co-pay rules go into affect. For many, this may be a non-starter. ER visits can be very expensive and can amount to thousands of dollars in just a few hours. Many patients will find themselves having to pay a 3-6 thousand dollar deductible early in the insured year before any of the benefits begin to contribute to reduce individual out of pocket costs. In some plans, the co-payment for a routine physician visit will go down by an average of 20 dollars and many generic drugs will be covered for free. However, specialty visit co-pays will increase and the prices for specialty medications will increase by 40-50%

In an effort to promote re-enrollment in 2015, the government implemented an automatic re-enrollment system. However, this has left many patients with increasing out of pocket costs due to the fact that multiple changes have been made—such as those described above. Many patients were unaware of the need to shop around for re enrollment and are now increasingly unhappy with their plans. Ultimately the ACA and its supporters in Washington have placed statistics and politics ahead of the patient. While the delivery of quality care to the patients who need it SHOULD be the goal, it appears that politics remains the top priority. Increasing out of pocket costs and higher deductibles—many requiring payment in the first half of the year—are having the opposite affect. One of the central tenets of the ACA is to focus on prevention through promoting regular access to primary care physicians for prevention of chronic disease and its complications.   However, rather than promoting and environment where patients are engaged and actively seek preventative care, many are using the insurance simply as a “disaster plan” simply due to the overwhelming costs. While out of pocket limits and guaranteed care consume the healthcare reform talking points of the Obama administration, the reality is that the way in which the ACA is structured and implemented has actually increased personal financial burden for many.

What Can Patients Do?

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Unfortunately, much of the burden of navigating the new healthcare landscape falls to the patient. The Law itself remains a moving target—with changes certain on the horizon. We must remember that insurers are for profit entities and will ultimately find a way to make a profit—often at the taxpayer and patient expense. While many have been encouraged by the Obama administration to continue to offer affordable premiums, most have found other ways to improve their revenue streams. Whether it is thru juggling co-payments and charges, shifting cost, denying procedure approval or limiting choice, all of these changes will–in the end—negatively impact patients. As a healthcare provider, my job is to educate patients about behaviors that may improve their overall health. Now with the implementation of the Affordable Care Act, this responsibility now extends to helping my patients manage their insurance choices. While this is not necessarily a traditional role of a physician, it is important that we make sure that our patients continue to have access to the care they need—without incurring a life altering expense.

There are a few things that I think that patients can do to actively advocate for themselves and others:

  1. Stay Informed: Make sure that you ask questions of your insurer—are their changes to my coverage? How are out of pocket expenses handled? Can I see my doctor and my specialist when I want or need to without incurring a penalty or increased cost?
  2. Shop Around: Just because you have had coverage with a particular company in the past does not mean that you have to remain locked in with them. Make sure you explore all of the options that are available to you through the exchanges. Carefully question insurance company representatives so that you completely understand policies BEFORE you agree to a contract
  3. Demand Transparency: If you are unable to get a clear answer from an insurer about costs and coverage BEFORE you sign up, it is very unlikely that you will get a clear answer once you are a customer. Once you are a customer, make sure that you have a clear idea of the costs involved prior to scheduling a procedure or test. A recent survey sponsored by the Robert Wood Johnson foundation found that nearly 56% of Americans get out of pocket cost information before accessing healthcare services.

As with most things that have occurred with the Affordable Care Act, it is the patient who ultimately suffers. Insurers continue to profit, as do drug makers and hospital systems and administrators. Physicians have seen reimbursement cut to levels that have forced integration with large hospital systems. Most tragically, however, patients tend to be caught in the middle and have seen their healthcare suffer. Surveys indicate that patients are now inquiring as to cost prior to office visits, tests and procedures. Many find that they must put off necessary preventative activities and even more opt not to have needed tests and therapeutic procedures due to cost. It is clear that the ACA has missed its mark. While insuring large numbers of Americans is a noble goal, this insurance must also provide value rather than meaningless statistics to be utilized at a White House press briefing. As my research mentors at Duke University taught me during my training–with any data analysis, it remains that garbage will equal garbage out. WE must find a better way to provide affordable care to our patients. For now, insurers, hospital systems and politicians are using patients as nothing more than a “Profit Center”. As reenrollment continues through this year and the next we must make sure that our patients are armed with the old adage—“Buyer Beware”

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Attending a Funeral: Mourning the Loss of a Friend AND Learning More About the Art of Medicine

(Please note that this blog is based on real people and actual events.  I am grateful to Ed’s family for granting me permission to use his real first name in this blog)

One of the best things about the practice of medicine is the ability to develop long-term relationships with patients and their families.  As physicians, we have the unique privilege of meeting and interacting with thousands of people throughout our careers.  Every once in a while, there are certain people who really make a lasting impact and forever change us as caregivers and as human beings.  Ed was one of those patients.

This week, I said goodbye to one of my long time patients and dearest friends.  Ed, a Korean War veteran, was an amazing man.  He was a dedicated father, a devoted spouse and lived a life that was an example of faith and service to others.  I met Ed through his daughter years ago.  He had moved locally to live near his children and needed a new cardiologist. Fortunately for me, his daughter asked me to take him on as a patient.

Ed had an ischemic cardiomyopathy and suffered from complications of congestive heart failure (CHF).  He was fairly well compensated on medical therapy but continued to have worsening CHF.  During the course of his illness, we eventually  implanted a Biventricular ICD and his symptoms improved significantly.  As with most patients with CHF, over the years, he began to have more frequent hospitalizations for CHF exacerbations.

Through it all, Ed was always cheerful and never complained–in fact it was sometimes difficult to monitor his symptoms due to his demeanor.  Ed always put others before himself.  His wife, suffering from her own chronic illness, was the focus of his final days.  He loved her deeply and wanted to be sure that she was comfortable and well cared for.  Because of my relationship with Ed and his family, I have been made a better cardiologist, and most importantly, a better man.

Men like Ed are few and far between–I was honored to care for him.  My professional role as his cardiologist is what provided me with the fortunate opportunity to be a part of his life and develop a relationship with he and his wonderful family.  As I have said many times before, Medicine is best practiced when relationships and tight bonds are formed between Doctor and patient.  As I left the chapel where the Catholic Mass celebrating Ed’s life was held, I could only wonder if I would ever have the chance to meet another “Ed”.  Healthcare in the US has become more fragmented than ever and care is no longer contiguous in many cases.  Many patients are experiencing access issues and are being told that they can no longer see their long time physicians because of “network” issues or insurance coverage rules.  Doctors are forced to spend more time typing and glaring at  computer screens and less time actually getting to know the “people” behind the diseases they treat.  Connections like I had with Ed are harder to form and personal bonds are less likely to occur in the current environment.  I fear that medicine is becoming more about the “system” and managing regulation than it is about listening and caring for those who suffer from disease.

Ed taught me many things during the time that I cared for him.  He taught me humility, kindness and selflessness–I have never met anyone quite like him. Most importantly, he taught me the value of relationships and TIME.  Even in death, he inspires me to be more to each of my patients–in spite of increasing government demands on both my time and talents.  Ed never stopped caring for others–he never wavered in his commitments to his God, his wife and his children.  It is my hope that I can stand firm and continue to fight for my patients and their right to receive exceptional care.  While I continue to actively speak out against the Affordable Care Act and the regulation of medicine that separates doctor from patient, I must do so in a way that is constructive and advocates for the patient rather than for the doctor.  That is how Ed would see it–of that I am sure.

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“Veritas”, Ivy and the Affordable Care Act: What’s Good for the Goose May Now NOT be Good for the Gander at Harvard

Prominent academics within the prestigious Harvard University department of Economics have long been vocal supporters of President Obama and his Affordable Care Act legislation.  In fact, many Harvard professors helped develop some of the concepts that were utilized in the drafting of the ACA.  During the debates over the ACA in Congress, these professors were frequently seen (and heard) touting the legislation as a fiscally responsible way to provide affordable care to all Americans.  The current Provost, Dr Alan Garber,  (not to be confused with MITs Gruber), was part of a group of economist who sent letters to the President in the early days of the ACA praising certain aspects of the bill such as “cost sharing” and the Cadillac tax applied to the best plans.

My how things have changed.  This week, as reported in the New York Times, these same Harvard faculty are in an uproar as they have seen their own healthcare plans completely overhauled.  Rather than being allowed to maintain their long time low cost (out of pocket) plans, the university has now implemented healthcare coverage that is consistent with the provisions in the ACA.  Now there are more up front out of pocket expenses for basic insurance plans and the Cadillac plans are much more expensive.

During a faculty meeting the vast majority of Harvard professors voted to oppose the changes in the Harvard health plan that would require them to pay more for their own healthcare—How dare Harvard adjust their own benefits and how dare the University actually expect them to be a part of a new ACA influenced health care plan at Harvard???

This type of attitude is even more prevalent among lawmakers in both the White House and in Congress.  Members of Congress as well as the President and all staffers are EXEMPT from the individual mandate.  This type of paternalistic governance is what is wrong with Washington today.  Many Democrats seem to have taken the attitude that they were elected not to represent the people but rather to do what they think is best for their constituents.    In an era when the ACA is wildly unpopular, many politicians continue to refuse to believe that changes to the legislation should be made.

If the ACA is such a great thing, why then do those who designed it and legislated it refuse to participate?

  1. The President and His Legacy:  The President continues to see the ACA as his legacy.  In spite of plummeting approval numbers and a negative referendum on his failed policies during the 2014 Midterm Elections, Obama refuses to examine the numerous issues associated with the healthcare law and does not appear to have any willingness to compromise on amending the act.  Unfortunately, Obama’s pursuit of his legacy appears to trump sensible bipartisan negotiations and will severely limit Washington’s ability to actually govern.
  2. Paternal Governance:  Currently, Many in power feel as though they know what is “best” for the rest of us.  Rather than represent a constituency, many of our leaders actually believe that the American people are incapable of making sound decisions for themselves and their own healthcare.  The “Big Brother” knows best attitude continues to alienate millions of voting Americans.  Interestingly, when those that helped craft the legislation (i.e. the now disgruntled Harvard economics professors) are subjected to the law that they supported, the outlook quickly changes.
  3. Partisan Politics:  Our country is the more divided politically than ever before.  Relationships in Washington are so polarized that compromise will be difficult to achieve.  Our elected government is divided with the President refusing to even consider bills that are put forward–instead he threatens vetoes in advance on any bills that address issues concerning the reform of the ACA.

So, What’s Next?

As a country we must begin to deal with the issue of healthcare in a more productive and collaborative way.  Politics as usual will result in another two years of decline in both the quality and affordability of the American healthcare system.  We must hold Washington accountable and the Obama administration MUST begin to work with Congressional leaders to find workable, effective solutions to the mountain of problems that has been created by the poorly thought out and recklessly implemented Affordable Care Act legislation.  And, those at Harvard (as well as those in Washington) should have to live with the same healthcare insurance programs that are mandated for the rest of us–No Exemptions.

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Reflecting on Medicine in 2014: Sailing Rough Seas and Finding Uncharted Waters Ahead

As we close out on a tumultuous 2014 in healthcare, many physicians are looking forward to a better and more stable 2015. For most of us, 2014 has been marked by significant change. Many healthcare providers have seen their jobs and their patient care roles transform completely. Physician autonomy has diminished and regulation and mandated electronic paperwork has more than doubled. Many physicians find that they are spending far less time caring for patients and a greater proportion of their available clinical time is now being spent interfacing with a computer—both at work and at home on personal time.

During the last year, we have all been affected by the rollout of the Affordable Care Act (ACA), changes in reimbursement, as well as the implementation of a new billing and coding system (ICD-10). For many of us, it also marked a year of transition to system wide electronic medical record systems such as Epic and the growing pains associated with such a major upheaval in the way in which medicine is practiced.   Many practices have continued the trend of “integration” with larger healthcare systems in order to remain financially viable. The American College of Cardiology estimates that by the end of 2014, nearly 60% of all physician members have integrated with hospital systems and this number is expected to rise even further in 2015—ultimately defining the death of private practice as we know it.

Why have these changes occurred?

Ultimately, I believe that the changes to the way in which healthcare is delivered has come about due to 3 distinct reasons:

 1. Declining Reimbursement

Currently reimbursement continues to fall. Multiple government budgetary “fixes” have led to much uncertainty and instability in medical practices (much like seen in any small business with financial and market instability). In addition, the implementation of the ACA has resulted in the expansion of the Medicaid population in the US—now nearly 1 in 5 Americans is covered under a Medicaid plan. Traditionally, Medicaid plans reimburse at levels 45% less than Medicare (which is already much lower than private insurance payments). While the Obama administration did provide a payment incentive for physicians to accept Medicaid, this incentive expires this week. Many practices are becoming financially non viable as overhead costs are risking to more than 60%. As for the ACA, many exchanges have set prices and negotiated contracts with hospital systems—leaving many practices out of network. Both patients and doctors suffer—longtime relationships are severed due to lack of access to particular physicians.

2. Increasing Administrative/Regulatory Demands

With the implementation of the ICD-10 coding system, now physicians are confronted with more than 85, 000 codes (previously the number of codes was approximately 15,000). In addition, “meaningful use” mandates for payment have resulted in increasing documentation requirements and even more electronic paperwork. In addition, the implementation of new billing and coding systems has required increasing staff (more overhead) as well as intensive physician training. Sadly, the new coding system that has been mandated by the Federal government includes thousands of absurdities such as a code for an “Orca bite” as well as a code for an “injury suffered while water skiing with skis on fire”.

3. Electronic Medical Record Mandates

Federal requirements for the implementation of Electronic Medical Records and electronic prescribing have resulted in several negative impacts on practices. While in theory, the idea of a universal medical record that is portable and accessible to all providers is a noble goal, the current reality in of EMR in the US is troubling. There are several different EMR systems and none of them are standardized—none of them allow for cross talk and communication. Many small practices cannot afford the up front expenditures associated with the purchase and implementation of the EMR (often in the hundreds of thousands of dollars).   In addition, the EMR has slowed productivity for many providers and resulted in more work that must be taken home to complete—not a good thing for physician morale. Finally, and most importantly, the EMR often serves to separate doctor and patient and hinders the development of a doctor-patient relationship. Rather than focusing on the patient and having a conversation during an office visit, many physicians are glued to a computer screen during the encounter.

So, What is next in 2015?

While I have probably painted a bleak picture for Medicine in 2014, it is my hope that we are able to move forward in a more positive way in 2015. I think that there are several very exciting developments that are gaining momentum within medicine and healthcare in general.  Innovation and medical entrepreneurship will be critical in moving healthcare forward in 2015.  Physicians must continue to lobby for the tools and freedoms to provide better patient care experiences for all stakeholders in the healthcare space.

2015 begins with much promise. I am excited to see what we as healthcare professionals will be able to accomplish in the coming year. We must continue to put patients first and strive to provide outstanding care in spite of the obstacles put before us. While 2014 provided challenges, we must rise above the fray and continue to advocate for a better healthcare system in the US today and in the future.

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Obama’s Latest Bait and Switch for Docs: Medicaid Payments to be Cut by 40%

As we enter year two of the Affordable Care Act, we have seen many issues arise during implementation.  Through both executive order and executive memorandum, President Obama has unilaterally changed the law more than 100 times in order to advance his own political agenda.  When it became important to publicize enrollment and increased coverage of the uninsured, the President and the ACA provided for an increased payment scale for patients with Medicaid.  With the rapid increase of Medicaid insured patients due to the implementation of the ACA, the administration utilized the increased payments as an incentive to attract more physicians to participate in Medicaid programs.  According to the New York Times, the ACA has resulted in the largest increase in Medicaid covered patients in history–now nearly 20% of all Americans are covered under this plan.  Attracting physicians to cover Medicare patients has been critical in order to meet the demand for access to care and  to adequately cover the newly insured.  Now, unless changes are made this week, Medicaid reimbursements will be cut once again leaving many physicians to wonder if they can continue to treat the increasing numbers of Americans covered thru these programs.

Traditionally, Medicaid has reimbursed physicians at rates significantly lower than Medicare–making practices with large numbers of Medicaid patients financially non viable.  As the ACA was rolled out, a provision provided for significantly better Medicaid payment rates to physicians in order to help provide larger networks of care for the newly insured.  Now, there looms an automatic payment rate cut of nearly 43% for Medicaid payments to primary care physicians–many of these are the same physicians who agreed to expand Medicaid within their practices in order to meet demand.  According to Forbes, traditional Medicaid reimbursement averages just 61% of Medicare reimbursement rates (which is often significantly lower than private insurance rates).  In addition, many Medicaid patients require a disproportionate amount of time and resources from the office–doctors are caught between a “rock and a hard place”–between a moral obligation to treat these patients and a desire to avoid financial ruin.  These patients tend to be sicker, have multiple medical problems and have suffered from a long time lack of preventive care.

Finances are not the only piece of the Medicaid puzzle. Government regulation and paperwork and processing often delays payments to physicians and impacts their ability to run a financially sound business.   Interestingly, a study from 2013 published in Health Affairs suggested that while physicians welcomed an increase in reimbursement rates as incentive to treat Medicaid patients that quicker payment times, reduced paperwork and simplified administrative processes would also need to be a part of any type of reform.  (of course, none of these items were included in the incentive package).

Many primary care physicians stepped up to answer the call for increasing coverage of Medicare patients when the ACA was initially rolled out.  Now, these same physicians are contemplating the need to drop these patients from their clinics with the pending change in reimbursement.  As mentioned above, in addition to lower reimbursement rates, the Medicaid program requires an enormous amount of administrative work in order to file claims and these claims are often paid very late–those running a small practice are forced with more work for less pay and often have to make difficult budgetary decisions in order to  payroll for their staff each week.   While the administration touts the swelling numbers of Medicaid covered patients–nearly 68 million currently–I suspect access to quality care will soon become an issue.  Just as with every other manipulation of the ACA over the last two years, legacy and political agendas have taken precedent over what really should matter–providing quality medical care AND prompt, easy access to care for the formerly uninsured.  In an effort to tout swelling numbers of “covered” Americans, the Obama administration has failed to anticipate the impact of short term financial incentives for primary care physicians to accept increasing numbers of Medicare patients.  Even in states such as California, officials are bracing for a large number of physicians who have announced that they will likely drop out of Medicaid plans if the planned cuts are implemented as scheduled.

It is time for the Obama administration to stop playing political games with our healthcare.  If the mission of the ACA is to provide affordable quality healthcare for all Americans, then we need to ensure that there are quality, dedicated physicians available to provide that care.  The Medicaid “bait and switch” is just one example of our President’s shortsightedness and lack of connection to those dedicated physicians who work tirelessly to ensure that ALL patients have access to care (regardless of insurance type).  It is my hope that the new Congress will engage with the physician community and find real solutions to the US healthcare crisis–and no longer allow the President to place his perceived legacy over the healthcare of those Americans who are in need.

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Image adapted from The Peanuts comic strip by Charles Shultz

Controlling the Costs of Innovation: Let’s Refocus and Remember The Patient

In a controversial study released this week, Tufts University’s Center for the Study of Drug Development estimates that the cost to bring a new drug to market exceeds nearly 2.6 billion dollars.  The study, which was 40% funded by industry has been criticized for over estimating these costs in favor of industry and misrepresenting some cost estimates.  While we will not know fully the extent of the methodology of the study until later in 2015 when it is published in a peer reviewed journal, these preliminary findings were released in advance and have already begun to spur debate.

However, irrespective of these criticisms, I believe that the study does have merit and brings an important issue forward—is the FDA stifling innovation with excessive fees and paperwork?  Are smaller, less well funded researchers/corporations unable to significantly contribute without partnering with big pharma? Who will ultimately bear the increased cost of drug development?

Innovation is what has always made healthcare in the US great–it is what separates us from the rest of the world.  For decades, the US has been able to attract talent from throughout the world and this has resulted in numerous “game changing” breakthroughs in medicine.  Through continued development of new drugs, new technologies and new ways to better treat disease, we are able to improve outcomes and reduce death from preventable disease.  The US has always been a place where others from around the world have come to incubate and grow ideas.  Now, it appears that innovation must come at a substantial cost–the increasing capital required for drug development as well as taxes on medical device companies only serve to squeeze out the “small guys with big ideas” and limit our ability to continue to produce new, more effective therapies and cures.  In addition, these additional costs to the pharmaceutical industry are not simply added to their bottom line–they are pushed on to the healthcare consumer as well as Federally funded healthcare plans.  Ultimately, the taxpayer bears the brunt of the increased cost.

The process of drug development is long and arduous.  Government regulation, politics and greed have served to make it even more difficult.  Physicians in academic medicine, scientists, pharmacologists and leaders in industry have learned to partner and share ideas in order to bring basic science principles from the bench to the bedside—ultimately translating ideas into cures.  Certainly, big pharma is in place to make profits and increase market share.  But as costs increase, many drug makers are putting less and less profit back into research and development.  Growth can become stagnant and new ideas may never reach the bench or bedside.  Federally funded research–such as NIH grants–face big cuts and budgets are often embroiled in political battles.  Legislators use research dollars as bargaining chips and fund projects that appeal only to a particular interest group or a group of favored donors.  We must find a better way to promote medical innovation and reward research.  We must find better ways to choose the most promising projects for funding.  We must be good stewards of the R & D dollar and make every single investment count.

As with most things in medicine, we must always pause and remember to focus on the patient.  Advocating for the patient suffering with disease is the reason most of us became involved in medicine in the first place.  Whether the study from Tufts over-estimates the cost of development or not, it should still serve as a wake up call to us all.  We must work to control the cost of developing new therapies—we must limit excessive taxation, we must promote entrepreneurship and begin to fix the current system of FDA approval for new therapies.  We must separate politics from medicine and streamline processes—eliminate paperwork and promote efficiency–if we are to continue to lead the world in medical innovation.  We must continue to make room for the “small guy with the big ideas”–If we do not–ultimately it will be our patients that suffer in the end.

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Should We All Die at 75?: Addressing the “Emanuel Principe” in Obamacare

Ezekiel Emanuel, one of the authors of the Affordable Care Act spoke publicly this week about his own desire to “die at 75” in a article published in the Atlantic.  In his piece, he argues that as he ages, he wishes to stop all preventative medical measures and “let nature take its course” as he approaches the age of 75.  This includes screenings such as colonoscopy as well as taking flu shots for the prevention of communicable illness.  While currently in excellent health, Mr Emanuel believes that while death is a loss–”living too long is also a loss.” He argues that the American obsession with living longer results in a larger number of elderly, disabled citizens.  I take significant issue with this position and fear that this is simply the beginning of a new phase in the ACA debate–the rationing of care. From the outset, many of us in healthcare and scholars of healthcare policy have seen Obamacare as a way to promote the rationing healthcare (particularly for the elderly).  While the administration has vehemently denied these claims throughout the legislative and implementation phases of the new healthcare law, it is particularly revealing that one of the principal architects of the law firmly believes that we should not pay attention to life expectancy statistics beyond the age of 75.  Medical advances have made it increasingly possible for seniors to lead healthy, productive exciting lives well into their 80s.  Now, I certainly am not arguing for providing futile care in the setting of terminal illness but–Why then should government (instead of doctors) now have the right to determine how healthcare resources are utilized and who gets what?  Is it all about age?  Do we value the young more than the more “seasoned” citizens? The US healthcare system, while certainly imperfect, offers some of the greatest technological advances in the world and the most significant thing that has always set US healthcare apart form others has been CHOICE.  With Obamacare in place, we now have less choice in our healthcare and very little improvement in access.  This latest article by Mr Emmanuel is no surprise–he has been clear about his belief in allocating health care dollars away from activities which may extend lifespans for Americans.  While, Mr Emmanuel certainly has the RIGHT to refuse care for himself at a certain age neither he (NOR OBAMA or any GOVERNMENT agent) should be able to determine an “acceptable” life span for each of us. Quality of life and health status can be very subjective and care must remain individualized rather than mandated (or withheld) based on actuarial tables or government rationing of resources. Medicine is all about innovation and the development of new technologies.  Through technology we are able to provide longer, more productive lives for our patients.  Our patients are able to retire from a life of work and enjoy spouses, family and friends–well into their 80s and 90s WITH a quality of life.  In fact one of my favorite “golf buddies” is 80 years old and going strong–He can still shoot in the 80s from time to time and never misses a game. In MEDICINE one size does not fit all.  OBAMACARE wants to force a ONE SIZE FITS ALL healthcare system on all of us and as a physician I find this to be unacceptable.  Just as we must cater therapy to individual patients—when (and how) you die must also be catered to each individual patients needs, desires and beliefs. Chronological age such as 75 may be different for different people AND we must respect individual needs.  Medicine is a clearly a science but in many cases the practice of medicine –particularly when making decisions about end of life issues–makes it more of an ART.  The government has no place in dictating ART.  Government should help to preserve and curate art–not regulate and mandate the way in which medical care is delivered to individual patients based on age. Ultimately, left to its own devices, I believe that the ACA will create rationing of care for Americans and we will have two classes of people–those that are wealthy and can afford private care and can pay cash for it–these can make their own healthcare decisions and decide when enough is enough.  The others–most of us–will be lumped into the disaster that IS obamacare and will have little or no choice in how our healthcare is delivered.  Waiting lists for advanced procedures and denials of advanced care for the elderly will be the standard–Just as Mr Emanuel envisioned it when he crafted the law just a few short years ago.

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Engaging Patients with an Apple and Health Apps: Watches Are No Longer Just for Telling Time

Today patients are increasingly connected.  The fastest growing demographic on Twitter is actually those that are between 45 and 65 years old.  Our patients are becoming better informed and are flocking to the internet and to social media to discuss and learn more about disease.  Prevention of disease is becoming more of a priority in our healthcare system as we begin to adjust to the mandates provided for in the Affordable Care Act and physicians are now expecting patients to take a more active role in their healthcare.  In the last 5 years, the concept of the electronic patient has emerged and is becoming more and more prevalent among mainstream patient populations.  These patients often come to office visits armed with information and data collected on the internet and are very technologically savvy.  They embrace new devices and are eager to track health indicators such as blood sugar, blood pressure and heart rate through easy to use phone applications.

This week, Apple intends to announce a new smartwatch and a group of associated health applications.  These innovations will further allow the electronic patient to become more of a mainstream phenomenon.  However, in order to be effective, physicians and other healthcare providers must embrace these technologies and begin to better understand their utility in all patient populations.  According to the Wall Street Journal, the announcement of the new smartwatch is expected to introduce no less than ten new sensors for monitoring health indicators.  Apple has created a data repository that will allow health related information to be stored (with the user’s permission) and directed to healthcare providers if so desired.  This assimilation and collection of massive amounts of health indicator data may be a significant game changer in the fight against chronic disease.  With many patients, compliance with medication or lifestyle modification plans is a challenge.  Many diseases such as hypertension do not produce immediate ill health effects–rather they accumulate over time.  However, if we can clearly demonstrate to patients the positive responses to interventions on a daily (or even hourly basis) they may be much more likely to comply with prescribed treatment plans.  Glancing at a smartwatch and noting a response to exercise or to a completed dose of medication can be a powerful motivational tool.

What if all of the data is collected simply by wearing a watch?

If we make collection and organization of information simple and user friendly, then important information can be transmitted to a physician who can review the data prior to the next face to face office encounter.  Real time feedback can then be provided to the patient and this may ultimately result in increased engagement and may actually spur change in habits or behaviors that are detrimental to a particular patient’s health.  Moreover, according to the WSJ, the new Apple operating system will include a Health icon that will allow for the development of a dashboard with many health indicators that are easily accessible in one place–lab results, heart rate, blood pressure, weight–even calories consumed and burned in a given time period.  The engaged patient can see what they are doing right, what they are doing wrong and can track improvements in habits rather quickly.  Having the data all in one place will likely increase compliance and improve overall health of the adopters of this technology.

What about security of sensitive personal healthcare data?

As with most new advances in medicine, there are significant concerns about data breaches and compliance with the federal Health Insurance Portability and Accountability Act (HIPAA) regulations.  According to a story in the New York Times, Apple is working with application developers as well as the federal government in order to ensure that any stored or tracked healthcare data will remain secure.  Partnerships with application designers, insurance companies, healthcare systems and physicians will be critical to the success of the new Apple smartwatch.  As these new technologies are rolled out and continue to develop, efforts to secure data will continue to evolve.

The development of new and exciting healthcare technologies and applications will continue to bolster the development and of the growing number of electronic patients.  Ultimately, the Apple smartwatch and other soon to be developed health indicator monitors, trackers and data repositories will only serve to further engage both patients and doctors and, in my opinion, significantly improve our ability to intervene EARLY and prevent the terrible consequences of chronic disease.

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