Tag Archives: ACA

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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Turf Battles and Collateral Damage: Are We Really Putting the Patient First?

Last week, Medpage Today reporter Sarah Wickline Wallan tackled a very controversial issue in medical practice.  In her piece, Ms Wallan explores the ongoing battle between Dermatologists and AHPs (Allied Health Professionals) over the performance of dermatologic procedures.  As independent NPs and PAs begin to bill for more and more procedures (thus potentially talking revenue away from board certified Dermatologists) specialists are beginning to argue that the AHPs are practicing beyond their scope of practice. According to the Journal of the American Medical Association, nearly 5 million dermatological procedures were performed by NPs and PAs last year–this has Dermatologists seeking practice limits–ostensibly to protect “bread and butter” revenue streams from biopsies, skin tag removals and other common office based interventions.

In response to this controversy and the article, I was asked to provide commentary for Med Page Today’s Friday Feedback.  Each week, the editors at MPT discuss a controversial topic and have physicians from all over the country share their feelings on the issue in order to provide readers with a mulit-specialty perspective.  This “Friday Feedback” feature is typically released on the web near the end of the day on Fridays and often spurs a great deal of social media activity and discussion.  Based on reaction to Ms Wallan’s article our topic this past Friday was “Specialty Turf Battles”.  Each respondent was asked to provide commentary on the growing angst between Dermatologists and Allied Health Professionals.    As I began to reflect on the issue itself and its potential impacts on all aspects of medicine, I felt that a complete blog would be a more complete forum to discuss my thoughts.

First of all I want to say that AHPs are essential to providing care in the era of the Affordable Care Act.  NPs and PAs are able to help meet the needs of underserved areas and do a remarkable job complementing the care of the physicians with which they work.  With the rapidly expanded pool of newly insured, as well as the increase in administrative tasks (electronic documentation) assigned to physicians, AHPs must help fill in the gaps and ensure that all patients have access to care.  In my practice we are fortunate to have many well qualified AHPs that assist us in the care of our patients both in the hospital as well as in the office.

We must remember, however, that physicians and AHPs have very different training.  Each professional posses a unique set of skills and each skill set can complement the others.  Many of us in specialty areas spend nearly a decade in post MD training programs and learn how to care for patients through rigorous round the clock shifts during our Residency and Fellowship years.  In addition, we spend countless hours performing specialized procedures over this time and are closely supervised by senior staff.  Most AHPs, in contrast, do not spend time in lengthy residencies and often have limited exposure to specialized procedures.  Turf battles have existed for decades and are certainly not limited to Dermatology–nor or they limited to MDs vs AHPs.  In cardiology in the late 1990s, for instance, we struggled with turf battles with Radiology over the performance of Peripheral Vascular Interventions.  In many areas, these battles resulted in limited availability of specialized staff to patients and a lack of integrated care.  Ultimately, the patients were the ones who suffered.

Fortunately, in the UNC Healthcare system where I work (as well as others across the country) we have taken a very different approach.  After observing inefficiencies and redundancy in the system, several years ago our leadership (under the direction of Dr Cam Patterson) decided to make a change.  The UNC Heart and Vascular Center was created–Vascular surgeons, Cardiologists, Interventional Radiologists, and Cardiothoracic surgeons–all working under one cooperative umbrella.  Patients are now discussed and treated with a multidisciplinary approach–Electrophysiologists and Cardiothoracic surgeons perform hybrid Atrial Fibrillation ablation procedures, Vascular surgeons and Interventional Cardiologists discuss the best way to approach a patient with carotid disease–all working together to produce the BEST outcome for each individual patient.  We have seen patient satisfaction scores improve and we have noted that access to multiple specialty consultations has become much easier to achieve in a timely fashion.  Most importantly, communication among different specialties has significantly improved.

Unfortunately, with the advent of the ACA and decreasing reimbursement I suspect that turf battles will continue.  Financial pressures have become overwhelming for many practices and the days of the Private Practice are limited–more and more groups will continue to “integrate” with large hospital systems in the coming years.  Specialists such as Dermatologists and others will continue to (rightly so) protect procedures that provide a revenue stream in order to remain financially viable.  However, I believe that our time will be better spent by working together to improve efficiency of care, quality of care and integration of care.  NPs and PAs are going to be a critical component to health care delivery as we continue to adapt to the new (and ever changing) ACA mandates.  We must put patients FIRST–turf battles and squabbles amongst healthcare providers will only limit our ability to provide outstanding, efficient care.  Let’s put the most qualified person in the procedure room–and make sure that ultimately patients get exactly what they need.

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More (or less) Hope and Change (for the worse) In Healthcare: Are Doctor Shortages Really All Due To Training Bottlenecks?

There is no doubt that Affordable Care Act has changed the landscape of medicine in the US.  Now, private practice is becoming a thing of the past. Financial pressures, increasing regulatory requirements, electronic medical records and outrageously complex coding systems are forcing long time private physicians to enter into agreements with academic centers and large hospital systems in order to survive.  As a result, medicine today is more about increasing patient volumes, completing reams of paperwork and administrative duties than it is about interacting with patients and providing superior care.  The American Academy of Family Practice (AAFP) estimates that there will be a significant shortage of primary care physicians in the next several years unless we increase the number of primary care trainees by more than 25% over the same time period.  In fact, the AAFP suggests that the primary care workforce must increase to 260K physicians by the year 2025–which translates to an additional 52K primary care doctors.

Given the need for more physicians and the pending shortage (particularly in primary care), many analysts have suggested that the reason for the shortage is a lack of training slots in primary care.  The ACA will add an additional 32 million patients to the pool of insured and primary care doctors will be at a premium.  In the New York Times this week, the editorial board collectively penned an article discussing their thoughts concerning the doctor shortage.  The NYT editorial board suggests that the shortage is all about an imbalance between Residency training slots and medical school graduates and can be easily corrected by federal funding of a larger number of training positions.  However, I think that the issue is much more complex and the solution is far from simple.

Primary care is an incredibly challenging specialty and requires a broad knowledge of much of medicine.  Reimbursements for primary care work continue to lag and physicians are now spending more time with administrative duties than they are with patients.   I do not believe that the so called post graduate training “bottleneck” will come into play.  I would suggest that many primary care training slots will go unfilled over the next 5-10 years even without increasing the numbers of available positions.  Increasing training slots for primary care specialties may do nothing to alleviate shortages if there are no students who wish to train.  While medical school enrollments have increased over the last decade, much of this increased enrollment may be due to a lack of jobs available to recent college graduates.  Moreover, as the ACA continues to evolve, physicians are now realizing lower compensation rates, increased work hours, more administrative duties and LESS time spent caring for patients.  Many physicians are forced to double the number of patients seen in a clinic day–resulting in less than 10mins per patient–in order to meet overhead and practice expenses.  In a separate article in the New York Times, author and cardiologist Sandeep Jauhar discusses the increased patient loads and subsequent higher rates of diagnostic testing that is required in order to make sure that nothing is missed–ultimately increasing the cost of care.

For most of those who have entered medicine, the attraction to the profession is all about the doctor-patient interaction and the time spent caring for others.  I would argue that the primary care shortage (and likely specialist shortage) will worsen in the future.  Many bright minds will likely forego medicine in order to pursue other less government-regulated careers.  In addition, many qualified primary care physicians will opt out of the ACA system and enter into the rapidly growing concierge care practice model.  The answer to the physician shortage may be more political than not–politicians must realize that laws and mandates only work if you have citizens willing to devote their time, energy and talents to the practice of medicine.  Going forward, more consideration must be given to physician quality of life and autonomy must be maintained.  In order to make healthcare reform sustainable, those in power must work with those of us “in the trenches” and create policies that are in the best interest of the patient, physician and the nation as a whole.  Cutting costs must be approached from multiple angles–not simply reducing the size of the physician paycheck.

Medicine remains a noble profession.  Those of us that do continue to practice medicine are privileged to serve others and provide outstanding care.  In order to continue to advance, we must continue to attract bright young minds who are willing to put patients and their needs above their own–at all costs.  I think that there is still HOPE to save medicine in the US.  It is my HOPE that our government will soon realize that in order to continue to propagate a workforce of competent, caring physicians we must provide time for physicians to do what they do best–bond with patients and treat disease.  (as opposed to typing into a computer screen and filling out endless reams of electronic paperwork).  It is my HOPE that those physicians in training  that will follow in my generation’s footsteps will realize the satisfaction that comes from impacting the health and lives of patients over time.  It is my HOPE that the ART of medicine can be saved before it is too late….

 

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Healthcare Industry CEOs and the Cost of Care: Too Many Men (and Women) in Black (Suits)?

Healthcare reform is a reality.  The ACA and its associated mandates have forever changed the landscape of medicine in the US today.  The Obama administration touts the goals of reform as providing affordable, cost effective, high quality care for all Americans.  Certainly these are noble and lofty goals–but have we completely missed the mark?  Today, many remain uninsured and the majority that have signed up for the exchanges are simply those who have lost their healthcare coverage from other providers.  Healthcare costs in the US remain above those of all other industrialized countries while physician salaries in the US continue to fall.  Even though the US spends more dollars per capita on healthcare than any other country on earth, our outcomes, when compared to other nations,  remain mediocre at best.

What about cost?  Who is actually delivering care?

Over the last 30 years, hospital administrators and CEOs have grown by 2500% while physicians have grown by only a modest amount.  In fact, according to the American Academy of Family Practice, there must be a 25% increase in primary care doctors over the next 10 years in order to keep pace with demand.  Multiple independent surveys (published by the AAMC) indicate a significant shortfall of all types of physicians nationally by the year 2020.  As administrators and insurance company executives grow, hospital staff and services continue to be cut—nurses and doctors are asked to care for more patients with fewer resources.  Executives continue to tout savings within their organizations and boards award these administrators with enormous financial bonuses.

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Source :  BLS and Hammelstein/Wool handler

Where are the Doctors in all of this?

The short answer is that physicians are caring for patients and managing the piles of paperwork that the government and other healthcare organizations and executives have created for them.  Doctors are now consumed with checking boxes, implementing EMRs and transitioning to a new coding system for billing—all while seeing increasing patient loads and meeting increasingly steep clinical demands.

This week in the New York Times, Elisabeth Rosenthal penned an article that spells out what many physicians have known for a very long time—the administrators and hospitals are the high wage earners–not the doctors.  As the numbers of administrators continues to rise exponentially, many independent physicians and physician groups are being driven to integrate with or leave practice altogether in order to remain fiscally viable.  According the the Times, the salaries of many administrators and CEOs (in both the hospitals and the insurance industry) are outpacing salaries of both general practice physicians, surgeons and even most specialists.  Astronomical wages such as those earned by Aetna’s CEO (total package over 36 million dollars) and others are a big contributing factor to the trillions of dollars that we spend on healthcare each year.  According to the New York Times, healthcare administrative costs make up nearly 30% of the total US healthcare bill.  Obviously, large corporations and CEOs will argue that these wages are necessary to attract the best and brightest executives to the healthcare industry.  What is there to attract the best and brightest scientists to medicine?  Certainly altruism is a big part of what physicians are about but economic realities must still come into play when bright young students are choosing careers (while accumulating graduate and professional school debt at record paces).

Why then does it seem as though physicians are the only target for reform?

That answer is simple–hospital administrators and insurance company CEOs are well trained businessmen (and women) with MBAs from prestigious schools.  They understand politics and how to effectively lobby.  They have been actively involved in reform and have participated in discussions on Capitol Hill rather than watch the change happen around them.  When costs are cut from the healthcare expenditures, they have made erudite moves–they have worked effectively to isolate themselves and their institutions from the cuts that are affecting the rest of the industry.   While reimbursement for office visits and procedures falls to less than 50% through many of the exchanges and other government based programs such as Medicare and Medicaid, CEOs and hospital administrators continue to financially outpace their colleagues in other sectors of business.

As physicians, we must continue to focus on our patients and their well being.  Individually, we must continue to provide outstanding, efficient, quality care to those who depend on us every single day.  As a group, however, doctors must begin to work harder to influence those in Washington for change.  While healthcare reform is essential and must be accomplished in a fiscally responsible way, it is my hope that those in a position to effect change will recognize that we must begin to better regulate and limit those in CEO and administrative positions in both the insurance and hospital industries.  Just as we reduce the numbers of nurses on the floor to care for patients in order to save healthcare dollars, maybe we should eliminate a few VPs with fancy offices on the top floors of our hospitals.  Which one do you think will positively impact patients more–fewer nurses or fewer dark suits?

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Obamacare Delays and Rearranging Deck Chairs on the Titanic: Old People Can’t Surf

This week the White House announced yet another Obamacare delay–actually, to be precise, they termed it an “accommodation”.  The reason given for the delay was that there were concerns voiced by the Obama administration that the “rush” to sign up during the final days may cause delays and result in a website crash.  Therefore, it was proclaimed that those who were “trying to sign up” would be given an extension to mid April to complete the process.  Overall there have been more than 20 unilateral changes/delays/exceptions made by the President without Congressional approval or oversight.  Exceptions have been provided for businesses and those who serve and work in our Congress BUT the individual mandate remains in place.   In the meantime, many that have been counted as “signing up” have no insurance and a large number have not yet paid their premiums.  However, the biggest problem with the manipulation of the Affordable Care Act (ACA) may actually be the commentary of one of its greatest supporters–Senator Harry Reid.

With the 2014 Midterm elections looming, many of those in Congress who are facing reelection have commented on the latest delays in an effort to positively spin the news.  As you might expect, those in leadership roles such as Senator Harry Reid have tried to minimize the impact of repeated Obamacare failures and fixes on his part (a desperate attempt to cling to a majority). In an effort to explain the need for the latest delay Senator Reid has shown his complete lack of connection with the nation.  He publicly proclaimed and was quoted in the Washington Times as saying that “some [old people] may not be educated about [or understand] the internet”.  In reality, more seniors than ever before are utilizing the internet in order to maintain medical information.  Pew Research Center data indicates that as of 2013, nearly 60% of all Americans in the 50-65 year old age group are actively engaged in internet based social media.  Even more telling is the fact that 50% of those over the age of 65 are involved in AT LEAST one internet based social media outlet.  It is clear that the internet and medicine will be intimately connected in the future.  Twitter, a popular site for micro-blogging in 140 characters or less has seen a 79% increase in utilization by users in the 50-65 year old age group.  When you carefully examine the Senator’s comments he is clearly referring to those in the 50-65 year old range–those over 65 will be enrolled in Medicare and have no need to go to the exchanges.  The younger populations-such as the millennials–are assumed to be web savvy from birth.

The delivery of healthcare is already evolving digitally–particularly in the areas of the electronic patient and in mobile health applications.  For Senator Reid to make such a statement concerning the inability of older Americans to “understand” the internet not only is insulting but  shows a complete lack of connection to and respect for the very people he claims to want to protect.  Seniors are more web savvy now and are able to access the web in a variety of ways–there is data from non biased scientific surveys (such as those conducted last year by Pew) to substantiate my statement.  In reality, his comments are a sad attempt to explain the inexplicable–why do the Democrats in Congress continue to hang on to a system that is clearly failing?

The ACA continues to suffer setbacks–most of them at the hands of the President who has dedicated his legacy to its success.  The latest delay (or accommodation, as the Obama Administration prefers to call it) is more about the lack of enrollees and less about the ability of older Americans to successfully interact with the internet.  Many seniors are surfing on a daily basis.  The internet is not the problem with the ACA and healthcare reform–rather it is the legislation that is broken and badly in need of a fix.

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