Is the EpiPen Price Elevation Just the Tip of the Iceberg in the Pharmaceutical Industry?

14089039_950180028444990_5005403533221290633_nIs it really true that manufacturers of pharmaceuticals really take advantage of the US population. A comparison study of cash prices of several drugs was done a few years ago in the US vs Canada: the Canadian non-subsidized drugs (same manufacturers as in the US) cost 1/3 as much as the US drugs, for both generics and name brands. Why do the manufacturers do this? Is it because they can. The US Government believes it is perfectly acceptable for the pharmaceuticals to charge whatever they want while maintaining their government monopoly on name brand drugs. Generic manufacturers have in the past 10 years followed suit- escalating their prices sometimes to within a few dollars of the name brand. In the US, it is all about $$$$$$$$$$. Nothing else matters to pharmaceutical manufacturers. Nothing. Not even people whose lives depend on rapid availability of injectable epinephrine.

Consider that latest insult, Members of Congress are in an unusual position as they demand an explanation for Mylan NV’s 400 percent price hike for the EpiPen and focus attention squarely on its CEO: Heather Bresch.

If lawmakers follow the usual script, Bresch could get called up to Capitol Hill next month to explain her company’s justification for raising the price on the life-saving allergy shot. But that could be awkward, since she’s the daughter of Democratic Senator Joe Manchin of West Virginia.

The scrutiny on EpiPen intensified Wednesday after Democratic nominee Hillary Clinton called the price increase “outrageous,” sending Mylan’s stock down as much as 6.2 percent. The intense political pressure could lead regulators to speed up their review of a rival product by Teva Pharmaceutical Industries Ltd., according to some analysts, or force Mylan to curb prices — in both cases hurting revenue and profits.

While CEO Bresch’s family ties may mute the ire of some lawmakers, others are already asking the company about taxpayers having to foot the bill for these price increases — particularly after Bresch and the company successfully pushed legislation to encourage use of the EpiPen in schools nationwide.

Mylan is the latest drug maker to provoke congressional ire for steep price hikes. Martin Shkreli and executives from the company he used to lead, Turing Pharmaceuticals AG, and executives from Valeant Pharmaceuticals International Inc. were called before congressional committees earlier this year to explain why they bought the rights to older drugs that lacked competition and raised the prices.

The Mylan controversy fits a similar pattern. Mylan has increased the price of its EpiPen from about $57 a shot when it took over sales of the product in 2007 to more than $600 for two auto-injectors. But the company’s EpiPen is a more mainstream drug used to treat life-threatening allergic reactions from bee stings, food allergies or other triggers, which could give the issue a larger constituency.

Mylan declined to comment when asked to explain the price hike or Bresch’s role in promoting legislation. Manchin’s office also didn’t respond to requests for comment. Members in both chambers expressed outrage this week. “I am deeply concerned by this significant price increase for a product that has been on the market for more than three decades, and by Mylan’s failure to publicly explain the recent cost increase, which places a significant burden on parents, schools and other purchasers of the EpiPen,” Senator Mark Warner, a Virginia Democrat, said Tuesday in a statement, noting that he is a parent of a child with severe allergies.

On Wednesday, the Senate Special Committee on Aging asked Bresch to turn over information used by Mylan’s board of directors related to the price increases. The panel wrote a letter to Bresch asking her to “provide a briefing to Committee staff on the pricing of EpiPen at a mutually convenient time no later than two weeks from today.” The committee’s chairman, Republican Senator Susan Collins of Maine, and its top Democrat, Claire McCaskill of Missouri, signed the letter.

Senator Richard Blumenthal, a Connecticut Democrat who has asked the company to lower its prices, is holding an event on Wednesday where he will call for investigations by the Senate Judiciary Committee and the Federal Trade Commission into potential antitrust violations and deceptive and illegal trade practices.

The issue of the price increase became presidential campaign fodder after Clinton issued her statement. “Since there is no apparent justification in this case, I am calling on Mylan to immediately reduce the price of EpiPens,” Clinton said in a statement from her campaign.

Mylan’s shares, which have dropped this week as the scrutiny increased, fell further after Clinton’s comments. The stock was down 6.1 percent to $42.86 at 3:25 p.m. in New York, bringing the three-day losses to more than 11 percent.

The company’s tactics in pushing legislation that helped boost the use of EpiPens may fuel congressional anger.

Mylan spent about $4 million in 2012 and 2013 on lobbying for access to EpiPens generally and for legislation, including the 2013 School Access to Emergency Epinephrine Act, according to lobbying disclosure forms filed with the Office of the Clerk for the House of Representatives. Mylan also was the top corporate sponsor of a group called Food Allergy Research & Education that was the key lobbyist pushing for the bill encouraging schools to stock epinephrine auto-injectors, of which EpiPen is by far the leading product.

But Bresch’s connections to Capitol Hill already have some lawmakers tiptoeing around the usual Washington blame game. For example, Blumenthal, a member of the Senate Judiciary Committee and a co-sponsor of the 2013 schools bill, asked Bresch in a letter Monday to explain the “shocking price increases.”

However, in an interview Tuesday, he was less eager to talk about Bresch herself or the prospect that she might soon be testifying to the committee.

He initially answered during one telephone call that he was unaware that she had any direct involvement in the pricing. Then, in a follow-up call, Blumenthal responded when asked again about the possibility of her coming before Congress by saying, “I am just not going to comment on that.”

Bresch, 47, has been CEO of Mylan since 2012 and previously held other senior posts at the company, including as head of government relations. Last year, she had to defend the company after it moved its corporate address overseas to lower its U.S. taxes in a transaction known as an inversion. Now incorporated in the Netherlands, its principal executive office is in Canonsburg, Pennsylvania.

Ross Baker, a political scientist at Rutgers University in New Jersey, said Tuesday that he assumes Bresch’s father, Manchin — who is not on the Judiciary Committee — would recuse himself “and put a lot of distance between himself and any investigation” into the matter. “He’d be unwise to rise to the defense of Mylan,” Baker said.

Senate Judiciary Chairman Chuck Grassley of Iowa, who is running for re-election, also wrote a letter to Mylan saying he was “concerned that the substantial price increase could limit access to a much-needed medication,” asking for an explanation by Sept. 6, the day the Senate returns from its seven-week summer recess. Jill Gerber, Grassley’s spokeswoman, said in an e-mail that he wants to hear back from Mylan before considering holding a hearing.

Mylan has given away more than 700,000 free EpiPen’s to schools since 2012 under a program that allows them to receive four free auto-injectors, the company said in a statement. Yet schools have to use their own funds to purchase additional pens. Mylan declined to comment on the price increases coinciding with legislation to encourage EpiPen use.

Senator Amy Klobuchar, a Minnesota Democrat, asked the Federal Trade Commission on Monday to look into whether Mylan had done anything to deny competitors access to the market in order to keep raising prices. She pointed to a competitor product, Adrenaclick, that she said is less expensive but has only minimal sales. Klobuchar was also a co-sponsor of the schools bill.

In the House on Tuesday, majority and minority staff members of the Oversight and Government Reform Committee held a meeting after receiving a letter from Representative Grace Meng, a New York Democrat, requesting the panel hold a hearing.

The majority staff scheduled a call with the company, though Democrats on the committee said they were waiting to hear back on whether a hearing will be scheduled.

A spokeswoman for committee Chairman Jason Chaffetz of Utah, said that as of Tuesday afternoon no hearing was scheduled. “And no comment beyond that,” said the spokeswoman, M.J. Henshaw.

The top Democrat on the Oversight Committee, Elijah Cummings of Maryland, said Tuesday that he wants a hearing when lawmakers return from their summer break to Washington in September.

“The recent price increase for EpiPens places a financial burden on those who desperately need this drug to prevent life threatening allergic reactions, which is why we have expressed our desire for an investigation of this issue and for the Committee to hold a hearing in September,” Cummings said Tuesday in a statement.

Liz Claman published an article pointing out that the Pittsburgh-based pharmaceutical giant at the center of a major drug pricing storm over the EpiPen, managed to pull off a tax-ducking corporate inversion just a year and a half ago.

And now the FOX Business Network has learned that allergy advocates are preparing to use the inversion strategy to convince lawmakers to investigate the company’s EpiPen.

“I definitely think Congress needs to get involved.  There needs to be an investigation,” Robyn O’Brien, founder of Allergy Kids Foundation told FOX Business Network.

O’Brien represents millions of families in America who depend on EpiPens to save lives in the case of deadly exposure to allergens.  The EpiPen is an auto-injecto device that delivers epinephrine, the drug that counters the effects of a fatal allergic reaction.  When Mylan bought the company that manufactures the EpiPen back in 2007, the cost for a single EpiPen was $57 dollars.

Today, just 9 years later, the cost has skyrocketed to as much as $700 for a pack of two. Many insurance companies cover some or most of the cost; however, Medicare, which is paid for by the American taxpayer, must cover millions of children of families who cannot afford insurance. Others saddled with high deductibles find themselves shelling out thousands of dollars for just a few packs of the device.

Mylan’s corporate inversion could now be used as a weapon against it.

Known officially as Mylan N.V., Mylan bought the small generic specialty drug arm of Abbott Labs (ABT) in early 2014.  That estimated $5 billion dollar purchase enabled the much larger Mylan (which has a current market cap of $24 billion dollars) to ‘move its headquarters’ to the Netherlands, a more tax-friendly country.

Mylan was able to complete one of the last corporate inversions before Congress, President Obama and Republican presidential nominee Donald Trump launched a full court press to demonize the practice which involves Company A (in this case Mylan) buying Company B (usually based in a foreign country with a lower tax rate) in order to lower Company A’s tax bill.

In Mylan’s case, it appears the company moved its corporate address to the Netherlands, but still maintains most of its offices in a suburb of Pittsburgh, PA, enjoying the benefits of taxpayer-funded police, fire and other city services.

President Obama has lashed out against the practice of inversion, calling it “one of the most insidious tax loopholes out there.” Trump, too, has ripped corporate inversions, calling them a “huge problem.”  What makes the Mylan case so problematic is that the company CEO Heather Bresch is the daughter of Democratic Senator Joe Manchin of West Virginia. Democrats, led by Democratic presidential nominee Hillary Clinton, have loudly denounced corporate inversions.

“They’ve built the business model on the backs of our kids, moving the headquarters to the Netherlands to avoid paying taxes into the US and as her own father said, something like that should be illegal,” said O’Brien. Calls by FOX Business to Mylan’s press department were not returned.

Complaints about onerous price hikes in the pharmaceutical industry are age-old and often go unanswered by the companies who hold the patents.  As patents expire, generic drug companies often jump in. But oddly, Israeli-based Teva Pharmaceuticals (TEVA) attempted to present a generic version but was soundly swatted down by the FDA, which cited “certain major deficiencies” to Teva’s product.  O’Brien smells a rat.

“There is no competition. They have a monopoly. The barriers to entry are really high and right now there’s a low cost alternative trying to work its way through the FDA. I’ve been in this for 11 years. We’ve seen Twin-ject come and go, Auvi-Q (by Sanofi US) come and go. Auvi-Q was recalled because of 26 unconfirmed reports. There needs to be an investigation into how (Mylan) has been able to maintain this monopoly that it has and yes, these are life saving devices but they can come in a lot of different forms and a healthy marketplace means healthy competition,” said O’Brien.

For now, Mylan has remained relatively silent after issuing an initial statement blaming insurance companies, co-pays and deductibles while offering coupons of $100 for the device. Investors, however, have done anything but remain silent. Milan shares fell 4.7% during Tuesday’s session and have lost 11% over the past 12-months.

Matt Krantz in his article last week pointed out that people might be shocked at how high drug prices have gotten. But equally lucrative are the compensation packages hauled in by drug company CEOs.

CEOs of the 14 biotech and pharmaceutical companies in the Standard & Poor’s 500 that served all of 2015 pulled down median compensation packages valued at $18.5 million in 2015, according to a USA TODAY analysis of data from S&P Global Market Intelligence. That was 71% greater than the median $10.8 million hauled in by S&P 500 executives in all industries in 2015, according to an analysis by Equilar.

“We all know drug prices are high,” says Eleanor Bloxham, CEO of compensation analysis firm The Value Alliance. “Companies award (the CEOs) very generous packages.” Health care CEOs received the highest median pay packages of any of the 10 sectors, according to the Equilar analysis.

Seeing such staggering pay packages for the titans of companies producing life-saving drugs stands out as lawmakers take a closer look at prices for drugs. Most recently, Mylan (MYL) found itself in the center of the controversy over drug prices following its roughly 500% increase in prices for its popular EpiPen allergy drug since 2007. Heather Bresch, who has been CEO of Mylan since early 2012, was paid $18.9 million last year, well above the median for the S&P 500 and up 109% since 2013.

But Bresch is far from being the highest paid among the ranks of drug company CEOs. Leonard Schleifer, CEO of biotech Regeneron Pharmaceuticals (REGN), wins there. He was awarded a compensation packaged valued at $47.5 million last year. The 63-year-old executive has been CEO of the company since 1988 and got a 13% raise in his total pay last year. The company makes treatments for a number of serious medical conditions, including its drug to deal with macular degeneration.  The company’s pay has been subject of controversy before. Investors can vote on the suitability of the company’s compensation plan every three years. In June 2014, only 62% of shareholders approved of the 2013 compensation plan. In its proxy statement released this year, the company says it has “spent a significant amount of time speaking with some of our key shareholders about executive compensation” and says it has made modifications.

Jeffrey Leiden, CEO of Vertex Pharmaceuticals (VRTX), is the drug maker CEO with the next largest compensation package. Leiden, 60, has been CEO of the company since 2012 and pulled down $28 million last year. Last year, investors expressed less confidence in the company’s pay structure causing the company to respond, “we increased our level of engagement in response to the decline in support for our advisory say-on-pay proposal at our 2015 annual meeting.” A say-on-pay proposal is a non-binding vote to allow investors to say if they approve of the way executives are paid.  The company, in its proxy statement, says, “We have designed the company’s compensation programs to closely align management’s incentives with Vertex’s strategic long- and short-term goals and with the interests of Vertex’s shareholders.”

While drug maker CEOs might get paid more than the typical CEO, last year wasn’t a great one for raises. CEOs at the 13 biotech and pharmaceutical companies in the S&P 500 who served both 2014 and 2015 saw their median pay fall nearly 19%. That’s a much steeper drop than the 5% decline experienced by S&P 500 CEOs in 2015, Equilar says.

Meanwhile, shares of drug companies were flat last year on average and this year they’re down 6.3% as investors worry about the sustainability of profit growth and rumblings from Capitol Hill about drug prices.  “Considering how fast medical costs are rising, this is becoming a public policy issue,” Bloxham says.

Untitled.blog.1aSo, as pointed out in the lead into this post Canada and other countries have Epi-Pens, etc. at lower prices, so why not purchase them over the Internet? Another alternative is to order 1:10,000 epinephrine preloaded syringe and have the patient keep it in a small zipped medical kit. Epipens have 0.3mg of epinephrine so 3ml of the 1:10,000 IM should suffice in an emergency. These cost about $12 from Henry Schein. Another option is $144 for 0.3mg epinephrine in 3ml auto injector made by Lineage Therapeutics or Greenstone Ltd.

It is time for the US pharmaceutical patents to be voided completely or shortened to 2 years. The pharm industry screws Americans because it can. It is not based on the incomes of people in different countries, insurance coverage, socialized vs capitalist health systems, or any other metric other than the US citizen has no other choice. Congress has granted patent exclusivity that through legal maneuvers is extended for decades, and there are absolutely no limits on what can be charged or the rate of escalation of prices, even on critical lifesaving medications.

The expiration of patents produces huge spikes in prices before the generics come onto the market. For decades, drug manufacturers have engaged in collusion in violation of the Sherman Antitrust Act to control prices by agreeing to pay generic manufacturers to not bring their products onto the market. This happened because the FDA does not allow multiple generics to come on to the market initially…it restricts the generic to a single manufacturer for a period of time before allowing others onto the market. This created a system whereby the name brand manufacturer paid off the generic manufacturer approved by the FDA to enter the market for a product or created a co-conspiracy situation where the generics would buy the product from the manufacturer and brand it as a generic. The courts have recently ruled this behavior is illegal, so now we are seeing massive spikes in name brand prices prior to patent expiration. The FDA and the courts have also made the situation much worse by colluding with the name brand manufacturer to extend patents as in the case of Oxycontin, where the manufacturer successfully argued before the courts that the formulation they manufactured for over a decade was unsafe, and therefore generics using that formulation should be prevented from entering the market.

There are more culprits that just the FDA. The FDA is one of the big ones, but so is a system where the end user doesn’t pay for the product but rather a third party pays, and the third party owns the distributors, and the third party (the insurance company) is able to pass the end user price to the funding of the pool from which the end user cost comes from. The third party doesn’t care what the product costs because they raise the money from insurance premium payers while the distributors, which they own make money on the margin mark up. There are many culprits although if there were more manufacturers,clearly the problem would not be as acute.

But there is more blame to go around. Why the huge prices? Blame the litigious patients who demand complication free everything and the darn lawyers who will sue any company, suggesting that it is to save another victim.

 

Trumpism!! Do We Need a Psychiatrist Here???

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I thought that it would be interesting to pursue that question that many are considering when we hear Mr., possibly future President, Donald Trump, lash out or just simply insult his nest victim. Is he really crazy???

Carey Benedict wrote an interesting article last week in the New York Times (Aug. 15) that I thought was provoking, “Is it fair to Analyze Donald Trump from Afar” psychologically that is? In the midst of a deeply divisive presidential campaign, more than 1,000 psychiatrists declared the Republican candidate unfit for the office, citing severe personality defects, including paranoia, a grandiose manner and a Godlike self-image. One doctor called him “a dangerous lunatic.”

But interestingly enough is to consider that many others running for that same office have had their personalities questioned.

The year was 1964, and after losing in a landslide, the candidate, Senator Barry Goldwater of Arizona, sued the publisher of Fact magazine, which had published the survey, winning $75,000 in damages.

But doctors attacked the survey, too, for its unsupported clinical language and obvious partisanship. In 1973, the American Psychiatric Association adopted what became known as the Goldwater Rule, declaring it unethical for any psychiatrist to diagnose a public figure’s condition “unless he or she has conducted an examination and has been granted proper authorization for such a statement.”

And now enter Donald J. Trump.

The 2016 Republican nominee’s incendiary, stream-of-consciousness pronouncements have strained that agreement to the breaking point, exposing divisions in the field over whether such restraint is appropriate today.

Psychiatrists and psychologists have publicly flouted the Goldwater Rule, tagging Mr. Trump with an assortment of personality problems, including grandiosity, a lack of empathy, and, I loved this diagnosis-“malignant narcissism.” The clinical insults are flying so thick that earlier this month, the psychiatric association posted a reminder that breaking the Goldwater Rule “is irresponsible, potentially stigmatizing, and definitely unethical.”

Putting a psychiatric label on a candidate they oppose can be a “seemingly irresistible tool for some in the field,” said Dr. Paul Appelbaum, a professor of psychiatry, medicine and law at Columbia University who disapproves of the practice. “This year, perhaps more than most, they’re persuaded they’re saving the nation from a terrible fate.”

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A 1964 article in Fact magazine led to what is known as the Goldwater Rule, the American Psychiatric Association’s declaration that it is unethical for any psychiatrist to diagnose a public figure’s condition “unless he or she has conducted an examination and has been granted proper authorization for such a statement.”

William Doherty, a psychologist at the University of Minnesota, believes exactly that. In June, Dr. Doherty posted an online manifesto against “Trumpism” that has been signed by more than 2,200 mental health specialists.

“Yes, for me this is an exception,” Dr. Doherty said. “What we have here is a threat to democracy itself.”

Supporters of the Goldwater Rule have cited three main rationales for adhering to it: Most diagnoses made from a distance turn out to be wrong; the labels themselves can cause real harm to the person and family members; and the practice undermines the field’s credibility, particularly its commitment to confidentiality. Not to mention, others say, that it could expose a left-leaning bias in the field.

But the psychoanalyzing of public figures by commentators, columnists and pop psychologists has had a long bipartisan history. Concerns about grandiosity and narcissism dogged Lyndon B. Johnson’s presidency. Suspicions of a deepening paranoia clouded the end of Richard Nixon’s. Accusations of manipulation, deceit and a sense of entitlement have trailed the Clintons for years, prompting speculation about deeper personality problems.

Mr. Trump himself has recently tried to turn the tables, accusing Hillary Clinton of being “unstable” and “unhinged.”

While the vast majority of therapists’ comments remain focused on Mr. Trump, some in the profession say that if public psychoanalyzing is going to be done, it should be directed at both candidates.

“Do those things rise to a diagnosable level? I sure don’t know,” said Don Sizemore, a family therapist in Lexington, Ky. “But if we’re diagnosing him, we should be doing the same for her.”

Yet history cautions against the armchair analysis of either one. Psychiatrists point to Goldwater himself as a prime example of getting it wrong. By the time he died in 1998, Mr. Goldwater was regarded as “one of his party’s most respected elder statesmen,” The Washington Post said in its obituary.

In the wake of the Monica Lewinsky scandal, many people longed for a diagnosis to explain or denounce President Bill Clinton’s behavior, said Dr. Nada Stotland, a psychiatrist at Rush Medical College in Chicago. “I remember getting all these media calls asking if he was a narcissist or a sex addict,” she said. “Well, sex addiction wasn’t a recognized disorder at the time. (Oh, my goodness…another narcissist?) And if it had been, was the behavior then not his fault? I ended up dancing around these questions, because this idea that we should go around, willy-nilly, putting diagnoses on people is just wrong.”

But those using clinical language to describe Mr. Trump’s behavior contend that this presidential election is vastly different, for a big reason: The proliferation of social media comments and video clips, which afford direct, unscripted access to candidates, was simply not available in previous races. The depth of that material creates a public persona complete enough to analyze on its own merits, they say.

More than 2,200 mental health professionals had signed an online manifesto at citizentherapists.com as midday Monday.

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Dr. Doherty said he and the therapists who signed his manifesto were not diagnosing Mr. Trump’s personal traits, but his public persona. The manifesto characterizes “Trumpism” as reinventing history, never apologizing, demeaning critics and inciting violence. “One can talk about his public behavior without knowing whether he is fully that way with his children, his wife, his friends,” Dr. Doherty said.

Dr. Steven Buser, a psychiatrist who with his colleague, Dr. Leonard Cruz, coedited a new book, “A Clear and Present Danger: Narcissism in the Era of Donald Trump,” stressed, “We are careful not to make a clinical diagnosis here, to say that Donald Trump has narcissistic personality disorder.” The contributing writers include psychiatrists and psychologists, but Dr. Buser said, “We are focused on the image he projects, on TV, in tweets, in quotes.”

Dr. Appelbaum calls this distinction a convenient splitting of hairs. “It takes a skilled therapist months, sometimes longer, seeing a person regularly and asking probing questions to make a determination of whether a disorder is present,” Dr. Appelbaum said.

And there is more, the stigma of mental vulnerability is especially damaging in politics. In the 1972 presidential race, Senator Thomas F. Eagleton of Missouri withdrew as George McGovern’s running mate after 18 days — at Mr. McGovern’s request — in the wake of revelations that he had undergone psychiatric counseling and electroshock therapy. In 1988, the Democratic nominee, Michael S. Dukakis, released his medical records to counter rumors that he had undergone psychiatric treatment. He had not.

During his libel trial, Mr. Goldwater was mystified by some of the psychiatrists’ comments about his personality, including one calling him an “anal character.” “I don’t know what an anal character would be,” he testified, according to news accounts. “I tried to look it up in the dictionary, but couldn’t find it.”

He took particular exception to a psychiatrist’s comment that he was “a counterfeit figure of a masculine man.” Such a charge “weighs several tons, and the effect is rather depressing,” he said.

If there are exceptions to the Goldwater Rule, psychiatrists apparently cannot agree on them. More distant historical figures tend to be fair game; “Lincoln’s Melancholy,” a book by Joshua Wolf Shenk making the case that Lincoln had suffered from depression, was well received.

Leaders of hostile nations may or may not qualify, depending on who is judging. A psychiatrist who provided a personality assessment of Saddam Hussein at the request of the George W. Bush administration was criticized by some in the psychiatric community, but not formally censured.

Retired politicians fall into a gray area. Therapists have penned books on George W. Bush, as well as Bill Clinton. Not all of their colleagues approve.

But in an era when private moments and comments are increasingly available for public consumption, some argue that the Goldwater Rule is due for an update.

“There’s another perspective on this altogether,” said John D. Mayer, a University of New Hampshire psychologist who has written widely on the rule. “The ethicists who wrote the rule have been entirely focused on the negative side of commentaries. But there’s a positive, adaptive side to every personality trait.

“If you call someone deceitful, whether Clinton or Trump,” Dr. Mayer said of this year’s nominees, “it needs to be said that, for a good politician, there are reasons you can’t always say everything you know, or exactly what you think.”

The most obvious assessment is that one has to be at least slightly crazy to run for President. It is difficult to assess Mr. Trump as to his psychiatric stability. But we all are concerned that if he is manic do we want him with his finger on the controls of a possible nuclear invasion? I have begged my connections to the campaign to get control of their candidate. Lately there seems to be a more controlled candidate.

Is this all part of the playbook of the Trump strategy? Is Trump actually continuing to play his TV game show? And more important, does Trump really want to be President or was this all part of the game to prove his power over the GOP and the GOP’s future destruction?

What a tangled web they weave! Who do we trust and are any of the politicians really sane?

Silliness-First Vaccinations and Now We Question Flossing and Believe Pokémon Go will the Correct Obesity Epidemic

13882216_943389095790750_4891677781261928741_nIt’s one of the most universal recommendations in all of public health: The dictum-Floss daily to prevent gum disease and cavities. Except there’s little proof that flossing works. Still, the federal government, dental organizations and manufacturers of floss have pushed the practice for decades. Dentists provide samples to their patients; the American Dental Association insists on its website that, “Flossing is an essential part of taking care of your teeth and gums.”

The federal government has recommended flossing since 1979, first in a surgeon general’s report and later in the Dietary Guidelines for Americans issued every five years. The guidelines must be based on scientific evidence, under the law.

Last year, the Associated Press asked the departments of Health and Human Services and Agriculture for their evidence, and followed up with written requests under the Freedom of Information Act. When the federal government issued its latest dietary guidelines this year, the flossing recommendation had been removed, without notice. In a letter to the AP, the government acknowledged the effectiveness of flossing had never been researched, as required.

The AP looked at the most rigorous research conducted over the past decade, focusing on 25 studies that generally compared the use of a toothbrush with the combination of toothbrushes and floss. The findings? The evidence for flossing is “weak, very unreliable,” of “very low” quality, and carries “a moderate to large potential for bias.”

“The majority of available studies fail to demonstrate that flossing is generally effective in plaque removal,” said one review conducted last year. Another 2015 review cites “inconsistent/weak evidence” for flossing and a “lack of efficacy.”

One study review in 2011 did credit floss with a slight reduction in gum inflammation — which can sometimes develop over time into full-fledged gum disease. However, the reviewers ranked the evidence as “very unreliable.” A commentary in a dental magazine stated that any benefit would be so minute users might not notice it. Remember, this was a commentary only.

The two leading professional groups — the American Dental Association and the American Academy of Periodontology, for specialists in gum disease and implants — cited other studies as proof of their claims that flossing prevents buildup of gunk known as plaque, early gum inflammation called gingivitis, and tooth decay. However, most of these studies used outdated methods or tested few people. Some lasted only two weeks, far too brief for a cavity or dental disease to develop. One tested 25 people after only a single use of floss. Such research, like the reviewed studies, focused on warning signs like bleeding and inflammation, barely dealing with gum disease or cavities.

Wayne Aldredge, president of the periodontists’ group, acknowledged the weak scientific evidence and the brief duration of many studies. In an interview at his private practice in New Jersey, he said that the impact of floss might be clearer if researchers focused on patients at the highest risk of gum disease, such as diabetics and smokers. Still, he urges his patients to floss to help avoid gum disease. “It’s like building a house and not painting two sides of it,” he said. “Ultimately those two sides are going to rot away quicker.” Aldredge also said many people use floss incorrectly, moving it in a sawing motion instead of up and down the sides of the teeth. Pressed about the origins of his organization’s endorsement of flossing, he said it may simply have “taken the ADA’s lead.” This is part of the problem and the studies need more time and a scientifically based study.

When the ADA was asked for proof of its claim that flossing helps prevent early gum disease and cavities, the group cited the 2011 review and a 2008 two-week study that measured bacteria and did not even consider gum disease.

In a later statement to the AP, the ADA said flossing “removes plaque” and “is proven to help remove” debris from between teeth. A video on its website proclaims that flossing “helps prevent gum disease.” When pressed, Matthew J. Messina, a practicing dentist and spokesman for the dental association, acknowledged weak evidence, but he blamed research participants who didn’t floss correctly.

Even companies with a big market share of the flossing business — by next year, the global market is predicted to reach almost $2 billion, with half in the United States, according to publisher MarketSizeInfo.com — struggled to provide convincing evidence of their claims that floss reduces plaque or gingivitis. Yet the industry has paid for most studies and sometimes designed and conducted the research.

Procter & Gamble, which claims that its floss fights plaque and gingivitis, pointed to a two-week study, which was discounted as irrelevant in the 2011 research review.

Johnson & Johnson spokesman Marc Boston said floss helps remove plaque. When the AP sent him a list of contradicting studies, he declined comment. The floss-making companies partner with the ADA through its Seal of Acceptance program. The ADA promotes the seal to companies as something that “directly affects the purchase decisions of consumers;” each manufacturer is charged $14,500 for the evaluation. If it approves the product, the ADA then charges an additional annual fee of $3,500. The ADA says it rigorously evaluates products and makes no profit from the program. However, floss companies themselves are allowed to design the studies.

“The funding can come from companies — no problem at all,” said dentist Marcelo W.B. Araujo, vice president of the ADA’s Science Institute, who joined the organization after serving as an executive for Johnson & Johnson. “The design can start from the company.”

When flossing first gained acceptance, no proof was required of remedies. Dentist Levi Spear Parmly is credited with inventing floss in the early 19th century. By the time the first floss patent was issued, in 1874, the applicant noted that dentists were widely recommending its use.

The ADA has been promoting floss universally since 1908. “They just looked into what they did every day in their clinical practice and what they would recommend for patients,” said Araujo.

Count dentist Damien Walmsley, scientific adviser to the British Dental Association, among the skeptics. “It’s important to tell people to do the basics. Flossing is not part of the basics.” And you are going to believe a British dentist when the British dental health is rated as some of the worse parts of their care and overall health.

Floss can occasionally cause harm. Careless flossing can damage gums, teeth and dental work. Though frequency is unclear, floss can dislodge bad bacteria that invade the bloodstream and cause dangerous infections, especially in people with weak immunity, according to the medical literature.

National Institutes of Health dentist Tim Iafolla acknowledged that if the highest standards of science were applied in keeping with the flossing reviews of the past decade, “then it would be appropriate to drop the floss guidelines.”

Regardless, he added, Americans should still floss. “It’s low risk, low cost,” he said. “We know there’s a possibility that it works, so we feel comfortable telling people to go ahead and do it.”

But discussing this with dentists, my wife and others, there is the question of where does this come and why now? They know the benefits and its effects on dental health it is just a bunch of flawed studies. These are not even acceptable research studies. But the technique has to be performed properly and when done decreases gum disease allowing patients to keep their teeth and avoiding the spread of bacteria to other sites such as heart valves. We, dentists and physicians, know the science behind flossing. It’s just hard to prove it and interestingly the company selling water flossing-The Water Pic Pro- are advertising like crazy.

And now Niantic Corporation has released Pokémon Go promoting it for increased physical activity. Niantic’s new smartphone game has unleashed a Pokémon fever that is spreading around the globe faster than swine flu. Now, researchers at Johns Hopkins are scrambling to study how Zubats and Pikachus might be affecting populations—possibly helping to combat another ongoing public health crisis: the global obesity epidemic.

From med students to middle-school kids, tens of millions have suddenly taken to the streets, phone in hand, in search of elusive virtual beasts.  The more you walk, the more likely you are to find these pixel critters, gain expertise and “level up.” With its incredible worldwide popularity, this immersive, augmented-reality game has the makings of a social, or health, experiment on a global scale.

As the obesity epidemic continues to grow and physical activity continues to decline worldwide, could chasing Pokémon be part of the solution? Each day in the US, only 1 in 3 children are physically active and less than 5% of adults get the recommended 30 minutes of physical activity. Over the past 5 years, hundreds of wearable technologies have emerged, but the jury is still out on whether these actually improve physical activity, especially among the sedentary. Public health studies have sought answers to these tough questions: Do wearables actually enhance physical activity? Can they replace expensive gym memberships or exercise equipment? Will people keep using them once the novelty wears off? Roughly 13 million Americans bought smart activity trackers in 2015, but 1/3 abandoned those New Year’s resolutions within 6 months.

Maybe the secret sauce is not trying to be a healthy app, but instead focus on a game that gets people off the couch, into the real world, with inadvertent health effects. In 2006, Microsoft’s Kinect and Nintendo’s Wii game consoles were heralded by many as the solution to getting a nation of young gamers off their couches—but in this case, only as far as the carpet in front of the TV. In just a week, more people have downloaded and used Pokémon GO than have ever bought the Wii Fit game. Even major fitness giants such as Nike have tried, unsuccessfully, to capture users in NikeFuel “Missions,” powered by a digitally-enhanced sneaker, only to dissolve most of their Digital Sports division 2 years after launch.

As a commercial digital game, Pokémon GO may be better at engaging users, especially currently sedentary ones, than health apps disguised as games. Pokémon GO not only builds on the appeal of a massively successful gaming franchise but also adds a hefty dose of 21st century tech. Kids and adults alike seem to be having no problem walking for city blocks when it doesn’t seem like exercise—like hiding broccoli in a smoothie. The best high-def video games may be no match for the hybrid game + real world mix when it comes to propelling users out of the house. Pokémon GO’s augmented reality superimposes Charizards and Squirtles on once-familiar buildings and sidewalks and turns churches and parking lots into state-of-the art Pokémon Gyms, allowing this exciting virtual environment to attract users out into the real world. On the other hand, embracing fast-food chains as Pokémon Gym sponsors could negate gains as players are drawn to the nearest McDonalds to fuel more than just their virtual menagerie. It seems clear that the game could be very useful in prevention and health promotion in a variety of ways.

Gamified health and fitness apps don’t seem to share the “stickiness” of the best digital games. Already fans are discovering nature trails they never knew existed, or historic landmarks they’d never noticed, thanks to the lure of another wild Pokémon. Active games like Dance, Dance Revolution! are based on high-energy, frenetic jumps and twists, but so far haven’t shown evidence they reduce body mass index (BMI). The shininess of an exergame quickly wears off. But GO is a commercial franchise, likely to build momentum and keep players hooked well beyond the proverbial chasm of long-term adoption. Savvy physical therapists have already incorporated GO into therapy for hospitalized children. Most public health agencies trying their hand at digital health can hardly dream of competing on this level.
Many parents express surprise at screen-bound preteens’ sudden desire to head outdoors since wild Pokémon appeared in our neighborhoods. Getting kids out in the open has clear health advantages, like increased Vitamin D levels (which helps strengthen bones), strengthened immune systems, lower stress levels (Head Start Body Start), and reduced ADHD symptoms (NIH). Following specific routes and checking in at points of interest along the way could encourage people to explore their communities, allowing them to rediscover unappreciated real-world landmarks. Niantic could even partner with state and national park systems to host ‘Pokémon
Many multiplayer online games, from Farmville to World of Warcraft, promote (or even require) virtual socialization, but it is intriguing to see how Pokémon GO fosters real-world, face-to-face interactions—a strong predictor of both mental and physical health. This interaction could be useful, especially for those who otherwise have difficulty in social situations; some users are already reporting improvements in depression and anxiety. In fact, Niantic could capitalize on this through new features that could encourage social interactions—perhaps by increasing the chances of rare Pokémon sightings or speeding progress when traveling with a group.

Of course, as public health professionals, we are also wary of a few potential areas of concern. As concerns about potential problems mount, we question whether guidelines for use might be needed, such as those proposed alongside the game’s release in Japan. Pokemon’s intro screen warns players to stay alert, but media reports are flooding in of people injured while focusing on Bulbasaur and not the busy traffic intersection. We wouldn’t be surprised to see hospitals adopting a new injury billing code in the near future, or officers writing tickets for driving while Pokémon hunting. Safety features, which completely disable interaction when in a moving vehicle may be warranted in future releases.

GO’s game mechanics have already been used to rob players of their phones and money by luring unwitting players to attractive ‘virtual’ locations. Reports of malware, piggybacked on illegally-downloaded copies have emerged, potentially able to intercept a user’s communications and locations. And, people may be less vigilant than usual while playing—venturing into areas they might not otherwise, alone or during times of day where they might be at increased risk of crime. Some have even warned of the risk of racial bias affecting how police or the neighborhood watch might misinterpret game-inspired wandering.

As noted with other highly engaging games, some users might find GO interfering with real life, causing relationship conflicts, low bank balances, and possibly neglect of work, school or sleep–problems common to behaviors that spiral out of control. It’s the very elements of GO and other games that are so fascinating and engaging that also make them potentially problematic. Attention to basic theories of behavioral reinforcement is integral to game design, and newer free-to-play games (like GO) use the enormous amounts of data they collect to develop analytics. These analytics are often used to identify and exploit “social whales”—those 0.15% of players who account for 1/2 of the in-app purchases, creating an ethical embarrassment. To offset this quandary, developers and scientists could collaborate over these data to prevent problematic gaming and to extend insights into public engagement.

There is no doubt that we, in the health community, have a lot to learn from the Pokémon playbook— whether it’s the way GO captures and motivates players, or the social element of a shared gaming experience. Alternatively, this is an opportunity for the health community to identify existing commercial games with the potential to have real world health impacts.

Collecting information about benefits and risks is important to public health scientists the same way monitoring use and demographic data is critical to a game’s marketing analysts (and capturing Pokémon is for 30 million Pokémon GO users). The FDA is joining other health agencies worldwide to pave the way for apps to be allowed to make health claims, but this will require plenty of evidence. If Pokémon GO or other games can be used to prevent obesity or improve social anxiety and depression, we’ll need evidence to encourage their use as “digiceuticals.”

Public health and clinical investigators can design the studies that will figure out if a future prescription should read, “Capture 60 Pokémon and call me next month.” But studies cost money, and the time it takes to get a study done, from conception to funding to published guidelines, can take a decade or more, by which time we’ll likely be talking about Pokémon GONE. Intentional collaborations between the gaming industry, gamers and global health could shrink this timespan dramatically.

It’s not clear yet what impact (or duration) this Pokémon epidemic will have in terms of societal benefits and consequences. Certainly, Pokémon GO is challenging public health scientists to rethink how to leverage mobile technologies and video games to engage a clearly willing gaming public to combat the looming and very-real epidemics of childhood obesity, depression and other noncommunicable diseases. The staggering $190 billion spent currently on obesity, and the projected costs of over $1 trillion from cardiovascular diseases by 2030 demands that we identify new solutions. Beyond healthy bodies, the ability of wild Pikachus to unite crowds of strangers may be just the prescription-strength app for the socially tense and politically divided times we live in.

Alain Labrique, PhD, MHS, MS, is an associate professor in the Department of International Health at JHSPH and the director of the JHU Global mHealth Initiative, a University-wide Center of Excellence in digital health research. Yorghos Carabas is a marketing and communications specialist and creative designer at the Johns Hopkins University Global mHealth Initiative. Michelle Colder Carras is a postdoctoral research fellow in the Department of Mental Health at the Johns Hopkins Bloomberg School of Public Health who studies media and mental health. Bruce Y. Lee, MD, MBA, is an associate professor of International Health at the Johns Hopkins Bloomberg School of Public Health, director of the Global Obesity Prevention Center, and director of Operations Research at the International Vaccine Access Center.

The Pennsylvania hospital system is one of several that see the popular game as a threat to patients’ physical safety and privacy, and a threat to hospital data security. Outside of the presidential race, perhaps no topic has been as divisive in our culture this summer as Pokémon Go. Proponents of the video game sensation say it’s bringing people together—some towns sponsoring Pokémon walks and it’s encouraging physical activity. Mental health advocates say the game can help some persons with mental illness. Michigan’s Mott Children’s Hospital is one of several healthcare organizations that encourage young patients to get out of bed and play the popular game. But the tide may be quickly turning. Many dislike the fact that the game is a distraction, causing people to crash their cars and even walk off the edges of cliffs. And, on top of that, some oblivious players have been trying to catch Pokémon in inappropriate locations, such as Arlington National Cemetery and at the Holocaust Museum. So it’s no surprise that, despite the fitness and possible behavioral health benefits, some hospitals are beginning to ask that patients abstain from playing the game while in their facilities. Pennsylvania-based Allegheny Health Network, a division of Highmark Health, recently asked Niantic, Pokémon Go’s manufacturer, to remove all AHN locations from the app.

“Because Allegheny Health Network hospitals and other facilities are technically public places, they are open to being identified as Pokémon gym locations,” stated a memo to all AHN employees. “The presence of Pokémon Go players in our facilities compromises physical safety, patient privacy, computer security, and personal safety.”

The Pokémon gyms mentioned in the memo are locations where players can pick up helpful items and battle other players. The gyms can be anywhere the game manufacturer considers to be public, which apparently included some AHN facilities.

“Watch out for people walking around focused on their smartphone virtual world and not on their immediate surroundings—which is a concern for patients and visitors in our facilities,” the memo continued.

“Remind players that unauthorized photography is prohibited on AHN premises. Immediately contact physical security to report anyone observed taking unauthorized pictures on AHN premises.”

ANH isn’t the only health system to come out against Pokémon Go. Massachusetts General Hospital recently asked staff to stop using the app while at work, and the American Hospital Association requested that Niantic remove its locations from the game.

Are we all crazy! First we tell people that flossing is worthless and then we encourage people to use an APP to improve the health and wellbeing of our patients.

Is Obamacare Improving Our Choices as Cities are Losing their Doctors?

13716115_930704983725828_5670205046666613626_nAs the U.S. population continues to grow — and age — demand for health care services is expected to increase, especially with the possible successes of the Affordable Care Act. Along with demographic changes, the number of Americans with health insurance has also increased considerably in recent years — another factor in the growing demand for health care services. As a result, the number of physicians needed in the United States will likely continue to rise.

However, while the number of doctors per capita has been indeed increasing nationwide, in a number of areas across the country, this pattern does not hold. Based on data from the U.S. Department of Health and Human Services, 24/7 Wall St. reviewed the metro areas shedding primary care physicians the fastest.

To identify the cities running out of doctors, 24/7 Wall St. reviewed the number of primary care physicians per 100,000 metro area residents in 2010, 2011, and 2013, and ranked them based on the percentage change from 2010 through 2014. Data came from the Area Health Resources Files published by the U.S. Department of Health and Human Services.

These are the cities running out of doctors.

  1. Kankakee, Ill.

> Pct. chg. primary care physicians 2010-2013: -10.2%

>Primary care physicians: 42.8 per 100,000

>Pct. population 65 and older: 14.8%

>Median household income: $51,000

The number of primary care physicians per capita declined by more than 10% in Kankakee, Illinois, the seventh largest drop of any U.S. city. In most of the cities shedding doctors’ jobs, relatively fast overall population growth contributed to the steep declines in per capita primary care physicians. However, this is not the case in Kankakee, where the population actually declined between 2010 and 2013 — by 1.1%.

Even before the precipitous drop in the primary care physicians available to the city, Kankakee was not an especially popular place for M.D.s. There were only 47.6 primary care physicians for every 100,000 area residents in 2010, far fewer than the national ratio of 73.0 doctors for every 100,000 Americans. As of 2013, there were only 42.8 primary care physicians for every 100,000 Kankakee residents compared to the national ratio of 75.7 per 100,000.

  1. Brunswick, Ga.

> Pct. chg. primary care physicians 2010-2013: -10.3%

>Primary care physicians: 43.0 per 100,000

>Pct. population 65 and older: 17.7%

>Median household income: $44,055

Physicians practicing medicine in affluent areas tend to earn more money, while doctors in lower-income areas typically earn lower incomes. With a median household income of $44,055, nearly $10,000 less than the national median income, Brunswick, Georgia, is one of the poorest cities in the country. Many residents may struggle to afford medical care, and many may also not go to the doctor at all. Among those too young to qualify for Medicare, the city’s uninsured rate of 19.8% is considerably higher than the 13.5% national uninsured rate.

With low incomes and nearly one of the highest uninsured rates in the country, it is perhaps not surprising that the number of primary care physicians as a share of the population is falling in Brunswick. The share of doctors in the city dropped by 10.3% between 2010 and 2013, while the share nationwide increased by 3.7%. As of 2013, there were only 43.0 primary care physicians in Brunswick for every 100,000 residents, one of the smallest ratios of any U.S. city.

  1. Morristown, Tenn.

> Pct. chg. primary care physicians 2010-2013: -10.8%

>Primary care physicians: 55.5 per 100,000

>Pct. population 65 and older: 18.3%

>Median household income: $39,822

The elderly are at greater risk of a number of serious health complications and conditions, and as a result, they often require more frequent doctor visits. In Morristown, 18.3% of the population is 65 and older, a far greater share than the 14.5% of Americans who are this age. While an older population would suggest a greater demand for doctors, there are only 55.5 primary care physicians for every 100,000 city residents, far fewer than the 75.7 per 100,000 national share. Despite a likely higher need, the city’s share of primary care doctors dropped by 10.8% in recent years, a steeper decline than in all but a handful of other U.S. metro areas.

Most doctors have invested a great deal of time and money acquiring their skill set, and usually seek appropriately high salaries. As a result, economically depressed areas may be less attractive to practicing M.D.s. In Morristown, Tennessee, nearly one in five people live in poverty, and the typical household earns only $39,822 annually, far less than the $53,482 a typical household earns nationwide.

  1. Cheyenne, Wyo.

> Pct. chg. primary care physicians 2010-2013: -12.2%

>Primary care physicians: 65.6 per 100,000

>Pct. population 65 and older: 14.4%

>Median household income: $58,324

Cheyenne’s population expanded relatively fast between 2010 and 2013. Over that period, Cheyenne’s total population grew by 4.0%, well above the corresponding nationwide growth. Despite fast population growth, the number of doctors in Cheyenne actually decreased. Adjusting for population, there were 12.2% fewer primary care physicians in Cheyenne in 2013 than there were in 2010.

The city’s declining share of medical doctors stands in stark contrast to the 3.7% national increase. There were 74.8 primary care physicians in Cheyenne for every 100,000 residents in 2010, slightly more than the 73.0 per 100,000 national ratio. By 2013, there were only 65.6 primary care physicians in the area for every 100,000 residents, considerably less than the 75.7 doctors per 100,000 Americans.

  1. Midland, Texas

> Pct. chg. primary care physicians 2010-2013: -14.2%

>Primary care physicians: 38.1 per 100,000

>Pct. population 65 and older: 9.7%

>Median household income: $66,689

More than one in five Midland residents do not have health insurance, one of the highest shares of any U.S. metro area. Those without insurance are far less likely to receive preventative care, and the high uninsured rate may lower demand in the West Texas city. There are only 38.1 primary care doctors for every 100,000 Midland residents, fewer than in all but seven other U.S. metro areas.

The share of doctors in Midland is also decreasing more rapidly than almost anywhere else in the country. Between 2010 and 2013, the numbers of primary care physicians per 100,000 area residents decreased by 14.2%. In contrast, the number of primary care doctors in the U.S. increased by 3.7% over the same time period.

  1. Kingston, N.Y.

> Pct. chg. primary care physicians 2010-2013: -14.7%

>Primary care physicians: 64.1 per 100,000

>Pct. population 65 and older: 17.6%

>Median household income: $58,592

The elderly often require frequent medical treatment, and as a result, older communities tend to have more physicians relative to the population. Kingston, New York, however, is an exception. Nearly 18% of Kingston’s 181,000 residents are 65 or older, a larger share than in the vast majority of U.S. metro areas. Yet, Kingston has fewer doctors per capita than the country as a whole.

Further, the number of primary care physicians per capita is declining in Kingston. Compared to 2010, when there were 75.1 primary care doctors for every 100,000 area residents — above average at that time — there are now 64.1 doctors per 100,000 area, a 14.7% drop.

  1. Jacksonville, N.C.

> Pct. chg. primary care physicians 2010-2013: -17.9%

>Primary care physicians: 30.2 per 100,000

>Pct. population 65 and older: 8.5%

>Median household income: $46,141

Considering the economic and demographic characteristics of the city, it is not surprising that there are relatively few doctors practicing in Jacksonville. For example, the elderly typically require more frequent medical attention, and as a result, cities with older populations tend to have more doctors. Jacksonville, North Carolina, is one of the youngest cities in the country with only 8.5% of the population 65 or older. Doctors also have a financial incentive to practice in relatively affluent areas where people are more likely to spend more on health care. However, relatively few Jacksonville residents are high earners. Only 1.2% of households earn $200,000 or more a year, one of the smallest shares of any city in the country.

After a nation-leading 17.9% drop in primary care physicians per 100,000 people, Jacksonville is home to relatively few doctors. Only three U.S. metro areas have fewer primary care physicians per capita.

The Bureau of Labor Statistics projects employment levels of physicians and surgeons to increase by 14%, considerably faster than average. From 2010 through 2013, the numbers of primary care physicians per 100,000 Americans increased by 3.7%. Yet, there are close to 100 metro areas where the number of primary care physicians per 100,000 people declined over that period. Of these areas, seven report declines of more than 10%.

In each of these seven U.S. cities there are also fewer doctors per capita than there are across the country as a whole. In most cases, this was true even before the loss of doctors. Fewer doctors per capita in a given area means primary care physicians are often strained with more patient visits in a single day, resulting in physician burnout and unfortunately the worst end point-suicide. Such a work environment is stressful, and doctors often leave such areas in favor of more urban areas with larger medical establishments.

Simple supply economic factors also play a role in where doctors decide to work. In an interview with 24/7 Wall St. Martin Kohli, chief regional economist with the Bureau of Labor Statistics explained that doctors’ “expected income is probably related in part to the expected income of their customers — poorer people probably can’t spend as much money on medical care as richer people.” Median household income in four of seven cities losing the most doctors is below the national median income. In Morristown, Tennessee, for example, a city that has suffered a 10.8% drop in the number of primary care physicians per capita, the typical household earns only $39,822 a year, one of the lowest median incomes in the country.

Doctors are drawn to areas with strong demand for health services. For example, because the elderly need more medical care, areas with older populations tend to have more doctors per capita. “The growth of the elderly population is one of the things that drives growth in health care in general, and in the offices of physicians in particular,” Kohli said.

The age of a given population is one of the factors that influences where doctors choose to practice, and some of the cities losing the most doctors are especially young. Midland, Texas, and Jacksonville, North Carolina are two of the youngest cities in the country, with less than 10% of the population 65 or older. The number of primary care physicians per capita dropped by over 14% in each of those two cities between 2010 and 2013.

Due to the number of factors that can affect the number of doctors per capita in a given area, including aging population, economic prosperity, physician productivity, and scientific advances in treatment technology, it is difficult to determine the consequences of declining numbers of doctors. According to the U.S. Department of Health and Human Services, while an area can certainly be underserved by its health system, there is no clear optimal doctor to population ratio but it predicted that the ratio will get worse.

And, yes it can and already is getting worse when the insurance companies are withdrawing from the ACA/Obamacare. Consider the latest announcement.

Aetna became the latest health insurer to cast doubt upon its future in the Affordable Care Act’s insurance exchanges after it called off a planned expansion Tuesday and suggested it could abandon that market completely.

A departure by Aetna, the nations’ third-largest insurer, could further reduce the number of choices for customers and eventually push insurance prices higher and therefore more patients will avoid heath care. Competition by insurers is a key feature of the exchanges, designed to keep a lid on prices, but several insurers are abandoning them because they are losing enormous amounts of money.

Aetna said Thursday it has been swamped with higher than expected costs, particularly from dicey specialty drugs, and it will take a hard look at its current presence on exchanges in 15 states. When asked by The Associated Press whether that meant the insurer might leave the exchanges entirely or just some markets in 2017, CEO Mark Bertolini said: “All of the above.”

Major insurers like UnitedHealth Group Inc. and Humana Inc. have already said they are scaling back their exchange participation in 2017, and several smaller, nonprofit insurance cooperatives are winding down business after losing millions.

The exchanges have helped millions of people gain health coverage, many with assistance from income-based tax credits. But will we have enough physicians and physician extenders to care for the increased patient population. But insurers say this relatively small slice of their business has led to large losses because claims have been higher than expected and they are getting less government help than they thought, among other issues.

Blue Cross-Blue Shield insurer Anthem Inc. recently reported a surprising loss from its exchange business.

Aetna said Tuesday it now expects to lose $300 million this year from individual coverage it sells on the exchanges, or triple what it lost last year. Earlier this year, Aetna had said it hoped to break even in 2016.

The insurer covers about 838,000 people and got hit with higher pharmaceutical costs than it expected. Bertolini told analysts Tuesday that a federal risk adjustment program designed to assist insurers that take on high-cost patients hasn’t helped with this expense.

“These people need this care, and it’s appropriate that they get it, but it’s really about how the system works,” he said. Also, will there be the healthcare staff to care for them?

The insurer said last Tuesday that it plans to sell part of its Medicare Advantage business in an effort to preserve its $34-billion acquisition of Humana. The Department of Justice sued late last month to stop that deal and Anthem Inc.’s $48-billion acquisition of Cigna Corp. mainly due to concerns about their impact on competition.

Both Anthem and Aetna have vowed to contest the government lawsuits in court. Aetna and Humana have agreed to sell some of their Medicare Advantage business to another insurer, Molina Healthcare Inc., for around $117 million. Medicare Advantage plans are privately run versions of the government’s Medicare program for the elderly.

The insurers say this deal should help alleviate regulator concerns that an Aetna-Humana combination would stifle competition in too many Medicare Advantage markets.

If the healthcare system or in the future the government, has more difficulties with their support systems and who pays the bills, physicians graduating from medical schools with huge debt of $180,000-$350,000 will not survive or as we are seeing, they will become employers of hospitals, universities or the larger healthcare delivery companies. Oh, wait that is already happening!! And interestingly, medical students are being charged an additional $1,275 registration fee for what is known as the Step 2 exam, which is expensive itself, but also because the test is offered in just five cities, and the students often have to bear the cost of travel and lodging. Fourth-year medical students who take the exam are traveling the country interviewing for residency programs about the same time, and they say that the bills can become unmanageable. The system keeps adding on the cost to become a physician but does not want to pay them what they need to pay back their loans and making it more difficult to start and maintain a practice. Patients don’t understand the expanding demands on their physicians. Doctors have to justify their time and substance of visits for each payment.  They are spending more time documenting the visits than the time for seeing their patients.  If a physician sees a patient for thirty minutes, they have to document for 30 minutes why they spent that time.  They then get the distinct honor of coding the assessments and then they get to code quality measures.  If diabetic, what is their Hemoglobin A1C?  What was their LDL- more than 130, between 101- 129, less than 100?  It’s not bad enough the government and the insurance companies have access to the patient records; but then they want physicians to code it for them in a language of alpha-numerics.  Every week the physicians get another set of codes to document. The government and the insurance companies dictate how physicians practice. And then physicians don’t get any additional reimbursement for all the paperwork and computer entry time! In addition, we all live with the threat of a malpractice suit every day of our professional lives and some for a long time after! Why would anyone want to go into this wonderful profession?

Then, where is the incentive to pursue the wonderful profession of health care? If we continue to penalize the physicians when they graduate, when they get into practice and make it more difficult to pay back their debt we will see less and less students choosing medicine as their future profession. Then, who will care for our increasing population of patients?

The Democratic Convention and the Single Payer Health Care System- A Pipe Dream!

13876607_935045163291810_6970900724155579177_nAs I listened to the Democratic Convention and their answer to health care I was disappointed, but as I mentioned last week, what did we expect? It was interesting to hear one of the delegates, a physician telling the “world” and “fellow physicians not to fear the single payer system. I suspect, as a primary care physician an all Medicare system would be better than what he sees in his practice with the addition of Medical Assistance, which pays about 10 cents on the dollar. However, he is missing the real point, realize the faults of a government run system.

Amid failures of Obamacare’s health care co-ops, Democrats plan to push their chips all-in with a government-run public health-care option now, The Washington Times reported Thursday. The move can be credited to the progressive influence of Sen. Bernie Sanders, pushing Hillary Clinton and the 2016 Democratic platform further to the left, but more like her original health care program, instead of ceding ground to the congressional Republican’s sway toward scaling back government involvement in health care, he wrote.

“This campaign is about moving the United States toward universal health care and reducing the number of people who are uninsured or underinsured,” Sanders told the Democratic National Convention in Philadelphia on Monday. “Hillary Clinton wants to see that all Americans have the right to choose a public option in their health care exchange.”

Co-ops, non-profit consumer operated and oriented health care plans, were introduced by the Democrats as a designed compromise to get the program passed in lieu of a public option in 2009, but they have been failing to compete in the marketplace and have opted out. The Times reported 16 of the original 23 co-ops have withdrawn from the Affordable Care Act’s web exchange. The move now appears to be all-in on a government-run public option, despite both the House and Senate being controlled by the GOP.

“When its big programs fail, the left’s answer is always bigger programs,” Republican Nebraska Sen. Ben Sasse said. “With co-op failures and crummy choices and costs, the Affordable Care Act’s central planning has been a disaster. It makes no sense for politicians to double down, especially when they’re gambling with the livelihoods of American families.”

We covered the problems of the VA and the lack of progress after the government has invested in millions and billions of dollars. But look at the ridiculous spending. The Veterans Affairs administration spent $20 million on expensive artwork and sculptures amidst the healthcare scandal, where thousands of veterans died waiting to see doctors.

The taxpayer watchdog group Open the Books teamed up with COX Media, Washington, D.C., for an oversight report on spending at the VA, finding numerous frivolous expenditures on artwork, including six-figure dollar sculptures at facilities for the blind.

“In the now-infamous VA scandal of 2012-2015, the nation was appalled to learn that 1,000 veterans died while waiting to see a doctor,” wrote Adam Andrzejewski, the founder and CEO of Open the Books, in an editorial for Forbes. “Tragically, many calls to the suicide assistance hotline were answered by voicemail. The health claim appeals process was known as ‘the hamster wheel’ and the appointment books were cooked in seven of every ten clinics.”

“Yet, in the midst of these horrific failings the VA managed to spend $20 million on high-end art over the last ten years—with $16 million spent during the Obama years,” Andrzejewski said.

The VA spent $21,000 for a 27 foot fake Christmas tree; $32,000 for 62 “local image” pictures for the San Francisco VA; and $115,600 for “art consultants” for the Palo Alto facility. A “rock sculpture” cost taxpayers $482,960, and more than a half a million dollars were spent for sculptures for veterans that could not see them. “In an ironic vignette, at a healthcare facility dedicated to serving blind veterans—the new Palo Alto Polytrauma and Blind Rehabilitation Center—the agency wasted $670,000 on two sculptures no blind veteran can even see,” Andrzejewski said. “The ‘Helmick Sculpture’ cost $385,000 (2014) and a parking garage exterior wall façade by King Ray Studio for the ‘design, fabrication, and installation of the public artwork’ cost $285,000 (2014).”

“Blind veterans can’t see fancy sculptures, and all veterans would be happier if they could just see a doctor,” he said.

But an article last week shows more of the inadequacies of a government run health care system one only has to look at the Native American experience.

It’s a common scenario: A distraught mother brings her young child to the pediatrician, seeking antibiotics for her child’s cold. The doctor determines that the child has a viral infection, not bacterial. Most responsible physicians would explain that prescribing antibiotics could harm to the child (in the form of side effects without benefits) and would worsen the public health problem of drug-resistant bacteria. They understand that antibiotics would be a false “solution” to the problem, and instead help provide other supportive care appropriate to the child’s condition.

Unfortunately, politicians are too prone to advocating false “solutions” to problems, which will be ineffective (at best) or downright harmful (at worst). In the realm of health care policy, one recurrent wrong solution is the continued advocacy by the political Left in a “single payer” government-run health system.

Newsweek recently profiled the many serious problems in the federal government’s Indian Health Service (IHS), which is responsible for the health care of 2 million Native Americans. Government health care is theoretically a “right” provided to these Native Americans, as part of federal legislation as well as federal treaties with the recognized Indian tribes. There’s a cruel joke often told in Indian country: “Don’t get sick after June.” The sick truth beneath those words is that by summertime the Indian Health Service—tasked with providing basic health care to the nation’s 2 million Native Americans and Alaska Natives—has typically blown its meager fiscal year budget for its Catastrophic Health Emergency Fund. Perhaps even more dangerous to the health of natives across the United States: The IHS does not typically provide coverage for preventive services. Without those types of checkups—the mammograms, colonoscopies and other services that are mandated by the Affordable Care Act—cancers don’t get found until it’s too late.

This infuriates many community advocates, like Donald Warne, the first Native American doctor to serve on the national board of directors of the American Cancer Society. “People are suffering and dying unnecessarily,” says Warne, who is also the chairman of the department of public health at North Dakota State University, the only master’s of public health program with a Native American concentration. “If someone does not have insurance, and they’re dependent on IHS, a [cancer] screening does not occur.”

The federal government funds the IHS IHS +%,and employs approximately 2,700 nurses, 900 physicians, 500 pharmacists, and 300 dentists in what is essentially a “single payer” system for these patients. Yet the quality of health care is considered abysmal:

There’s a cruel joke often told in Indian country: “Don’t get sick after June.” The sick truth beneath those words is that by summertime the Indian Health Service — tasked with providing basic health care to the nation’s 2 million Native Americans and Alaska Natives — has typically blown its meager fiscal year budget for its Catastrophic Health Emergency Fund.

Victoria Kitcheyan of the Winnebago Tribe of Nebraska described the horrifying conditions to the US Senate: I am not talking about unpainted walls or equipment that is outdated. I am talking about a facility which employs emergency room nurses who do not know how to administer such basic drugs as dopamine; employees who did not know how to call a Code Blue; an emergency room where defibrillators could not be found or utilized when a human life was at stake; and a facility which has a track record of sending patients home with aspirin and other over-the-counter drugs, only to have them airlifted out from our Reservation in a life threatening state.

You want more evidence of the problems with a singe-payer system, consider the ongoing strife in Ontario, Canada. Because physicians are paid via a single payer system, which happens to be the government, there are rancorous negotiations every few years over what they are paid per service/interaction/procedure/etc.

Our medical association and the provincial government have been unable to come to any agreement. So, for the last 2 years, they have had a contract ‘imposed’ on them – i.e. they’ve/ the provincial government unilaterally decided what to pay them. They have had across the board cuts of 7%, plus additional targeted cuts (e.g. to us in radiology, 30% fee cut to ultrasound, about the same for nuclear medicine, among others).

Their provincial organization recently announced that they reached an impromptu, backroom ‘deal’ about a month ago or so. The deal agrees to further cuts, and places a hard cap on the total budget for paying physicians. A general referendum was set in a rushed timeline (the result of that vote, btw, would not have been binding…it would have simply been ‘advisory’ to the subsequent medical association councilors vote).

The problem is that independent estimates suggest that the hard cap is not enough to meet the growing demand (they set the total budget for an increase of 2.5% per year, plus a top-up payment). The proposal means that if the budget goes over, which most believe it will, the overage will be clawed back from physicians. In other words, we don’t know how much we’ll be cut further, and from whom it will come from.

There has been a large grassroots movement called the ‘Concerned Ontario Doctors’ who overnight became a force of some 14,000 MDs. Multiple specialty societies have joined up and formed a coalition. The coalition is now battling the provincial medical association for fair representation (the deal, by the way, was reached without any real involvement of the negotiations advisory committee…there were two higher-ups at the provincial organization that did the negotiating, bypassing the usual checks and balances).

Now the Coalition has successfully filed a successful legal petition to force a general meeting, resulting in the vote being canceled. Meanwhile, our med association has been spending millions (estimated at $3 million) to ‘sell’ the proposal as being good to its own membership. We receive multiple emails daily saying how we should vote yes. But district leaders are not allowed to use their email directory to contact their own district members (who they represent) to email negatives about the proposal.

This physician has been in practice all that long, but this is the first time that he has seen anything close to this – the general membership battling what is supposed to be its representative body, the provincial medical association. As an aside, all physicians are legally required to pay the medical association annual dues (this was written into provincial law years ago, and was a ‘concession’ to the med association in another negotiation…though its general membership generally disagree with this).

So, why do the Democrats or we think that their program will be any different? Especially when you consider what I pointed out last week. How are we going to finance the program and do we think that the government managing the federal single payer system will be any better than the VA, the America Indians, Massachusetts or Vermont systems health care system and what is being voted on this year in Colorado.

In December, 2014, Vermont Governor Peter Shumlin (D.) announced that he was pulling the plug on his four-year quest to impose single-payer, government-run health care on the residents of his state. “In my judgment,” said Shumlin at a press conference, “the potential economic disruption and risks would be too great to small businesses, working families, and the state’s economy.” The key reasons for Shumlin’s reversal are important to understand. They explain why the dream of single-payer health care in the U.S. is dead for the foreseeable future—but also why Obamacare will be difficult to repeal the most important one is one that I keep mentioning. The Vermont plan would have required a 160 percent tax increase to finance it further. But we can discuss the Vermont system further in another post.

Paul Krugman stated it oh, so well in his column in The New York Times when he stated that a Single-Payer Health Care System is a Pipe Dream. He stated that the Affordable Care Act is “what engineers would call a kludge.” It’s a “awkward, clumsy device with lots of moving parts,” yet it has largely succeeded in what it was designated to do: make health insurance available to all Americans and reduce the number of uninsured by 20 million. But because it’s messy and imperfect, should Democrats “try for something better”- a single-payer. Medicare-type program covering everyone, as Bernie Sanders suggested and then Hillary announced was her aim? No, because there is zero chance of enacting such a proposal as well as the cost of such a program.

A single-payer scheme would require large tax increases ( remember the 160% increase for Vermonters) on not just the wealthy but also the middle class; even if eliminating premiums offset these taxes, as Sanders suggested, they would still be hugely unpopular, and a furious backlash would ensue.

Doctors and the insurance industry would also rebel, and so would the millions of Americans who would lose the good insurance they currently get through there jobs.

Lets not forget that Obamacare barely passed, and didn’t get a single Republican vote. It makes no sense for Democrats “to spend political capital on a quixotic attempt at a do-over, not of a political failure, but of health reform-their biggest victory in many years.”

What a crazy time that we live in with 2 candidates running for President that have the highest disapproval rating. I’m not sure who will be better for the health care system and even more who will be best for our Country!

Do any of you all out there have any suggestions????

 

Why Obama’s ‘Public Option’ May Disappoint

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Dan Diamond wrote a piece last week reviewing the Public Option touted by both President Barack Obama and Hillary Clinton over the past week, where both called for a new government-run insurance option, the “public option”. But the “public option”— which some Democrats have been trying to enact since health law negotiations in 2009 — isn’t a panacea for the problems plaguing Obamacare, Harvard expert Katherine Baicker tells POLITICO’s “Pulse Check” podcast.

The President said “Some parts of the country have struggled with limited insurance market competition for many years, which is one reason that, in the original debate over health reform, Congress considered and I supported including a Medicare-like public plan,” Obama wrote in the piece.

A public option would mean a government run health insurance plan.

“Adding a public plan in such areas would strengthen the marketplace approach, giving consumers more affordable options while also creating savings for the federal government,” the president wrote.

Obama’s call comes days after presumptive Democratic nominee Hillary Clinton voiced support for a public option, in a nod to supporters of Bernie Sanders, who wanted the federal government to take over providing health care coverage for all Americans.

Remember our discussion last week- Both supported a public insurance option at the national level but opposition from moderate Democrats prevented that proposal from being included in the health overhaul law.

But Sanders and many of his supporters continue to debunk her commitment to progressive healthcare and social change and belittle her claims of past achievements. They point to her failure in the mid-1990s as field marshal for the Clinton administration’s healthcare reform effort to win passage of universal coverage legislation as proof of her ineffectiveness and timidity in confronting powerful special interest groups.

“What Secretary Clinton is saying is that the United States should continue to be the only major country on earth that doesn’t guarantee healthcare to all of our people,” Sanders said during a debate last month.

“I do believe in universal coverage,” Clinton shot back. “Remember, I fought for it 25 years ago.”

Millennial voters, who have skewed heavily toward Sanders in the Democratic primaries and tend to scoff at Clinton’s record, are too young to know her history. Even Baby Boomers are prone to forgetting it. It seems like a good time to revisit Hillary Clinton’s healthcare story.

Two people with first-hand knowledge of that story are Neera Tanden, CEO of the Center for American Progress, a liberal research and policy group based in Washington, and Fran Visco, executive director of the National Breast Cancer Coalition. Both say the Hillary Clinton they know is nothing like the self-serving politician described by her critics.

Reviewing what I previously reported what Tanden wrote (who served as a senior policy adviser to Clinton when she was first lady, legislative director when Clinton was in the Senate, and policy director when she ran for president in 2008)—she emphasized Clinton’s tireless work as first lady in helping pass and implement the State Children’s Health Insurance Program, which now covers 8 million kids. It’s widely acknowledged that Clinton played a pivotal role in building congressional and White House support for the 1997 passage of that legislation.

She pushed her reluctant husband to support $24 billion in funding for the new program in the Senate bill, rather than the $16 billion approved by the House. “The children’s health program wouldn’t be in existence today if we didn’t have Hillary pushing for it from the other end of Pennsylvania Avenue,” Democratic Sen. Ted Kennedy, who co-authored the CHIP bill with Republican Sen. Orrin Hatch, told the Associated Press in 2007.

Tanden’s account of Clinton’s CHIP implementation efforts squares with her sometimes-mocked image as a detail-oriented policy wonk. Hillary was the person in the Clinton administration most focused on outreach and enrollment for the new children’s insurance program, bringing together private-sector officials from the Ad Council and AT&T to organize advertising and a toll-free line to get information out to the public, Tanden said.

“She recognized this legislation would stand or fall on whether people knew about it and signed up kids,” Tanden says. “She rolled up her sleeves and figured out how to get a high take-up rate. The amount of free advertising we got for CHIP was monumental given that we had no resources.”

Even when she was running for Senate in 2000, Clinton still checked up regularly on the CHIP enrollment rate, just as she closely monitored the progress of the Affordable Care Act legislation—and lobbied Democratic lawmakers to support it—in 2009 when she was secretary of state, Tanden says.

“After the CHIP bill passed, she didn’t just rest, she kept at it,” Tanden said. “Healthcare is very close to her heart.”

The CHIP legislation was just one of several ambitious healthcare initiatives Clinton worked on. In the Senate, she developed comprehensive healthcare quality legislation, which included precursors of accountable care organizations and other payment reform models, though it did not pass. “Very early on, she was talking about the problem that we have a sick care system rather than a system of keeping people healthy,” Tanden said. “She was a leading thinker on a lot of these issues.”

“More competition in insurance markets is a great idea,” Baicker said. “It’s not clear to me that the public option is going to be an effective way to introduce that competition.”

Baicker, a respected economist who served on President George W. Bush’s Council of Economic Advisers, has standing to weigh in: In the JAMA article where Obama laid out his public option earlier this week, no expert was cited more than her.

But Baicker questioned whether the government is well-positioned to launch a new insurance plan, pointing to the failure of Obamacare’s co-ops, which were similarly conceived as a way to inject competition into state insurance markets. Two-thirds of the co-ops have shuttered in the face of heavy losses, many because of operational problems, and the remainders are facing financial problems too. Congressional Republicans also worked to undercut them. This is true but the system has been flawed from the beginning and we still don’t realize this or are we like the “orthodox” Democrats we are ignoring and continue to deny the problems in the face of all the data and therefore the evidence?

Creating co-ops “was a great idea,” Baicker said, but “they were ill-equipped to manage the complicated contracting necessary to operate effectively on an exchange.” A public option would likely face the same political and operational complications, if not more, she said.

Baicker is familiar with how politics and policy can collide: She’s one of the leaders of the Oregon Health Insurance Experiment, a groundbreaking study to test the effects of expanding health coverage. The team’s ongoing research was thrust into the spotlight after the Supreme Court ruled in 2012 that states had the choice to expand Medicaid under the Affordable Care Act. And while Baicker’s team found that Medicaid expansion led to better access to health care, improved finances and self-reported measures of health, they also concluded that patients’ utilization of health care went up significantly, boosting state spending.

“It would have been nice if all those benefits came for free. But they don’t,” Baicker said. “People got health care, and that’s great — but it costs money.”

The study’s findings have been wildly interpreted across the political spectrum. Proponents of the Affordable Care Act say it’s proof that Medicaid expansion is a necessary fix to improve Americans’ health, while opponents argue that it shows the benefits are small and the costs are significant.

One key battleground has been over emergency room visits, which surged by about 40 percent per person who received coverage in Oregon. That was a surprise to many advocates of Obamacare, who maintained that expanding health coverage would allow previously uninsured patients to find regular doctors and stop relying on emergency services. Baicker says the evidence needs more scrutiny: “The next set of questions we’re going to answer [will] dig into emergency department use,” she said.

Having seen the fight over her own research, Baicker warned that lawmakers and beltway pundits continue to distort health research findings when making health policy, often focusing on anecdotes while ignoring bigger, structural problems. For instance, she believes that lawmakers are overdue for a reckoning with public spending, like whether Medicare should pay for certain high-end cancer treatments that only benefit a few patients. Spending so much on health care is crowding out other public sector priorities, Baicker said.

“It’s hard to talk about resource allocation in health care in a rational dispassionate way without sounding like a big jerk,” Baicker said. “People say you can’t put a price on your health.”

“Well, yes you can, and you probably should.”

But as my friend Kate Tillman so rightly stated, “we have seen the proposed plans and wonder what they are thinking (or not) in the wake of so many changes, regulations, chaos with O’s (Obama’s) public option push. Also, there appears to be a deeper divide between policy makers and the patients.  I think we have to build on what we have or we will all be in the poor house. Who has that answer in this changing world?

They still don’t “know what’s in it” as P (Pelosi) said, so the carping for control by both sides seems mute. The lack of HHS/CMS/FDA transparency is a very real obstacle.  Sort of like terrorists, we have to define the problem before we can address solutions.

Obama made several other recommendations for improving Obamacare. He called on the 19 states who have not expanded Medicaid to do so and on Congress to increase financial assistance to make Obamacare coverage more affordable. And he said Congress should help reduce the cost of prescription drugs by requiring drug makers to disclose their production and development costs, increasing the rebates manufacturers must give for drugs prescribed to certain Medicare and Medicaid beneficiaries, and allowing the federal government to negotiate prices for certain high-cost medications. Again, all great ideas, especially those addressed at the pharmaceutical companies, but do you know who is going to foot the eventual bill to pay for all the costs….we tax payers, in one form or another!!

Three years after Obamacare’s exchanges opened for business, the program is still facing challenges.

Many insurers found enrollees have higher health care needs than expected, forcing them to hike rates. A recent Kaiser study found the benchmark silver plan premiums are projected to rise 10% for 2017, on average, for a 40-year-old consumer in 14 major cities. That’s double the 5% increase for 2016 policies, but it could change since state regulators often reduce insurers’ rate requests. If you look across the country, most of the insurers are about to increase the cost of insurance premiums by double digits and also the deductibles, making the cost of coverage to the average person more out of touch with reality or their pocketbooks

Without politicizing the whole discussion we continue to ignore the unique parts of the equation in our country- the cost of educating the physicians, the cost of malpractice insurance, which every physician must have to practice but the costs are still out of control. And how do we, our country or the government pay for the money that both Clinton and President Obama want to “throw” at the program? Remember, we now have a national debt of $20 trillion. The cost of the public option or future eventual program, the universal health program will cost anywhere from a minimum of $40 billion to $1.5 trillion per year. Do we keep on borrowing money to financially support these programs, increase our taxes, whether income taxes or a national sales tax or value added tax? And remember our history of how a healthcare system run by our government takes care of their patients. Look at the VA health care system and appreciate how just throwing money at the system just didn’t work, Go back to my discussion of the VA system and the lack of improvement in my Veteran’s Day post.

I beg each and every potential patient the educate themselves so that the can demand a health care system that will care for all, but one that is financially sustainable. Eventually, it will be your and my purse and pocketbook who will pay for all the “give a ways” that have been promised!!

Next week I am going to point out a very real problem that we are seeing in a number of cities and may become a real impact on the care of the patient. See you next week and stay cool and well hydrated!

 

 

And Clinton and Obama Finally Raise Their Ugly Heads on Health Care! New healthcare proposals, I Doubt it!!

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The Associated Press reported that in another nod to primary rival Bernie Sanders, Hillary Clinton is proposing to increase federal money for community health centers and outlining steps to expand access to healthcare across the nation.

Clinton’s campaign says the proposal is part of her plan to provide universal healthcare coverage in the U.S. The presumptive Democratic presidential nominee also is reaffirming her support for a public-option insurance plan and for expanding Medicare by letting people age 55 year and older opt in, that is purchase Medicare coverage.

The announcement Saturday was a clear gesture toward Sanders, who ran a strong primary campaign against Clinton and has held back from endorsing her candidacy as the party’s convention nears.

In a statement, Clinton said: “We have more work to do to finish our long fight to provide universal, quality, affordable healthcare to everyone in America.” Do you all realize why this statement is so important??

Clinton’s campaign noted that Sanders had promoted doubling money for primary care services at federally qualified health centers. Money for these centers was increased under the Affordable Care Act, an effort led by the Vermont senator.

According to the Clinton campaign, her proposal would make money for these centers permanent and expand it by $40 billion over the next 10 years. Her campaign said the money would be mandatory and not subject to annual appropriation. The proposal would more than double the money for the centers, which currently get $3.6 billion annually.

Sanders, in a conference call after the Clinton campaign’s announcement, said her proposal “will save lives” and “ease suffering” and represented “an important step forward in expanding healthcare in America and expanding health insurance and healthcare access to tens of millions of Americans.”

Clinton’s policy overtures come as Sanders appears to be close to supporting her candidacy.

Two Democrats with knowledge of Sanders’ plans told the Associated Press that Sanders was closing in on offering his public endorsement of Clinton. The Democrats spoke on condition of anonymity to discuss private conversations they were not authorized to disclose.

Sanders told reporters that the two campaigns “are coming closer and closer together in trying to address the major issues facing this country.” He added: “We’ll have more to say, I think, in the very near future.”

Clinton and Sanders frequently clashed over healthcare during the primaries. Sanders campaigned on a “Medicare for all” plan that would have provided universal coverage. Clinton said that would undercut President Barack Obama’s health law, rely too heavily on GOP governors and reopen a contentious debate with Republicans in Congress. But look what President Obama just announced, which I will review at the end of this post.

Clinton’s healthcare priorities have centered on capping out-of-pocket costs for prescription drugs and providing tax credits for families facing high medical costs.

Clinton has reiterated her support for a “public option” for states to set up their own health insurance plan to compete against private insurers. Sanders was instrumental in passing legislation that would allow that.

Both supported a public insurance option at the national level but opposition from moderate Democrats prevented that proposal from being included in the health overhaul law.

But Sanders and many of his supporters continue to debunk her commitment to progressive healthcare and social change and belittle her claims of past achievements. They point to her failure in the mid-1990s as field marshal for the Clinton administration’s healthcare reform effort to win passage of universal coverage legislation as proof of her ineffectiveness and timidity in confronting powerful special interest groups.

“What Secretary Clinton is saying is that the United States should continue to be the only major country on earth that doesn’t guarantee healthcare to all of our people,” Sanders said during a debate last month.

Here is the key comment from Hillary: “I do believe in universal coverage,” Clinton shot back. “Remember, I fought for it 25 years ago.” Yes, she did and my prediction is that we will face the transition to a true Universal Health Care Program run and “financed” by the Government….No the Taxpayers, either with higher income taxes, value added taxes or continued burrowing from foreign sources. How long can that continue… Is this strategy sustainable?

Millennial voters, who have skewed heavily toward Sanders in the Democratic primaries and tend to scoff at Clinton’s record, are too young to know her history. Even Baby Boomers are prone to forgetting it. It seems like a good time to revisit Hillary Clinton’s healthcare story. Yes, I will do this over the next few weeks.

Two people with first-hand knowledge of that story are Neera Tanden, CEO of the Center for American Progress, a liberal research and policy group based in Washington, and Fran Visco, executive director of the National Breast Cancer Coalition. Both say the Hillary Clinton they know is nothing like the self-serving politician described by her critics.

Tanden—who served as a senior policy adviser to Clinton when she was first lady, legislative director when Clinton was in the Senate, and policy director when she ran for president in 2008—emphasizes Clinton’s tireless work as first lady in helping pass and implement the State Children’s Health Insurance Program, which now covers 8 million kids. It’s widely acknowledged that Clinton played a pivotal role in building congressional and White House support for the 1997 passage of that legislation.

She pushed her reluctant husband to support $24 billion in funding for the new program in the Senate bill, rather than the $16 billion approved by the House. “The children’s health program wouldn’t be in existence today if we didn’t have Hillary pushing for it from the other end of Pennsylvania Avenue,” Democratic Sen. Ted Kennedy, who co-authored the CHIP bill with Republican Sen. Orrin Hatch, told the Associated Press in 2007.

Tanden’s account of Clinton’s CHIP implementation efforts squares with her sometimes-mocked image as a detail-oriented policy wonk. Hillary was the person in the Clinton administration most focused on outreach and enrollment for the new children’s insurance program, bringing together private-sector officials from the Ad Council and AT&T to organize advertising and a toll-free line to get information out to the public, Tanden said.

“She recognized this legislation would stand or fall on whether people knew about it and signed up kids,” Tanden says. “She rolled up her sleeves and figured out how to get a high take-up rate. The amount of free advertising we got for CHIP was monumental given that we had no resources.”

Even when she was running for Senate in 2000, Clinton still checked up regularly on the CHIP enrollment rate, just as she closely monitored the progress of the Affordable Care Act legislation—and lobbied Democratic lawmakers to support it—in 2009 when she was secretary of state, Tanden says.

“After the CHIP bill passed, she didn’t just rest, she kept at it,” Tanden said. “Healthcare is very close to her heart.”

The CHIP legislation was just one of several ambitious healthcare initiatives Clinton worked on. In the Senate, she developed comprehensive healthcare quality legislation, which included precursors of accountable care organizations and other payment reform models, though it did not pass. “Very early on, she was talking about the problem that we have a sick care system rather than a system of keeping people healthy,” Tanden said. “She was a leading thinker on a lot of these issues.”

Clinton also was ahead of the curve on health information technology. In 2003, she introduced the Health Information for Quality Improvement Act, which called for a new office to create a national health information infrastructure including patient safety, privacy, and interoperability initiatives. The following year, the Bush administration established the Office of the National Coordinator for Health Information Technology.

The breast cancer coalition’s Visco recalls first meeting Clinton just before her husband was elected president in October 1992. She was struck by how much Clinton cared about the issue of breast cancer and how much she knew about policy relating to the disease. With the first lady’s support, the coalition succeeded in persuading Congress to increase federal funding for breast cancer research from $100 million a year to more than $400 million, with some of that funding going to the Defense Department.

But the Pentagon didn’t want to spend money on the breast cancer research program. “So we went to Hillary Clinton, and she went to the president and made it happen,” Visco said. “She was our ally from Day 1. I’ve never known her to be cautious when it came to doing the right thing.”

Tanden particularly debunks the criticism from Sanders and his supporters that Clinton has kowtowed to powerful industry groups. “I find that so ridiculous,” she says, pointing to Clinton’s losing battle with the health insurance industry in 1993-1994 to pass comprehensive healthcare reform. “She wasn’t worried about sacred cows in insurance. They spent a ton of money against her.”

“She always tries to think about what’s best for families,” Tanden continues. “She’s been a fearless advocate for taking on special interests (when they are) in direct conflict with families. She thinks about these things in terms of the difference it makes in someone’s life.”

It remains to be seen if Clinton can make her case to voters as compellingly as Tanden and Visco make it. The candidate herself is painfully aware of her shortcomings as a communicator. “I am not a natural politician, in case you haven’t noticed, like my husband or President Obama,” she said in the March debate. “I just have to do the best I can” and “hope that people see that I am fighting for them.”

And what happened in the last week when President Obama suggested an ”advance” in his Affordable Care Act? President Obama joined the chorus of Democrats calling for the creation of a government run health insurance program as Obamacare is facing growing problems.

And now our President, in an article published Monday in the Journal of the American Medical Association, the president called for Congress to revisit the “public option” for Obamacare in areas where few insurers offer coverage.

“Some parts of the country have struggled with limited insurance market competition for many years, which is one reason that, in the original debate over health reform, Congress considered and I supported including a Medicare-like public plan,” Obama wrote in the piece.

A public option would mean a government run health insurance plan.

“Adding a public plan in such areas would strengthen the marketplace approach, giving consumers more affordable options while also creating savings for the federal government,” the president wrote.

Obama’s call comes days after presumptive Democratic nominee Hillary Clinton voiced support for a public option, in a nod to supporters of Bernie Sanders, who wanted the federal government to take over providing health care coverage for all Americans.

Some Democrats have long wanted to develop a government-sponsored health plan that would insure Americans under the age of 65, but they have never succeeded.

Instead, Obamacare funded the creation of non-profit co-op insurers to provide consumers with alternatives. But more than half of them have failed since their debut in 2014, undone mainly by enrollees’ unexpectedly high medical use. Other insurers — particularly UnitedHealthcare (UNH) — have announced they are pulling out of Obamacare, further restricting consumers’ choices.

Residents in 664 counties, most of them rural, may only have one insurer to choose from in 2017, according to a Kaiser Family Foundation review. That’s up from 225 counties this year. Obama notes that 12% of enrollees live in areas with only one or two insurers.

Three years after Obamacare’s exchanges opened for business, the program is facing challenges. Look at the great number of state Co-Op’s that are bankrupt or on the brink of insolvency and the eventual closing of programs.

Many insurers found enrollees have higher health care needs than expected, forcing them to hike rates. A recent Kaiser study found the benchmark silver plan premiums are projected to rise 10% for 2017, on average, for a 40-year-old consumer in 14 major cities. That’s double the 5% increase for 2016 policies, but it could change since state regulators often reduce insurers’ rate requests.

In the JAMA article, Obama made several other recommendations for improving Obamacare. He called on the 19 states who have not expanded Medicaid to do so and on Congress to increase financial assistance to make Obamacare coverage more affordable. And he said Congress should help reduce the cost of prescription drugs by requiring drug makers to disclose their production and development costs, increasing the rebates manufacturers must give for drugs prescribed to certain Medicare and Medicaid beneficiaries, and allowing the federal government to negotiate prices for certain high-cost medications.

The President hailed Obamacare for reducing the uninsured rate from 16% in 2010 to 9.1% in 2015 and providing more comprehensive coverage for millions of Americans. He also credited health reform for helping slow the growth rate of health care costs in recent years.

So, why go to the public option? Things are not rosy in DC and across the nation in health care.

And if you all remember, I predicted that this was all going to happen and that this system was filled with flaws and lack of financial sustainability.

You know, I don’t particularly like Mr. Trump, but seeing what Hillary has in mind for our future has me scared.

If you all agree with Ms. Clinton and support her health care policies……be prepared for a two tiered system with lots of waiting for your care and limitation of services and higher taxes!