Author Archives: raaorsini

So Wolf’s book suggests that maybe Trump Privately Floated ‘Medicare for all’ Maybe, we should examine that subject further!

26731003_1412987805497541_1000579279265395780_nPresident Trump reportedly floated the idea of expanding Medicare to cover everyone and initially appeared disinterested in repealing ObamaCare, according to a bombshell book about his first year in office. 

Michael Wolff writes in “Fire and Fury: Inside the Trump White House” that the president “probably preferred the notion of more people having health insurance than fewer people having it.”  “He was even, when push came to shove, rather more for ObamaCare than for repealing ObamaCare,” Wolff writes in his book, which was released midnight Thursday and has been attacked and dismissed as “fake news” by the White House.

Wolff wrote that Trump was disinterested in the details of the GOP’s repeal-and-replace legislation and went along with the plan so he could move on to other issues.  Trump frequently lamented in public that he wished he started with tax reform before ObamaCare repeal and often expressed his impatience with repeal efforts, which took up nearly a year before Republicans threw in the towel after a failed Senate vote.

“I want to get to taxes,” Trump said in a speech in March in Nashville.  “I want to cut the hell out of taxes. But before I can do that — I would have loved to put it first, to be honest — there is one more very important thing that we have to do, and we are going to repeal and replace horrible, disastrous ObamaCare.”

Trump also faced widespread mockery in February when he noted how difficult health-care reform was.  “It’s an unbelievably complex subject. Nobody knew health care could be so complicated,” he said.

Trump also asked aides about “Medicare for all,” Wolff said in the book, one of Sen. Bernie Sanders’s (I-Vt.) key issues in his 2016 presidential campaign. “Why can’t Medicare simply cover everybody?” Trump reportedly asked.

Trump criticized Sanders’s Medicare-for-all bill when it was introduced in September, calling it a “curse on the U.S.”  But Trump has previously made positive comments about single-payer. Trump said earlier this year that Australia, which has a single-payer system, “has better health care than we do.”

Trump also advocated for single-payer in his 2000 book “The America We Deserve,” writing, “We must have universal healthcare.”

Revelations from Wolff’s book have consumed Washington’s first week of the new year, with questions about it dominating White House press briefings on Wednesday and Thursday. Trump ripped the “phony book” on Twitter both Thursday and Friday, saying it was “full of lies.”

The GOP doesn’t have much time to repeal and replace the Affordable Care Act but the reaction to the removal of the Individual Mandate is already being felt, at least locally. Evidently, as reported by my former nurse who works for Care First is the “The Blues” have lost a lot of money and this week as the employees of Care First came into work and were told not to sit down… The outcome over a hundred employees were fired/let go with 6 months of severance pay.

They have lost a great deal of money taking on the riskiest patients and realizing that without the Individual Mandate with the enforced premiums would decrease revenues to cover Obamacare covered clients now and in the future.

Republicans start the year divided over whether to tear down or prop up Obamacare, a split that could derail their legislative agenda leading up to the 2018 midterm elections.

GOP leaders on Capitol Hill don’t want a repeat of last year’s Obamacare fumble: They spent precious time on a failed attempt to repeal the health care law every member of the GOP was presumed to hate.

But they also don’t want to take repeal off the table, which would provoke conservatives who are still determined to undo Obamacare.

The reality is the GOP is so divided on Obamacare, they don’t have the votes to achieve either objective — repeal or stabilization. That means former President Barack Obama’s signature legislative accomplishment could keep limping along, crippled by the repeal of the individual mandate in the tax law but lifted by the surprisingly strong enrollment for the coming year.

President Donald Trump has declared Obamacare “over,” saying that axing the individual mandate means the health law is basically repealed. But he hasn’t made clear precisely what he wants Congress to do next. He’s recently spoken favorably about a bill that would completely dismantle Obamacare and turn it into state block grants, as well as another measure that would shore up the Obamacare markets by restoring subsidies that he personally halted.

Nor is Obamacare the only health program the divided Congress must confront in 2018. The GOP is split over what other health and social programs should be atop its agenda, including whether to make another run at reshaping Medicare and Medicaid.

Republicans and Democrats alike promise to swiftly renew funding for the bipartisan Children’s Health Insurance Program — though they couldn’t agree on more than a short-term patch in December. Several Obamacare taxes take effect this year, though there’s bipartisan interest in delaying them. And the raging opioid crisis is driving a disturbing decline in U.S. life expectancy.

Yet it’s the caustic politics around Obamacare — including the constant threat of repeal — that might be most politically nettlesome, particularly as GOP lawmakers try to show voters they can get things done before the midterm elections in November.

Just last month, the House blocked a Senate-led effort to fund the health law’s cost-sharing subsidies for two years — a conservative victory that underscores how loath they are to do anything that props up the health law said Rep. Mark Walker (R-N.C.), who leads the conservative Republican Study Committee.

“You can see the difference on this side versus the Senate side as far as how much energy there is” for repeal, Walker said.

That rift could reappear almost immediately. Moderates — who say they have Trump’s backing — want to try again this month to fund those subsidies, which help low-income people pay out-of-pocket medical bills.

Republican Sen. Lamar Alexander of Tennessee and Democratic Sen. Patty Murray of Washington say they will resume talks on the Obamacare payments with a goal of shoring up the health markets. Trump called Alexander in late December to encourage him to keep at it, the Tennessee Republican said. But even if he and Murray reach a new deal, the bill stands little chance of getting through the House without Trump’s public and consistent cheerleading.

“If they can get their heads together and President Trump endorses it, it will pass,” Sen. Roger Wicker (R-Miss.) predicted.

So far, House Republicans aren’t on board. “Alexander-Murray is a really tough one, I think, in this chamber,” said Rep. Kevin Cramer (R-N.D.). House Republicans would want to add abortion restrictions, Cramer and other GOP lawmakers say, and they don’t want to send “bailout” money to insurance companies.

Meanwhile, Sen. Lindsey Graham (R-S.C.) is already working on resurrecting a fast-track procedural motion to pass the Graham-Cassidy proposal, which would tear up much of Obamacare and block-grant smaller sums to the states. It was the heart of a last-ditch repeal effort in September, but the GOP ran out of time and shelved the idea. Graham and Sen. Bill Cassidy (R-La.) argue the idea has promise because Sen. Lisa Murkowski of Alaska, one of three Republicans who voted against the repeal effort over the summer, was open to the idea of block grants as long as she felt her state’s interests were protected.

Graham argues that after repealing the mandate in tax reform — and thus weakening how the Obamacare market functions — Republicans have to live up to a “you break it, you buy it” contract with Obamacare.

“The Republican Party cannot avoid the obligation to replace,” Graham said.

But are Republicans crazy to try repeal again in 2018 with one less vote in the Senate — Alabama Sen.-elect Doug Jones is a Democrat — after spending nine months of last year in a fruitless effort?

“I think it would be crazy if you don’t,” Graham said. “How can you repeal the individual mandate and say we’re done? The thing’s going to crumble. We better find a replacement that works.”

But to dramatically shift the dynamic of division, Graham and Cassidy would have to be able to go to Senate Majority Leader Mitch McConnell with an ironclad promise of 50 votes for their Obamacare repeal.

A handful of moderate Republicans told POLITICO that they’d like to move away from Obamacare and on to legislation like infrastructure. But they don’t want to be quoted saying that repeal is dead.

And that’s the crux of leadership’s Obamacare problem. GOP leaders don’t have a solution, but they don’t have an exit ramp, either; not after Republicans made repeal a central campaign pledge again and again for years.

Even McConnell, in his year-end news conference, said twice that he would love to uproot more of Obamacare, but indicated that it’s unlikely.

“I’d love to be able to make more substantial changes to Obamacare than we have,” he said. “As soon as we have the votes to achieve it, I’d like to do it.”

How will our health care system be reshaped in 2018? Rebecca Zisser reported that 2018 is going to be a long year, and probably a hard one to keep up with the ever-evolving world of healthcare.                                                                                                            Let’s take a step back from the minute-by-minute onslaught and take stock more broadly of the big, overarching trends that will animate this year in health policy.

  1. Politically induced chaos

The most consistent theme in the politics of health care last year was uncertainty, and that seems highly unlikely to change in 2018.

  • The Affordable Care Act’s exchanges are a mess of competing priorities that no longer reflect any cohesive policy vision.
  • The individual mandate is about to disappear; Congress still has to make a decision about cost-sharing payments and reinsurance. And we’ll see new regulations from the Trump administration that will make the landscape even harder for insurers to predict.
  • That will push a lot of the action to the states, where insurers will lobby for reinsurance funding, regulatory waivers (on which the Trump administration would have to agree) and state-level coverage requirements. The inevitably mixed results mean an increasingly uneven playing field from one state to the next — and from one county to the next.

And that’s just the individual market. Open gubernatorial races in this year’s midterms will have an enormous effect on health policy for years to come. Medicaid expansion will be explicitly on the ballot in a handful of states. House Speaker Paul Ryan wants to take another crack at Medicare and Medicaid cuts.

Buckle up. These are just the battles we already know about, barely 24 hours into the year.

  1. Industry consolidation

The healthcare industry is consolidating rapidly — hospitals are merging with each other and with insurers; pharmacies are buying insurance companies, and drug companies are snapping up other drug companies.

The big question: Are these deals good for consumers?

  • What happens to networks of hospitals, doctors, and pharmacies? Those options will likely narrow as different types of health care businesses end up under the same roof.
  • Regulators ultimately will have to consider whether merged companies are gaining too much negotiating power and whether these deals will lead to lower health care costs.

What’s next: Regulatory reviews of all these mega-mergers will fall to the Federal Trade Commission — which already has limited resources — and the Department of Justice.

  • Many current deals, including CVS-Aetna, don’t present the same antitrust issues that sunk previous health care mergers.
  • The end of 2017 was among the busiest seasons of mega-mergers in a long time. Expect the trend to continue, while the deals announced last year moved closer to reality.

Don’t forget: Many people have overlooked the part of President Trump’s healthcare executive order that said his administration will “focus on promoting competition in health care markets and limiting excessive consolidation.”

  1. A pipeline full of expensive drugs

This year will see crucial clinical trials — and potential FDA approval — for a host of drugs, including highly watched therapies in oncology and immunology.

Retail drug spending growth has actually been mild over the past two years, but the pending arrival of expensive new treatments, including CAR-T therapies, will add new fuel to the drug-pricing fire, much like expensive new hepatitis treatments helped blow the issue open in 2014 and 2015.

The impact: This isn’t just a political debate: These products can place a real strain on insurance premiums, and could cripple taxpayer-funded health care programs.

  • Two academic doctors who study drug economics, Walid Gellad, and Aaron Kesselheim, offered in May 2017 some policy ideas to keep spending in check.
  • Value-based drug contracts — in which drug companies are only paid if their drugs are effective — are the policy du jour. But we still don’t know a lot about how they are designed or whether they work.
  • Drugmakers often point out that some of these new products are more expensive but also far more effective than their predecessors. But there still is nothing stopping drug companies from buying old, inexpensive drugs and jacking up their prices — the type of behavior that made Martin Shkreli infamous. And that only gives the industry’s critics more ammunition.

What to watch: Policymakers, including HHS secretary nominee Alex Azar, have supported some proposals to crack down on price-inflating tactics, including drugmakers’ patent strategies and the secretive rebate system used by pharmacy benefit managers.

  1. A new era in Medicaid

The Trump administration has barely gotten started on what might end up being one of its biggest healthcare legacies — a new, more conservative vision for Medicaid. But those changes are just around the corner.

  • Seema Verma, who leads the Centers for Medicare & Medicaid Services, has already said CMS will begin allowing states to impose some form of work requirements on Medicaid recipients.
  • Using Medicaid “as a vehicle to serve working age, able-bodied adults does not make sense,” Verma said in November.
  • Most states already rely on private managed-care organizations — that is, insurance companies — to administer their Medicaid programs. This has quietly become a big line of business for the insurance industry, giving insurers a growing stake in the kinds of regulatory flexibility states are seeking from CMS.
  1. The opioid crisis goes on

The opioid crisis is so bad, nationwide, that Americans’ life expectancy is going down, despite myriad advances in medical technology.

  • There are pieces of a response in place — FDA commissioner Scott Gottlieb has taken an aggressive stance on promoting medication-assisted therapy, and some states have developed comprehensive plans.

Yes, but: There’s no coordinated national strategy to try to get this crisis under control, much less reverse the rising tide of addiction, overdoses, and death.

  • Neither Congress nor the Trump administration has put much federal money behind an opioid response.
  • The White House has declared it an emergency and released a long, detailed set of policy recommendations that cut across a broad swath of federal, state and local agencies. But no one is in charge of putting those ideas into practice.


Look at what is already happening,! The new health insurance rule aims to deliver on Trump’s promise. The Trump administration is proposing regulations to facilitate the interstate sale of health insurance policies that cost less but may not cover as much.

But it’s not immediately clear whether the new proposal from the Labor Department will fulfill President Donald Trump’s long-standing promise to promote competition across the country.

The rule would make it easier for groups — or associations — to sponsor health plans that don’t have to meet all consumer protection and benefit requirements of the Affordable Care Act.

Those requirements improve coverage, but they also raise premiums.

Insurers are skeptical of Trump’s idea. Patient groups are concerned about losing protections. And some state regulators object to federal interference.

There’s another wrinkle: Health insurance, like real estate, reflects local costs, which vary widely.

These are all interesting but what is more interesting was an article appearing in The Week. It described Britain’s National Health Service, which the article proclaims is in “chaos”, as described by Denis Campbell and Sarah Marsh in the Guardian.

Remember, this is a health care system that the proponents of the single-payer system keep pointing to as evidence and of the benefits of such an option. A surge in flu patients, colder weather, and high levels of respiratory illness has slammed hospitals across the country. Beds are full, patients are waiting on trolleys in hallways, and ambulances can’t respond quickly to emergency calls. The pressure has led the NHS in England to take the “unprecedented” step of postponing up to 55,000 non-urgent surgical procedures.

This mess is the result of seven years of austerity by the ruling Conservative Party, said Dr. Ravi Jayaram. The NHS has been consistently underfunded in a way that seems purposeful, as the government wants a crisis so it can declare socialized medicine a failure and speed up the privatization of services. Just last fall, the boss of NHS England asked for an extra $5.5 billion for the winter crush, but the government gave only about a third of that. “Primary care services have been compromised,” so people go to the ER instead of their own doctor. And with Brexit approaching, we’re losing many doctors and nurses from European Union countries who no longer feel welcome in the UK.

Money alone won’t solve the problem, said The Mail on last Sunday. The NHS is antiquated. It was designed “for a population of manual workers” who died young. Now, though, it must treat “millions of well-housed sedentary workers who eat too much and exercise too little”-and still live into their 80”s. The whole system needs a redesign, said Camilla Cavendish in The Times.

So, maybe we should be careful which health care system is best as we design our own “ The Best Health Care System” for our wonderful country. Now on to a discussion of single payer systems. Yes, there are different systems.

Can We Make Medicine Better in 2018 or will the Politicians get in the Way?

26167657_1405077166288605_6566726140975836839_nMilton Packer described three ways that we could move forward in the New Year to improve healthcare.

It is traditional at this time of the year to look back at our experiences and look forward to our opportunities. Most people do this on a personal level, and communities (including those in the medical community) do so as well. Yet, it is really hard to engage in this exercise in an unbiased manner. If we are feeling well, we may highlight the positives of 2017. If we have been disappointed, we may focus only on events that we regret.

There are likely to be generational issues. Those early in their careers often find themselves tackling issues that none of us could have imagined decades ago. Those who have already made their major contributions may be grateful that these new challenges will largely be addressed without them.

I grew up in an era of unbridled enthusiasm and optimism, much of it undeserved. My children are growing up in an era where options are more limited, and traditional institutions are no longer trusted. One might think that they would be horribly pessimistic about life. Yet, the emerging leaders of the future seem to be more optimistic than I would have ever imagined. The older generation may have experienced fewer impediments, but we largely ignored the problems that we had or that we created. In contrast, the younger generation sees the problems for what they are and are no longer content with sweeping them under the rug. Many are determined to repair things and make them work.

There are three roles that we can play in 2018 and beyond.

Some of us will look at the world as a crumbling place and will strive primarily to achieve a path of survival. They will focus on themselves: How can we endure and prosper in a world with distorted values? How can we capitalize on the weaknesses of the current system so that we will benefit? These are the takers.

Others look at the challenges in the world and work to devise ways to make things better — for everyone: How can we recreate (or create) mechanisms of trust? How can we make the world fairer and more sustainable? They will accomplish that goal by taking thousands and thousands of small positive steps. These are the doers.

Still, others will simply throw in the towel: emotional surrender. They think of the world as being hopeless and beyond repair, so they will neither strive to exploit it nor make it better. They will simply complain, acting as if that were somehow useful. These are the cynics.

There is comfort in being cynical, but it is short-lived.

To maintain a feeling of self-worth and comfort, the cynic needs to find (or invent) new targets. Otherwise, the machinery of cynicism runs out of fuel. But finding targets is not equivalent to finding solutions. When they confuse the two, cynics deceive themselves into thinking they are making a positive difference in the world.

Cynics often espouse the belief that everything needs to be destroyed — reduced to ashes — before things can get better. That attitude allows them to avoid the responsibility and risk of proposing solutions.

Yet, proposing (and perhaps trying) thousands of small solutions is the way that we will meet our current challenges.

I eagerly look forward to hearing your thoughts and reactions. The readers of this blog have made it a popular platform for the past year. And I hope that you will help me — and MedPage Today — make it a mechanism of change in 2018. We can all be doers.

Now How Do We Fix Medicine’s Broken Windows?

Starting with the small things applies to healthcare, too, says Suneel Dhand, MD. Dr. Suneel Dhand stated that I am honored to be a member of the medical profession. Being a physician is a great job and a highly rewarding thing to do. One of the aspects that I like most, unlike so many other desk or number jobs, is that you can never go home thinking that you haven’t done something good with your day (if you do, there’s something seriously wrong).

The everyday interactions with patients and families, getting to know them, and using one’s skills to serve them — are not only deeply rewarding, but also very humbling. It’s those positive interactions that sustain me, even on the worst days. I have zero regrets becoming a physician, something, which I’ve written about previously.

Having said all of this, it’s no secret there’s an epidemic of physician burnout and job dissatisfaction out there. This is for a multitude of reasons, but everything ultimately boils down to a monumental loss of autonomy and independence among doctors, as there’s been a dramatic shift of power and clout away from individual physicians toward administrators and the business side of healthcare.

Somewhere along the journey, we have lost our direction completely.

Unfortunately, in many ways, we have nobody but ourselves to blame collectively, because for any large and respected group of people to surrender so much autonomy so quickly, a lack of strong leadership must always be a factor.

I am a huge fan of the broken windows theory of starting to get a grip on a problem. In the 1980s and early 1990s, New York City was a place in terminal decline. Growing up in England, I knew many people who came back from trips to America telling us about how terrible and dirty the city was. Times Square was basically a no-go area full of aggressive panhandlers. It was a dangerous and scary place.

Enter Mayor Giuliani in 1994, and the city underwent a rapid transformation. I understand that some aspects of what Mayor Giuliani did were viewed by (some) as controversial, but the results were unquestionable. The broken windows theory of turning around New York City went something like this: Heavily target the minor offenses first. Zero tolerance for broken windows, graffiti, and other things such as “squeegee men” who would aggressively approach you when your car was at a red light. So the philosophy goes: Clamp down on the small infringements, and the bigger things will take care of themselves.

The results of this clampdown for New York City were indisputable. By the time I first visited America in 1998 — New York City is my first stop on a countrywide tour with my family — Manhattan had become one of the safest and most pleasant places in the country. There was a visible police presence on every street corner, and the city was immaculately clean.

Whatever people say, drastic circumstances call for drastic actions. Even today, Manhattan is still one of the safest cities in America and tourists from all over the world give glowing accounts of their stay in the Big Apple (in fact, low-level crime is actually much lower than many European cities, including my home city of London). Thank you, Mayor Giuliani.

We all probably have our own personal experiences of how true the broken windows theory is, and its everyday applicability. Teaching children behavior is one such example: not allowing major bad habits to flourish starts with forbidding the small things first.

But let’s get back to healthcare. For positive change to occur, here are seven broken windows for physicians:

Completely reject the word “provider.” I have written previously about the implications of the now universal use of the word “provider,” and also penned an open letter with the president of the American College of Physician Specialties, William Carbone, to all medical societies and organizations. The word really has taken over, especially evident during the last decade. I am equally shocked by how new residents are being churned out of some of the most prestigious academic centers in the country (my experiences are with the ones in Boston), and are adopting the word so casually, happily describing themselves as “providers” on correspondence including their social media accounts. The business and marketing world really has done a number on us and have run rings around the medical profession. Unfortunately, physicians are also very naïve as a group in understanding the immense power of words, and how not calling ourselves “doctors” or “physicians” anymore is extremely bad for our profession. I personally am okay with many other terms if a more encompassing one is required for certain correspondence, including “clinician” or “practitioner” — but the provider is deliberately dehumanizing, and also in my view, an insult. If you refuse to use the word and call people out on it, they will stop calling you one. It should be removed from all administrative correspondence including information technology systems.

  • Insist on a good physician lounge in your hospital. It’s so much more than a   physician lounge. It is a marker of professional respect and autonomy. This (very small) job perk has rapidly fallen away. I recently wrote an article on this, which went viral online, being shared over 20,000 times. That’s because it struck a chord with thousands of physicians who have seen it happen. Lobby for its return to the hospital where you work and encourage physicians to use it again in their downtime — even for brief meetings.
  • Stand your ground with administrators. As much as hundreds of thousands of employed physicians across the country have a fraught and tense relationship with their administrations. Administrators are very much needed in any organizational structure, and healthcare desperately needs good ones. However, if you sense that any directive is coming through that will interfere with or be detrimental to frontline care, it’s crucial you sensibly and diplomatically stand your ground. If you don’t stick up for good healthcare and your patients, nobody else will.
  • Fix electronic health records. Almost every current study of physician job satisfaction and career burnout lists the burden of cumbersome and clunky electronic medical records at or near the top of the list of everyday frustrations. It’s an issue that is almost invisible to bureaucrats and administrators, but no doctor went to medical school to spend the vast majority of their day clicking boxes and typing out bloated notes for billing purposes. Most electronic medical record systems (I’ve worked with nearly all of them, and in my opinion they all suck) can be optimized in small ways to improve workflow and reduce the “click burden.” What it does require is relentless feedback to your hospital IT department to do so (remember the main vendor has no motivation whatsoever to improve things, because they have a monopoly once installed). Electronic medical records are one of the only examples of technology where the end-user is not the “customer” (imagine how bad the iPhone would be if it worked like that). The companies sell to administrations, so it’s up to physicians to be as vocal as they can.
  • Keep other physician perks. Being a physician is one of the most intense and grueling jobs one can have. Practicing medicine is not for the faint-hearted. Yes, everyone in healthcare works hard, but no profession should be actively losing things. Are other useful perks like car parking, a nice office, or cleaning services being taken away from you? Well, they shouldn’t. What about the other useful workflow issues, like the transcription service, axed to save costs (now stuck with tremendous inefficiency, with what used to be a thorough, logical note dictated in five minutes now becoming a series of tick boxes, typed sentences, and incoherent computer-generated mishmash)? It may take multiple emails, phone calls or face-to-face meetings, but you should insist on keeping job perks that a professional of your level of education and intelligence deserves. If the executives in your hospitals have reserved parking spots and secretaries to make their lives easier, there is no way that the physicians should not!
  • No profession is anything without collegiality. It’s one of the reasons why the physician lounge issue is so important. Doctors need to see themselves again as a unified profession — not one that is fragmented where everyone is in their own little corner specialty. Get to know as many different specialties as you can, organize social events where all physicians can mingle, and talk to each other about how you can get things done. Along the same lines, the link between primary care and hospital-based specialists has been breached by the fact that primary care doctors no longer come to the hospital (even as a hospital medicine doctor myself, I see immense drawbacks to this). We need to restore communication between all physicians, especially the primary care offices.
  • Professional respect. I am all for respecting everyone I work with, and healthcare is a team-based effort. But when it comes to a clinical situation, the physician is the leader of the team. Period. However, there are lots of ways in which I’ve noticed physicians nowadays being treated much more as “co-workers” rather than as the team leaders they are (and to be fair, physicians also need to step up to the mark). One such example I’ve noticed is that many colleagues in the hospital now immediately address doctors by their first name instead of “doctor.” Now, I’m not someone that minds being called by my first name, and thankfully most people ask first — but I just find something inappropriate when someone in the hospital, who may actually be much younger than me (frequently also including administrators), walks up and calls me off the bat by my first name.

Interestingly, I have heard feedback that this actually tends to happen much more to female than male doctors. Every physician has earned the title and deserves to be addressed as such initially in the professional setting. Again, this is not to sound haughty, but most doctors will find anything else a bit uncomfortable and not protocol. The same for certain other professions — be it a university professor, airline pilot, or even the military — titles are the norm of introduction until told otherwise.

These are just seven of many relatively low-hanging fruit scenarios that physicians can, on a daily basis, work towards making sure they retain their professional status. Most of them are free or with minimal associated cost. Remember, we are an ancient and noble profession, and being a doctor is very special. It’s a privilege to use our education and skills to help people get better every day. If you want to advocate for the medical profession, deal with low-level stuff, and the rest will start to take care of itself. Of course, there are undoubtedly much bigger things than the five seemingly small things noted above: reimbursements, overwhelming bureaucracy, and information technology — to name just a few. They will all have their time and place to be dealt with. Suggestion doctor, start fixing those broken windows first.

And Politics still gets in the way as we consider that the CHIP Funding Could Run Out On Jan. 19 For Some States.

Some states are facing a mid-January loss of funding for their Children’s Health Insurance Program despite spending approved by Congress in late December that was expected to keep the program running for three months, federal health officials said Friday.

The $2.85 billion was supposed to fund states’ CHIP programs through March 31. But some states will start running out of money after Jan. 19, according to the Centers for Medicare & Medicaid Services. CMS did not say which states are likely to be affected first.

The latest estimates for when federal funding runs out could cause states to soon freeze enrollment and alert parents that the program could soon shut down.

The CHIP program provides health coverage to 9 million children from lower-income households that make too much money to qualify for Medicaid. Its federal authorization ended Oct. 1, and states were then forced to use unspent funds to carry them over, while the House and Senate try to agree on a way to continue funding.

Phil Galewitz reported that Congress extended funding on Dec. 21 — and said the temporary patch would give states enough money to continue the program while Congress works on a long-term funding solution. But a CMS official says it can only guarantee that appropriation will be enough to fund all states through Jan. 19.

CMS says the agency is in discussions with states to help deal with the funding shortfall.

“The funding … should carry all the states through January 19, based upon best estimates of state expenditures to date,” says CMS spokesman Johnathan Monroe. “However, due to a number of variables relating to state expenditure rates and reporting, we are unable to say with certainty whether there is enough funding for every state to continue its CHIP program through March 31, 2018.”

“States need to know whether they will need to find additional funding for children covered under the Medicaid CHIP program at a much lower federal matching rate; send letters to families and reprogram their eligibility systems,” says Lisa Dubay, a senior fellow at the Urban Institute. “Of course, the implications for families with CHIP-eligible children cannot be understated: Parents are worried that their children will lose coverage. And they should be.”

Although the program enjoys bipartisan support on Capitol Hill, the Republican-controlled House and Senate have for months been unable to agree on how to continue funding CHIP, which began in 1997.

The House plan includes a controversial funding provision — opposed by Democrats — that takes millions of dollars from the Affordable Care Act’s Prevention and Public Health Fund and increases Medicare premiums for some higher-earning beneficiaries.

The Senate Finance Committee reached an agreement to extend the program for five years but did not unite around a plan on funding.

Before the CHIP funding extension on Dec. 21, Alabama said it would freeze enrollment Jan. 1 and shut down the program Jan. 31. Colorado, Connecticut, and Virginia sent letters to CHIP families warning that the program could soon end.

After the funding extension, Alabama put a hold on shutting down CHIP. “Some states will begin exhausting all available funding earlier than others,” a CMS official says. “But the exact timing of when states will exhaust their funding is a moving target.”

Bruce Lesley, president of First Focus, a child advocacy group, says Congress should have known its short-term funding plan was not enough. “The math never worked on the patch, as it only bought a few weeks,” he says. “Congress must get this finalized before Jan. 19.”

Are we ever going to make improving the health care system about delivering good health care to the voters and not about politics?

I guess it is time to exam the possible solutions to a sustainable health care system here in the U.S.A. Single payer system????

Some of the Biggest Healthcare Stories of 2017

25994527_1398929976903324_2887044155808618694_nSince we will be welcoming in a new year tonight I thought that it would be interesting to review a few healthcare stories from last year.

Interestingly enough our fine President Donald Trump made his prediction for the coming year. He is predicting that Democrats and Republicans will “eventually come together “on a new health care plan for the country. I’m not sure that I believe that prediction!

Sending a Twitter post early Tuesday from his Florida resort, Trump said: “the very unfair and unpopular Individual Mandate has been terminated as part of our Tax Cut Bill, which essentially Repeals (over time) Obamacare.”

Much of former President Barack Obama’s Affordable Care Act remains intact, however, and the sign-up period for the various options was carried out as normal this year.

Majority Republicans sought repeatedly to repeal the 2010 law this year, but couldn’t get it through the Senate.

American healthcare went on a roller-coaster ride in 2017. It was a year marked by tremendous change, potential disruption, and stunted progress, with familiar headlines running alongside startling new revelations.

President Trump declared the nation’s opioid epidemic a “public health emergency” in October, two months after a top pharmaceutical CEO stepped down from the president’s American Manufacturing Council. A rash of shootings sparked renewed debate about mental health reform while, across the pond, a British-born infant with a rare genetic disease was placed in the center of a heated debate about parents’ rights.

One could make a solid case for any of these stories, or dozens of others, as the top healthcare headline of the year. The following three were selected for their social, political and business impact in 2017, and for their potential to drive important health care changes in the future.

Merger Mania Goes Vertical

The year began with the impending merger of several large U.S. health plans. The “big five” – covering an estimated 90% of all commercially insured Americans – entered 2017 with the potential to become the even-bigger three.

Anthem was poised to acquire Cigna. Aetna, meanwhile, was on track to take over Humana. With purchase deals in place, all that remained was regulatory approval from DOJ.

This particular hurdle, however, proved too tall for insurers. Citing the risk of “drastically constricting competition” in a number of key markets, then-Attorney General Loretta Lynch sued all four merger hopefuls in 2016. The insurers’ underlying merger strategy, the DOJ argued, was a clear attempt to increase market power. The courts upheld that view.

By May, both deals were dead. Aetna and Anthem were on the hook for billions of dollars in financial penalties and additional damages. Come summertime, merger mania appeared to be yesterday’s news.

However, talks of new mega-deals emerged early this month.

This time, vertical integration took center stage, led by pharmacy giant CVS, which proposed the $69 billion purchase of the nation’s No. 3 health insurer Aetna.

CVS officials claim the buyout will lead to cheaper drug prices for consumers, along with greater operational efficiencies for the business. Experts note the deal could also disintermediate major parts of the delivery system, drawing patients out of local emergency rooms and into CVS’s lower-priced retail clinics, especially during times when most doctors’ offices are closed.

UnitedHealth Group, the nation’s largest insurer, announced its second multi-billion dollar acquisition of the year in December. After buying Surgical Care Affiliates for about $2.3 billion in March, United recently entered into a $5 billion agreement to acquire DaVita’s primary and urgent care network. The latest move would give United more control over the care-delivery process, especially among DaVita’s 1.7 million members.

Merger rumors swirled once again this month with talks of Walmart possibly purchasing Humana, eyeing access to the insurer’s extensive Medicare Advantage membership. And although not a healthcare company yet, Amazon’s acquisition of Whole Foods may be the online retailer’s first big step toward a play in the pharmacy space.

Despite Trump’s executive order in October declaring, “My administration will … continue to focus on promoting competition in health care markets and limiting excessive consolidation throughout the healthcare system,” most prognosticators are betting the more vertically oriented deals will go through, with only slight concessions required from these industry giants.

Political Intrigue Rises From The Ashes

The Republican party entered 2017 with control of the U.S. House, Senate, and the presidency – marking the first majority sweep by either party since 2009-2010, the same era that ushered in President Obama’s signature healthcare legislation.

With the shock of the 2016 presidential election dominating headlines early in the year, Trump looked to make good on campaign promises by urging Congress to repeal and replace the Affordable Care Act.

In May, the House narrowly passed The American Health Care Act of 2017, despite estimates from the CBO that 23 million Americans would lose their health insurance within a decade.

As the debate moved to the Senate floor in June, many elected officials who campaigned against the ACA learned a difficult lesson. That is, it’s easy to engage voters on Obamacare’s failings but hard to sell them on legislation that takes their health coverage away.

Without a meaningful “replacement” plan, the GOP’s attempts to undo Obamacare stalled out in the wee hours of July 28 when Republican Senator John McCain delivered a decisive thumbs-down vote.

Having failed three times to pass a bill in Congress, most people and pundits assumed federal healthcare reform would need to wait until 2018.

But like the phoenix rising from the ashes, the GOP tax plan was brought to vote in December, passing by a narrow margin in the Senate. The bill included a provision to repeal the “individual mandate,” the law requiring individuals to have an ACA-compliant insurance plan or pay a financial penalty.

Although nearly two-thirds of American voters opposed the tax plan, Republicans moved quickly to push the bill through conference committee. Having lost a Senate seat in the reliably red state of Alabama last week, the GOP found itself with an even slimmer margin for error. Rather than letting the process drag on into January, when Democrat Doug Jones is expected to be sworn in as Alabama’s newest U.S. Senator, the bill is expected to reach the president’s desk for signature as early as this week.

By eliminating the individual mandate, the CBO estimates that 13 million Americans will lose their health coverage, thus saving the federal government $338 billion over the next decade. Only time will tell if either projection proves accurate.

Sexual Misconduct Exposed 

In 2017, the Silence Breakers were named TIME Magazine’s “Person of the Year” for their willingness to shine a light on a problem long kept hidden in the shadows.

Fueled by actors Rose McGowan and Ashley Judd, who came forward with allegations of sexual assault and harassment against Harvey Weinstein, the #metoo movement gained nationwide attention.

Other disturbing reports surfaced throughout 2017, detailing the exploitation of power by politicians, businessmen, media members and cultural icons. Each new revelation required courage from the individuals who stepped forward, many of which faced threats of threats of retaliation and legal action.

Bringing these stories into the public domain has proven important for many reasons. Among them are the health consequences of this type of harassment and abuse. The link between interpersonal abuse and public health has been well validated.

Victims of sexual assault, as well as those who suffer intimate partner violence (IPV) and adverse childhood events (ACEs), frequently experience severe anxiety, depression and chronic illness. What’s more, health issues resulting from trauma are known to negatively impact not just the victims, but often their children and grandchildren, as well. Complicating matters further is that people who suffer abuse rarely get the treatment they need, often due to feelings of shame, fear or self-blame.

Although the disclosure and public acknowledgment of abuse cannot fully reverse the harm inflicted on the victims, removing the stigma of speaking out can encourage more people to step forward and, importantly, seek help.

Ultimately, by providing assistance to those impacted, we can help prevent future abuses and improve the overall health of our nation.

We should expect more revelations to surface in 2018.

A Great question has raised its ugly head, after Individual Mandate Repeal, Who’ll Pay for Rising in Uncompensated Care after millions are expected to drop insurance coverage? Jack O’Brien of HealthLeaders Media, noted that the passage of the Republican tax reform bill included a provision to remove the individual mandate penalty, a key aspect of the Affordable Care Act, also known as “Obamacare,” which will have a significant impact on how hospitals care for more uninsured patients.

The bill did not repeal the individual mandate but gutted the penalty for Americans without insurance, which is 2017 was either a $695 fine or 2.5% of income, whichever amount was greater.

The decision is expected to increase the uninsured population by four million in 2019, according to a Congressional Budget Office (CBO) report released last month. The number of uninsured Americans is expected to rise by 13 million by 2027 as young adults drop out of the market without the mandate penalty.

With a higher uninsured rate, health system leaders must now address how to care for a larger population lacking insurance coverage. The long-planned reduction of federal payments to disproportionate share hospitals (DSHs) poses an additional challenge.

Currently, the Centers for Medicare & Medicaid Services (CMS) administers payments to DSHs, which predominantly tend to low-income patients including those without insurance. The Urban Institute estimates that the federal government covers 35% of uncompensated care costs, the total amount of healthcare provided with no payment received.

Federal DSH Spending Rises with Uninsured Rates

The funding formula for both Medicaid and Medicare DSH payments is based in part on a state’s uninsured rate. The Medicaid DSH formula specifically relies on how well the state directs payments to hospitals with high volumes of Medicaid inpatient utilization, and how well the state directs payments to hospitals with high levels of uncompensated care.

Federal DSH spending totaled $12 billion during the fiscal year 2016, according to information from the Kaiser Family Foundation (KFF). The CBO in its November analysis estimated that a $44 billion increase in DSH payments would be needed over the next decade due to the individual mandate repeal.

Since automatic increases in DSH spending are based on higher uninsured rates, the burden of uncompensated care will be partially offset by the increase in the amount of money a hospital receives, Matthew Fiedler, Ph.D., a fellow with the Center for Health Policy in the Brookings Institute’s Economic Studies Program, told HealthLeaders Media in an interview. “The uninsured rate will have a direct effect on the amount of uncompensated care and an indirect effect on the amount of DSH payments that are made, in Medicare at least, because the uninsured rate is part of the formula that determines how much DSH payments any given hospital is entitled to.”

DSH Funding on 8-Year Reduction Plan

In the original text of the ACA, federal funding reductions were planned for DSH payments to coincide with an expected decrease in the uninsured rate nationwide. The reductions were set to go into effect in the fiscal year 2014 and last through the fiscal year 2020, but legislation was passed in 2013 to postpone them until the fiscal year 2018.

Despite the 4-year layoff, nearly two-thirds of states did not sufficiently allocate their FY 2018 budgets for the scheduled reductions, according to KFF. In July, CMS proposed a rule that ordered the beginning of reductions with $2 billion in FY 2018.

The current DSH reductions are projected to run through the fiscal year 2025, totaling $43 billion.

The potential impact of changes to the DSH program on hospitals is unclear until Acting Secretary of Health and Human Services Eric Hargan makes cuts or redistributions of DSH allotments, said David Mosley, managing director with Navigant Healthcare in Atlanta.

The impact will depend on the cost of people who utilized services without payment compared with the number of people who will be uninsured and eligible for DSH, Mosley said.

“I would love to have some wonderful prognostication,” he said, “but the answer is there are a few variables out there that, until someone tells us the value of those variables, we don’t know.”

An Entire OR team Kneels During Time Out Protocol to Protest Administrators!

And on a funny note- in a stunning turn of events, entire OR teams including Anesthesia kneeled today during all surgical timeouts today at Bellin Hospital.  The shocking display of unity against the hospital administrators has sharply divided the medical community across the globe.

The impetus of the mass genuflection was a lone General Surgeon, Dr. Bessie Jandle, who refused to comply with the mandate from Joint Commission that all OR staff wear bouffant scrub caps.  Jandle started kneeling during timeouts in protest over a year ago, but no one paid much attention to it even after his contract with Bellin Health was not renewed.

This summer, several other isolated surgeons started kneeling during their own timeouts, which caught the attention of Bellin Health hospital administrator Timofy Weeber MPH, MHA, GED, POS.  Weeber demanded that all departments fire any and all surgeons who refused to stand for timeouts.  Weeber’s demands, which he didn’t have the authority, ability or spine to enforce, actually served to galvanize and unite the entirety of the OR staff.

In OR 2, every person in the OR including the patient dropped down to a knee arms interlinked for the timeout.  Numerous other OR’s had similar happenings with 75% of all OR teams dropping to a knee or sitting down for the timeout.  When word started to spread of the protests, several anesthesiologists claimed that they have been sitting down during timeouts and even entire cases for years.

Meanwhile, in OR 4, Ortho also took a knee and replaced it with a better one.

Happy New Year to All! May you all! Enjoy a Wonderful New Year! Words to guide us all in 2018: Gratitude, Kindness, Love, Honesty, Empathy, and Forgiveness!


Obamacare is hardly repealed, but some may have more and costlier insurance choices-i.e. and Other Effects of the Tax Bill

25551900_1394093210720334_2253461270479693121_nSometimes, in fact, more and more times I really believe that our leaders are reminiscent of the comedy team, the Three Stooges. I wonder if our elected officials are comedians or idiots.

Jayne O’Donnell and Herb Jackson wrote that hours after Congress passed the tax bill Wednesday; President Trump declared the Affordable Care Act “essentially” repealed.

In fact, it’s barely touched. But is or was it repealed?

What was repealed — effective in 2019 — was the requirement that nearly everyone has insurance or pay a penalty at tax time.

“This is important but it’s not the heart of the ACA, by any means,” says Sara Collins, vice president of health care coverage and access for the non-profit Commonwealth Fund.

What the tax bill doesn’t change:

  • The federal and state exchanges that sell insurance to those who don’t get it from their employers will remain open and people who gained Medicaid coverage under the expansion of the program will be able to keep it.
  • Subsidies will remain available if these people who make below 400% of the federal poverty limit (about $98,000 for a family of four).
  • Most employers will still be required to offer plans that comply with the law. And a variety of other requirements for insurers, doctors, and hospitals will be intact until or unless Congress or the Department of Health and Human Services (HHS) changes them by legislative or regulatory fiat.

The mandate’s “effect was highly exaggerated because it wasn’t an effective mandate to begin with,” says health care economist Gail Wilensky, who headed the Centers for Medicare and Medicaid Services in the George H.W. Bush administration.

The penalty for not having insurance was often far less than the cost of having insurance. Besides, there were too many ways people could be exempted from the requirement, says Wilensky, a senior fellow with the global health foundation Project Hope.

Mitch McConnell said that he is Ready To ‘Move On’ From Obamacare Repeal, But Others In GOP Say Not So Fast!

Senate Majority Leader Mitch McConnell wants 2018 to be a year of bipartisanship, even if that means moving on from GOP dreams of cutting welfare and fully rolling back the Affordable Care Act. How refreshing!

The Kentucky Republican on Thursday broke with House Speaker Paul Ryan, R-Wis., on the approach to paring back spending on programs like Medicaid and food stamps. In an interview with NPR, McConnell said he is “not interested” in using Senate budget rules to allow Republicans to cut entitlements without consultation with Democrats.

“I think entitlement changes, to be sustained, almost always have to be bipartisan,” McConnell said. “The House may have a different agenda. If our Democratic friends in the Senate want to join us to tackle any kind of entitlement reform, I’d be happy to take a look at it.”

McConnell said he wants to spend much of next year focused on issues on which Republicans can work with at least some Democrats in the Senate.

“This has not been a very bipartisan year,” McConnell said. “I hope in the new year, we’re going to pivot here and become more cooperative.”

Republicans spent most of the year struggling and failing, to follow through on promises to repeal and replace the Affordable Care Act, also known as Obamacare. Democrats refused to work with Republicans while they were trying to dismantle President Barack Obama’s signature domestic achievement, and McConnell hopes that next year will be different.

“Well, we obviously were unable to completely repeal and replace with a 52-48 Senate,” McConnell said. “We’ll have to take a look at what that looks like with a 51-49 Senate. But I think we’ll probably move on to other issues.”

McConnell is referring to the political reality that the odds for legislation with only GOP support become longer in January when Sen.-elect Doug Jones, a Democrat from Alabama, takes office.

Republican demands to gut the ACA also declined after Congress effectively eliminated the individual mandate by zeroing out the tax penalty in Obamacare as part of the tax bill approved this week. McConnell hopes to focus instead on stabilizing the insurance marketplaces to keep premiums from skyrocketing in the early months of 2018, a promise he made to moderate Republican Sen. Susan Collins of Maine to get her support for the tax bill.

“I think the repeal of the individual mandate takes the heart out of Obamacare,” McConnell said. “We want to steady the insurance markets if we can … and I think we’ll probably be addressing that part of health care sometime next year.”

Republican Sen. Lindsey Graham of South Carolina immediately pushed back on McConnell’s comments. “To those who believe — including Senate Republican leadership — that in 2018 there will not be another effort to Repeal and Replace Obamacare — you are sadly mistaken,” Graham said in a statement and on Twitter.

But remember that Speaker Paul Ryan (R-Wis.) said that lawmakers need to “revisit” ObamaCare, but also pointed to welfare reform as the focus of next year.                                                                                                                                                        “ObamaCare is collapsing and failing, so we won’t be able to ignore that problem,” Ryan said at a news conference. “So we’re going to have to revisit the problem of a health-care marketplace that is collapsing and that is something that we’re just going to have to get on to.”

However, Ryan did not make clear whether ObamaCare repeal would be part of next year’s fast-track process known as reconciliation to get a measure through the Senate without needing Democratic votes.  Republicans only get one shot at that process next year, and Ryan mentioned health care after saying that welfare reform would be the focus of the fast-track process next year.

“Next year, we want to take on criminal justice reform, we want to take on skills, getting people the skills they need to get the jobs they want, career and technical career education and welfare reform, so those are the kind of entitlement reforms that we’re talking about,” Ryan said.

Some conservatives want the fast-track reconciliation bill to include both welfare reform and ObamaCare repeal.

Any effort on health care faces long odds in the Senate, made even tougher by the victory of Democrat Doug Jones in Alabama this week. Senate Republicans will be able to lose only one vote, and more than that number of Republican senators opposed various ObamaCare repeal efforts earlier this year.

How the GOP Tax Bill Could Affect Health Care

Healthcare Dive reported that Companies should brace for change.

The 30-plus-year drought since the last tax code overhaul may be over as Congress sets out to vote on and place a now-finalized tax bill on President Trump’s desk.

The bill slashes the corporate tax rate from 35% to 21%, and also includes massive changes to how income earned or kept offshore is treated.

In other words, this week could be monumental for business accounts nationwide. Every industry could see effects — including healthcare. Here’s a 60-second overview of what the bill could change, and where industry associations stand on it:

The effect on Healthcare:

IMPACT: Repeal of the Affordable Care Act’s individual mandate is likely to upset payer risk pools and ripple to other players, but hospitals averted elimination of their ability to use tax-exempt bonds.

POSITION: Hospitals and insurers overwhelmingly oppose repealing the individual mandate, but in general the industry stands to gain substantially from the bill’s cut to the corporate tax rate.

ANALYSIS: Repealing the individual mandate would result in about 14 million fewer people with coverage in 2026 and premium increases of about 20%, according to the Congressional Budget Office. Fewer people with health plans mean fewer people seeking care services. Mandate repeal is likely to pull younger and healthier consumers out of the market, resulting in higher premiums and an increase in high-deductible health plans. The rate of insured could also be compromised if the changes to the tax code trigger automatic cuts to Medicare that could reach $25 billion a year under congressional budget rules.

One big win for industry: The final bill keeps the ability of hospitals to use so-called private activity bonds to finance infrastructure and other investments.

Healthcare companies will also be pleased the final product retains the deduction for certain medical expenses and also lowers the threshold from 10% to 7.5% for two years.

Republican leaders have said the separate budget legislation will address destabilization of ACA exchange markets by funding cost-sharing reduction payments and reinsurance programs. Analyses, however, have shown those measures aren’t enough to give the market a sound structure.

What is the Bigger Picture?

The tax reform does not just affect healthcare. Here’s how the bill may alter other industries.

The Effect on the Biopharma Industry:

IMPACT: The GOP tax plan is largely a win for pharma and biotech companies, which stand to benefit from a lower tax rate on cash they have parked abroad.

POSITION: The trade group BIO backed the Senate version of the bill, praising the corporate tax rate cut. But plenty of big pharma CEOs have publicly stated their support for tax reform.

ANALYSIS: The industry will benefit in large part due to a reduced tax rate on foreign income, allowing companies to repatriate cash. Analysts estimate that large-cap pharma alone keeps nearly $98 billion offshore. The new plan lowers that rate from 35% to 15.5%.

During a 2005 tax holiday allowing companies to bring some profits back at a 5.25% tax rate, Pfizer Inc., Merck & Co., and Johnson & Johnson were among the biggest beneficiaries.  A study later found companies tended to cut jobs and use the money for stock buybacks.

Some top pharma players, including Pfizer, have said they were holding off on any meaningful M&A this year until they had clarity on tax reform since they can use the offshore cash for such transactions.

The new bill cuts the overall corporate tax rate to 21% from 35%. Yet, most biopharmas typically pay far less than the statutory rate already. Data compiled by a professor from NYU  recently showed that across 164 drugmakers, the aggregate effective tax rate was 19.41% — so for most big pharmas, in particular, the lower rate will be a neutral/negative development.

Orphan drug credit: The final bill also trims the 50% write-off enjoyed by companies that develop orphan drugs to 25%. One version of the bill cut it altogether, so the trim is a win. The credit applies to R&D for rare disease drugs with the intent of spurring development in orphan indications.

The effect on Human Resources:

IMPACT: Tax reform is expected to impact several areas of interest to HR: paid leave, fringe benefits, automation, and offshoring.

POSITION: The tax proposal could, on balance, be good for companies and in turn good for HR professionals. The industry has not taken a specific stance on the issue to date.

ANALYSIS: Tax reform is expected to impact several areas of interest to HR including some core issues such as paid leave, fringe benefits, automation, and offshoring.

One proposal would give employers a tax credit equal to 25% of an employee’s salary if it paid them during FMLA leave. There are several proposals to scrap deductions for benefits employers often are involved in, like transportation and relocation expenses.

Some thought the bill might create new tax incentives to encourage employers to create jobs. (That’s what the Trump administration promised, after all.) Instead, it proposes to allow employers to write off the full value of machines right away, perhaps encouraging automation without an accompanying incentive for hiring humans.

The bill proposes to exempt some income from U.S. companies with operations outside the country. This encourages business to send work overseas, some experts have said.

HR will probably like the paid leave proposal, as it gets at an existing problem without a mandate. Instead, it’s an incentive to do something many are already doing anyway. On the flip side, the fringe benefit exclusions do the opposite, creating a disincentive for employers to offer those benefits.

The automation and offshoring items are, on their face, good news for companies. Some, however, say they’re not as useful without an incentive to hire people, too. After all, machines can’t be upskilled when needs shift.                                                                 Insurers are bracing for the repeal of the individual mandate.                                                                                                                          Shelby Livingston reported that the GOP tax proposal, slated for a vote on Tuesday, would ax the Affordable Care Act’s requirement that most individuals enroll in an insurance plan or pay a financial penalty starting in 2019. The potential repeal of the individual mandate, which is now a sure thing, has some health insurers worried and already thinking about potential rate hikes that would be needed to keep them from losing their shirts.
Even though open enrollment for 2018 individual coverage ended last week, insurers already have their eyes on 2019. Initial requests for 2019 individual market coverage are due in the spring. If the mandate is repealed, industry experts predict that younger, healthier people would drop their coverage, leaving insurers to cover a population that skews sicker, costlier and heavily subsidized.

In fact, the Congressional Budget Office projected that 4 million people would drop their health insurance plans in 2019, rising to 13 million by 2027.
Insurers would have to raise rates significantly to cover the cost of insuring a sicker population. Some insurers would likely stop selling coverage altogether.

It would be “a little bit like insuring only burning houses,” said Chet Burrell, CEO of Blues insurer CareFirst, which has already lost north of $600 million on its individual ACA plans from 2014 through 2017. “When you insure a whole geographic region of houses, it’s one thing. When you insure only those that are burning, it costs a bloody fortune.”

The individual mandate requires most Americans to buy coverage or pay a penalty of $695. It has long been the most unpopular piece of the ACA, but insurance experts say it’s a necessary piece that keeps the individual insurance market, including the ACA exchanges, from collapsing.
About 84% of exchange customers, or 8.6 million people, in the first half of 2017 received a premium tax credit, which helps lower the cost of premiums for people with incomes up to 400% of the federal poverty level.

How the repeal of the mandate affects an insurer depends on the mix of customers an insurer enrolls. Blue Cross and Blue Shield plans, for instance, attract a higher-income population, many of whom don’t receive premium tax credits. So plans like CareFirst face losing a large portion of healthier members if the mandate is repealed and may have to raise rates significantly to cover them. Those premium increases would fall on the shoulders of the remaining unsubsidized members, who may then choose to drop coverage.

On the other end of the spectrum, an insurer like Centene isn’t fretting over the absence of a mandate because its predominantly low-income, heavily subsidized population will keep its insurance even without a mandate. Because federal tax credits grow as premiums rise, members with subsidies will be insulated from insurers’ price hikes.

“I don’t think it’s going to affect us,” Centene CEO Michael Neidorff said. “There’s a lot of people who, now that they’ve had (insurance), will want to keep it.” He added that Centene’s ACA exchange business continues to do well. The insurer is one of the few health plans that has turned a profit on the exchanges, thanks to its experience managing the care of Medicaid recipients.

“Do I wish we still had the mandate? Overall, it was put in for a good reason. But it’s not going to stop me from continuing to be successful with these products,” he added.

Sabrina Corlette, a health insurance expert at Georgetown University, said insurers like Centene may see the repeal of the mandate as an opportunity. If other insurance companies leave the market, Centene could swoop in to take up the leftover business.
For most insurers and many unsubsidized patients, though, the loss of the mandate will be a blow, she said, especially considering the many other actions undertaken by the Trump administration and Congress in the last year that have weakened the individual market. The repeal of the individual mandate comes after the Trump administration ended the cost-sharing reduction payments that lower out-of-pocket costs for consumers and promoted the sale of short-term plans through an executive order.
“You take the mandate plus all the policy actions that have taken place to this date, I actually think it’s understandable that carriers would look at the situation and say: I don’t have a trusted government partner; why would I stay in this market?” Corlette said.

Even with the individual mandate in place, insurers have been retreating from the ACA exchanges because of regulatory uncertainty and because they are having trouble turning a profit. Large, national insurers, including Aetna, Anthem, Humana and UnitedHealth Group, have mostly fled the marketplace, which is now dominated by regional Blue Cross and Blue Shield companies.
Corlette expects the jockeying between insurers and regulators that occurred this year when states were trying to plug bare exchange counties to continue in 2019. State insurance commissioners and local politicians were successful in ensuring there were no counties lacking insurers for the 2018 coverage year. But “they may not have a lot of leverage in 2019,” she said. Some insurers “are saying it’s not worth the headache.”
Corlette expects the jockeying between insurers and regulators that occurred this year when states were trying to plug bare exchange counties to continue in 2019. State insurance commissioners and local politicians were successful in ensuring there were no counties lacking insurers for the 2018 coverage year. But “they may not have a lot of leverage in 2019,” she said. Some insurers “are saying it’s not worth the headache.”
Joel Ario, managing director of Manatt Health and a former Obama administration official, said a repeal of the individual mandate would lead insurers to demand other ways to stabilize the insurance market. States could also impose their own individual mandate penalties, but it’d be hard to gather political support for such an unpopular ACA provision.
More likely, insurers will call for reinsurance programs.
“There will be many insurers, if not most insurers, talking about reconsidering their participation in 2019, and as that talk settles in, the pressure on Congress to approve a reinsurance fund will increase,” Ario said.
CareFirst’s Burrell has already called for a federally funded reinsurance program in which the federal government would help finance the extremely high costs of the sickest individuals above a certain threshold. By removing those high-cost members from the general risk pool, premiums for other members would decrease. Some states, including Alaska, Minnesota, and Oregon, have reinsurance programs of their own.                                                                                                                                                     So, we don’t really know what the GOP will do to health care, but it looks like they will have a limited time to do anything before they lose their majority is in jeopardy. I do like Mitch McConnell’s desire for a bipartisan approach for stabilizing the insurance industry, health care, and entitlements. This could be an interesting year.

My family just wanted me to make this a very short blog post and just wish you all a Merry Christmas. But I really believe in keeping the education process going as we approach the consideration of the single-payer health care system and whether it is the best approach for the U.S.A.

Anyway, Merry Christmas to all and wishes for a wonderful New Year!

The Individual Mandate Would Be a Big Loss and Speaker Ryan Wants to “Revisit” ObamaCare And Suicide once again hits our community

22688058_1339790372817285_5486209735099127087_nA blow to Obamacare is one more reason not to like the Republican tax bill. I have mentioned that the present tax renovation tax bill repeals the individual mandate included in the Affordable Care Act In its failure to repeal Obamacare this fall, Congress should have learned a simple lesson: Americans want the government to see that everyone has health insurance. Instead, the Republican majority tirelessly insists on moving in the opposite direction. Thus, their shambles of a tax bill repeals Obamacare’s requirement that everyone have health insurance.

This change would cause some 13 million fewer people to have insurance by 2026. While that’s less than the million who would have lost insurance had Obamacare itself been repealed, it’s a giant backward stride.

President Donald Trump and other Republicans like to out that the individual mandate is unpopular. Maybe. Nonetheless, it’s essential to the effort to keep health insurance affordable and cover as many people as possible.

Keep in mind that, in the U.S., the private insurance market is the mechanism that shares out the cost of health care. The premiums that people (and their employers) pay create pools of money used to finance care. The Affordable Care Act makes this mandatory: Everyone must have insurance — whether it’s an individual policy, one provided through an employer, or a public benefit such as Medicaid or care provided by Veterans Affairs — or pay a tax penalty.

People may resent being told to buy something. But if they don’t buy health insurance, premiums rise for those who do. And taxpayers are on the hook for the emergency care that many uninsured people fail to responsibly anticipate.

Those 13 million people who will go without insurance if the individual mandate is lost can be expected to delay doctor visits, struggle to pay medical bills, and generally experience poorer health, much evidence suggests.

Republican Senator Susan Collins of Maine seems to understand this. She was willing to block the repeal of Obamacare — but now she says she’s willing to see the individual mandate go if Congress promises two years’ worth of other funding to keep premiums down. That might help in 2019, but it would not make up for the loss of the individual mandate in the long run.

Fact is, no workable replacement for the mandate has been proposed. Sound familiar? Just like the “Repeal and Replace” venture.                                                                                                 There’s still time for Collins and other reasonable Republicans to grasp this truth, preserve the

individual mandate, and keep the U.S. health-care system moving toward its rightful goal of truly universal coverage.

Consumers as of last week are still Hunting For Health Insurance Find High Prices — And Some Great Deals. My wife and I received a notification that in fact, we still need to have health care insurance or suffer a penalty on our tax returns.

The open enrollment period to sign up for a health plan on runs through Dec. 15; several states with their own health care exchanges have later deadlines.

Gene Kern, 63, retired early from Fujifilm, where he sold professional videotape. “When the product became obsolete, so did I,” he says, “and that’s why I retired.”

Kern lives in Frederick, Md., and has been an enthusiastic enrollee in Maryland’s health exchange since it began in 2014. But this fall he received a letter from his insurer explaining that the cost of his policy’s premium would jump from $800 a month to $1,300 in 2018.

Premiums have risen for many 2018 policies, though most people won’t actually have to swallow those higher costs, because subsidies have gone up, too. Gene Kern is one of the exceptions.

“Because of my income, I am slightly above the 400 percent poverty level,” he says, “and as a result, I get no subsidy from the government.”

So Kern has switched to an HMO plan on the insurance exchange for around $900 a month. That’s more than 20 percent of his income, which comes partly from Social Security and partly from his retirement account. But, he says, “It’s the best I can get,” and he wants very much to stay insured for the next two years, at which point he will qualify for Medicare.

Louise Norris is a health insurance broker and analyst in Colorado. She says there are a number of people like Kern who earn too much for a subsidy and will pay more for health insurance next year than they did in 2017. “Rates are high,” she says. “There’s no way to sugarcoat that.”

But she warns her clients against the temptation to get a less expensive plan that doesn’t comply with the minimum standards set out by the ACA.

“It seems like a good deal because it’s cheap,” Norris says. “But then you find yourself being that person who has a heart attack and needs a triple bypass. And hundreds of thousands of dollars later you wish you had that ACA-compliant plan.”

Prices for ACA-compliant health policies went up in Tennessee, too, where state regulators approved average rate increases ranging from 20 to 40 percent.

Brenda Linn has already been paying $750 a month just to cover her own medical needs; so the retired kindergarten teacher and her husband logged on to to check the price of 2018 plans. To her surprise, the website brought up a great deal.

“And I’m like, ‘Dave, this has to be a mistake,’ ” she says. The price Linn was quoted was less than $5 a month. Why? A slight loss of income had made her eligible for a subsidy for 2018. “Because we didn’t qualify last year, I wasn’t really that hopeful,” Linn says.

But a large majority of marketplace shoppers do get subsidies. And for 2018, on aggregate, these subsidies are larger.

Tony Garr, a volunteer application assistant with the Tennessee Health Care Campaign, says more than ever this year, people should shop around on the exchange to see what kind of subsidies they may be eligible for.

“Generally speaking, they will find out that help is there,” he says.

Any many people who got a price break in the way of a subsidy in the past can get even more for their money this year.

For example, Daniel Prestwood, who is self-employed and cleans fish tanks around Nashville, says he found a better plan for 2018, with monthly premiums that dropped from $300 to $200. He says he tries not to get too frustrated by the political wrangling over health care.

“All I know is that for 2018 I’ll have a good health care plan in place,” he says, “and that’s the best I can hope for at this point.”

And even with the Trump administration’s efforts to hobble the ACA, in Tennessee, the number of applications processed by federally funded insurance guides — known as navigators and certified application counselors — has already surpassed last year’s. As of early last week, with 10 days left in open enrollment, more than 1,200 individuals had applied with official help, eclipsing the total from all of 2016, when the enrollment period was several weeks longer.

While application assistants only work with a tiny fraction of the 235,000 Tennesseans who have marketplace plans, Sandy Dimick of Family and Children’s Services Nashville, says she expects total enrollment will exceed last year’s total, as well. Navigators around the U.S. have worried that cuts to the federal advertising budget in 2017, and a lack of cheerleading from the White House, could drive down enrollment.

Take note: Though enrollment for most states ends Friday night, residents of nine states (California, Colorado, Connecticut, Maryland, Massachusetts, Minnesota, New York, Rhode Island and Washington) and the District of Columbia have slightly more time to sign up.

Peter Sullivan wrote that Speaker Paul Ryan (R-Wis.) said Thursday that lawmakers need to “revisit” ObamaCare, but also pointed to welfare reform as the focus of next year.

“ObamaCare is collapsing and failing, so we won’t be able to ignore that problem,” Ryan said at a news conference. “So we’re going to have to revisit the problem of a health-care marketplace that is collapsing and that is something that we’re just going to have to get on to.”

However, Ryan did not make clear whether ObamaCare repeal would be part of next year’s fast-track process known as reconciliation to get a measure through the Senate without needing Democratic votes.

Republicans only get one shot at that process next year, and Ryan mentioned health care after saying that welfare reform would be the focus of the fast-track process next year.

“Next year, we want to take on criminal justice reform, we want to take on skills, getting people the skills they need to get the jobs they want, career and technical career education and welfare reform, so those are the kind of entitlement reforms that we’re talking about,” Ryan said.

Some conservatives want the fast-track reconciliation bill to include both welfare reform and ObamaCare repeal.

Any effort on health care faces long odds in the Senate, made even tougher by the victory of Democrat Doug Jones in Alabama this week. Senate Republicans will be able to lose only one vote, and more than that number of Republican senators opposed various ObamaCare repeal efforts earlier this year.

Democrats have also been warning that Ryan would target Medicare and Medicaid next year, programs the Speaker said this month that he wanted to reform next year.

Ryan’s comments on Thursday, though, did not mention Medicare or Medicaid, instead focusing on welfare and workforce issues as “entitlement reform.”

And as we start to explore the concept of a Single payer system we still find that Healthcare for veterans needs another big fix.

John McCain and Jerry Moran reviewed some of the ongoing problems of the VA system. The VA is not coordinating well with community care programs or paying them promptly, and funding crises threaten access to private care.

More than a century ago, President Abraham Lincoln signed a law establishing a new agency dedicated to the support of our Civil War veterans. Its mission was “to care for him who shall have borne the battle, and for his widow, and his orphan.” Today, our Department of Veterans’ Affairs (VA) provides essential services to 22 million Americans who have served in the armed forces.

All Americans are indebted to our veterans for the enormous sacrifices they have made on our behalf. These men and women took an oath to defend the Constitution and served dutifully to preserve our way of life. Like their valiant forebears who humbled dictators and liberated millions from oppression, they exemplify what is best in our country.

Regrettably, the VA has at times struggled to uphold its obligations to our veterans. In 2014, our country was shocked to learn that thousands of veterans were denied care or experienced unconscionable delays in treatment at the Phoenix VA. Dozens of those veterans died while waiting for care. Unfortunately, this wrongdoing was not confined to Phoenix. The VA Office of Inspector General has completed at least 100 criminal investigations related to wait-time manipulation at VA facilities nationwide.

In the wake of that scandal, Congress gave veterans the freedom to receive medical care from providers in their local communities through the Veterans Choice Program. The program was intended to make certain that veterans would never again be forced to wait in long lines or drive hundreds of miles to access the care they deserve. Demand for Choice has since grown considerably; more than a million veterans are receiving care closer to home, through millions of appointments with community providers.

From the program’s inception, however, we emphasized that Choice was only the first step toward broader reform of veterans’ health care. That’s why we have introduced legislation that incorporates lessons learned from Choice to transform the VA into a modern, high-performing and integrated health care system that will improve veterans’ access to timely and quality care — within the VA and in the community. This bill tackles some of the most significant flaws and problems we’ve seen in recent years, including the VA’s slow payment process to community providers, poorly coordinated community care programs and — crucially — an inability to accurately predict demand for Choice, which has resulted in multiple funding crises that threaten veterans’ access to community care.

One of the fundamental undertakings in our bill is the creation of a Veterans Community Care Program, which would consolidate existing community care programs at the VA and increase care coordination with community providers. We would require the VA to use objective data on health care demand to set standards for access and quality, and to identify and bridge gaps in veterans’ care. We would also ensure that the VA promptly pays community providers, opens access to walk-in clinics, offers telemedicine, increases graduate medical education and residency positions for employees, and improves VA collaboration with community providers.

Unlike other proposals, our legislation creates and specifies the tools the VA must use to reform health care rather than relying on the bureaucracy to determine the rules. We have learned over time that Congress must provide clear direction and guidance to the VA to prevent inconsistent experiences, enhance veterans’ quality of life, and achieve better health outcomes.

Key veterans’ service organizations such as American Legion, AMVETS and Concerned Veterans for America have expressed their support for this effort, which will transform the VA into a 21st-century healthcare system that seamlessly weaves together both VA and community health care services.

We need to know this information, including the goods as well as the bad effects, on one of this Country’s long-standing Single Payer system as we go forward to define and investigate the option of a single-payer health care system for our country. Let’s see whether this new tax bill gets passed this week!

And finally, our community just learned of another suicide in a young person. We are devastated and continually ask our selves why.

Look at this headline-“U.S. suicide rate highest in 30 years, CDC report shows.”

Nina Flanagan reported a while ago that a new report from The Centers for Disease Control and Prevention (CDC) shows the U.S. suicide rate is the highest it’s been in 30 years, increasing 24% from 1999 to 2014.

  • Middle-aged women between the ages 46 to 64 had the second largest increase in suicides since 1999 at 63% and women in other age groups showed an average increase from 31% to 53%. The suicide rate for men in the same age bracket increased by 43%. Older men aged 75 and above had high suicide rates but only fewer deaths
  • Only one group in the U.S. showed a declining suicide rate: African-American men over age 75.

 The data come after another recent CDC report that showed life expectancy for white, non-Hispanic U.S. women went down by about one month from 2013 to 2014, from 81.2 to 81.1 years. Though the difference for white women is small, such a dip for a major demographic group is rare and troubling, experts said, particularly because of the reasons why: Suicide, drug overdoses, and complications from alcohol and smoking.

A blog on in response to the CDC study suggested Medicaid may alleviate the high suicide numbers. The author, Harold Pollack, said many states with the worst public health problems are denying Medicaid coverage to the lowest-income citizens, and in turn, harming their mental health.

Oregon did an insurance study, the Oregon Health Insurance Experiment, where Medicaid was allotted by a lottery between treatment and a control group. Those who received Medicaid had large and immediate reductions in depressive symptoms and stress. However, the same experiment showed disappointing results when it came to physical health. The mental health benefits may not have been specifically from improved treatment, the author suggested, but because those with Medicaid had less anxiety over medical bills or their circumstances if they became ill.

Our community’s last experience with suicide was a physician that I also knew personally and also asked why.

To this person’s family, we grieve also and offer our heartfelt sorrow and wishes for comfort and empathy. We all will never understand why this happened and what would lead a young person to give up on life.

U.S. Health Spending Hit $3.3 Trillion in 2016 and the Cost of Physician Burnout

health diner991With all the discussion regarding taxes and cutting of taxes, especially from the rich corporate greedy people and the replacement of the Affordable Care Act one has to wonder how we are going to pay for healthcare. Especially when we consider the cost of health care.

National health spending decelerated a bit in 2016, with a growth rate of 4.3% — versus the 5.8% growth rate seen in 2015, according to figures released Wednesday by the Centers for Medicare & Medicaid Services (CMS). But spending growth slowed by 1.5 percentage points from year before.

The increase in 2016, though smaller than the previous year, pushed per-capita spending on healthcare over $10,000 for the first time.

The slowdown in spending growth “was broadly based — growth slowed for three major payers: private insurance, Medicare, and Medicaid,” Micah Hartman, a statistician at the CMS Office of the Actuary said at a briefing sponsored by Health Affairs. “The slower growth in Medicaid and private insurance reflected slower growth in enrollment, as most of the impact in the ACA [Affordable Care Act] coverage expansion occurred in 2014 and 2015.”

Spending slowdowns also occurred in the majority of medical goods and services, led by prescription drugs, he said. In particular, growth on spending for physician care and other clinical services dropped to 5.4% in 2016, compared with 5.9% the year before, said Anne Martin, an economist in the CMS Office of the Actuary.

Physicians and clinical care spending “slowed slightly but remained relatively strong,” Hartman said. “The main drivers of slower growth in 2016 were Medicaid and Medicare. The deceleration in Medicaid was due in part to slower enrollment growth, [while] the deceleration in Medicare was driven by a slowdown in Medicare Advantage physician expenditures.”

The growth in non-price factors such as service use and intensity of services increased by 3.8% and drove spending in 2016, albeit at a slower rate than the 4.5% increase in 2015, he added.

Untitled.cost of healthcare.1Hospital spending increased by 4.7%, to $1.1 trillion, which was a 1-percentage point drop from the 2015 growth rate. “In 2016, hospital utilization … showed a decline in the number of inpatient days and hospital discharges,” said Hartman. “At the same time, hospital prices were up slightly from 0.9% growth in 2015 to 1.2% growth in 2016 … From a payer perspective, Medicaid and private health insurance spending [on hospital care] slowed in 2016, mainly driven by [slower] enrollment growth. Medicare hospital expenditure growth remained flat for the fourth consecutive year.”

In addition, spending on retail prescription drugs increased 1.3%, to $328.6 billion, a large drop in the rate of growth compared with the 2015 increase of 8.9%.”The slower growth in 2016 was driven by fewer new drug introductions and less spending for new drugs to treat hepatitis C,” Hartman said on an afternoon phone call with reporters.

At the briefing, Martin noted that the decrease in overall spending for hepatitis C drugs “was about $3 billion from 2015 to 2016, according to outside sources, so there is still over $10 billion being spent on hepatitis C patients.”

She added, however, that “in the first 2 years when the drug first came out, that’s when they were reaching people who needed treatment the most, and once they cured the patients they reached, the utilization dropped off so fewer patients were being treated in 2016, and there was also some price effect because manufacturers were offering higher rebates.”

Despite stories about large price increases and eye-popping prices for new cancer treatments, “some of the drugs … showing up in the news lately are relatively smaller in utilization and the number of prescriptions dispensed, and some are generics, which are less expensive, so they haven’t been moving the needle,” Martin said. “Higher-priced specialty medications such as [the hepatitis C treatment] Harvoni have come in over $10 billion per year for the last 3 years, so those are the ones impacting spending growth.”

As for how the healthcare dollar was divided up in 2016, 32% went to hospital care, followed by 20% for physician and clinical services and 20% for “other spending,” according to the report. Prescription drug spending accounted for another 10%, while “government administration and the net cost of health insurance” accounted for 8%.

Despite the slowdown in spending growth, total healthcare expenditures still grew faster than the overall economy, so healthcare’s percentage of the gross domestic product increased, rising from 17.7% to 17.9%, Hartman said.

Untitled.cost of healthcare.2

One unusual feature of this year’s numbers was the slowdown in growth among all three major categories of goods and services (hospital care, physician and clinical services, and prescription drugs) and the spending by all three major players — Medicare, Medicaid, and private insurance, Micah said on the phone call.

“The most recent time we saw all three major categories of goods and services slow [at once] was in 2010, but I don’t think we’ve seen recently the three major services and the three major players slow down,” he said. “We saw two major things in 2014 and 2015: an enrollment expansion that impacted both Medicaid and private health insurance, and rapid spending growth in retail prescriptions drugs. When you add people to the rolls of private health insurance and Medicaid, they’re going to be using all types of medical goods and services, and when that starts to wear off, you see the slowdown we saw in 2016.”

And the cost of the physician burnout??? This is adding ot the cost of healthcare. An  article from Reuters explains how gardening, Yoga and personal coaches really haven’t done anything to stop the rising rate of physician burnout.

Some leading healthcare executives now say the way medicine is practiced in the United States is to blame, fueled in part by growing clerical demands that have doctors spending two hours on the computer for every one hour they spend seeing patients.

How are these people called “leading executives” if they are just figuring this out now?  Sounds like they are idiots to me because they have been told for years what was happening.  And the only reason these executives, and the hospitals they consult to, care is because they just realized it is costing them money.

Experts estimate, for example, that it can cost more than a $1 million to recruit and train a replacement for a doctor who leaves because of burnout.

Kelly reports form the Washington Times that “Around six million Americans today have clinical Alzheimer’s or some other form of dementia, with that number expected to more than double in the next 40 years,” researchers projected in findings published online Dec. 7 in Alzheimer’s and Dementia: The Journal of the Alzheimer’s Association.

And according to the NBC News website, investigators arrived at these projections after collecting “all the data they could find from studies of Alzheimer’s disease,” then examining studies involving people with current cases of Alzheimer’s and mild cognitive impairment.

Imagine adding these patients to Medicaid and Medicare, especially when Senator Ryan stated that this coming up this coming year they are going to look at cutting Social Security, Medicare and Medicaid to reduce the deficit increase created by this new tax reduction bill. Is this really fair, ethical and does it make any sense??

I think it is important that we need physicians who are business leaders. Davis Liu reviews this important concept. “Does physician leadership matter?” asks cardiologist and author Dr. Sandeep Jauhar in his New York Times opinion piece “Shouldn’t Doctors Control Hospital Care?” He opens his piece with the termination of the elected leaders of the medical staff office at the Tulare Regional Medical Center due to poor performance. He answers his rhetorical question with the obvious and simple response that doctors should control hospital care. Though he cites physician-led and well-respected healthcare organizations, like the Cleveland Clinic and Mayo Clinic, his conclusion begs a different question. In the past, doctors were in control of hospital care, so why the shift to businesspeople running hospitals?

The issue lies in the false dichotomy Jauhar and others often create by asking whether physicians or businesspeople should ultimately be responsible for hospital care. A complete answer would be the importance of physicians leaders embracing both medical and business perspectives.

Physicians leading alone are not enough.

Today, it takes more than a medical degree to lead a healthcare organization. Physician leaders must embrace the new expectations of doctors, patients, and purchasers. Insurers, regulators, and employers demand more transparency on quality outcomes, preventive testing and screening rates, as well as costs of tests and procedures. Data needed to be collected, analyzed, and reported. Process improvements plans need to be implemented to close care gaps. Patients, who decades ago would have died or survived surgery, now recover but are more complex with more comorbidities and illnesses. The clinical care needed requires a multidisciplinary, team-oriented, and systematic approach. With all of these demands, doctors and staff are facing epic levels of caregiver burnout and stress.

Is it possible that physician leaders delegated these challenges, reporting, process improvement and management tasks to businesspeople? Doctors went to medical school to be clinicians and care for patients. Even today, medical school education is essentially unchanged from decades ago. Few schools offer the business training and the mindset needed to enter this new era of higher expectations of improved access, better quality at lower cost with increasing levels of physician, and staff disengagement. Is it possible that since few physicians had an interest, desire, or training in these areas that businesspeople consolidated more power?

The type of physician leader matters.

But businesspeople don’t understand medical care any more than physicians understand the science and discipline of business. Often both camps don’t respect enough the other’s unique language, perspective, and focus to solve the common issues. This has to change. Despite caricatures in healthcare, there are mission-driven charitable businesspeople and greedy, unethical doctors.

Many great clinicians don’t aspire to become physician leaders. Yet, partnering and helping businesspeople understand our challenges, embracing the science, perspective, and discipline of business to solve problems — and overcoming these biases and obstacles — are the keys to success for organizations like the Mayo Clinic, which Jauhar highlights for excellence. Doctors at Mayo Clinic are expected to take on leadership responsibilities during their time there, work collaboratively with businesspeople, and still be practicing clinicians. As noted in Management Lessons from Mayo Clinic: Inside One of the World’s Most Admired Service Organizations, ” … physicians must distinguish themselves in their specialties before assuming leadership roles … [leaders] are asked by their peers to make a sacrifice for the good of the Clinic.” By taking on these roles, most of these leaders “confess they have a sense of loss as a result of sacrificing at least a part of the clinical and academic careers they have already established.”

However, these chosen “reluctant” leaders are precisely the ones needed to make Mayo so successful. The organizational culture at Mayo is such that “if physicians appear conspicuously ambitious for high positions in leadership, their chance of rejection is high.” In addition, physician leaders are supported by administrators who also “must be team players” and who are willing to join the Clinic even though “the top positions all go to persons with the title of ‘MD.'”

A study at Mayo found that “behaviors of physician supervisors have a direct impact on the personal well-being of the physicians they lead,” but that “physicians often receive little training in how to be an effective leader” and that “new strategies are needed to identify potential physician leaders and better prepare them to lead.”

It is clear that, at Mayo, physicians are in charge. Those who lead are doing so for the greater good of the entire organization with the strong support of businesspeople.

Physician leaders need to ask the difficult questions to make care better.

A recent article in STAT, “Not even the mattress pads were spared: An inside look at a Brigham and Women’s Hospital’s struggle to cut costs,” highlights the skills needed for physicians leading hospitals. It is about trust and understanding the needs of doctors and staff.

When CEO Dr. Ron Walls faced a shortfall of tens of millions of dollars, his team reviewed expensive assets like ORs and MRIs to see if they were being used effectively.

Though surgeons were seen as the “key power center of the hospital” and OR schedules were considered so sacrosanct that hours are written into employment contracts, Walls and his team wondered if they could improve on the OR utilization which ran in the low 70 percent range. This meant that a significant number of OR times were staffed and available but unused because cases were not scheduled. To maximize OR access and with the support of Brigham’s chair of surgery, individual surgeons agreed to give up unused reserved block time ten days in advance for other surgeons to use. In return, they were guaranteed that they would also have access to the OR at the last minute. This change required a level of trust that comes only from physicians leading physicians.

A couple of months later, ORs were running at 85 percent capacity. The number of surgical cases increased, patient access to the OR improved, and the hospital closed its financial gap.

The future is bright if doctors lead.

At the recent Permanente Executive Leadership Summit, senior physician leaders of all the Kaiser Permanente regions affirmed their commitment to the following:

We are here to make a difference in people’s lives.

  • To practice what we believe, and to fulfill the promise of medicine
  • To serve, to heal, to do right by our patients, and to bring compassion, dignity, and humanity to healthcare

Jauhar was partially right. If physicians wish to maintain our autonomy and professionalism, then we must embrace the importance and role of physician leaders. Physicians must lead and control hospital care. However, they will need to embrace the duality of both the science and discipline of business and medicine if they are to be successful. Like the physician leaders of Mayo and Permanente, this is an added burden, responsibility and sacrifice past and current physicians weren’t necessarily trained or expected to do. Yet, no one else is better suited to make the changes needed to make care better, more affordable, and accessible and improve professional satisfaction than physician leaders.

Next we should consider the various single payer systems to be considered. Let’s start with the famous Bernie Sanders and his solution to the health care problem.

The Effect of Passing of the New Tax Bill, the Cost of Drugs and Obamacare signups on Health Care.

21740517_1305560666240256_2316702778312680128_nSo the New Tax Bill seems ready for passage if the House and the Senate can come together and resolve the differences. My concern is that the GOP is using this bill to attack the Affordable Care Act by removing the Individual Mandate to “force” all to purchase health care insurance. I do understand the rationale of removing the mandate but now the GOP hasn’t come up with the answer to the domino effect of eliminating this mandate, the probable increase in premiums by the insurance companies. Let’s review, early Saturday morning, the Senate voted to pass the Republican Party’s sweeping tax refom bill, and among other provisions, the bill would eliminate the penalty for not buying health insurance starting in 2019.

So next year, you still need to be covered — at least, as of now. The individual mandate clause of the Affordable Care Act (a.k.a. Obamacare) requires individuals to buy insurance or pay a penalty at tax time, unless they qualify for a limited number of exemptions. If the Senate’s proposal survives in the final version of the tax bill, then beginning in 2019 consumers will be able go without coverage and not face a fine. The penalty for going uncovered for 2018 will be $695 per adult or 2.5% of household income in excess of tax filing thresholds, whichever is higher.

Members of the House and the Senate will now work to reconcile their versions of the GOP tax bill. Lawmakers have said that they’d like to finalize a tax reform plan by Christmas, so they can send it to President Donald Trump for signing into law. The House tax bill didn’t waive the penalty for going uninsured.

Open enrollment ends Dec. 15 for Affordable Care Act plans. If you’re on the individual insurance market, you have until that date to sign up for a new plan or change your existing plan. While it’s possible that the final version of the GOP tax bill could have a different plan for the individual mandate, that may not become clear until after the sign-up deadline.

For now, the individual mandate penalty remains in place for 2018. Existing customers should shop around rather than allow the system to re-enroll them in their current plans, says Sabrina Corlette, research professor at the Center on Health Insurance Reforms at the Georgetown University Health Policy Institute. There are plenty of bargains out there: Kaiser Family Foundation estimates that more than half of subsidy-eligible, uninsured individuals could buy a bronze-level plan for no premium contribution—that is, a $0 premium.

And regardless of what the tax reform bill says, it’s simply a smart idea to have health insurance. “You should buy insurance because it helps you get access to care, and it’s critical financial protection in case something awful happens,” Corlette says.

You can expect the individual market to look very different if the penalty goes away, experts say. The non-partisan Congressional Budget Office estimates that repealing the individual mandate starting in 2019 would result in 4 million losing coverage in 2019 and 13 million losing coverage in 2027. Many healthy people would voluntarily opt to go without coverage, and insurers could raise their premiums to cover the remaining, sicker population. These higher premiums would in turn cause more consumers to become priced out of the market. Remember the insurance companies are going to always cover their loses and increase premiums to make sure they profit.

Technically, the GOP tax bill doesn’t repeal the individual mandate, Corlette says; it simply reduces the penalty for going uncovered to zero, But in practice, eliminating the penalty will have the same result as eliminating the individual mandate altogether.

How about the huge cost of drugs to patients, which contribute to the high cost of health care?

Report: Here’s What The Feds Can Do To Cut Drug Prices

Alison Kodjak researched an important facet of the high cost of health care, drug prices. What makes drug prices so high? Let us count the ways.

Drug prices are too high, and we had better do something about it. That is the nutshell conclusion of a 201-page report from the National Academies of Sciences, Engineering and Medicine.

“High and increasing costs of prescription drugs coupled with the broader trends in overall medical expenditures, which now equals 18 percent of the nation’s gross domestic product, are unsustainable to society as a whole,” says Norman Augustine, the former CEO of defense contractor Lockheed Martin and the chair of the committee that conducted the study released Thursday.

The same sentiments were expressed Wednesday by President Trump’s nominee to lead the Department of Health and Human Services. “Drug prices are too high,” said Alex Azar in a hearing before the Senate Health Education and Labor Committee.

But the National Academies didn’t stop there. The independent advisory group’s report lists dozens of suggestions for what U.S. officials could do to rein in those rising prices. Many have been tossed around Washington for years. And given the power of the pharmaceutical lobby — it has spent more than $200 million on lobbying so far this year, according to the Center for Responsive Politics — few of them are likely to be implemented soon.

Here’s a rundown of key recommendations:

Allow the federal government to negotiate drug prices and refuse to cover some expensive medications

This idea is not new, and Trump himself has advocated for allowing the government, through Medicare, to negotiate lower prices for the drugs it buys. But doing so would take an act of Congress.

Current U.S. law prohibits Medicare officials from interfering in the negotiations between drugmakers and the insurance companies that administer Medicare’s prescription drug program.

Medicare accounts for about 29 percent of all prescription spending, so bringing that purchasing power under one roof could give it the ability to force drugmakers to slash their list prices.

The National Academies report points out that the government negotiates or sets prices in almost every other industry where it is a buyer, including defense equipment, uniforms and even stationery.

“The effect of not allowing HHS to negotiate prices is to tilt the balance of bargaining power further in favor of drug manufacturers,” the report says.

It adds that Medicare and other government health plans also should have the authority to refuse to pay for medications that have cheaper equivalents or that aren’t adequately effective.

Speed the approval of generics and biosimilars and ensure patients have access

Scott Gottlieb, the administrator of the Food and Drug Administration, has been preaching this message since he took office in May.

“While FDA doesn’t have a direct role in drug pricing, we can take steps to help address this problem by facilitating increased competition in the market for prescription drugs through the approval of lower-cost generic medicines,” he said in a June blog post.

The National Academies point to so-called “pay for delay,” where a branded drugmaker pays a generic company to delay putting its competitor drug on the market.

The practice “tends to inflate prices and reduce the quantity of prescriptions for several years after the settlement,” the report says.

But eliminating pay-for-delay won’t be easy because courts have ruled that the agreements between the companies have to be evaluated individually.

Can we shed light on who pays what for prescription drugs?

This is something that lawmakers and regulators have called for many times. The prescription drug payments system is a tangled web of prices, incentives, discounts and rebates among drug companies, pharmacy benefit managers and insurance companies.

When pharmaceutical companies are criticized for raising their list prices, they routinely protest that nobody actually pays those prices. Yet the true money flows remain a mystery.

There are bills in both houses of Congress designed to increase drug price transparency, and several states — most recently California — have proposed or passed laws to require more information on what drug makers and pharmacy benefit managers actually charge for medications.

The National Academies panel recommends that HHS require pharmaceutical manufacturers to report each year the list price of medications, along with all the rebates and discounts in the system and, finally, the average price paid for those drugs.

Discourage those endless ads pushing prescription drugs and stop giving patients coupons to try medication

Pharmaceutical companies spend far more advertising their medication than they do on research into new products, the report notes. That marketing boosts drug costs both by directly increasing costs to drug makers that they then incorporate into the price of drug and by increasing consumer demand for medication they may not need.

“Direct-to-consumer advertising of prescription drugs can adversely influence consumer choices,” the report says.

The reports says lawmakers should prohibit drug companies from deducting the cost of advertising from their taxes and should also ban coupons that allow people to purchase expensive brand-name drugs for the same out-of-pocket cost as generics.

Cut the cost to consumers for their prescription drugs

This recommendation seems at odds with the earlier one calling for the elimination of coupons. But the National Academies report concludes that keeping costs low to consumers can ensure that patients take the medications they need, which could reduce overall health care spending.

Insurance companies often require patients to pay bigger copayments for expensive medications as a way to encourage them to use cheaper options.

“High cost sharing can also have downsides, since it can lead to reduced adherence or the discontinuation of medications because of high out-of-pocket costs to consumers,” the report says.

The report recommends that Congress limit how much people should have to spend on prescriptions in government-run health programs like Medicare and Medicaid.

Take away incentives for doctors to administer high-cost drugs

This recommendation goes to a failed effort by the Department of Health and Human Services to encourage doctors who treat cancer and arthritis to use lower-cost medications if they’re appropriate. Medicare pays doctors who administer drugs in their offices, including chemotherapy or arthritis drugs that are delivered intravenously, a percentage of the drug’s price.

That gives physicians a financial incentive to choose the most expensive medication available.

Last year, HHS proposed changes to that system, but doctors launched an intense lobbying effort against it.

Bruce Gould, the president of the Community Oncology Alliance, called it an “inappropriate, potentially dangerous and perverse experiment on the cancer care of seniors who are covered by Medicare.”

The program was killed. Given the outcry, the chances that HHS will try again are slim.

But there was dissent, too

The report also includes a dissenting opinion from two of the 16 members of the committee. The dissent defends the need for profits in the pharmaceutical industry to give companies the incentive to chase treatments and cures for difficult diseases like Alzheimer’s.

“Creating a drug is a problem completely subject to human biology with all its

intrinsic complexity, variability, and unpredictability,” the dissenting report reads. “If drug invention were simply an engineering problem, then by now we would have a vaccine for AIDS (35 years after the beginning of the outbreak) and a cure for Alzheimer’s disease.”

But even in the dissent, there was some agreements, specifically in the need for greater transparency in how drugs are priced, and how the money flows through the system. The dissenters suggest that pharmacy benefit managers have outsized power and take too much money from the system.

Trump has said he wants to make lowering drug prices a priority. This report offers up plenty of suggestions on how to do that.

Obamacare enrollment and the Exchanges

And Tami Lubby wrote that nearly 2.8 million people have signed up for 2018 Obamacare policies on the federal exchange during the first 25 days of enrollment season.

That’s quite a bit more than at this point in prior periods. Last year, 2.1 million people signed up in the first 26 days.

While those numbers may seem to bode well for the future of the health reform law, it depends on how you look at it.

True, an average of 111,300 have signed up each day this season, compared to 82,200 a year ago and 72,900 two years ago, according to data crunched by Get America Covered, which aims to promote Obamacare open enrollment.

“Enrollment continues to outpace previous years,” said Lori Lodes, a former Obama administration official who co-founded Get America Covered.

Another plus: The exchanges are attracting many new customers. Some 718,300 of those who signed up so far are new, compared to 519,500 last year. The rest are returning enrollees.

All but one of the 39 states in the federal exchange saw enrollment growth. Some 53% more residents in Maine have picked plans, while 52% more Texans and Wyoming residents have signed up. Only West Virginia saw a drop — of 1%.

Several states that run their own exchanges are also reporting increased interest. For instance, the Washington Health Benefit Exchange on Wednesday reported a 43% jump in new sign-ups and an 18% uptick in traffic through first four weeks of open enrollment. In New York, enrollment is outpacing last year by about 13%, with more than 140,000 consumers picking Obamacare plans and nearly 700,000 signing up for essential plans (for moderate-income residents) in the first four weeks.

All this is good news for Obamacare supporters, who say that the law is essential for and remains popular among millions of Americans despite President Trump and Congressional Republicans’ vows to repeal it.

But the picture is not as rosy if one considers that the open enrollment period is a little more than halfway over.

The Trump administration slashed the enrollment season so most people only have until Dec. 15 to pick plans, rather than the three months or more they had in previous years. (Some state-based exchanges have extended the period to as late as Jan. 30.)

That means the pace will have to pick up substantially to come close to the 9.2 million who signed up on the federal exchange by the end of open enrollment for 2017. (Another 3 million people picked plans through the state-based exchanges.)

Even Lodes acknowledged that in her assessment on Wednesday. “Another solid week for enrollment but we need it to pick up the pace to track enrollment from last year,” she said.

To be sure, many consumers wait until the last minute to enroll. So it’s tough to estimate how many people will sign up in the final 20-day stretch.

The pace, however, has been slowing since the enrollment period began on Nov. 1. In the first four days, an average of 150,400 people signed up daily. Those are likely sicker Americans who really need the coverage.

Obamacare supporters worry that many other potential enrollees — particularly the younger and healthier Americans that insurers crave and that keep premiums down — don’t realize that they have less time to sign up this year.

The administration cut the advertising budget for open enrollment by 90%, ending some of the most effective marketing tools, including television and radio spots.

Americans are noticing — or in this case, not noticing. Some 45% said they heard less about open enrollment than they had in previous years, according to a Kaiser Family Foundation poll conducted in mid-November. Another 38% said they heard about the same amount, while 16% said they heard more.

One thing that will boost the figures is that a hefty number of current enrollees will be automatically put into plans for 2018 on Dec. 16. Last year, about 2.2 million consumers were auto renewed in the federal marketplace.

Many experts expect sign ups will decline for 2018, after dipping by half a million this year. S&P Global projected that between 10.6 million and 11.4 million people will pick plans by the end of the enrollment period. Charles Gaba, a blogger who tracks enrollment at, estimates about 10 million people will sign up — 7.5 million on the federal exchange and another 2.5 million on the state exchanges.

Consumers aren’t considered enrolled until they make their first premium payment. Enrollment also varies during the year as people drop out because they find coverage elsewhere or they stop paying their premiums. Others join after losing their jobs or have other major life changes.

Matthew Herber, of the Forbes staff reviewed a survey that showed that Americans wanted healthcare reform, but were also cynical and afraid of change. Call it the central dilemma of healthcare reform: a new survey, released by CVS Health at the Forbes Healthcare Summit, illustrates a vexing problem for those who want to change the way Americans get medical care. Most people in the U.S. do inded think the country’s healthcare system is headed in the wrong direction and in need of reform. But the vast majority of those who do have insurance are happy enough with the plan they have– and likely afraid of change.

That leads to the quandaries that have beset both the Affordable Care Act and its potential replacement: how do you change what’s broken without breaking what works? The national survey of 2,201 adults was conducted online by Morning Consult on behalf of CVS Health, a sponsor of the summit, in October. Over half (56%) of Americans said that they feel the U.S. health care system does not work for them. Seventy-three percent said it is in need of reform. Forty-one percent say that the system has gotten worse, not better.

And if you have some time this holiday season you have to get to the movies and see “Wonder.” Wonder tells the story of Auggie Pullman, a fictional 10-year-old boy with a severe case of Treacher Collins syndrome — a rare genetic craniofacial disorder. Auggie must navigate new challenges in a new school, such as how to talk about his condition, make friends and handle bullying.

Due to the severity of his condition, Auggie has undergone nearly 30 surgeries before he enters middle school. When a classmate asks Auggie about plastic surgery, Auggie jokes, “This is after plastic surgery — it takes a lot of work to look this good.” There is truth to this light-hearted moment. Auggie’s birth defect, which ranges in severity, is characterized by underdeveloped facial bones that affect his eyes, ears, cheeks, palate and jaw structure.

Although Wonder is a fictional film, it represents reality for many of the children and young adults with craniofacial abnormalities. I have witnessed this firsthand in my fellowship in reconstructive surgery on the craniofacial rotation and later in my practice. It’s my hope that Wonder can serve as a catalyst for millions of people to better understand craniofacial disorders and the amazing children who persevere with these conditions.

A major highlight of the movie is watching some of Auggie’s classmates discover he is no different from their other friends. He’s a smart, nice kid with a great sense of humor. It’s the same message we’ve heard about judging others based on their color, race or creed. Don’t do it.

We are all much more than our physical differences. I hope Wonder reminds patients with facial differences that they possess the strength, wisdom and courage to defy the odds and overcome their adversity every day.