Tag Archives: Doctors

Election 2020: What Exactly Is Joe Biden’s Healthcare Plan? And Really, Telehealth to Care for Our Patients?

So, first I wanted to relate an experience, which exemplifies the failure of telehealth, or maybe the failure of healthcare workers who are taking advantage of the “new” health care system of patient care.

Consider the case a two weeks ago. As I was about to operate on a cancer surgery patient, I was asked to evaluate a patient healthcare conundrum. One of our nurse teammate’s husband was sick and no one knew what was the problem. He had lost 23 pounds over 3 ½ weeks, was dehydrated, appetite, sore throat, weak and needed to go to the emergency room multiple times for intravenous fluids. Each time he was told that they were very sorry but they had no idea what the problem was.

His Primary care physician would not see him in person, and he had another telehealth visit, which he was charged for and was prescribed an antibiotic with no improvement.

I asked if he had a COVID test which he did and it was negative.

I then asked if I could examine him or if she had any pictures. She had pictures, with no skin rashes except I noticed something interesting on the intraoral pictures, which showed left sided ulcers on his cheeks, left lateral posterior tongue and palate, again-only on the left side.

I asked if this was true in that the ulcers were only on one side of his mouth? When his wife responded with a yes to the question I then responded that he had intraoral shingles involving the nerve to the tongue, cheek, palate ( glossophyngeal nerve ) and sometimes also affected additional nearby cranial nerve, which is probably why he was having some of his stomach problem. She thought that was interesting and wanted to know what to do since he was about to have some gallbladder studies.

I outlined a treatment plan and low and behold he is getting better. My question is why didn’t anyone in the doc’s office or ER never complete a thorough physical exam? Oh, wait- how does one do a complete physical exam through the telehealth system? What about heart or lung disease patients, how does a nurse or physician listen to their heart or lungs, etc?? Are we physicians forgetting our teachings and training regarding the proper approach to physical diagnosis?

And now what about Biden’s proposal for health care?

Leigh Page pointed out that physicians — like all Americans — are trying to size up Joe Biden’s healthcare agenda, which the Democratic presidential nominee has outlined in speeches and on his official website.

Many healthcare professionals, patients, and voters of all political stripes think our current healthcare system is broken and in need of change, but they don’t agree on how it should change. In Part I of this article, we take a look at Biden’s proposals for changing the US healthcare system. Then, we include comments and analysis from physicians on both sides of the fence regarding the pros and cons of these proposed healthcare measures.

Part 1: An Overview of Biden’s Proposed Healthcare Plan

Biden’s proposed healthcare plan has many features. The main thrust is to expand access to healthcare and increase federal subsidies for health coverage.

If elected, “I’ll put your family first,” he said in a speech in June. “That will begin the dramatic expansion of health coverage and bold steps to lower healthcare costs.” He said he favored a plan that “lowers healthcare costs, gets us universal coverage quickly, when Americans desperately need it now.”

Below are Biden’s major proposals. They are followed by Part 2, which assesses the proposals on the basis of comments by doctors from across the political spectrum.

Biden Says We Should Restore the ACA

At a debate of the Democrat presidential candidates in June 2019, Biden argued that the best way to expand coverage is “to build on what we did during the Obama administration,” rather than create a whole new healthcare system, as many other Democratic candidates for president were proposing.

“I’m proud of the Affordable Care Act,” he said a year later in his June 2020 speech. “In addition to helping people with preexisting conditions, this is the law that delivered vital coverage for 20 million Americans who did not have health insurance.”

At the heart of the ACA are the health insurance marketplaces, where people can buy individual insurance that is often federally subsidized. Buyers select coverage at different levels ― Gold, Silver, and Bronze. Those willing to pay higher premiums for a Gold plan don’t have high deductibles, as they would with the Silver and Bronze plans.

Currently, federal subsidies are based on premiums on the Silver level, where premiums are lower but deductibles are higher than with the Gold plan. Biden would shift the subsidies to the Gold plan, where they would be more generous, because subsidies are pegged to the premiums.

In addition, Biden would remove the current limit on subsidies, under which only people with incomes less than 400% of the federal poverty level qualify for them. “Many families making more than 400% of the federal poverty level (about $50,000 for a single person and $100,000 for a family of four), and thus not qualifying for financial assistance, still struggle to afford health insurance,” the Biden for President website states.

Under the Biden plan, there would still be a limit on insurance payments as a percentage of income, but that percentage would drop, meaning that more people would qualify. Currently, the level is 9.86% or more of a person’s income; Biden would lower that level to 8.5%.

“We’re going to lower premiums for people buying coverage on their own by guaranteeing that no American ever has to spend more than 8.5% of their income on health insurance, and that number would be lower for lower-income people,” Biden said in the June speech.

Add a Public Option, but Not Medicare for All

In the primary, Biden parted company from rivals who backed Medicare for All, a single-payer health system that would make the government pay for everyone’s healthcare. “I understand the appeal of Medicare for All,” he said in a video released by his campaign. “But folks supporting it should be clear that it means getting rid of Obamacare, and I’m not for that.” But he nor anyone else who supported Obamacare has come up with a way to finance this type of healthcare system.

However, Biden embraced a “public option” that would allow people to buy into or be subsidized into “a Medicare-like” plan. It is unclear how similar the public option would be to regular Medicare coverage, but the Biden campaign has made it clear that it would not take funds from the Medicare trust fund, which is expected to start losing funds by 2026.

The more than 150 million Americans who have employer-sponsored insurance could keep it, but they could still buy into the public option if they wanted to. In addition, the public option would automatically enroll ― at no cost to them ― some 4.8 million low-income Americans who were excluded from the ACA’s Medicaid expansion when many states chose to opt out of the Medicaid expansion.

In addition, the 37 states that participate in expanded Medicaid could switch coverage to the new public option, provided that they continue to pay their current share of the costs. (In June, Oklahoma became the 37th state to allow the expansion, following the results of a ballot measure.)

“We need a public option now more than ever, especially when more than 20 million people are unemployed,” Biden said in the June speech. “That public option will allow every American, regardless of their employment status, the choice to get a Medicare-like plan.”

Lower the Medicare Age

In spring 2020, Biden proposed lowering the age to qualify for Medicare from 65 to 60. This provision is not included among the official policies listed on the Biden for President website, but it has been cited by many, including the Biden-Sanders Unity Task Force.

This provision would bring almost 23 million people into Medicare, including 13.4 million from employer-sponsored coverage, according to one analysis. It’s not clear whether these people would buy into Medicare or simply be covered. Their care would not be paid for by the Medicare Trust Fund but would use tax dollars instead. Oh, finally, we find out that our taxes would go up. How much is the problem as we consider all the other programs that Biden and Harris have promoted.

Provide Relief in the Covid-19 Pandemic

Biden would cover the cost of COVID-19 testing and the cost of health coverage for people laid off during the pandemic.

“Testing unequivocally saves lives, and widespread testing is the key to opening our economy again,” Biden said in his June speech. “To fix the economy, we have to get control over the virus.”

Prescription Drug Reform

Biden would repeal a Bush-era exception that bars the Medicare program from negotiating prescription drug prices for the Part D prescription drug benefit. “There’s no justification for this except the power of prescription drug lobbying,” the Biden for President website states.

In addition, Biden’s prescription drug reform plan would do the following:

• Limit launch prices for drugs. The administration would establish an independent review board that would assess the value of new drugs and would have the power to set limits on their prices. Such drugs are “being abusively priced by manufacturers,” the Biden for President site says.

• Limit price increases to inflation. As a condition of participation in government programs, drug prices could not rise more than the general inflation rate. Biden would impose a tax penalty on drug makers whose prices surpassed inflation.

• Allow consumers to buy prescription drugs from other countries. Biden would allow consumers to import prescription drugs from other countries, provided the US Department of Health and Human Services certifies that those drugs are safe.

• Stop tax breaks for pharma ads: Biden would drop drug makers’ tax breaks for advertising, which amounted to $6 billion in 2016.

Stop Surprise Billing

Biden proposes to stop surprise billing, which occurs when patients receive care from a doctor or hospital that is not in their insurer’s network. In these situations, patients can be surprised with very high bills because no payment limit has been negotiated by the insurer.

Twenty-eight states have enacted consumer protections to address surprise medical billing, but Congress has not passed such a measure. One proposed solution is to require payers to pay for out-of-network services on the basis of a benchmark, such as the average Medicare rate for that service in a specific geographic area.

Closely Monitor Healthcare Mergers

Biden would take a more active stance in enforcing antitrust laws against mergers in the healthcare industry.

“The concentration of market power in the hands of a few corporations is occurring throughout our health care system, and this lack of competition is driving up prices for consumers,” the Biden for President website states.

Overhaul Long-term Care

Biden’s latest plan calls for a $775 billion overhaul of the nation’s caregiving infrastructure. Biden says he would help create new jobs, improve working conditions, and invest in new models of long-term care outside of traditional nursing homes.

Restore Funding for Planned Parenthood

Biden would reissue guidance barring states from refusing Medicaid funding for Planned Parenthood and other providers that refer for abortions or that provide related information, according to the Biden for President website. This action would reverse a Trump administration rule.

Boost Community Health Centers

Biden promises to double federal funding for community health centers, such as federally qualified health centers, that provide care to underserved populations.

Support Mental Health Parity

Biden says he supports mental health parity and would enforce the federal mental health parity law and expand funding for mental health services.

Part 2: Physicians’ Opinions on Biden’s Healthcare Plans: Pro and Con

Biden’s plans to expand coverage are at the heart of his healthcare platform, and many see these as the most controversial part of his legislative agenda.

Biden’s Medicare expansion is not Medicare for All, but it can be seen as “Medicare for all who want it.” Potentially, millions of people could enter Medicare or something like Medicare. If the Medicare eligibility age is dropped to 60, people could switch from their employer-sponsored plans, many of which have high deductibles. In addition, poor people who have no coverage because their states opted out of the Medicaid expansion would be included.

The possibility of such a mass movement to government-run healthcare alarms many people. “Biden’s proposals look moderate, but it is basically Medicare for All in sheep’s clothing,” said Cesar De Leon, DO, a family physician in Naples, Florida, and past president of the county’s medical society.

Reimbursements for Doctors Could Fall- No, Will Fall!

A shift of millions of people into Medicare would likely mean lower reimbursements for doctors. For example, the 13.4 million people aged 60 to 65 who would switch from employer-sponsored coverage to Medicare would be leaving some of the best-paying insurance plans, and their physicians would then be reimbursed at Medicare rates.

“Biden’s plan would lower payments to already cash-strapped doctors and hospitals, who have already seen a significant decrease in reimbursement over the past decade,” De Leon said. “He is trying to win the support of low-income voters by giving them lower healthcare prices, which doctors and hospitals would have to absorb.

“Yes, the US healthcare system is dysfunctional,” De Leon added, “but the basic system needs to be fixed before it is expanded to new groups of people.”

The American Association of Neurological Surgeons/Congress of Neurological Surgeons warns against Biden’s proposed government-run system. “We support expanding health insurance coverage, but the expansion should build on the existing employer-based system,” said Katie O. Orrico, director of the group’s Washington office. “We have consistently opposed a public option or Medicare for All.

“Shifting more Americans into government-sponsored healthcare will inevitably result in lower payments for physicians’ services,” Orrico added. “Reimbursement rates from Medicare, Medicaid, and many ACA exchange plans already do not adequately cover the costs of running a medical practice.”

Prospect of Higher Taxes- Absolutely, grab your wallets and your retirement funds!!

Paying for ambitious reforms means raising taxes. Biden’s plan would not make the Medicare trust fund pay for the expansions and would to some extent rely on payments from new beneficiaries. However, many new beneficiaries, such as people older than 60 and the poor, would be covered by tax dollars.

Altogether, Biden’s plan is expected to cost the federal government $800 billion over the next 10 years. To pay for it, Biden proposes reversing President Trump’s tax cuts, which disproportionately helped high earners, and eliminating capital gains tax loopholes for the wealthy.

“Rather than tax the average American, the Democrats will try to redistribute wealth,” De Leon said.

“The elephant in the room is that taxes would have to be raised to pay for all these programs,” said Gary Price, MD, president of the Physicians Foundation. Because no one likes higher taxes, he says, architects of the Biden plan would try to find ways to save money, such as tamping down reimbursements for physicians, to try to avoid a public backlash against the reforms.

“Physicians’ great fear is that efforts to keep taxes from getting too high will result in cutting physician reimbursement,” he said.

Impact of COVID-19

Perhaps an even larger barrier to Biden’s health reforms comes from the COVID-19 crisis, which didn’t exist last year, when health reform was the central issue in the presidential primary that pitted Biden against Vermont Senator Bernie Sanders, the chief proponent of Medicare for All.

“The top two issues on voters’ minds right now are the pandemic and the economy,” said Daniel Derksen, MD, a family physician who is professor of public health policy at the University of Arizona in Tucson. “Any other concerns are pushed down the list.”

The COVID-19 crisis is forcing the federal government to spend trillions of dollars to help businesses and individuals who have lost income because of the crisis. Will there be enough money left over to fund an ambitious set of health reforms?

“It’s not a good time to start reforms,” warned Kevin Campbell, MD, a cardiologist in Raleigh, North Carolina. “Given the current pressures that COVID-19 has placed on physicians, healthcare systems, and hospitals, I don’t believe that we can achieve meaningful change in the near term.”

However, supporters of Biden’s reforms think that now, during the COVID-19 crisis, is precisely the right time to enact healthcare reform. When millions of Americans lost their jobs because of the pandemic, they also lost their insurance coverage.

“COVID-19 has made Biden’s healthcare agenda all the more relevant and necessary,” said Don Berwick, MD, who led the Center for Medicare & Medicaid Services (CMS) under President Obama. “The COVID-19 recession has made people more aware of how vulnerable their coverage is.”

Orrico at the neurosurgeons group acknowledges this point. “The COVID-19 pandemic has exposed some cracks in the US healthcare system,” she said. “Whether this will lead to new reforms is hard to say, but policymakers will likely take a closer look at issues related to unemployment, health insurance coverage, and healthcare costs due to the COVID-19 emergency.”

Many Physicians Want Major Reform

Although many doctors are skeptical of reform, others are impatient for reform to come and support Biden’s agenda ― especially its goal to expand coverage.

“Joe Biden’s goal is to get everyone covered,” said Alice Chen, MD, an internist who is a leader of Doctors for Biden, an independent group that is not part of the Biden campaign. “What brings Democrats together is that they are united in the belief that healthcare is a right.”

In January, the American College of Physicians (ACP) endorsed both Medicare for All and the public option. The US healthcare system “is ill and needs a bold new prescription,” the ACP stated.

The medical profession, once mostly Republican, now has more Democrats. In 2016, 35% of physicians identified themselves as Democrats, 27% as Republicans, and 36% as independents.

Many of the doctors behind reform appear to be younger physicians who are employed by large organizations. They are passionate about reforming the healthcare system, and as employees of large organizations, they would not be directly affected if reimbursements fell to Medicare levels ― although their institutions might subsequently have to adjust their salaries downward.

Chen, for example, is a young physician who says she has taken leave from her work as adjunct assistant clinical professor of medicine at the University of California, Los Angeles, to raise her young children.

She is the former executive director of Doctors for America, a movement of thousands of physicians and medical students “to bring their patients’ experiences to policymakers.”

“Doctors feel that they are unseen and unheard, that they often feel frankly used by large health systems and by insurance companies,” Chen said. “Biden wants to hear from them.”

Many idealistic young physicians look to health system leaders like Berwick. “I believe this nation needs to get universal coverage as fast as we can, and Biden’s policies present a path to get there,” the former CMS director said. “This would be done chiefly through Biden’s public option and his plans to expand coverage in states that have not adopted the ACA Medicaid expansion.”

But what about the potential effect of lowering reimbursement rates for doctors? “The exact rates will have to be worked out,” Berwick said, “but it’s not just about who pays physicians, it’s about how physicians get paid.” He thinks the current fee-for-service system needs to be replaced by a value-based payment system such as capitation, shared savings, and bundled payments.

The Biden-Sanders Task Force

Berwick was a member of the Biden-Sanders Unity Task Force, which brings together supporters of Biden and Sanders to create a shared platform for the Biden campaign.

The task force issued a report in early July that recommended a variety of healthcare reforms in addition to expanding access to care. One of them was to find ways to address the social determinants of health, such as housing, hunger, transportation, and pollution, which can harm health outcomes.

Chen specifically cites this provision. “We need to focus on the social determinants of heath and try to encourage better health,” she said. “I remember as a doctor advising a patient who was a young mother with several small children that she needed to exercise more. She asked me, ‘When am I supposed to exercise, and who will watch my kids?’ I realized the predicament that she was in.”

Price is also glad to see the provision in Biden’s plan. “Social determinants of health has been a key focus of the Physicians Foundation,” he said. “To my knowledge, this is the first time that a political candidate’s healthcare policy has included this point.

“Physicians are not in control of the social determinants of health, even though they affect their reimbursements,” he said. Under Medicare’s Merit-based Incentive Payment System, for example, doctors are penalized when their patients don’t meet certain health standards, such as when diabetes patients can’t get their A1C levels under control, he says.

However, Price fears that Biden, in his efforts to make peace with Sanders supporters, may have to some degree abandoned his moderate stance on health reform.

Is the Nation Ready for Another Health Reform Battle?

Clearly, many Democrats are ready to reform the system, but is the nation ready? “Are American voters ready for another major, Democratic-led health reform initiative?” asked Patricia Salber, MD, an internist and healthcare consultant who runs a blog called The Doctor Weighs In.

“I’ve been around long enough to remember the fight over President Clinton’s health plan and then President Obama’s plan,” she said. Each time, she says, there seemed to be a great deal of momentum, and then there was a backlash. “If Biden is elected, I hope we don’t have to go through the same thing all over again,” Salber said.

Derksen believes Biden’s proposed healthcare reforms could come close to rivaling President Obama’s Affordable Care Act in ambition, cost, and controversy.

He shares Biden’s goal of extending coverage to all ― including paying the cost of covering low-income people. But the result is that “Biden’s agenda is going to be a ‘heavy lift,’ as they say in Washington,” he said. “He has some very ambitious plans to expand access to care.”

Derksen speaks from experience. He helped draft part of the ACA as a health policy fellow in Capitol Hill in 2009. Then in 2011, he was in charge of setting up the ACA’s insurance marketplace for the state of New Mexico.

Now Biden wants to begin a second wave of health reform. But Derksen thinks this second wave of reform could encounter opposition as formidable as those Obama faced.

“Assuming that Biden is elected, it would be tough to get this agenda passed ― even if he had solid Democratic majorities in both the House and Senate,” said Derksen,

According to polls by the Kaiser Family Foundation (KFF), 53% of Americans like the ACA, while 37% dislike it ― a split that has been relatively stable for the past 2 years, since the failed GOP effort to repeal the law.

In that KFF poll, the public option fared better ― 68% of Americans support the public option, including 42% of Republicans. These numbers help explain why the Biden campaign moved beyond its support of the ACA to embrace the public option as well.

Even when Democrats gain control of all the levers of power, as they did in 2009, they still have a very difficult time passing an ambitious healthcare reform bill. Derksen remembers how tough it was to get that massive bill through Congress.

The House bill’s public option might have prevailed in a reconciliation process between the two bills, but that process was cut short when Sen. Ted Kennedy died and Senate Democrats lost their filibuster-proof majority. The bill squeaked through as the Senate version, without the public option.

The ACA Has Survived-But at What Cost?

The ACA is much more complex piece of legislation than the public option.

“The ACA has survived for a decade, despite all efforts to dismantle it,” Salber said. “Biden wants to restore a law that the Republicans have been chipping away at. The Republicans eliminated the penalty for not having coverage. Think about it, a penalty of zero is not much of a deterrent.”

It was the loss of the ACA penalty in tax year 2019 that, paradoxically, formed the legal basis for the latest challenge of the ACA before the Supreme Court, in a suit brought by the Trump administration and 18 Republican state attorneys general.

The Supreme Court will make its ruling after the election, but Salber thinks the suit itself will boost both Biden and the ACA in the campaign. “I think most people are tired of all the attempts to repeal the ACA,” she said.

“The public now thinks of the US healthcare system as pathetically broken,” she added. “It used to be that Americans would say we have the best healthcare system in the world. I don’t hear that much anymore.”

Physicians who oppose the ACA hold exactly the opposite view. “Our healthcare system is in shambles after the Obamacare fiasco,” Campbell said. “Even if Biden has a Democrat-controlled House and Senate, I still don’t think that there would be enough votes to pass sweeping changes to healthcare.”

Biden Could Choose Issues Other Than Expanding Access

There are plenty of proposals in the Biden healthcare plan that don’t involve remaking the healthcare system.

These include making COVID-19 testing free, providing extra funding for community health centers, and stopping surprise billing. Proposals such as stepping up antitrust enforcement against mergers would involve administrative rather than Congressional action.

Some of these other proposals could be quite expensive, such as overhauling long-term care and paying for health insurance for laid-off workers. And another proposal ― limiting the prices of pharmaceuticals ― could be almost as contentious as expanding coverage.

“This proposal has been talked about for many years, but it has always met with strong resistance from drug makers,” said Robert Pearl, MD, former CEO of the Permanente Medical Group and now a faculty member at Stanford School of Medicine and Graduate School of Business.

Pearl thinks the first item in Biden’s drug plan ― to repeal a ban against Medicare negotiating drug prices with drug makers ― would meet with Congressional resistance, owing to heavy lobbying and campaign contributions by the drug companies.

In addition, Pearl thinks Biden’s plans to limit drug prices ― barring drug makers from raising their prices above the general inflation rate and limiting the launch prices for many drugs ― enter uncharted legal waters and could end up in the courts.

Even Without Reform, Expect Lower Reimbursements

Although many doctors are concerned that Biden’s healthcare reforms would reduce reimbursements, Pearl thinks reimbursements will decline even without reforms, owing in part to the COVID-19 pandemic.

Employer-based health insurance has been the bedrock of the US healthcare system, but Pearl says many employers have long wanted to get rid of this obligation. Increasingly, they are pushing costs onto the employee by raising deductibles and through premium sharing.

Now, with the pandemic, employers are struggling just to stay in business, and health insurance has truly become a financial burden, he says. In addition, states will be unable to balance their budgets and will try to reduce their Medicaid obligations.

“Before COVID-19 hit, healthcare spending was supposed to grow by 5% a year, but that won’t happen for some time into the future,” Pearl said. “The COVID economic crisis is likely to continue for quite some time, forcing physicians to either accept much lower payments or find better ways to provide care.”

Like Berwick, Pearl believes healthcare will have to move to value-based payments. “Instead of producing more services, doctors will have to preserve resources, which is value-based healthcare,” he said. The primary form of value-based reimbursement, Pearl thinks, will be capitation, in which physicians agree to quality and service guarantees.

Even steadfast opponents of many of Biden’s reforms foresee value-based payments taking off. “Certainly, there are ways to improve the current healthcare system, such as moving to value-based care,” said Orrico at the neurosurgeons’ group.

In short, a wide swath of observers agree that doctors are facing major changes in the payment and delivery of healthcare, regardless of whether Biden is elected and succeeds with his health agenda.

Notice that no one has mentioned tort reform in healthcare. Why Not???????

When This War Is Over, Many of Us Will Leave Medicine and the Stresses of Healthcare Workers on All Fronts

One ER physician recounts the stress of constant intubations and PPE shortages

Michele Harper reviews the stress of our frontline healthcare workers and here is a case.

I couldn’t see. My face shield was blurred by a streaky haze. I tilted my neck back and forth in an effort to peer beyond it, beneath it, through it, whatever might work. Was it condensation? I started to raise my hands to my face to wipe it away before I remembered and yanked them back down: I cannot touch my face, can’t ever touch my face — neither inside this room nor outside it.

As I stood at the head of the patient’s bed in ER Room 3, her nurse, Kate, secured a mask over the patient’s face to deliver additional oxygen. I checked to ensure the oxygen was cranked up to the maximum flow rate while we waited for the respiratory therapist. Even with that increased oxygen, the patient was saturating 85% at best, and her blood pressure was dropping.

Ninety minutes earlier, the patient — a woman of 68 years with significant impairment from a stroke — had been fine. The nurse at her nursing home called to inform us they were sending the patient to the ER for evaluation of “altered mental status” because she was less “perky” than usual. Her oxygen level on arrival was normal with no shortness of breath. Her blood pressure was a little low, but her blood glucose read high. Nothing a little IV fluid couldn’t fix, and initially, it did.

I had requested a rectal temperature; it read 103 degrees. The combination of her being a nursing home resident and running a fever was a red flag during these coronavirus times. I placed her on respiratory isolation and asked Kate to be extra vigilant for any decline. I ordered broad-spectrum antibiotics to kill any likely source of infection while I awaited her chest X-ray, urine, and blood tests. Her portable chest X-ray was done first and revealed what I had already anticipated: diffuse atypical infiltrates, a presumed telltale sign of Covid-19. Although our understanding of this viral infection is ever-evolving, it seems the only observation we can reliably conclude is that we have not yet identified anything pathognomonic about it.

Seventy-five minutes later, another nurse, Charlene, called, “They need you in Room 3.”

“Okay,” I replied as I entered orders on the next chest pain patient with shortness of breath.

“Dr. Harper, they need you in Room 3 now,” Charlene called again.

“Room 3? The nursing home patient? I’ll be right there. What happened?”

“Her oxygen is at 67%.”

I asked the clerk to call respiratory therapy for intubation. I then turned back to Charlene to ask her to help Kate prepare for the procedure.

Then the personal protective equipment (PPE) sequence. I grabbed gloves to remove my N95 mask from its paper bag and placed it over my face, checking it was snug over my nose and lower jaw. After removing those gloves, I donned my face shield, then walked to the cart for a new gown. Lastly, a fresh set of gloves before entering the patient’s room.

I was scared, and I don’t get scared. Other doctors do, but not ER doctors. We don’t scare easily.

Now I waited for the respiratory therapist. It was good that she needed extra time to get the ventilator and then don her PPE because I had to figure out why I couldn’t see without manually manipulating my face shield. My thoughts were pierced by the sound of panting. I checked the patient who was taking the oxygen quietly, rapidly, ineffectively at regular intervals that didn’t register a sound. Her eyes remained closed—no flip of an eyelash, no wince of her forehead, no twitch in a limb. Despite her instability, the patient was in no visible distress. No heaving breath there. The nurse to my left was concentrating on the patient’s oxygen. I heard only the crinkle of her gown as she adjusted her stance. The panting wasn’t hers. The nurse to my right prepared to administer the intubation medications. He read out my orders — the name and dose of the medication in each syringe and the order in which they were to be pushed. His voice was steady. It wasn’t him hyperventilating. The nurse just outside of the room kept documentation of the procedure on scrap paper she used to carefully transcribe each detail onto her laptop. She was too far away to be heard unless she yelled, so that audible breathing certainly wasn’t hers.

The panting was my own.

A hailstorm of thoughts ensued. Was my breath the fog on my face shield? If so, my N95 mask had a leak. Unsuspecting, had I already inhaled the virus? Would I be intubated next?

The respiratory therapist had arrived with the ventilator and put on her face shield. She was almost ready, so there was little time to pull myself together.

Breathe in, I commanded myself: One, two, three. Breathe out. I obeyed: One, two, three, four.

Was I already short of breath? Had I not noticed my symptoms when I drove to work this morning? Yesterday? Last night?

Breathe in. One two, three. Breathe out. One, two, three, four.

I was scared, and I don’t get scared. Other doctors do, but not ER doctors. We don’t scare easily. We’re a type of special forces who step in when everything else has failed. Typically, we do our job anonymously then leave when the mission is complete. Any injury to ourselves incurred in the line of duty is dealt with after we’re off the clock.

Once in a while, however, there are circumstances when the capacity to compartmentalize is overwhelmed, when the chronic stress breaks through so that the fear works on you. Now, as I stood at the patient’s bed with the video laryngoscope blade in one hand and the endotracheal tube in the other, panic pushed its way through me in involuntary. forceful. rapid. shallow. breaths.

Breathe in on one, two, three. Breathe out on one, two, three, four.

The respiratory therapist slapped on her gloves and in moments was at my side. It was time for intubation.

Breathe in on three and out on four.

At last, my breathing was smooth, measured, sound.

I looked through my mask again. It wasn’t condensation. It was streaks from the sanitizing wipes because we had to reuse our equipment.

I adjusted my eyes to the clear spaces. Finally, I could see. My N95 mask fit. I could breathe.

The room was relatively quiet, what I like to call “ER calm.” All was still, save for the bagging of respiratory therapy, save for the swoosh of oxygen jetting from its port aerosolizing everything.

I requested that the intubation medications be administered then checked for a response. After visualizing the vocal cords easily with the video laryngoscope, I slid in the endotracheal tube, and respiratory connected it to the vent. The patient’s oxygen increased to 100% on the monitor.

Those of us who survive will return each day to battle. But when this war is over, this is why many of us will leave.

Doffing my gown and gloves, I put on new gloves to remove and sanitize my face shield. I couldn’t imagine there was a way to effectively clean the foam band across the forehead. I hoped to remove the streaks. I also hoped the impossible: to remove the virus, because it was the same shield I had to use repeatedly during my shift. I took off the N95. We’re now told that we can reuse it, too, numerous times before getting a new one due to the PPE shortages, so I put the contaminated mask back in the bag until I would need to do it again for the next patient.

This is how we get infected. This is how we die.

Those of us who survive will return each day to battle because we do not walk away from war until it’s done. But when this war is over, this is why many of us will leave.

I walked to the back of the ER to use the restroom in the seven minutes before the patient was ready for CT and saw my ER director standing in the lounge. I waved hello.

“How did it go?” she asked, her eyes gentle, her smile sympathetic.

“It went,” I replied.

“How did you feel in the PPE? Did you feel protected?”

I paused to regulate my answer. Her intentions were good. She was an ER doctor who did her best to walk the fine line between the docs on the front lines and the administrators who notified me that “doctors don’t get paid sick leave” and “thank you for your service,” which were graciously sent out in two separate emails. Just another reminder that we health care providers are regarded as more disposable than our PPE. But this wasn’t her fault, so I felt responsible, in that moment, for her feelings too.

I pulled in my tone. “No. That equipment doesn’t protect us. There’s no way that we’re not all covered in Covid, but we’re following the ‘guidelines.’”

She nodded and frowned.

“Honestly,” I continued, “and I hate to say this, but my feeling is that the majority of people will have contracted this virus. Most people will get through it, and others won’t. Many will die. I don’t want any of us to die, but many health care providers will. The thing is, it’s impossible to know which camp we’re in until it happens.”

She nodded again.

We smiled at each other, and I continued to the bathroom. I washed my hands, turning them over each other, lathering the soap along each finger, under each nail. As I dried my hands, I looked up at the mirror, noting that my breath was now imperceptible when my phone rang.

A FaceTime request from my nine-year-old nephew, Eli.

My policy used to be to not answer the phone at work unless it was critical. But this is a different era. Eli is sheltering-in-place at a military base in California while his mother, my sister, is away for deployment.

I swiped the phone to answer. “Hi, Eli!”

“Hello, Aunt,” he announced more softly than usual. His eyelids hovered low, and his eyes weren’t their typical bright.

“How are you, Eli?” I inquired, masking my concern.

“I’m good.” He smiled with sleepy eyes. “I just woke up.” He yawned; his bushy eyebrows raised high. Years ago, he said his eyebrows were the indisputable evidence that Frida Kahlo was his great, great grandmother so he had to meet her forthwith. Upon being told that she had already passed away, he cried for the woman he had decided was his long-lost ancestor. Now, as he yawned again, his thick eyelashes shut tight. His head drifted back and his mouth reeled open expelling the strongest exhale of the bravest lion cub.

Smiling to myself, I sighed easily.

He breathed.

I breathed.

Today we are OK.

Anxiety on the Frontlines of COVID-19 

It’s not just healthcare workers’ physical health but also their mental health that’s suffering

Richard van Zyl-Smit, M.D./PhD described to a friend this week the current feeling of being in the hospital with COVID-19, as like sitting under a 1,000V high-tension electricity cable: there is a constant humming above your head, which is unnerving and just does not go away.

Two years ago, he published a book called They Don’t Award Nobel Prizes to Dead People about my experience as an academic clinician with a stress-induced anxiety disorder. The context is very different now, but the lessons I learned in that time might be of help to those of you feeling this intangible “humming” — a sense of anxiety that is neither defined nor visible even with no COVID patient contact — and for those of you who are caring daily for COVID-19 patients.

The first and most important aspect of this time is to recognize that anxiety is real. This is not something you might have experienced before. For those of us who have previously or currently suffer from anxiety, it is easily recognizable for what it is, but you may never have experienced it quite like this. You are not losing your mind or losing control, you are experiencing a loss of control of your environment. In many ways, the daily changing updates, the ever-changing schedules and call rosters are unsettling at best and can be completely unnerving as we can’t be certain from one day to the next. There is not a lot you can do about it, except to acknowledge it and talk about it.

The second aspect relates directly to that gnawing “hum.”

I learned previously the benefit of and strongly believe in “downtime.” Getting away from the humming, which is not so easy anymore as we don’t have rugby or soccer scores to get excited or depressed about, we don’t have news about politics or current affairs — except COVID, COVID, COVID. I used to play Candy Crush to get my mind off work and to get away from the “hum,” but recognized that did not accomplish much — it just kept my mind going, and the anxiety was still there. I now try to be creative, to garden, draw, write, crochet (see below), paint, anything that I can do that takes the focus off my work.

Exercise is great too — but now restricted to indoors! I don’t look at the hundreds of WhatsApp group messages unless I am at work; the latest medical publication of how I should treat my ventilated COVID-19 patient on my next week on call is not important when I am at home.

I am convinced that switching off the social media, medical media, and media media when you are not working is vital for your mental health. For some, it might mean no social media, for others less, but getting out from under the electricity cable when you can, is an important way to ensure your own sustainability over the next few months.

The last aspect relates to relationships: physical distance is key — but find, and seek out the people who can support you; keep talking to each other, be kind to each other and to yourself, and talk about the anxiety, fears, worries, or stress. Professional services are available to those feeling very out of control, but simply talking with someone is a fantastic way to get the humming out of your head.

As much as we need to care for our COVID-19 patients and protect ourselves with PPE, we also need to look after ourselves and protect our mental health. It is not a sign of weakness but requires courage and bravery to ask for help.

“Asking for help is not giving up, it is refusing to give up.” — Charlie Mackesy

We are all in this together — we need to be kind to each other and to ourselves.

India coronavirus doctors: Notes on hope, fear and longing Reporter Vikas Pandey shows us how the Corona virus is affecting doctors in India. Dr Milind Baldi was on duty in a Covid-19 ward when a 46-year-old man was wheeled in  with severe breathing difficulty.

The man was scared for his life and kept repeating one question: “Will I survive?”

The question was followed by a plea: “Please save me, I don’t want to die.” Dr Baldi assured the man that he was going to do “everything possible to save him”.

These were the last words spoken between the two men. The patient was put on a ventilator, and died two days later. The doctor, who works in a hospital in the central Indian city of Indore, vividly remembers the 30 “terrifying minutes” after the patient was brought to his hospital.

“He kept holding my hands. His eyes were full of fear and pain. I will never forget his face.”

His death deeply affected Dr Baldi. “It ate away my soul from inside and left a lacuna in my heart.” Seeing patients die in critical care wards is not uncommon for doctors like him. But, he says, nothing can compare to the psychological stress of working in a Covid-19 ward.

Most coronavirus patients are kept in isolation, which means, if they become critically ill, doctors and nurses are the only people they see in their final hours.

“No doctor ever wants to be in this scenario,” says Dr A Fathahudeen, who heads the critical care department at Ernakulam Medical College in southern India.

Doctors say they usually share the emotional burden of treating someone with that person’s family. But Covid-19 doesn’t allow that. Dr Fathahudeen says he will never forget “the blankness in the eyes” of a Covid-19 patient who died in his hospital.

“He wasn’t able to talk. But his eyes reflected the pain and the fear he was experiencing.” Dr Fathahudeen felt helpless because the patient was going to die alone. But there was a tiny sliver of hope: the man’s wife was being treated for coronavirus in the same hospital.

So, Dr Fathahudeen brought her to the ward. She stood still and kept looking at him and said her goodbye. She never thought her 40-year marriage would end so abruptly.

The experienced doctor says the incident left him “emotionally consumed”. But, he adds, there was “some satisfaction that he didn’t die without seeing his wife”. “But that won’t always happen. The harsh truth is that some patients will die without saying goodbye to their loved ones.”

The emotional toll is made much worse as many doctors are themselves in a form of isolation – most are staying away from their families to protect them. As a result, Dr Mir Shahnawaz, who works at the Government Chest Hospital in Srinagar, says it’s “not just the disease we are fighting with”.

“Imagine not knowing when you will see your family next, add that to the constant fear that you may get infected and you will begin to understand what we are going through.”

Adding to the stress, is the fact that they also have to constantly deal with the emotional outbursts of patients. “They are very scared and we have to keep them calm – be their friend and doctor at the same time.”

And doctors also have to make phone calls to the families of patients, and deal with their fears too. The whole process, Dr Shahnawaz says, is emotionally draining.

“It hits you when you go back to your room in the night. Then there is the fear of the unknown – we don’t know how bad the situation will get.”

Doctors are used to saving lives, he adds, and “we will continue to do that no matter what”. “But the truth is that we are also human beings and we are also scared.” He says that the first coronavirus death in his hospital made his colleagues break down: it was when they realized that Covid-19 doesn’t afford the family a final glimpse of their loved one.

“Family members want to remember the final moments of a patient – a faint smile, a few last words, anything really to hold on to. But they can’t even give a proper burial to the dead.”

Dr Fathahudeen says such psychological pressure needs to be addressed and each hospital needs to have a psychiatrist – both for doctors and patients. “This is something I have done in my hospital. It’s important because otherwise the emotional scars will be too deep to heal. We are staring at cases of PTSD among frontline workers.”

Doorstep doctors

It is not just those working in Covid-19 wards who are on the front line, but also the doctors, community health workers and officials who are involved in contact tracing and screening suspected patients by going door-to-door in virus hotspots.

Dr Varsha Saxena, who works in the badly affected northern city of Jaipur, says she walks into grave danger knowingly every day. Her job is to screen people for possible symptoms. “There is no other option. It’s the fight of our lifetime, but one can’t ignore the risks,” she says. “But it poses great risk because we don’t know who among the ones, we are screening is actually positive,” she adds.

She says doctors like her don’t always get proper medical-grade personal protective equipment. “The fear of getting infected is always there and we have to live with it. It does play on our mind and we have to fight hard to keep such negative thoughts away.”

But her biggest fear, she says, is getting infected and not showing any symptoms. “Then the risk is that we may end up infecting others. That is why field doctors also need PPE,” she adds. And the stress, sometimes, also comes home.

“It’s so draining. My husband is also a doctor, most nights we don’t even have energy to cook and our dinner involves just bread.”

Aqueel Khan, a bureaucrat and a colleague of Dr Saxena, acknowledges that psychological stress is a reality for all frontline workers, including officers like him who are embedded with medical teams. The fear really comes home for these workers when somebody close to them dies.

“I lost my uncle and a friend recently. It shook me, I can’t stop thinking about them. You can’t stop thinking that it can easily happen to you,” he says.

Mr. Khan is also staying away from his family: this year is the first time he will miss his daughter’s birthday. “My heart says to go home and see her from far, but the mind tells me otherwise. This constant struggle is very stressful.

“But we can’t turn our backs on the job. We just have to just keep at it, hoping that we come out alive on the other side of this fight.” ‘The risk is always there’

There is no respite for doctors and nurses even when they are not directly involved in the fight against coronavirus. People with other ailments are continuing to come to hospitals. And there has also been a surge in the number of people who are turning up at hospitals with coronavirus-like symptoms.

Dr Mohsin Bin Mushtaq, who works at the GMC Hospital in Indian-administered Kashmir, says coronavirus has “fundamentally changed our lives”. “We are seeing patients every day for other ailments. But the risk is always there that some of them could be infected,” he said.

And it worries him even more when he reads about doctors getting infected despite wearing PPE and dying. A number of doctors have died in India and dozens have tested positive. There is nothing we can do about it, he says, adding that “we just have to be mentally strong and do our jobs”.

Dr Mehnaz Bhat and Dr Sartaz Bhat also work in the same hospital, and they say that the “fear among patients is too much”. Dr Sartaz says people with a slight cold end up thinking they have coronavirus, and rush to the hospital. “So apart from treating them, we also have to deal with their fear,” Dr Sartaz adds.

He recently diagnosed Covid-19 symptoms in a patient and advised him to go for testing. But his family refused and took him away. The patient was brought back to the hospital after Dr Sartaz called the police. He says he had never imagined doing something like this in his medical career. “This is the new normal.”

The way patients are examined has also changed for some doctors. “We really have to try and limit close interactions with patients,” Dr Mehnaz Bhat says. “But it’s not what we have been trained for. So much has changed so quickly, it’s stressful,” she says.

And several attacks on doctors and nurses across the country have made them even more worried. She says it’s difficult to understand why anybody would attack doctors. “We are saving lives, risking our lives every day. We need love, not fear.” she adds.

And even worse:

E.R. doc on COVID-19 ‘front lines’ died by suicide                             To show how serious the stress is seen in this report by Cory Siemaszko reported that a New York City emergency room doctor who was on the “front lines” of the fight against the coronavirus has died by suicide, police said Monday. Dr. Lorna Breen, 49, who worked at New York-Presbyterian Allen Hospital, was in Virginia when she died on Sunday, said Tyler Hawn, a spokesman for the Charlottesville Police Department.

“The victim was taken to U.V.A. Hospital for treatment, but later succumbed to self-inflicted injuries,” Hawn said.

It was her father, Dr. Phillip Breen, who revealed the first details about his daughter’s tragic death. “She tried to do her job, and it killed her,” he told The New York Times. “She was truly in the trenches of the front line.”

He said his daughter seemed very detached of late and that she had described some of the horrors she had witnessed at the hospital while battling the virus. “Make sure she’s praised as a hero, because she was,” Phillip Breen said. “She’s a casualty just as much as anybody else who has died.”

The hospital confirmed Lorna Breen’s death in a statement released by chief spokesperson Lucky Tran, but gave few other details. “Words cannot convey the sense of loss we feel today,” the statement said. “Dr. Breen is a hero who brought the highest ideals of medicine to the challenging front lines of the emergency department. Our focus today is to provide support to her family, friends, and colleagues as they cope with this news during what is already an extraordinarily difficult time.”

NewYork-Presbyterian Allen Hospital has 200 beds, is in northern Manhattan and is one of the seven hospitals that make up NewYork-Presbyterian Hospital.

Infectious Disease Expert Makes Chilling Prediction for States Reopening Amid Pandemic                                                                 Reporter Lee Moran noted that infectious disease expert Michael Osterholm warned that the states starting to reopen amid the coronavirus pandemic “will pay a big price later on.”

Osterholm, the director of the Center for Infectious Disease Research and Policy at the University of Minnesota, told CNN’s Jake Tapper on Thursday that states like Georgia, Colorado and others that are easing social distancing restrictions were “putting gasoline on fire.”

“I think right now, this is one of the things we’ve learned, if we’re going to learn to live with this, then you just don’t walk in the face of it and spit in its eye, because it will hit you,” said Osterholm. “And I think that that’s a really important issue right now,” he continued. “When we have transmission increasing, when our hospitals are not able to take care of it and we don’t have enough testing to even know what’s going on, then that’s not the time to loosen up.”

Osterholm suggested it was “the worst example of how to start this discussion” about the “loosening” of society. “I wouldn’t do it,” he added. “I fear that these states will have to pay a big price later on because of what they’re doing.”

COVID-19: National Psychiatrist-Run Hotline Offers Docs Emotional PPE                                                                                              Emily Sohn reported that Mona Masood, DO, a Philadelphia-area psychiatrist and moderator of a Facebook forum called the COVID-19 Physicians Group, reviewed post after post about her colleagues’ fears, anxieties, and the crushing pressure to act like a hero, inspiration struck. Would it be possible, she wondered, to create a resource through which psychiatrists would be available to provide frontline physicians with some emotional personal protective equipment (PPE)?

She floated the idea in the Facebook forum, which has more than 30,000 members. The response was immediate. “All these psychiatrists just started contacting me, saying, ‘Please let me be a part of this. I want to volunteer,’ ” she told Medscape Medical News.

On March 30, Masood launched the Physician Support Line, a free mental health hotline exclusively for doctors. Within the first 3 weeks, the hotline logged more than 3000 minutes of call time. Some physicians have called repeatedly, and early feedback suggests the resource is meeting a vast need.

“Most of the cases have a lot of emotion from both sides. There are a lot of tears, a lot of relief,” said Masood.

“If Not Me, Then Who?”

Physicians have been facing mental health challenges long before the pandemic, and doctors have long struggled with stigma in seeking psychological help, says Katherine Gold, MD, a family medicine physician at the University of Michigan, Ann Arbor, who studies physician well-being, suicide, and mental health.

As a whole, physicians tend to be perfectionists and have high expectations of themselves. That combination can set them up for mental distress, Gold notes. Studies that have focused mainly on medical students and residents show that nearly 30% have experienced depression. Physicians are also at significant risk of dying by suicide.

Compounding the issue is the fact that physicians are also often reluctant to seek help, and institutional stigma is one persistent reason, Gold says. Many states require annual license renewal applications in which physicians are asked questions about mental health. Doctors fear they’ll lose their licenses if they seek psychological help, so they don’t pursue it.

A study conducted by Gold and colleagues that analyzed data from 2003 to 2008 showed that compared to the general public, physicians who died by suicide were less likely to have consulted mental health experts, less likely to have been diagnosed with mental health problems, and less likely to have antidepressants in their system at the time of death.

The COVID-19 pandemic may exacerbate these trends, suggests a recent study from China in which investigators surveyed 1257 healthcare workers in January and February.

Results revealed that a significant proportion of respondents had symptoms of depression, anxiety, insomnia, and distress. This was especially true among women, nurses, those in Wuhan, and frontline healthcare workers who were directly engaged in diagnosing, treating, or caring for patients with suspected or confirmed cases of COVID-19.

As Masood watched similar concerns accumulate on the COVID-19 Physicians Group Facebook forum, she decided to take action. She says her mentality was, “If not me, then who?”

Assisted by a team of experts, she created the hotline without any funding but with pro bono contributions of legal and ethical work, and she received a heavy discount from a company called Telzio, which developed the hotline app.

The hotline is open daily from 8:00 AM to midnight Eastern Time, and calls are free. Services are available only to physicians, in part because as a group, doctors tend to harbor guilt about asking for help that someone else might need more, Masood says.

When other types of healthcare workers call in, volunteers redirect them to hotlines set up for first responders and other healthcare providers.

So far, more than 600 psychiatrists have volunteered. They sign up for hour-long shifts, which they fit in between their own patients. Two or three psychiatrists are available each hour. Calls come directly through the app to their phones. There is no time limit on calls. If calls run long, psychiatrists either stay on past their shifts or pass the call to another volunteer.

Since its launch, the number of calls has steadily increased, Masood says. Callers include ICU doctors, anesthesiologists, surgeons, emergency department doctors, and some physicians in private practice who, Masood says, often express guilt for not being on the front lines.

Some physicians call in every week at a certain time as part of their self-care routine. Others call late at night after their families are in bed. If indicated, psychiatrists refer callers for follow-up care to a website that has compiled a list of psychiatrists across the United States who offer telehealth services.

There are no rules about what physicians can discuss when they call the hotline, and popular topics have evolved over time, says Masood. In the first week after the hotline’s launch, many callers were anxious about what the future held, and they saw other hospitals becoming overwhelmed. They worried about how they could prepare themselves and protect their families.

By the second week, when more doctors were in the thick of the pandemic and were working long hours, sometimes alone or covering shifts for infected colleagues, there were concerns about coworkers. Some were grieving the loss of patients and family members. The lack of personal protective equipment (PPE), says Masood, has been a common topic of conversation from the beginning.

Given the many unknowns about the virus, physicians have also grappled with the uncertainty around safety protocols for patients and for themselves.

On a deeper level, physicians have expressed a desire to run away, to stop going to work, or to quit medicine altogether. These escape fantasies are a normal part of the fight-or-flight response to stress, Masood says.

Doctors often feel they can’t share their fears, even with family members, in part because of societal pressures to act like heroes on the front lines of what has been framed as a war, she adds.

Heroes aren’t supposed to complain or show vulnerability, Masood says, and this can make it hard for physicians to get the support they need. Through the hotline, psychiatrists give doctors permission to feel what they are feeling, and that can help motivate them to go back to work.

“They don’t want to look like cowards, because that’s the opposite of a hero,” she said. “Saying it to another doctor feels much better because we get it, and we normalize that for them. It’s normal to feel that way.”

Each week, Masood conducts debriefing sessions with volunteers, who talk about conversations filled with raw emotion. When conversations wind down, most physicians express gratitude.

They tell volunteers that just knowing the hotline is there provides them with an emotional safety net. Masood says many physicians tell volunteers, “I know that if anything’s going wrong, I can just call and somebody will be there.” Volunteers, too, say they are benefiting from being involved.

“We are all really having this desperate need to be there for one another right now. We truly feel like no one gets it as much as we get one another,” said Masood.

Long-term Fallout

The need for psychiatric care is unlikely to end after the pandemic retreats, and Masood’s plan is to keep the hotline running as long as it’s needed. Like the rest of the world, physicians are in survival mode, but she expects a wave of grief to hit when the immediate danger ends. Some might blame themselves for patient deaths or question what they could have done differently. The long-term impact of trauma is definitely a concern, Gold says. Physicians in the ER and ICU are seeing many patients who decline quickly and die alone, and they witness young, previously healthy people succumb to the virus.

They’re seeing these kinds of cases over and over, and they’re often doing it in an environment where they don’t feel safe or supported while people in many places stage protests against the measures they feel are helping protect them.

Like veterans returning from war, they will need to reflect on what they’ve experienced after the adrenaline is gone and there is time to think.

“Even when things calm down, it will be great to have resources like this still functioning that can help folks think back through what they’ve been through and how to process that,” Gold said. “Things are going to remind them of experiences they had during COVID, and they can’t predict that right now. There will be a need for the support to go on.”

Masood is optimistic that the pandemic will bring the issue of physicians’ mental health out of the shadows.

“We have a really deep feeling of hope that that there’s going to be a lot more empathy for one another after this,” she said. “There’s going to be a willingness to not take mental health for granted. Doctors are people, too.”

We understand about those on the frontline of this pandemic. But do you all realize that many physicians and nurses are being furloughed during this pandemic due to elimination of elective surgery, many of which are necessary such as transplants and cancer treatments and surgery as well as limitation of their practice during this pandemic.

How do physicians pay their malpractice insurance and pay their staff and overhead and their huge education loans?

I fear that we may see a mass quitting/retirement of many nurses and physicians in our country and maybe world wide or many suffering from PTSD (Post Traumatic Stress Syndrome).

What then happens to our healthcare system? Will this pandemic force Congress to finally get serious regarding improving our healthcare system for All?

The Biggest Losers

I ended the last blog hinting about the losers in this new health care program and was encouraged to pursue this discussion while reviewing two articles.

But let me first set things straight, as a strategic planner, the reason we are where we are is due to the lack of real research and planning. As much as I am not a President Obama fan, I really believe he and years before, Hillary Clinton, really believed what they were proposing was a good thing for the American people. I only object to the method that was chosen and the politicization, the lack of real research and planning with people in the know.

I comments in this last paragraph were further strengthened when I read the comments by the Speaker of the House discussing the Republicans mistakes and the lack of ability to overturn the health care law and the need to modify it and make it work. It was interesting to read that House Speaker John Boehner inadvertently revealed that repealing Obamacare “isn’t the answer,” and that “Republicans also need to offer a replacement.”

I also object to Harry Reed and Nancy Pelosi being so arrogant and closed minded in not allowing a non partisan discussion and resolution of difficulties to result in a bill which can “get the job done” efficiently and effectively for all the American people.

This has become a political ping-pong ball and shows that our elected officials really don’t care about Middle America especially and also points to the necessity for term limits.

Jonathan Bernstein wrote that“ The challenge is that Obamacare is the law of the land. It is there and it has driven all types of changes on our health care delivery system. You can’t recreate an insurance market overnight…. So the biggest challenge we are going to have is—I do think at some point we’ll get there—is the transition of Obamacare back to a system that empowers patients and doctors to make choices that are good for their own health as opposed to doing what the government is dictating they should do.”

This is interesting to me due to one of my previous blogs and the strategy that needs to be embraced- getting over the repeal idea and instead find ways to make the law work.

Think about the question that I posed at the end of my last blog-Who are the Biggest Losers? Byron York in his latest Op-Ed piece notes that Obamacare losers are harder to discern. I think not! He finally noted that “The plans being offered through the exchanges in 2014 appear to have, in general, lower payment rates for providers, narrower networks of providers, and tighter management of their subscribers’ use of health care than employment-based plans do.” The Congressional Budget Office (CBO) said “These features allow insurers that offer plans through the exchanges to charge lower premiums (although they also make plans somewhat less attractive to potential enrollees).”

The health care analyst, Bob Laszewski, questions who is harmed and points out that “when carriers converted their old policies to Obamacare-compliant policies, it was typical for the insurance company to increase costs about 35%” and “That increase could come in the form of higher premiums, more co-pays and deductibles and narrower networks.” This is what we are seeing in that enrollees are facing higher premiums and higher deductibles, which add up to a total higher cost, as well as a narrower choice of hospitals, doctors and prescription drugs than they had before. Therefore, what we are finding is that health care is becoming a more expensive and troublesome system.

Rick Newman in his article in The Exchange (April 25, 2014) points out that there are three subsets of people whose policies were canceled and then are the posers under the Affordable Care Act (ACA): people who are self-employed, those over 35, those who are white, or some combination of all of these three.

The biggest losers to ACA are the people who lost their insurance coverage but are unlikely to qualify for subsidies through one of the exchanges, which require an income of less than $47,000 for an individual or $95,000 for a family of four. Some of these people who lost insurance coverage report paying twice as much with deductibles of $4,500-$7,500 or more. It was interesting that Mr. Newman pointed out that it so happens that these groups so impacted negatively tend to be Obama’s political opponents.

Do the insurance companies lose? In a previous blog I pointed out that WellPoint was planning to increase their premiums and now I read that CEO of Aetna, Mark Bertolini, stated that their premium increases would range from low single digit to double digits, based on its first quarter earnings. So the insurance companies never lose. The have to make a profit and usually the profit is much larger than the proposed profit margins that the committees and government departments are demanding for health care facilities.

Ethan Rome (The Truth About Health Insurance Company Profits: They’re Excessive) reviewed health insurance company profits and went on to further review the American trade group American Health Insurance Plan’s (AHIP) focus on profit margins which he thought was misleading when they quoted 4.4%, and designed to protect their massive income by shifting attention away from their return on equity — a key measure of profits as a percentage of the amount invested. “That return is a phenomenal 16.1% as of today. By that measure, health insurers are ranked fourth highest of the 16 industries in the health care sector. They also deliver a higher return for investors than cellphone companies, beer companies, mortgage companies, life insurance companies, TV broadcasters, drug store companies or grocery stores.”

In May 2011, the New York Times reported “the health insurance industry is enjoying record earnings while millions of Americans get less medical care. Wall Street investors are delighted with the industry’s profits, and to health insurance executives, that’s all that counts. Insurance CEOs want investors to buy their stock and keep share prices marching higher, and that’s exactly what has happened. To achieve excessive profits, insurers are happy to gouge consumers and small businesses, do little to rein in medical costs and spend billions of our premium dollars on lobbying, secret political activities, bloated executive pay and stock buybacks.”

How about the greedy doctors? Are they losers? In the beginning and for quite a while they will lose as they have for years as their reimbursements (what they are paid by the insurance companies and the government, i.e. Medicare and Medicaid) are further discounted. But they will not be able to keep their offices open unless they become employees of the hospitals, universities or convert to boutique type practices. The boutique practices will charge patient fees to become practice members and or start to do procedures that they are not trained for and for which the complication rate will be high. But the added income will be necessary to maintain their overhead expenses.

Having insurance policies that include $5,000- $7,500 deductibles means that almost all health care needs, office visits, tests and surgery will be out of pocket expenses. How does the new plan then encourage good health care behavior and encourage preventative care?

Yes, the uninsured, if they fulfill the requirements for the government subsidies, will get coverage, but who will take care of these patients and cane you change their “bad” behavior? Will we have enough doctors to provide care and what type of care will be provided? I will discuss these topics further in future blogs.

Let us also consider who is in control of the ACA and what their history predicts. These are the same government systems that have control of the problematic Medicare, Medicaid and Veteran health systems. Remember what we have been hearing about concerning the Veteran Administration Health Care problems in the last few weeks. Long waiting times, poor care, lack of care, deaths, suicides, etc. What then can we expect for the future control and management of the ACA?

Let’s Look at the Equation Again

This past week I was interested in a front-page article in our local paper-Rural healthcare lags behind. What does that mean and how does the Affordable Care Act (ACA) affect areas like the Eastern Shore of Maryland as well as other rural areas of this State and around the country?

There are other areas in similar to the Eastern Shore of Maryland where the rural population consists of a large Medicare and Medicaid patient population needing health care.

Isn’t this why ACA was designed? The article describes these areas as challenges of providing health care where the patients are very sick and the resources, which are very scarce. These areas are lacking health care providers contributing to health disparities that include higher rates of heart disease and obesity and lower life expectancy. The author, Megan Brockett, compares the situation is akin to a “Third World country.”

Maryland is especially problematic in that in the national 2014 County Health Rankings released by the Robert Wood Johnson Foundation and the University of Wisconsin Population Health Institute, found that five of the 10 least healthy jurisdictions in Maryland are considered partially or completely rural by federal standards and three others in the bottom 10 fall under the state’s broader definition of rural. The article further points to the lower rankings in health care outcomes.

The experts and advocates link the disparities to the scarcity of health care providers in these rural areas and the decreased access to care. The ratio of primary care providers to residents is horrible from a best-case scenario of 1 in 1,056 – to the worst case of 1 to 2,915.

“As a result, people living in rural areas often have to travel long distances for health care, a disincentive to getting even the basic preventative care they should be receiving.” Now add the additional burden of high deductibles, where the patient has a higher out of pocket expense in their health care.

Ms. Brockett goes on to point out that the rate of specialty care providers is worse in the rural areas through out the state. And the effects are seen regularly in the clinics around the state.

Much of the campaign to improve the situation centers on efforts to recruit and retain health care providers to practice in these rural communities and the workforce shortage in rural areas is the biggest barrier to care.

This article is so interesting to me, a specialist practitioner, who practices in one of the state’s rural areas. I have had my billing agency beg me to move my practice out of the rural area to increase my reimbursements by 17-20 %. This is true in a state, which is so backward in that they have demographic areas that pay the physicians at a lower rate than a county/ areas 30 to 45 minutes away. Why would any new physician graduating with a debt in loans of on average of $325, 000 want to practice here where they may never be able to pay back their debts?

Do we get a break in malpractice premiums or practice overhead in the rural areas? No and No.

So, why would any new practitioner want to come to one of the rural areas in Maryland or in any rural area in the US?

Nothing will change regarding the practitioner to patient ratio to acre for the additional enrollees until the educational costs and tort reform is reality.

Another article appeared in The Week magazine, April25, 2014, Page 12 by Daniela Drake-Why doctors are so unhappy. It is a summary of her review in The Daily Beast, starting with the quote “Being a doctor has become a miserable and humiliating under taking.” She states something those of us who went into medicine 20-30 years ago, that “caring for the sick used to be the country’s most prestigious and admired professions.” However, today an emotion that I feel almost daily, that America has declared war on physicians and yes I continuously attempt to discourage others from entering the practice of medicine.

Not only primary care physicians, but also all physicians toil thanklessly in a hectic, unsatisfying profession, which is dominated by the insurers, politicians and their agencies, and malpractice attorneys. We physicians work long hours cramming in more patients than reasonable, 20-30 per day because of regulated fees and the cost of filling out insurance forms, which averages $58 per patient. Right now without all the added enrollees secondary to the ACA the average patient visit lasts 12 minutes. What information, what type of diagnosis can be made in that short period of time?

It is amazing to me that no one challenges the “salaries” that actors or professional athletes make, however they try to make doctors feel guilty when they make money. Do you think that it costs nothing to run a practice with electronic medical records. computers, specialized staff of nurses, billing personnel, etc.?

Patients question and try to make doctors feel guilty about changing their practices to boutique or concierge type of practices. However, more and more physicians will need to convert their practices to this type of practice as the government further discounts physician’s reimbursements and deductibles rise or face bankruptcy or early retirement.

Affordable health care will add more bureaucracy and pressure to cut costs and make it more expensive to maintain their practices. Health care providers, doctors, nurses, nurse practitioners, physicians and the hospitals will be losers in the future of the new system. Who are the other losers? I will delve deeper in the “losers” of ACA or Obamacare. Can you think who will be the “Biggest Losers?”

Doesn’t anybody care except the perceived “rich” doctors?

Again I say, wake up America! We need to have a system that understands what it takes to have a truly affordable health care system that is sustainable and fair to all.