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Monday, April 29, 2013

Health Reform, ACA, Medicaid, Congress and the Edsel


Time is marching on towards January 2014, the next date for implementation of the major stages of the Affordable Care Act.  There are those who live in denial hoping for the best and those who realize the tsunami is on it’s way.  Like Tsunami’s the water rushing out does more damage than coming on shore.’

The initial incoming wave will be the increase of previously uninsured entering the system.  Not only will there be more patients, they will be the sickest with more problems, more chronic illnesses, previously undiagnosed, untreated and at more advance stages of their illnesses.


As the wave rushes in it will inundate the health system, peak and then rush out, sucking with it the vestiges of the old system.  There will be many innocent bystanders, rich and poor, and only the ones standing on the highest ground will not be effected.

Avik Roy, who writes for The Apothecary opines

The Apothecary is  a blog about health-care and entitlement reform.


Congress, Fearing 'Brain Drain,' Seeks to Opt Out of Participating in Obamacare's Exchanges

Exchanges are crucial to the future of health reform

The idea was simple: that if Congress was going to impose Obamacare upon the country, it should have to experience what it is imposing firsthand. But now, word comes that Congress is quietly seeking to rescind that provision of the law, because members fear that staffers who face higher insurance costs will leave the Hill.

While I have many friends who work for Congress, and I wish them well, it is absolutely a good thing that members and staffers are enrolled on the exchange. It is vital for these individuals to experience, first-hand, how Obamacare’s costly mandates and regulations will drive up the price of health insurance. Staffers will, in particular, be affected by Obamacare’s “community rating” provision, which jacks up the cost of insurance for young people. (Most Hill staffers are in their twenties and early thirties.)

Sen. Grassley’s original idea was to require all federal employees to enroll in the exchanges, instead of in the Federal Employee Health Benefits Program, where most gain coverage today. Indeed, a previous Senate Finance Committee amendment proposed putting members and staffers on Medicaid. But “fierce opposition from federal employee unions” sank Grassley’s effort, and he had to water his amendment down to only apply to Congress and congressional staff.

Even those in CMS are worried;

CMS on Obamacare's Health Insurance Exchanges: 'Let's Just Make Sure It's Not a Third-World Experience'

Increasingly, officials in the Obama administration are worried that the rollout of the exchanges will be chaotic, given the law’s complexity and unrealistic deadlines. “We are under 200 days from open enrollment” on the exchanges, noted Henry Chao, deputy chief information officer at the Centers for Medicare and Medicaid Services, at a recent conference. “I’m pretty nervous—I don’t know about you.”

Rate shock is a bigger danger than implementation

It’s almost certain that the rollout of the exchanges will be choppy, in terms of the user experience, the Byzantine application process, and the degree to which insurance plans are capable of formulating their products on time, given how late HHS has been at giving regulatory guidance to carriers. But while exchanges are complicated to set up, it’s not an impossible task; after all, Massachusetts has had an Obamacare-like exchange for years.

“In some markets,” said Aetna’s CEO, Mark Bertolini, insurance premiums could increase “as high as 100 percent. And we’ve done all that math. We’ve shared it with all the regulators. We’ve shared it with all the people in Washington that need to see it. And I think it’s a big concern.” Privately and publicly, most of Bertolini’s peers at UnitedHealth, WellPoint, Humana, and Cigna have said the same thing.

It seems incredulous that  Congress would invoke a “WalMart’ feature to insure those who work for our federal government.  Imagine the most powerful nation in the world insuring their government workers through medi-caid. 

Medi-caid has such a bad name that no matter what was done to it it’s still the Edsel of health systems.


What is in a name?  Sometimes everything.


Sunday, April 28, 2013

Well Healed ? Turf War


SACRAMENTO — Obamacare is supplying fresh ammunition for one of the oldest turf wars in Sacramento.

It pits doctors — represented by the politically powerful California Medical Assn. — defending their turf against other medical providers. They're nurse practitioners, optometrists and pharmacists.

In an article published in the Los Angeles Times by George Skelton he describes a ‘turf war’ breaking out over the monies the Affordable Care Act will govern.

The effects will certainly be inflationary, which is what every federal program creates, rather than diminishing expenses.

Contrary to what Mr. Skelton asserts that  the ‘well heeled doctors “ are holding their ground, the opposite is true.  Firstly the  docs are not well healed, after a ten year losing battle with insurance and medicare reimbursement cut backs and restrictions and the never ending increase in bureaucracy, chaos and confusion caused by the affordable care act. 

When the act kicks in next January, most Americans will be required to buy health insurance or pay a penalty.

In California, that is expected to swell the insurance rolls by 4 million to 5 million people. (About 7 million currently are uninsured, but that includes illegal immigrants, who won't be eligible for Obamacare.)

There simply won't be enough doctors to care for all the newly insured, contend the turf invaders.

But now the nurse practitioners, optometrists and pharmacists are attacking all-out, fighting for a larger chunk of the action to be funded by Obamacare, officially called the Affordable Care Act.


Bottom line……….More providers….more cost. Using telehealth and telemedicine as well as remote monitoring most of these tasks can be done remotely. Including

1. Electronic stethoscope

2  EKG

3  pO2

4. Vital signs

5  Blood glucose levels

6 Others in development using nanotechnology and microchips.

Location: Almost anywhere with a cell phone connection or internet


1.Little upfront cost

2 No additional provider licensing requirements

3. Assure one standard of care

4. Could be integrated into academic teaching programs.

There are cost effective means to expand accessibilty to primary care. CMS needs to open the door for effective reimbursements either on a per case basis or a flat fee model using a monthly schedule. There will be secondary gains, including fewer admissions to hospitals.


Tuesday, April 23, 2013

Have Physicians lost their MoJo ?



Medical decision making is a complex process, poorly understood by non physicians, and often judged inaccurately by non peers. 

In today’s world changes are gradually occuring which erode physician confidence, and in some cases impinge upon moral and/or ethical decisions.

Twenty years ago we rarely heard of ‘disruptive physicians’ although I am sure there were many.  At that time it was   politically incorrect to  point out or collar the “offensive physician”, and the ‘whistle blower’ would face further embarassment or even official reprimands.

Medical trainees today are taught to be polite to handle conflict and ‘insubordination’. Certain behavior in an academic medical center may not be acceptable in the ‘real world.

Certain enlightened academic  department heads can deal effectively with their trainees… Community hospitals should have in place process on dealing with disruptive physicians to remediate disruption and also to be certain that prohibited substances, alcohol or misappropriation of prescription medications are not a factor.


Physicians often see problems at their workplaces relating to patient quality of care, financial practices, mistreatment of staff, and other issues. But as more doctors take jobs as employees of hospitals, medical groups, and other large organizations, they increasingly face the same dilemmas as millions of other working stiffs. 

Across the country, a growing number of physicians are indeed losing their jobs -- and often their hospital staff privileges -- after protesting employment conditions. Such complaints may involve patient quality-of-care problems, short staffing, misallocation of funds, improper financial incentives, fraud and abuse, discrimination, overuse or withholding of medical services, or other misconduct.

When they come across actions or policies that they don't think are right, they have to decide whether it's worth it to speak out and get labeled as a troublemaker -- or perhaps even get fired.

Physicians should communicate their concerns to their employers as professionally and objectively as possible through official channels, such as their medical staff organization or medical group, experts say. But physicians sometimes don't take the ideal approach and risk getting labeled as disruptive personalities or troublemakers.

2. Be careful how you express yourself

3.There is no guarrantee the outcome will be successful even in the most ideal situation

4. Does vindication make it worthwhile?

5. Still there are some limitations .

The employer (group) holds the upper hand and when the provider signs a contract the physician should realize that fact.

The AMA statement explicitly accepts that physician employment contracts may allow hospitals to strip doctors of their medical staff membership and clinical privileges at the same time they are terminated, known as a "clean sweep" clause. "If that's accepted by the AMA, the rest of the principles protecting physicians are meaningless," he argues. "If physicians can be fired without cause and then automatically lose their medical staff membership and its due process protection, how many will dare be a patient advocate?"

Some experts advise physicians not to sign employment agreements with such onerous provisions. But others say that physicians often have little leverage to remove them. "It's not an equal negotiating table," says Dr. Gatrell, who's now working for a small urgent care practice.

Attorneys who represent physicians in such cases say that doctors need to think hard before they do stand up. Massachusetts attorney Peter Noone represents Veterans Administration staff physician Anil Parikh, MD, who was fired in 2007 after he disclosed confidential patient information to members of Congress out of concern over what he viewed as poor-quality care at the Jesse Brown VA Medical Center in Chicago. Dr. Parikh won a 2011 decision by the federal Merit Systems Protection Board that reinstated him on the basis of the federal Whistleblower Protection Act.

And that reminds me what my father told me, a long time ago….”Life is not fair'”

NEXT:  I work so hard, and I am penalized so often…………



What Happens if Healthcare Reform Really Works


Most of us who are physicians often wonder how and if the ACA will reach it’s intended goal of more universal coverage.

It also runs the risk of not working, or working and having other non intended consequences.

By James Doulgeris

Even modest achievement of the triple aim of decreasing costs, improving outcomes, and improving patient experience creates an uncomfortable economic conundrum.

Let’s set some real and doable goals over the next several years for the sake of argument: Cut just a quarter of the obvious waste in the system by eliminating duplication of tests and services by coordinating care, move the dial a little on the cost of treating chronic disease, modestly impact negative patient behavior and eliminate just half of the unnecessary ER visits, hospital admissions, and hospital readmissions.

In summary, we’re cutting a quarter of the waste in healthcare, or $190 billion per year, and getting a handle on chronic disease, cutting its cost by just 10 percent, saving another $210 billion a year after accounting for the eliminated waste, for a total of $400 billion per year.

Here’s what happens:

The overall healthcare spend would shrink by 13.3 percent. The entire U.S. economy would take a direct hit of 2.2 percent, and an indirect hit of nearly two percent. With growth at about one percent, that is a net 3.2 percent drop in the Gross National Product, far worse than the Great Recession.

Unemployment would soar by nearly two percent, or almost 2 million of the over 20 million direct healthcare providers plus million or so indirect workers. All told, that is about 1.9 percent of the entire workforce.

But, that’s only half of the story. As we saw with the federal budget sequester, the predicted apocalypse was more akin to a non-event. Two factors ameliorate the impact of shrinking the country’s total healthcare spend and one is a wild card:

Here are some possible positive outcomes:

The ACA puts somewhere north of ten million newly insured people into the system who, as happened with Medicare, will consume far more services than projected; and,

The savings, thanks to the ACA’s 85 percent rule forcing a return of unspent premiums to the private sector, are put back into the economy, offsetting much of the impact.

The wild card is the Federal and State governments, which must do two things:

Not tax the unspent premiums to allow the money to go directly into the economy and,

Apply its savings to reduce the deficit, taxes or both.

It will still negatively affect the economy in the short term, but it is likely to save it in the long term.

If the government commits to real reform and to what it will do with its windfall, the light at the end of the healthcare tunnel will be sunshine.”

Interesting thoughts, is this a win-win  or a lose-win or maybe even a lose-lose…My bet is it will be another ‘non-event’ like the sequester. 

Monday, April 22, 2013

Should You do More than One Thing at a Time?


Certain physician specialties lead to decreased physical activity, boredom, and may even create dumbness.  This is true of many occupations and doctors are not immune.

Radiologists, pathologists, anesthesiologists, psychiatrists, medical directors, and a few others are less mobile and tend to be less physically active during their work days.

Scientists discovered that when we sit all day, "electrical activity in the muscles drops… leading to a cascade of harmful metabolic effects," and sadly even getting regular doses of exercise doesn't offset the damage. But now there's new evidence of the harm of sitting. Not only is it making you fatter, it might also be making you dumber.

Sabine Schaefer, a researcher at the Max Planck Institute for Human Development in Germany, recently looked at the effect of walking on working memory. Your mother may have warned you not to walk and chew gum at the same time, but when Schaefer compared the performance of both children and young adults on a standard test of working memory when they were sitting with when they were walking, her results contradicted mom's advice. The British Psychological Society's Research Digest sums up the research results:


The headline finding was that the working memory performance of both age groups improved when walking at their chosen speed compared with when sitting or walking at a fixed speed set by the researchers. This was especially the case for more difficult versions of the working memory task, and was more pronounced among the children than the adults. So, this would appear to be clear case of mental performance actually being superior in a dual-task situation.

What type of activities do you perform that allow ‘duality of thought and exercise during your work day?


Of course, not every mental activity can or should be performed while walking, but this new research reinforces anecdotal evidence and other research findings that suggest being too tightly chained to our desks is bad for our minds as well as our physical health. Science shows we often have creative breakthrough when our minds are disengaged from the problem we're wrestling with, hence the common experience of getting great ideas while relaxing in the shower.

My next blog will be outlining these steps which should make you wiser, less dumb and perhaps even less fat.

This topic has some opposite opinions which I will discuss next time.  What activities do you use?


Friday, April 19, 2013



Perhaps  the term “Health Insurance”  has become an oxymoron. Health Insurance now has become a waste-basket term that encompasses many different categories for medical bill reimbursement.

McCallister retiring Jan. 1Bruce Broussard, CEO of Humana Inc..

Here's what Humana's CEO has to say about the future of health insurance.

“The health care system of the future will likely come with fewer guarantees,In other words, rather than offering a health plan, employers will probably begin offering specified payments and telling their employees to buy their own insurance.

“Our role becomes a role around health more than just the financing of health care,” he said.

“What happened to retirement is probably going to happen to health care, The shift, from defined-benefit to defined-contribution plans, is exactly what happened when 401k retirement accounts replaced pensions.”

Broussard’s forecast reveals that the insurance companies no longer think of themselves as insurers based upon risk.  Risk is being removed from the underwriting of health events.

Broussard and the others in the C-suites of health insurance companies have a crystal ball far more accurate than the Washingtonians and academicians who don’t have a clue as to what the ACA is doing and will do in the next decade.

In one full swoop Congress has entangled the entire federal government and state governments in delivering health care, along with commerce, defense, and international relations. 

I have ‘such a headache' !”

Did President Obama miscalculate ?


Thursday, April 18, 2013

Celebrate the Success in Improving the Lives of Patients with Cystic Fibrosis


Each year the Cystic Fibrosis Foundation reaches out and has been successful in raising funds for research in cystic fibrosis to develop treatments for this terrible disease. And the progress has been enormous since 1990 in diagnosis, locating the exact gene that regulates the chloride transfer gate in the cell walls of the lungs and intestinal mucosa.

The extent of this fatal genetic flaw reaches far beyond what I can say in this blog. Cystic fibrosis kills slowly…first by starvation and wasting, and then by pulmonary insufficiency.  It is not a pleasant sight to watch a child to fail to thrive, struggle to breathe, and eventually look like a victim of famine.

There is no cure, but these successful treatments have increased the average life expectancy from 12-16 years old in 1990 to 37 in 2013. This generation has benefitted beginning in 1993 with the development of a genetically engineered enzyme that liquefies thick mucus in the lungs, and also enzymes that allow fat and proteins  to be digested and absorbed in the intestinal tract.

Cystic fibrosis is a family disease, not just by inheritance but also how it affects the finances, daily living, and resources for brothers, sisters and parents.  Untreated, it leads to a quick death, yet prevention is a daily task which can be very successful in significantly improving the quality of life for those with CF and their loved ones.

Robert J. Beall, PhD, President of the CF Foundation tell us,

“Last year was an incredible year at the CF Foundation. People like you have shown their support and dedication to finding a cure for CF. Your generous support paved the way for the groundbreaking treatment, Kalydeco™ , the first drug to treat the underlying cause of CF.

While Kalydeco is effective for about 4 percent of patients who have a specific gene mutation, this advance brings hope to all people with CF. Kalydeco has provided us with a “road map” that is already leading to the development of more promising treatments for all with the disease.

We have made real progress toward a cure, but our work is far from over.
We will not rest until a cure is found for all people with CF.
Right now, we are expanding our research partnerships with biopharmaceutical companies and laying the groundwork to develop new therapies.

As we continue to pursue every opportunity to help develop new lifesaving therapies for people with CF, it is more important than ever that patients can access these treatments. The need for our advocacy and patient assistance programs has never been greater.
To make sure that critical research and care initiatives continue we have set an ambitious goal for the 2013 Annual Fund: $2.5 million.”

Each year in localities near you there is a ‘Great Strides’ for Cystic Fibrosis Event. It is a wonderful opportunity to sponsor or be sponsored and keep fit while creating donations for the Cystic Fibrosis Foundation.  For specifics you can go to the registration page and log in.

Help make progress possible. Please join Partners in Progress.


Fitness and the Internet



Do you sit in an office chair for more than six hours a day? If so, your risk of heart disease has increased by up to 64 percent. Some users who are required to be on the internet most of the day use a stand-up desk and can walk or exercise in place. These handy add-ons will help remind you to get up and move around!

Mobile health applications have been around for some time already. Nike has their own remote monitoring devices, such as FitBit as well as several other provide incentives for exercise and fitness.

Mozilla has entered the arena now as well, with the announcement of several new browser add ons for their Firefox Web Browser that remind the user that it is time to take a break from computing.

Consider this, from the software developers at Firefox

“We are now a world of people who are plugged-in 24/7. We’re always looking at our computer screens and our mobile devices. It helps us stay informed, educated and entertained, so it’s a good thing!

But more and more stories are coming out in the media about how bad it is to sit at our computers/devices all the time. We need to stay active!

Guess what? Firefox gives me (and you) solutions, built right into my browser. That makes it easy to do something about it!

The easiest option is an add-on called Simple Timer. It is super customizable and allows you to select when you want to receive a notification. You can set as many as you want. I set it up to alert me every hour as my reminder to get up!

Then there’s the Take a Break add-on which flashes a little icon every 15 minutes to remind you to take a mini break – close your eyes, look away from the screen, etc. Then a pop-up box will remind you to take a bigger break each hour to stretch, get a drink of water, etc. You can adjust the timers to suit your schedule.


If you’re like me, you know you need to take a break but you don’t know what to do with yourself. That’s why StretchClock holds a special place in my routine. Not only do you get an hourly (that’s customizable) alert, but it gives you a suggested stretch or exercise to get that blood flowing!


Courage in Sports: Jerry Cahill - YouTube : CysticFibrosis

Courage in Sports: Jerry Cahill - YouTube : CysticFibrosis

"You cannot fail ! "

Wednesday, April 17, 2013

News-Analytics or Newsana


The impending demise of google reader has stimulated us to search for other sources of breaking newsworthy subjects.-`

Health Train Express and Digital Health Space curate news from many independent blogs, health publications, foundations, information technology well as official government sources.

We are pleased to announce we have been invited to join Newsana (beta). Newsana opens an entirely new and rich interactive resource for our readers.

In the next several weeks you will see content from Newsana. At the same time we will be feeding our blog postings to Newsana.

You may also request an invitation to the Newsana (beta). I invite commentary about our new relationsip with Newsana.


Gary Levin MD  Founder & Publisher


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Monday, April 15, 2013

Patient Centered Reception Areas


I don’t think many patients could resist interfacing with this ‘art’. They might even forgive the long wait to see their physician.


I cannot and won’t add much to this beautiful digital art.


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Sunday, April 14, 2013

Where is Your Center ??




The patient is the center of our universe. Although pundits and bureaucrats emphasize this,  many of their edicts and actions run counter to this proposal.

I remember an event in residency when after a long night on call, one of my junior residents was complaining how tired and angry he was with patients calling in during the early morning hours with what he thought were ‘spurious’ and unnecessary calls.  Granted he and many of us were doing every other night call and working over 100  hours/week. (back in 1977).  

As it turned out the head of our department overheard his complaints about “foolish calls’ from patients.

It was as I like to call it ….a Bob Hope Moment’  as written in The Laugh Makers.

Our chief came back with his one liner, “That is why you have a job !”

For my junior resident it was probably a scary moment to be caught in the act of disparaging a patient in need.  For me it was a poignant moment in training which has  stayed with me for over 30 years of medicine.

It was my introduction to ‘Person-Centered Healthcare’, in 1976 long before the current shift from disease centered management to patient centric healthcare.

In an outpatient environment it is easier to maintain patient centered care and management.  In an inpatient setting it is far more difficult.  In the hospital environment compressing activities into a limited time frame is mandatory. Patients cannot just drop in for an MRI, lab work, or surgery.  Medical emergencies occur more often in hospital and the most critically ill patients are placed in an ICU so that their level of intense care is isolated and does not impact more routine hospital care.

Medicare and payers limit hospital length of stay according to diagnosis and/or procedures. Inpatient stays that are in excess of a standard length are not reimbursed, and require additional paper work for authorization and payment.

The centricity of patient care in the hospital requires some additional steps for providers, and their extenders (nurses, therapists, administrative clerks and others who have contact with a patient.  Many of these requirements apply to other businesses, and in many cases hospitals have adopted these subtle techniques.

Patients by and large are very unfamiliar and anxious about hospital admissions.  Anxiety can affect outcomes, if excessive.   Frequently patients may exhibit the worst of their personalities under this stress, requiring additional time on  the part of staff.

It helps me to remember

1. No one wants to be ill (even addicted drug dependent patients).

2. No one wants to go into a hospital, except perhaps to give birth, and then there is anxiety about pain, and a healthy newborn.

3. Illness brings out strange behavior in patients, that can only be measured in relation to the perceived threat by the patient.

4. I would be out of my job were it not for ill people. 

5. Few people will pay to stay well even though most of preventive medicine is relatively inexpensive. 

       a. Good nutrition, balanced diet, special attention to nutritional   

       requirement of some diseases, ie diabetes, hypertension, cystic


       b. Routine exercise programs, with special attention to

           physical challenges

       c. Risk evaluation for a patient related to family history, genetic    

           profile, and past medical history.

       d. Emotionally balanced life style.

6. The realization that Most of my stressors  are not driven by patient demands, but from bureaucrats, and payers. In other words it is not the patients’ actions causing difficulty.

Saturday, April 13, 2013

Direct Pay and Concierge Medical Practice


Many physicians as they continue to practice medicine in an increasingly hostile environment attempt to remove aspects of their business which increase work loads at diminishing yields. I use a term coined by T. Boone Pickens (the Oil Entrepreneur who now favors recyclable energy sources, such as wind, and solar power)

He coined the term “PEAK OIL” which defines the point at which it takes more energy to find, drill, and extract oil than the energy yield from the oil.

Health care and medical care has also reached “PEAK HEALTH”

Increased administrative costs are bleeding our health system, not just for Medicare and Medicaid but private insurance and private practices.

Some physicians eliminate much of the insurance bureaucracy by refusing to accept insurance companies. They accept only direct pay…via cash, credit cards, checks or barter.  By refusing to accept Medicare/medical/ and insurers many regulatory requirements no longer apply

In addition to direct pay many communities will have access to a cooperative payment method based on direct pay and administered and controlled by your local community.

MedAccess USA will provide such a structure. It is currently in development with a planned roll out in January 2014.

How would a Direct Care Practice Work For You?

The Direct Care Consulting Calculator

will analyze the results for your practice if you convert a portion or your entire practice to direct pay.

Instructions: Follow the three simple steps.

  • Step One is about your current practice
  • Step Two is about how many Direct Care Patients YOU want in your practice
  • Step Three is to calculate the Revenue Numbers

    Some Physicians choose to enhance their annual revenue by adding a per visit fee or a per minute fee for patient visits. Contact us Today! To learn how you can price your practice!

  • MedAccess is recruiting providers interested in enrolling in the cooperative. There is no obligation. Contact MedAccess at  Also please support our effort to develop a CMS direct pay model by contacting your Congressman and ask  them to support Congressman Alan Grayson’s letter to CMS innovation program on Direct Pay and MedAccess.