Rapper, Internist ZDoggMD on the 'Hard Doc's Life'

 In this segment of Medscape One-on-One, Editor-in-Chief Eric J. Topol, MD, interviews Zubin Damania, MD, a practicing internist who uses musical parody as a clinical teaching tool and to bring attention to the concerns facing practicing clinicians. Performing under the name ZDoggMD, Dr Damania has used music to broach many topics from conveying the need for a more humane approach to end-of-life care to the frustrations of using a less-than-intuitive electronic health record (EHR) system.

After spending 10 years in the "Hard Doc's Life" working as a hospitalist in the Silicon Valley, he was lured to Las Vegas by Zappos CEO Tony Hsieh, a former classmate of Dr Damania's wife. There, Dr Damania founded Turntable Health as part of Mr Hsieh's $350 million investment to revitalize downtown Las Vegas.

Rapper, Internist ZDoggMD on the 'Hard Doc's Life'

Many Say High Deductibles Make Their Health Law Insurance All but Useless - The New York Times

 Obama administration officials, urging people to sign up for health insurance under the Affordable Care Act, have trumpeted the low premiums available on the law’s new marketplaces.

But for many consumers, the sticker shock is coming not on the front end, when they purchase the plans, but on the back end when they get sick: sky-high deductibles that are leaving some newly insured feeling nearly as vulnerable as they were before they had coverage.

“The deductible, $3,000 a year, makes it impossible to actually go to the doctor,” said David R. Reines, 60, of Jefferson Township, N.J., a former hardware salesman with chronic knee pain. “We have insurance, but can’t afford to use it.”

In many states, more than half the plans offered for sale through HealthCare.gov, the federal online marketplace, have a deductible of $3,000 or more, a New York Times review has found. Those deductibles are causing concern among Democrats — and some Republican detractors of the health law, who once pushed high-deductible health plans in the belief that consumers would be more cost-conscious if they had more of a financial stake or skin in the game.

“We could not afford the deductible,” said Kevin Fanning, 59, who lives in North Texas, near Wichita Falls. “Basically I was paying for insurance I could not afford to use.”

He dropped his policy.

Sylvia Mathews Burwell, the secretary of health and human services, issued a report analyzing premiums in the 38 states that useHealthCare.gov. “Eight out of 10 returning consumers will be able to buy a plan with premiums less than $100 a month after tax credits,” she said.

But in interviews, a number of consumers made it clear that premiums were only one side of the affordability equation.

Exceptions, waivers and options are not known by most ACA enrollees.

Tax Credits are a false incentive for many enrollees

Many are in a category with income low enough they do not pay taxes, however if they have withold from their payroll they would be entitle to a full refund of their witheld taxes.  However, these refunds do not become available until after the early months of the following year. For the initial year of enrollment there are no excess funds for tax credits.

Health officials and insurance counselors cite several mitigating factors. All plans must cover preventive services like mammograms and colonoscopieswithout a deductible or co-payment. Some plans may help pay for some items, like generic drugs or visits to a primary care doctor, before patients have met the deductible. Under the Affordable Care Act, health plans must have an overall limit on out-of-pocket costs, to protect people with serious illness against financial ruin.

In addition, people with particularly low incomes can obtain discounts known as cost-sharing reductions, which lower their deductibles and other out-of-pocket costs if they choose midlevel silver plans. Consumer advocates say this assistance makes insurance a good bargain for people with annual incomes from 100 percent to 250 percent of the poverty level ($11,770 to $29,425 for an individual).

Dave Chandra, a policy analyst at the liberal-leaning Center on Budget and Policy Priorities, has some advice: “Everyone should come back to the marketplace and shop. You may get a better deal.”

White House Details Privacy Rules for Precision Medicine Initiative - iHealthBeat

On Monday, the White House unveiled a series of privacy principlesfor President Obama's precision medicine initiative, FierceHealthITreports (Hall, FierceHealthIT, 11/11).

Initiative Details

In February, Obama in his fiscal year 2016 budget proposal asked Congress for $215 million in funding for a precision medicine initiative that centers on the creation of a massive database containing the genetic data of at least one million volunteer participants. A panel of experts in September endorsed the plan for creating the database (iHealthBeat, 9/18).

Details of the Privacy Principles

The privacy principles aim to protect the data of individuals participating in the precision medicine initiative. 

White House Details Privacy Rules for Precision Medicine Initiative - iHealthBeat

Medicare blocks Research into Substance buse

HIPAA is interfering with legitimate research goals

In an eye-catching study last week, Nobel Prize for Economics, for 2015, winner Angus Deaton and his co-author Anne Case found that deaths among middle-aged white men are spiking — and concluded that alcohol and substance abuse are at least partly to blame.

Rising morbidity and mortality in midlife among white and non-Hispanic Americans in the 21st century

The finding is "shocking," health care historian Paul Starr wrote at the American Prospect. "This midlife mortality reversal had no parallel in any other industrialized society or in other demographic groups in the United States."But here's an even bigger surprise: The federal agency that oversees the nation's largest trove of health data won't let researchers study the problem. 

In an unusual move, the Centers for Medicare and Medicaid Services in 2013 began quietly deleting substance use disorder data from the files they share with researchers. Up until that point, CMS had freely allowed researchers to use the data to track health care procedures related to substance use across millions of patients.

We know substance abuse deaths are rising. But Medicare won't let researchers study the problem.

Given our results, and the great interest in what is happening, it is clear that the removal of those data is particularly ill-timed, although I am sure it was done for legitimate reasons," Deaton says. "There is an enormous amount of stigma associated with addiction, and perhaps [CMS officials] were concerned about that. I don't know. But it certainly makes it harder to dig down into a vitally important question of social and health policy."

10 well paid jobs of the future - Telegraph

10 well paid jobs of the future - Telegraph

The remedy is to reimagine health

Sometimes the road to imaging health is to imagine disease. The vision of disease and/or death is striking. However health cannot be evaluated strictly by looking at a person.  We all have heard about people who look good, fit, are very active and who suddenly die. It leaves us all perplexed.  However careful appraisal and digging into details results that all is not what it  seems.

The Remedy is to Reimagine Health







The Affordable Care Act is similar to comparing disease and health.  It ain't what it seems. The ACA diverted most clinicians away from the essentials of modern medicine, the rapid technological advances that have occured and even more, that which is on the near horizon.

Healthcare Industry | Digital Revolution | Entrepreneurship | Innovation | The remedy is to reimagine health | Vision Magazine

Healthcare Industry | Digital Revolution | Entrepreneurship | Innovation | The remedy is to reimagine health | Vision Magazine

Medical Marijuana: No snake oil, but it may hold hope for some - AgingCare.com

Growing older is a bit like early childhood. Each day evolves differently.  It is a bit like childhood in reverse. As a child matures he gains some ability, in speech,  motor activity, cognition and emotional development.  The stages are all there.



As we age maturation appears to reverse itself, gradually at first, then more quickly.  The process is sensescence. We recognize some of this by cognitive changes, behavioral changes, physical changes, and at times the expression of infantile or emotional reactions of early youth.





Medical Marijuana: No snake oil, but it may hold hope for some - AgingCare.com

How Doctors Became Subcontractors | THCB

In our healthcare system, the “middleman” is not who you think



Your doctor no longer works for the patient, but to satisfy a payer.



It works like this. You, the patient pay a monthly premium in return for payment coverage to your physician. The requirements for payment are complicated, and if the physician does not meet these inflexible demands he is not paid ("Denied"). Often times there is no explanation.



This has been a gradual shift in doctor-patient relationship which has become the dominant model for reimbursement.  What this means essentially is that your doctor works not for you, but your insurer. You pay the premium for the insurer to reimburse a doctor of their choosing (see your provider directory) Often times your  doctor is part of a group practice and in a closed network.



It has been a pervasive cancerous expansion of limiting your access to care, and you are paying the insurance company to limit your freedom of access. It is part and parcel of the "Nanny State", one in which someone else is deciding what is good or bad for you, the patient.



It is not the only organization which uses the Nanny state approach. It is the means which Government now controls almost anything.Your freedoms are disappearing.



The Health Care Blog carries the important message from MICHEL ACCAD, MD, who says, In our healthcare system, the “middleman” is not who you think"







How Doctors Became Subcontractors | THCB

The Personal Toll of Corporate Medicine

The Personal Toll of Corporate Medicine

The Ommani Center - Ommani Center

The Ommani Center - Ommani Center

Universal Payer.....Are we on the way?

The Affordable Care Act catalyzed the free-market health system into a flurry of mergers and acquisitions   among some already very big insurance carriers.  These companies are risk averse, and have been required to expand coverage to previously uninsured and people who have not had medical care. The incidence of neglected conditions is higher than that in the insured population.

Premiums are rising due to the increased risk and utilization.  The health system is not yet in equilibrium, and may not be for several more years. The mergers of companies increases their underwriting assets, as well as decreases competition.

On the care delivery side of the equation the additional cost of administering accountable care organizations, meeting HEDIS criteria, and the loss of efficiency of improperly designed HIT (read EHR) is increasing practice overhead driving further mergers of medical practices, and health systems.

The same is true of pharmaceutical retailers and manufacturers.The pricing of drugs is unstable, as well and opportunities exist for profiteering while the going is good.  Witness this article taken from the  Journal of the American Medical Association,

Options to Promote Competitive Generics Markets in the United States

Clay P. Wiske, MPhil, MBA1,2; Oluwatobi A. Ogbechie, MD, MBA2,3; Kevin A. Schulman, MD2,4

[-] Author Affiliations

1Warren Alpert Medical School of Brown University, Providence, Rhode Island
2Harvard Business School, Boston, Massachusetts
3Harvard Medical School, Boston, Massachusetts
4Duke Clinical Research Institute and Department of Medicine, Duke University School of Medicine, Durham, North Carolina 

JAMA. Published online October 29, 2015. doi:10.1001/jama.2015.13498

"In August, the price of the 62-year-old drug pyrimethamine (Daraprim), used to treat many potentially fatal parasitic infections, was increased practically overnight from $14 to $750 per tablet. This colossal increase attracted renewed attention to generic pharmaceutical price spikes, prompting public outrage and a new round of proposals to address this issue. Over the past few years, increasing drug shortages and price spikes have affected generic drugs, which now account for 86% of prescriptions and 29% of pharmaceutical spending.1 A stable supply of affordable generic pharmaceuticals is crucial to improve health care access and appropriate utilization for many Americans."

 A 2014 report from the US Government Accountability Office found that the number of active drug shortages increased steadily from 154 in 2007 to 456 in 2012, and the majority of the affected drugs were generic.2 According to a recent Senate subcommittee investigation, many generic drugs prices have increased substantially as producers have left the market; for example, the price of albuterol sulfate tablets, used for asthma and other lung diseases, increased 4014% between October 2013 and April 2014 from $11 to $434.3 These generic drug shortages and price spikes are adverse outcomes of a malfunctioning marketplace.

Some solutions have been offered

THREE MARKET-BASED PROPOSALS TO OPTIMIZE GENERIC DRUG COST AND AVAILABILITY

Three potential business strategies—restricted market entry, long-term contracting, and creation of a futures market—could stabilize the generics drug market, but each has strengths and limitations. Paradoxically, for free-market advocates, these proposals all entail efforts that appear to be somewhat anticompetitive. The intent is to create a generics market that is economically viable for several firms to supply each product in the market. This result will likely lead to the most stable market over time.

Two features of the US generic drug market make it more prone to price swings and shortages than other commodity markets. First, entry into the generic drug market is restricted, including financial barriers (the cost of product formulation, quality assurance, and bioequivalence testing) and a time barrier due to the need for abbreviated clinical testing and the uncertainty of the Abbreviated New Drug Application (ANDA) review cycle. Second, again in contrast to more efficient commodity markets, there are barriers to the substitution of other products for a given generic drug molecule.

The economics of the generic drug market are driven by the opportunity for 180 days of market exclusivity for the first generic product on the market. These products are available at prices only slightly reduced from those of the originator products. Generic manufacturers may enter the market after 180 days in the hope of a substantial financial return in the short period of time before the price of the product declines. Firms take a calculated risk in financing bioequivalence studies and in entering the marketplace without knowing how many competitors will enter the market nor how quickly the price of the product will decline. As other firms enter the market and the price of a product approaches its marginal cost, the incentive to remain a supplier diminishes.4 At that time, firms make decisions about exiting the market without knowledge of the actions of other firms. Eventually, exit of enough firms supplying a particular product can lead to substantial price increases as the remaining firms operate with little competition, or drug shortages if remaining firms lack the capacity to supply the entire market. These are the drug shortages and price increases observed by Congress.

Option 1: Restrict Market Entry

Option 2: Encourage Long-term Contracts From Wholesalers

Option 3: Create a Futures Market

___________________________________________________________________________

Corresponding Author: Kevin A. Schulman, MD, Duke Clinical Research Institute, PO Box 17969, Durham, NC 27715 (kevin.schulman@duke.edu).

Published Online: October 29, 2015. doi:10.1001/jama.2015.13498.

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Schulman reports receiving honoraria from McKesson and Cardinal Health; consulting fees from Genentech, Novartis, sanofi-aventis, and Cytokinetics; and holding stock in Alnylam Pharmaceuticals. No other disclosures were reported.

Additional Contributions: This article was developed in collaboration with Aaron S. Kesselheim, MD, JD, MPH (Brigham and Women’s Hospital). He received no compensation for her contribution.

Walgreens to buy rival Rite Aid for $9.4 billion, creating drugstore giant - LA Times

The proposed deal follows a wave of mergers elsewhere in the healthcare industry, with insurers, hospital operators and pharmaceutical companies all combining to gain more leverage with suppliers and cut costs as the Affordable Care Act and other issues roil the outlook for revenues and profits.

In July, for instance, Anthem Inc. reached a $54-billion deal to buy rival Cigna Corp. and create the nation's largest health insurer.

But some observers questioned how much the public is being helped by having fewer players in each of the health industry's major industries.

Companies can make the argument that a larger company is necessary to negotiate better deals, but that might not translate to a boon for consumers, said Carmen Balber, executive director of Consumer Watchdog.

“It's fair to assume that drug prices will increase for consumers because of this merger,” Balber said. “There are less companies negotiating with the pharmacy managers, and there are less companies negotiating with the pharmaceutical companies.”

In downtown Los Angeles, where Walgreens and Rite Aid stores face off across the intersection of 7th and South Hope streets, Jeffrey Portnoy said his only worry about Walgreens buying Rite Aid was the effect on drug prices.He also said there would likely be a review of the stores' overlapping coverage areas and that the Department of Justice would require them to shed some stores in certain regions, including California.

Walgreens overall has about 13,100 stores in 11 countries, and it operates a leading pharmaceutical wholesale and distribution network with sales in 19 countries. The company employs about 370,000 people. Rite Aid has about 89,000 employees.



Walgreens to buy rival Rite Aid for $9.4 billion, creating drugstore giant - LA Times