In America, the art of doctoring is dying - The Washington Post

For almost 20 years  I practiced Ophthalmology and geriatrics in my own office. I had tens of thousands of face-to-face interactions with a group of folks who, with time, grew to trust me. I respected them as well; many I came to love — a term that I hesitate to use in this hypersensitive age. Given how geographically dispersed families are today, for many of my older patients I functioned as a surrogate son.

Things began to change abruptly in 1989, as HMOs, capitated reimbursement, as well as a flurry of eponyms guiding how medicine should be practiced.

There is no doubt that the kind of medicine I was fortunate to practice is disappearing. Most doctors are employed by large group practices, hospitals or insurance companies. Many want to have personal connections with their patients but have too little time. Young primary-care doctors are relegated to assembly-line clinics; their patients pass through as widgets, not as individuals with complex inner lives, wrought family structures, varied spiritual and cultural beliefs — not to mention their individual capacities to understand and deal with their medical symptoms, diagnoses and multiple medications, as well as their own hopes and fears.

There is no doubt that the kind of medicine I was fortunate to practice is disappearing. Most doctors are employed by large group practices, hospitals or insurance companies. Many want to have personal connections with their patients but have too little time. Young primary-care doctors are relegated to assembly-line clinics; their patients pass through as widgets, not as individuals with complex inner lives.

Physicians are now insulated from knowing too much about their patients. It is all about the technology, the testing, the imaging, the electronic health record, the data — once collected by the doctor, but now so regulated and overwhelming that paramedical professionals have been enlisted to record the so-called minutiae, the often rote information in which may lie important clues. Some of these may remain forever buried, the patient not wanting to share sensitive details with just anyone, especially someone who no longer makes eye contact, whose face remains buried behind a computer screen, who seems uninterested or just unskilled in reading body language — that downward glance, that shift in the chair, that half-swallowed response.

The art of being a physician has disappeared, and also the art of being a patient, replaced by EMR, patient portals, mobile health devices.  All of this in the 'name' of being more efficient, caring for more patients, and to  yield data for the government and insurance companies to manipulate using algorithms derived from 'big data' and analytics.The relative isolation of medicine as what was called a 'cottage industry' had a secondary purpose, one often not recognized.  The ability for physicians to make decisions in private, and protection of patients. Although HIPAA strives to set a standard to protect patient information, it does not. Physicians practice medicine according to the Hippocratic oath which contains the following phrase.

(Original translation from the Greek)

"I will respect the privacy of my patients, for their problems are not disclosed to me that the world may know. Most especially must I tread with care in matters of life and death. If it is given me to save a life, all thanks. But it may also be within my power to take a life; this awesome responsibility must be faced with great humility and awareness of my own frailty. Above all, I must not play at God."

(Modern version)

 I will respect the privacy of my patients, for their problems are not disclosed to me that the world may know. Most especially must I tread with care in matters of life and death. If it is given me to save a life, all thanks. But it may also be within my power to take a life; this awesome responsibility must be faced with great humility and awareness of my own frailty. Above all, I must not play at God.

Note that the two versions are identical.  Despite centuries of existence our oath remains unchanged, while the world around us has changed. It seems to parallel the existence and intepretation of the U.S. Constitution set forth over 250 years ago.  Today we alter the foundation based upon our present day needs.

For my younger colleagues, who ask, "What was it like to practice medicine in your day ?" My answer is "the patients are the same, the treatments are better. Isn't science wonderful ? " The Creative Destruction of Medicine.




In America, the art of doctoring is dying - The Washington Post

Excise Tax On Medical Marijuana Sales Proposed In California - capradio.org

AP) - A state senator from Northern California has introduced a bill that would impose a 15 percent tax on retail sales of medical marijuana.

 

Sen. Mike McGuire estimated that the excise tax he proposed Wednesday would bring the state over $100 million annually.

 

The Healdsburg Democrat's SB987 directs 30 percent of the revenues collected to the new state agency charged with enforcing the new medical marijuana licensing regulations the Legislature approved last year.

 

The Bureau of Medical Marijuana Regulation would be charged with distributing the funds as grants to help local governments with the costs of enforcing the regulations.

 

McGuire's bill also would dedicate 20 percent of the excise tax money to running and maintaining state parks and 10 percent to county substance abuse programs.

 

Like other tax measures, the bill requires a two-thirds vote to pass.

Brown Approves Statewide Regulation Of Medical Marijuana

Excise Tax On Medical Marijuana Sales Proposed In California - capradio.org

Excise Tax On Medical Marijuana Sales Proposed In California

(AP) - A state senator from Northern California has introduced a bill that would impose a 15 percent tax on retail sales of medical marijuana.

 

Sen. Mike McGuire estimated that the excise tax he proposed Wednesday would bring the state over $100 million annually.

 

The Healdsburg Democrat's SB987 directs 30 percent of the revenues collected to the new state agency charged with enforcing the new medical marijuana licensing regulations the Legislature approved last year.

 

The Bureau of Medical Marijuana Regulation would be charged with distributing the funds as grants to help local governments with the costs of enforcing the regulations.

 

McGuire's bill also would dedicate 20 percent of the excise tax money to running and maintaining state parks and 10 percent to county substance abuse programs.

 

BREAKING: OMB receives CMS rules overhauling Medicaid - Modern Healthcare Modern Healthcare business news, research, data and events

BREAKING: OMB receives CMS rules overhauling Medicaid - Modern Healthcare Modern Healthcare business news, research, data and events

The CMS has sent a sweeping finalized rule that will overhaul the managedMedicaid program to the Office of Management and Budget for review.

The 653-page proposed version of the rule suggested the biggest changes in Medicaid managed-care regulations in more than a decade. It would cap insurer profits, require states to more rigorously supervise the adequacy of plans' provider networks, encourage states to establish quality rating systems for plans, allow more behavioral healthcare in institutional settings and encourage the growth of managed long-term care.

That version had a requirement that states needed to make sure plans had adequate provider networks.

At a minimum, Medicaid plans' provider networks must have time and distance standards for certain types of providers, including hospitals, primary-care physicians and OB-GYNs. The CMS said time and distance more accurately capture whether beneficiaries have adequate access to care than provider-to-enrollee ratios. States must also consider whether plans offer an adequate number of providers who speak languages other than English.

The CMS encouraged states to include pediatric primary, specialty and dental providers in their networks because of the large number of children covered under Medicaid and CHIP.

The CMS rule also sets a medical-loss ratio (MLR) of 85%, meaning at least 85 cents of every premium dollar must be used for medical care. The remainder can go toward administration, marketing and profit. Plans would not be penalized if they don't meet the ratio, but states could lower future payments if plans don't meet the minimum MLR. 

The CMS' proposed rule suggests that states establish a quality rating system for Medicaid plans to help beneficiaries select plans. The CMS already has a star rating system for Medicare plans. But the agency said it would defer to the states on this issue.

Although the health-plan industry has lobbied against inclusions of a minimum MLR, observers say the new Medicaid requirement would not have much effect on large national insurers. About three-quarters of states with Medicaid managed care already require average MLRs of at least 85%, according to the Kaiser Family Foundation.

The proposed CMS rule also could significantly improve access to behavioral healthcare for Medicaid beneficiaries. Since the creation of Medicaid 50 years ago, there has been a coverage exclusion for behavioral and substance-abuse treatment at inpatient facilities with more than 16 beds. The new proposed rule, however, would allow states to pay plans for behavioral care to beneficiaries who have a stay of no more than 15 days in a so-called institution for mental disease. 

About 46 million people, or 73% of all regular Medicaid beneficiaries, are in managed-care plans, and that figure will continue to rise through the Affordable Care Act's expansion of Medicaid to low-income adults, according to consulting firm Avalere Health. Millions of kids in the Children's Health Insurance Program are also in managed care and would be covered by the proposed rule.

A curable condition that causes blindness - Andrew Bastawrous

Health Insurance Private Exchanges: Are They Making the Cut? - TalentCulture

Health Insurance Private Exchanges: Are They Making the Cut? - TalentCulture

It wasn’t long ago that the Affordable Care Act (Obamacare) swept over the American healthcare landscape, bringing with it a real focus on private exchanges. Consultants, brokers—and anyone with products to sell—were all focusing on these exchanges, which had a dramatic impact on both individuals, and businesses of all sizes, concerning the health care benefits afforded employees.

Fast forward to today.

Have Private Health Exchanges Lived Up To The Hype? 

With the cost of healthcare on the rise, many companies in the United States have been trying to figure out how to cut those hefty employee insurance premiums. Businesses have responded in different ways, with some organizations eliminating coverage altogether.

Of course, that’s only an option for the smallest of businesses due to the Affordable Care Act (ACA) employer mandate and penalty, which go into effect this year.

Another response has been for companies to increase the deductible their employees must pay before employer-sponsored coverage kicks in. Still other organizations have turned to private health insurance exchanges, which emerged in the wake of the ACA as an insurance marketplace for employers.

Private health exchanges allow companies to control contributions while giving employees the ability to choose from different plans and find a policy that best fits their needs. The use of Private health exchanges is an approach to employee benefits which has been thriving over the past few years.

In 2014, the private health exchange market included 2.5 million users. Last year, that number doubled. Industry analysts, such as consulting firms Accenture and Oliver Wyman, expect the market to grow to as many as 40 million users by 2018.

Private health exchanges offer a chance for employers to manage their costs and risks while giving employees control over their health coverage. But exchanges aren’t a revolutionary cure-all, either. To be the solution they could be, there’s still a lot of work to be done.

According to a survey by the Deloitte Center for Health Solutions, most employers who’ve made the switch from traditional benefit models to private health exchanges are happy with the result; just eight percent of those surveyed said they were dissatisfied with their experience. The majority of them saw their costs drop and say they now play a less active role in providing benefits that are comparable, if not of higher quality, to what employees had before.

On the whole, however, private health exchanges are a good option with a lot of advantages. The ones who succeed will have some, if not all, of the following attributes:

• A forward-looking approach to the ACA. The ACA changes that will take effect this year are only the tip of the iceberg. Many employers are concerned about 2018 when a 40 percent tax—commonly referred to as the “Cadillac tax”—will be applied to what employers and employees jointly pay for coverage above a certain amount. Staying on top of these changes and offering compliance-driven products will set platforms above their competitors.

• A strong focus on technology. Multiple technological failures set the ACA program back when it launched in 2013. Our expectations as users are high; if a platform doesn’t work well, it won’t last. Exchanges with platforms that aren’t consistent, easy-to-use, and high-functioning will be passed over for more user-friendly options.

• Demonstrated compensation transparency. For the private exchange system to thrive, all stakeholders need to receive some value, and transparency of data and benefit will play a fundamental role in current and future success. Employers who want to stay on top of costs will gravitate toward providers who offer clear fee schedules and compensation information.

• Demonstrated administrator experience. Inexperience has been a stumbling block for private exchanges so far. Both benefits and exchange administrators may not have the industry experience or training needed to manage day-to-day operations of the exchange setup effectively. Better training and communication will drive successful relationships between employers and exchange providers in the years to come.

Right now, the private health exchange market is growing and becoming increasingly successful—but not as quickly as experts predicted five years ago. Of course, this doesn’t mean private health exchanges aren’t a solid option; it only means the industry needs more time to evaluate how the new model measures up.

The Federal government stepped in several years ago with a government website. Many states decided to build their own.  Health.gov is a prime example how not to roll out a not for prime time sofrware platfrom.  The Health.gov web site singlehandely almost destroyed the Affordable Care Act.

Private exchanges can ill afford repeating that scenario, and at this time have avoided that minefield.

Brown Nearing MCO Tax Deal With Health Plans - capradio.org

The unforseen effects of the Affordable 

Care Act

California lawmakers could vote this week on a proposal to restructure a tax on health care plans in order to avert a potential $1 billion state budget hole.

This “managed care organization” (MCO) tax brings in federal funds for Medi-Cal, California’s health care program for the poor. The federal government say the state’s current structure is no longer acceptable – and must be fixed by the end of June for the state to keep getting the money.

So Gov. Jerry Brown and health plans have been negotiating for months – and now talks are in the final stages.

Any deal would require Republican votes to pass the Legislature. There are signs that the votes could be there for the right deal as long as it's “revenue neutral“ – that is, the federal funds offset any tax liability to the health plans so the insurance companies don’t pass costs on to the rest of us.

A deal would also likely include funding increases for in-home care for the elderly and disabled (known as in-home supportive services or IHSS), and programs that benefit people with developmental disabilities.

Brown Nearing MCO Tax Deal With Health Plans - capradio.org

The Silence Around Stillbirth is Unspeakable

7,200 lives are lost every day to stillbirths. Imagine if we could reduce that number and stop this epidemic 
Almost 2·6 million babies are stillborn worldwide every year. That’s roughly the population of Rome, wiped out. Yet we still don’t talk openly about stillbirth. Vulnerable girls and women are often left to suffer in silence. It only perpetuates the stigma when they have little to no information on the topic. More must be done to cut through the sociocultural, religious, and health barriers that inhibit open dialogue.

A healthy pregnancy should be a universal right. Millions of women worldwide are still denied access to basic education about pregnancy and stillbirth. Education must include information about sexual health, birth control and treatable diseases, as well as the risks associated with smoking, obesity, and pregnancy in later life.

Skilled health professionals matter. Their care is vital for all expectant mothers. Yet they are in short supply. We must value health workers, including skilled birth attendants, in order to succeed–boost their numbers, increase access to quality training, give them a visible community presence, and remove the barriers to access.  

 1·3 million of the 2·6 million stillborn babies started labour alive

The Lancet | The Best Science for Better Lives