McConnell delays start of recess to third week in August

Senate delays recess to work on GOP health bill 

Despite public and partisan rhetoric, the congress is attempting to correct the weaknesses ot the Affordable Care Act.  There is much in the new law that is good. Perfection is the enemy of the good. Everyone admits that healthcare is complicated.  This is not a new situation.

Our system evolved from a strictly pay for production (fee for service) to a polyglot system of private insurers, PPOs, and HMOs. Add to those are the military, Veterans health system, Indian Health System, Medicare and medi-cal has resulted in a barely functioning financial support system. 

Some have proposed a 'universal payor system.  At face value UPS sounds very nice, however it does not address underlying health care disparity, nor underlying structural failures in health care delivery. It ignores the gordian knot of many other facts.

The decision to give up a part of the summer recess means Congress is serious about working on the impasse.  There is no time like the present to deal with the crisis.  Congress has many other important and critical issues to resolve.

Thanks to those who serve, to give up a deserved respite.  It is especially gratifying for those who have lived in the District of Columbia, a hot, sweltering miserable season.  I'd rather be in my home district, fishing, being with family, or perhaps just sleeping in late.  Our representatives now have a thankless job.

As we head into the summer doldrum take a minute to call and thank your representative. 

(CNN)Senate Majority Leader Mitch McConnell has delayed the start of the August Senate recess until the third week in August in order to allow more time for his conference to complete "its work on health care reform" among other tasks.

"In order to provide more time to complete action on important legislative items and process nominees that have been stalled by a lack of cooperation from our friends across the aisle, the Senate will delay the start of the August recess until the third week of August," McConnell announced in a statement.

While Republicans are still working through their plan to overhaul Obamacare, McConnell says there is plenty more work to do after that.

"Once the Senate completes its work on health care reform, we will turn to other important issues including the National Defense Authorization Act and the backlog of critical nominations that have been mindlessly stalled by Democrats," McConnell said.

The delay of the August recess came after a handful of rank-and file Republicans urged leadership to stay in Washington to finish their business rather than return home for the district work period.

McConnell delays start of recess to third week in August - CNNPolitics.com

You've heard of Brexit? Here's what they call doctors who are leaving. DRexit

NIRAN S. AL-AGBA, MD | POLICY | APRIL 25, 2017

Sean MacStiofain said, “most revolutions are caused … by the stupidity and brutality of governments.” Regulation without legitimacy, predictability, and fairness always leads to backlash instead of compliance.

Here’s a prediction for you: If something is not done to stop MACRA implementation, more physicians will opt-out of Medicare and Medicaid than is fathomable.

Once DRexit begins, there will be no turning back.

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) is destructive to the physician-patient relationship because it prevents physicians from prioritizing patient care. MACRA supporters like to point out this legislation was passed with bipartisan support; in reality, it was passed simultaneously with the repeal of the sustainable growth rate formula.

The sustainable growth rate formula was enacted through the Balanced Budget Act of 1997 and was designed by lawmakers to control Medicare expenditures. The SGR formula limited the annual increase in cost per Medicare beneficiary to the growth of the national economy. Under the SGR formula, if overall physician costs exceeded target expenditures, a reduction in payments would be triggered. Expenditures continued to climb, so Congress stepped in 17 times with short-term legislation (referred to as “doc fix”) to avert the payment reduction since 2002.

Enter stage left, MACRA, known as the “permanent doc fix,” which was passed concurrently with the sustainable growth rate formula repeal legislation. This was the original “repeal and replace.” MACRA established yet another new (and untested) method by which to pay doctors. MACRA is the largest scale reform on the American health care system since the Affordable Care Act in 2010, and the jury is still out how great (or not) that system is working for the American people.

Under MACRA, the Secretary of the Department of Health and Human Services was tasked with implementation of a Merit-Based Incentive (MIP) program which consolidated three useless incentive programs into one big colossal unworkable program for eligible physicians everywhere. The legislation also allows for Advanced Alternative Payment Models (APM), which shockingly, are not actually saving money on care.

You've heard of Brexit? Here's what they call doctors who are leaving.   RETIRED

The Smart-Medicine Solution to the Health-Care Crisis - WSJ

Eric Topol M.D.

Dr. Topol is a cardiologist and professor of molecular medicine at the Scripps Research Institute in San Diego and the author of “The Patient Will See You Now: The Future of Medicine Is in Your Hands” (Basic Books, 2015). He consults for Illumina and Apple on some of the issues discussed here, sits on the board of directors of Dexcom and is a co-founder of YouBase.

Dr. Topol coined the term 'precision medicine', which was co-opted by political interests.

A Diagnosis for Personalized Medicine (a post from May 25, 2017)


Technology, smartphones and accessory attachments offer inexpensive testing platforms which in many cases rival much more expensive ultrasound machines, chemistry panels,  electrocardiogram units.

These new sensor units combined with smartphones will commoditize medical instrumentation. It should lead to a reduction in cost. The main barriers will be institutional resistance to change, a long standing barrier in hospitals and medical organizations.

These small devices, coupled with physician demand for decreased administrative and regulatory burden could lead a marked reduction in health costs.

A sequencing chip from Thermo Fisher Scientific uses semiconductor technology to detect DNA associated with cancer and inherited disease. PHOTO: THERMO FISHER SCIENTIFIC

Dr. Topol goes on to say,

"At the Scripps Research Institute, we are working with the support of a National Institutes of Health grant and several local partners to develop a comprehensive “health record of the future” for individual patients. It will combine all the usual medical data—from office visits, labs, scans—with data generated by personal sensors, including sleep, physical activity, weight, environment, blood pressure and other relevant medical metrics. All of it will be constantly and seamlessly updated and owned by the individual patient. "

Interoperability and cross institutional collaboration are essential for this to occur, and cooperation will be necessary from health plans to accept these new devices as eligible for reimbursement.

Our health-care system won’t be fixed by insurance reform. To contain costs and improve results, we need to move aggressively to adopt the tools of information-age medicine

The Smart-Medicine Solution to the Health-Care Crisis - WSJ

Pre-authorization is hell. Here's why.

Enter the prior-authorization

We have all been to our physicians who tell us we need a certain test. A decade or so ago, you made an appointment and had the x-ray, MRI or scan and that was it.  Now if you need a referral to a specialist, or physical therapist, the referral must be approved by a clerk at the insurance company.
It gets even worse.  Speaking of prior authorization, we have now been informed that we need to get prior authorization to prescribe a muscle relaxer for any patient over the age of 65. Muscle relaxers are apparently so dangerous, and my judgment as a physician so faulty, that the prior authorizers need to get involved. I guess I’ll just have to write more prescriptions for Percocet now because I don’t have time for all these prior authorizations.

Not to beat a dead horse (prior authorizations), but now we are being encouraged to go through Cover My Meds to obtain medication prior authorizations. Cover My Meds “was founded in 2008 with a mission to help patients get the medication they need to be healthy … by electronically automating the medication prior authorization (PA) process, saving health care professionals valuable time and ensuring patients receive the medication they need to be well.” How wonderful! Except that my staff informs me that the process takes, on average, 7-10 days to complete! That’s about 7-10 days longer, I think, than the process ought to take.

Really ?!  Let's face it. These roadblocks are to discourage tests or medications.  They are not in the interest of quality of care.  In fact over 90% of requests for prior authorizations are "rubber stamped"

Prior-authorization is hell. Here's why.

This April, my turn to take the medical board exam rolled back around, necessary every ten years for maintenance of certification. I studied diligently for the better part of three months preceding the test (and I think I did well). It was actually pleasurable to go back over details that I had forgotten and to catch up on newer developments in the field. I realized that I don’t do nearly as much studying, or reading the medical literature as I once did. I used to read an article or two and browse the general medical literature for updates on a daily basis. But my priorities have changed over the last few years.

Now, instead my staff and I spend our time fighting through the incredible sea of silly red tape necessary to get paid and to get our patients even basic care. Here are the highlights from just this last week:

Time taken away from seeing patients, reading journals or studying for maintenance of competence exams.

Distracted, How Regulations have destroyed the practice of Medicine and preventing true Health Reform . Matthew Hahn M.D.

Health Insurance, What's a grad to do?

This article is a re-publish from May 17, 2017.  

Graduating students now have several options for insurance plans. The Affordable Care Act has introduced several options.

As graduation approaches for thousands of young adults this spring, sorting out your health insurance options may seem more daunting than any political economics problem you faced at school.

You may not think it’s a high priority, but remember: Even healthy young people wind up in the emergency room for all sorts of mishaps, and having health insurance will let you get preventive care, including contraceptives, without paying for it.

As graduation approaches for thousands of young adults this spring, sorting out your health insurance options may seem more daunting than any political economics problem you faced at school.

You may not think it’s a high priority, but remember: Even healthy young people wind up in the emergency room for all sorts of mishaps, and having health insurance will let you get preventive care, including contraceptives, without paying for it.

There are several items to consider when choosing.

Take A Look At Your Parents’ Health Insurance.

In 2015, 29 percent of 19- to 25-year-olds were covered as dependents on their parents’ job-based plan, according to a Commonwealth Fund analysis of data from the U.S. Census Bureau’s Current Population Survey. It was the most common type of coverage for this age group.

Employer-sponsored plans are often more generous than an individual plan on the marketplace, with more comprehensive benefits and lower premiums and out-of-pocket costs. And parents can pass these benefits on.

Compare Coverage Through Your Employer.

Seventeen percent of young adults were insured by their own employer in 2015.

Large employers often offer insurance plans, called PPOs, that let workers choose their own doctors and providers from the insurer’s network and often allow them to seek care outside the network if the patient pays a larger share of the cost. A typical PPO plan offered by an employer with at least 500 employees paid for 87 percent of enrollees’ health care costs on average, according to data from benefits consultant Mercer. Compare that with the most popular silver-level plans sold on the ACA’s online marketplaces, which pay 70 percent of costs.

One benefit of an employer’s plan over your parents’: Buying your own plan may improve the odds that you’ll find doctors and hospitals nearby that are in your health plan’s provider network, said Erin Hemlin, director of training and education at Young Invincibles, an advocacy group for young adults.

If Employer Coverage Isn’t An Option, Consider The State Marketplace.

Twenty-two percent of young adults under 26 had marketplace coverage in 2015.

Marketplace plans must provide comprehensive coverage, including hospitalization, drugs and doctor visits. In addition, if your income is between 100 and 400 percent of the federal poverty level (about $12,000 to $48,000 for an individual) you could qualify for tax credits that will help cover the cost of premiums.

If you have a college health plan that ends when you graduate, you may qualify for a special enrollment period to sign up for a marketplace plan. But if you’re uninsured or insured through your parents, you probably can’t buy a marketplace plan until the next open enrollment period in the fall.

A key consideration: If your parents claim you as a tax dependent, you can’t claim the premium tax credit yourself, said Judith Solomon, vice president for health policy at the Center on Budget and Policy Priorities.

Unemployed? Uninsured? Consider Medicaid.

In 2015, 15 percent of people between ages 19 and 25 were on Medicaid.

To date, 31 states and the District of Columbia have expanded Medicaid coverage to adults with incomes of about $16,000 or less.

If you don’t have a job or earn very little and you live in one of these states, you may qualify for Medicaid, which provides comprehensive coverage, typically without a premium.

Unlike marketplace coverage, there’s no open enrollment period for Medicaid. You can apply anytime through your state Medicaid agency, healthcare.gov or your state marketplace.

A key consideration: If your parents claim you as a dependent on their taxes, it could also affect your eligibility.

This story was produced by Kaiser Health News, an editorially independent program of the Kaiser Family Foundation.

What' a Grad to do?

How Ketamine Infusion Will Transform the Way Depression is Treated

Dan Hancock, MD 

The newest method to treat depression is an anesthetic medication, ketamine.

People suffering from depression aren’t alone. In fact, depression is one of the most common mental health issues in the United States today, with nearly 15.7 million American adults suffering from these feelings of persistent sadness and irritability. More than 300 million people experience depression worldwide, according to the World Health Organization. Untreated, depression can become a chronic debilitating disease, leading to anxiety disorders, eating disorders, substance abuse issues, heart disease, and even suicide.

Fortunately, there’s new hope for healing severe depression and improving lives—and it’s called ketamine infusion therapy. Ketamine is an anesthetic medication that, in traditional doses, has been used for more than 50 years to sedate adults and children in emergency and operating rooms. In recent years, ketamine has emerged as a very safe, rapidly-acting, and effective alternative for treatment-resistant depression. In fact, ketamine has been touted as one of the most significant advancements in treating certain treatment-resistant chronic diseases including:

• Depression (including postpartum depression)
• Obsessive-compulsive disorder (OCD)
• Post-traumatic stress disorder (PTSD)
• Generalized anxiety disorder (GAD)
• Bipolar disorder (manic with refractory depression)
• Fibromyalgia
• Complex regional pain syndrome (CRPS), also called reflex sympathetic dystrophy (RSD)
• Neuropathic pain
• Migraine headaches/Persistent daily headaches

How ketamine infusion therapy works

Simply put, ketamine improves and rebuilds synaptic connections in the brain.  Traditional oral antidepressants can take weeks or even months to reach therapeutic levels, and only half of all patients get relief from their symptoms. As a NMDA receptor antagonist, ketamine has a positive effect on the neurotransmitter glutamate. Emerging evidence has linked depression with dysfunction in this neurotransmitter. Research has shown that subanesthetic doses of ketamine not only produces a rapid and robust antidepressant effect where it can lift depression in many patients within hours, but it also can put a quick end to suicidal thinking.

Ketamine is a very safe drug with few side effects. As anesthesiologists, we regularly administer this medication and are specifically trained to monitor and respond to its effects. With low doses of ketamine, side effects can include feelings of euphoria, confusion, dizziness, drowsiness, fuzzy vision, and nausea. These side effects clear up quickly, within approximately 10-15 minutes after completion of the infusion. There are no long-term reported side effects with ketamine infusions.

The majority of the patients see some mood elevation and symptomatic relief between the first and second infusion. If the infusions are effective, a series of four additional infusions are scheduled over the following 10 days. After that, maintenance “booster” infusions may be scheduled weeks/months later to maintain a positive response. Each patient is unique, so the dosage, frequency, and total length of treatment can vary and is customized to maximize the most effective sustained response.

Research shows it is changing lives for the better

A recent study, which was published May 3rd in Scientific Reports, reinforces ketamine’s reputation as an effective antidepressant both as a monotherapy and adjunctive therapy. Researchers at Skaggs School of Pharmacy and Pharmaceutical Sciences at University of California San Diego mined the FDA Adverse Effect Reporting System (FAERS) database for depression symptoms in patients taking ketamine for pain. They found that depression was reported half as often among the more than 41,000 patients who took ketamine, compared to patients who took any other drug or drug combination for pain. The team found that the incidence of symptoms of depression in patients who took ketamine in addition to other pain therapies dropped by 50% compared to patients who took any other drug or drug combination for pain.

Setting the record straight

There are some controversies surrounding the use of ketamine, which has been known to have a reputation as an illicit party drug (with a street name of “K” or “Special K”) due to its hallucinogenic effects at high doses. Like many drugs, if abused and misused, there can be harmful side effects with the potential to overdose. But current studies do not demonstrate an addictive potential for ketamine infusion therapy. We mitigate the risk of abuse by limiting access to the infusions and instead of sending patients home with oral medications, our trained health care providers are providing ketamine in a medically supervised clinical environment. This approach greatly minimizes the potential for addiction and misuse.

There is an additional concern with using ketamine infusion therapy because although the U.S. Food & Drug Administration (FDA) has only approved this medication for anesthetic purposes, it has not yet been approved for its use in treating chronic conditions such as depression. It is said that ketamine has never been tested for its safety and effectiveness in treating depression in a large-scale clinical trial due to financial reasons and the ethical controversy surrounding the misuse of it.

If more research can continue in this field, including large-scale clinical trials, ketamine infusion therapy may transform the way the public and other medical professionals think about treating depression, and it could open the door to even more effective forms of treatment.

Find the right, multi-faceted treatment

Not all people who suffer from the chronic diseases we’ve mentioned will respond to ketamine infusion therapy, and even those who are responders from this therapy may require a multi-faceted approach for a comprehensive treatment plan. Ketamine infusion therapy may not be a “silver bullet” treatment to heal depression. As caregivers, we need to address all aspects of a person’s disease, including social, environmental, biological, and psychological considerations. However, for some patients, ketamine infusion can be the long-awaited solution to return to a good quality of life.

Those who have one of the chronic diseases mentioned, and feel they’ve exhausted all treatment options, should talk to their primary care provider about whether ketamine infusion therapy may be the next step in their care.

How Ketamine Infusion Will Transform the Way Depression is Treated

Why are Nursing homes and extended life facilities so expensive.

Nursing Home vs. Cruise Ship

At first it appears to be comparing Apples and Oranges.  However when analyzing the cost of each service it turns out the cruise liner is cheaper and the service is outstanding.  There is no comparison to either facility, nor the customer service rendered.

CBO Reveals Winners, Losers In Senate Health Care Plan : Shots - Health News : NPR

What you should know about the House and Senate bills to repeal/amend the Affordable Care Act.  

CHART: CBO Weighs Who Wins, Who Loses With Senate Health Care Bill

The nonpartisan Congressional Budget Office weighed in on the Senate health care bill on Monday, saying that 22 million people would lose health coverage in the next 10 years under the Senate's plan. Of those, 15 million would lose Medicaid coverage. It's projected to lower the deficit by billions over 10 years, and also cut taxes on corporations and the wealthy.

Medicaid covers low-income people including children, pregnant women, older people in nursing homes and the disabled. Under the Affordable Care Act, the federal government offered subsidies to help states to cover more people, though 19 states chose not to accept the federal money.

For individuals who purchase health coverage on the exchanges, the CBO says prices will vary — some will see lower premiums, especially in states that opt out of some consumer protections, which will allow insurers to sell plans that offer fewer benefits. However, for people would like to purchase plans that cover the essential health benefits mandated by the Affordable Care Act, including mental health coverage, addiction treatment, maternity care and prescription drug coverage, costs could go way up.

Other provisions in the Senate proposal would reduce subsidies and cause out-of-pocket costs to rise, the CBO says. As a result, starting in 2020, "despite being eligible for premium tax credits, few low-income people would purchase any plan."

AFFORDABLE CARE ACT (OBAMACARE)

Can get insurance through a parent’s plan or buy independently.

HOUSE BILL: AMERICAN HEALTH CARE ACT

Stays the same.

SENATE DRAFT: BETTER CARE RECONCILIATION ACT

Stays the same.

Adults under 65

AFFORDABLE CARE ACT (OBAMACARE)

Can buy insurance on health exchanges, with tax credits and subsidies if they meet income requirements up to 400 percent of poverty level. Cost of insurance is based on tobacco use and age, with the people nearing 65 paying no more than three times what the youngest pay. Premiums can’t cost more than 9.5 percent of income. Those with very low or no income qualify for Medicaid.

HOUSE BILL: AMERICAN HEALTH CARE ACT

Will see tax credits to pay premiums based on age, not income, and that max out at $4,000, much less than under the ACA. The oldest people under 65 can be charged five times more than the youngest, and maybe more depending on state rules. Medicaid cut after 2020.

SENATE DRAFT: BETTER CARE RECONCILIATION ACT

The CBO report says 22 million people would lose health insurance over the next 10 years, with people between 50-64 disproportionally impacted. The oldest people under 65 would pay five times more than younger people on the exchanges. Subsidies to help pay for insurance would be less and end at incomes of 350 percent of poverty level. Federal contributions to Medicaid start to decline in fiscal year 2020.

Low-income nursing home residents

AFFORDABLE CARE ACT (OBAMACARE)

Skilled nursing care covered by Medicare up to 100 days. Medicaid is available based on income.

HOUSE BILL: AMERICAN HEALTH CARE ACT

Skilled nursing care covered by Medicare up to 100 days. Medicaid services could be cut as states see federal funding decline.

SENATE DRAFT: BETTER CARE RECONCILIATION ACT

Skilled nursing care covered by Medicare up to 100 days per illness. Medicaid coverage for nursing home services could be cut as federal payments to states decline.

People with pre-existing medical conditions

AFFORDABLE CARE ACT (OBAMACARE)

Coverage cannot be denied or cost more.

HOUSE BILL: AMERICAN HEALTH CARE ACT

States can get permission to let insurers charge more for some pre-existing conditions and to exclude some people altogether. States would have access to federal money to help those with expensive policies or conditions.

SENATE DRAFT: BETTER CARE RECONCILIATION ACT

Insurance companies would be required to accept all applicants regardless of health status. But the draft bill lets states ask permission to reduce required coverage, also called “essential health benefits,” which would give insurers some discretion over what they offer in their plans. That could result in “substantial increases” in costs for people who want those services, according to the CBO. Caps on annual and lifetime spending by patients would no longer apply if the benefit is no longer classified as essential.

People who go to Planned Parenthood

AFFORDABLE CARE ACT (OBAMACARE)

Federal programs reimburse for most Planned Parenthood services.

HOUSE BILL: AMERICAN HEALTH CARE ACT

A one-year block will be placed on federal reimbursements for care provided by Planned Parenthood.

SENATE DRAFT: BETTER CARE RECONCILIATION ACT

A one-year block will be placed on federal reimbursements for care provided by Planned Parenthood. The CBO estimates 15 percent of women would lose access to family planning care, increasing birth rates and Medicaid spending for childbirth and children’s insurance. But those increases would be offset by Planned Parenthood cuts.

People with disabilities

The majority of Medicaid dollars go to people with disabilities.

AFFORDABLE CARE ACT (OBAMACARE)

May qualify for Medicare and also Medicaid.

HOUSE BILL: AMERICAN HEALTH CARE ACT

Services covered by Medicaid could be cut as federal funding to states declines over time.

SENATE DRAFT: BETTER CARE RECONCILIATION ACT

Services covered by Medicaid could be cut as federal funding to states declines over time. The CBO report suggests that by 2026, Medicaid enrollment would fall by more than 15 million people.

People who use mental health services

AFFORDABLE CARE ACT (OBAMACARE)

Covered by all plans under essential health benefits.

HOUSE BILL: AMERICAN HEALTH CARE ACT

Could lose coverage in states that get waivers from covering essential health benefits.

SENATE DRAFT: BETTER CARE RECONCILIATION ACT

States could request waivers to opt out of requiring essential health benefits. If a state opted out of coverage for mental health care, the CBO says insurance that includes mental health care coverage could become “extremely expensive.”

Either plan leads to reduced access to plans for patients. Medicaid plans would be impacted.

CBO Reveals Winners, Losers In Senate Health Care Plan : Shots - Health News : NPR

The U.S. Senate has drafted it's own version of the Affordable Care Act,   The Senate bill, called the Better Care Reconciliation Act (BCRA), also would reduce the federal deficit by $321 billion over the next 10 years, $202 billion more than what the House bill would save, the CBO said in a report released today. 

Senate Bill Replacing ACA Leaves 22M More Uninsured, CBO Says.

The House of Representative formulated it's own bill, The American Health Care Act.  U.S. President Donald Trump on Tuesday backed a draft Republican proposal to dismantle Obamacare that was unveiled Monday, saying the proposed healthcare legislation was "out for review and negotiation."

Trump, in a tweet on Tuesday morning, described the bill proposed by fellow Republicans in the House of Representatives as "Our wonderful new healthcare bill."

The plan, released late on Monday, would undo Democratic President Barack Obama's 2010 healthcare law, removing the penalty paid by Americans without insurance coverage and rolling back extra healthcare funding for the poor.

The plan was swiftly criticized by Democrats.

Although Obamacare has long been a common target of Republicans, the proposal also met with skepticism from some in the party who are concerned about the replacement plan's tax credits for buying health insurance and changes to coverage under Medicaid, the government health insurance program for the poor.

The plan must pass both the Republican-led House of Representatives as well as the Senate, where it faces a higher bar for passage, making its future uncertain.Both bills address cost saving as compared to the original affordable care act.  Neither addresses insuring the uninsurable or pre-existing clauses for denial of insurance coverage.

The BCRA has already been panned by major medical societies for reducing healthcare coverage, particularly in the Medicaid program. One of the most strongly worded criticisms from organized medicine came today from the American Medical Association (AMA). In a letter to the US Senate, AMA Executive Vice President and CEO James Madara, MD, said the BCRA in many ways violates the physician's imperative of "first, do no harm".

"We believe that Congress should be working to increase the number of Americans with access to quality, affordable health insurance instead of pursuing policies that have the opposite effect," Dr Madara wrote.

Neither House or Senate Bill prioritizes patient access or quality of care. It is more about budgetary requirements.  Patients seem to be a side issue.

Senate Bill Replacing ACA Leaves 22M More Uninsured, CBO Says