The Clare Spark Blog

March 27, 2017

Dr. Pagano on failure of health care bill

Filed under: Uncategorized — clarelspark @ 7:26 pm
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James Pagano, M.D.

The failure of the Republicans to repeal and replace Obamacare was a disappointment but not a surprise. Sensing there would be no consensus on this I sent a letter to Paul Ryan’s office a couple of weeks ago outlining what I thought a reasonable, comprehensive, patient-oriented, market based health plan would look like.  I based it on 35 years of Emergency Medicine practice and practice management in both for-profit and County facilities.  I’m fairly certain it never got read.

Before describing my plan I think it important to review for a moment why some sort of replacement is necessary. Obamacare is failing due to its design.  It is based on an expansion of Medicaid and was, I believe, constructed to fail.  The Holy Grail for Democrats is a single payer, government run health care system.  Their thinking seems to have been to enroll large numbers of people in Medicaid, cost free, and foster an entitlement mentality.  Then, when the federal subsidies to the states ended there would be pressure on the federal government to do something.  That something, they hoped, would be either a bailout of Obamacare with increased federal subsidies, a single payer system, or at least a competing ‘public option’, the bridge to single payer.

Given the election results it is unlikely that Obamacare will be getting any additional federal funds. And it shouldn’t.  It is going to collapse and good riddance when it does.  People insured under Obamacare do not have insurance.  Not really.  If you have been enrolled in a managed Medicaid plan and can’t find a doctor to see you, you are essentially uninsured.  If you have one of the ‘metal’ plans but can barely afford the premium, let alone the deductible, and are afraid to use it, you are essentially uninsured.

What Obamcare does provide is free access to hospital emergency rooms—at least for the Medicaid members. Since its inception ER patient volumes have risen and the amount of primary care being delivered by Emergency Physicians has become substantial.  This, we were told, was precisely what would not happen if the law was enacted.  This inappropriate use of the ER further drives the cost up and is hastening the law’s demise.

But even those for whom ER care is free under this plan are still out of luck, in many cases, if they require specialty care beyond the Emergency Room. There are few surgical subspecialists outside large teaching hospitals and trauma centers willing to take call for ER patients, especially those covered by any iteration of Medicaid.  They simply cannot afford it.

July 9, 2012

James Pagano M.D. on effects of Obamacare

Filed under: Uncategorized — clarelspark @ 5:20 pm
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James Pagano, M.D.

[This is Dr. James Pagano’s latest guest blog on the drastic changes in health care policy just declared constitutional by the Supreme Court. His second blog can be found here: Don’t miss the comments where Pagano lays out his suggestions for fixing the problems with pre-ACA health care.]

[Pagano:] On March 29th of this year I wrote about the Affordable Care Act and some of the effects it would have on the availability and quality of healthcare in this country should it be allowed to stand.  At the time it seemed as though there was a better than even chance the Supreme Court would find it unconstitutional as written and we would be spared from its damage.  As it turns out, it was.  But we have not been spared.  Chief Justice Roberts, through a tortured and convoluted logic and for reasons about which we can only speculate, found the individual mandate unconstitutional as written but then re-wrote the law.  He determined the mandate to be a tax, precisely what the authors of the law and President Obama claimed it was not at the time the bill was being debated, and thereby constitutional.  The law stands.  Hooray for democracy.  I think.

So now we have a bad health care law, a bad legal precedent, and a monstrous new tax.  The States are scrambling to either set up health insurance exchanges, expand their medicaid programs, and make a grab for the Federal subsidies, or use the Roberts decision to scale back their medicaid programs and herd their citizens into the Federal exchanges.  Which, at last glance, don’t yet exist.  Physicians and their patients have all but been ignored.  Those of you who believe the federal government is a benign guardian of your health and well-being, committed to doing what is right, with no other political agenda, can stop reading now.  You are about to get what you so richly deserve.  I wish you all the best.  Good luck.

If you are still reading my guess is you have some doubts.  You should.  The ACA is designed to provide a lowest common denominator health care delivery system.  One size fits all.  It will be overseen by a panel of government appointed, non-physicians, beyond the reach of congress and the people affected by their decisions.  They will decide who qualifies for what sort of treatment, what treatment options are allowed, and which are not, who will be paid, and how much.  If you have an HMO plan, you are already familiar with this type of system.  You need authorizations for referrals, for special tests.  You are discouraged from using the emergency room because it is expensive, and because your HMO cannot control the treatment you receive there.  You are probably also familiar with the common practice of primary care doctors working in HMO’s actively referring their patients to ER’s to bypass the authorization process.  If you need a CT scan and your doctor feels you can’t wait three weeks to get the OK, just go to the ER and it will be done.

This is not optimum, but it is better than what you are about to receive.  Now, you have doctors making treatment and rationing decisions.  They are making these decisions based on their knowledge of you and your unique set of medical problems.  You have a physician advocate.  In the brave new world of the ACA those decisions will be taken away from your doctor and moved to that politically appointed panel in Washington D.C.  Whether or not you will be allowed a certain treatment will be based on statistics, your age, whether or not you are still a ‘productive member of society’.  You will not have the option to bypass the system and go to the ER.  Doctors will be held accountable for the tests they order, the treatment plans they design.  If their practice falls beyond the guidelines established by the panel, not only will they not get paid, they will get fined and quite possibly sent to prison.  I’m not kidding.  The law is that Draconian.

In order to make the law even theoretically affordable there will need to be healthcare rationing on a grand scale.  If you are a senior, or about to become one, this is especially worrisome.  You are now entering the period of your life when you expect to wind things down a bit, take it a little easier, maybe retire altogether.  You are about to become a less productive member of society.  You deserve it.  You’ve worked your entire life to be able to do just that.

You are also entering that phase of life during which you can expect your need for healthcare services to increase.  You aren’t worried.  You have Medicare to help you with that.  You’ve paid a small fortune into the program during your working years and now it’s time to reap the benefit.  Unfortunately, things have changed.  Over half a trillion dollars is earmarked to be removed from the Medicare budget to help pay for the subsidies going to the new medicaid enrollees.  Your benefits have just decreased.  You are also not at the top of the list to receive expensive treatment modalities.  You are too old.  Society can’t afford to carry you.  The very young and very old are expendable according to the new credo.

What can you do?  In the past I’ve limited my discourse to the law itself, apart from politics.  Now, though, the only thing standing between you and the monster that is the ACA is politics.  We tried throwing out only the bath water, but the Roberts decision quashed that effort.  It is now time to throw out the baby.  The healthcare system in this country needs to be fixed.  No argument there.  But it needs to stay in the hands of those who understand medicine and the needs of patients.  It needs a market-based restructuring, with perhaps some government funding for the safety net but private management.  I can go into some details in a later posting.

The only way we are going be able to achieve these goals is by voting President Obama out of office.  He is committed to the lowest common denominator.  We deserve better.

November 21, 2010

Dr. James Pagano on ObamaCare (2)

Filed under: Uncategorized — clarelspark @ 3:24 am
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Rembrandt: The Anatomy Lesson of Doctor Tulp, 1632

Two weeks have passed since the midterm elections.  The anxiety, anticipation, and exhilaration they inspired have had time to dissipate and now a clearer picture of where we stand, and what we have to do to move forward, is beginning to emerge.  While there are many fronts on which battles should, and will, be fought I will confine my comments to the one issue I am most qualified to critique—ObamaCare.

 It was crafted in secret with no bipartisan support.  It is monstrous in its scope.  It is being touted by those who created it as being about ‘healthcare for all’, and yet to get it passed, with supermajorities in both the House and Senate, votes had to be bought outright.  It has to go.

 While everyone agrees that there are problems with the cost and delivery of healthcare in this country I can guarantee you this law will not solve them.  It will make them worse and the cost for this ‘de-provement’ will be an American public indentured to the Federal government for the foreseeable future.

 This country was founded on the principle that individuals have value and rights.  Nowhere is this more apparent than in our system of healthcare.  Doctors are trained to treat patients as individuals, each with his own problems and circumstances, and patients have come to expect their doctors to make decisions regarding their care based on what is best for them.  Period.

 The architects of ObamaCare see things differently.  Our president, a self-proclaimed ‘progressive’, believes what all progressives believe.  Namely, that the welfare of society is more important than the welfare of any individual.  Individuals don’t matter in general, and when they cease to be ‘productive’ members of that society, they matter even less.  The fact that a society is nothing more than a collection of individuals working to achieve some common goals is somehow lost on these people.

 This belief in the primacy of ‘society’ underlies the key element of ObamaCare—stripping half a trillion dollars from MediCare to pay for thirty-some million people soon to be enrolled in various forms of Medicaid.  This is a disaster on a few different levels.

First, patients on MediCare are by definition older, sicker, and more in need of medical services, services that by and large they have earned during their ‘productive’ years by paying large amounts of money into the system via MediCare taxes. 

 Second, Medicaid is not what people think it is.  Specifically, it is not ‘insurance’ but merely a free pass for those who have it who will then never face a premium payment, a deductible, or a co-payment.  This creates a class of healthcare consumer with no skin in the game.  This is exactly what we don’t need if we want to control overuse of services and spiraling costs.

When I say it isn’t insurance I’m referring to the fact that very few physicians accept Medicaid patients.  They can’t afford to.  This is true for most primary care physicians and even more so for the great majority of specialists and subspecialists.  So when the Medicaid patient comes to the ER with a broken arm, we see him, do the exam, take the x-rays, make the diagnosis, and apply the splint.  But if that broken arm needs to be reduced, or operated on, we can’t get the orthopedist to take the case. 

 Some have suggested that a physician’s license to practice be dependent on his willingness to care for these patients.  I hope we’re not considering bringing back slavery. 

 The true goal of ObamaCare is to squeeze out private insurance companies and force everyone into a single-payer, government-run healthcare system.  Why seemingly intelligent people think this is a good idea baffles me.  In countries where this is being practiced, notably Canada and England, there is widespread acknowledgement that it doesn’t work very well.  Private clinics are popping up in Canada and doctors in border cities are doing a brisk business caring for Canadians who feel they can’t wait six months to a year for their joint replacement or their MRI.  My British friends are equally unenthusiastic about their system.

If we want to reform healthcare in this country then that’s what we should do.  Identify the specific problems that need to be addressed, the recisions, the denials for pre-existing conditions, the lifetime caps on benefits, and the availability of coverage for the great majority of people in this country, and then do the work of finding specific solutions in concert with physicians and insurers.

 We do not need the Federal government using healthcare as an excuse to commandeer a sixth of our economy.  We do not want bureaucrats deciding who gets what care and when.  We don’t need rationed care, we need rational care.  There’s a difference.


 If Obama succeeds in destroying the current private healthcare system his appointees, like Dr. Berwick, will be instituting a large number of ‘practice guidelines’ as a means of making healthcare delivery more homogeneous across geographic and social lines, and more affordable.  There are already such guidelines in place for certain diagnoses and they are referred to as ‘Core Measures’.  These guidelines are supposed to be the result of rigorous scientific study and are supposed to represent ‘best practices’ for the diagnoses they cover.

 In some instances they make sense, in others they seem arbitrary.  But even the most egregious of these guidelines—the one requiring us to obtain blood cultures on patients suspected of having pneumonia, which most physicians realize is a waste of time and money, remains in force.  Such is the inertia of government.

 The guidelines to come are not going to be anywhere near as pleasant as our current ‘Core Measures’.  My guess is that they will be closer to Draconian.  They will be designed to shift care, and the money it costs, away from the ‘non-productive’ members of society.  And yes, if this sounds like the ‘death panel’ stuff people were ranting about a year ago, well, it is.

 It is true that something like eighty percent or so of healthcare dollars are spent on the last 2-3 years of life.  We don’t need the government to fix this.  We need to promote rational care, where physicians feel free to discuss end-of-life issues with patients and families and where they do not have to live under the threat of being sued every time one of their patients has a bad outcome.  If you believe that death is a bad outcome, then we are all bound to have one.  It is not necessarily your doctor’s fault.

Educating the public about what we can and cannot do for the terminally ill, and having the courage to make decisions on that knowledge, will eventually save the dollars we are looking to save.  All without the government taking over, without Dr Berwick, without Obama.

 James Pagano, MD

Dr. Pagano’s first blog can be found here: Dr. Pagano has just published a novel, The Bleed, “about ER doctors, sleazy trial lawyers, ne’er-do-well patients, gangs and girls–and what happens when their worlds collide.”  I have just read the novel, and its detailed account of a medical malpractice case and the current administrative difficulties that discourage doctors from a one-to-one relationship with patients should alert us to the dangers to individual and public health being advanced by left-liberals today. In Pagano’s own words to me, it is a good airplane read.

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