YDS: 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.

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December 14, 2012

James Pagano MD on healthcare chaos: Updated

Filed under: Uncategorized — clarelspark @ 9:27 pm
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James Pagano, M.D.

James Pagano, M.D.

[See two earlier blogs: https://clarespark.com/2012/03/29/james-pagano-m-d-on-affordable-care-act/,  https://clarespark.com/2012/07/09/james-pagano-m-d-on-effects-of-obamacare/, including the comment section where Pagano lays out his suggestions for improved care. For Pagano’s website see http://jamesvpagano.com/.]

I asked Dr. Pagano what his plans were for the future, given the current flap over the Affordable Care Act. Here is his update, September 29, 2013:

Since the evening of Obama’s re-election I’ve been considering the future, ours in general, but mine in particular, and what part the practice of medicine will play in it.  I’m still not certain, mainly due to the fact that the situation is still fluid, but I can best answer your question by making a few assumptions.

So, lets first assume that Obamacare will roll out as written and on schedule.  This is almost laughable considering the amendments and exemptions that have already taken place, most notably the one-year reprieve for some businesses and the exclusion of Obama, his family, the House and Senate, their families, their staff, and their families from this law.  (The big labor unions, once so vocal in their support of Obama and his health care law will be the next large group seeking relief from it now they’ve had time to figure out what it entails.)  But we need to start somewhere.  If all goes as initially planned, there will be a massive enrollment of previously uninsured individuals, as well as previously well-insured but now no longer insured individuals due to their employers opting to drop their coverage, in the new exchanges.  Whether they enroll in the Silver, Gold, or Platinum plans makes little difference.  It is all basically Medicaid which means choices of physicians, hospitals, medications and ancillary health services will be limited.

These patients will increasingly access hospital-based emergency departments for their primary care, or less-than-emergency-care, needs.  It is happening already in LA county.  Thousands of patients previously covered by MediCal have been herded into new MediCal managed care products, like Healthy Way LA.  They are assigned to a ‘medical home’, with a primary care physician to oversee their care and arrange for any specialty consultations they might require.  The problem is that most of these people either can’t get in to see their primary care physician in a timely manner, or prefer to be treated on an episodic basis with no appointments needed.  They go to the ER because they know they must be seen, no financial questions asked, and they must be proven not to have an emergency medical condition prior to being discharged, regardless of how much testing is required to do so.  Viva EMTALA.

As this practice becomes more pervasive ER’s will become increasing crowded.  Despite heroic efforts by the CMS, hospitals, and ER physician groups to legislate, regulate and mandate that wait times and lengths of stay not only remain as they are but actually go down, such is not likely to be the case.  Speaking as an ER physician this is good and bad.  The pressure to see more patients in less time while maintaining diagnostic and treatment accuracy at 100% and high patient satisfaction scores is more than a little annoying.  But, the fact that a higher percentage of these patients will have some means of paying for the care they receive could result in some small net positive, income-wise.  At least for the first year or two, until other aspects of the law kick in–like the one demanding parity between Medicare and Medicaid reimbursement.  At that point the ER doctor will be seeing more patients, more regulations, with fewer consultants and specialists on call, for less money.  It seems clear that a number of them, particularly those in the latter parts of their careers, will be heading for the exits and an early retirement.

Now let’s assume the House is successful at either defunding the law or getting it postponed in its entirety for another year.  As noble a goal as this is, it seems at best unlikely and at worst suicidal considering the stakes–a government shut-down–involved.  Still, we should consider the possibility.  The thinking here seems to be that putting it off past the next election cycle could allow the Republicans to gain more seats in the Senate while maintaining control of the House and a chance thereby to scuttle the entire ugly mess.  That would be wonderful, provided that at the same time some serious work got done to actually reform healthcare, and not, as Obama and the Democrats have done, merely expand the role of the federal government and redistribute wealth at the SAKE of good medicine.  For the next year things would limp along essentially as they are: ER’s would be crowded but manageable, physician reimbursements would go down, but probably not precipitously, and insurance companies will continue to be good investments, because they will do well with or without Obamacare.

Despite passionate remonstrations from the Left, capitalism actually does work.  Free markets have a way of anticipating the future and finding ways to profit from changes.  The healthcare market is no different.  In the past few years a new version of an older healthcare delivery model has arisen and will, I think, become an important piece of the system.  Urgent Care Centers, owned and operated by residency-trained, Board-certified emergency medicine specialists are becoming prevalent in places like LA and New York City.  Once staffed by general or family practitioners with an emphasis on occupational medicine, the modern urgent care center is now attracting the well-insured and well-healed with problems that would have required ER care a few years ago, but which can now be handled on an episodic, no-appointment basis by a trained emergency medicine specialist.  Point of care lab testing, imaging studies, and transfer arrangements to a near-by hospital for those who need a higher level of care are making this type of urgent care center the ideal venue for those with non-life or limb threatening medical conditions.  No crowded ER, no inflated ER bills.

So to answer your original question, I’m not completely sure what I’ll be doing a year from now, but if I had to guess I’d say I’ll be working part-time in one of the new urgent care centers and spending the rest working on my next novel, next guitar CD, and perfecting the gnocchi.  Unless, of course, healthcare actually does get reformed, in which case I might be in the ‘Pit’ a while longer. [End, Pagano update 9-29-13]

[The original blog starts here:] The fuse has been lit, the bomb is ticking, the ship has hit the iceberg—whatever silly metaphor you might want to use, the fact is Obamacare is off and running. Unfortunately it seems to be running amok.  This might be a good time to give you some insight into where, exactly, it seems to be going and how it will affect the delivery of healthcare to you, the hapless patient, and to other Americans.

Let’s start with millions of newly ‘insured’ individuals on the Medicaid rolls with nowhere to go, millions more on MediCare living the dream that they have managed to save their entitlement by voting Democrat, and doctors heading for the exits.  What?  Nothing seems different to you?  Why am I being so ‘negative’?

I’m not.  I’m being honest.  I know this must be difficult for many of you who’ve been feasting on lies for the last two years.  But try it.  Just a little.  If you don’t like it you can stop reading and go back to whatever version of reality makes you feel comfortable and validated.

The reason everything seems fine for now is because nothing much has happened. Yet.  It’s like the guy who, having jumped off the top of the Empire State building, is asked ‘How’s it going?’ as he sails past the fiftieth floor and replies, ‘So far, so good’.  But just as the pavement is waiting to greet the jumper the beast that is Obamacare is right behind the door, waiting for you to walk inside.

The very best parts of the health care law have already been put into place.  Coverage for pre-existing conditions is now the law.  Good.  Dependent children can stay on their parents’ policies until the age of 26.  Fine.  Those reforms would have taken about three sentences to legislate.  So what about all the stuff in the extra twenty-seven hundred pages?  It’s coming.

First will be the exchanges.  It is unclear to just about everyone what they are going to look like and how they are supposed to function.  From what little I’ve been able to see so far it would seem that ‘ugly’ and ‘not very well’ are fair descriptors.  The exchanges will be entities that sell subsidized health insurance to those who qualify.  Those who do not qualify will be picking up the tab through taxation.   The product they sell will be, essentially, Medicaid.

Medicaid does not reimburse physicians well enough for them to meet their costs.  To entice physicians to accept these newly ‘insured’ patients the federal government has offered to pay at MediCare rates for the first two years.  What happens after that time is anyone’s guess.  My guess is that by then Medicare rates will have been reduced dramatically, and the government will be paying for both classes of patients at deeply discounted rates.  Letters will be sent to patients explaining that their doctor no longer accepts their ‘insurance’ plan and they will need to find another who will.

If this seems overly harsh consider this: California’s MediCal program has one of the lowest reimbursement rates for doctors and hospitals in the entire country.  It is also a state with one of the highest costs of living.  Just yesterday the 9th Circuit Court of Appeals issued an opinion that will allow California to cut its MediCal rates by 10%.  MediCal is California’s version of Medicaid.

So as I was saying, two years from now things are going to get difficult for the seniors.  Unless they get difficult a lot sooner.  There is a thirty percent cut in MediCare reimbursement set to go into effect January 1, 2013.  It is part of the fiscal cliff problem.  This has been an issue over and over in the past.  There has always been a last minute ‘fix’.  This time is different.  The sense is the cut may be allowed to finally stand.

If it does, and MedCare reimbursement drops by 30%, you can expect a number of physicians to drop out of the program.  Seniors on MediCare will look too much like Medicaid patients from a financial standpoint.  Seniors, who were lied to and frightened into voting Democrat to ‘save MediCare’ will learn that they actually killed it.  Whether it dies in 2013 or two years later is not significant.  The point is that Obamacare had the demise of MediCare built into it from the start.  Obama lied by accusing Paul Ryan of throwing Granny off the cliff.  Truth is, Granny was already in free fall, thanks to his healthcare plan.

Where, then, will all these patients go for their care needs?  The answer can be seen in what is already happening here in Los Angeles.  In anticipation of Obamacare the County has been furiously assigning existing MediCal patients and patients new to the system to MediCal managed care plans.  Things like Healthy Way LA, Healthy Families, LA Care, and other euphemistically titled HMO’s place these patients in ‘medical homes’—multi-specialty provider groups contracting with the government either directly or through a third party intermediary to provide care for this patient class.  The problem is that these practices are already overwhelmed and underfunded.  Patients are being referred to the emergency room in ever-increasing numbers.

For instance, a woman with abdominal pain is somehow able to see her primary care doctor.  He suspects a gall bladder problem.  He tells her to ‘go to the emergency room’ where the ER physician will be obligated to run expensive tests, like lab work, ultrasounds, and CT scans to rule out an emergency medical condition.  The cost for this will be borne by the hospital and the reimbursement it receives will be the Medicaid managed care rate, something like 85% of the Medicaid rate.  The ER doctor will likewise be paid a nominal sum for his efforts.

The more patients there are enrolled in these types of ‘insurance’ plans the more often this scenario will play out.

But let’s look at the bright side.  Let’s assume that the Medicare rates don’t drop next year and seniors actually will be able to keep their doctor.  Problem solved.  Obama saved MediCare.  No.  Ask yourself, when was the last time the federal government took control of anything, paid less for it, and got more for its money?  Right.  Never.  Remember the 750 billion dollars we are going to save by not spending it on MediCare so we can pay for Obamacare?  Where do you think that’s going to come from?  It comes from providing fewer services to seniors.  It’s called health care rationing.

This won’t be evident immediately, either.  The health care law will not be fully implemented until 2014.  It will then take some time for a MediCare patient to develop a problem, seek care for it, and be told that his or her options are limited.  Too old for a new knee, too sick for an expensive chemotherapy drug, not sufficient quality years of life left, according to their calculations, to warrant much of anything.  It will take more time for this to occur often enough to reach the general consciousness.  The media will not be running stories about it, just like they refused to run stories that might have harmed Obama’s chances of re-election.  So it might not be until 2015 or later that the seniors realize they’ve been had.  By then it will be too late.  It’s too late now.

March 29, 2012

James V. Pagano M.D. on Affordable Care Act

Filed under: Uncategorized — clarelspark @ 10:08 pm
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There are a lot of things not to like about the Affordable Health Care Act, including the fact that it isn’t actually affordable, but I feel certain that the great majority of people, those who favor the law and those who do not, would agree that two of its purported benefits are good things.  Those would be near-universal coverage and improved access to medical care.  The problem is that the law does not provide either.

To achieve near-universal coverage the law seeks a huge expansion of the Medicaid program.  Some twenty million people or so will be added to the various state-run programs, which in my state is known as MediCal (i.e., Medicaid).  Proponents of the law call this providing health insurance to those currently without it.  But MediCal isn’t insurance.  It’s welfare.  There’s a difference.

Insurance is something you buy.  You pay premiums, deductibles, and co-pays for a product that, in theory, indemnifies you against large financial losses in the case of illness or injury, helps with the cost of medications, and avails you of the services of a wide range of physician specialists.  Because it is expensive, you use it judiciously.

Medicaid is something provided to the medically indigent as a safety net.  There are no premiums, deductibles, or co-pays.  It is paid for by tax dollars.  As a practicing emergency room physician for over thirty years I can attest to the benefits it provides those who must rely on it for their healthcare needs.  I also understand its limitations.

Reimbursement rates under the Medicaid program are absurdly low.  As a result most specialists, especially surgical specialists like orthopedists and ENT’s, don’t take it.  Increasing numbers of primary care doctors don’t take it, either.  Which leads to the AHCA ‘s second false promise, that of improved access to health care.

Simply having a Medicaid card does not guarantee you will get to see a doctor.  Unless that doctor is working in an emergency room.  We who work in the specialty of Emergency Medicine have always provided care to all comers, insured or not, and the EMTALA law codified that practice when it was passed in 1986.  Under the new health law we will continue to see and treat all who come seeking care, but it will become even more difficult to do.

In the face of twenty million more patients with nowhere else to go our ER’s are going to become more crowded than they already are and waiting times will increase.  Compounding the problem will be patients needing a specialist with no specialist on-call.  This is already the case in many hospitals where trying to find an orthopedist, neurosurgeon, plastic surgeon or otolaryngologist is nearly impossible because these physicians have taken themselves off the ER back-up panels as a means of protecting themselves from having to provide high-risk, uncompensated care.  The Medicaid patient needing a fracture reduced or repaired surgically will be splinted, treated for pain, and parked in an ER bed until a transfer can be made to a County hospital.  That ER bed remains unavailable to another patient until the transfer can be made, and the overcrowding and wait times get worse.

To pay for the new health care law over half a trillion dollars will be taken from the MediCare program.  MediCare is still accepted by most primary care physicians and a sufficient number of specialists and sub-specialists to make the treatment of those covered by it reasonably easy.  Once the MediCare budget is cut, that will change and then seniors and the disabled will find themselves in the ER waiting room alongside the Medicaid patients.

Although there is speculation that the Supreme Court’s decision about the law’s constitutionality might render this entire discussion moot it is nevertheless an important discussion to have.  One way or another our system of healthcare delivery and the way we pay for it is going to be revamped.  If the Court gives us a do-over we must use that opportunity to construct a system that can actually do what the current law only pretends to do, namely make quality healthcare available to all Americans at a reasonable cost.

As I said at the top of this piece there are many reasons not to like the Affordable Health Care Act.  If the Court allows the law to stand I will likely be writing about some of them between now and the November elections, which will then be our only chance to avert this impending disaster.

James V. Pagano, M.D., FACEP

Dr. Pagano is the author of two novels, The Bleed, and The Drain    

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.

Hygeia

 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: https://clarespark.com/2010/03/19/dr-james-pagano-on-obamacare/. 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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