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.

March 18, 2017

Dr. James Pagano on the reasons for a doctor shortage

Filed under: Uncategorized — clarelspark @ 2:49 pm
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The doctor shortage is real and most acute in certain specialties, like family medicine, internal medicine, and pediatrics.  There are various reasons for this.  Economics of course-these specialties pay less that others.  But over the course of the past 7 years under the ACA the bureaucratic and regulatory burden that has been placed on office-based primary care doctors has become so onerous that many are retiring early and fewer students are willing to enter those areas of medicine.

To counter this graduate schools are cranking out ever-increasing numbers of ‘mid-level providers’—physicians’ assistants and nurse practitioners.  As I’ve mentioned previously, these providers can do an excellent job in certain situations, but they don’t have the breadth and scope of knowledge a physician has.  Another trend of Obama era medicine was the development of ‘best practices’, ‘core measures’, and various diagnostic and therapeutic algorithms.  The alleged purpose was to identify the most appropriate approach to various illnesses and presenting complaints and to create a checkbox system of treatment.  Financial penalties were instituted against providers and hospitals for non-compliance.

My own suspicion was that CMS wanted to create a centralized system for delivering health care that did not rely upon physicians to administer it.  A mid-level could use the guidelines and get it right for something like 85% of the people 85% of the time.  Population medicine was the focus of the physicians and politicians working for the Obama CMS—and much of the paperwork being required of office-based doctors is providing data on treatments and outcomes to generate more algorithms.  Not all of this is bad.  Some useful information will be gleaned and some more effective or efficient or affordable treatments will be developed.  It is not, though, the type of practice doctors of my generation were taught.  We were taught to study the evidence and then use our clinical skills to tailor our therapies and diagnostic evaluations for the benefit of individual patients.

An example of check box medicine run amok is the core measure for the treatment of sepsis.  Briefly, sepsis is a condition of systemic infection with abnormal vital signs and evidence of failure in one or more organ systems.  It has a high mortality rate, especially if not diagnosed early and treated aggressively.  As part of the core measure for sepsis, patients have to have lactic acid levels drawn and repeated.  This value is used to determine whether or not sepsis is present, and if so, to what degree.  Unfortunately many other conditions besides sepsis can cause an elevated lactic acid level.

For ‘severe sepsis’, defined by the CMS as a lactic acid level greater than 4, the patient is supposed to be given a 30 cc per kg bolus of saline IV.  Regardless of whether or not the patient has another underlying condition, like renal failure or congestive heart failure, that would make this fluid bolus dangerous and possibly fatal.  If the fluid isn’t given the case falls out of compliance, the doctor and hospital don’t get paid, and this ‘poor performance’ is published on line by the CMS for all to see and few to understand.  Even if the physician documents clearly why the fluid is being withheld or the amount modified the case is still considered a fall-out.  This absurdity was recently reviewed by the CMS and kept in the protocol.

This sort of governmental interference leads to cynicism among physicians, nurses, and hospital administrators.  It would be more honest for the CMS to simply say they don’t want to pay for certain care than to create a bogus protocol that needs to be gamed in order to be compensated.  A study was done and published in the New England Journal of Medicine a year or so ago in which the authors compared the outcomes of patients with sepsis treated either according to protocol or according to clinic judgment.  The study found no significant improvement in outcomes among those patients subjected to the protocol.  The Obama ‘science administration’ did much to pervert science across its broad spectrum, from the environment to healthcare.  Maybe some of this gets fixed over the next few years.

 

(more…)

September 25, 2013

Ted Cruz, Generational conflict, and Remarque

Filed under: Uncategorized — clarelspark @ 10:15 pm
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GermanWarPosterWhile Ted Cruz was calling Republicans to arms to overturn Obamacare, I was watching the movie version of Erich Maria Remarque’s All Quiet on the Western Front (1930), in its uncut version.  (Ben Urwand insists that Universal pictures caved to German pressure to remove certain incendiary scenes that impugned the older generation for mindless nationalism that slaughtered their young soldiers. I watched the uncut version that attacked the upper class older generation for murdering their unprepared lower class young men, through glorifying sacrifice for the Fatherland, teaching irrelevant subjects in schools, and for inadequate training, food, leadership, hygiene, and medical care while in combat.)

The original uncut movie reminded me of the pacifism that moved the formation of Pacifica Radio immediately after WW2. Such Remarque-like antiwar sentiments lack an analysis of the lead up to wars, but imagine an undifferentiated class of enlisted men, badly led by undifferentiated old and middle-aged men.  Indeed, Remarque himself was born into a Catholic home (his father was a bookbinder, not a politicized worker), then after his recovery from wounds in the war, went on to write numerous novels after his autobiographical first novel (that of course was banned and burned by the (relatively young) Nazis in power. His brazen book was riotously protested before the Nazis were put in power by…old men: the monarchists and conservative nationalists of Germany who hoped to control Hitler and his hotheads in order to destroy communism and the independent working class movement that opposed the Nazis.

Remarque, a handsome fellow, went on to a successful career as an author and affairs with glamorous movie stars. In trying to place him as if he existed later in the 20th century, I would have to locate him in the counter-culture, not in any political faction. In the 1960s, boys like him might have been draft dodgers or protesters against the Viet Nam conflict. But the more politicized would have had a more sophisticated analysis of WW1. For instance, they might have looked to rival imperialisms, or to the failure of the Socialist Parties to oppose the war in 1914, voting for war credits in Germany.  Or if more attuned to the errors of diplomats, they might have come to agree with Niall Ferguson’s The Pity of War.

By the time Remarque wrote his novel, disillusion with the idea of progress pervaded what we now call the Jazz Age. Hemingway had written two antiwar novels (The Sun Also Rises about an aimless generation), then A Farewell to Arms (more overtly antiwar and vaguely autobiographical).  I have found one quote where Remarque prefigured the anti-technology sentiments of the counter culture, arguing for a vague humanism and faith in humanity; he was no nihilist.

paulandyingcomrade

The conflict du jour is over whether or not Ted Cruz is a hothead and ambitious for personal power. I am reminded of a line from the much lauded House of Cards remake, offered by Netflix to its subscribers. This time, a ruthless Southern Democrat, “Francis Underwood” (played by Kevin Spacey), explains to the audience that he isn’t in it for the money but for “power”.  Such is the charge now leveled at Ted Cruz by an older generation that hews to a more bipartisan approach to the management of social policy.

We know much more about this political war than Remarque knew about his war as an eighteen year old Catholic boy.  Given what I have studied about the moderate men—i.e, the older generation in charge today, it is difficult not to call them out for utopianism.  (See https://clarespark.com/2010/11/06/moderate-men-falling-down/.)

finalshot

June 6, 2013

Morale in the time of crisis overload

Filed under: Uncategorized — clarelspark @ 7:33 pm
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MORALE_G_20110814213222[This blog is dedicated to the thousands of Americans and allies who gave their lives in the invasion of Europe: D-Day, June 6, 1944. They knew what a fascist was.] Here is an excerpt from my research in the Harvard University Archives that seems especially relevant today, in the light of multiple scandals, even panic, descending upon our electorate, for we may be in danger of losing the will to resist the juggernaut of anti-Americanism, surveillance, and corruption that has been revealed since the Benghazi affair last September:

[Book excerpt, Hunting Captain Ahab, chapter 2:] In the case of the [Henry A.] Murray-[Gordon] Allport worksheets [distributed nationally to progressive groups ca. 1941], those limits were scientistically delineated; the Jeffersonian tradition was co-opted and redefined in the indispensable “Values of the Past”: “The more awareness there is of the group’s heroic past the better the morale. (Freedom from Old World Oppression, Jeffersonian Democracy, etc.) The more awareness of a national tradition of which the group is ashamed or guilty, the worse the morale…The slogan “Make The World Safe For Democracy” was anchored neither in the historical past or future. A durable morale must be historically anchored in the past and in the future, as well as in the present (Worksheet #4, 4, 5).” So much for the messianic republican mission…. The ever-questioning, self-critical temper of the Enlightenment, the very Head and Heart of the libertarian eighteenth century, could only lead to bad morale. … they went on to say that racial or economic discrimination were bad for morale, that there could be no doubt about the prospects for a better postwar world. A hodge-podge of factors: “communism, fascism, economic chaos, depression, or uncertainty,” all would impair morale (6). Peace aims were suggested: an International Police Force would ensure that “There will be a better distribution of the goods of the earth; all classes will be benefited” (Red-bound typescript, 13).” But war aims must remain vague, for we were a “pluralist society,” not a “unified society”; there were different strokes for different folks: “Disparities of statements shouldn’t be too obvious or made visible” (#4, 7).Properly guided we would be historically anchored in promises of abundance and an illusion of unity, yet we were not fascists. [end excerpt https://clarespark.com/2011/03/27/progressive-mind-managers-ca-1941-42/.]

I have been in red-hot conflict with some internet comments that insist we are already under the thumb of fascists (as opposed to, say, proto-fascists as the Murray-Allport worksheets suggested), and that civil war is inevitable. My line is this: as long as the internet and dissenting publications and television stations exist, the republic is not finished, and certainly not comparable to Hitler’s Germany, Mussolini’s Italy, or Franco’s Spain, at least not yet. (See https://clarespark.com/2013/04/21/fascism-what-it-is-what-it-is-not/.) These persons whom I oppose are either trolls, agents provocateurs (same as trolls), or paranoid. They have been egged on by the doom and gloom contingent of internet rightist magazines, that ask for our financial support in the emergency that never goes away. I am familiar with this technique having participated in innumerable Pacifica Radio fund drives.

However, I do remember David Dellinger at one of our KPFK teach-ins warning other post-60s activists not to lead “emergency lives” (his exact words). In warning against burn-out Dellinger echoed the advice of Murray and Allport, quoted above: too much emphasis on failure in the nation’s past is bad for morale. Instead they recommend that moral failures be corrected. (I didn’t care for their particular nostrums, but that is another story.)

There is something obscene in the claims of these trolls or deluded rightists that all is lost, and those who would stop this administration must mount the barricades.  It is true that thanks to checks and balances and the internal reformation of the Republican party (still in process), that there are reputable journalists who have uncovered lawbreakers and liars in the current administration. But there has been no military coup to shred the Constitution or any demonstrable move by POTUS to remain in office past his second term.

Instead, we have the most vigorous debates over key issues, possibly the best writers on the once impenetrable Middle East (Barry Rubin, David P. Goldman, a.k.a. “Spengler”) that I can remember. It is true that some conflicts seem confused and murky (such as the arguments pro and con immigration reform), and that not enough attention is paid to public education, but that too is changing.

Political affiliations are not carved in stone. We can collapse in exhaustion and depression, or we can take heart that our institutions have been exposed, which gives an opening for new political choices. Our future will depend on our ability to be flexible and alert for fresh coalitions, perhaps even to relegate the distractions of the culture wars to the bottom of our list of “must think about now.” (For my defense of secularism see https://clarespark.com/2012/04/01/secularism-and-the-affordable-care-act/.)

De Chirico: The Terrible Games, 1925

De Chirico: The Terrible Games, 1925

March 9, 2013

Feel no pain: Rand Paul’s secret weapon

Filed under: Uncategorized — clarelspark @ 7:14 pm
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scaryangrybearThis blog is about the reasons that Rand Paul’s filibuster regarding “drone attacks” upon American soil garnered approval from individuals and pundits who may not themselves be isolationists. My thesis is that we tend to repress scary events and influences, thus providing receptiveness to anyone who proposes that we are in danger of sudden annihilation out of the sky or from trusted family members and their surrogates in the political world.

Here are some stressors. Some are recent, others are ongoing, but all of them prepare the soil for panic and paranoia: North Korea/Iranian nuclear threat, internal jihadists, 9-11, Obamacare: its cost, rationing, and “death panels,” ongoing nuclear threat leftover from the Cold War, uncertain economic future, growth of the federal government under the Democratic Party that backs off from American superpower status (making us vulnerable to internal subversion), culture war angst, the pervasive rhetoric of family while stigmatizing the “individual” as destroyer of family harmony.

(Note that the pervasive rhetoric of family in all political propaganda and advertising reinstates the parents as controlling the now infantilized “children”—even as we are mature adults. This is one cause of regression, making us ever more dependent on “leaders” or “celebrities” who do our thinking and feeling for us. And we dare not confront these “Good Kings,” for it is their anodyne that protects us from wild animals, the “nanny state”, alien invaders, and any and all sinister forces.)

It is possible that Rand Paul’s filibuster was a relief to those who feel helpless in the face of all these unresolved and perhaps unresolvable stressors (I’m thinking of parents and siblings who may or may not have been bullies). While some dismiss Rand Paul’s “stunt,” here was a surrogate action for our helpless selves, standing up to Eric Holder, and demanding an unequivocal answer regarding the safety of loyal Americans.

wolf

My own views are contained here, and are supplemented by fine, well-researched guest blogs by Tom Nichols (an authority on international relations, nuclear threats, and war) and Phillip Smyth (a researcher specializing in Mid-East conflicts and neo-isolationism on the American Right). See https://clarespark.com/2013/03/07/blogs-on-neo-isolationism/. My blogs note the ongoing influence of such isolationists as Charles Lindbergh, and the presence of American First members or sympathizers in the sociology that followed the trauma of World War 2, and that have affected the programming of “alternative media.” It should be noted also that two of Joseph McCarthy’s most prominent enemies were active in establishing community radio: I refer to Paul G. Hoffman and William Benton. See https://clarespark.com/2010/06/19/committee-for-economic-development-and-its-sociologists/.

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.

October 10, 2012

Obamacare–One Last Time (James Pagano, MD)

Filed under: Uncategorized — clarelspark @ 6:00 pm
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James Pagano, M.D.

[For previous blogs by Dr. Pagano, see https://clarespark.com/2012/07/09/james-pagano-m-d-on-effects-of-obamacare/. This has link to the first blog.]

As the election draws close and the race tightens it seems a good time to take one more look at what is about to befall us as patients and consumers of healthcare.  In the past I’ve spoken from my perspective as a career Emergency Medicine specialist, a physician for over thirty years, practicing at the precise point where the worlds of medicine, politics, and public policy collide.  I have been, and continue to be, a part of the safety net everyone pays lip service to but few truly understand.  I have had a lot to say about why I think Obamacare, (an acceptable appellation since the president himself adopted it during the recent debate), is a disaster.

But, having recently entered my seventh decade, I have new concerns.  Not as a provider of healthcare, but as a consumer.  A patient.  A soon-to-be- senior on Medicare.  Having spent the bulk of my productive life providing first-rate care to others, what is going to be available to me in the years ahead?  Well, that depends.

Both Governor Romney and President Obama agree that under the new healthcare law 716 billion dollars will be removed from the current Medicare budget.  Starting now.  Romney calls it a cut in Medicare spending.  Obama calls it a savings.  It is a ridiculous distinction if you believe that all money is saved the same way.  Whether it is from ones childhood allowance, the family household budget, or the government-sponsored portion of healthcare, money is saved by not spending it.  Despite all the bluster and obfuscation it really is that simple.  A penny saved is…well, you get it.

So let’s call it a savings.  Fine.  How, exactly, does Obama think this savings is going to be realized?  To understand that we must take a look at what gets paid for under Medicare.  Doctors, allied healthcare providers, hospitals, drug manufacturers, the retail outlets that sell the medications to Medicare beneficiaries, and device manufacturers—think about the titanium hip that could be in your future—are responsible for just about all of Medicare’s budget.  Note that there are no jewelry stores or exotic car dealerships on the list.  We won’t be saving a dime by not paying for frivolities.

What, then, will not be paid for to achieve these savings?  Obama cites overpayments to providers and hospitals as being a principal source of savings.  The problem with that is the fact that Medicare already pays less than most insurance plans now.  Under the current fee schedule many physicians, particularly surgical subspecialists—there’s that hip again—are not accepting new Medicare patients.  If the proposed fee cuts scheduled for this January are allowed to go into effect, Medicare will look a lot like Medicaid.  In that scenario you can expect more physicians to not only refuse to take new Medicare patients, but to possibly opt out of Medicare altogether.

Hospitals, too, will have to reconsider their participation in the program.  They are currently paid according to a DRG system—Diagnostic Related Groups.  Every diagnosis is given a dollar value and a maximum in-patient length of stay.  For the hospital to make money, it must not spend more on the care of a patient than it will be reimbursed.  If your DRG says you can stay for 2 ½ days and the total cost will be $4300, then to make money the hospital has to keep you for sometime shorter and spend something less.  Cutting the amount allowed will lead to fewer services being provided.

To date hospitals have managed to do well in the Medicare system, and many are looking to Obamacare to provide additional revenue by covering the uninsured, who currently pay nothing for their hospital care.  However, drastic cuts, I mean savings, in the Medicare program combined with a massive influx of underinsured Obamacare patients will, I think, change things.

One of the biggest sources of ‘savings’ will come from something no one currently supportive of the healthcare law wants to discuss—healthcare rationing.  Like the systems in Canada and Great Britain, certain services will not be made available to certain patients.  If you need a hip, but are overweight, you might not get it until you reduce, if at all.  If you have cancer, but it is going to cost more than, say $47,000 per year of ‘quality’ life to treat, you won’t be treated.

The decisions about what constitutes ‘quality of life’, what therapies will and will not be made available, who, basically will live a while longer and who will not, will be made by a 15-member board, the great majority of whom not medical professionals, appointed by the president and not answerable to congress or the people whose lives they will control—patients on Medicare.

Much of this may not have been clear to many when the law was enacted, and much was still unclear when the Supreme Court voted to uphold the law—while specifically stating they were not in the business of protecting the People from their own bad political decisions—but it should be clear now.  If you are currently on Medicare or will be soon, you are in trouble.

We have heard a lot from this administration about the Republicans’ ‘wars’ on a variety of things—the alleged ‘war on women’, the ‘war on the middle class’, the ‘war on immigrants’, and it has become tiresome.  Phony wars devised by this administration to hide from view the only real war being prosecuted—the war on Medicare recipients.  The war on seniors.  It is real, it is happening now, and Obamacare is its name.

Romney’s healthcare plan will change nothing for those of you on Medicare now, or the rest of us age 55 and older who expect to be on Medicare sometime in the next 10 years.  We who have worked, planned, and saved according to a social promise made years ago will be able to reap that benefit in full.

For those younger than 55 there will be money given to offset the cost of buying an insurance plan.  The amount provided will vary according to need, as it should.  The Romney system mirrors that currently available to members of congress and their families.  It allows for choice, puts patients and their doctors in control of their healthcare decisions, and keeps Medicare viable into the entire foreseeable future.

As always, there will be a safety net for those who fall through the cracks.  And, as always, there will be someone like me providing that care.

Obamacare was never about healthcare in the first place.  It was about wealth redistribution using government-controlled healthcare as the means.  If it was about improving healthcare, and if it was to be his signature piece of legislation, why was implementation delayed until after the re-election bid?  If it is so good, why not implement it before the election so it’s wonderfulness could be touted as a reason to re-elect?

Whether or not you share this administration’s desire to redistribute wealth, I am fairly certain you would like to maintain your current level of healthcare quality and access.  You would like to ‘keep your doctor’.  The only way that is going to happen now is by voting Obama out of office.

James V. Pagano, MD, FACEP

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: https://clarespark.com/2012/03/29/james-pagano-m-d-on-affordable-care-act/. 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.

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.

March 19, 2010

Dr. James Pagano on Obamacare

Filed under: 1 — clarelspark @ 11:01 pm
Tags: , ,

Hygeia: Roman copy of Greek statue, in Hermitage Museum

[This is a guest blog by my friend, emergency room physician, Dr. James Pagano:]

“The longer this drags on the more obvious it becomes that the bill is a complete disaster and the process of getting it passed is bordering on criminal.  The cost estimates are completely trumped up, the deficit reduction Obama is touting is a fantasy.  The end result if this is passed and allowed to actually go into effect will be a severe erosion of health care in this country for everyone for the alleged benefit of the few–alleged because they will be given the equivalent of Medicaid, which is almost worthless, at the cost of degrading Medicare to a level of near-worthlessness, increased taxes on just about everyone who actually pays taxes, decreased access to physicians, limited choices of therapies, extreme rationing of services to the elderly and ‘non-productive’, and the eventual creation of a single-payor system run entirely by the government, with annual escalations in the cost that will cripple our ability to maintain any sort of leadership role in the world.

 But that’s the whole point, isn’t it?  Obama doesn’t care about our health.  He cares about creating the socialist utopia–the utopia that has never been realized in the past though it has been tried on numerous sad occasions.  He doesn’t want the U.S to play a leadership role, he wants us to succumb to a new world order.  He is so ridiculously naive and ideological it depresses me that so many seemingly intelligent people were fooled by his smooth rhetoric, and that many are still unable to see through his systematic, ‘do whatever it takes’, lies and deception.

 Many physicians understand that this will be the final, fatal blow to their careers.  The trial lawyers, (think John Edwards here), have succeeded in taking the joy out of the profession, and now the socialists will take away our ability to earn the sort of decent living we deserve doing the essential, stressful, time- and education-intensive work we do.

 Our hope lies in the up-coming elections.  To save health care, and our entire way of life, we must get the democrats out of office.  If we can do this, much of what Obama is trying to do can be undone.  There will be a spate of legal challenges to this bill the minute it passes–these, too, offer a measure of hope.  Finally, we have to make certain that this president does not last more than one term.”

[Clare: my father was a physician who always treated poor and lower-middle class patients. He was opposed to socialized medicine in any form. Non-physicians may have little idea of the stress and danger experienced by idealistic doctors.]

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