Complacency, Acceptance Then Dependency— A Master Plan?

Maybe, I’ve been watching too many spy movies and TV series where the plot is to cause a government downfall, but events over the last several years have made me question my previous position of it couldn’t happen to us. My belief has been that our nation’s leaders, no matter who holds this country’s highest office, have similar goals to that of our forefathers.

The long-standing structure of tripartite governance of checks and balances that prevents one branch of the government from taking over, is being put to the test with our current administration. To a certain extent, this occurs with most Presidents. But the efforts seem more concerted with President Obama, as if there is some of some sort of master plan that will take this country in a different direction— as he promised just prior to taking office.

Four events appear to be the major factors that have contributed to the stark changes that seem to be leading this country today:

9/11 shattered this country’s naïve belief that, despite what was happening in other parts of the world, the United States was, in some way, immune to threats from those outside our borders. Now, privacy and independence are being pitted against personal safety. Although heightened airport security is the prime example, the growing reach of the National Security Agency (NSA) and the Central Security Service (CSS) are potentially even more intrusive into the privacy rights of the individual citizen.

The roots of the 2008 recession (July, 2011, @ http://robtenerymd.com) go back to the Community Reinvestment Act of 1977 that was enacted during the Carter administration. In attempting to provide affordable housing to a population that couldn’t afford it, the House of Cards finally came crashing down despite the efforts of every administration since President Carter. We have not yet fully recovered from this protracted economic downturn, and much of the free world was dragged down with us.

This country has failed to address the consequences of a virtually open border with Mexico. Not only do we face the economic problems of supporting many of these illegals who fill our schools, hospitals, jobs and jails, but also the growing political power they exert as their numbers continue to increase. Both political parties have failed to reach a conclusion for somewhat different reasons. The Republicans, even when they had the opportunity, failed to do much more than give lip-service to a meaningful resolution. The Democrats, hoping to gain a larger share of the legal Mexican voters, are in no hurry to tackle the hard questions surrounding amnesty and actually closing the border.

It is naïve, and in some cases unrealistic, to support sending all illegals currently residing in this country, back to their native country. A pathway to citizenship, or some form of legal status, is the only solution. The haphazard methods of enforcement not only feed this country’s appetite for illegal drugs, but have turned the Mexico/United States border into a war zone, where countless lives are threatened and lost every day. Meaningful border closure, whether it is virtual or real, must be accompanied by a firm date, after which there are almost no exceptions— no amnesty, no getting back in line, just automatic extradition for all those who are apprehended.  Finally, put an end to automatic citizenship (December, 2010 @ http://robtenerymd.com) for those who are born in this country, unless, at least one parent is a legal citizen at the time of their birth.

The last event that has changed this country is the election of a President who fundamentally believes that the United States should move in a different direction. Even those who agree with the President’s principles can’t disagree that he told prospective voters of his plans for the United States even before he was elected to this country’s highest office. Many of those who voted for then Senator Obama just didn’t believe he would be so intent and effective in carrying out his pledges.

Not that the President alone has created these events while he has been in office, but he has either created or allowed a culture in Washington that has fostered these changes: Under the Obama administration, this country is rapidly moving toward an entitlement society. Why work when individuals can get almost as much out of the entitlement programs than from a job? The explosion of the food stamp program is the ‘poster-child’ example.

Prior to the passage of the Affordable Care Act (Obamacare, ACA) over 45+ million of or citizens were without some type of health care coverage.  Even after an almost total transformation of this nation’s health care delivery system, the uninsured are still only projected to be reduced to 30 million.  Several trillion dollars later, one has to ask, “Are the congregate of patients in this country better off?” My guess, the answer will be a resounding no!

The scary scenario is if the President’s experiment doesn’t work and all the private health care payers move on to other markets, the only recourse will be a single payer system.  “Vladimir Lenin, one of the founders of socialism and communism, said that socialized medicine is the keystone of the arch to the socialist state. In other words, you’ve got socialized medicine as the foundation because it gives you control of the people. Once you have control of them, you can do whatever you want,” a Ben Carson, M.D. quote on The Kelly File on October 9, 2013.

The apparent expansion of the scope of authority of the Department of Homeland Security (DHS) is alarming. Consolidation of this new cabinet department came after passage of the Homeland Security Act of 2002, during the George W. Bush Administration. The original premise was to ‘prevent terrorist attacks within the United States, reduce the vulnerability of the U.S. to terrorism and minimize the damage from attacks that do occur.’

However, worrisome are: The 1.6 billion rounds of ammunition that the DHS has reportedly already stockpiled. The March 3, 2013 report of the 2,717 mine resistant, armor protected vehicles (MRAP) that have been retrofitted for the streets here in this country. The 704 million more rounds of ammunition (a significant number which are .40 caliber hollow-points) that the DHS has contracted to purchase over next four years. The 300 acre ‘fake city’ that the U.S. Army has constructed at a cost of $96 million in Virginia which was ostensibly built to prepare U.S. troops for occupation of cities abroad.

The President’s Affordable Care Act calls for the Ready Reserve Corps that is directed to ‘assist full-time Commissioned Corps to meet both routine public health and emergency response missions.’ Even before he was elected to the Presidency, then Senator Obama called for the creation of a ‘civilian national security force that’s just as powerful, just as strong, just as well funded as the U.S. military.’

With every horrific mass shooting by some deranged outcast, the administration and their supporters in the Congress push for stricter laws on gun ownership, background checks, automatic weapons and magazine capabilities. Using the tragedies brought on by a few malcontents, some of whom are probably acts of terrorism, there appears to be a push to disarm the American people. However, only the opposite is occurring as more Americans, fearing for their own safety, are violating state laws (example is Connecticut) and stockpiling weapons and ammunition in even larger numbers.

The most recent revelation is the projected defense budget cut, just released by Defense Secretary Chuck Hagel, that would decrease military operations to Pre-World War II levels, even in the face of Russia’s recent take over of Crimea. Granted the world has changed. Domestic terrorism now is more likely than a full-scale invasion from a foreign power. Advances in surveillance, weapon technology and mobility have changed the battlefields of today. ‘Feet-on-the-ground’ is being replaced by satellite surveillance and drones in the sky. President Reagan’s success that brought down the Berlin Wall, and Russia to the brink of financial ruin, carries a price that this country can’t afford. Even the most hawkish agree that the United States can no longer be the world’s policeman. Hopefully, we have also learned that becoming involved in ‘culture wars,’ such as in Iraq, is almost always futile in the long run.

A change in our military agenda was predictable. But how far the United States should back off its deterrent posture to a more protective position may only be answered if we are put to the test. Unfortunately, by then it could be too late.

This country must stand ready to defend its allies and its best interests abroad. At the same time, guard its citizens on their home soil. Whether the Obama administration has chosen the right balance between deterrence and protectionism will ultimately be judged by the historians.

Even those, who are behind President Obama’s vision for this country, must recognize several troubling trends. The privacy provisions our citizens have enjoyed are being sacrificed for more protectionism. There appears to be a purposeful ‘redistribution of the wealth.’ The explosion of the entitlement programs of ‘cradle-to-grave’ government support is threatening to turn the United States from the world’s economic leader into an extension of the European community. We, the people, are being stripped of the power to defend ourselves both at home and abroad, and we are losing our voice in Washington as the Executive Branch assumes more and more control. With the President and his administration essentially abandoning many of the principles that make up our Constitution, the culture, the opportunities and the freedoms that were the foundation of this country are quickly being diluted into a sea of complacency, acceptance and dependency.

History tells us that democracies follow a predictable arc of rise and fall. As they reach their zenith, those with less elect to public office those that promise them more. When the desires of those with less rise to the level that they become the voting majority, one of two, or both, scenarios ensue: Unaffordable debt is incurred to be funded by future generations, or the wealth of those with more is redistributed to those with less. When the standard of living falls, as it does in either situation, the arc is completed.

Then sometime off in the future, the capitalistic incentives will be born again in the hopes of those who are willing to raise themselves above those who are just content to go along.

Are the changes that are taking place in the United States a part of some master plan or just the normal evolution of a democracy? The upcoming two elections, this fall and in 2016, could stop this country’s slow slide into socialism. But only if enough voters are willing to look beyond their own pocketbook, skin color and professed political party.

Sadly, I doubt that will happen!

Does Bedside Manner Matter Anymore?

“My doctor is really good.” Contrast this to another comment, “My doctor must be good.” The former statement is positive, while the latter conveys a lingering doubt. Both quotes connote a continuing ownership in the relationship. In the latter, the doctor has failed to make a connection and the patient is looking for reassurance. If the physician’s competence is also in question, patients often look elsewhere. The bridge to make that connection is what is called the ‘art’ of medicine. This art, which takes the relationship to a higher level, is often referred to as the physician’s bedside manner.

The term compassion is frequently used to describe this art of medicine. Caring not just about the malady, but caring about the patient. Caring that they do not suffer, caring that they do not recover alone and caring that those who love them are also suffering. Compassion without outwardly demonstrating that sensitivity is without meaning.

The art is in being able to show this higher level of involvement. It is a willingness to be more than just a scientist by giving of one’s self rather than just a ‘peddler of pills.’ It demonstrates an investment in one’s patients and not just in what is wrong with them. That ability to practice this art is often the single most important factor that elevates one physician above another.

The art is more encompassing than just showing compassion. It is about showing respect. It is about remembering that each physician is also a representative of the medical profession— those who have gone before and those who will come after. It is not just about commitment to one’s patients, but to the patients of others as well. It is an appreciation of being part of the medical profession.1

Although much is written about medical ethics, very little mention is given to medical etiquette. The two disciplines are similar and frequently overlap, but clearly not the same. Although open to interpretation, medical ethics predominately deals with the concerns of right versus wrong. While etiquette is the discipline that addresses the variances in the individual’s personal approach, it is best framed with terms such as demeanor, conduct, body language and deportment. It is about how physicians act, react and the manner in which they dialogue not only with their patients, but everyone they encounter in their role as a physician.

The pioneers of medicine were introduced to this profession in an era when taking care of patients was considered an act of beneficence and not just a transaction. When undesirable outcomes were accepted as ‘acts of God’ and not misdiagnoses. When medicine was a calling to most and not just a vocation. Advances in the science, third-party payment systems, marketing and fear of reprisals have changed all that. Unfortunately, there is no going back!

What have not changed are the patients. Although they are no longer all accepting, they are still afraid. They still are in pain. They still want their physicians and the other medical professionals who care for them to care about them too.

The term bedside manner is not just about making the correct diagnoses and prescribing the most appropriate treatments. That is the science. It is also not just about the ethics of ‘right versus wrong.’ Bedside manner is more about how physicians conduct themselves and how they relate to those that they are around. Their demeanor and how they adhere to the rules of etiquette. How they connect! Bedside manner is about the ‘art’ of medicine.

In the broader sense, bedside manner is not just about one patient, but realizing that physicians are part of a community of patients and other caregivers. What they say and do reflects on all of those who are part of the family of medicine. It is about not losing sight of the lessons they have learned from those who came before them. Finally, it is about giving back to this noble profession that has given so much to them.

 

  1. Tenery, R., Bedside Manners: A Compendium of Physician Relationships. CreateSpace Independent Publishing Platform, 2014.*

 

* Now available through Amazon books in paperback and eBook, my hope is that Bedside Manners will find its way into all sectors of the medical community, especially into the hands of those who are beginning their journey into medicine. Cover-to-cover, the ‘little book’ takes no longer than a short seminar to read, but lays out a lifetime of lessons and experiences that can guide physicians and all caregivers in their roles as practitioners, mentors, teachers and role-models.

Outcome Measurements Could Be a Two-Edged Sword

 

In 2007, with the purported intent of ‘promoting high-quality, patient–centered care and accountability,’ the Centers for Medicare and Medicaid Services (CMS) and Hospital Quality Alliance (HQA) began making public each hospital’s 30-day mortality outcomes for acute myocardial infarction and heart failure. The reporting was extended to pneumonia, in 2008. To add even more impetus, a federal program, called Value-Based Purchasing, was created that assigned penalties in Medicare reimbursement to hospitals that didn’t meet CMS’s stipulated clinical-care measures, while giving bonuses to those hospitals that exceeded them. Although the percentages of the penalties were most often far less than one percent (maximum of 1.25%), the losses mounted to hundreds of thousands in revenue to the so-called under-performing hospitals. In a report by Fierce Health Care in August of last year, 2,225 of the nation’s 5,700 hospitals will receive Medicare payment reductions totaling $227 million starting October 1, 2013.

More recently, under section 3025 of the Affordable Care Act, the Hospital Readmissions Reduction Program (HRRP) was established which requires CMS to reduce payments to IPPS hospitals (those that participate in the Medicare part A funding) with excess readmissions, beginning on October 1, 2012. Under the dictates of the program, CMS began reimbursing hospitals less if a Medicare patient is readmitted for the same problem within 30 days of discharge. Although less touted than the goal of improving the quality of heath care, the leadership of CMS, and those that dictate their policies, have come to the decision that one of the ways to control this country’s spiraling health care costs is by reimbursing health care services based on outcomes. The assumption is that by rewarding good results, or, more often, penalizing poorer results, the outcomes will be better.

On the positive side, these CMS requirements will most likely create better discharge planning, and efficiencies in the utilization of diagnostics and the prescribing of therapeutics. However, this goal to increase efficiency, and thus cost savings, using outcome measurements, introduces the potential for several disturbing consequences. It also casts disparaging insinuations on a profession that prides itself on quality, dedication and beneficence.

The inference that physicians and hospitals will only give their full measure unless incentivized by rewards or face penalties, is not only degrading but inflammatory. The premise also potentially cheapens the patient/doctor relationship from professional to one of prostitution— pay more to get more. It works for ‘the trade,’ but in the professional world, that must deal with the unpredictable science of medicine, third party mandates and a sue-crazy public, the premise does not always hold true.

In the case of the recent CMS HRRP program, the use of perverse incentives doesn’t necessarily reward the institutions and the physicians that have better measurable outcomes (fewer readmissions), but more often penalizes those who have a higher readmit rate. Varying age, education and severity demographics play significant roles in outcomes, but tend to distort the results. More than that, it discourages physicians and health care institutions from moving or expanding into locales where the sickest patients often congregate.

A recent study by Health Service Research reported that hospitals that treat more poor seniors who are both Medicare and Medicaid have higher rates of readmission.  Lane Koenig, Ph.D., president of KNG Health Consulting in Rockville, MD, who was the author of the study, quotes, “While these hospitals are more likely to be hurt, they are also more likely to be struggling financially.”

What are the population demographics surrounding the referring area of the admitting institution? What about referral institutions such as city/county hospitals, heart hospitals and cancer centers? Should they be held to the same standards with respect to readmission criteria?

Koenig went on to say, “currently, CMS does not take socioeconomic status into account when calculating readmission rates. It is possible that adjusting HRRP calculations for socioeconomic data could mask disparities in quality of care. The counter argument is that by not adjusting it, you may be penalizing hospitals simply because they treat a potentially sicker or more-difficult-to-manage population.”

Often left out of the discourse, are the patients’ perceptions, when they see that the hospital they use when they are sick, is being penalized because of lack of compliance with Medicare’s so-called standards. Similar to the ‘best doctor’ lists periodicals often publish to sell more advertising space in their publications, it potentially raises doubts if the patient’s doctor is not on the ‘list.’ Then there are the liability concerns that arise with poor results, if patients feel that their care was below the standards rather than an ‘act of God.’

Also, there are the extra costs and resources necessary to insure compliance. (As an example, there are the projected 1000s of additional IRS agents necessary to enforce compliance of the Individual Mandate clause of the ACA). What party established the standards? It harkens back to the DRGs. With respect to the CMS readmit policy, is there a real difference between four weeks and five, except for the differing reimbursement levels?

More important, what parties suffer the most? The answer is easy— the sicker and more vulnerable patients and the very hospitals that they rely on to get them through their difficult times. It also raises concerns as hospital systems evaluate development in new areas or expansion of their current facilities. Why go to or grow areas with potentially sicker populations?

The desire to encourage better discharge planning and increase efficiencies is sound. But, as with DRGs, there are patients who are potentially put at risk. A past example is the mothers, and their newborns, whom would have benefitted by an extra day or two stay in the hospital. In this more recent case, it’s the most fragile elderly, often who return to their less protected environments.

The larger question that lurks in the background is what do outcome measurements and other government mandates such as electronic medical records, e-prescribing, DRGs and the upcoming ICD 10 requirements, that are being pushed onto medicine, have in common? One would like to think that they are to allow more efficient utilization of our limited health care resources.  To advance the level of health care services to a larger sector of the population. To control the escalating costs that threaten this country’s future financial viability.

The answer may be all three or none of the above. The chilling observation is that by controlling a country’s heath care system, the rest will soon follow was once considered Orwellian.

Now, I’m not so sure!

It Always Seems to Boil Down to Politics

In 2009, when the final vote was taken on The Patient Protection and Affordable Care Act (ACA, Obamacare), it was split along party lines. Since the Democrats held the majority in both Houses of Congress, they already had a distinct advantage.

But, it was the additional deals ‘arranged’ by the administration and the Democratic leadership that were necessary to insure the controversial legislation’s passage. They were the ‘not-so-secret’ promises to certain elected representatives and influential bodies in the health care industry.

There was Democratic Senator Mary Landrieu’s ‘Louisiana Purchase’— the provision that would provide $300 million in Medicare subsidies for people living in Louisiana. Senator Landrieu denied that her vote on health care reform was contingent on the Medicare subsidy. However, she did not publically commit to supporting the health care reform bill until the subsidy for her home state was included.

In early November, Senator Landrieu stated, in a speech on the floor of the Senate, that she had been mislead when she voted for the ACA in 2010. She was responding to the growing uproar as millions of patients across the country were losing their health care coverage as the dictates of the ACA were being implemented.

With Democratic Senator Ben Nelson, as a key holdout vote on the bill, Senate Majority Leader Harry Reid made a deal with him to allegedly secure his vote, giving the Democrats the 60 votes needed to kill a Republican filibuster. The deal, referred to as the ‘Cornhusker Kickback’ included language giving Nebraska 100 percent federal funding of the Medicaid expansion indefinitely. The deal drew so much fire from critics — who said it amounted to Nelson selling his vote – that he asked Senator Reid to remove the permanent Medicaid exemption from the legislation.

However, the real genius of the Obama administration, as opposed to the Clinton task force proposal in 1993, was in the President’s handling of the pharmaceutical industry, AARP and the AMA.

The drug industry backed, what would later be called Obamacare, in return, they were promised a 10-year limit of only an $80 billion cut in prescription drug costs. (A drop in the bucket of their almost $3 trillion in projected revenues over the next decade). They were also given assurances that the administration would continue to work against importing the lower-cost Canadian drugs. All the pharmaceutical industry had to do was put its formidable advertising budget at the disposal of the administration. Of the estimated $120 million spent lobbying for the passage of legislation, the drug companies funded $26.1 million of that total.

A subsidiary of the American Association of Retired Persons (AARP) was the supplier of Medi-gap insurance— a privately purchased coverage that picked up where Medicare benefits left off. The George W. Bush administration created the Medicare Advantage program that was a lower-cost alternative to the Medi-gap coverage. More than 11 million seniors took advantage of the program that significantly cut into AARP’s Medi-gap revenues. President Obama eliminated subsidies for the Medicare Advantage program that had made the more-expensive Medi-gap coverage more competitive.

Even though over $700 billion in projected funding for the Medicare program would be diverted to cover the new enrollees under the ACA, and although seniors would end up paying more money for their coverage, the leadership at AARP threw its support behind the proposed new law. Appearing to be more concerned with corporate revenues than abandoning the seniors, who comprised its membership, the leadership of AARP donated millions of dollars toward the advertising campaign and lobbying efforts in support of the proposed legislation. Referred to as ‘corporate cronyism’ much of their membership openly rebelled against its leadership.

When the Board of Trustees of the American Medical Association (AMA), and reaffirmed by its House of Delegates (HOD), openly supported the current administration’s proposal to solve the growing problem of the uninsured, it came as a shock to much of the physician-community. A survey by a physician recruitment firm, Jackson & Coker, revealed that only 13% of physicians surveyed agreed with the organization’s decision. Another study, the National Physicians Survey, reported that more than three times as many physicians believed that the quality of the American health care system would ‘deteriorate’ rather than ‘improve’ under the mandates of the ACA and nine out of ten physicians thought the proposed legislation would have a negative impact on their profession.

Several reasons have been floated for the AMA’s surprising support.  The major reason given to the AMA’s membership was that the President would throw his support behind a permanent ‘fix’ to Sustainable Growth Rate (SGR). Since the 1997 Balanced Budget Act first went into effect in 2002, the SGR formula, which is used to calculate levels of Medicare reimbursements to physicians, has not taken a realistic approach to increases in patient volume and the complexity of the science. Therefore, each year physician organizations across the country have groveled at the feet of the representatives in Washington, only to be granted a temporary reprieve from the fee cuts mandated in the Balanced Budget Act. Each year they had been promised a permanent fix. Each year there wasn’t. There was real hope that, with the President’s influence, this time it would be different. It hasn’t been, until possibly this coming year. The flawed SGR formula still looms over their heads. And, the AMA’s already dwindling membership has taken another hit.

The Supreme Court’s ruling, that the ACA was constitutional, as a tax but not a mandate, seemed to seal the fate of those who still held out hope that the controversial law could be overturned. That was until the Republican led House of Representatives decided to block funding for the new legislation. Although the House softened its demands to only delaying implementation of the Individual Mandate clause of the law for one year, Senate Majority Leader Harry Reid used his position so that the continuing resolution sent over by the House never even came to the floor of the Senate for debate. This apparently irresolvable divide was what led to the most recent government shutdown.

Giving him credit, Senator Reid was able to put together a temporary compromise, not necessarily to end the debate over the health care legislation, but to end the government shutdown and raise the debt ceiling. However, it only extends until February 7, 2014. He broke the logjam by eliciting the support of Senate Minority Leader Mitch McConnell. Unfortunately, the real differences between the two parties still exist, but thanks to Senators Reid and McConnell, the federal government is once again up and running.

Did I mention that the bill released by the Senate, passed by the House and signed by the President to end the most recent shut down also included an authorized spending increase of $1.2 billion for an already proposed $1.718 billion construction project on the lower Ohio River in Illinois and Kentucky— the state represented by Senator McConnell?

As implementation of the ACA chokes and sputters to ‘get out of the gate,’ and failing to meet its projected goals on most levels, the administration has issued exemptions and delays on almost a routine basis.  The ACA’s future appears to rest in the hands of the administration and of the results of the upcoming election in November.

These compromises, delays issued by CMS and Presidential mandates that appear to fly in face of the law and almost indiscriminate exemptions give us a peek into how things really work in our nation’s capitol.

And we just thought it was about the issues!

The End of the Shift or the Next Patient

A recent study at the Johns Hopkins Hospital concluded that a surprising number of interns lacked what is referred to as ‘common courtesies’ when communicating with their patients.  The study leader, Leonard S. Feldman, M. D., an assistant professor of medicine at the Johns Hopkins School of Medicine, and his trained observers, followed 29 internal medicine interns for three weeks during January 2012.

Their findings were disturbing! Using five key strategies, that Dr. Feldman calls etiquette-based communication— the touch, asking open-ended questions, introducing one’s self, explaining one’s role and sitting down with the patient— the study reveals the following: The interns touched their patients, either as part of the physical exam, a handshake or as a caring gesture, only 65% of the time. During only 75% of the encounters, did they ask open-ended questions, such as “how are you feeling?” They introduced themselves only 40% of the time and explained their role at the hospital only 37% of the time. Finally, they sat down with the patient only on 9% of the visits. 1

Feldman’s co-author, Lauren Block, M.D., a former internal medicine fellow at Johns Hopkins, feels that one of the reasons for the interns’ lack of social protocol is that their teachers, the senior doctors that they learn from, often fail to use them. Block also points out that this breakdown in communication could also explain why some research has shown that “only 10% of patients can name a doctor who cared for them in the hospital.”

“My doctor is really good,” said a friend recently. Contrast this to another comment; “My doctor must be good.” The former statement is positive, while the latter conveys a lingering doubt. Both quotes connote a continuing ownership in the relationship. In the latter, the doctor has failed to make a connection and the patient is looking for reassurance. If the physician’s competence is also in question, patients often look elsewhere. The bridge to make that connection is what is called the ‘art of medicine.’ This art, which takes the relationship to a higher level, is often referred to as the physician’s bedside manner.2

Feldman also reports that research suggests that not only is patient satisfaction improved with the more frequent use of bedside courtesies, but that medical outcomes improve also.1 The literature chronicles numerous references to validate that improved mental health yields better physical outcomes. To even the most skeptical, it is impossible to deny that an emotional connection with someone who is treating them, but also cares about them, decreases pain and suffering.

The Johns Hopkins study clearly demonstrates that, what Feldman and his researchers label etiquette-based communication, appears to be of much less importance to many of the doctors that are entering practice today than the traditional responsibilities of physicians of past generations— the  key difference between being a good doctor versus a good physician.

The advances in the science are no excuse to abandon bedside courtesies!

The answer might be found in the time-honored concept of the doctor’s role of ministering to his/her patients. Translated, this means attending to the needs of the patient. To often, we tend to forget, that those needs are not just physical.

When patients refer to their doctors, but can’t recall their names or when doctors only remember their patients by their diagnoses are two examples of emotional abandonment by each party. Even more important, such physicians have failed to uphold the covenant our forefathers first made with their patients many years ago.

In a day when almost any advance can be construed as inappropriate, physicians must not be forced to abandon actions that insure commitment. A gentle touch, a reassuring smile and eye contact are sometimes the most effective therapy during difficult situations. At the very least, they are gestures of kindness and make a connection.2

Applying the science is only a part of the practice of medicine. In restaurant lingo, the concept is similar to eating great food, but being served by a terrible waiter. The food almost never makes up for bad service.

A simple observation seems to say it all: The doctor, who is primarily concerned with the science, looks forward to the end of the shift, while the true physician looks forward to helping the next patient.

Maybe, the most important legacy our generation of physicians can leave for the generations that follow are passing on the tenets that define this noble profession. But, how can these ‘new’ doctors know these time-honored principles, if we don’t follow them ourselves?

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References:

(2) Tenery, R., Morse, L., Bedside Manners: A Compendium of Physician Relationships, Createspace, 2014.

Have We Given Up On Meaningful Dialogue?

This country was founded on two principles— opportunity to achieve one’s goals and freedom from undue encumbrances. More specifically, ours is a republic based on equal opportunity, but there are no guarantees of equal results. The injustices to the Native Americans and slavery were exceptions. Even today, those scars still remain.

Putting the color of one’s skin and religious preference aside, the problem that polarizes our country is the growing number and discontent by the so-called poor. Instead of equal opportunity, many have come to expect benefits through a myriad of entitlement programs. No longer content to just exist, the have-nots want more, and instead of a hand-up, they have come to expect a handout. The addicting entitlement programs are turning this country into a welfare state where the incentives of capitalism are being subverted by the acceptances of socialism.

Our current two party system has failed miserably to resolve the growing divide between the so-called privileged and those on the lower end of the economic scale. The Democrats have moved farther to the left by promising more and more to the growing segment of the electorate that put and keeps them in office. While the Republican party, mired in the battle between the ‘old guard’ and Tea Party, is seen as searching for its role as the fiscal conciliator.

This republic of the people, by the people and for the people is being slowly, but inexorably, eroded away. An over-reaching Executive branch, an increasingly deaf and uninformed Congress and a Supreme Court that pushes the limits of our Constitution is centralizing the power in Washington and not in the hands of the individuals and their elected state legislators, where it was originally intended.

The Affordable Care Act (ACA) is a classic example of a proposed solution by the Washington insiders to a local and state problem. Current estimates put the number of medically uninsured in this country at 47 million or about 15.5% of the population. Projections are that even when this legislation is fully implanted, there will still be over 30 million without health care coverage. This is not to say that the President’s effort was ill founded. But is it worth the costs, sacrifices and possibly dismantling of the world’s best health care delivery system for the remaining 300 million citizens and future generations who will be asked to pay for it? * The enactment of ACA does accomplish one undisputable goal— further centralization of federal control over the United States populous.

So why is the country so divided? Why do family members, former classmates, peers and coworkers with similar backgrounds come down on opposite sides CONCERNING which direction that this country should take in the future?

The overriding concern can be put in one succinct question: Do we address the escalating costs of this country’s entitlement obligations and the exploding federal deficit on the backs of the underprivileged, by taking it out of the pockets of the so-called wealthy or dump it in the laps of our children and their children?

Even the most strident followers on both sides of the aisle would agree that these should be our problems to solve and not put off to our children and their children to follow. So where is the compromise?

If the sole solution is for the ‘rich’ to pay more, this country gradually turns into a socialistic state where allocation of goods and services is determined by the whole of the community and the rewards from individual pursuits and accomplishments are dispersed among the community. In simpler terms, capitalism is replaced by socialism. If the sole answer is for the poor to accept less, then the basic premises upon which this country was founded of guaranteed opportunity and freedom from undue encumbrances are gone.

The answer may come by, once again, examining the obligations of the community for heath care for all its citizens. The President espouses that health care is a right given by the long-held protections of life, liberty and pursuit of happiness. But does that right extend to all health care services? The answer is obviously no, as seen in the allocation process with the organ donation program. Some gravely ill individuals are not eligible or are listed so far down the line that they will never live long enough to get a donor organ that could save or prolong their lives. A more reasoned answer is to health care delivery is access to an affordable level of basic health care services.

The compromise is for the less privileged, either by income or likelihood of outcome, have to settle for less, while the so-called more privileged have taken on the responsibility of insuring the creation a package of affordable health care services that fulfill the moral obligations of the community. Isn’t it equally morally unjust to deny those who have more the opportunity to purchase more, than to deny those with less, the opportunity to better their situation?

Washington seems to be in a permanent state of gridlock. The safeguards of checks and balances put in place by our founding fathers have in some ways made this democracy too democratic. Both political parties have taken positions that are too far to the left and correspondingly to the right. Maybe the only thing that we can agree on is that Washington doesn’t always have the best answer.

Do we, as individuals, want more or less centralized control? Once we have made that critical decision, then, just maybe, we, or the representatives that we have elected, can sit down together and establish a meaningful dialogue.

The analogy may be found in the world of boxing, where it is do or die when opponents face off in the ring. In preparation for an upcoming bout, boxers hone their skills with sparring partners. They are both still fighters, trained in the art of rendering their opponents into a state of unconsciousness. The difference is the sparring partner is not out to destroy their partner, only make him better.

Maybe the Democrats and the Republicans can still spar on the issues of amnesty, gay marriage and abortion. But take their gloves off when it comes to the potential knockout punches of the out of control entitlement programs, the role this country should play in a very dangerous world and class warfare issues that are literally ripping this country apart.

  • The current United States population estimate is 317 million.

Is This All Just About Obamacare?

“If you read Saul Alinsky’s book, Rules for Radicals, it talks about the need to ridicule. It also talks about never having a real conversation with your adversary, because that humanizes them and your job is to dehumanize them. Therefore, we see people coming out and saying about those who oppose Obamacare. For instance, that they want older people to die and they want kids to be deprived of food and all these things are just straight out of the text.

What’s really interesting that is Vladimir Lenin, one of the founders of socialism and communism, said that socialized medicine is the keystone of the arch to the socialist state. In other words, you’ve got socialized medicine as the foundation because it gives you control of the people. Once you have control of them, you can do whatever you want.

What’s really surprising, and is very serious, and is being missed in this whole discussion is that the fundamental relationship between the people and the government is shifting, and has shifted, with the implementation of the Affordable Care Act. It puts the government now at the pinnacle of the power structure. So we are now government centric as opposed to people centric.

I don’t think the average person understands what’s going on. This is very serious.

Benjamin Carson, M.D., live interview on The Kelly File, October 9, 2013.

 

The President went to selected members of the Congress who were ‘on the fence’ with his plan and cut deals to influence their vote. He made promises, many that he probably knew he couldn’t keep, in order to garner the support of influential groups, such as the American Medical Association, the American Association of Retired Persons and the pharmaceutical industry. With most of the medical community on his side, or, at least relegated to the sidelines, and with a majority of both houses of Congress aligned with his party, the controversial legislation still barely squeaked through.

The majority of members of both houses of Congress, who did not fully read or understand all the implications of the 2000+ page proposed legislation voted for its passage anyway. Chief Justice Roberts, apparently concerned that a rejection of the new law would be interpreted as ruling from the bench, led a majority of the Supreme Court to rule that the new law was constitutional, not on the original premise that it was a mandate, but a tax.

What does this controversial legislation mean to this country? It means that over 30 million of our citizens will not have to worry about going without health care, or face financial ruin, because of illness or injury. It means that millions of patients will not be rated-up or denied coverage because of pre-existing medical conditions. It means that doctors and hospitals will receive billions of dollars in funding that previously went uncompensated.

It also means that hundreds of billions of dollars previously designated to care for our elderly are to be shifted out of the Medicare program to fund these newly insured in an expanded Medicaid program. It means that a 15-member board of Presidential appointees will determine who is eligible for what care and who isn’t. It means an increase in taxes on investment income, the Medicare payroll tax, a 10% tax on medical devices and a 40% excise tax on the more expensive health care plans starting in 2018. It means raising the ceiling for medical expense deductions, lowering the cap on flexible spending accounts and making the pharmaceutical companies anti-up more to pay for closing the ‘donut-hole’ in the Medicare part D program.

It means that many employers will hire fewer new employees, or cut back existing ones to part-time, rather than be forced into paying the increased costs of providing health care coverage for them. It means that untold numbers of individuals will be tracked down and fined if they have not obtained health care coverage for themselves and the dependent members of their families. It means that the private practice of medicine will ultimately be available only to the wealthy (or those selected few who are granted waivers), while the majority of the population will probably end up being relegated to federally supervised health care delivery systems called Accountable Care Organizations (Exchanges).

And for what? It is now predicted by some experts that, even when the ACA is fully enacted, there may be as many as 30 million individuals who still have no health care coverage. Reports from states such as California point out that instead of rates for health care coverage going down as promised, they are projected to increase by over 160%. It is already a given that as many individuals lose access to their own physicians, they will be forced to wait in long lines to see a primary physician, as demonstrated by Romneycare in Massachusetts. Company after company is reporting changes to their hiring policies, in an attempt to avoid the punitive dictates for the required health care funding.

There are lessons to be learned here. Lessons about recognizing a problem— the  over 40 million people in this country with no health care coverage— and resolving a problem. Give our President credit on the first part. Recognizing that President Clinton had failed in his attempt to address this issue, and being aware that President George W. Bush and his Republican majority had only given lip service to meaningful change in the health care delivery system when they had their turn, President Obama decided to make health care reform the issue that would define his presidency. He enlisted his trusted advisers, his medical confidents and representatives from the SEIU, to draw up a plan.

President Obama recognized that Clinton’s plan, which was very similar to the one he would propose, failed because Mrs. Clinton and Ira Magaziner essentially excluded the parties that would be affected in putting together their plan. Deciding to do them one better, the President first went after support from influential sectors of the health care industry by making them promises that would favor each sector’s own agenda. He didn’t encounter much resistance from the hospital sector for his plan because, with potentially more millions of paying patients, these institutions’ losses in uncompensated care would be reduced significantly, under the dictates of the ACA. Additionally, recognizing the current trend of increasing physician employment by large hospital-owned corporations, the Accountable Care Organization model, proposed by the ACA, gave hospitals direct control over even more of the revenue stream.  The hospital community even agreed to phase out the ‘disproportionate share’ distribution that they received from the government to partially cover their losses from uncompensated care. However, with the rounds of new regulations being heaped on them, such as the ‘productivity adjustments’ that are designed to control the escalating expenditures in the government funded programs, and the projected increasing cuts in Medicare reimbursements, the hospitals are now having second thoughts in their decision.

The passage of time may be the only determinant as to whether President Obama’s vision and his political prowess were in this country’s best interest. Change usually takes adjustments and sacrifices. Some efforts succeed and some fail.  As the legacy of our President crystallizes in the future, will it be one that he gave our ‘disadvantaged’ a level of health care coverage that they deserve and one that society can afford, or will it be that he buried the best health care delivery system in the world with an avalanche of paralyzing regulations, new taxes and unprecedented federal control?

Even the Lexicographers Have Noticed the Change

The 1955 edition of my Grandfather’s Oxford Universal Dictionary defines a physician as one who practices the healing art. The dictionary program that comes with my Mac computer defines that person as one who is qualified to practice medicine. The difference between the two definitions, fifty-five years apart, clearly demonstrates that the lexicographers realized that this profession has evolved from the art of healing to the science of practicing medicine.

Reflecting on my over 38 years of practice, there are very encouraging signs that our profession will be in even better hands. The diagnostics and therapeutics available to these new physicians dwarf what we had to offer.  The ability to share the latest breakthroughs and advances make our ‘snail mail’ systems archaic. Many problems that were insurmountable just years ago, are relegated to day surgery or a prescription for oral medications. There is no question that the science of medicine is infinitely better. But the art, the personal side of that relationship, has been compromised, and in some ways, so have the physicians.

Although third party payers and federal dictates distance physicians from their patients, so do the advances in the diagnostics and therapeutics. The example is submitting a vial of the patient’s blood for evaluation and a short while later a profile of his/her blood chemistry appears on the closest CT screen. If the answer is still unclear, often instead of delving into the history further or going back to the patient for a more thorough examination, another battery of tests are ordered.

When my grandfather started his practice in the early 1900s, he relied on his stethoscope, probing hands and a highly trained ear to arrive at a diagnosis. Today’s physicians rely increasingly on a battery screening panels and digital imaging. My physician father would reach out to take the pulse on virtually every patient on which he rounded. Today’s physician is often seated at the nurses’ station bringing-up the patient’s particulars on the CT instead of further query at the bedside.

The term clinical acumen is a way of judging the ability to cipher out the correct diagnosis and proceed with the best therapy. With advances in the diagnostics, the physical examinations, and to a lesser extent, the histories are moving into the background. The physician’s role as an examiner, listener and caregiver is evolving into one of an interpreter and prescriber.

In the past, what has set physicians apart from the other disciplines in the medical field is their more thorough understanding of the basics of the anatomy, physiology and pathology that they acquired in the long hours of medical school and their early years of training. Today that is changing for several reasons.

Most of the other disciplines have raised the standards of their educational requirements, bringing them closer to those of the medical schools. Second, there are the advances in the science that bypass the need for this more in-depth understanding. The example being the wide utilization of blood panels and digital imaging for even the most minor problems. Even though these advances more often lead to a correct diagnosis sooner, there is the potential to ‘dumb-down’ the practitioners that rely on them.  The often-quoted adage that if you don’t use it, you lose it may apply when referring to the basics of the science that physicians learned in their early years of training. Also as the other disciplines work to expand their scope-of-practice through the state legislatures, these improved diagnostics tend to make-up for many of the shortfalls in their training.

The other factor that pushes physicians further away from direct care is their delegation of services. The practice of medicine has never been exclusive to physicians.  The many disciplines rendering health care services are not new. What is relatively new is physicians allowing or encouraging others to practice with their imprimatur.

Nurses have always stood alongside the physicians, rendering whatever care that was ordered. That role is changing too. Not only are nurses drifting away from the physician’s side, they are going out on their own. As the administrative and regulatory demands of health care increase, nurses are moving into teaching, up to the ‘front desk’ or as primary care givers themselves.

Frontline care, such as physical exams, the treatment of ‘lumps and bumps’ and post-operative routine rounding are increasingly being relegated to others. Physicians’ assistants act as physician extenders, allowing ‘their’ physicians to devote their attention to the more complex problems. It was only a matter of time until the discipline of a nurse practitioner would move away from the direct connection with a physician. Several of the national pharmaceutical chains have joined this movement by establishing drop-by clinics, mostly staffed by nurse practitioners, for the evaluation and treatment of the so-called minor maladies.

Certain specialties, such as ophthalmology are essentially giving away frontline care to optometry. Refractions and contact lens fitting, considered too mundane by many new ophthalmologists, have long been delegated to their staff. With the move toward increased specialization, many ophthalmologists don’t even offer refractions and many are all to glad to turn over the minor infections, abrasions, refractive complaints and management of their postoperative patients that complicate their already busy practices. Unfortunately, when it comes time for the state legislatures to address any expanded scope of practice legislation put forward by the optometric associations, the ophthalmologists’ retorts get less sympathy and public support.

Psychiatry has long jostled with the scope of practice issues raised by the psychologists. Anesthesiologists with the nurse anesthetists. Orthopedists with the chiropractors and the podiatrists. These examples, either by advances in the training of the other disciplines, delegation or lack of interest, as in ophthalmology, are changing the face of health care.

There is a real threat that the advances in the science, the expanding presence of the other health care disciplines and the reimbursement differential between primary care services and procedures are changing the physician who practices the healing art into a doctor who practices the science of medicine.

It seems ironic that all one has to do is look up the definition of a physician in the dictionary to see what was has changed in medical profession.

Where Did Physicians First Go Wrong?

Health insurance was first introduced in 1929 to cover the medical expenses of teachers in the Dallas Independent School District through Baylor University Hospital in Dallas, Texas. Later that company would become Blue Cross/Blue Shield of Texas. The beginnings of what would be formally called the Medicaid program was first established when President Franklin Roosevelt signed the Social Security Act into law in 1935. Initially the program covered the indigent elderly, the blind and disabled children.  When President Lyndon Johnson signed into law the Social Security Amendments of 1965, the social programs of Medicare and Medicaid were formally created.

At first, the health insurance programs and Medicare set the rates that they would reimburse their subscribers for a particular malady such as appendicitis, uncomplicated delivery, etc. Patients would then pay their doctors with the money the insurers had reimbursed them; any differences were still the responsibility of the patients. Not infrequently, the patients kept the money, and the doctors were left ‘holding the bag.’ To deal with these concerns, patients agreed to assign their payments from the insurer over to their doctors. Doctors, weary of past experiences, gladly accepted this new form of payment— direct reimbursement by the payer.

It didn’t take long until physicians became accustomed to accepting direct payments from the payers. Also patients began to feel that their coverage contract was between their doctors and the insurers. Patient responsibility for the remainder of their bill began to fade into the background. Thus, both parties were ‘easy pickings’ for what would follow— assigned payments evolving into allowable charges. Doctors, afraid that they would lose their patients to other doctors who would be willing participants in this arrangement, conceded. The payers took control and the rest is history!

So why not just say no? Many have!

An increasing number of physicians are dropping out of Medicare and many more don’t participate in Medicaid or Workman’s Compensation. Some don’t participate any insurance programs. The new specialty of concierge (also called retainer-based and boutique) medicine is finding growing favor in select populations. Although there are wide variations in structure and payment responsibilities, the commonality is the patient and his/her doctor have agreed to a financial arrangement outside of the patient’s coverage— a throwback to days prior to assigned payments by the payers.

Unfortunately, for the medical profession, the option of just saying no may be too late— not necessarily on an individual basis, but as a group.

As the divisiveness over support for the Affordable Care Act clearly demonstrates, the physician community has not been able to come together as a unified voice. The American Medical Association that could have been that unifying structure has been plagued with dwindling membership since the 1950s. In most cases, the national specialty organizations have not been able to put their own special interests aside for the overall good of the profession. Many of the state and county medical associations, as powerful as they can be in the state legislatures, are not only fighting membership issues, they are fighting the political gerrymandering with the allied health care providers every time their legislatures are in session. The state specialty organizations mostly secede political issues to the national specialty organizations or work through the state medical organizations because of their greater influence and common need to speak for the whole of the profession.

Apathy for any cause, other than one that creates direct benefit, has grown to epidemic proportions beginning with the ‘me now’ generation of the 1960s. Dwindling participation in conventional churches, volunteer organizations such as the Masons and participants in the political process are examples of a generation that expects to have ‘someone else’ do it for them. Individual initiative centers on personal gratification, rather than working toward a greater cause. Granted there are exceptions, such as Habitat For Humanity, the Bible churches and the Salvation Army, but increasingly, they are the exception.

The physician population falls right in with this anemia of participation. Take physicians’ low participation rate in many of the organizations that represent them. The exceptions are the national specialty organizations that are crucial to acquiring and maintaining board certification and recertification that are required by most payers.

The Medical Group Management Association reports that there has been an almost 75% increase in the number of doctors employed by hospitals or hospital systems since 2000. They also project that by next year, half of all doctors will be working for or integrally associated with some form of hospital system. In a recent survey, the consulting company, Accenture, reported that in 2000 that 57% of physicians were ‘on their own.’ Today that percentage has fallen to 39%.

An interesting side from this same report noted that there was a decrease in productivity by almost 25% under these arrangements. An example cited in the Orlando Sentinel on April 3, 2013, reported a 44% higher cost for a standard heart-perfusion study if a hospital-employed cardiologist performed the procedure, than if that same procedure was performed by an independent physician.

With this trend from private participation (solo or group practice) to corporate association, the rules change. When physicians’ roles change from an employer (private practice) to an employee of the corporation, attitudes change. They are still practicing medicine, but protecting the viability of the treating entity now potentially comes into conflict with what is best for their patients. They must now share their loyalty between their patients and their employers. Additionally, not only does the corporate entity (hospital) usually take over negotiation with the payer for reimbursements, it puts them in control of the physicians’ revenue stream. The patient/doctor relationship has added two new members to the family: the facility (corporation) and the payer.

The inertia virus of nonparticipation is infectious and has permeated all aspects of our society. Why go to a meeting when the ‘first tee’ is a short drive away? Why create a new organization or change the AMA to an organization that has the real authority to speak for all physicians on issues such as the ACA, the SGR and Medicare fee adjustments? Why ask the national specialty societies to give up some of their autonomy and become an integral part of that national organization?

Without changes in physicians’ priorities and a reordering of the organizations that represent physicians, the decline of this noble profession will continue. That may be okay for a 9 to 5 job, but I’m not sure that is what the founders of this profession envisioned.

It’s Only a Matter of Time…

A memorandum, dated May 18, 2012 from John D. Shatto and M. Kent Clememens, who work in the Office of the Actuary of the Department of Health and Human Services (HHS), published the following information concerning Medicare and Medicaid reimbursement rates for physicians based on the current law:

—the resulting comparison of future Medicare and Medicaid payment rates for physician services relative to private health insurance payment rates. Medicare payment levels in 2009 were about 80% of private health insurance payment rates, and Medicaid payment rates in 2008 were about 58%… Medicaid payment rates increase to 73% of private health insurance levels in 2013 and to 77% in 2014 and then return to 58%. Medicare physician payment rates decline to 55% of private health insurance payment rates in 2013, due to the scheduled reduction in the Medicare physician fee schedule of more than 30% under the SGR (Sustainable Growth Rate) formula in current law. (In practice, Congress is very likely to override this reduction, as it has consistently for 2003 through 2012.) Under current law, the Medicare rates would eventually fall to 26% of private health insurance levels by 2086 and to less than half of the projected Medicaid rates.

As predicted, Congress again diverted the 26% rate cut in physician reimbursement. But without a permanent fix in the current law, it is only a matter of time until the physicians who currently care for Medicare patients will just say no. No to taking on new Medicare patients, and no to continuing to take care of their current Medicare patients. It’s not if, but when!

For those few individuals in this country who are still uninformed on this issue, the answer is pretty straightforward. Without the relatively higher reimbursements for procedures, such as surgery and complex diagnostic evaluations, physicians simply can’t afford to run their practices on what they get paid from Medicare for nonprocedural services. That’s why specialties such as Urology and Ophthalmology are still readily accessible by seniors. Whereas, the Family Practice and Internal Medicine specialties are becoming increasingly stringent with regard to the Medicare patients they are accepting into their practices.

The bureaucrats in the CMS and HHS, many, if not most, of our elected officials on both sides of the isle in Washington and our state capitals and, at least, the last four administrations in the White House don’t get it. Naively, they operate on the premise that health care is a commodity and if the quality or availability falls to a certain level, the consumer will shop elsewhere. They cite the auto industry in Detroit as an example. The difference is patients are not consumers in the same sense. They can’t just buy a Honda when their Chevrolet falls apart.

Basic health care services are not a straightforward commodity; they are essential services guaranteed to them by the founders of this nation in the Life, Liberty and Pursuit of Happiness clause included in the Declaration of Independence. The other point is that the vast majority of our seniors have also prepaid and continue to pay for these guarantees though their Medicare taxes. They purchased Medicare insurance to protect them in the latter part of their lives. Why are they being forced to buy insurance that is either taken away (the $716 billion that is proposed to be taken out of Medicare to fund the newly insured under Obamacare over the next ten years) or reimburses at such a reduced level that no qualified provider is willing to treat them? Are we Cypress? Is there a new world order where those in leadership can take from anyone and anywhere they decide? Sounds familiar to the way the Jews were treated in Germany in the 1930s and 1940s, when many of their own countrymen and the rest of the world stood silently by.

Constitutionality aside, it really doesn’t matter whether Obamacare and the Balanced Budget Act are mandates or taxes. They are wrong if they harm a particular portion of our population.

Then there is the ‘sequester’ (the 10% overall cuts in all federal spending) that appears to target the most vulnerable of the Medicare population— the cancer patients. In a recent report, the spokesmen for cancer clinics across the country claim that the reduced funding brought on by the sequester, which took effect on April 1, will “make it impossible to administer expensive chemotherapy drugs while staying afloat financially.” North Shore Hematology Oncology Associates in New York has projected that the clinic would no longer see one-third of their 16,000 Medicare patients. Chief executive, Jeff Vacirca said, “the drugs we’re going to lose money on we’re not going to administer right now…It’s a choice between seeing these patients and staying in business.” (1) Tragic as this is, the selection of which cuts should be spared and which should be implemented by the sequester legislation may be subject to political manipulation by those in Washington who oppose the legislation.

Even though Obamacare is only in the early stages of implementation, it’s already happening now. Increasingly, new patients that move into Medicare coverage are having difficulty finding physicians, not just because the physicians don’t participate, but also because there are not enough of them. The projected physician shortage of 45,00 primary care physicians by 2020, along with the added covered lives, projected to be 30 million, under Obamacare, only adds to this already pressing problem. Additionally, many physicians are either dropping their participation in the Medicare program, picking specialties that are not as dependent on the Federal programs, such as Pediatrics and OB-Gyn, setting up ‘concierge’ practices that rely on preset fees or moving into hospital based practices.

What options do patients have if they are sick and need health care? They go to emergency rooms. They seek care from alternative or less qualified providers. Or, they do without. Emergency room care is always more costly because the evaluation and therapy are usually more complex and the appropriate therapy is often started later in the course of the disease. Substitute physicians, as they should be called, fill a need, but lack the rigors and depth of knowledge that separates physicians from other health care providers. Already a spokesman for the American Association of Nurse Practitioners, with a membership of 43,000, claims their members “can offer basic care if state laws would just let them set up an independent practice without doctor supervision.” In retort, the American Academy of Family Physicians points out that “family physicians have four times as much education and training, accumulating an average of 21,700 hours, whereas nurse-practitioners receive 5,350 hours. (2) Finally, doing without care, needs no explanation.

One large hospital in the Dallas area is now offering what they call a ‘Senior Clinic.’ Staffed by physicians or providers who are directly linked to physicians. A limited number of seniors can now seek care for their medical concerns in our community, if they are unable to find physicians who will accept them into their practices.

Is this what our senior citizens deserve? Waiting in long lines at a clinic set up just for them, possibly only seeing a substitute physician, sometimes being turned down for diagnostics and therapeutics that might add quality or prolong their lives. Isn’t that scenario hauntingly similar to what the Obamacare legislation is supposed to address in the crowded charity hospitals and clinics across the country? The difference is that instead of the uninsured these institutions will be filled with our senior citizens. I think we  (the seniors) deserve better!

  References:

  1. http://www.washingtonpost.com/blogs/wonkblog/wp/2013/04/03cancer…away-thousands-of-medicare-patients-blame-the sequester/?hpid=z1
  2. http://blog.aarp.org/2013/03/29/nurse-practitioners-the answer-to-the-doctor-shortage/