Published in the Orange County Register: July 24, 2013

The Affordable Care Act, such as it is, was never about care and it is surely not affordable. The fact that it is inoperable is no surprise to those of us who read the bill. Like a malignant tumor, the law has wrapped its head around the most integral and vital parts of our cultural anatomy.

Being human is about the opportunity for a productive life. America, by reputation, has been the world’s poster child for finding a means to that better life. But that can only happen with a healthy economy and when our own personal health is good. Chopping away at this tumor one piece at a time will not save the patient. Moreover, prolonging the life of this sick, dying law is expensive and agonizing for all of us. That is how our patients feel – they feel sick.

Every morning there is a new report of an additional disaster associated with the implementation of the ACA, bringing new questions to the minds of all Americans.

Many patients want to know what the law will mean for them. To not have an answer is painful and frustrating. It’s no different for those of us on the professional side of the question. We don’t know what it means for us, either. Should I sell my practice? Move my practice? Work for a hospital? Work for an insurer? Retire? None of that is reassuring to our patients.

Sadly, when it comes to solving Obamacare, there is no surgery, no prayer that can salvage what was written but never read, was ill-conceived and even more poorly executed. So what do I tell my patients?

I tell my patients what I have always told them. Find a doctor who you can get to know and trust. I tell them insurance is not assurance of anything. While the ACA does not promise any patient that they can keep their doctor, it could open up avenues for new relationships. Doctors, like patients, are looking for ways out of the bureaucratic morass and are adopting cash practices. Posting retail prices and allowing patients to buy health care directly from their doctor is the “new Marcus Welby.” Price-fixing and increased regulations only serve to increase the cost of medical care and decrease availability of physicians. The irony is that this “cash for care” solution does what the ACA intended all along.

Affordable accessible care will emerge when the patient and the doctor can be accountable to each other. The sanctity of the patient–doctor relationship is preserved when there is a direct fiduciary relationship. Americans with a vision will always find a way to make the world a better place if given the opportunity.

In the end, keeping the government out of the exam room and the politics out of the medicine jar will be therapeutic for both patients and doctors and probably for the national budget.

Marcy Zwelling-Aamot, M.D., is the vice chair of the American Academy of Private Physicians.

Published in the Orange County Register: May 21, 2013

A little-known loophole in California law has created dangerous financial arrangements between health insurers and pharmacists, placing the health of many California patients in jeopardy and raising questions about just who is in charge when it comes to health care decisions.

California health insurers are currently allowed to provide a financial kickback to your pharmacist each time that the pharmacist switches your medication to a cheaper and non-chemically equivalent alternative than what your doctor has prescribed.

Doctor decisions about what treatment is best for patients are not serendipitous decisions. Treatment decisions are based on a variety of factors, including years of medical training, patient history, cost and availability, current studies and medical literatures and broad knowledge of the full universe of treatment options.

One local pharmacist refused to give one of my patients his medication that he had been on for years to control his atrial fibrillation simply because the pharmacist decided the patient was too old. Another patient was refused medication because he had a history of prostate cancer and his pharmacy would not allow him to take a drug offered by his internist after the internist had consulted with the patient, his oncologist and his surgeon.

This is not simply an issue about money – the lives of California patients potentially hang in the balance. Switching patients to drugs from a different therapeutic class – that is, non-chemically equivalent drugs – means that patients are exposed to different ingredients and dosages, and that the drugs come with different side effects.

Often, patients do not know that their pharmacists are not legally allowed to give medical advice. Although some pharmacists get around this regulation by saying they are only consulting, not prescribing, that is a semantic difference that often leaves patients in a dangerous place. The practice of providing pharmacists financial incentives to therapeutically switch patient medication must stop.

The California Legislature is currently considering Assembly Bill 670 that will make it illegal for a pharmacist to change a medication from one therapeutic class to another and get a kickback for making the change. AB670 is common sense legislation and a good first step to preserving patient confidence that decisions made about their care are based only on what is best for the patient.

Medications prescribed by a licensed physician should be executed at the pharmacy as they are written. This is not just a “scope of practice” issue. This is a life and death matter.

Marcy Zwelling-Aamot, M.D., is the vice chair of the American Academy of Private Physicians.

Published in the Orange County Register: April 18, 2013

Each day America is getting the news the Affordable Care Act is delayed, morphed, more expensive than expected, or failing. Americans were promised that it would change our health care delivery system forever. That part is surely true.

The promise that everyone will have insurance simply cannot happen because Obamacare has made insurance too expensive for the average American even with a subsidy. The alternative to pay the penalty of $1000 a year is a far better deal when you can buy insurance at any time with no penalty and at no added cost regardless of any pre-existing condition. Insurance under Obamacare is no longer an actuarial bet. It is becoming a perishable commodity available for intermittent purchase – not unlike the disposable cellphone.

As the risk pool becomes almost exclusive to those with an illness, the cost of a policy will only continue to rise, leaving those who would be in the healthy risk pool to find another means to access care. The “cash and carry” health care marketplace will likely find its way into any variety of retail establishments.

Flu shots are available at drugstores for cash. Why not buy direct at a cash lab in your local mall? The day is almost here when doctors and labs will post their lab prices at what will look like old fashion retail establishments. Talk about direct to consumer marketing.

It is true that Obamacare will distort the marketplace. However, Americans are much wiser than Congress would make them out to be. We know how to shop. Prices will become competitive and many Americans may finally have access to affordable health care. At least in this we may be able to thank Obamacare for the opportunity.

Marcy Zwelling-Aamot is past president of American Academy of Private Physicians.

The Audacity Of Power: President Obama Plays The Bully

By Charles Kadlec
March 11, 2013

http://www.forbes.com/sites/charleskadlec/2013/03/11/the-audacity-of-power-the-obama-administration-as-the-bully

In one of the most blatantly political moves in U.S. history, President Barack Obama, members of his Cabinet and his Senior Advisors have decided to use the vast power of the federal government to bully the American people into giving them even more control. By so doing, he exposes the big lie of the Progressive movement: that big government is benign, or to put it more precisely, the men and women in public office can be trusted to use their power for the public good.

Instead, the President has chosen to abuse the powers of his office to serve his political ambition. As reported by the Washington Post, the President’s tactics surrounding the battle with Republicans over the $85 billion in automatic spending cuts required by the sequester had virtually nothing to do with fiscal issues at hand, and everything to do with his desire to flip the Republican House of Representatives back to Democratic control in 2014. With a Democratic House and Senate, he could push through the rest of his Progressive agenda on gun control, immigration, climate change and taxes during the last two years of his Presidency.

To achieve that goal, the President willfully sought to mislead the American people by claiming, falsely, the sequester was a Republican idea when, as we now know thanks to the reporting of Bob Woodward, it originated inside his senior staff. In another untruth, the President said the sequester would lead to janitors and security guards on Capitol Hill taking a pay cut. And, his Secretary of Education Arne Duncan told reporters a school district was already laying off teachers, which also proved to be untrue.

Such prevarications are more than political hype. They are indicative of the general disrespect the President has for the truth and the American people. How else to explain the decision to cancel the high profile tours of the White House, denying thousands of high school students, boy and girl scouts, and average tax paying Americans the experience of walking into the White House. This action, which may come to symbolize the second Obama term, saves little if any money. Rather, it is calibrated to stir up as much anger as possible against the Republicans in the House. “Blame it on the sequester” is the new slogan of a President who believes in putting government first.

For those who haven’t yet gotten the message, more – and more serious initiatives – are underway to make sure the American people experience the brunt of the effects of a mere 2% reduction in government spending.

Before the sequester even took place, the so-called Department of Homeland Security released 2,000 illegal immigrants in its custody, more than 10 times the number Press Secretary Jay Carney originally admitted in a White House briefing. And, in brazen assault on the safety of the American people, DHS Secretary Janet Napolitano has announced plans to release an additional 3,000 detainees, bringing the total to more than 16% of those held by the DHS. However, Napolitano found enough money in her budget to stockpile 1.6 billion rounds of ammunition, and purchase 7,000 assault weapons.

There’s more. On the very first morning of the sequester, the U.S Customs and Border Patrol, also under DHS Secretary Napolitano, reduced staffing at several major international airports, leading to wait times in excess of two hours for 70 flights arriving at JFK, and 55 flights at Miami International Airport. In addition, DHS’s Transportation Security Administration issued a statement last Monday saying “travelers can expect to see lines and wait times increase as reductions to overtime and the inability to backfill positions for attrition begin to occur next month.” The TSA insists the sequester is forcing it to impose a hiring freeze on positions that serve the traveling public, but no word of staff reductions or redeployment of the thousands of its employees manning the bureaucratic front in Washington. And the week before the sequester took place, the Administration approved spending $50 million on new uniforms for TSA employees.

President Obama is also threatening the people with increased risk of life threatening illness and higher food prices. According to a White House fact sheet: “Outbreaks of foodborne illness are a serious threat to families and public health. If a sequester takes effect, up to 2,100 fewer food inspections could occur, putting families at risk and costing billions in lost food production.” Ignoring the statutory obligation to provide meat and poultry inspections is an action so extreme it was not taken by President Bill Clinton during the government shutdowns of 1995-6 when not one food inspector was furloughed. We can anticipate the next outbreak of food poisoning will be blamed on the sequester. Come to think of it, the President has given every federal employee a ready-made excuse for any mistake: The Sequester!

But, sequester be damned, the public servants in the executive branch are assured of the high life. As the Wall Street Journal reports, furloughs will not keep employees of the Agriculture Department from a resplendent conference in California featuring “‘exceptional local wines” and sampling ‘tasty dishes’ prepared by ‘special guest chefs.’” The USDA will also sponsor the Priester National Health Extension Conference in Corvallis, Oregon, a four-day event featuring an agenda to “‘provide resource support to professionals and community leaders working to improve community health.’”

Let’s not forget, this is the very same President who in August 2011 used senior citizens as pawns in his battle with House Republicans over the debt limit, threatening then to withhold Social Security checks in spite of the payroll tax revenues flowing into the Treasury and $2.7 trillion in Treasury securities held in the Social Security Trust Fund. He is also the President whose Health and Human Services Secretary ruled the Catholic Church must provide its employees with insurance that covers activities it has long considered sinful –including the abortion inducing morning after pill and contraceptives. He then used the predictable resistance by the Catholic Church to this trampling of the First Amendment guarantee of the free exercise of religion to conjure a “war on women” as part of his 2012 presidential campaign.

And now, even as he makes a show of “reaching out” to Republican senators, Peggy Noonan reported in her weekly Wall Street Journal column that his political operatives at Organizing for Action issued a blast email signed by his 2012 deputy campaign manager, Stephanie Cutter, claiming the sequester would produce more mayhem ahead for the American people including the loss of “100,000 ‘teaching jobs… 70,000 spots for preschoolers in Head Start, $43 million for food programs for seniors, and $35 million for local fire departments’ and nutritional assistance for ‘over half a million women and their families.’”

Capturing control of the House of Representatives has become President Obama’s top priority. The loss of property, income and life suffered by the American people are acceptable collateral damage in service of his will to power. Such an assault on the American people reveals that when then candidate Barack Obama spoke of a “post partisan Washington” on his way to winning his first term in office, what he had in mind was a one party state that would do his bidding and yield to his will. If his strategy is successful, we can only imagine the lengths this President, or some future President, would go in the use of the federal government’s power to attack the American people in order to achieve a political end.

Tyranny Obama style may not be at the point of a gun. Rather we will find ourselves coerced by the threat of dangerous food and long lines not only in our airports, but at the front door of every medical facility that soon will be under the effective control of the government through the rules and strictures known ironically as ObamaCare. This potential reality is the true audacity of President Obama’s quest for power.
–
Charles W. Kadlec

Published in the Orange County Register: March 8, 2013

LOS ALAMITOS, Marcy Zwelling-Aamot, past president, American Academy of Private Physicians:

Sen. Ed Hernandez, D-Covina, chairman of the state Senate Health Committee, admits that there are not enough physicians to treat California’s patients in 2014 when more than 2 million persons get their new insurance cards. To fill the void his answer is to expand the “scope of practice” of nurse practitioners, optometrists, psychologists, physician assistants and even pharmacists. But, California’s physicians know that this move could compromise patient safety. Dumbing down health care will not make it more efficient or effective.

Professionals trained in medical ancillary services have an important service to offer our patients but not as physicians. Physician services are specific in their own right. Physicians are trained to prevent the unlikely and/or to recover the rare adverse occurrence. While it may seem as though our work is thoughtless and routine, that’s proof of our professional expertise.

Doctors have been forced to increase patient volume as reimbursements have decreased. Government regulation has forced physicians to spend time behind a computer or filling out paperwork. Hands-on health care has been replaced with protocols and processes.

It is true that nurse practitioners on average take more time with patients, and patient satisfaction is greater when a provider spends time. Expanding the scope of practice for ancillaries may be the Legislature’s answer to maintaining or enhancing access to health care, but it is not the answer to how our state can control health care costs or improve the quality of care we deliver.

The good news is that the private marketplace is coming to the rescue. Right here in California, working with Stanford University on a computer program for health care, the private market is developing an IBM Watson super computer to elevate the intellectual capacity of doctors and make our work more efficient. Technology has re-invented the operating room and information technology can now expand opportunities in the exam room.

Expanding the expertise of our doctors is a far better answer to improving the efficiencies of the delivery system. Allowing the ancillaries to work with physicians rather than replace them allows all professionals to reach their nirvana and improves the quality of care.

The Affordable Care Act presents innumerable economic conundrums for the state. As it unfolds the government will try to patch and mend where it can. But let’s not allow the state Legislature to dismantle the integrity of what is good about health care: the opportunity for every patient to see a professional physician.

The private marketplace has always been the American answer; it still is.

As a member of the Los Angeles County Hospital Commission, I have access to “those in the know” at the Department of Health Services to learn their strategy for working with the state and federal governments to fulfill the obligations of the Patient Protection and Affordable Care Act (PPACA).

At the last meeting I asked a most basic question, “The federal government has promised to fund our Medicaid program in full for the next 3 years. What does that mean? What if they run out of money or refuse to fund the existing program plus the additional 2.3 million (or more) persons expected to be eligible?” The answer was silence. There are no plans. It would seem that no one believes that the government could run out of money.

We heard this weekend that the federal government has already hit the wall and can no longer fund the Pre-Existing Condition Insurance Plan. This is the federal plan designed to be a bridge for those with pre-existing conditions who cannot find insurance until PPACA takes effect in 2014 when all persons will be able to purchase insurance at the “community rate.”

The PCIP plan has a $2000 deductible and patients pay 30% of most of their expenses except preventive care that pays 100 % of the cost. But the premiums are still between $400 and $650 per month (Massachusetts being among the most expensive). In Orange County, the rate is $481 for those 60-64 for the PCIP and $1200 per month for the MRMIP program, the state run program for those with pre-existing conditions.

Initially, patients were not signing up in large part because of the cost and because patients were required to be without insurance for 6 months before they could become eligible for the plan. Now, they can’t sign up for the federal program at all. Those already in the program will remain covered… for now.

Now that we have learned that we cannot expect the federal government to feed our every need, is it finally time we start to take back our lives and assume some personal responsibility? Sadly and once again, the government has compromised the integrity of our financial and insurance institutions, making health care more expensive for everyone. And this before PPACA rolls out.

Expect further delays and closings. After all, the country is bankrupt.

This past week, we witnessed the second inaugural of President Barack Obama. His speech was telling not only as a window into his vision for America’s future but also as a reflection of his personal interpretation of the Declaration of Independence and that may shine a light on what we might expect as the Affordable Care Act rolls out over the next several years.

Our Declaration speaks out on human equality, specifically as an opportunity. But Obama warns us: the constitution’s words are only a “never ending journey to bridge the meaning of those words with the realities of our time.” There is no more ominous “reality of our time” than the government takeover of the healthcare system. We can expect a vigorous debate over the meaning of what is “fair” and how the new progressive understanding of equality might play out in patients’ health care opportunities under the new law.

Will every patient be offered an equal opportunity for cancer therapy? Or will the government limit opportunities as regulators try to pigeonhole all patients and doctors into protocols based on population based outcome analysis. North Korea has population based everything. Do we really want to give up our right to direct our own healthcare vision and strategy?

The bottom line always comes down to the question, who owns your life? It’s time for Americans to answer that question when we go to the polls in 2014. Let’s start that conversation now.

Foreseeable and (perhaps) Intended Consequences of our Health Care Law

Of late, PPACA (the Patient Protection and Affordable Care Act) has come under fire from employers, employees, doctors, patients, and legislators. Having followed Congresswoman Pelosi’s admonition to “pass it so we could find out what’s in it,” the world has come to conclude that PPACA does not protect patients, is not affordable, and has nothing to do with care.

The taxes including the mandate tax will hit even the lower middle class. Those who cannot afford the huge benefit package that has been mandated by the law will be forced to pay the tax. It’s the right choice for some when the options are food for their children or insurance that covers fertility care. But, weren’t we assured that this was about helping the poor? Really?

The device tax has forced some medical device businesses to fire employees. Welch Allen has slashed 160 jobs over 3 years and Stryker has let 5% of its workforce go in order to comply with PPACA. Some companies will surely pass the 2.3% tax down to the consumer. Weren’t we told that this law would hold down healthcare costs and be good for the economy? Really?

Employers with more than 50 employees are finding it necessary to move full time employees to a part time position in order to stay “in the black.” Companies with more than 50 employees cannot afford the benefit package they would be forced to purchase for all their full time employees. The CBO projects millions of Americans will lose their insurance when their employer is forced to pay the fine rather than provide insurance.

Weren’t we told that patients would be able to keep their insurance? Really?

Employees will not just lose their insurance. Many are losing their doctor because doctors are quitting or closing their practice to become an employee of a hospital or an insurance company. Those patients who are able to follow their doctors have found care to be much more expensive when the doctor is employed. Further, they are not given the time they once had with their trusted physician because the doctor is on a “schedule” and must prove his productivity or risk being fired. Weren’t we promised higher quality, lower cost, more consistent care for all? Really?

And yet, the only thing we hear thru the media is that the government is building yet newer and better financial healthcare models: models that still fail to address basic economic theory.

The idea of basic market economics and healthcare remains anathema in any dialogue about fixing our dismantled medical care system. Practicality is lost in paper work and process.

We have data that proves that when a patient pays for their care, the demand is appropriate (as opposed to stifled when a patient must receive permission for a test or lavish if not unnecessary when free to the consumer and paid by a third party). The government loves to talk about the cost curve but no one knows the cost of care. When told that a chest x-ray can be purchased for $35, patients are surprised (pleasantly) and when offered the opportunity to pay $350 for their MRI or wait a month for an authorization, checkbooks come out.

It works for food, clothing and shelter, why not for healthcare? Why should the value of my medical expertise remain a secret? Why shouldn’t I be able to compete with other doctors by posting the price of my expertise and expecting to get paid directly by the patient. Why is healthcare always an exception to the rules of human nature?

None of the news is unexpected.

Those who deal with real people know that we could have expected Americans to respond logically and in their own interest. The problem resides in the fact that PPACA is a political circus imposed on good people trying desperately to take care of their lives.

Expect things to continue to dismantle until Congress writes legislation that gives patients control of their own health care dollars.