Archive for December, 2011

Living with Medicare’s Moral Bankruptcy

Nothing speaks to the truth like the acrid odor of reality.  The bite can be surly leaving us with no where to go except to work with it.  So it was today when I faced our new Medicare reality.  Its ugly.  Beware as you read on.

No, there are no death panels.  It is worse.  

Today, my patient was helicoptered to an ER from a cruise ship where she fell and was unable to ambulate.  She came to the hospital where I practice specifically so I could care for her.  I have known her for well over 20 years. But, upon admission to the ER, she was evaluated and sent home in an ambulance unable to walk with her 85 year old husband.  No call to her doctor.  No call to her children.  Oh, and did I mention that she was given opiates for her pain.  Had the ER doctor called and asked, I would have told him or her that opiates make most seniors crazy and put them at risk of falling but my patient can't take them at all.  

Her daughter called me today having found her mother lying in her own urine.  The ambulance company had delivered her to her bed and left her there where she couldn't move. I called the hospital and learned, this is the new Medicare.  As a matter of fact, I learned that twice today.  My patient's daughter was so concerned about her mother's condition she had her mother transported to an ER where her orthopedist was on call.  Evaluation there demonstrated no fractures and again she was sent home having been told that this was a custodial issue and hospitalization was not covered by Medicare.  Nothing was done to assure her safety. No call was made to her doctor. No follow up was expedited.  

No tears … I will call a home health agency in the AM and make sure she has a foley catheter so she doesn't have to lie in her own urine.  Her family has already paid for 24 hour care giver to stay with my patient until we can arrange for PT to help her bear weight. Then, we will get her into rehab and get her walking again, provided that her hip and knee are really okay.  In seniors, we often find tiny chip fractures or other abnormalities on MRI when we thoroughly investigate why they can't bear weight or walk.  Thank goodness, my  patient has a wonderful family who will help.  But, millions of seniors have no family and no committed doctor.  They are left to lie in their own urine… the new Medicare.  No its not a death panel.  It really is worse.  Sometimes, death comes as a matter of respect to our integrity as a human. Being left to lie in our own urine is disrespectful and not human and when executed by the medical community as a matter of course, it is unconscionable.  Welcome to government run healthcare.  Welcome to a morally if not fiscally bankrupt Medicare system.  

I fear it will only get worse.  As 2012 approaches, I have already received notification from Medicare Part D about my patients medication coverage. So sad, too bad… the meds your patient has been taking for 20 years to keep him or her alive is not covered.  Doctor….. take care of it. Now it is in my hands and depending on my patient's bank account, I will or will not be able to provide the help they need.   And I have 3 days to find a solution before the new year.  

And we all understand that Medicare cannot cover custodial issues.  But, when did we stop providing for the safety and welfare of our seniors?  When did it become okay to leave them to lie in their own urine ?  Congress is busily debating the SGR and what they are going or not going to pay me. Does that really matter if we have lost sight of human dignity?  Isn't it about time we put our patient's life and safety as our focus rather than how many benefits Obamacare will cover?  Medicare is not just fiscally bankrupt.  It has been stripped of any decency.  It is morally bankrupt.  

This is the Medicare that Congress promised not to change.  This is the Medicare that President Obama promised to preserve.  Perhaps we would be better off if those in charge just showed our parents and grandparents some respect.  That would be priceless.  

my letter to the editor: WSJ

Medicare Reform Requires that Americans take Personal Responsibility 

I am thrilled that there is bipartisan discussion about Medicare reform.  Paul Ryan and Ron Wyden should be commended for their efforts.  But, as big as this reform may seem, it does not transform Medicare or our healthcare delivery system.  It is not the solution to the question, "How do we create a healthcare delivery system that is both affordable and accessible to all Americans?"

Moving some of the risk from the public sector to the private sector will start to take the pressure off our national debt crisis.  But, like alcohol, the idea of premium support only masks the problem and is inebriating in the short run.  The cost of Medicare continues to climb at an accelerating pace and will continue to do so as long as the recipients of Medicare have no "skin in the game."  Moreover, no insurer or public entity can continue to pay for a benefit package that persistently grows beyond things medically necessary like the infamous and well-advertised motorized scooter (at absolutely no cost to you).  

No insurer or public entity will be able to afford to take the risk of a medical insurance policy until that policy resembles insurance, an actuarial bet to protect the purchaser from financial catastrophe.  Congressmen Ryan and Wyden make it clear that their legislation would insist that all competing plans be at least as comprehensive as Medicare.  The cost of these competing benefit plans will be boundless and not affordable to most Americans, much like commercial insurance is today.

Americans love and deserve choice but choosing a favorite requires that there are distinguishing features. As it is, most Americans don't choose their insurance, their employers do. And when offered the choice, the plans are so confusing and incomprehensible, no ordinary American can decipher them.  My patients generally ask me what to choose. I love the idea of choice but with the mandates placed on the private insurers, I'm not sure where the choice would come.


Reforming Medicare demands that Americans take back the responsibility of their own health.  Freedom is NOT free.  The right to self-determination with regard to medical decisions requires a transparent, market-driven system where doctors and hospitals post their prices and patients pay directly for those services that are not insurable. Preventive care, for instance is not insurable.  

Preventive care includes everything from wearing a seat belt (not paid for by the government or any insurer), eating healthy food (also a personal responsibility except in the case of the very poor), to having your cholesterol checked routinely  A mammogram at this time is $75.00 cash.  A Chest-x-ray is $35.00 cash.  A routine doctor's visit is usually less than $100.  A lab test to check your cholesterol is less than $15. This is affordable healthcare that when paid for by the patient does not require a special form or an authorization making it much more available than it is even now when paid for by insurance. 

I believe that most Americans do feel the moral obligation to pool our resources and take care of those who need our help.  Cancer is an unforeseeable medical catastrophe that should be covered by insurance, whether public or private.  But most Americans do not want to pay for their neighbor's blood pressure medication particularly when their neighbor is overweight and spends Sundays eating potato chips in front of their television.   That neighbor should buy his own medication and that medication should be affordable in a transparent marketplace.


It is reasonable and wise to ask Medicare to compete with private insurers but only if we truly reform the system into a legitimate medical insurance system.  At the same time, things not insurable should be able to be purchased in a transparent marketplace.  If personal responsibility and the opportunity for patients to buy non-urgent medical care directly is not central to Medicare reform, we can only expect that the problems of accelerating costs and lack of access will intensify and hasten the death of what was once the best healthcare delivery system in the world.

 

Marcy L Zwelling-Aamot, MD FACEP

Chair of the Board, American Academy of Private Practice

562-900-2650

marcy@choicecare.md

Regulators and doctors must work together to ensure safety of biologic medicines

THE HILL
 

Regulators and doctors must work together to ensure safety of biologic medicines

By Dr. Marcy Zwelling-Aamot, chairperson of the Board of the American Academy of Private Physicians (AAPP) - 12/15/11 04:41 PM ET

The U.S. Food and Drug Administration (FDA) is holding an important public meeting today on its proposed biosimilar user fee program recommendations.  This meeting is a major step in making biosimilars available for the first time in the United States.  Biosimilars will benefit the patient community-at-large – but only if important safety measures are adopted.

Biosimilars are the lower cost imitative versions of biological medicines, which are advanced therapies made in living systems.  These cutting-edge medicines treat non-Hodgkin’s lymphoma and several other cancers, Hepatitis C, and even Multiple Sclerosis.  Over 350 million patients worldwide have benefited from approved biologic medicines, and over 650 new biologic medicines and vaccines are being developed to treat more than 100 diseases, yet there are no “biosimilar” versions of these products available in the United States.

In 1984, when Congress enacted legislation ushering in generic versions of chemical drugs, biologics were not included as they were considered “too complex”.  Yet a provision in the 2010 healthcare reform package authorized the FDA to figure out how to approve biosimilars for cost saving purposes. The FDA is expected to issue its guidance, known as the “biosimilars pathway” by end-of-year.  Industry, physicians and patients are waiting intently to see what measures will be included.

Patient safety is vital because biologics pose challenges above and beyond traditional chemical medicines.  Unlike traditional drugs that are made from chemicals, biologics are very complex compounds whose characteristics and properties are highly dependent on the manufacturing process. Due to their complexity, these compounds can sometimes have unexpected or even adverse effects in patients.

It appears the FDA recognizes the unique challenges of biologic and biosimilar medicines.  In its proposed recommendations for a biosimilar use fee program, it refers to the “nascent state of the biosimilars industry in the United States” and notes the “complexity and level of effort required for FDA oversight of manufacturing and post-marketing safety issues.”

Accordingly, to ensure patient safety and efficacy of all biologic and biosimilar medicines, the FDA will have to implement robust clinical and nonclinical measures.  This includes clinical trials, unique proprietary names to reduce medication errors and a track and trace system in case a patient accidentally gets sick from a medicine.  Above all else, we must ensure that the patient-physician relationship is maintained.  Only patients, in consultation with their physicians, are in a position to make critical medical decisions.

It is worrisome that upholding the patient-physician relationship has not been endorsed by the U.S. American Medical Association (AMA), the professional body of doctors that has large influence over national and state healthcare laws and regulations.  In a recent meeting in New Orleans, the AMA amended its position on biosimilar medicines, enabling a pharmacist to switch a patient from a biologic to its biosimilar version without expressed consent or even knowledge from the patient or the physician.  This policy is misguided because it could hurt patient choice and access to all biologic products and complicate patient safety.

As a physician residing in the state of California, I want what’s best for my patients.  We must ensure that all drugs are safe and work, no matter the cost. As biologic medicines are much larger and multifaceted compared to traditional medicines like Tylenol or cholesterol drugs, we cannot apply the same thinking to their approval process and policy guidelines.   So far it appears the FDA recognizes the importance of patient safety but it’s critical that physicians and regulators work together to ensure these measures are ultimately adopted.

Dr. Marcy Zwelling-Aamot, whose practice is in Los Alamitos, is the former president and current chairperson of the Board of the American Academy of Private Physicians (AAPP).

Source: 
http://thehill.com/blogs/congress-blog/healthcare/199773-regulators-and-doctors-must-work-together-to-ensure-safety-of-biologic-medicines
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Medicare’s Economic Reality: Not Sustainable

It’s December and once again Congress must decide how it is going to pay America’s doctors.  The Sustainable Growth Rate, the formula the government uses to formulate the payment rate has been found to not be sustainable at all. This is only one problem with financing our healthcare delivery system but every year in December, it becomes a pressing issue. How much will the government threaten to cut doctors’ pay?  How many doctors will quit Medicare?  How long can this go on?  

 

Don’t expect any solution to the Medicare financing crisis any time soon.  In order to find a solution, we must start asking the right questions and we have to face a bit of economic reality. I have not heard any politician come close to an honest discourse about the economic actuality of our healthcare delivery system failure.

 

The nation is finally coming to understand that Medicare is “not sustainable.” It is just a fairy tale to pretend that the government can continue to pay for all things for all seniors.  And it is not honest to call Medicare just an insurance policy. Truly, the Medicare program has become a medical bank that pays for all health related “things” for all seniors including scooters and persons to clean your home if you are not able.

 

Any politician promising that this can continue is only pandering to assure his or her own election. “Not sustainable” does not just mean that young Americans won’t have Medicare as we have come to know it.  “Not sustainable” means that Medicare and the entire healthcare delivery system must change NOW:  for Seniors NOW, for everyone NOW.  The system is broken and we have to deliver medical care better and less expensively for everyone.

 

It is foolish and naïve to think that any mandate (whether constitutional or not) will fund medical care for all.  Universal insurance coverage does not change the healthcare delivery system. It does not improve access and it does not make things less expensive. Further, in every insurance market including the Medicaid market, there are about 15% who choose not to participate regardless of the cost.  In fact, the Medicaid market has been very difficult to penetrate even though the insurance is free to those who qualify.  A mandate only allows us to create another expensive, burdensome bureaucracy to chase down “violators.” 

 

If we more fully examine why medical care is SO expensive, we can only conclude that it is government regulations that add dollars to the expense column but nothing to the quality of care.  “Pay for Performance” programs have been an abject failure.  Programs that punish those who don’t comply don’t change habits.  More government interference does not make for better healthcare, enhance outcomes, increase the number of insured, or decrease the cost of anything. 

 

When Congress authored the Medicare bill back in 1965, people lived on average, to about 64 years of age.  It was never intended that the Medicare tax would actually pay for any senior’s medical care.  If there were some dollars paid out, it would only be for a very short period of time.  Now, we live longer and retire earlier.  It is nonsense to expect the government to pay for a senior’s medical needs for 30+ years when they paid into the system at a marginal rate for only 40 years. 

 

If America were willing to concede that Medicare should work like a real insurance system (an actuarial bet to protect the purchaser from financial catastrophe), we might be able to make things work.  The government would only be responsible for covering a medical catastrophe.  That would require that seniors purchase re-insurance from commercial insurers and we would need to turn the outpatient marketplace into a transparent competitive market.

 

The good news is that this would definitely make healthcare at every level more affordable and more accessible.  Moreover, it would allow the government to fund either directly or through voucher systems a real insurance program and not go bankrupt.  It would also allow for more personal choice and demand that physicians be directly accountable to their patients. 

 

The vision of affordable accessible high quality care can only be met without government interference.  This bite of economic reality could mean a sweet transformation into an accountable medical care delivery system but only if our legislations come to the table looking for real answers.