From the AMA November, 2018:

“The dysfunctional U.S. health system may be working to improve hospital and payer bottom lines, but it’s not working as intended for patients or the doctors that care for them,” according to the head of the country’s largest physician organization.

At the AMA’s interim meeting, American Medical Association President Barbara L. McAneny, M.D., said, “The healthcare system often gets in the way of actual healthcare. This can be seen in payer issues, such as restrictive prior authorization and the industry’s ongoing appetite for consolidation,” she said.

If we look back to prior Blogfinger posts on this subject, starting in 2013, our 2014 and 2016 updates are of particular interest.  The comments from readers are particularly enlightening, and  my concerns remain valid.

BF ACA post two years ago, but still relevant

3 years ago I said on Blogfinger, “Some of you have berated me for having a negative attitude regarding Obamacare. The truth is that many good things will come out of our new healthcare system, but I am alarmed by the negatives which continue to slowly drip out the cracks and insinuate themselves seemingly overnight and unannounced into our experiences with doctors, hospitals, drug companies, etc. I am concerned that the negatives will outweigh the positives and cause damage to our loved ones as they seek care.”

2 years ago I said on BF:   “When Obamacare first was passed, I wrote a series of articles on Blogfinger predicting that this new healthcare system would compromise the doctor-patient relationship and would reduce quality of care. I sensed that early, because it was clear that doctors would not be able to provide highly individualized care, as they have been trained to do. Maybe formalized care using guidelines and physician extenders would work for most medical issues, but it is those cases with the quirky and concealed elements that separates the men from the boys in medicine, and then mistakes are made and patients can suffer.

How do doctors feel about their jobs in 2016?

In 2018 we have been focusing on a number of related issues:

a. Republicans have been talking about repeal of the ACA, but in view of the recent election giving the Dems control of the House, that won’t occur.

b. The use of “mid-level” providers  (MLP’s) such as PA’s and NP’s has soared across the country, both in doctors’ offices and in hospitals. A recent report found that office visits to such providers  (usually functioning as primary care professionals) has gone up 129% in primary care offices, while visits to primary care doctors have dropped about 18%.

Surprisingly, the fees paid for these mid-level providers are not much different than the fees for primary care office visits with physicians.  So the cost savings may not be there.    This seems to be more about dealing with physician shortages and physician burnout.   In some states, such MLP’s are allowed to open their own offices.  But who’s to say that all this lower level care is good for quality?

c. Another change is the implementation of “team care” in hospitals where MLP’s and medical assistants follow protocols such that doctors are not needed for certain steps in a process, such as trauma care.  I believe that this is potentially dangerous especially when acute care situations are concerned

d.  These physician “alternates” are supposed to free up physicians for more complicated tasks, but it does not always work that way.  The AMA has stressed that all these new patterns of care must be be supervised by physicians, but that often does not work that way either.

I remain concerned about quality of care.  These new approaches may result in more mistakes being made, but I haven’t seen any studies that look into that.

However, I have had personal experiences with this topic, and others tell me about their own worrisome events.   There is reason to be suspicious, and all patients need to be alert, informed and willing to question.  Here are some recent concerns:

—-Electronic medical records are improving, but they don’t live up to the promise so far.

—-Communication between doctors has deteriorated.  Electronic check lists are passed around, but not enough person to person conversations are occurring, even as healthcare continues to become more complex.  Important facts do fall between the cracks.

—-It is difficult for patients to speak to physicians.  Instead the patient is forced to talk to a MLP, and the physician may  be cut out of the loop altogether, and some issues may be missed.

—Medical offices are more likely to be run by corporate efficiency experts who may not even discuss practice procedures with physicians who know best what quality care requires, but they may be powerless employees. This results in physician cynicism, frustration, and early retirements.

——There are too many routine office visits and routine testing done.  It seems like every doctor has some sort of shtick (ie procedure or excuse for an office visit) which may not be necessary. It often looks like churning to make up for declining reimbursements.  One specialist told me that his group is requiring that he conduct 10 minute office visits—outrageous!

For example, Medicare patients who are doing well must return for office visits but now, in addition, there are prevention visits to go over information that could be taken care of at a routine visit.   If Medicare weren’t paying for these special visits, they would not be deemed essential.

I love Dr. McAneny’s quote,  “The healthcare system often gets in the way of actual healthcare.”  This a very insightful remark, and we all need to remember what she said, and keep our eyes open.


Crazy for you…

Ft. Myers, Fla. January, 2015. By Paul Goldfinger ©

Ft. Myers, Fla. January, 2015. By Paul Goldfinger ©



Sun makes dramatic re-appearance the next morning, 11/16/18, at 9 am, as predicted. Wegman’s Ocean.  Blogfinger photo. ©




Piazza della Signoria by Eric Lindbloom. This image introduces the book of this collection from Florence, Italy 1994.


By Paul Goldfinger, photography editor @Blogfinger.net

In 1994, American photographer Eric Lindbloom published his book, Angels at the Arno, containing  images in Florence from 1979-1987.

The preface says, “This is a city not so much of paintings and trattorie as of mysterious, hidden sculptures, emerging from the ancient architecture like stone made flesh. As Linda Pastan writes in her preface, Lindbloom’s Florence is “transformed from a city of blaring car horns and leather vendors, impressive piazzas and forbidding facades to a quiet place of small streets and courtyards, of homespun angels whose wings throw light and shadow over everything, even at high noon.”

I saw this collection in 1994 when an exhibit at the Howard Greenberg Gallery in SoHo featured this body of work. As a photographer I was impressed by the soft richness of his images, especially since they all were obtained with a Diana camera, a plastic toy.

Cameras such as this have imperfections due to light leaks and a plastic lens, but in the right hands, they can create remarkable photographs.   There is a cult following for this genre.

I purchased a signed copy of this book at the exhibit as well as one of his prints, all of which were beautifully crafted in the dark room.

Lindbloom, born in 1934,  has continued to exhibit his black and white landscapes, with his most recent gallery show this past summer at Vassar College in Poughkeepsie, New York.  He is one of the founders of the Center for Photography in Woodstock, NY.



Published 1994.


From the soundtrack of the Godfather III.

“Va, Pensiero.”   Nabucco by Verdi.


An Ocean Grove resident was handed this today by Code Enforcement. March 4, 2014.

An Ocean Grove resident was handed this today by Code Enforcement. March 4, 2014.



Ken Buckley–crusader for fines if you don’t clear a path.


Into the woods….

Ocean Township. By Paul Goldfinger ©  Click to enlarge

It keeps changing
I see towers
Where there were trees
All the stillness
The solitude,
All the time
When things were beautiful…”


SUNDAY IN THE PARK WITH GEORGE by Stephen Sondheim.  “Beautiful.”

Baby, I love your way….

Signs of the times:  Oakhurst, NJ. Blogfinger.net photo. 11/15/18




Stokes in a fog..

Stokes. By Paul Goldfinger ©


RUFUS WAINWRIGHT    (Rufus Does Judy at Carnegie Hall.)


In Apple Blossom Time

Paul Goldfinger ©. Ocean Grove.





Salisbury, England. She was not with us.This image was not posed.     Photo by Paul Goldfinger ©

Salisbury, England. She was not with us. This image was not posed.     Photo by Paul Goldfinger ©  Click to enlarge.


SALISBURY CATHEDRAL BOYS AND GIRLS CHOIR . “The Lord is my Shepherd” from the album Angels Sing. New Music from the Salisbury Cathedral.

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