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Archive for the ‘Healthcare Topics @Blogfinger’ Category

Disease was once thought to be due to sin. We now know more,  but not enough.

Edited and reprinted from a prior edition of Blogfinger.

By Paul Goldfinger, MD, FACC

Most people have high hopes when they go to a doctor with a problem.  They want to believe that their physician will do some tests, find out what’s wrong, and then fix the situation. That is usually what happens. However, doctors sometimes do not recognize their own limitations. They may not  like to admit to themselves or to  patients that they do not know what’s wrong and what to do. The fact is that there is much that doctors do not know and there is much that they do which is unproven.

Sometimes a physician will suggest a second opinion. That is always a good idea, but the patient should go to someone who is a known authority in the field, even if it means a trip into New York or Philadelphia. Seeing a real expert may help put a halt to the doctor-shopping.  But what happens when no doctor knows the answer no matter how many you consult?  What happens when a situation hits the wall of the unknown?

There is a parallel universe where people reside with persistent symptoms despite the best efforts of doctors.  I know someone who has chronic vertigo. He has seen multiple specialists in New York City and has had every possible test for this condition. No diagnosis or effective  treatment has been found. The patient is still dizzy; he has been seen by professors without answers as well as charlatans who waste his time and money. He makes the best of it, but he keeps looking for another doctor who might help. He scours the internet for solutions.

Most everybody has something physical that bothers them, and if there is no definite diagnosis,  they try to get by, one way or another.   Some get conventional care from their doctors, while others resort to alternative therapies and OTC medications.  Many simply accept their fate and lead their lives without further tinkering by the medical establishment. But the ones who keep bouncing around from doctor to doctor, without diagnostic or therapeutic success,  are the ones who need the most guidance from the medical profession.

Physicians sometimes need to stop the snowballing of tests and opinions. Stopping means to admit that the patient’s problem cannot be solved, so the doctor needs to shift gears and focus on attentive and supportive symptom relief. It’s difficult to judge when that time has come. It has to be a decision made by the doctor and his patient. But once the decision is made, the physician  should continue to follow the patient, because you never know when an answer might appear.

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Coffee time at Nagle’s. By Paul Goldfinger


This article was first published on Blogfinger in 2012. There is an update at the end.: *

NBC Nightly News (5/16/12) reported that a new study suggests that “coffee drinkers are slightly more likely to live longer than non-coffee drinkers.”

The Los Angeles Times (5/17/12) reports that for the study, published in the New England Journal of Medicine, “the National Cancer Institute researchers turned to data on 402,260 adults who were between the ages of 50 and 71 when they joined the NIH-AARP Diet and Health Study in 1995 and 1996.

The volunteers were followed through December 2008 or until they died — whichever came first.” The researchers found that, “compared with men who didn’t drink any coffee at all, those who drank just one cup per day had a 6% lower risk of death during the course of the study; those who drank two to three cups per day had a 10% lower risk, and those who had four to five cups had a 12% lower risk.”

Blogfinger Medical Commentary   by Paul Goldfinger, MD, FACC:

This is what we have to say about coffee in our book  “Prevention Does Work:  A Guide to a Healthy Heart” by Eileen and Paul Goldfinger, published 2011, prior to this coffee study:

“Coffee drinking confers no protection (against heart disease,) and some studies in the past have suggested an increased risk with coffee. If coffee is boiled, as in Europe, it can raise cholesterol levels, but if filtered, as in the U.S., it does not. In addition, some studies suggest a health benefit of coffee in lowering the risk of gall bladder disease and colon cancer. A recent trial suggested that coffee can protect against Alzheimer’s disease.

Some individuals are sensitive to the caffeine in coffee and can experience heart palpitations, anxiety and insomnia. It is not true that all heart patients need to eliminate caffeine, but you should check with your doctor. Watch for hidden sources of caffeine such as colas and dark chocolate.  One cup of tea has 50 mg., while coffee (brewed) has 135 mg of caffeine per 8 oz. cup. Colas contain 37-45 mg.in 12 oz, while dark chocolate has 30 mg.  in a 1 1/2 oz  bar.”

The trial described above is almost amusing since the relationship between coffee and dying in this study  is a happy one for those of us who like coffee, but it doesn’t give a clue as to how the relationship works.  Research trials in the past have been contradictory in terms of coffee as a risk factor for coronary heart disease.  In one trial, they postulated that the milk we put in coffee accounts for an increased risk. I’ve always been suspicious of that conclusion because the milk we use in coffee doesn’t amount to much.

Skim milk is awful in coffee, and half ‘n half seems to me to be a scary item.  Coffeemate contains high fructose corn syrup.  My own approach is to use skim- plus in my coffee  (that is skim milk with extra milk solids, so it is creamy, but is non-fat and has calcium and protein—a pretty darn good product in my anecdotal opinion).  But if I’m at Wegmans and get coffee, they don’t offer skim-plus, so I use whole milk because I can’t believe that the one ounce of milk will hurt me.

So, now that this New England Journal of Medicine study has been hyped by  the media, what have we learned?  My conclusion is to drink coffee, as long as you know about the addictive and cardio-stimulatory  potential of caffeine, and don’t worry about coffee as a risk factor for heart attacks.

Yet we all need something to worry about, so put coffee drinking on the back burner and worry instead about obesity, smoking, high blood pressure, diabetes, family history, hypertension, lack of exercise, stress, and diet.

And speaking of the latter, if you can, with your coffee, try to avoid the “and” which often accompanies the Joe.  If you have to fear your food, forget worrying about coffee and instead try being scared to death of Dunkin Donuts, fast food, cheese danish, cream puffs, twinkies, fudge cake, etc etc.  Avoid sugars of all types, bad fats, processed foods, excess calories and big portions.  Have a cucumber with your morning joe and eat more fruit and oatmeal. Then walk around the block.

OK, now if I can only follow my own advice

* Editor”s Note:   This coffee article was originally posted on BF in 2012. Now, in 2015, a new study from the National Institutes of Health shows that patients with stomach cancer experience reduced mortality rates and lowered recurrent cancer with coffee drinking.  The study was reported in the Journal of Clinical Oncology and studied 1,000 cancer patients.  The benefit was with caffeinated coffee, over 4 cups per day.  The research on coffee has also shown reduced risk of Parkinsonism, type II diabetes, and some cancers.  (August, 2015)

Here is a 2015 link:   www.nbcnews.com/health/cancer/coffee-aids-colon-cancer-recovery-study-finds-n411326

FRANK SINATRA    “Coffee Song.”

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By Paul Goldfinger, MD.  Editor @Blogfinger

An editorial * today in the Wall Street Journal is about Senator Schumer’s  (D-NY) speech yesterday regarding how the Democrat Party had made a mistake in putting so much effort into Obamacare instead of seeking other priorities including dealing with the sad economics of the middle class.

But what caught my attention was a paragraph at the end. As most of you know, I am a physician whose focus in the healthcare debate has been to see how the new system will affect quality care and, in particular, how it might compromise the doctor-patient relationship.

Until recently, there was very little information about quality issues—mostly it’s about insurance. But now that the ACA’s mandates and controls are being implemented, we will begin to see discussions about quality, and the quote below from that WSJ editorial actually says that quality is being negatively impacted and that the deterioration is due to the ACA.

At last, the conversation will, I hope, begin.

“Mr. Schumer is still missing the crucial point. ObamaCare is not merely a disaster for big government but a disaster of big government. The law is unpopular because its mandates, taxes and central planning are harming the economy and the insurance and medical care of average Americans.”

Schumer article  (WSJ Nov. 26, 2014)   *

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Restaurants with more than 20 locations fall under the calorie law.  Wall Street Journal photo

Restaurants with more than 20 locations fall under the calorie law. Wall Street Journal photo

From the AMA:

The Wall Street Journal (11/25, Tracy) reports that the Administration and the FDA are planning on unveiling final rules expanding calorie labeling on Tuesday. The rules will require restaurants with at least 20 locations to display calorie counts on their menus. In addition, the rules will apply to amusement parks, convenience stores, movie theaters, and others. The rules have been repeatedly delayed, and have faced significant opposition from the food industry.

The Washington Post (11/24, Dennis) reports that, according to FDA Commissioner Margaret A. Hamburg, “Americans eat and drink about one-third of their calories away from home,” and as a result “people today expect clear information about the products they consume.” Hamburg expressed hope that the new rules will aid people in making “more informed choices” about the food they eat. The Post adds that “activists who for years have pushed for more transparent and consistent menu labeling,” as a means of managing the nation’s epidemic of obesity, “praised the FDA’s action.”

Blogfinger Medical Commentary:  By Paul Goldfinger, MD, FACC and Eileen Goldfinger

In our book Prevention Does Work: A Guide to a Health Heart, we pointed out that rigid diets don’t create success in weight loss; instead, what matters more is the desire to change your lifestyle.

We said, “The trend now is to focus on portion size, calories, exercise and psychological factors such as motivation and sticking to the program.”   We also pointed out the need to increase intake of fresh fruits, vegetables and grains, while avoiding carbs. But counting calories is the most important component.

So yes, counting or paying close attention to calories is critical for weight loss, and you need to be careful of  hidden calories in restaurants and grocery stores.

However, most people who are motivated already  know which foods are high in calories. At the present time, most foods you buy in grocery stores have nutrition labels.

Do we really need more rules imposed on food businesses to alert you to calorie rich foods?   If you stroll into Five Guys because you crave a cheeseburger, fries and a milk shake or soda, do you need to know the specific amount of calories?  Isn’t it enough that you already know that your meal will be high in calories?   If you walk into a fine French restaurant, do you really want to see the calories listed on the menu?

Hidden calories in restaurants are often due to ingredients like butter which is used to enhance flavor.  But a customer who is concerned can ask about ingredients in a restaurant. Most people don’t want to know, and there is no obesity epidemic in French restaurants.

Grocery chains like Wegmans offer prepared dinners from fresh ingredients at low cost.  Trying to keep up with calorie counts on those items will be cost prohibitive, and your low-cost dinner will go up in price.  Don’t you already know that the fried fish is not as good a choice as the grilled chicken?  Then, it is up to you, not the government, to assess calories in your diet.

We  worry that those who really need the calorie disclosures are the ones who won’t read the calorie labels .  Consider cultural norms where high calorie foods are preferred such as carbs (rice and beans) among Hispanics and high fat foods (fried chicken/fish, ham hocks, fried steak, fat back) which are popular in the African-American community.

At NYU a study was done which suggests that more labeling requirements won’t help reduce obesity in this country.   What we really need now is more nutrition education in schools and communities.

And finally, we said, “Remember that one can gain weight with a heart healthy diet if calories are not limited.”  Do you recall the Seinfeld episode where Jerry and Elaine gain weight on non-fat yogurt?

RON MOODY  from original cast album of Oliver    (let those hungry kids finish the songs)

 

 

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Jersey Shore University Medical Center is the flagship hospital of Meridian Health. Internet photo

Jersey Shore University Medical Center is the flagship hospital of Meridian Health. Internet photo

Hackensack University Medical Center. Internet photo

Hackensack University Medical Center. Internet photo. There is no sign of a university medical school  near either of these hospitals.

 

By Paul Goldfinger, MD.  Editor @Blogfinger.net

According to a report in today’s Asbury Park Press, this merger of two large healthcare systems is being done because of “financial pressures” on both systems due to the Affordable Care Act, “better known as Obamacare.” It will result in the largest such system in New Jersey.

This is just part of a frenzied re-shuffling of the healthcare deck which we are experiencing all around us. Hospital mergers like this have been occurring over the last ten years, but they have been accelerating due to pressures resulting from the ACA.

For example, on the physician side, we have seen most of the oncologists in New Jersey joining together and then merging with similar groups in nearby states. All of this is part of a power struggle for health providers to stay afloat and make money. As far as hospitals are concerned, they are trying to become huge corporate players by swallowing up their neighbor hospitals and maneuvering private practice doctors into becoming employees. In addition they are becoming like Amazon.com, trying to be the providers for everybody for everything, including all sorts of outpatient services like imaging centers, physical therapy facilities, surgical centers, and even nursing homes and insurance plans.

The result of such consolidations might raise the cost of healthcare, even though Meridian-Hackensack claims that they will lower the costs, as promised by the ACA. The insurance industry is less sanguine about this point. Wardell Sanders, who is president of an insurance trade group said, “Providers and hospital consolidations are often sold as measures to increase ‘efficiency’, but ironically they often result in higher prices for employers and individuals as efficiencies can be overshadowed by higher charges that larger health care systems often leverage in negotiations.”*

In plain English, your insurance premiums will probably go up, sooner or later.  (Note: For the next few years, the Federal Government is subsidizing insurance companies to keep them afloat, but when those subsidies end in 2017, the cost of insurance will go up more, even as they are already going up for some now.)

You will be told that these consolidations are about quality care, but I seriously doubt that, having experienced a hospital merger in Morris County first hand in the late 1990’s. In this  Meridian-Hackensack instance there is minimal talk about quality, with some vague references to prevention as a way to reduce costs. I am very skeptical about that point, and on Blogfinger, we have been focusing on quality concerns since the ACA appeared on the scene.

The first thing that happens when hospitals merge is that employees are fired in large numbers to save money, especially at the hospitals that are deemed expendible after a merger. This is accomplished by consolidating services, such as neurosurgery (ie “neurosciences services”) which might, for example, wind up in Hackensack. Next, once they have bought up rival hospitals, they may downsize them and then close them, deeming them to be useless (a self-fulfilling prophecy) and thus accessing the patient base of those hospitals.

Note that the discussions about this merger, as reported, do not include the words “regional healthcare planning,  patients’ needs, or patients’ freedom of choice.”

Presumably these two players will divide up the categories of care and then establish “centers of excellence” in one area or the other. This happened when Mt. Sinai in New York merged with NYU, but the whole thing fell apart over turf wars.

There is a giant snowball rolling down hill in healthcare, and patients should keep their eye on that ball, focusing on cost and quality.  The ACA horror and success stories will be evident as time goes by; we don’t know how the scales will tip.  Meanwhile, we are in the beginning of first inning of a long game ahead.

 

* Article from NJ Spotlight:    Merger report on NJSpotlight.com

AL JOLSON  with a song that might apply to how the patients view this situation.

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The Detroit News (4/4, Bouffard) reports that “eleven medical schools from across the nation will meet at the University of Michigan Monday to brainstorm how to adapt to the new health care environment taking shape under the” ACA. This convention “is part of an American Medical Association (AMA) initiative, ‘Accelerating Change in Medical Education.’” According to AMA president and CEO James Madara, “The basic structure (of medical education) has been pretty static for a century.” Madara added, “Medicine used to be almost (entirely) about acute disease, and now it’s more about chronic disease. We can anticipate a huge chronic disease burden and most of that will be outpatient.”

In the Detroit News article, the author Karen Bouffard  says, “The federal Affordable Care Act is also changing how hospitals and physicians’ practices operate, because it rewards health care providers who improve medical outcomes while trimming costs, and penalizes those who don’t.”

Blogfinger Medical Commentary  by Paul Goldfinger, MD, FACC

In recent years, on Blogfinger, we have been speculating about how the ACA will affect the practice of medicine, but all we heard about were insurance and cost issues.  Some, on Blogfinger, even said that the ACA will have nothing to do with how medicine is practiced, but we were skeptical.  This article is an example that illustrates the fact that the ACA will influence much about how physicians will function in the future. Specifically, as described above, we have medical schools planning major changes in what doctors will learn compared with what has been taught over the last hundred years.

In medical school we learned almost nothing about the everyday care of outpatients with chronic diseases. We learned the equivalent of two languages, but it was mostly memorizing a mountain of information. We rarely got to see the inside of a doctor’s office, and during the clinical years, we saw mostly hospital and emergency room cases. That is changing already in many med schools.

When I arrived at Mt. Sinai Hospital  in New York City for my internal medicine internship, the teaching service was mostly filled with patients having complex and/or rare diseases that I had either never seen before or even heard of:  monoclonal gammopathy, myasthenia gravis, systemic lupus,  porphyria, and sarcoidosis, among others. But that’s what you run into in major teaching/referral institutions.  I don’t think that bothered anyone, because we felt that if we could handle those difficult cases, then we could do anything that  eventually might cross our paths.

By the time I was finished there, five years later, I was an expert in acute medicine, but, as a cardiologist eligible for board exams, I had never taken care of  chronically ill heart patients with common disorders over time.  That all changed when I became a Navy cardiologist in a big hospital with a large outpatient clinic population, where I got to see and follow chronic cases  (mostly retired Navy men) with “bread and butter” conditions such as mild to moderate hypertension, stable coronary disease, diabetes mellitus, and prevention issues such as weight/lipid control.

When I began my private practice in Morris County,  the primary care doctors were often quite weak in terms of what they should have been doing. Later some able internists showed up and improved the situation.  After retiring to Ocean Grove, I discovered that some primary doctors  I ran into in Monmouth County were  suboptimal. It became a challenge to find one who did the job correctly.  So, as the ACA began to roll out, I suspected that  many of the  primary care  doctors would not be able to  meet the demands of the “new medicine” on the horizon and that there would be shortages of effective primary physicians.

Thus the AMA sponsored  convention noted above which aims to restructure medical school education for the future has its eye on the ball.  But in the near future, it will be a challenge for patients to get the chronic care that they will need and which is being proposed and defined under the ACA.

It will be interesting to watch the way the medical profession changes to meet the new demands and challenges.

 

 

 

 

 

 

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By Paul Goldfinger, MD, Editor@Blogfinger

Last week we posted an article on Blogfinger that looked at the coercive effects of financial incentives in healthcare. We talked about ethics among doctors and we printed a letter to the editor from a physician who sent it to the New York Times.  That doctor bemoaned the compromise of traditional medical ethics while doctors get caught up in the pursuit of profits.  A Blogfinger Medical Commentary accompanies that post.   The link to that BF article is below.

Part 1 of BF healthcare business for doctors

Today the conversation in the Times continued as some physicians and others concluded that capitalism was not a good way to provide healthcare because of the profit incentives which ensue from  large corporations which have been taking over healthcare in this country.  In the process, many doctors have become employees and have to function according to the mandates of bottom-line-oriented executives.

Below is a link to today’s Times article, kindly provided by one of our FOB’s  (friends of Blogfinger) named Radar.

Medicine as a business NY Times Feb 9

Blogfinger Medical Commentary  Part II on this subject by Paul Goldfinger, MD, FACC:

I am frustrated, as are many doctors, by how the current economic system which drives healthcare creates  an environment for fraud, waste and abuse. To some physicians it seems that healthcare is a right which doesn’t lend itself to a capitalistic economic system.  (see today’s  NYT discussions linked above)

Our current healthcare is tarnished by out of control costs, corruptive fee- for-service reimbursement for doctors, and bottom-line oriented corporate management.   The costs are driven up by super expensive device manufacturers and pharmaceutical companies which have contributed to an unaffordable situation.

But I hasten to add that our current capitalistic system has produced the highest quality in providers, medical education, innovators, and creators of  extraordinary pharmaceuticals, high-tech diagnostic tests , and bioengineered/genetically driven advances of all sorts which promise a whole new future in medicine for this country and the world.

Other countries that have socialistic single payer  systems may be spending less, but they are not the innovators, and their quality and access cannot compare to ours. They look to America for the new advances.

Finally I am especially leary of Obamacare because, so far, it is overwhelmingly about cost and insurance, with little apparent concerns about quality.    As the ACA, with its mountains of regulations and restrictions , kicks in, Americans will, in my opinion,  become furious over access issues,  expensive premiums, and compromise of quality.

There is a chance that we will wind up with a single payer socialistic system.   Perhaps a compromise healthcare economy can be worked out over time with the government providing infrastructure, universal coverage, and regulation, but keeping physicians in charge of patient care.

In  Israel they have socialized medicine, but their medical care is excellent, and their high tech companies are world leaders and profitable. Similarly here there will have to be room for traditional American incentivization if we are to continue our successes while we fix the problems.

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This letter to the editor appeared in the New York Times on February 5, 2014  from a physician who is concerned about the loss of traditional medical practice ethics:

To the Editor:

Recent accusations against the for-profit hospital chain Health Management Associates (“Hospital Chain Said to Scheme to Inflate Bills,” front page, Jan. 24), including that it put pressure on doctors to admit patients to increase profits, demonstrate the destructive power of the corporatization of medicine on the practice of medicine. The ethical base is lost when businesspeople take over and destroy the traditions of medical practice. Hospital Corporation of America, the nation’s largest for-profit hospital chain, is under investigation for similar practices.

Leaders of corporate America care little about the credo that established medicine as a noble profession, operated not for profitability but for the good of the patients. Sadly, doctors within the corporate system who have opposed fraudulent and illegal practices designed to maximize profitability are punished and terminated. Meanwhile, the white-collar criminal behavior of corporate executives is not adequately punished.

Such practices have a corrosive effect on independent doctors as well. This leads many to game the system and find loopholes to maximize profits. Costs soar. Hospitals and medical schools are often complicit.

Many decent doctors deplore the changes in health care delivery systems that foster such abuses. But I find it hard to be heard when I speak of accountability. I call on our current and next generation of medical school graduates to have the vision and courage to take back the leadership of medicine and restore its right to be considered a noble profession.

HOWARD A. CORWIN

Naples, Fla., Feb. 3, 2014

The writer was a clinical professor of psychiatry at Tufts University School of Medicine.

Blogfinger Medical Commentary.  By Paul Goldfinger, MD , FACC

I think we must agree that medicine, a “noble profession,” has not been totally squeaky-clean when it comes to putting financial gain ahead of the best interests of patients. But Dr Corwin is certainly correct when he claims that the medical profession,  for the most part,  has lived up to its credo to always put the best interests of patients first.

Of course there are exceptions, but somehow, without an actual ruling body, doctors have usually done what’s right, and it is a source of pride to those of us who are physicians that we adhere to long-standing traditions regarding ethics, and most doctors can be trusted to honor their traditional priorities.

But, in my experience, financial conflicts of interest due to the fee-for-service system cause an ethical tug of war for some doctors, and such ethical failings have been going on for a long time including fee splitting which I saw when I first entered private practice.

Insurance companies are part of the problem in the other direction because they make more money by trying to withhold care. And  patients are also sometimes complicit because they don’t worry about such “abuses” as long as they are not paying directly.

Dr. Corwin is correct when he puts his finger on recent corporate practices that attempt to require doctors to churn services such as when employee-physicians are pressured to admit more patients just to increase the numbers. If healthcare allocation decisions are put into the hands of bureaucrats or corporate managers, the financial bottom line will be the guiding touchstone for practice policies.

Whatever ethical shortcomings might exist among doctors, they can be dealt with in a new healthcare system, but, as I have repeatedly said, doctors need to be in charge of patient-care decisions.

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By Paul Goldfinger, MD, FACC. Editor @Blogfinger

Since the Affordable Care Act was passed three years ago, I’ve been floundering around trying to latch onto any snippet of information which would give us advance notice about how the new law would affect quality of care. In the absence of transparency, we have been left to speculate and wait for the law to take effect.

Lately we have experienced the flawed rollout and we have seen all sorts of fiddling with the law by the administration, a process which has been questioned as being unconstitutional.  We have heard about canceled insurance policies and inaccurate information such as “you can keep your doctor.’

Finally we can begin to get to the clinical aspects, so we have discussed practice guidelines and physician networks. Then, from Oregon, we learned that people given new Medicaid policies use the ER’s even more than those with no insurance—another surprise.

But getting into the weeds without some overall understanding of what is going to happen has been frustrating.  Carol Rizzo told us that the ACA was mostly about insurance reform, and the clinical aspects would be found elsewhere.  I was skeptical, so I was pleased to see two major figures in healthcare appear on Sunday at Meet the Press.  Both are MD’s and both are CEO’s of major health systems.  Great!  These guys should be able to explain the overall scenario.

Dr. Toby Cosgrove is from the Cleveland Clinic and Dr. John Noseworthy is from Mayo.  When asked if they really know what to expect from the ACA, Dr. Cosgrove said, “We really don’t understand this.”

Dr. Noseworthy said that the current healthcare system is a “bunch of cottage industries” which need to be turned into an integrated “system.”  He said, “We don’t understand the implications of the ACA for hospitals and doctors.”

They both seemed to agree that only time will reveal what the ACA will bring and if it will be successful.  They said, “The ACA will take its own path.” As for the changes being made in the ACA as we speak, they agreed that many more changes will have to  be made if the “entire healthcare system” is to be reformed .

They pointed out that Medicare is involved in 50 %  of healthcare and that its “insolvency is looming.”  The payment systems need to be modernized, and the way that providers are paid must be changed.  Dr. Noseworthy said that everyone in the system will be paid less if the ACA is to work.

They also had something to say about the patients, “Something has to be done with incentives to encourage patients to take better care of themselves.”  They offered the “epidemic of obesity” as an example.

So I was sort of relieved by this conversation. Now we know:  the chaos and murkiness of the ACA rollout seems that way because this freight train is heading into a fog of unanswered questions.

We can keep going into the weeds and looking at what is emerging, but let’s stop seeking the holy grail of completely understanding the ACA, because full understanding now is just impossible. Even if you read every page, you will still be left like the two doctors above who “really don’t understand this.”

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