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By Paul Goldfinger, MD, FACC

The silent killer:  Prevention doctors use this term to stress the fact that you could have high blood pressure without having symptoms  that might suggest a problem. Untreated high blood pressure can cause stroke, heart attacks, rhythm issues like atrial fibrillation, or congestive heart failure. That is why blood pressures are often checked on all comers at health fairs, drug stores, doctor offices  (even if it is a urologist) and other venues. 

Home devices:  I believe that every hypertensive patient should check his blood pressure readings at home.  All you really need is a simple home device which runs on batteries and is usually accurate. They sell them at most drug stores.   But you have to pay attention to the technique of placing the cuff. 

I don’t trust the ones that take a reading from your finger.  Write down your result, indicate the time and make a note if there are special circumstances  (such as being stressed or having just run up the stairs.)  Because of some anxiety associated with taking your own pressure reading, I recommend ignoring the first reading, waiting 1 or 2 minutes and then repeat.

Cuff size:  The cuff that goes around the upper arm should be placed carefully according to the directions,  and the size of the cuff needs to be correct for the size of the arm in order to get an accurate reading. If you are buying a home BP device, ask the pharmacist if the cuff is correct for you.  Sometimes a large cuff has to be special ordered.  For very obese patients, a thigh cuff may be needed—i.e. a cuff that would ordinarily be used to measure pressures in the legs. 

Echocardiograms:  Why should a doctor order this ultrasound procedure on patients with hypertension?  Uncontrolled hypertension causes the heart to work harder against an elevated pressure. That stresses the heart, and the heart muscle can thicken.  The echo measures cardiac wall muscle  thickness. A stressed heart can get weak and begin to enlarge.  The echo measures the size of the heart and the strength of contraction of the main pumping chamber–the left ventricle.  The test also assesses valve function. The “echo” is a very useful noninvasive test for following patients with hypertension.

Weight loss as therapy.  Even losing as little as 10 pounds can result in an improved blood pressure reading.  If you lose weight, you might be able to reduce the dose of your meds or avoid meds altogether.

Tailored therapy A doctor treating a patient with hypertension has to choose from a large list of drugs. There are variety of ways that anti-hypertension drugs work, so sometimes a drug is chosen for a specific reason. For example, if someone has a kidney problem , the doctor might choose an ACE inhibitor for its renal protective properties.  If a patient is young and has elevated blood pressure due to high adrenaline effects, then a beta blocker would be a good choice.

Dizziness from BP drugs  I called a friend, and when he picked up the phone he said, “I stood up and got dizzy.” He is hypertensive and takes a BP medication. I asked him if he ever told his doctor about his symptom and if his doctor ever took his BP standing. He said no to both.

One of the side effects of anti-hypertensive drugs is orthostatic hypotension, which means that the BP drops excessively when standing, often resulting in dizziness or even fainting.  Many of these drugs work by opening (dilating) blood vessels, but an exaggerated effect can cause the BP to drop excessively thus reducing blood flow to the brain.

The doctor ought to check the BP standing when evaluating anyone on such drugs, and the standing BP should be measured immediately and then after standing for a few minutes.

Mixing Viagra with your BP meds.  Viagra dilates blood vessels as do some BP drugs, and although it works somewhat differently than your BP meds, the combination of Viagra with a vasodilator BP drug may cause a problem such as dizziness due to low blood pressure. If you are on such BP meds, you should speak with your doctor about a low Viagra dose, at least to start. The last thing you want is to be in a romantic situation and then pass out on the floor. 

Should “White-coat hypertension (WCH)” be treated?  There are quite a few people whose BP is high in the doctors office but normal at home. The diagnosis is made by doing home BP readings or by 24-hour ambulatory BP recordings.  Medicare will pay for the latter test when a doctor needs to find out if his patient has WCH.

Once the diagnosis is made, should the doctor treat it?  Most experts say no, but there are some studies that say “maybe.” At the very least, patients with WCH can evolve into full-blown hypertension over time, so ongoing surveillance is important.

There are many issues that we are not covering today, and perhaps we will return to some of those another time.  Meanwhile, more than 60% of you will develop hypertension if you reach the Medicare years, so it is an important subject for discussion at the Blogfinger School of Medicine and Health Sciences based in Ocean Grove, New Jersey and at the Ocean Township Wegmans.

So, for now, our hypertension series is concluded, and this doctor’s office is closed. If you have a true medical emergency call 911 and hope that your insurance policy is still in effect.

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By Paul Goldfinger, MD, FACC    Editor@Blogfinger

As many of you know, my main concern regarding Obamacare relates to how it will affect quality of care. But all we hear is about insurance and economics. But even with that, we can begin to see the effects on quality, because some people will be left naked on Jan 1 when they no longer have coverage. Obviously, if you don’t have health insurance, the quality of your care will be reduced.  But I am certain, as you know, that quality will be negatively impacted in many ways and I recently reported on the situation with practice guidelines potentially  interfering with the doctor-patient relationship.

However, on Jan 1, as people actually seek care under the ACA, I suspect we will hear many horror stories having to do with the deterioration of quality care. In today’s Wall Street Journal we find an opinion piece by Marc Siegel, MD, and Professor of Medicine  at the NYU School of Medicine. Dr. Siegel says he has awakened “to the harsh realities of our medical future.”  His piece rambles a bit, but you can see from his observations that you don’t need a weatherman to tell you which way the wind is blowing.  Here is Dr. Siegel’s “The Death of the Bedside Manner”     *Wall Street Journal, Dec. 27, 2013.

WSJ on Obamacare

BOB DYLAN:

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Abbott posted this new topic:

“Medicare is not a good  analogy for the ACA.   Medicare is funded through payroll taxes (all pay the same tax rate).  Individuals are not required to participate in Medicare.  Medicare does not seek to massively subsidize one part of the population at the expense of another (although they have started down that road with premiums adjusted for income to a limited degree).   Medicare does not have restrictive networks of hospitals and physicians.  

“Said another way, the reason the majority of Americans are opposed to the ACA is that it forces people to buy something the may not want, it forces them (in many ways) to subsidize other Americans to buy something, and it is disrupting a healthcare system that works well for a majority of Americans.  

“Let’s face it — probably the only people who really support the ACA are the folks who want to be subsidized (financially and/or by spreading their bad risk).”

Blogfinger Medical Commentary:  By Paul Goldfinger, MD, FACC

Prior to the passage of the ACA,   80% of Americans said that they were satisfied with their health insurance and their doctors.  The ACA bill was sold to the public as being about providing coverage for the other 20% .

Some  parts of the plan were intentionally not revealed, leaving most Americans to believe that the ACA would not impact them.  This is lying by omission.  Some believe that the ACA was passed under false pretenses.

Abbott also mentions  doctor and  hospital networks . Prior to the ACA, most insurance plans that were considered to be good plans allowed the policy holders to see any doctor and to go to any hospital.  That was the norm and was true for Medicare and Medicaid as well.  This was one reason why many seniors preferred regular Medicare compared to the more restrictive Medicare Advantage plans. Most people still prefer  freedom of choice.

But ACA-approved insurance plans all seem to include networks of hospitals and doctors.  This will produce a big change in how medicine will be practiced, and there wasn’t a mention of it when the ACA was explained to the public before it was passed.  If any of you have found Obamacare plans that give free choice, please let us know.

Interestingly, Dr.  Ezekiel Emmanuel, an architect of the ACA,  said on TV last Sunday that you can have your usual doctor, but you may need to buy a more expensive plan that has your doctor in-network.  To his way of thinking, there was no lie when we were told that we could retain our doctor.

Also, every ACA plan seems to have significant deductibles and copays, and the lower the premiums, the larger the out of pocket costs. Many current pre-ACA plans  do not have copays or deductibles.  Some, however, may have caps on spending, which the ACA plans do not,  and policy holders can be balance billed by providers unless the doctors are “in-network.”  

Abbott makes another point when she says that Obamacare will “disrupt” our current healthcare system.  Some say that Obamacare is not about the delivery of  healthcare, but rather is about insurance reform. However, there is no doubt but that the ACA will change the way medicine is practiced in a multiple ways including enforceable practice guidelines, rationing of care, restricted physician networks, etc. The actual enforcers of practice changes will often be the insurance companies who will be trying to lower costs and follow ACA rules.

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This topic is suggested by David Lurie of Ocean Grove who has included a link to the New York Times, December 9, 2013 issue. The paragraph below is written by him:

“Worth reading. Here are some examples of the actual people who are being helped, and who have been paying huge prices for our current system of providing (or not providing) care.  I  found telling the example of immigrants from China who – as children – had to return there for medical treatment and pharmaceuticals.  The cancer patient who was skimping on his chemo was more than a bit disturbing as well.  These realities, it seems to me, need to be reckoned with by anyone who want to nullify the ACA.”

Here is the link from today’s NY Times.

Amid the Uproar Over the Health Law, Voices of Quiet Optimism and Relief 

Blogfinger Medical Commentary:   By Paul Goldfinger, MD, FACC

We already know about some positive results that have occurred with Obamacare, including  the elimination of pre-existing illness restrictions by insurance companies, allowing young people to stay on their parents’ plan and the removal of dollar caps from health insurance plans.

But besides that, at this point, we have mostly promises which include providing coverage to over 30 million people. However we know that promises don’t count—only results–because of the broken promises regarding keeping your insurance and your doctors.

The New York Times article linked below by David Lurie is inspiring, and we all welcome relief for those in need, but putting out anecdotes like this will convince only the naive that the new healthcare system will make our country healthier.

We need to wait until  at least 2014 to learn how well the ACA is working in terms of the practice of medicine. I have been repeating that mantra and I will look forward to seeing documentation of success in the form of numbers and not anecdotes. If Obamacare delivers on its promises, then we all can jump on board and be happy.  But if it fails, then we will need to reinvent healthcare in the US.

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To the Editor:

Re: Redistribution of wealth as a subtopic of our Obamacare series.

The redistribution of wealth keeps coming up in this healthcare topic and distracts from the ACA issue. I propose we discuss redistribution (distribution) of wealth and income in America.

I will quote no less an expert than Lloyd Blankfein, Chairman of Goldman Sachs, on  this  to start things off. In an interview with the PHILLY ENQUIRER he said: “This country does a great job of creating wealth, but not a great job of distributing it.”  And he ought to know.

Ken suggests this Philly.com link

KENNEDY BUCKLEY

Ocean Grove, NJ. Dec. 8, 2013

Editor’s note: We are offering the opportunity to isolate and discuss a variety of issues related to healthcare on Blogfinger. We do not want to get into global discussions about life in America.

So, although Ken wants to dissect out this subject because it is a “distraction” that interferes with analysis of the ACA,  please try to focus  your comments regarding redistribution of wealth as it pertains to healthcare.  If we don’t, then we will open the door to a large array of national issues that are not part of our mission on Blogfinger such as racism, poverty and CEO salaries, all fine for the NY Times, but enough to give me a huge headache on Blogfinger.   —-PG

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By Paul Goldfinger, MD. Editor @Blogfinger

It seems that the problems surrounding the ACA web site are not over:

1.  Many customers seeking insurance plans are eligible for subsidies. Those subsidies have already been budgeted for, but there is a problem getting that money to the insurance companies which are counting on it.  The “back end” of the website is supposed to establish the subsidies and then get the money to the companies, but evidently, those functions are not yet established due to web design delays.

If the subsidies are not paid to the insurance companies, then they may not pay the doctors, and if that happens, the doctors may refuse to see you.     Insurance companies might, under the circumstances, choose to drop out of Obamacare.

But it is said that the Administration is readying a “bailout” of sorts by paying money to the companies based on what the companies say that they are owed due to subsidies.  As it is , the insurance companies feel oppressed by Obamacare because of the large “bad risk pool” which consists of sick people with expensive care needs that is not being balanced by young healthy people. 57%  of young people  ages 18-29 disapprove of the ACA  (NY Times)   and not enough of them are signing on.

This payout to insurance companies, if it materializes,  will be a big break for them as they struggle while waiting for  Obamacare to get its act together. But some small insurance companies may run short of funds if these payments are not made soon.

These subsidies are often going to pay for  Medicaid qualified polices which are largely serviced by Medicaid HMO’s that have”cheap”doctor networks. (i.e. They choose doctors who are willing to work for low reimbursments.)

2. It seems that the projected doctor shortage may be overstated because the doctors of the future will be more productive due to technology and due to the greater  use of physician extenders such as nurse practitioners.  (link from Dave of Ocean Grove:    Doctor shortage link )   But, at this time, the new plans being created for Obamacare often have physician networks that have not yet been formulated or, as the insurance companies try to populate their networks with”cheap doctors” who will accept low fees, the end result will be physician networks that are shrunken, i.e. contain 40-50% fewer specialists than current plans. Many doctors are refusing to sign contracts with plans that offer inadequate reimbursements. The administrators of Obamacare have been lax in supervising the creation of doctor networks by insurance companies.

In effect, this can result  in a doctor shortage  for certain plans and less of a chance that your doctor will be in your plan’s network .  Remember “You can keep your doctor?”  Come January, when patients seek care with their new policies, they will find out which doctors are in their network.  Then they will have till March to run around and find another insurer.

Source:  The American Enterprise Institute

3.  From the New York Times December 8:  “Obamacare Turns a Corner?”  This opinion piece speculates on the factors that may determine the long term success of the ACA.

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To the Editor:

Re: New healthcare topic:

Employers are increasingly scheduling workers to fewer hours to avoid providing healthcare coverage thus hitting employees with a double whammy: less income and no healthcare. The law needs “fixing” so that every hour of work should provide some amount of healthcare coverage or this conundrum will reach its logical conclusion…a workplace of mostly part timers with fewer and fewer full timers.

Ken

Ocean Grove, N.J.  Dec. 6, 2013

Editor’s Note:  Here is a link to The Guardian from several months ago on this topic:

The Guardian link

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Will this doctor, your favorite, be in your new network?

Will this doctor, your favorite, be in your new network?

Editor’s Note:     We are running this series of posts to introduce new issues that are emerging almost daily as a result of the roll-out of the ACA aka Obamacare. We don’t want to repeat old news that everyone already knows about. Healthcare is a massive subject, and so I am trying to find ways to get focused, such as our Hotline posts.

So please, if you comment on this post, try to stay on the subject at hand.  If you want to introduce another sub-topic on healthcare  (or anything else) just sent a letter to the editor  (Blogfinger@verizon.net.)   There also is our recent healthcare post featuring Carol Rizzo.  You can still comment there, but you have to scroll down a bit to find it.

We usually don’t cover national issues,  but I’m making this an exception. It is difficult to keep the herd in the corral.  I will try not to post any Holstein waste and  I promise we will not cover the budget problems in DC.   —-PG

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1.   The  Washington Examiner (11/21, Pollock, 319K) reports that consumers visiting healthcare.gov are not able “to learn whether their doctors participate in an Obamacare-approved health care plan because the website doesn’t include such information.” Jessica Waltman, senior vice president of government affairs for the National Association of Health Underwriters, explained to the Examiner: “Under the exchanges, the government did not require health plans to submit detailed network information. That’s why the networks aren’t listed on healthcare.gov. When you go to look in at the plan choices, you can’t see the provider networks.”

2.       Many “top” NYC hospitals will not accept most exchange plans. The AP (11/21, Caruso) reports that some of the “top hospitals” in New York City are not accepting insurance plans sold through health insurance exchanges. Nationwide, in order to reduce costs, many plans offer limited provider networks. Another reason for the New York plan refusals comes from “hospitals being cautious about agreeing to take new, untested insurance products.” Although the number of accepted plans differs, Memorial Sloan-Kettering Cancer Center, NYU Langone Medical Center, and New York-Presbyterian Hospital will accept at most a minimum of available plans.

Link to this AP story:    Best NYC hospitals missing in some plans

Blogfinger Medical Commentary by Paul Goldfinger, MD, FACC

Regarding the Washington Examiner report, this is a serious problem, because many patients want to find plans that have their favorite doctors in the network. Being able to see your regular doctor who knows the details and subtleties of your medical condition is very important for those whose conditions are complicated. Also, typically, for sick patients, a team of doctors work together, and that collaboration can be demolished by the need to get new insurance policies.

As for the top NYC hospitals, one of the advantages of living in the Big Apple is having access to some of the best medical facilities in the world. I practiced in New Jersey, but if I had a really tough case and needed a second opinion, I skipped the local docs and sent them to NYC to  a “the buck stops here” kind of referral center such as Columbia Pres. and NYU.  I would not choose a plan that didn’t offer access to those places.

BLOGFINGER MEDICAL GUIDELINE #1  “Coconut””   HARRY NILSSON from the album “Nilsson Schmilsson”

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Editor’s Note:  (Paul Goldfinger, MD  Editor @Blogfinger)     The last time I saw Grover Carol Rizzo, she was directing traffic near the Pavilion for the OG Citizens’ Patrol. Carol is a bonafide expert in healthcare, having worked as CTO of Kaiser-Permanante  in California as well as in other high level positions in the financial world, and lately as a consultant for the healthcare industry. Every once in a while she surprises us with one of her knowing insights as to what is going on in healthcare.  She is the sort of expert that appears in the Wall Street Journal rather than in a blog like ours, so we thank her, and all of us should pay careful attention to her opinions.

Carol and I had a little email discussion recently.  She thought I was being a bit too gloomy.

She said, “I am not as gloomy about the future with the ACA though I have seen a few issues and missteps from the current administration. Attention to detail is truly not a strength of American government (federal or state).”  And then she followed with the following:

By Carol Rizzo:

“The reason, I am not so gloomy is because the ACA is primarily focused on payment reform rather than practice reform. The real issue that the ACA is focused on is affordability which I suppose is all well and good but where we need reform is on the cost side which if left untouched, just moves the cost onto taxpayers. After working in healthcare and seeing how health practices, specifically hospitals work, I can tell you they really don’t have a handle on cost. And there is far too little transparency.

“The ACA does not directly address that issue. That’s being addressed more by CMS* and insurers who are focused on capitation** and bundled payments via Accountable Care Organizations—ACO’s), etc. (see the Accountable Care  Organizations dialogue here…. http://www.kaiserhealthnews.org/stories/2011/january/13/aco-accountable-care-organization-faq.aspx )

“Until we have are a real dialogue on why our costs are so much higher than the rest of the worlds, we aren’t solving the problem.

“The rest of the industrialized world negotiates price for their national health systems with pharma and medical devices; we are actually subsidizing those countries.  So when Medtronics bids for the pacemakers business in the UK or India, they have to compete against a host of vendors, but those countries gets them cheaper from Medtronics!  Also regulators move faster in those countries  because it’s in the national interest to get the best drugs and the best devices and avoid health costs.

“In 2000, I was in India on business with an American colleague who was wearing a Holter monitor. When we landed, his doctor at Johns Hopkins paged him to get to a hospital immediately because he needed the newly FDA approved Medtronics pacemaker. We flew down to Chennai where the doctor at Johns Hopkins could not believe that the Indian cardiologist had been using the brand new Medtronics pacemaker for over  two years!  The bill for 7 days of hospitalization, 24 hour nursing, the cardiologist and surgery was about $11,000; at a fraction of the cost here. (Still expensive though for the average Indian)

“What I am more concerned about is that hospitals are buying up practices and they are doing that so they can direct where emergency and surgical care will be given.”

Regards,

Carol

* CMS:  Centers for Medicare and Medicaid Services

** Capitation:  A payment arrangement where a set fee is paid, for example to a medical group, to cover all the care for each patient covered by an insurance company that pays doctors that way.

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By Paul Goldfinger, MD, FACC

Our emphasis on Blogfinger regarding Obamacare has been to focus on how quality of healthcare will be affected. Since we haven’t yet seen how the new system will actually work on patients, we will discover some significant issues emerging later, and I am worried that we will not like the results as far as quality is concerned.

Recently the conversation has been mostly about insurance, but the health insurance issue has a profound connection to quality. Under Obamacare, everyone who acquires an ACA approved insurance policy will have healthcare subject to all the rules, regulations and stipulations of those policies.

Their quality of care will depend on what is allowed under their plans, and that will be enforced by the willingness of the payers to pay. So, for the system to work, most everyone needs to have an ACA approved policy. And those policies will be defined by thousands of rules and regulations which will change every aspect of healthcare and will, by necessity, be very bottom-line oriented.

As we inch along the road to the new system, we gradually learn more about it, but by the time we learn the latest news, such as the cancellation of millions of policies, it is already a fait accompli. In plain English, as we hear over and over, you can’t put the toothpaste back into the tube.

The latest aspect of the ACA that has emerged is the realization that there will be winners and losers.  Some have used the R word, i.e. redistribution of wealth. No one can deny that, because the poorer and the sicker will be given expensive insurance for no cost or low cost.  There will be stipends for those who make less than 400% above the poverty line.   And to help raise the money for this program, there will be 1/2 trillion dollars more in taxes and higher cost premiums and deductibles for most of those who already have insurance. All this will become more obvious as the business community is forced into the program.

Wealth is usually described as having money and possessions, but that is not all that is being redistributed.  The part I am focusing on is the way that healthcare, which 80% of Americans have “enjoyed” and which includes everything that makes quality care possible, will be compromised to some extent.  And that is a sort of wealth redistribution as well.

Without a doubt we will have rationing in various forms, difficulty seeing the doctor of your choice, trouble getting care at the hospital of your choice, shortages of all sorts of medical providers, trouble getting physician appointments, inability to get tests done efficiently, deterioration of doctor-patient relationships, and compromise of  the ability of your doctor to treat you the way he wants.  Low fees will drive the best physicians to create boutique practices or become hospital employees or to leave medicine altogether.

Will there be good things to come out of all this?  Yes there will, and many people will accept the “redistribution of wealth,”  but did they really have to destroy the existing system to achieve those good things?  Healthcare is about 20% of our economy.  Was Obamacare the best way to fix our existing system? And will quality care decline as numbers insured get bigger?

What do you think?

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