Healthcare In A Minute - May 2017

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by George Chapman, GW Chapman Consulting

House repeals ACA.  It took over seven years, but the House finally managed to get enough votes, barely, to repeal the Affordable Care Act (ObamaCare) and replace it with the American Health Care Act (TrumpCare). The fate of the AHCA bill now is in the hands of a much more moderate Senate. Once enough votes were pledged, the bill was intentionally sent to the floor for a House vote before the Congressional  Budget Office could take a look at the bill and figure out what the financial and coverage consequences would be.

If you recall, the CBO estimated that the original version of the AHCA would cause 24 million people to lose coverage. The revised bill sets aside $8 billion for pre-exiting conditions or for high risk pools. That sounds like a lot, but it is only $1.6 billion per 5 years. According to industry experts, about 226,000 people had pre-exiting conditions covered by the ACA at a cost of $2.5 billion in 2011. So the $8 billion proposed by the ACHA would only cover about half the 226,000 people with pre-existing conditions. Employer plans could be impacted by the AHCA by a provision that could jeopardize the current cap on out of pocket expenses.

The bottom line is sicker people will pay a lot more for their insurance or go without. The latter option means hospitals and physicians will once again be faced with providing uncompensated care to the people who are the sickest and most vulnerable. Almost all of the industry’s major trade associations have expressed their concerns over potential reductions in insurance subsidies (cost sharing reductions) including: American Medical Association, American Nurses Association, American Hospital Association, and American Health Insurance Plans. The CBO analysis of the ACHA sent to the Senate should be out by the time you read this.     

AHCA pre-existing conditions. The list is far more extensive and pervasive (ridiculous?) than you think. The ACHA would allow all commercial insurers to charge more all their customers for the following: cancer, chronic obstructive pulmonary disease, Crohn’s disease, cystic fibrosis, depression, diabetes, down syndrome, eating disorders, epilepsy, glaucoma, gout, heart diseases, heartburn, high cholesterol, hypertension, kidney problems, mental health issues, sleep disorders, TB, and tooth disease among others. This issue, along with cost sharing reductions  will get the most attention when the Senate takes a look.

Drug prices. Americans use more drugs per capita than any other country. We also pay more for drugs than other country. Drugs now account for 10% of total healthcare spending. Recent accounts of price gouging by drug companies has brought the issue to the forefront. Even drugs made right here in the USA are cheaper in most other countries. The simple solution is already on the books. The FDA is empowered by the 2003 Medicare Modernization Act to allow drug imports to the USA, if they are deemed safe and less expensive. The drug lobby has been very effective at preventing anyone in the FDA or HHS from employing this provision. It is ultimately up to the President, who oversees HHS and the FDA, with one executive order.

VA closures. The VA is contemplating closing over 1,100 vacant and underutilized facilities in order to save $25 million a year and to shift more care to the private sector. President Trump recently signed a bill extending the period in which vets can seek medical care from private physicians and hospitals. The move towards privatization was recently accelerated by reports of long, often fatal, waits for care at certain VA facilities.

End of life.  According to an “end of life”  survey conducted by the Kaiser Family Foundation, half of the respondents believe they will not be in control over their own medical decisions towards the end of life. 56% said they are more likely to have serious discussions with a family member than with a physician. Only 11% of the respondents said they have discussed end of life wishes with their personal physician. 71% of the survey respondents said they would prefer to die at home, but only 41% expected to do so. 54% do not want their family members burdened by their care. 42% said once they are deemed terminal, they just want to be comfortable and pain free. Only 23% of respondents wanted to live as long as possible, no matter what it takes. It is natural to postpone or not even think about end of life decisions while relatively young, but one never knows what will happen in life. We are being encouraged to broach the subject with our primary care physicians, so when the time comes we will maintain control and our wishes will be honored.

Healthcare dilemma.  The healthcare industry has added a lot of jobs to the economy over the last ten years and most of the jobs are good paying jobs. The increase in hospital staffing has been in response to an aging population, increased regulatory burdens and increased demand for services as more people are insured. Reimbursements that have not kept up with  increasing costs and the uncertainly over the AHCA (TrumpCare) have caused even the largest hospital systems to reduce staff. Brigham and Women’s Hospital in Boston announced plans to offer buyouts to 1,600 employees. Catholic Health Initiatives will cut 900 positions through layoffs and buyouts. The Anderson Cancer Care Center in Texas plans to cut 1,000 jobs. NYC Health & Hospitals announced organizational restructuring that would eliminate 600 positions across their system. Before the ACA was repealed, the Urban Institute estimated even a partial repeal of the ACA, let alone a full replacement, would increase uncompensated care to providers by about $1 trillion a year for the next 10 years. Many hospitals will face credit downgrades if the ACHA causes millions to lose their insurance. To make matters worse, as staffing cuts are made, hospitals must deal with increasing physician and nurse burnout.

We’re #37. The World Health Organization ranks the healthcare systems in 190 countries. The rankings are based upon several factors including: the overall health of the population; health disparities within the population (poor v. rich; public insurance v. private insurance); system responsiveness/patient satisfaction; distribution of responsiveness within the population (uninsured v. insured; urban v. rural);  distribution of financial burden (who pays: government, employer, self). All things considered, the WHO ranks the US  #37. The top 5 countries are: France, Italy, San Marino, (an independent sovereign country within Italy); Andorra, (an independent  sovereign country between Spain and France), and Malta. Other notables are: UK #18, Germany #25, Canada #30, Russia #130, China #144. In last place at #190 is Myanmar. The US remains firmly entrenched as the #1 country for highest cost per capita at about $10,500 and percentage of GDP at about 18%. In the 1960s, healthcare was 5% of the US GDP.

Warren Buffett’s take.  At the annual meeting of Berkshire Hathaway, Buffett, the founder multi-billionaire and philanthropist was asked if the AHCA was a good first step in a broader strategy to relieve the tax burden on American businesses. Buffett responded that taxes aren’t the problem. If you want to make American businesses more competitive you have to fix what it costs us for healthcare. He labeled our healthcare costs/system “the tapeworm of American competitiveness”. It is 18% of our GDP. Other countries spend an average of 11%, so US businesses are at a huge competitive disadvantage. He advocates a single payer system to drive down costs and waste.   

House repeals ACA.  It took over seven years, but the House finally managed to get enough votes, barely, to repeal the Affordable Care Act (ObamaCare) and replace it with the American Health Care Act (TrumpCare). The fate of the AHCA bill now is in the hands of a much more moderate Senate. Once enough votes were pledged, the bill was intentionally sent to the floor for a House vote before the Congressional  Budget Office could take a look at the bill and figure out what the financial and coverage consequences would be. If you recall, the CBO estimated that the original version of the AHCA would cause 24 million people to lose coverage. The revised bill sets aside $8 billion for pre-exiting conditions or for high risk pools. That sounds like a lot, but it is only $1.6 billion per 5 years. According to industry experts, about 226,000 people had pre-exiting conditions covered by the ACA at a cost of $2.5 billion in 2011. So the $8 billion proposed by the ACHA would only cover about half the 226,000 people with pre-existing conditions. Employer plans could be impacted by the AHCA by a provision that could jeopardize the current cap on out of pocket expenses. The bottom line is sicker people will pay a lot more for their insurance or go without. The latter option means hospitals and physicians will once again be faced with providing uncompensated care to the people who are the sickest and most vulnerable. Almost all of the industry’s major trade associations have expressed their concerns over potential reductions in insurance subsidies (cost sharing reductions) including: American Medical Association, American Nurses Association, American Hospital Association, and American Health Insurance Plans. The CBO analysis of the ACHA sent to the Senate should be out by the time you read this.     

AHCA pre-existing conditions. The list is far more extensive and pervasive (ridiculous?) than you think. The ACHA would allow all commercial insurers to charge more all their customers for the following: cancer, chronic obstructive pulmonary disease, Crohn’s disease, cystic fibrosis, depression, diabetes, down syndrome, eating disorders, epilepsy, glaucoma, gout, heart diseases, heartburn, high cholesterol, hypertension, kidney problems, mental health issues, sleep disorders, TB, and tooth disease among others. This issue, along with cost sharing reductions  will get the most attention when the Senate takes a look.

Drug prices. Americans use more drugs per capita than any other country. We also pay more for drugs than other country. Drugs now account for 10% of total healthcare spending. Recent accounts of price gouging by drug companies has brought the issue to the forefront. Even drugs made right here in the USA are cheaper in most other countries. The simple solution is already on the books. The FDA is empowered by the 2003 Medicare Modernization Act to allow drug imports to the USA, if they are deemed safe and less expensive. The drug lobby has been very effective at preventing anyone in the FDA or HHS from employing this provision. It is ultimately up to the President, who oversees HHS and the FDA, with one executive order.

VA closures. The VA is contemplating closing over 1,100 vacant and underutilized facilities in order to save $25 million a year and to shift more care to the private sector. President Trump recently signed a bill extending the period in which vets can seek medical care from private physicians and hospitals. The move towards privatization was recently accelerated by reports of long, often fatal, waits for care at certain VA facilities.

End of life.  According to an “end of life”  survey conducted by the Kaiser Family Foundation, half of the respondents believe they will not be in control over their own medical decisions towards the end of life. 56% said they are more likely to have serious discussions with a family member than with a physician. Only 11% of the respondents said they have discussed end of life wishes with their personal physician. 71% of the survey respondents said they would prefer to die at home, but only 41% expected to do so. 54% do not want their family members burdened by their care. 42% said once they are deemed terminal, they just want to be comfortable and pain free. Only 23% of respondents wanted to live as long as possible, no matter what it takes. It is natural to postpone or not even think about end of life decisions while relatively young, but one never knows what will happen in life. We are being encouraged to broach the subject with our primary care physicians, so when the time comes we will maintain control and our wishes will be honored.

Healthcare dilemma.  The healthcare industry has added a lot of jobs to the economy over the last ten years and most of the jobs are good paying jobs. The increase in hospital staffing has been in response to an aging population, increased regulatory burdens and increased demand for services as more people are insured. Reimbursements that have not kept up with  increasing costs and the uncertainly over the AHCA (TrumpCare) have caused even the largest hospital systems to reduce staff. Brigham and Women’s Hospital in Boston announced plans to offer buyouts to 1,600 employees. Catholic Health Initiatives will cut 900 positions through layoffs and buyouts. The Anderson Cancer Care Center in Texas plans to cut 1,000 jobs. NYC Health & Hospitals announced organizational restructuring that would eliminate 600 positions across their system. Before the ACA was repealed, the Urban Institute estimated even a partial repeal of the ACA, let alone a full replacement, would increase uncompensated care to providers by about $1 trillion a year for the next 10 years. Many hospitals will face credit downgrades if the ACHA causes millions to lose their insurance. To make matters worse, as staffing cuts are made, hospitals must deal with increasing physician and nurse burnout.

We’re #37. The World Health Organization ranks the healthcare systems in 190 countries. The rankings are based upon several factors including: the overall health of the population; health disparities within the population (poor v. rich; public insurance v. private insurance); system responsiveness/patient satisfaction; distribution of responsiveness within the population (uninsured v. insured; urban v. rural);  distribution of financial burden (who pays: government, employer, self). All things considered, the WHO ranks the US  #37. The top 5 countries are: France, Italy, San Marino, (an independent sovereign country within Italy); Andorra, (an independent  sovereign country between Spain and France), and Malta. Other notables are: UK #18, Germany #25, Canada #30, Russia #130, China #144. In last place at #190 is Myanmar. The US remains firmly entrenched as the #1 country for highest cost per capita at about $10,500 and percentage of GDP at about 18%. In the 1960s, healthcare was 5% of the US GDP.

Warren Buffett’s take.  At the annual meeting of Berkshire Hathaway, Buffett, the founder multi-billionaire and philanthropist was asked if the AHCA was a good first step in a broader strategy to relieve the tax burden on American businesses. Buffett responded that taxes aren’t the problem. If you want to make American businesses more competitive you have to fix what it costs us for healthcare. He labeled our healthcare costs/system “the tapeworm of American competitiveness”. It is 18% of our GDP. Other countries spend an average of 11%, so US businesses are at a huge competitive disadvantage. He advocates a single payer system to drive down costs and waste.   

Why You Should Hire An Independent Consultant

There are basically two types of consulting businesses. The first type is the large consulting firm that employs not only a bunch of consultants, but people who do other things as well. The second is the independent consultant, an individual who decides he or she doesn’t want to be a part of the corporate structure, wants to work on their own, and is fairly flexible in the types of things that they will work on. PCA is mainly comprised of the second group.

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There are a lot of pros for working with an independent consultant. Yet many companies and small businesses seem to believe that they have to go for what’s known as the “Thud Factor” or “Big Bang” theory. The belief is that a big name has to be ultimately multiple times better than an independent or small consulting firm.

That’s false of course, and one way to illustrate that is to look at what's happened to many businesses that were in trouble and brought in major consulting firms, especially hospitals. Many times the employees those firms send in are taught procedures for evaluation which may or may not work, whereas an independent consultant will have had some significant years doing the needed work and can actually offer real solutions.

To better illustrate why independent consultants are the way to go, here are 5 reasons why they might be better for you or your business.

1. Independent consultants will cost you less.

Independent consultants aren't cheap, but they’ll cost you a lot less than hiring a major consulting company. In the central New York area a few years ago, a hospital in financial constraints needed some consulting help. They went out and hired a large consulting firm from another state, spending almost $5 million. They totally ignored all local consultants, all of whom would have cost them less than $500,000 total. Not only would that have solved the hospitals financial issues better, since they probably wouldn't have had to pay for most of the expenses that were doled out to the organization from out of town, but the local consultants would have cared more because it would have been good for the area.

2. With an independent consultant, you know who you’re getting.

When someone contracts with large consulting companies, they rarely get the person they’ve been talking to as their consultant. Therefore, any rapport that’s been built up is lost. Every once in awhile, the consultant you get is an independent consultant who’s subcontracting with the large company; you could have eliminated the middle man, saved some dollars, and gotten more specific help with your needs.

3. Independent consultants have done the work you need help with.

Many years ago I had a subcontracting contract with a large consulting firm in another state. Out of the team of 9 consultants, only myself and two other people had ever worked in that particular field, and out of that group, only myself and one other person had ever done the work we were specifically consulting on during the project. The other consultants were young and hungry but drastically inexperienced, and mainly asked questions from a template rather than having any real knowledge of what would have helped them accurately diagnose and correct the problems. Then again, since the large consulting firm was more interested in increasing billable hours than solving any issues, it paid for them to have lower paid consultants with little experience so they could stay longer.

4. Independent consultants usually come with some years of experience behind them.

When I got into consulting, I’d been in the business nearly 20 years. Although there are independent consultants in certain businesses that may have less than 5 years of critical experience, the majority of independent consultants will have at least 10 to 15 years of quality business experience behind them, and that's not including consulting time. This means they've probably encountered your types of issues previously and can fix your problems quicker and more efficiently.

5. Independent consultants are flexible and beholden to you only.

Large consulting companies have to concern themselves with shareholders and partners. Independent consultants are only concerned with their own income, as well as their reputation. Most independent consultants have contracted with large companies, so they have an idea of how those organizations operate and try to be better and more dedicated to their clientele. Some large consulting companies won’t even talk to you if your yearly revenues aren’t in the multiple millions; independent consultants will work with anyone with the ability to pay them. Independent consultants know your success is their success; their business is built off reputation and recommendations.

The next time you’re looking for help, think about working with an independent consultant. Do you want to go to someone like Smith Barney, who won’t even assign you an independent representative if your not investing at least $25,000, or a small independent consultant who you can at least talk to from time to time, who gets to know you and works with you and your money?

Healthcare In A Minute - March 2017

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by George Chapman, GW Chapman Consulting

Affordable Care Act.  A bill to replace the ACA, called the “American Healthcare Act”,  has just passed the Ways and Means committee in the Republican controlled House. The bill would: eliminate many of the taxes that support expanded Medicaid and the premium subsidies on the exchanges and replace them with consumer tax credits, provide block grants to the states for Medicaid, and discontinue the individual mandate requiring all to have insurance or pay a penalty. The bill would continue, however, the basic cornerstones of the ACA: allow children to remain on a parent’s plan until age 26, no life time monetary caps on illnesses, and insurers cannot deny coverage for pre-existing conditions. Rather than going through a disruptive and highly political repeal and replace process, many industry observers wonder why the changes proposed in the new bill were not simply introduced in Congress, over the last six years, as amendments to the ACA. The insurance lobby (AHIP) has expressed approval of some of the changes, but it has expressed concern about the potential decline in coverage and the negative impact on our most vulnerable populations. The American Medical Association flat out will not support the new bill. The hospital lobby says the probable increase in the uninsured will cost hospitals billions. Washington observers and healthcare policy experts believe the bill, as written, will not garner enough support in the Senate. The Congressional Budget Office still has to determine if the new bill’s numbers add up. The CBO has estimated that 15  million people could lose their insurance.

Mega merger drama.  Critics of the ACA have maintained many consumers really don’t have choices because one in three markets has only one insurance company left on the exchange. Consequently, consumers, physicians and hospitals could potentially be at the mercy of monopolistic pricing. Insurance companies maintain that mergers (resulting in less choices) will  allow them to reduce costs and increase efficiencies which would benefit the consumer. The Department of Justice isn’t buying that has blocked the mega merger of Anthem and Cigna, the second and third largest commercial insurers in the nation. Incredibly, Cigna is now suing Anthem to end the merger agreement and for damages. Anthem has countersued. The AMA has expressed its strong concern over the possibility of politically driven settlement negotiations between Anthem and the DOJ that could result in Anthem closing the deal with Cigna.

Accountable Care Organizations. ACOs were established by the ACA to cut costs and improve access and quality.  More than 850 ACOs across the country care for over 28 million people.  Hospitals, physicians and insurers have been collaborating the past six years. The majority of ACOs participate  in shared savings programs with Medicare and commercial insurers. Industry experts are confident ACOs will survive any changes in the laws of the land.

Telehealth.   More and more insurance companies are paying for telehealth. The immediate benefits are easier access, enhanced doctor/patient communication and remote monitoring of incapacitated patients. It will take more time and experience to determine whether or not the increased utilization of physician services via telehealth is eventually outweighed by cost reductions in other areas like inpatient care and drug utilization.  A study published in Health Affairs followed three years of claims for respiratory infections. The study concluded that nine of ten telehealth visits (for this condition) represented new or additional utilization versus visits that substituted for an in person encounter. The authors of the study recommended insurers or even providers might want to increase patient out of pocket costs to prevent frivolous or unnecessary telehealth utilization and that  telehealth might have more of a positive impact for those patients with traditionally undertreated conditions like diabetes and mental health.

Obesity.  In a study published in “Cell Metabolism”, researchers found that a dopamine deficit may be the major cause of physical inactivity which has often been blamed on obesity.  Lab mice were divided into two groups. The first group was fed low fat food while the second received high fat food. The mice on the high fat diet naturally gained more weight, but researchers noted all ice were inactive, due to low dopamine levels, to start. So weight gain itself did not lead to inactivity in these mice.

Dementia.  46 million people worldwide suffer from some sort of dementia. In the US, 5 million people have Alzheimer’s disease. One in three seniors will die from dementia complications. Dementia costs us about $236 billion a year. Researchers at Boston University school of medicine found that people who sleep more than nine hours on average are TWICE as likely to develop dementia than those who sleep less than nine hours on average.

Social media. Social media (SM) is having more and more of an impact on consumers and their behaviors every year. 40% say information gleaned from SM affects how they deal with their health. 19% of smartphone owners have at least one health related app. 41% of us say SM influences our choice of providers and hospitals. 30% of healthcare professionals use SM for networking. When it comes to sharing health info via SM, 43% of us are comfortable sharing with hospitals, 47% with physicians, 38% with insurers and 32% with pharmacies. 60% of physicians report SM actually improves the quality of health in their patients.

Really? And finally this. “Nobody knew that healthcare could be so complicated”. President Donald Trump. February 27, 2017.

Co-Working, Co-Living & One Million Cups By Troy Evans

On December 9th, we had a presentation by Troy Evans of 16th Avenue Inc talking about the concepts of co-working, co-living and One Million Cups Syracuse style, and how each could apply to consultants in a much different way than most of the people in the room had ever thought of.

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The first concept came under the name of Syracuse Coworks. In essence, it's an open working space where people who work independently can go, set up their laptops or computers, and not only do their work but be surrounded with a lot of other independent business people doing the same. What it offers is the chance to talk to other people who aren't potential customers and bounce ideas off, something that doesn't happen all that often when we work out of our homes. It also gives people a chance to have a conversation face to face and possibly even go to lunch or to grab a cup of coffee.

That's not the only reason it's unique. For only $100 a month you have access to free high speed wi-fi, there's a conference room, a space where you can put on a small event or presentation, a soundproof space if you want to do podcasting or videos, and even a few individual offices; those will cost you a little more than the $100 though. True, it's downtown Syracuse on Jefferson Street, but if you're bored or going stir crazy at home this is a great and inexpensive option to consider.

Next Troy talked about CommonSpace, which is the co-living piece. This consists of 2 floors of one bedroom apartments of only 300 square feet of space. Once outside that you have common areas such as a large kitchen, living room type areas, game rooms, movie area and a place to work out. These units are both short and long term lease and of course the wi-fi is free.

The initial expectation was that 50% of the people living there would also be working in the downstairs space, but it's turned out that only 15% of the residents work in the Coworks area. Most of the people are 3 month short term residents from out of the area, including some from other countries. The age ranges are from 26 to 55, with 4 couples living there.

The starting price is around $800 a month, and once a week there's a group dinner and once a month a group event. Troy mentioned that his hope was to create an internal neighborhood more than just another apartment complex.

The final piece of his presentation concerned One Million Cups, which was actually started in Kansas City by the Kauffman Foundation a few years ago. It's intention was to be more of a think tank for up and coming businesses that wanted an opportunity to present their business to a group of other independent business people and then ask their advice on promotion, marketing, the product itself… pretty much anything.

Presentations are between 5 and 6 minutes and then it's questions and recommendation time. It happens at the same time everywhere across the country (Wednesdays at 9AM) depending on time zone and the coffee and hot chocolate are free. One thing Syracuse Coworks offers (it might be offered elsewhere but we're not sure) is that anyone who comes on Wednesdays can use the co-working space for free that day, which is pretty cool.

The members loved this presentation because it offers something that most consultants could use. Getting out of the house every once in a while can be a good thing, and it's hard to beat the $100 a month price (other than going to the library) and the opportunity to talk to someone during the day (which the library would frown on). It's learning about things like this that makes PCA of CNY such a special group to belong to.

 

Healthcare In A Minute - October 2016

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by George Chapman, GW Chapman Consulting

Hospital ratings. The recent five star ratings of hospitals by Medicare raised the issue of whether large teaching hospitals got a fair shake because the survey upon which the ratings were based (Hospital Consumer Assessment of Healthcare Providers and Systems) did not account for patient acuity. Large teaching hospitals treat more trauma and often care for difficult patients transferred to them by surrounding rural and suburban hospitals.   A study published in the Journal of General Internal Medicine looked at online hospital reviews by consumers on Yelp. About 25% of the almost 3,800 hospitals in the Medicare survey also had ratings on Yelp. The correlation between the Medicare rating received by a hospital and the Yelp reviews was very strong. Yelp reviewers reported on staff quality and compassion, access, convenience, bedside manner, cost, billing, scheduling, treatment of family and visitors. Researchers found that consumers are more savvy than the industry thinks. Hospitals that performed better on both outcome and processes enjoyed greater market share and growth. Word gets around and patients seek care where it’s the best.

Telemedicine.   Many argue telemedicine will never be as effective as a real face to face encounter between patient and provider. So far, the technology has proven effective in many scenarios such as: the patient is incapacitated (sick, injured, contagious); foul weather; transportation is unavailable (commercial or care giver); patient just needs remote monitoring;  patient needs encouragement or compliance pep talk; patient needs medicine checked; patient has mental issues and acts out; patient can’t leave work; on call provider can refer to video visit.

RomneyCare update.  Industry observers keep an eye on what is happening In Massachusetts because it is consider the harbinger of things to come under the Affordable Care Act. The Massachusetts Center for Health Information  reported that costs in 2015 were $8,424 per capita which is an increase of 3.9% over 2014. The benchmark or target was an aggressive 3.6%. (Everyone in Massachusetts has insurance.)  As with the rest of the nation, drug costs were responsible for most of the cost “overrun”, accounting for a third of all costs. Larger, more efficient healthcare systems are putting a lot of financial pressure on smaller community hospitals and rural systems.

2016 election.  Both candidates agree drug companies seemingly raise prices arbitrarily and something needs to be done.  Trump would allow Medicare/Medicaid and commercial payers to purchase drugs from countries like Canada. Clinton would appoint a federal watchdog to monitor price increases and limit the amount of income consumers would have to spend out of pocket on drugs. But controlling the pharmaceutical industry, let alone prices, will not be easy unless the revolving door between the FDA and the drug manufacturers is controlled. The FDA has data on how many of its former employees now work as consultants or lobbyists to the pharmaceutical industry but has not released such data.

National spending.  In 2014, we spent $9,523 per capita. Still the most by far of any developed country. At $3 trillion, healthcare was 17.5% of our GDP in 2014. (it is currently trending at 18%.) Medicare and Medicaid accounted for 36% of spending. Commercial insurance accounted for 33% and out of pocket another 11%. The remaining 20% is VA, federal employees, Public Health Service and other federal programs.

Specialty rankings.  According to a study of online physician reviews published in Becker’s Hospital Review, consumers report the highest satisfaction levels with neuromuscular specialists, thoracic surgeons, podiatrists, plastic surgeons and colorectal surgeons. The lowest ranking were with: psychiatrists, preventive medicine specialists, pain specialists, emergency physicians and neurologists.

Physicians refusing care.  A debate over how much autonomy a physician should have when he/she has a conscientious objection to providing a service like abortion, birth control, unnecessary testing and assisted suicide is published in the Journal of Bioethics.  Those who argue a physician does NOT have the right to refuse care feel access to care, especially when there are few if any alternatives, must override a physician’s personal beliefs. Those who argue a physician DOES have the right to refuse care argue they are entitled to have values like everyone else. Sweden and France bar physicians from refusing any legal service and can suspend or revoke a practitioner’s license. The US, Canada and the UK have historically allowed the refusal of services based on conscientious objection. Most physicians who will not provide certain services due to moral objections will be happy to refer their patients to another provider without disrupting the overall relationship between them.

Watch your scale.   The good news, according to a study by a Cornell professor published in the New England Journal of Medicine, is your weight might be at an annual low…. right now. The bad news is that, thanks to the upcoming holidays, you will gain weight and a lot of the gain will be permanent if you don’t pay attention. Weight gain typically starts 10 days before the holiday season and peaks around New Year. Because the study participants were aware they were in a weight study, the professor believes the weight gains were probably artificially low to moderate and that weight gain in the general public is worse. Other studies have found that after 30, most of us gain two pounds of permanent weight every holiday season.

CNY Smokeout.  3K fun run to promote giving up tobacco products and creating healthy lifestyles. Sunday November 6, 2016. Onondaga Lake park. 8 am registration.  $20 entry fee. 727-3074 for more information.