Wednesday, March 31, 2010


To help understand the impact of the health care bills This is a summary of the law's provisions by years when they go into effect. Subsequent years will follow
The Health Care Reform Act mandates in 2010

Immediate Access to Insurance for Uninsured Individuals with a Pre-Existing Condition. Provides eligible individuals access to coverage that does not impose any coverage exclusions for pre-existing health conditions. This provision ends when Exchanges are operational.

Small Business Tax Credit. Initiates the first phase of the small business tax credit for qualified small employers for contributions to purchase health insurance for employees. The credit is up to 35 percent of the employer's contribution to provide health insurance for employees. There is also up to a 25 percent credit for small nonprofit organizations.

Eliminating Pre-Existing Condition Exclusions for Children. Bars health insurance companies from imposing pre-existing condition exclusions on children's coverage.

Prohibiting Rescissions. Prohibits abusive practices whereby health insurance companies rescind existing health insurance policies when a person gets sick as a way of avoiding covering the costs of enrollees' health care needs.

Eliminating Lifetime Limits and Restricting Use of Annual Limits. Prohibits lifetime limits on benefits in all group health plans and in the individual market and prohibits the use of restrictive annual limits.

Covering Preventive Health Services. All new group health plans and plans in the individual market must provide first dollar coverage for preventive services.

Extending Dependent Coverage. Requires any group health plan or plan in the individual market that provides dependent coverage for children to continue to make that coverage available up to age 26.

Bringing Down the Cost of Health Care Coverage. Health plans, including grandfathered plans, must annually report on the share of premium dollars spent on medical care and provide consumer rebates for excessive medical loss ratios.

Reducing the Cost of Covering Early Retirees. Creates a new temporary reinsurance program to help companies that provide early retiree health benefits for those ages 55-64 offset the expensive cost of that coverage.

Strengthening Community Health Centers and the Primary Care Workforce. Provides funds to build new and expand existing community health centers, and expands funding for scholarships and loan repayments for primary care practitioners working in underserved areas.

Improving Consumer Assistance. Requires that any new group health plan or new plan in the individual market implement an effective appeals process for coverage determinations and claims.

Improving Consumer Information through the Web. Requires the Secretary of HHS [Health and Human Services] to establish an Internet website through which residents of any State may identify affordable health insurance coverage options in that State. The website will also include information for small businesses about available coverage options, reinsurance for early retirees, small business tax credits, and other information of interest to small businesses. So-called "mini-med" or limited-benefit plans will be precluded from listing their policies on this website.

Cracking Down on Health Care Fraud. Requires enhanced screening procedures for health care providers to eliminate fraud and waste in the health care system.

Rebates for the Part D "Donut Hole." Provides a $250 rebate for all Part D enrollees who enter the donut hole. Currently, the coverage gap falls between $2,700 and $6,154 in total drug costs.

Improving Public Health Prevention Efforts. Creates an interagency council to promote healthy policies at the federal level and establishes a prevention and public health investment fund to provide an expanded and sustained national investment in prevention and public health programs.

Strengthening the Quality Infrastructure. Additional resources provided to HHS to develop a national quality strategy and support quality measure development and endorsement for the Medicare, Medicaid, and CHIP [Children's Health Insurance Program] quality improvement programs.

Extending Payment Protections for Rural Providers. Extends Medicare payment protections for small rural hospitals, including hospital outpatient services, lab services, and facilities that have a low-volume of Medicare patients, but play an important role in their communities.

Establishing a Patient-Centered Outcomes Research Institute. Establish a private, non-profit institute to identify national priorities and provide for research to compare the effectiveness of health treatments and strategies.

Ensuring Medicaid Flexibility for States. A new option allowing States to cover parents and childless adults up to 133 percent of the Federal Poverty Level (FPL) and to receive current law Federal Medical Assistance Percentage (FMAP) will take effect.

Non-Profit Hospitals. Establishes new requirements applicable to nonprofit hospitals beginning in 2010, including periodic community needs assessments.

Expanding the Adoption Credit and Adoption Assistance Program. Increases the adoption tax credit and adoption assistance exclusion by $1,000, makes the credit refundable, and extends the credit through 2011. The enhancements are effective for tax years beginning after December 31, 2009.

Encouraging Investment in New Therapies. A two-year temporary credit subject to an overall cap of $1 billion to encourage investments in new therapies to prevent, diagnose, and treat acute and chronic diseases. The credit would be available for qualifying investments made in 2009 and 2010.

Tax Relief for Health Professionals with State Loan Repayment. Excludes from gross income payments made under any State loan repayment or loan forgiveness program that is intended to provide for the increased availability of health care services in underserved or health professional shortage areas. This provision is effective for amounts received by an individual in taxable years beginning after December 31, 2008.

Excluding from Income Health Benefits Provided by Indian Tribal Governments. Excludes from gross income the value of specified Indian tribal health benefits. The provision is effective for benefits and coverage provided after the date of enactment.

Establishing a National Health Care Workforce Commission. Establishes an independent National Commission to provide comprehensive, nonbiased information and recommendations to Congress and the Administration for aligning federal health care workforce resources with national needs.

Strengthening the Health Care Workforce. Expands and improves low-interest student loan programs, scholarships, and loan repayments for health students and professionals to increase and enhance the capacity of the workforce to meet patients' health care needs.

Special Deduction for Blue Cross Blue Shield (BCBS). Requires that non-profit BCBS organizations have a medical loss ratio of 85 percent or higher in order to take advantage of the special tax benefits provided to them under Internal Revenue Code (IRC) Section 833, including the deduction for 25 percent of claims and expenses and the 100 percent deduction for unearned premium reserves.

Indoor Tanning Services Tax. Imposes a ten percent tax on amounts paid for indoor tanning services in lieu of the tax on cosmetic surgery. Indoor tanning services are services that use an electronic product with one or more ultraviolet lamps to induce skin tanning. The tax would be effective for services on or after July 1, 2010.

Tuesday, March 30, 2010


Thursday is April Fool's Day. That is the day when Congress in its mandate to make to make the Health Care Reform actuarial "affordable" by deliberate inaction triggers a 20.5% cut in Medicare payments to physicians

It is to early to know what the effect on patient care will be, but for the over 65 age group it may be a disaster. There will also be an impact on every patient in the practice.

To operate a practice not only does the overhead have to be met but there must be sufficient amount of income for the doctor to maintain a standard of life.

I am not crying wolf. Imagine if your cash flow (income) suddenly was only 3/4th of what was normal. Today's medical practice is no longer a personal affair between doctor and patient. Medical practices even an one physician type, an increasing rarity, requires a support staff for all the paper work, compliance with rules and regulations, and self legal protection. These factors have been a major impetus to the creating of multi-physician practices.

With the mark reduction in cash flow there will be a greater need to form larger groups so that the non professional expenses can be spread over a greater number of doctors. The delivery of care will be similar to a clinic situation. The "office" will have to have longer operation hours, which will mean slotting doctors into time intervals.

The one on one relationship will give way to who is available. With mandatory electronic records needed not only so that whatever physician is seeing the patient who will no longer be "Mrs. Mary Jones" but "JON**MAR1234" will have knowledge of "her history and medications, but if not kept will result in severe penalties.

Medicare patients will be given less time, the exams will be more perfunctory, and the doctors actual time will be minimized. Office aids will be doing the initial paperwork, questioning, blood pressure, weight etc, and in many cases Nurse Practitioners or Physician Assistants will do the actual examination before a physician briefly sees the patient. That scenario is already operational in many large practices but will be the survival norm in the next few years.

Many offices will cut back on the number of Medicare patients they see or set certain days to see 10 Medicare patients in the time they usually see 6 patients either with "good insurance plans or self paying. There could be a greater delay in scheduling appointments for Medicare patients.

In the past decade there has been a surge of physicians selling their practices to hospitals or larger groups and then working as employees. This trend which has been driven by the present economic and litigious factors will no doubt be accelerated.

The first noticeable effect of the new ideal Health Care World will be in the physician's office.It will be the impersonal clinic. Longer waits, shorter visits and more "tests" will be the rule of thumb .

Oh for the days when I first began my practice; the days when the post war office visit was an unheard $3.00 and house calls made from Cranford to South Bound Brook were $5.00 net.


A few have requested that I continue the saga of March 24:

Now that we were safely on the ground we were committed to our job. That meant locating the Aid Station sire and getting there.

We had no idea where we were. Nothing resembled what I had studied on the aerial photo maps. I showed the German where we wanted to be. He pointed out where we were; on the wrong side of the river. He agreed to lead us to the river and to a crossing near the farmhouse. I decided to trust him having no other choice. Moreover it was obvious that he wanted out.

Being lazy, I “permitted” him to carry my heavy medical bag and field pack. With my “captive as guide we took off in file, the jeep towing the trailer, supposedly in the direction of the Wessel Canal. In retrospect I can ‘t believe how naive we were as to the possibility of danger, I suppose we hoped the Red Cross would protect us.

We reached what look like an overgrown brook and followed a dirt road on the bank for a short distance. Suddenly, we noticed American soldiers lying prone sheltered by the brook’s near bank. It was our A Company whose Captain yelled out “Doc get down. We are in the midst of a fire fight”. However, we had heard no shots, so we went down the bank, waded across the ankle high "river" and up the other side while the Jeep and trailer went over a little bridge. We soon reached our destination, a farmhouse that had been designated for use as our aid station. Again, I can not remember when or how Irby and the rest of the section got there. It could have even been before we did.

Even though it was spring, the large fields surrounding the farmhouse were filled with haystacks. For several days, we kept unexpectedly flushing out German soldiers who had hidden in those haystacks. They were hungry, scared, but happy to be alive, and wanted to surrender. A few had even hidden in the farmhouse attic which supposedly we had searched upon occupying the house. One day one of our men went to the attic with a comrade. He saw a German soldier's hat behind a trunk and thought he would scare his friend. He yelled "Achtung"; to his amazement, the hat began to rise and there was a German ready to give up. Needless to say, that for all of us, each episode was a shock and surprise.

In the afternoon of day one, there was an air re-supply mission. The planes were Liberators. They flew very low just above the tree tops. Unfettered, the crew pushed the supplies out of an opened door. As they flew over, unfortunately, one of the men fell out of his plane. Our re-supply included British plasma as well as dehydrated British tea with milk. We did not like the tea, and did not have the equipment to use their plasma. One cannot help but admire the men who flew such a hazardous mission.

In a period of little over a week, we had been part of the 3rd Army, the 1st Allied Airborne Army and the 9th Army. The next few days were spent chasing the German army across Westphalia. For about a week, the British 6th Guards Armored. Brigade was attached to us for tank support. The war stopped at 4 pm when the British paused to brew their tea, a daily ritual. At night, the British often lit small, even though it pinpointed a target for enemy fire. While the Americans would not even smoke a cigarette out doors at night unless hidden, the Brits had no reluctance to light a match and smoke.

Airborne divisions lacked sufficient vehicles. Therefore, we commandeered all available civilian vehicles including Volkswagens. I am sure we looked like a rag tag army. There were also times when obviously we did not know where we were. We split the medical section when we were in column. Irby usually was with HQ Company, while I had the majority of the detachment near the rear of the Battalion column. We were usually out of touch with the lead vehicles. I remember one time moving down a dirt road when we saw a column approaching us from the opposite direction. As the first Jeep passed, one of the officers from Headquarters Co. called out “Doc where are you going?" I replied, "I don't know but you seem to be going to where we were". Anyhow, we turned around and as one column continued until they bivouacked in the woods for the night.

That was the other time I dug a “hole”, a slit trench, to spend the night. The few German shells that were aimed at us exploded over the trees. I pulled the Jeep's trailer over my trench and slept under it. I think that was the same day that I can recall our column moving down another dirt road, supposedly chasing the German army. At a cross road, parked by itself, was an ¾ ton Red Cross truck serving doughnuts and coffee

Monday, March 29, 2010

The Seder

The first night of Passover is devoted to the Seder. This is a happy family affair and probably no two families conduct it in the same manner. The uniqueness of the Seder arises from it being just a family or small cohesive group ceremony, not one that belongs in a house of worship. All members of the family from the youngest to the elderly participate in the reading of the "Haggadah" the prayer book used. There are many different Haggadahs but the basic format is the same .

From the 1920s to this date Maxwell House Coffee has printed and distributed copies of the Haggadah. It is in both Hebrew and English, with occasional transliterations for those who wish to say the prayers in Hebrew but can not read it.

The first part of the "service" is devoted to retelling the story of a the bondage in Egypt and the escape fro9m slavery, the exodus to the chosen land. After a break for the traditional meal, the service resumes with a recounting of all of the Lord's blessings to mankind from the creation of Earth and the favors he reigned on the Israelites as long as they kept the belief of the one and only God. This is the part of the evening when the kids get restless and hope the reader will skip some pages. Each household to its own.

Because of memories of over 50 years of our own Seders from full to extended family and final just two, I will instead of printing an opine blog tomorrow continue an excerpt from my "OLDDOC'S WAR continuing after we landed in one piece in Germany.


I must share this letter to my Granddaughter by my 8 year old great grandson. Too often we underestimate the thought capabilities of our "babies" I hope it is readable.


I hope everyone understands that I agree with the concepts in the Health Care Reform bill. My fears are in the implementation of the various segments. This is where the danger of the politician influence on the bill can ,indeed probably will, have negative effects on health care.

I have posted articles from outside sources about the changes in patient/physician relationships. How it has been changing in the past few decades from a personal one on one situation to an increasingly provider/consumer contact. Medicare, Medicaid, and the HMOs insurance companies by reference changed the physician into a "Provider" and the patient into a "Consumer". The interaction was no longer a personal one between two humans, but a commercial transaction involving the giving of services and the use of resources.

Governmental agencies attempt to make their programs affordable by increasingly reducing reimbursements and at the same time requiring more "paper work" with the threat of penalties. The insurers added the addition factor of limitations on usage and denying reimbursement for many new procedures or treatment modalities. As a side effect an increasing cost for a doctor to maintain an office went to employing additional personnel to fill out paper.

The Senate as adjourned for the Easter break-two weeks- without acting on correcting the present law which mandates a 21.5% cut in physician reimbursement on April 1. No business can continue to operate at a loss, which will be the result of this action.

There will be further closure of individuals offices and small groups resulting in the increase dependency on walk in facilities or ERs for primary care, and specialist refusing to treat Medicare patients.

I do not know how many MDs still have offices in Plainfield or North Plainfield. I would expect as the trend continues the sole "providers" of primary care will be the Health Center off Rock Ave. or the Muhlenberg ER with long waits for treatment.

I could not practice today. I felt that I had to have a relationship with those I treated; to know them as individuals not case # 2065. This was true of more than 90% of my peers. But we are now in a more materialistic world and we must live with it.

This is not the post that I was going to write. I had read in Sunday's ' Star Ledger a story form the Bloomberg News about a section of 45 pages in the2,400 page act that created a $500mil a year agency to study comparative effectiveness and value of different treatments and medications. I will opine on this shortly.

Saturday, March 27, 2010


A charrette (pronounced [shuh-ret], often Anglicized to charette and sometimes called a design charrette) consists of an intense period of design activity.

After not finding that word in 4 -yes 4- dictionaries including one door stop variety and one coffee table show off, I turned to Wikipedia; The word is derived from the French, and the "charett" spelling is an Anglicized version. It is used by urban planners as a substitute for "workshop".

Since the subject of Saturday's exercise was a "vision" for Plainfield's railroad corridor.The format and breakdown has been covered by Councilor Storch in his blog.
At least 70 Plainfielders actively participated. Among those present during the 6 hours were the Mayor and Assemblyman Green.

The NJIT presenters were well prepared for each of the 6 localities under consideration and the summaries introduced many worthwhile suggestions from the citizen participants. This will all be incorporated in the final document to be submitted to the Council.

One of the reoccurring factors is the emphasis on high density residential units along the corridor, preferably as 3 over1, or 4 over 1 buildings with the ground floor being commercial. One area mot previously considered by the city was the conversion of the old factory (National Starch?) buildings west of Clinton Ave. into Apartments. with perhaps the DOT rebuilding a station at Clinton Ave. There would be a redevelopment of the commercial area there.

The final product if accepted by the Council could then be incorporated as amendments to the City's Long Range Plan.It would then be up to Administration to act in compliance with the goals set forth when selecting developers for the various areas.

In the meantime this is a plus step for Plainfield, let us hope it is not an exercise in futility.



I would hope that no one has the impression that I am against reform in the delivery of Health Care, Far from that. The system we have been suffering with for the past few decades has been inadequate and producive of sub-ideal care. I do however have serious concerns whether this bill as enacted can result in an overall improved pattern.

It is inconceivable to me that there has been such a reaction of violence and religious and racial bigotry by groups that oppose the President. That is a danger to our way of life that each and everyone of us must guard against. Sad to say the Southern Poverty Law Center has found New Jersey to be the home of many such bigoted groups.

I have alluded to some of my health care concerns in recent postings. I do intend to amplify and I hope to clarify my worries in upcoming posts.

Meanwhile this article from 3/26/10 New York Times illustrates what is happening in the delivery of care that I find can only decrease quality although on paper it appears to be an improvement.

More Doctors Are Giving Up Private Practices

WASHINGTON — A quiet revolution is transforming the waymedical care is delivered in this country, and it has very little t do with the sweeping health care legislation that President Obama just signed into law. But it could have a big impact on that law’s chances for success.

Traditionally, American medicine has been largely a cottage industry. Most doctors cared for patients in small, privately owned clinics. But an increasing share of young physicians, burdened by medical school debts and seeking regular hours, are deciding against opening private practices. Instead, they are accepting salaries at hospitals and health systems. And a growing number of older doctors — facing rising costs and fearing they will not be able to recruit junior partners— are selling their practices and moving into salaried jobs, too.

As recently as 2005, more than two-thirds of medical practices were physician-owned — a share that had been relatively constant for many years, according to the Medical Group Management Association. But within three years, that share dropped below 50 percent, and analysts say the slidehas continued.

Ideally, bigger health care organizations can provide better, more coordinated care. But for all the vaunted efficiencies of health care organizations, there are signs that the trend toward them is actually a big factor in the rising cost of private health insurance.

In much of the country, health systems are known by another name: monopolies. With these systems, private insurers often have little negotiateing power in setting rates — and the Congressional health care legislation makes little provision for altering this dynamic.

The trend away from small private practices is driven by growing concerns over medical errors and changes in government payments to doctors. But an even bigger push may be coming from electronic health records. The computerized systems are expensive and time-consuming for doctors, and their substantial benefits to patient safety, quality of care and system efficiency accrue almost entirely to large organizations, not small ones. The economic stimulus plan Congress passed early last year included $20 billion to spur the introduction of electronic health records.

In many ways, patients benefit from higher quality and better coordinated care, as doctors fromvarious fields join a single organization. In such systems, patient records can pass seamlessly from doctor to specialist to hospital, helping avoid the kind of dangerous slip-ups that cost the lives of an estimated 100,000 people in this country each year.

And yet, the decline of private practices may put an end to the kind of enduring and intimate relationships between patients and doctors that have long defined medicine. (GARDINER HARRIS)

I boldfaced the last paragraph because that relationship is essential to good care, and I will go into that subject in the future.