ON/OFF THE RECORD

 From Bob Ingle's column and worth listening to for an insight into politics and politicians.

 From the archives: Huntley/Brinkley give JFK a second shot at answers

Posted on June 19, 2013 by Bob Ingle

What we believe to be  spontaneous fact may be otherwise.

I did oversleep and  will post later today about the Court decisions.

ABOUT BLOGS AND BOE

In the masthead of this blog I remarked that the purpose of this blog was to be a “vehicle to expound at nonspecific intervals my opinions regarding politics-local to international, health care, life, society, and perhaps religion plus periodic vignettes about Plainfield.”

I added to that proposition by posting interesting art works from the covers of JAMA , the weekly scientific publication of the American Medical Association. In the early years I also posted photos from our trips including some to then exotic places such as Afghanistan during its pre-Russian and Taliban eras and Iran under the Shah (long long ago).

The last few years it seems that greatest reader interest comes from blogs devoted to local political issues and at one time the Board of Education.  Whether a subject dear to my heart, Health Care, has been of reader interest eludes me since there is a drop in hits and few comments received on those days.

Therefore, I am happy that the Courier today has two front page articles; one dealing with the Rutgers Board of Trustees and the University’s organizational structure, the other with the legal costs and their legitimacy paid by the Plainfield BOE in the past 4 years.  

These of course plus the spate of Supreme decisions stimulate more than “obiter dictum” as the basis for forth coming opinionated blogs.

Today, however I shall be contented to once more express my disenchantment with an elected board.  The last decade has been marked with a lowering of the educational standards in our system, to frequent turnover in top personnel, excessive legal fees, absence of accountability, and an opaque transparency by the present “political group” who control the board.

This year with the change of the BOE elections to be concurrent with the general election may increase the number of citizens that cast a vote but once again we have only two political based slates to choose from in this so called non-partisan election.

There is no question that judging by its track record of commission appointments that under the present administration having a Mayor appointed BOE would not have been an improvement.

Never the less, even understanding that politicians like leopards do not change their spots; I would strongly advocate a referendum to restore the “Appointed Board”. There will be accountability which is lacking today.

POTPOURRI

Yesterday I wrote about natural disasters focusing on floods. Some have been due to heavier than normal spring snow melt supplemented by record rainfall. The rains and windstorms have been erroneously blamed on El Nino. Actually according to NOAA since the mid 2010 the equatorial Pacific water temperatures have been either consistent with a La Nina (cold) or lately neutral period so that has not been the source of our ‘Sandys” and tornadoes.

But did you read Tuesday or hear on the “news”; As reported by The National Oceanic and Atmospheric Administration (NOAA).

.”A Rare Tsunami Hit The East Coast Earlier This Month
The West Coast and Alaska Tsunami Warning Center said the source of the wave is "complex and under review," but they believe it was caused by a strong storm and perhaps even the "the slumping at the continental shelf east of New Jersey."

The weather service says that Brian Coen, who was spear fishing near Barnegat Inlet in New Jersey, saw the effect of the tsunami first hand.

He told the weather service that he noticed an outgoing tide that lasted a couple of minutes and exposed rocks that had been submerged. That was followed by a big six-foot wave.

to Paul Whitmore, director of the tsunami center.
He explained the weather system that moved through the area may have changed the air pressure enough to "generate waves that act just like tsunamis." When that happens, the wave is called a "meteotsunami" — in other words a tsunami caused by meteorological conditions, not seismic activity.”

Christie missed that.

I was going to write more today about a man-made disaster; the state of our Health Care Delivery System. There is almost some daily article in the New York Times or the Wall Street Journal on this subject. Tuesday Times article was about the prospects of a financial collapse of Medicare.  The OK projections that administration gives us are based on a mandatory 25% reduction in physician reimbursement. With a constant inflation such action will drive many of the doctors to not accept Medicare patients.
That may be part of my rant (personal) when I next post on the subject.

THIS WET WORLD

“Tis the wrath of (the) God(s) or just another unusual year for natural disasters. 

Although not a “disaster” Ne w Jersey had an earthquake last week. Of course you had to be almost standing on top of it to have felt it.

I am not going to dwell on the “wind” related storms, or the extraordinary large number of wild fires that have plagued the American West and earlier Australia this year.

Instead 2013 may be remembered as the year of the floods. Not so much in the US where with the exception of earlier flooding of the upper Mississippi which necessitated a stoppage of shipping, Only West Texas had severe enough flooding that Two women  died in severe flooding in San Antonio, which had been hit by torrential rains.  

Severe flooding has been a worldwide phenomenon this May and June. In Europe, although the Rhine was not affected badly this year Shipping was halted on extensive stretches of the Rhine, Main, and Neckar rivers.

The two river systems that did have major flooding were the Elbe and the Danube. The Elbe and its tributaries, the Saale (Germany) and the Vltava (Czech Republic) experienced severe flooding, Prague esplanades were under water, as was central areas of Dresden among other cities.

Even worse was the Danube system. Austria had seen 2 months’ of rain fall in 24 hours. The historic centre of Passau, where the Danube, Inn and Ilz converge, was underwater with the highest recorded levels in history. Also impacted were Budapest  and Bratislava; s were other river towns.

Australia too had major flooding this In January 2013, ex-Tropical Cyclone Oswald and associated monsoon trough passed over parts of Queensland and New South Wales.

Just this past week Calgary, Alberta city center was submerged Alberta, Canada, experienced heavy rainfall that triggered catastrophic flooding described by the provincial government as the worst in Alberta's history. Areas along the Bow, Elbow, Highwood, Red Deer, Sheep and South Saskatchewan rivers and their tributaries were particularly affected.

In June 2013, the North Indian states of Uttarakhand and Himachal Pradesh, some regions of Western Nepal and their adjoining areas experienced heavy rainfall that triggered devastating floods and landslides, As of 22 June 2013, more than 1,000 people have died with many more missing

The flooding has not been limited to the north in India. Parts of Haryana, Delhi and Uttar Pradesh, and some parts of Western Tibet also experienced heavy rainfall. This included the Ganges River.

The 2013 Jakarta flood is a flooding of Jakarta, the capital of Indonesia, and affected several other areas surrounding the city, such as West Java and Banten.

Severe flooding is reported to have hit Jakarta on numerous occasions in the past, including in 1621, 1654, 1918, 1942, 1976, 1996, 2002 and 2007. An important part of the flooding problem is caused by the fact that a substantial part of Jakarta is low-lying. Around 24,000 ha (about 240 square km) of the main part of Jakarta is estimated to be below sea level. Flooding can become severe if heavy rains happen to coincide with high tides.

Other parts of the world that have had flood disasters this year include Buenos Aires Province, Argentina, and the. Greater La Plata  region at least 86 reported deaths. And Greater Buenos Aires reported 8 deaths and is said to be the worst flooding in La Plata's history.

In Columbia 140,000 people have been affected by floods and landslides. Almost 700 homes were destroyed and over 14,000 damaged. The most affected areas were on the Pacific Coast in Chocó.

Africa had to participate; Mozambique has had severe rainstorms this year with destructive flooding and many deaths.

AHCA AND YOU #3

Somerset Hospital merges with RWJUH; Hunterdon Medical Center affiliates with the Atlantic Health Systems. The latter differs from a complete merger in that Hunterdon will keep its individual corporate identity and separate medical staff yet all services in both organizations will be commonly available. The Somerville merger will mean that the hospital will be absorbed by RWJUH.

These two actions announced last week is symptomatic of the extreme changes taking place in the health care industry.

I use the term industry advisably since the change from delivery of health care to an industry which began with the advent of the HMO era and the domination of health care by the insurance companies is entering the ultimate stage of commercialization.

The trend of hospital mergers is only part of the process. The days of the Non-profit hospital seems to be in its final existence. For profit commercial hospitals are replacing the traditional non-profit institutions which are in increasing financial difficulty.

This radical restructuring in the Health delivery system is not limited to institutions; the basis of care which  once started in the physician’s  office  has become a dinosaur.   

Not only has the solo doctor’s practice become obsolete in favor of groups; but the groups are in increasing numbers abandoning their independence by becoming units in Hospital controlled mega groups.

  

Is all of this interconnected? The answer is yes. Then the questions are; why, what is the cause, and what is the impact on you the patient.

The why is the simplest to answer; dollars and cents.  Years ago Health Insurance was designed to help pay for the cost of extraordinary medical expenses. 

Medicare and Medicaid determined reimbursement rates for specific but limited elements of society. As Socialism in health care took hold the impact of the HMOs started the revolution which for better or worse is the state of patient care in the second decade of the 21^st Century.

The HMOs (Insurance Companies) not only tied up the people they would service; but determined where they would get care. That included not only the doctors but also the hospitals and institutions that were available to the members of the HMO. Moreover they set “take it or leave it” low fees which often were below Medicare’s. Some carriers even used Medicaid reimbursement which was below economic survival as their base.

The cause is the concept of Socialism which has dominated political philosophy for much of the post WWII Baby Boomers world. There is no denial that the concept is meritorious, but the impact of the application has not been anticipated.  

For Obama care to be practical there has to be a definitive balance between income and expenses.  There are four ways to accomplish this: (1) Increase income by raising (a) insurance premiums, (b) taxation increases ;( 2) lower payouts –reimbursement schedules; (3) limit services; or (4) any combination of the above.

The one element that is politically unacceptable is to raise taxes; so that will be the last resort.

Insurance premiums will be raised since there will be increased demand and usage of services if it does not cost the participant. The insurers are not in the game because they love humanity; profit is the word.

Reimbursement rates are already below market level. This is one of the driving forces that are causing the changes in hospital configuration. Merges are for better cost controls and eliminating reduplicated services. Also it can by sharing assets limit the available resources which are a form of rationing services. Also they will further reduce personnel to bare minimums. All this will compromise quality of care.

Hospitals that do not have a positive merger and whose major patient base is Medicaid or uninsured will not survive ala Muhlenberg.

Once a hospital has been closed the probability of it ever being replaced even in a restricted form is almost nil. The local population base is usually incapable of supporting a non-profit institution. State and/or Federal funding are unlikely since both have dangerously overextended their resources. If the federal government should default on even a portion of its debt there will be runaway inflation.

The time to have sought a commercial for profit corporation to take over the hospital was lost by perhaps deliberate local political inaction and ignoring the at least two that expressed an interest when JFK’s action became apparent.

  

Now-a-days even Physician groups cannot afford the additional expenses imposed upon them by laws. The electronic health records are, contrary to the social pundits, a failure. The systems are expensive to install and maintain (yearly fees). To enter the data in the computer the doctor must either ignore the patient if doing so concurrent with the visit or take extra time afterwards. Different systems do not speak with each other. Much of the data entered by check list is garbage, and has to be repetitive.

One result has been the increased isolation of a physician from the patient and the greater reliance on less well trained Nurse Practitioners and/or Physicians Assistants. Please understand that there are many excellent NPs and PAs but they do not have the broad education exposure that doctors must have. That has to reflect in the level of care. 

Another negative impact on patient care is the fragmentation of care. No longer is there the one on one doctor/patient relationship that persists throughout an illness. There will be different care givers in a hospital from those in the outside world.

With the change in the physician’s role from a self employed or small group partner to an employed member of a large professional unit has also resulted in a marked psychological alteration in the patient/physician relationship.

Gone is the intra-personal intimacy that in my era made the practice of medicine a pleasure. Physicians liked their patients and patients trusted their doctors. Many considered their physician to be a close friend and advisor. The patient was a person not a case number or first name.  The openness that existed impacted on the response to treatment.

The “conversational” office visit that had a positive impact on patient care is no longer possible. There is pressure to accommodate large numbers of patients, so there is a production approach to the visit. Skipping, the first visit paperwork, on a typical visit the initial contact is with an aid who does the routine questioning, and vital signs. Then the doctor comes in reviews the chart, asks a few questions, may check the portion of the body that caused you to seek attention and order more tests or prescribe medication.

This is in part only a fraction of the changes that are going to accelerate in 2014.   

Much of the material I have used for resources comes from the Wall Street Journal which is of course far to right and reactionary. However, there is also  a great deal of commentary in the New York Times; both in its news columns as well as  by slanted op-ed writers. All are worthy of reading. In this Sunday’s (6/23/13) Times on the first page there is an article A Louisville Clinic Races to Adapt to the Health Care Overhaul  with the heading “Remaking Medicine” .It is very informative.

I hope that you have read the first two in this series, and that they have made some sense. I have more planned to follow.