In my previous
column, I reported on the problem of widespread burnout among doctors and medical students — and I described a response that, in recent years, has spread to half the nation’s medical schools: a course called
The Healer’s Art, created by a physician, Rachel Naomi Remen, to help doctors and students discover and reconnect to the deep meaning of their work and maintain their commitment for it. The article touched a sore spot. Hundreds of readers — patients, medical students, doctors and spouses and children of doctors among them — contributed comments describing their personal experiences, many of them raw with emotion. Some of the most poignant notes came from doctors themselves, and their words revealed a deep sense of betrayal.
“Yes, changing the culture of physician training is important,” he added. “But we also need to turn back the disastrous process of the McDonaldization of healthcare.”
The toll begins early.
Holly, a fourth-year medical student, from Maryland, wrote: “I am emotionally exhausted and suffering from burnout. I realize how scared and vulnerable my patients must be feeling. Unfortunately, I am unable to spend the time I’d like with each patient because I have so many other patients whose needs must also be met.”
In my reporting on The Healer’s Art, I interviewed numerous medical students and doctors, who reported that the course provided them with a unique opportunity to talk about their personal and family experiences as patients, doctors, or doctors in training, and to share their fears, joys, rewards and struggles. They said the course allowed them to reflect on these experiences alongside peers and teachers in a safe setting that was unavailable elsewhere in the medical curriculum. Many added that the experience enabled them to maintain their spirits and their sense of “wholeness” during their training, and, later, dealing with a dysfunctional health system that seemed designed to “beat the humanity” out of them.
The new online health insurance exchanges continued to experience heavy traffic and technical problems in their second day of operation Wednesday, as officials said the systems were still drawing more users than they had anticipated.
Many state-run systems seemed to be functioning — albeit, in some cases, slowly and with scattered problems — but the federal system operating the exchanges for 34 states remained trouble-plagued. Consumers trying to log on to that system encountered long waits, malfunctioning Web pages and messages telling them to try again later.
Officials said Wednesday that the federal exchange Web site, healthcare.gov, had 4.7 million unique visitors in its first 24 hours — many times as many as had ever visited, for example, the Medicare Web site in a single day — and that 190,000 people called the government call centers for the program. They said 104,000 visitors requested Web chats with enrollment counselors.
But reports by government officials, consumers and private groups designated as “navigators” to help consumers use the system all indicated that relatively few people were able to establish accounts, and fewer still were able to go beyond that step to shop and compare plans. Even fewer were able to apply for coverage.
“That I know of, none of our people got through on the system,” said Matthew Hayes, who is running the navigator program at Legal Action of Wisconsin, a state using a federally run exchange.
In another state using the federal system, Jill Hanken, project director for Enroll Virginia, said members of her team were able to help some people set up accounts, and even enroll in health plans, but that most attempts failed. “The system was obviously pretty overloaded,” she said.
Federal officials declined to discuss either the nature of the problems — whether they were caused by sheer volume, design flaws or other factors — or their extent. Even so, they pronounced themselves pleased, saying that the intense interest showed a pent-up demand that demonstrated the need for the Affordable Care Act, the 2010 law known as Obamacare, which created the exchanges.
People working with all the exchanges, state and federal, said the demand was far heavier than they had anticipated, and remained heavy Wednesday.
“We expect to see similar volume as yesterday,” said Joanne Peters, a spokeswoman for the Department of Health and Human Services. “While this overwhelming interest is continuing to cause wait times, there will be continuing improvements in the coming hours and days.”
The demand “exceeds anything that we had expected,” President Obama said at the White House on Tuesday afternoon.
Officials said most of the initial volume consisted of people not yet looking to buy insurance policies, but just looking for answers about their eligibility for various programs, prices and choices. Among the states, New York and California had especially heavy traffic to their exchanges — 10 million first-day visits and 5 million, respectively — but the states could not say how many unique visitors those figures represented, or how many people had successfully enrolled.
As Demand Stays High, Officials Try to Address Problems in Exchanges
Federal and state officials moved Wednesday to strengthen the computer underpinnings of the new online health exchanges, which proved inadequate to handle a flood of consumer inquiries that began as soon as the system opened on Tuesday and continued into the next day.
On the second day of the exchanges’ operation, users were still encountering long waits, malfunctioning Web pages and messages telling them to try again later, particularly in the 34 states where the marketplaces are being managed by the federal government. Most system managers around the country reported that traffic on Wednesday continued to exceed their expectations, though in places it declined somewhat from the peaks of Tuesday.
The federal exchange Web site, healthcare.gov, opened to the public at 8 a.m. Tuesday, and by Wednesday afternoon, it had had 6.1 million unique visitors, the Department of Health and Human Services said — a pace many times as great as the Medicare site had ever seen. “While this overwhelming interest is continuing to cause wait times, there will be continuing improvements in the coming hours and days,” said Joanne Peters, a department spokeswoman.
The rollout laid bare the complexity of the endeavor, which requires state and federal systems, and the work of myriad private contractors, to communicate as a seamless whole. In some cases, officials conceded that they could not be sure which problems were caused by simply not having the computer capacity to handle the initial demand — a shortfall that should correct itself in time — and which might be signs of design flaws or software bugs.
“It’s like building a bridge from two sides of the river; you just hope it comes out in the middle,” said Kevin Walsh, a senior executive at Xerox, which won a $72 million contract to build Nevada’s state-run exchange. With such complexity, he said, “usually you do a lot more testing than we’ve had time to do.”
A Health and Human Services official said Wednesday that the government would be adding computer servers to the system to make it more robust. The official, who was not authorized to speak publicly and spoke on the condition of anonymity, said the department was “working with highly qualified experts to improve the system capacity,” though it was not clear whether that would involve more than just additional hardware.
New York State’s exchange doubled its computer capacity from Tuesday to Wednesday, said Donna Frescatore, the executive director, leading to smoother operation of a system that had been overwhelmed on the first day. She said it was not yet clear how many people had visited — or tried to visit — the exchange’s Web site, but that 12,000 had filled out forms or browsed through their options.
In Maryland, with one of the most trouble-plagued state-run systems, enrollment counselors said they had to resort to paper applications for a second day because the state exchange Web site remained so slow. Rebecca E. Pearce, the executive director of the Maryland Health Benefit Exchange, said that “there’s a bottleneck in the account creation process,” and that officials were considering adding more computing and routing capacity.
Millions of Poor Are Left Uncovered by Health Law
A sweeping national effort to extend health coverage to millions of Americans will leave out two-thirds of the poor blacks and single mothers and more than half of the low-wage workers who do not have insurance, the very kinds of people that the program was intended to help, according to an analysis of census data by The New York Times.
Because they live in states largely controlled by Republicans that have declined to participate in a vast expansion of Medicaid, the medical insurance program for the poor, they are among the eight million Americans who are impoverished, uninsured and ineligible for help. The federal government will pay for the expansion through 2016 and no less than 90 percent of costs in later years.
Those excluded will be stranded without insurance, stuck between people with slightly higher incomes who will qualify for federal subsidies on the new health exchanges that went live this week, and those who are poor enough to qualify for Medicaid in its current form, which has income ceilings as low as $11 a day in some states.
People shopping for insurance on the health exchanges are already discovering this bitter twist.
“How can somebody in poverty not be eligible for subsidies?” an unemployed health care worker in Virginia asked through tears. The woman, who identified herself only as Robin L. because she does not want potential employers to know she is down on her luck, thought she had run into a computer problem when she went online Tuesday and learned she would not qualify.
At 55, she has high blood pressure, and she had been waiting for the law to take effect so she could get coverage. Before she lost her job and her house and had to move in with her brother in Virginia, she lived in Maryland, a state that is expanding Medicaid. “Would I go back there?” she asked. “It might involve me living in my car. I don’t know. I might consider it.”
The 26 states
that have rejected the Medicaid expansion are home to about half of the country’s population, but about 68 percent of poor, uninsured blacks and single mothers. About 60 percent of the country’s uninsured working poor are in those states. Among those excluded are about 435,000 cashiers, 341,000 cooks and 253,000 nurses’ aides.
“The irony is that these states that are rejecting Medicaid expansion — many of them Southern — are the very places where the concentration of poverty and lack of health insurance are the most acute,” said Dr. H. Jack Geiger, a founder of the community health center model. “It is their populations that have the highest burden of illness and costs to the entire health care system.”
Despite Criticisms, Health Care Law’s Impact on Jobs Is Still Unclear
WASHINGTON — To Speaker
John A. Boehner, it is “job-killing.” To Senator Ted Cruz, it is “hurting the American people.” To Senator Mitch McConnell, it is a “big reason we are turning into a nation of part-time workers.”
But to many independent economic analysts, it remains too early to tell how the sweeping Affordable Care Act will affect the jobs market.
The
health care law expands insurance coverage to tens of millions of Americans, in part through the “exchanges” that began enrollment this week, and later through rules mandating that certain businesses provide coverage. The government has shut down in no small part because of Republican opposition to the law on economic grounds: It is harming businesses and sapping strength from the economy, they argue.
But major provisions of the law have yet to take effect, meaning many of the assertions about how the law is slashing hours or encouraging part-time employment are not backed by statistical evidence, economists from across the political spectrum said. “The script is still being written,” said Mark Zandi of Moody’s Analytics. “I don’t see any evidence Obamacare is impacting the job market.”
N. Gregory Mankiw, a Harvard economist who worked in President George W. Bush’s administration, agreed. Asked how much the Affordable Care Act had affected the economy so far, he said, “Probably not a whole lot.”
Economists said that in time the law might have an enormous and varied impact on the labor market, including on the behavior of millions of workers and businesses. Part-time work may increase, as may worker mobility, job-switching and entrepreneurship rates. For some workers, hours may decrease.
But the current data do not show the health law affecting job growth, wage growth or the proportion of part-timers in the labor force, Dr. Zandi and other economists said. With major portions of the law still not in force — including the
Medicaid expansion in about half the states, the subsidized insurance exchanges in all of them and the so-called employer mandate requiring certain businesses to offer insurance coverage — it is too soon to tell.
As the federal government struggled on Wednesday to explain the technical problems experienced by would-be users of the health exchange Web site, www.healthcare.gov, computer security specialists say they had ruled out a cyberattack known as a denial of service, or DDoS, attack. Those occur when attackers fire huge amounts of traffic at a Web site until it collapses under the load.
Such attacks typically entail hundreds of millions of data requests to a site per second. The federal health care site experienced 4.7 million unique visitors in the first 24 hours. New York State’s site experienced 30 million Web requests, which could have been fueled at least in part by a New York advertising blitz on sites like CNN.com, media coverage, and links from news sharing sites like Reddit.
By comparison, Connecticut reported just under 80,000 Web site visits by the end of Tuesday.
The more likely source of the problems, security specialists say, was growing pains. Some questioned whether the government had enough database resources to accommodate the huge spike in first- and second-day Web site traffic from insurance shoppers. Federal officials have yet to respond to questions about the problems.
Medical-device tax repeal is an idea full of holes
IF THE Capitol Hill impasse ever ends, it will probably be through a compromise under which House Republicans abandon their demands to delay or
defund Obamacare — in return for a concession Senate Democrats can tolerate. One scenario involves Republican support for a spending bill in return for repealing one source of funding for the health-care law: a
2.3 percent excise tax on medical devices.
Republicans hate the tax, which took effect Jan. 1, because, well, it’s a tax, and because it pays for Obamacare. More than a few
Democrats are against it, too, ostensibly because it’s a job-killing burden on small business. In March, 33 Democratic senators voted for a nonbinding resolution that called for repealing the tax. Among them were liberal lions such as
Al Franken (Minn.) and
Elizabeth Warren (Mass.), whose home states have large medical-device industries.
Given those political realities, the No. 2 Senate Democrat, Richard Durbin of Illinois, suggested Tuesday that his party “
can work on something . . . on the medical-device tax,” as long as the House first passes a “clean” spending bill, with no Obamacare-related strings attached, and agrees to replace the $30 billion in revenue that the tax would raise over the next decade.
It figures that the only policy idea that might bring the two parties together is not a terribly good one.
The medical-device tax is one part of a package that was supposed to pay the
$1.3 trillion cost (over 10 years) of covering
27 million uninsured people. The excise tax amounts to asking the medical-device industry to chip in 2.3 percent of the tab, just as other health-care interests, such as insurance companies and the drug industry, were also asked to pony up. We hasten to add that this is hardly the optimal financing method; a generally applicable program ought to be financed with generally applicable taxes. Still, the $100 billion-plus medical-device industry is
highly profitable. While the tax might
impose some pain on the business, we
doubt that it would doom it. We’re also skeptical of free-market pleadings from an industry that owes much of its prosperity to federal programs such as Medicare and Medicaid. Indeed, the influx of new insured patients because of expanded coverage would, to some extent, create offsetting demand for devices.
Pressure mounts to fix health insurance exchanges
Yesterday at 9:34 PM
The high interest from Americans wanting to buy health insurance is seen as a postive, but website glitches could dampen enthusiasm for the law.
The Associated Press
The pressure is on for the federal government and states running their own health insurance exchanges to get the systems up and running after overloaded websites and jammed phone lines frustrated consumers for a second day as they tried to sign up for coverage using the new marketplaces.
In some ways, the delays that persisted Wednesday were good news for President Barack Obama and supporters of his signature domestic policy achievement because the holdups showed what appeared to be exceptionally high interest in the overhauled insurance system. But if the glitches aren’t fixed quickly, they could dampen enthusiasm for the law at the same time Republicans are using it as a rallying cry to keep most of the federal government closed.
DHHS says the service is still inadequate and the company has until Dec. 1 to fix it.
The state is on the brink of canceling its contract with a company it hired for $28.3 million in taxpayer funds to arrange rides to medical appointments for thousands of MaineCare patients, according to a memo released Wednesday by the Department of Health and Human Services.
Connecticut-based Coordinated Transportation Solutions, which has been the ride broker for six of eight transportation regions statewide since Aug. 1, has been put on the equivalent of probation for failing to provide adequate service, according to a memo dated Monday and signed by Stephanie Nadeau, director of MaineCare services in the DHHS.
The department is giving the company two more months to fix the problems, and some state lawmakers say that’s too much time.
The rides program for low-income Mainers has been in turmoil since the state switched from a system in which local nonprofits arranged and provided the rides, to a system in which regional brokers connect patients with the transportation providers. The DHHS said it made the change to comply with federal rules requiring more accountability and transparency.
In the program’s first two months, thousands of patients have missed rides to doctor’s appointments, therapy sessions, counseling and other medical services.
Posted Oct. 02, 2013, at 5:55 p.m.
BREWER and PORTLAND, Maine — Eastern Maine Healthcare Systems’ bid to expand its footprint into southern Maine has cleared a final regulatory hurdle.
Nearly a year after the Brewer-based EMHS
announced plans to add Portland’s Mercy Health System of Maine to its network, the state issued final approval Tuesday, according to a joint press release from the health organizations.
The Maine Department of Health and Human Services’ certificate of need unit recommended the approval in August with two conditions — that for three years EMHS report any cost savings from the merger and that Mercy notify the state of any changes to its charity care policy, which governs free and discounted care for people who can’t pay their medical bills.
Both conditions have been addressed and the deal now moves toward an official closing, according to EMHS spokeswoman Karen Cashman.
EMHS, parent organization to Bangor’s Eastern Maine Medical Center and six other hospitals throughout northern and eastern Maine, will bring into its fold the 230-bed Mercy Hospital in Portland, as well as VNA Home Health Hospice in South Portland, an addiction treatment center in Westbrook and Mercy’s primary and urgent care centers.
The merger brings EMHS into the backyard of MaineHealth, Maine Medical Center’s parent system and Mercy’s main competitor in Portland. The deal is expected to buoy the financially struggling Mercy while giving EMHS its first foothold in southern Maine.
Central Maine Healthcare halts effort to take over Parkview medical center in Brunswick
Posted Oct. 01, 2013, at 2:47 p.m.
Last modified Oct. 01, 2013, at 4:02 p.m.
LEWISTON, Maine — Central Maine Healthcare has withdrawn its application to take over Parkview Adventist Medical Center in Brunswick, saying state regulators aren’t playing fair and are “inexplicably but undeniably committed to denying this application.”
The state denies that it has unfairly pushed the application forward, saying instead that the health care companies were actively partnering before regulatory approval.
CMHC, the parent organization of Central Maine Medical Center in Lewiston, last year filed a certificate of need application seeking state approval for Parkview to join CMHC. The two health care organizations have worked together for years but wanted to deepen and formalize the relationship.
The request
proved controversial, even drawing a competing takeover request from Brunswick competitor Mid Coast Hospital the following month. The Department of Health and Human Services’ Licensing and Regulatory Services division declined to review Mid Coast’s application “on a competitive basis with the submission received by the department by Central Maine Healthcare,” according to DLRS records.
CMHC pushed forward until last winter, when DLRS, which reviews and recommends approval or denial of projects by health care facilities, got
set to recommend denial of the CMHC-Parkview merger. It said CMHC didn’t provide enough information in its application.
But CMHC officials said they were surprised this summer when the department notified them that it was reactivating the application early, against CMHC’s wishes.
“Six months is not a year,” CMHC spokesman Chuck Gill said.
Mercy Hospital Merges with EMHS, Continuing Consolidation Trend
Lewiston-based Central Maine Health Care and Brunswick-based Parkview Adventist Medical Center have had a partnership of sorts for years. About eight years ago, Central Maine Health gave Parkview a financial lift, and now there's a formal relationship between the two hospitals, which they were hoping to make even stronger through a merger.
"You know, it's a new frontier in the world of medicine and of hospitals," says Tory Ryden, a spokesperson for Parkview. "We really have to be looking at creative, smart ways to help the community."
Translation: better care and lower costs. That was the idea behind the merger with Central Maine Health Care, or CMHC, which has already brought Bridgton and Rumford Hospitals under its umbrella of care.
..........................
While that merger is on hold, Mercy Hospital and Eastern Maine Healthcare Systems celebrated state approval of their merger on Wednesday. EMHS spokesperson Karen Cashman says it's unclear when the merger will officially begin, but she says Mercy patients won't notice too much of a difference.
"They'll still receive the same high quality care they've always received from Mercy," Cashman says. "However, hopefully we'll be able to bring in certain pieces to the care delivery that will help to enhance care."
Health Care for All: Why We Need a New Prescription
A conversation with Dr. Don McCanne
By Scott Tucker
Truthdig, Oct. 1, 2013
The right-wing assault on Obamacare is a distraction, but the “progressive” (or rather party line) defense of the Affordable Care Act is also a dead end. While the tea party and MoveOn descend to mud wrestling, Dr. Don McCanne of Physicians for a National Health Program is not just staking out the moral high ground in the debate on health care. He is also making the practical case for the kind of health care we, the people, both deserve and can afford.
McCanne quotes passages from the daily news, political debates, and medical journals, and adds his running commentary. These columns are collectively titled Quote of the Day, and can be found archived at the website of PNHP. His columns are also available by email subscription.
McCanne’s daily comments on health care range over both present policies and the possibilities of comprehensive reform. He is helping to build the bridge from here to there, but he is not pointing to some utopian island over the horizon. Medicare, for example, offers one flawed but real foundation for health care justice. We need a single-payer system, but we also need a wider network of community health clinics, and health maintenance programs in schools, neighborhoods and workplaces. If we limit our vision of health care reform only to the programs that career politicians deem “pragmatic,” then we are placing their careers above our own lives.
McCanne’s decency and public spirit shine through his work, though he was almost self-effacing when I first asked him to consider an interview. For myself, and many others, McCanne is our translator of choice when we try to orient ourselves in health care policy debates. He received his B.A. at the UC Riverside in 1959 and his M.D. from the UC San Francisco in 1963. He served two years as a medical officer in the U.S. Army, and then practiced as a family physician for more than 30 years in San Clemente, Calif. He has served as chief of staff of his community hospital and as chairman of the board of a community bank. He served as president of PNHP for two terms, in 2002 and 2003, and is currently senior health policy fellow for PNHP. Every good cause involves a division of labor, and McCanne is a daily laborer for health care justice through PNHP and through his public talks and writing.
http://www.pnhp.org/print/news/2013/october/health-care-for-all-why-we-need-a-new-prescription
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