For 17 years I was President and CEO of a safety net hospital. TrumpCare will “disinsure” twenty million+ people and devastate the hospitals we all depend on.

A little background….

I was appointed President and CEO of Jersey City Medical Center (JCMC) 1989, one year after JCMC had been converted to not-for-profit governance after a long and colorful history as a public hospital (including bankruptcy protection from 1982 to 1985). JCMC was and still is Hudson County’s (500,000+ residents) regional referral center “safety-net” hospital.

“As defined by the Institute of Medicine, the health care safety net comprises hospitals and other providers that organize and deliver a significant level of health care and other health-related services to patients with no insurance or with Medicaid. Often referred to as providers of last resort, safety-net hospitals (SNHs) have historically assumed a major role in the provision of comprehensive services to medically and socially vulnerable populations.” (A)

When I started New Jersey Hospitals were reimbursed through an all-payor state rate-setting system for Medicare, Medicaid, and commercial insurance, which assured hospital financial stability if managed effectively.
This was coupled with a robust Certificate of Need (CN) process which rationed approval of certain tertiary care services to assure access to them throughout the state, rather than based on a hospital’s fiscal situation, since approved CNs garnered additional reimbursement in reimbursement rates.

Already the sole designated paramedic provider for the County, together rate-setting and CN allowed JCMC: to apply for and be designated as a Regional Perinatal Center (1992), Level Two Trauma Center ((1994), and Medical Coordination Center for Emergency Preparedness (2003); and build a total replacement hospital on a new site (CN approved in 1986, hospital opened in 2004) where an Open Heart Surgery CN (approved in 1999) was started. JCMC became a state approved Children’s Hospital in 2000. Along the way JCMC became LibertyHealth adding two community hospitals, Greenville and Meadowlands (which in 1996 opened a CN designated inpatient rehabilitation unit). In 1997 JCMC became a major teaching affiliate of Mount Sinai School of Medicine (now Icahn School of Medicine at Mount Sinai).

All as a safety-net hospital.

Why am I writing all this?

“Hospitals that primarily serve low-income patients could collectively lose $40 billion in funding over the next decade if the Affordable Care Act is repealed and not replaced by something comparable, according to a new analysis by America’s Essential Hospitals.
That amount represents lost coverage and cuts to Medicaid and Medicare disproportionate share hospital (DSH) funding from 2018 through 2026. The ACA called for those cuts because hospitals would have theoretically needed that funding less as more people gained coverage on the marketplaces and through Medicaid expansion.” (B)

“People with health insurance tend to think of safety-net hospitals the way airline travelers think of the bus: as a cheaper service they would use only if they had to. But without these essential hospitals — which specialize in the care of our country’s most medically and financially vulnerable, particularly the uninsured — our entire health care system would be in danger.” …
For uninsured patients, lifesaving surgeries and treatments, along with a limited recovery period, are often covered through Emergency Medicaid funds. But patients who don’t fit neatly into our medical system for reasons of health or finances or their social situation — the “medical misfits” that any one of us can become under the wrong circumstances — need far more long-term support. This is often where safety-net hospitals step in. “(C)

“Despite promises to the contrary, it will leave millions of people without health coverage, and others with only bare bones plans that will be insufficient to properly address their needs. As the nation’s medical schools and teaching hospitals see every day, people without sufficient coverage often delay getting the care they need. This can turn a manageable condition into a life-threatening and expensive emergency.” (D)

“In short, Democrats are focused on trying to maximize the number of people who have decent health insurance, and are willing to accept whatever tax increases and arrangements with health insurers and other private interests are needed to make that happen. They seek the broadest possible availability of health care, whatever the cost and political trade-offs it takes to achieve it.
Republicans are focused on trying to minimize taxes, especially on investment income, and keeping federal subsidies for health care to a minimum. They are willing to accept the wrenching consequences that attaining those goals might have for Americans’ insurance coverage, betting that lower taxes and smaller government will fuel a more vibrant economy.” (E)



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Is there more “heart” in the Senate health care bill? Or is it “meaner” than the House bill?

Let’s recall that President Trump called the House “Repeal and Replace” bill “mean” after having celebrated its passage by bussing House Republicans to the Rose Garden. And then we were promised a Senate bill “… that’s going to be a phenomenal bill to the people of our country: generous, kind, with heart. That’s what I’m saying.”” (A)

so here are some articles to help you decide–

“The Affordable Care Act gave health insurance to millions of Americans by shifting resources from the wealthy to the poor and by moving oversight from states to the federal government. The Senate bill introduced Thursday pushes back forcefully on both dimensions.
The bill is aligned with long-held Republican values, advancing states’ rights and paring back growing entitlement programs, while freeing individuals from requirements that they have insurance and emphasizing personal responsibility. Obamacare raised taxes on high earners and the health care industry, and essentially redistributed that income — in the form of health insurance or insurance subsidies — to many of the groups that have fared poorly over the last few decades.
The draft Senate bill, called the Better Care Reconciliation Act, would jettison those taxes while reducing federal funding for the care of low-income Americans. The bill’s largest benefits go to the wealthiest Americans, who have the most comfortable health care arrangements, and its biggest losses fall to poorer Americans who rely on government support. The bill preserves many of the structures of Obamacare, but rejects several of its central goals.” (B)

now, to dig deeper…

CHART: Who Wins, Who Loses With Senate Health Care Bill

Who gets hurt and who gets helped by the Senate health care bill

The Senate health care bill: What’s in it and what to watch for in the CBO report

The Congressional Budget Office has not yet issued its analysis of how this bill would affect the federal deficit and the number of Americans who have health coverage. That “score” is expected to be released next week. It’s also not clear yet whether the Senate parliamentarian will give all of the bill’s provisions her go-ahead.




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When I was a kid the only thing as scary as the polio epidemic was practicing getting under our desks for a nuclear attack…

It was 1952 and we lived in Haddonfield, New Jersey and the public swimming pool was closed for the duration. A town in full panic!

So today’s New York Times article on a polio outbreak in Syria is particularly disconcerting.
Polio Paralyzes 17 Children in Syria, W.H.O. Says (A)
“The polio virus, once thought to verge on eradication, is one of the most contagious diseases in inadequately protected areas. One confirmed case of paralysis is considered an outbreak, as doctors assume it means up to 200 other people may have been exposed to the virus.”…..
“Unlike Syria’s first polio outbreak in 2013, caused by a wild strain that paralyzed 36 children before it was brought under control, the new outbreak derived from the polio vaccine itself…..
The vaccine, a weakened form of the polio virus that triggers the immune system’s response, is secreted in the waste of vaccinated children, and over time can mutate into an infectious strain that may afflict the unvaccinated. The risks are especially high in areas where not all children have received the vaccine and where the mutated virus can spread from contaminated sewage or water.”

A 2012 article noted:
“In 1952 alone, nearly 60,000 children were infected with the virus; thousands were paralyzed, and more than 3,000 died. Hospitals set up special units with iron lung machines to keep polio victims alive. Rich kids as well as poor were left paralyzed.
Then in 1955, the U.S. began widespread vaccinations. By 1979, the virus had been completely eliminated across the country.
Now polio is on the verge of being eliminated from the world. The virus remains endemic in only two parts of the globe: northern Nigeria and the border between Afghanistan and Pakistan.” (B)

In a world full of conflict such Syria, Iraq and Yemen (C) are we likely to see a broad reemergence of polio?


Are we prepared for emerging viruses?
“Whatever the explanation, hepatitis C (1989), West Nile virus (1999), SARS (2003), Chikungunya (2005), swine flu (2009), MERS (2012), Ebola (2014) and Zika (2015) have all since had their time in the media spotlight. A further 33 diseases have featured in the World Health Organization’s Disease Outbreak News since its inception in 1996. Of the “big eight” listed above, six are known zoonotic diseases – and the remaining two (hepatitis C and Chikungunya) are assumed to be so, although the animal reservoir remains undiscovered.”

To learn more click on
ZIKA UPDATE #1. EBOLA is back in Africa. Is ZIKA next? Are we prepared?
Lesson Learned from recent EBOLA and ZIKA episodes. We need to designate REGIONAL EMERGING VIRUSES REFERRAL CENTERS (REVRCs).




(A) Polio Paralyzes 17 Children in Syria, W.H.O. Says by Rick Gladstone,
(B) Wiping Out Polio: How The U.S. Snuffed Out A Killer by Jason Beaubien,
(C) 10 Conflicts to Watch in 2017 by Jean-Marie Guéhenno,

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Should doctors and patients call each other by their first names? R-E-S-P-E-C-T (Aretha Franklin)

Recently I visited a medical specialist I have known for twenty five years. Back then I was a new hospital President and he was a junior attending. About ten years later I became his patient. And hadn’t seen him in two years.

When he saw me he said “hello Dr. Metsch” and I responded “hello Dr. Green” then we switched to first names. Even though I retired ten years ago and he is now a senior attending our initial greeting reflected mutual respect.

Mid-career I worked in the President’s Office at Mount Sinai for ten years for four physician CEOs. I always called them Doctor even as my younger colleagues would call them by their first names; they bristled at this informality.

About that time (1988) this was written: “The paper discusses the moral difficulties physicians encounter when determining the level of formality they will use when addressing their patients. It is argued that physicians ought not to use a patient’s first name unless the patient also uses the physician’s first name. In short, physicians and patients should always address each other with the same level of formality. It is argued that this is so even when patients invite physicians to address them informally.” (A)

“Developing a good rapport with a patient is essential, and what transpires during a first meeting can set the stage for the ongoing relationship. But unfortunately, there are no definitive guidelines on how physicians and other providers should be addressed, how patients prefer to be addressed, or how staff should introduce themselves.” (B)

There are certainly various points of view on this.
“If I call a patient by their first name, it would seem only fair and equal that I offer up my first name. I have always addressed my patients by their last names and titles, particularly in San Antonio, Texas, where military titles are extremely important. Familiarity also seems inappropriate in an environment where the patient does not see the same provider at each visit and has to start from scratch. Long gone are the days of a family physician who cared for three generations of the same family. Since a sizeable portion of patients and physicians may be offended by the use of their first name, it seems best that, unless invited to do so, we stick to formal titles.” (C)

“I address my patients (over the age of 18) by their titles and last names unless they have given me permission to do otherwise. When I meet new patients, I address them by their first and last names and then ask them how they would like for me to address them. My expectation is that they will address me as I prefer to be professionally addressed: “Dr. Middleton.”” (D)

Maybe I’m old school but I think all successful patient-doctor relationships are based on mutual respect. If a physician calls a patient by his first name, she should allow the patient to do the same. If a physician wants to be called Doctor, then he should use Mr., Mrs., Ms. or Doctor, Professor, Reverend, Captain or any other appropriate title.

I think formality should prevail initially and over time informality might be mutually OK and here’s a good example:
“I have at least a hundred patients who call me James, Jimmy, Dr. James, Dr. Bowtie, Dr. S, Herr Doctor or Jim. I have no need of an ego-massaging label. The difference is that we have long-standing relationships, and those patients have usually asked permission. We are friends, colleagues, in battle against the dread disease. I gain satisfaction to have built relationships where mutual respect is expressed in this way. Even so, when the proverbial excrement hits the spinning blades, many of those patients revert to “doctor.” That makes emotional sense to me.” (E)

To this day I never call a doctor by his or her first name without asking first and being comfortable the answer will be “yes.”

“I speak to everyone in the same way, whether he is the garbage man or the president of the university.” Albert Einstein

(A) What doctors should call their patients, by Michael Lavin,
(B) Should Patients Call You by Your First Name?, by Roxanne Nelson,
(C) What’s In a Name: What Should Patients and Doctors Call Each Other?, by Richard C. Senelick,
(D) Should doctors be addressed by their first name?, by Jennifer Middleton,
(E) Calling a Doctor by His or Her First Name, by James C. Salwitz,


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The Mystery of the Hospital CLAUSTROPHOBIA CLUSTER

Recently a friend was told by his doctor he needed an MRI and said that he could get it at the hospital on the campus where the doctor’s office was located, or at a private imaging center two blocks away.

This reminded me of the mystery of the Claustrophobia Cluster about twenty years ago, in a community hospital that (CH) was part of the system where I was then CEO.

Our Teaching Hospital (TH) had just acquired a new state-of-the-art MRI, CH was only a little over a mile away, there was an MRI transfer protocol in place, and we ran a robust county-wide EMS transport system.

But almost every insured patient at CH who needed an MRI was referred to a “private” free-standing Imaging Center due to CLAUSTROPHOBIA. Somehow, also mysteriously, Medicaid patients and the uninsured made it to TH.

The problem was compounded by the fact that we were under a DRG reimbursement system where we got reimbursed an all-inclusive rate for every diagnosis, and had to pay for “outside” MRIs out of that bundled payment. These very expensive outside MRIs often meant that CH and the system lost money on many of these patients.

Since 1989 Federal Law “Prohibits a physician from making referrals for certain designated health services (DHS) payable by Medicare to an entity with which he or she (or an immediate family member) has a financial relationship (ownership, investment, or compensation),…

The following items or services are DHS: Clinical laboratory services; Physical therapy services; Occupational therapy services; Outpatient speech-language pathology services; Radiology and certain other imaging services; Radiation therapy services and supplies; Durable medical equipment and supplies; Parenteral and enteral nutrients, equipment, and supplies; Prosthetics, orthotics, and prosthetic devices and supplies; Home health services; Outpatient prescription drugs; Inpatient and outpatient hospital services. (A)

Whichever entity provides the service tacks on a Facilities Fee to the professional fee charged, for example, by a radiologist.

This raises the question of whether self-referral is a purely clinical recommendation or might “ownership” and the Facilities Fee be an influence.

We never solved the CLAUSTROPHOBIA CLUSTER mystery but we all can help make sure that a diagnostic or treatment referral is clinical and not financial:
– Ask the referring physician if he or she has a financial interest in any of the facilities on the list of sites. Make sure you have not signed away that right when registering.
– Make sure your insurance will cover the charges before you go to a diagnostic facility.
– If uncertain, get a second opinion from another physician who is not in a referral relationship with the first physician.


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REVISE and RECALIBRATE Obamacare. Prevent Republican’s “mean” plan.

It is obvious that Repeal and Replace shouldn’t and won’t happen.

After bussing republican House members to the White House Rose Garden several weeks ago to celebrate House passage of the American Health Care Act, President Trump now “… bluntly derided a House attempt to repeal the Affordable Care Act as “mean,” “ and said “that he expected the Senate to come up with something more generous…” (A)

President Trump tweeted “”2 million more people just dropped out of ObamaCare,” “It is in a death spiral. Obstructionist Democrats gave up, have no answer = resist!” (B)

We know that the Obama administration planned to look at the following changes: Expand The Medicaid Expansion; Simplify Health Insurance Plans; Fix Surprise Medical Bills; Extend Coverage For Kids; Buff Up The Cadillac Tax; Improve Insurance Provider Networks; Rein In Prescription Drug Costs (C)
Any big new program like Obamacare has a “million” moving parts and some assumptions in the initial algorithms need to be recalibrated. Fortunately there has been plenty of evaluation and recommendations to do a mid-course correction to maintain access and address affordability.

Here is a list of approaches that must be considered:

Some initial corrections: (D)
1. Patch things up: Since affordability is a big issue, the federal government could spend more money to bring down the costs that individuals and families face. This could be done directly by raising the level of subsidies available for plans purchased on the exchanges, or raising the income thresholds at which the subsidies phase out—or both. Alternatively, the government could offer more generous subsidies to insurance companies, particularly those serving high-risk populations, in which case they wouldn’t have to raise prices as much, or impose such large deductibles.
2. Apply some force: One of the big problems that insurers are facing is that too few healthy people, and too many sick people, are signing up for the plans sold through the exchanges. For insurers, that changes everything. Faced with higher claims per enrollee than they expected, they seek to raise their prices, which makes healthy people, especially young healthy people, even less likely to sign up the following year. If unchecked, this process could lead to a spiral of rising prices and falling enrollment.
3. An obvious way to address this problem would be to drastically raise the fines that people face if they don’t purchase insurance. Under the terms of the Affordable Care Act, getting enrolled wasn’t meant to be a choice—it was a legal obligation. For political reasons, however, the penalty for flouting this “individual mandate” was set at a very low initial level, which is supposed to grow gradually. In 2015, the fines started at three hundred and twenty-five dollars per adult
4. Generally speaking, private insurance markets only work well when there is a large and diversified risk pool. If we are going to rely on them to provide universal, or near-universal coverage, the individual mandate will have to be enforced. That means raising the penalties for non-compliance and enforcing them effectively.
5. The Public Option: The rising cost of health care is an issue all over the world. The way most countries have dealt with it is by enrolling the entire population, or almost all of it, in a single-payer system, and using the bargaining leverage that creates (usually coupled with administrative fiat) to keep down costs. So far, the American political system, which is highly vulnerable to capture by powerful interest groups, such as doctors, hospitals, and pharmaceutical companies, has resisted going down this route. But this may be changing.

Stabilize the marketplace: (E)
6. “Marketplaces will only succeed if enough insurers participate, and many are running away from what they perceive as a high-risk, low-reward market opportunity,” …..All of this — insurer withdrawals and sharply escalating premiums — was avoidable and is fixable. We know how to draw insurers into markets, keep them there, and limit premium growth. We can do so by subsidizing plans more and by limiting their risk of loss. We’ve done both before.”
7. The Medicare Modernization Act also established Medicare’s prescription drug program, Part D, which offers another lesson. It’s also run entirely through private plans. They’re cushioned against large losses by a risk corridor program. This helps plans stay in the market if they miscalculated the mix of patients they’d attract, and it allows them to keep premiums lower than they might need to if they had to hedge against the full brunt of potential losses.
8. The Affordable Care Act included a risk corridor program for marketplace plans, too, but it expires at the end of this year. So does a reinsurance program that compensates insurers for unusually high-cost enrollees. Following the model of Part D and making the risk corridor program permanent, as well as the reinsurance program, could help stabilize the marketplaces.

Policy fixes that could plausibly improve Obamacare and attract bipartisan support. (F)
9. Defuse the Crisis. The leading enemy of stability is uncertainty, and for insurers who must decide what to do about the exchanges by June, the leading source of uncertainty before last Friday was the Republican repeal push itself. That threat has apparently subsided, but the House lawsuit over cost-sharing subsidies could still blow up the exchanges. The House put the suit on hold after Trump’s election, anticipating Obamacare’s repeal, but if the Republicans want to avoid a major mess, they need to make the suit go away and make sure the subsidies keep flowing.
10. Insure the Insurers: The Democratic push for health reform in 2010 relied on what The Washington Post described as “the near-daily demonization of the insurance industry.” Obama routinely attacked “insurance company bureaucrats who raise premiums and deny care.” Pelosi called them “villains.” And Obamacare included tough new rules that prohibited them from discriminating against customers with pre-existing conditions or capping how much they could spend on any customer.
11. Relax the Rules: The best evidence so far that the Trump administration hopes to prevent the kind of implosion the president keeps predicting is a new set of rules his Department of Health and Human Services recently proposed for the exchanges. The rules involve fairly modest adjustments for the 2018 enrollment, giving insurers more flexibility to offer slightly more generous plans while closing loopholes the insurers thought consumers were using to game the system. But they amount to an insurer wish list, which suggests a desire to keep insurers happy on the exchanges.
12. A Drug Deal: Obamacare has helped reduce the overall growth of health care costs to the lowest rate in half a century, but prescription drug prices have continued to soar. The cost of six brand-name diabetes medications rose more than 150 percent over the past six years. Multiple sclerosis drugs now cost more than $5,000 a month, increasing more than fivefold since 2001. Connolly says the nonprofit plans she represents now spend more on drugs than hospitalization. “That’s mind-boggling,” she says. “There’s no rhyme or reason to it, and it’s driving up premiums.”

Changes that would help bring down premiums on the exchanges. (G)
13. Require all insurers who want to sell in the individual insurance market to offer their plans through the exchange, so they couldn’t cherry-pick individuals outside the exchange (this is an idea championed by Henry Aaron of the Brookings Institution).
14. Reduce the waiting period for those on disability insurance to get Medicare coverage from two years to six months to move some of the very high-cost enrollees out of the individual-market pool.
15. Require any insurer that wants to offer a Medicare Advantage plan in an area also to offer a plan in the marketplace for under-65 enrollees.
16. Have the federal exchange adopt the procedures used by California in actively bargaining with plans instead of acting as a passive clearinghouses.
17. Create a public option for those aged 55-64 clearly identified as an early buy-in to Medicare.Create a second federally run public option for enrollees from 18 to 54.
18. Restore the risk corridor and reinsurance provisions that have expired that were intended to protect exchange plans against adverse selection.

A good summary – (H)
“First, despite some genuine problems, the Affordable Care Act is mostly working quite well.
Second, far from solving the problems of Obamacare, the Republicans’ AHCA would have made them worse.
Third, real leaders don’t run away from problems; they fix them. Fourth and most important, a compromise plan could have appealed to — and could still appeal to — enough members of both parties to pass.”



(A) Trump, in Zigzag, Calls House Republicans’ Health Bill ‘Mean’, by Thomas Kaplan, et al,
(B) Trump: Dems ‘gave up’ on fixing ObamaCare, by Rebecca Savransky,
(C) How Obama Would Fix Obamacare If Congress Would Let Him, by Jeffrey Young
(D) Three Ways to Fix Obamacare, by John Cassidy,
(E) Politics Aside, We Know How to Fix Obamacare, Austin Frakt,
(F) Four Things Trump Could Do Right Now To Fix Obamacare, by Michael Grunwald,
(G) Obamacare has some problems. Here’s how we can fix them, by Paul Waldman,
(H) Want to fix Obamacare? Here’s how by Henry Aaron,



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Study Findings: Five percent of pregnant women with a confirmed Zika infection.. went on to have a baby with a related birth defect

DOCTOR tracked ZIKA last year and proposed the designation of REGIONAL EMERGING VIRUSES REFERRAL CENTERS.
It seems that when it was an isolated mainland event in south Florida, public concern disappeared and public health authorities breathed a sigh of relief.
Even though we now know that more ZIKA outbreaks are likely and that the consequences for some babies will be catastrophic, authorities apparently are leaving every hospital to plan on its own.
Here’s one reason centralized planning is a necessity and Referral Centers need to be designated.

The New York Times story, by Catherine Saint Louis, noted:(A)
“Women who do not have any symptoms of Zika virus still may give birth to a baby with Zika-related birth defects, research has shown. The only way to catch those infections is to screen women because they may have been exposed to Zika-infected mosquitoes or may have had sexual contact with an infected partner.
In this new report, “The presence or absence of symptoms was not predictive of whether a baby would be damaged,” … “There were women who had asymptomatic Zika whose babies were damaged.”
Currently, only about 60 percent of babies born alive in United States territories had results of Zika laboratory testing reported to pregnancy and infant registries. It’s important that all babies who may have been affected are monitored, as early intervention can help.
For instance, some babies who appear normal at birth later develop an unusually shrunken head. Only with long-term tracking can health officials get an accurate estimate of the scope of the problem.”

Previous ZIKA related DOCTOR posts:
ZIKA UPDATE #1. EBOLA is back in Africa. Is ZIKA next? Are we prepared? (B)
All pregnant women with Zika diagnosed at community hospitals must be referred to academic medical centers for prenatal care! (C)
Former hospital prez says: Designate local Zika centers now. “Medical experts do not know if, or where, or how much, or on what trajectory the Zika virus may spread across the United States.” (D)


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