“ the move is a winner for Republicans, who.. would have little to show for 7 years of…repeated efforts to kill Obamacare..”

“With the bill finally headed to a vote this coming week, taxpayers are scrambling to determine whether the legislation renders them winners or losers.
WINNERS
PRESIDENT TRUMP AND HIS FAMILY. Numerous industries will benefit from the Republican tax overhaul, but perhaps none as dramatically as the industry where Mr. Trump earned his riches: commercial real estate. Mr. Trump, along with his son-in-law Jared Kushner, who is part owner of his own real estate firm, will benefit from lower taxes on so-called “pass through” income, which is money earned by partnerships and other types of businesses whose income is passed through to its owner and taxed at the individual tax rate. Mr. Trump and Mr. Kushner benefit since they own properties through limited liability companies and other similar vehicles.
LOSERS
PEOPLE BUYING HEALTH INSURANCE. With the repeal of the individual mandate, some people who currently buy health insurance because they are required by law to do so are expected to go without coverage. According to the Congressional Budget Office, healthier people are more likely to drop their insurance, leaving insurers stuck with more people who are older and ailing. This is expected to make average insurance premiums on the individual market go up by about 10 percent. All told, 13 million fewer Americans are projected to have health coverage, according to the Congressional Budget Office.” (A)

“The tax bill barreling toward a final vote in Congress guts the most unpopular “Obamacare” provision, its requirement that virtually all Americans carry health insurance or face fines.
Politically, the move is a winner for Republicans, who otherwise would have little to show for seven years of rhetoric and repeated legislative efforts to kill the Affordable Care Act.
But if estimates by the nonpartisan Congressional Budget Office are right, it will lead to more uninsured people and higher premiums for those buying individual health insurance policies.
Congress may then find itself considering other ways to nudge people to get health insurance.
Other popular parts of the Affordable Care Act would remain in place, including subsidized premiums, “essential” benefits and protections for people with pre-existing medical conditions.” (B)

“The severity of the impact is a matter of debate among health policy experts.
The Congressional Budget Office predicts that four million fewer people would be covered in the first year the repeal would take effect. That number would rise to 13 million by 2027, as compared to current law. Meanwhile, premiums would rise by about 10% in most years of the decade.
But the agency also said it is reviewing its methodology. Others say fewer people would be left uninsured. S&P Global Ratings, for instance, projects that only three to five million more consumers would lack coverage over a decade because the mandate is not a key driver for obtaining insurance.
Still, many experts feel that removing the mandate would cause the individual market to tilt even more towards sicker and older consumers. That’s because the mandate serves as a stick to prod some younger and healthier Americans to sign up for coverage.
That shift may prompt some insurers to drop out of the market, especially since they would still be required to cover those with pre-existing conditions but would not be able to charge them more based on their medical history.
If a wave of insurers exit Obamacare, some consumers could be left without any providers on their exchanges in 2019. Already, 29% of current enrollees on the federal exchange have only one option in 2018, according to federal data. Residents in eight states — Alaska, Delaware, Iowa, Mississippi, Nebraska, Oklahoma, South Carolina and Wyoming — have only one insurer next year.” (C)

“The nongroup market refers to people who buy their own health insurance. Most Americans are covered by an employer. Many are covered by Medicare or Medicaid, a few get military health benefits and the so-called Obamacare markets were meant to help the rest get “nongroup” health insurance.
Health insurance premiums in this nongroup market will go up by 10 percent, the CBO predicted.
This will hit one group in particular, according to the Commonwealth Fund, which conducts studies in health policy and released a report Thursday on the Affordable Care Act.
“People who buy their own coverage on the individual market and who have incomes above 400 percent of the federal poverty level (about $48,200 for an individual and $98,400 for a family of four) — the threshold for ACA premium subsidies — would face the brunt of the premium increase,” it said.
A 40-year-old customer buying health insurance on one of the federal exchanges would pay $556 more in premiums in North Dakota and $1,264 more in Nebraska, the group calculated.” (D)

“The election of Doug Jones as the first Democratic senator from Alabama in a generation did many things: It opened a realistic, although still difficult, path for Democrats to capture a Senate majority in 2018, it deepened the divide between the GOP establishment and the self-styled insurgents led by Stephen K. Bannon, the former White House strategist.
And it probably ended GOP hopes of repealing the Affordable Care Act…
Throughout the past year, the Trump administration has taken one swing after another at the healthcare law, and seemingly each one has generated a chorus of predictions about the “death of Obamacare.”
That hasn’t happened….
The latest data on sign-ups came as a new study from the Commonwealth Fund, comparing data across states, showed that the law has, indeed, helped patients get to the doctor and pay their medical bills, contrary to the assertions from President Trump and others in his administration that the law was providing coverage that didn’t actually help people….
The only way to truly undo what the law has accomplished would be to cut off the billions of dollars that currently go to help more than 20 million people pay medical bills. Republicans tried repeatedly this year to cut back on that flow of funds with their various efforts to repeal Obamacare. They were poised to repeat that effort in 2018. But Jones’ upset victory now will likely put that prospect out of reach in the Senate.
Jones made healthcare a top issue in his campaign and explicitly told voters he would oppose repeal. “Repeal and replace is a political slogan,” he would say. “It’s not something that’s workable.” (E)

“But won’t the entire Obamacare system collapse without the mandate? Not if the states step into the breach. They’ve got the power to patch the hole that repeal of the mandate would leave in the ACA. The most ambitious states could even take steps to strengthen the law.
Massachusetts had an individual mandate well before the US did.
For starters, the states can adopt their own individual mandates to replace the one that Congress repeals. There’s nothing stopping them. Before the ACA existed, Massachusetts had a mandate; it’s still on the books. And, as Vox’s Sarah Kliff reported last week, a number of states — including California, Maryland, and Washington, as well as the District of Columbia— are toying with creating their own mandates.
Adopting mandates at the state level would help stabilize insurance markets, thereby keeping premiums in check and forestalling coverage losses. It would also provide a welcome source of revenue: Some people will still prefer to pay a penalty than buy insurance. Plus, the states don’t need to stick with the precise terms of the federal mandate, which has been reviled (from different quarters) both for heavy-handedness and its ineffectuality. Stiffer state-level penalties would still be unpopular, but at least they’d work better.” (F)

“Health economist Gail Wilensky said repealing the mandate might take some of the political steam out of the health care debate. It may even point to a path for lawmakers of both major parties to consider measures that would help stabilize insurance markets for people who don’t get coverage on the job.
It “may be enough to take away what has been the single most hated part of the ACA for both Republicans and Democrats,” said Wilensky, who served in a previous Republican administration.
But that won’t solve the problem of providing affordable coverage for people who don’t qualify for subsidies through “Obamacare.”
President Donald Trump’s administration is working on another track: regulations that would allow broader sale of lower-cost plans with limited benefits.
How much consumer appeal that alternative will have remains to be seen.” (G)

“Sen. Susan Collins said Thursday she isn’t concerned that House Republicans didn’t include Obamacare stabilization bills in its short-term funding bill, saying GOP leadership will add them to the Senate version.
The House GOP released a short-term continuing resolution Wednesday that funds the government until Jan. 19. It does not include two bills that the centrist Maine Republican has been pushing to stabilize Obamacare’s exchanges in return for her vote for tax legislation that includes a repeal of Obamacare’s individual mandate penalties.
Collins shrugged off the House snub, saying it didn’t matter if the House passes a spending bill that doesn’t include the legislation.
“That has never been the plan,” she told reporters. “The plan is for the majority leader to add [the bills] in the Senate.”…
Collins said Thursday that the plan is still to pass the bills by the end of the year, and the new continuing resolution would be the only opportunity left.” (H)

(A) The Winners and Losers in the Tax Bill, By JESSE DRUCKER and ALAN RAPPEPORT, https://www.nytimes.com/2017/12/16/business/the-winners-and-losers-in-the-tax-bill.html
(B) Tax Bill Guts Unpopular ‘Obamacare’ Insurance Mandate, https://www.nytimes.com/aponline/2017/12/16/us/politics/ap-us-taxes-health-care.html
(C) Will Obamacare survive the tax bill?, by Tami Luhby, http://money.cnn.com/2017/12/15/news/economy/obamacare-individual-mandate-tax/index.html
(D) Tax bill kills health insurance mandate. Who will pay more?, by MAGGIE FOX, https://www.nbcnews.com/health/health-care/tax-bill-kills-health-insurance-mandate-who-will-pay-more-n829846
(E) How Alabama saved Obamacare and other effects of an upset, by David Lauter, http://www.latimes.com/politics/la-pol-essential-politics-20171215-story.html
(F) The tax bill destroys an important part of Obamacare. The states can save it., by Nicholas Bagley, https://www.vox.com/the-big-idea/2017/12/14/16773294/obamacare-aca-states-protect-coverage-after-tax-bill
(G) Tax Bill Guts Unpopular ‘Obamacare’ Insurance Mandate, by RICARDO ALONSO-ZALDIVAR, https://www.usnews.com/news/politics/articles/2017-12-16/tax-bill-guts-unpopular-obamacare-insurance-mandate
(H) Susan Collins: Senate eyes adding Obamacare bills to short-term funding deal, by Robert King, http://www.washingtonexaminer.com/susan-collins-senate-eyes-adding-obamacare-bills-to-short-term-funding-deal/article/2643551

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Are drug manufacturers in cahoots with pharmacy benefits managers, making us pay more for prescriptions?

When a physician prescribes medication I always ask if there is a generic and I watch carefully when a brand name drug becomes available generically, often changing a $50+ co-pay to $5 or less. But if we fill prescriptions on cruise control that is without asking the right questions, we can wind up with much larger co-pays.

These guidelines are typical “there may be cost-sharing implications for choosing non-preferred brand medications when generics are available. Your cost share depends on which of the three generic substitution coverage levels you have — voluntary, mandatory or restrictive. Refer to your benefit summary or enrollment materials for more information.” “ (A)

“Consumers have grown accustomed to being told by insurers — and middlemen known as pharmacy benefit managers — that they must give up their brand-name drugs in favor of cheaper generics. But some are finding the opposite is true, as pharmaceutical companies squeeze the last profits from products that are facing cheaper generic competition.
Out of public view, corporations are cutting deals that give consumers little choice but to buy brand-name drugs — and sometimes pay more at the pharmacy counter than they would for generics.
The practice is not easy to track, and has been going on sporadically for years. But several clues suggest it is becoming more common.
In recent months, some insurers and benefit managers have insisted that patients forgo generics and buy brand-name drugs such as the cholesterol treatment Zetia, the stroke-prevention drug Aggrenox and the pain-relieving gel Voltaren, along with about a dozen others, according to memos and prescription drug claims that pharmacies shared with ProPublica and The New York Times. At the same time, consumers are sounding off on social media. (B)

“Success is when you get doctors selling the product for you,” said former pharmaceutical representative Michael Oldani, now an associate professor of medical anthropology at the University of Wisconsin-Whitewater.
The patients present the card to the pharmacist when they’re having a prescription filled. The card cues the pharmacist to fill the prescription using the brand-name drug, even though it can cost much more than the generic version.
At one Toronto pharmacy, brand-name Lipitor (10mg/90 pills) sold for $168.83 while the generic version, atorvastatin, cost $28.24.
“The pharmaceutical companies are not making a charitable donation when they hand out cards. They’re definitely planning to turn a profit. It’s part of a marketing strategy.”
In theory, the drug company is supposed to pay that cost difference.
But in practice, sometimes the drug company never gets the bill, because some company insurance plans pay the full cost of the more expensive brand-name drug if a doctor specifies its use.
In reaction to the cards, many insurance companies now refuse to reimburse patients for brand-name drugs when there is a generic alternative.
To get around that rule, doctors are encouraged by drug company sales representatives to write “no substitutions” (C)

“Having health insurance is supposed to save you money on your prescriptions. But increasingly, consumers are finding that isn’t the case….
In an era when drug prices have ignited public outrage and insurers are requiring consumers to shoulder more of the costs, people are shocked to discover they can sometimes get better deals than their own insurers. Behind the seemingly simple act of buying a bottle of pills, a host of players — drug companies, pharmacies, insurers and pharmacy benefit managers — are taking a cut of the profits, even as consumers are left to fend for themselves, critics say.
Although there are no nationwide figures to track how often consumers could have gotten a better deal on their own, one industry expert estimated that up to 10 percent of drug transactions involve such situations. If true nationwide, that figure could total as many 400 million prescriptions a year…
Pharmacy benefit managers, the companies that deal with drug benefits on behalf of insurers, often do negotiate better prices for consumers, particularly for brand-name medications, …, but that’s not necessarily true for some generic drugs. Insurers’ clients are frequently employers overseeing large numbers of workers, and the companies are focused on overall costs. So when insurers seek deals for generic drugs, they do so in batches, reaching agreements for groups of different drugs rather than getting the lowest price on every drug.
As a result of these complicated layers of negotiation — which are not made public — different insurers end up paying different prices for individual drugs. Further compounding confusion for consumers, some insurers require a set co-payment for each prescription — say, $15 or $20 — even when the insurer reimburses the pharmacy at a much cheaper rate.” (D)

(A) Is Grassley Concern Over DAW Penalty Much Ado About Nothing?, by Angela Maas, https://aishealth.com/archive/ndbn050117-04
(B) Take the Generic, Patients Are Told. Until They Are Not, by CHARLES ORNSTEIN and KATIE THOMAS, https://www.nytimes.com/2017/08/06/health/prescription-drugs-brand-name-generic.html
(C) ‘Success is when you get doctors selling the product for you’, by Kelly Crowe, http://www.cbc.ca/news/health/drug-companies-using-doctors-discount-cards-to-skirt-generic-substitutions-1.3042773
(D) Prescription Drugs May Cost More With Insurance Than Without It, by CHARLES ORNSTEIN and KATIE THOMAS, https://www.nytimes.com/2017/12/09/health/drug-prices-generics-insurance.html

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“..the compromise tax bill from House and Senate negotiators will end the health law’s requirement that all individuals buy insurance or pay a fine….”

Doing so could jeopardize Obamacare’s already-shaky marketplaces, by reducing the number of healthier people who sign up for insurance.
The bill will “repeal Obamacare’s individual mandate tax, delivering relief to low- and middle-income Americans who have struggled under an unpopular and unworkable law,” the Kentucky Republican said in an emailed statement.” (A)

“Susan Collins believes, or claims to believe, that Paul Ryan can be trusted to protect Medicare. She thinks that seniors and Americans with disabilities who rely on the program’s benefits should trust him too. That requires ignoring everything that Ryan has ever said about Medicare…
Not only is Collins insisting that Ryan is to be trusted, and can deliver the votes, when it comes to protecting Medicare. She is showing the same gullibility — or hypocrisy — with respect to the health care of those not yet of Medicare age. The tax bill she voted for would repeal the individual mandate, an essential provision of the Affordable Care Act. That would result in 13 million people losing their insurance coverage. For those who still remain in the ACA marketplaces, premiums would go up by an average of ten percent.
But Collins claims that these harms will be mitigated because Congress will separately pass the Alexander-Murray agreement to stabilize the marketplaces. Why is she so sure they will pass it? McConnell and Ryan promised…and of course, they would never go back on their word. If they are so willing to pass it, why didn’t they do so already as part of the just-passed extension of the continuing resolution? A different vehicle will make passage even harder” (B)

“To assume that Collins was “duped” into voting for the tax bill requires thinking that she is profoundly stupid. She might be, but I don’t think she is. An alternate analysis is that Collins is not naive; that she knew all along that McConnell’s promises were worthless; and that she simply wanted a reason to justify (to constituents or to herself) voting for the tax bill. Vote for the bill, then perform disappointment when McConnell pulls the rug out from under you or the House refuses to even consider the “deal” you claim you were promised. Bada-bing, bada-boom….
Susan Collins is not an innocent bystander to the country’s destruction by her party, and it’s time for political commentators to stop treating her as such. Susan Collins is a centrist in today’s Republican Party, which is to say she surpasses the lowest possible bar for basic human decency that exists. Susan Collins is a moderate Republican in the same way that your Aunt Sue is your favorite aunt by default, because at least Aunt Sue doesn’t drink too much chardonnay and tell you the HPV vaccine is going to kill you.
If I had to bet, I’d say Susan Collins will vote for the final version of the tax bill, knowing full well that most of her constituents in Maine would detest it if they knew all its grisly details. I hope she proves me wrong.” (C)

“What happens if the Obamacare death spiral occurs?
The future of the health insurance market, and of President Obama’s signature legislation, is decidedly uncertain. If Republicans make no further changes during the remaining three years of President Trump’s term, the exchanges may limp along, and the Obamacare market may essentially become an expensive, high-risk pool in which insurers offer costly coverage and the government pays ever-increasing subsidies to cover rising premiums.
Or the death spiral may be used as a pretext to repeal the law entirely, throwing the insurance market into further chaos unless a replacement plan is put in place.
Those buying policies on the open market may wish to consider investing in a health savings account so they at least have pre-tax funds available to pay for healthcare expenditures in case the insurance market is upended and the disruption causes a temporary gap in coverage.” (D)

“A group of insurance experts is warning Congress against repealing ObamaCare’s individual mandate, saying the move would raise premiums and could cause insurers to drop out of the market.
The American Academy of Actuaries wrote to congressional leaders on Tuesday saying that “eliminating the individual mandate would lead to premium increases…
The insurance experts also say that a measure pushed by Sen. Susan Collins (R-Maine), intended to help offset the premium increases from repealing the mandate, would not be enough to make up the difference.
That bill, sponsored by Sens. Lamar Alexander (R-Tenn.) and Patty Murray (D-Wash.), would fund key ObamaCare payments known as cost-sharing reductions. The actuaries say the payments “would not offset premium increases due to an elimination of the mandate…”
“Insurers would likely reconsider their future participation in the market,” the actuaries write. “This could lead to severe market disruption and loss of coverage among individual market enrollees.” (E)

“House conservatives are launching a full-court press to preserve a key provision rolling back ObamaCare in the final tax-reform bill being crafted behind closed doors by congressional negotiators…
“ObamaCare’s coercive individual mandate represents perhaps the worst example of the federal government violating individual freedom and liberty — which is why we have repeatedly promised to repeal it,” Walker and 70 other committee members said in letter to lead negotiators Texas Rep. Kevin Brady and Utah Sen. Orrin Hatch. “We urge you to help fulfill our promise to the American people and include this language in a final conference package.”
Repealing the mandate would at least give Republicans a significant victory toward the larger goal of a full repeal-and-replace….
The president wants a final GOP tax plan on his desk before Christmas.” (F)

“Ms. Collins remained respectful and strained to convince the room of about a dozen skeptics that the promises that had been made to her were ironclad.
She defended her decision in the face of the group’s challenges that previous Republican promises for the tax bill had been broken, including a commitment to not add to the deficit and to not benefit the rich, and that written agreements are not law.
“I do not believe that I’ve given up leverage,” Ms. Collins said. “I’ve used my leverage to negotiate agreements that are promises to me.”” (G)

(A) GOP Tax Compromise Would Repeal Obamacare’s Individual Mandate, by Zachary Tracer, https://www.bloomberg.com/news/articles/2017-12-13/obamacare-coverage-requirement-undone-in-gop-tax-compromise
(B) Will Susan Collins Save Medicare?, https://www.huffingtonpost.com/entry/will-susan-collins-save-medicare_us_5a317543e4b06a512dd69cdf
(C) Susan Collins Isn’t Being Duped Into Anything, by Emma Roller, https://splinternews.com/susan-collins-isnt-being-duped-into-anything-1821188722
(D) What Is the Obamacare “Death Spiral” — and Can It Be Stopped?, http://www.foxbusiness.com/markets/2017/12/10/what-is-obamacare-death-spiral-and-can-it-be-stopped.html
(E) Actuaries warn of premium increases from repealing ObamaCare mandate, by PETER SULLIVAN, http://thehill.com/policy/healthcare/364514-actuaries-warn-of-premium-increases-from-repealing-obamacare-mandate
(F) Conservatives fight to keep ObamaCare mandate repeal in tax bill, by Joseph Weber, http://www.foxnews.com/politics/2017/12/12/conservatives-fight-to-keep-obamacare-mandate-repeal-in-tax-bill.html
(G) Last-Ditch Effort to Sway Senator on Tax Bill Involves Personal Pleas, by ALAN RAPPEPORT, https://www.nytimes.com/2017/12/14/us/politics/susan-collins-tax-bill.html?_r=0

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Have you met your interventional pathologist or interventional neurologist or interventional oncologist?

A few weeks ago I met a physician who said he was an interventional gastroenterologist. I didn’t know what that meant.
Back in the day vascular procedures were the domain of vascular surgeons. So I started Googling and found that besides cardiology, stenting has expanded to GI, neurology, oncology, radiology, urology, nephrology, pulmonology, and pain management.
So now as an educated patient you should know more about interventional procedures and who is performing them on you. Some questions: Is the procedure evidence-based? Does the physician have special training in the procedure and certification, if these are the gold standard? Does the physician do enough of the procedure to ensure proficiency and good outcomes?

But first…

A new study has found that while stents can be lifesaving in opening arteries in patients having a heart attack, the devices are ineffective in relieving chest pain.
A procedure used to relieve chest pain in hundreds of thousands of heart patients each year is useless for many of them, researchers reported on Wednesday.
Their study focused on the insertion of stents, tiny wire cages, to open blocked arteries. The devices are lifesaving when used to open arteries in patients in the throes of a heart attack….
When the researchers tested the patients six weeks later, both groups said they had less chest pain, and they did better than before on treadmill tests.
But there was no real difference between the patients, the researchers found. Those who got the sham procedure did just as well as those who got stents.
Clinical guidelines in the United States say stenting is appropriate for patients with a blocked artery and chest pain who have tried optimal medical therapy, meaning medications like those given to the study patients… (A)

Now let’s look at ever expanding interventional medicine.

“A vascular surgeon diagnoses, treats, and manages conditions in your arteries and veins, also called your blood vessels. These specialists treat a range of health problems, from spider and varicose veins to life-threatening aneurysms, and can help patients manage chronic conditions throughout their lives.
A vascular surgeon treats many conditions that affect the blood vessels in every part of your body except for your heart and brain. This can include: Aneurysm, a bulge or weak spot in an artery; Atherosclerosis, or hardening of the arteries, where plaque builds up on your artery walls; Carotid artery disease or peripheral artery disease (PAD), where the arteries that bring blood to your neck or limbs become narrow or blocked; Compression disorders like nutcracker syndrome and thoracic outlet syndrome; Dialysis access, or the placement of a graft or fistula that allows you to receive dialysis treatment for kidney disease; Deep vein thrombosis (DVT), a blood clot in a vein deep below your skin; Spider veins, or small webs of veins just below the surface of the skin; Trauma to arteries and veins caused by accidents or injuries; Varicose veins, or large, swollen, twisted veins that can cause pain or aching in your legs; Venous ulcers and arterial and diabetic (neuropathic) wounds, which are nonhealing wounds that result from poor blood flow, especially in the legs” (B)

“Interventional Cardiology represents advanced training in cardiovascular disease and focuses on the invasive (usually catheter-based) management of heart disease.
Clinical issues usually managed by interventional cardiologists include: Ischemic heart disease (percutaneous coronary intervention (angioplasty), stent placement, coronary thrombectomy); Valve disease (valvuloplasty, percutaneous valve repair or replacement); Congenital heart abnormalities (repair of atrial and ventricular septal defects, closure of patent ductus arteriosus, angioplasty of the great vessels).” (C)

“Interventional Radiology” (IR) refers to a range of techniques which rely on the use radiological image guidance (X-ray fluoroscopy, ultrasound, computed tomography [CT] or magnetic resonance imaging [MRI]) to precisely target therapy. Most IR treatments are minimally invasive alternatives to open and laparoscopic (keyhole) surgery. As many IR procedures start with passing a needle through the skin to the target it is sometimes called pinhole surgery!
The essential skills of an interventional radiologist are in diagnostic image interpretation and the manipulation of needles and the use of fine catheter tubes and wires to navigate around the body under imaging control. Interventional radiologists are doctors who are trained in radiology and interventional therapy.” (D)

“Interventional Nephrology is a new and emerging subspecialty of Nephrology that mainly deals with ultrasonography of kidneys and ultrasound-guided renal biopsy, insertion of peritoneal dialysis catheters, tunneled dialysis catheters as a vascular access for patients undergoing hemodialysis as well as percutaneous endovascular procedures performed to manage dysfunction of arteriovenous fistulas or grafts in end stage renal disease patients.” (E)

“Interventional urology provides care for many urologic diseases in the most minimally invasive fashion possible. New approaches include state of the art prostate cancer screening technologies, focal therapies for prostate cancer, minimally invasive kidney cancer treatments, embolization for BPH, non-surgical approaches to treat varicoceles and erectile dysfunction.” (F)

“Interventional oncology uses image-guided technology to directly target solid tumors. It’s a complementary intervention that I hope will eventually be integrated into standard care algorithms. It gives clinicians another focused area of cancer care in which we can collaborate with other specialists. We perform targeted procedures that can be characterized as either arterial or ablative. Interventional oncology, and to some extent interventional radiology, also involves the use of biopsies for genomics analysis, in a similar way as other oncologic specialists use biopsies to help guide their biological therapies or systemic therapies.” (G)

“Interventional pulmonology is a relatively new field in pulmonary medicine. Interventional pulmonology uses endoscopy and other tools to diagnose and treat conditions in the lungs and chest.
These procedures may be offered by pulmonologists (lung specialists) who have undergone extra training. Cardiothoracic and other surgeons also routinely perform interventional pulmonology procedures.
Procedures for interventional pulmonolgy include: Flexible bronchoscopy. Biopsy of lung or lymph node.
Airway stent (bronchial stent). Rigid bronchoscopy. Foreign body removal. Pleuroscopy. Thoracentesis.
Pleurodesis. Indwelling pleural catheter. Bronchoscopic thermoplasty.
Interventional Pulmonary Diagnostics: Endobronchial ultrasound system (EBUS); Electromagnetic navigation bronchoscopy (superDimension) (H)

“Interventional (gastrointestinal) endoscopy is a minimally invasive procedure that involves the use of a thin, flexible tube (or scope) that is equipped with a camera and light at its tip. The endoscope is inserted either in the mouth or rectum and passed through the esophagus or intestines to make color images of the esophagus and intestinal tract. It also can be used to make images of surrounding organs such as the pancreas.
Interventional endoscopy can be used to screen, diagnose, manage, and treat: Colon and rectal bleeding, polyps, and cancer; Complete and colon polyp resection, including large polyps; Complications from bariatric surgery; Diseases of the esophagus; Gallbladder disease; Gastric stomach diseases; Pancreatic diseases; interventional endoscopy also is used to prevent cancer by removing growths (polyps) before they become cancerous.” (I)

“Endovascular neurosurgery is a subspecialty within neurosurgery. It uses catheters and radiology to diagnose and treat various conditions and diseases of the central nervous system. The central nervous system is made up of the brain and the spinal cord. This medical specialty is also called neurointerventional surgery.
Interventional neuroradiology is a subspecialty within radiology. It also involves catheters and radiology to diagnose and treat neurological conditions and diseases.
The term endovascular means “inside a blood vessel.” Endovascular neurosurgery uses tools that pass through the blood vessels to diagnose and treat diseases and conditions rather than using open surgery. The surgeon often uses radiology images to help him or her to see the part of the body involved in the procedure.” (J)

“A variety of interventional procedures can be used to treat a range of pain conditions, from chronic low back pain to migraine headaches. Many of these techniques are performed under X-Ray guidance, which helps the physician deliver the therapy—whether it’s a steroid injection or heat-based remedy—to the exact source of the pain.
The range of interventional pain management treatment options include: Epidural Steroid Injections;
Medial Branch Blocks / Facet Joint Injections; Radiofrequency Nerve Ablations; Major Joint Injections (Knee, Hip, Shoulder); Occipital Nerve Blocks; Kyphoplasty (Balloon kyphoplasty). (K)

“Pathologists use microscopic examination and supporting tests to study tissues taken from biopsies and make diagnosis. In conventional pathology, the samples are taken by a surgeon and then sent away to a pathologist for analysis.
Interventional pathology is a new, less invasive option that allows for preliminary sample testing to be done in-person by the pathologist. It enables the pathologist to directly commnicate with the patient and helps the doctor put the biopsy samples in context with the patient as a whole. This achieves faster, more accurate, and more complete diagnoses. With interventional pathology, patients can receive a better diagnosis than is available with conventional pathology, and in fewer trips to the doctor’s office.” (L)

(A) ‘Unbelievable’: Heart Stents Fail to Ease Chest Pain, by GINA KOLATA, https://www.nytimes.com/2017/11/02/health/heart-disease-stents.html
(B) Learn About What Vascular Surgeons Do, https://www.acponline.org/about-acp/about-internal-medicine/subspecialties/cardiovascular-disease/interventional-cardiology
(C) Interventional Cardiology, https://www.acponline.org/about-acp/about-internal-medicine/subspecialties/cardiovascular-disease/interventional-cardiology
(D) What is Interventional Radiology?, by David Kessel, https://www.bsir.org/patients/what-is-interventional-radiology/
(E) Interventional Nephrology: a new subspecialty of Nephrology, by G Efstratiadis, I Platsas, P Koukoudis, and G Vergoulas, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2464263/
(F) Interventional Urology, http://www.mountsinai.org/patient-care/service-areas/urological-conditions-and-surgery/areas-of-care/interventional-urology
(G) Burgeoning Field of Interventional Oncology Is Poised for Takeoff: A Q&A With Dan Brown, MD, by Andrew J. Roth, http://www.onclive.com/publications/obtn/2013/november-2013/burgeoning-field-of-interventional-oncology-is-poised-for-takeoff-a-qanda-with-dan-brown-md
(H) Interventional Pulmonology, https://www.webmd.com/lung/interventional-pulmonology-uses-effects#1
(I) WHAT IS INTERVENTIONAL ENDOSCOPY?, https://www.summitmedicalgroup.com/service/Interventional-GI-Endoscopy/
(J) Endovascular Neurosurgery and Interventional Neuroradiology, https://www.hopkinsmedicine.org/healthlibrary/test_procedures/neurological/endovascular_neurosurgery_and_interventional_neuroradiology_135,39
(K) Interventional Pain Procedures Under X-Ray Guidance, http://www.mountsinai.org/patient-care/service-areas/pain-management/pain-management-services/interventional-spinal-procedures-under-x-ray-guidance
(L) Interventional Pathology, https://sites.google.com/site/pathdiag/upcoming-seminars/our-company

Note: This blog shares general information about understanding and navigating the health care system. For specific medical advice about your own problems, issues and options talk to your personal physician.

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“Regardless of how many years you have been with the same doctor, there may come a time when you need to find a new one.”

“William Osler, often called the father of modern medicine, famously advised his students: “Just listen to your patient; he is telling you the diagnosis.” A century later, clinicians and health system leaders started tuning out the patient’s voice, turning instead to electronic health records and the latest care protocols to manage their most complicated and high-need patients. We believe it’s time for an urgent and strategic reset. The factors that lead people to become our nation’s costliest are complex. But they call for, at the start, the simplest intervention: listening.” (A)

“Five years ago, when he started seeing his internist, everything was fine. But Groopman says that in time, the internist became more popular — and hence more busy and harried — right when Groopman needed him most.
“I have a strong family history of high cholesterol and heart disease. Every male in my family has had a [heart attack] in his 50s and 60s,” he said. “I was moving into middle age, and I just didn’t feel that my doctor was looking at me as an individual and taking those factors into account.”
But Groopman — a physician and author of four books about doctors and patients — found it difficult to leave his internist of five years. “It sounds strange, but I didn’t want to insult him.”…
Groopman “says says a doctor who doesn’t like a patient often stereotypes him or her. “I was terribly guilty of this as a young doctor. One of my patients said she had indigestion, and I got very irritated with her and thought she was a whiner and a complainer,” he said. “It was catastrophic, because she actually had a torn aorta.”
The woman died. “I have never forgiven myself for failing to diagnose it,” he writes in “How Doctors Think.” “There was a chance she could have been saved.” “ (B)

“I always liked my primary care doctor personally. He routinely welcomed me to his office with a cheery hello and a smile. We asked about each other’s children. We often discussed our respective exercise regimens, running in his case and pickup basketball in mine. For more than 20 years, we even confided about our ambitions as writers.
But I often questioned his judgment in medical matters.
Take, for example, the time my neck bothered me. I complained to him about frequent soreness and stiffness – probably a result of spending hours planted in front of a computer. He suggested I obtain a neck brace to wear while working. “Is that necessary?” I asked him. No, he said.
At no point did he ask me where my neck hurt, or how much, or how often. He never physically examined my neck, nor instructed me to turn my head in order to observe my range of motion. He neglected to propose I do specific exercises to rehabilitate my neck or get a new chair or just take frequent breaks from sitting at a keyboard.
Rather, he advised me to see an orthopedist or physiatrist. He also printed out some medical journal articles about neck problems for me to read, all well over my head. (C)

“Moving on from your physician could open you up to certain challenges, so it’s important that the situation is dealt with carefully. No one wants to be without care, or to spend a lot of time looking around for a physician. In some cases you may be able to switch between physicians in the same practice, but some groups frown on that. If there’s not a lot of choice in physicians in your local area, it’s important not to burn any bridges. The best-case scenario is for both you and your physician to agree that you’ve gone as far as you can together, and that it’s time for a change.
Before you decide to fire your doc, you should try to first repair the relationship. You’ll need to put your finger on the cause of the problem: is it the doctor or is it you (and let’s be honest!)? If the problem is something that you feel the two of you can work on, you’ll want to take steps to smooth things over and try to establish a better working relationship. If it’s impossible to work out your differences, you’ll want to consider if it’s time to fire your doctor and switch to a new one… (D)

“The last time I saw my gynecologist, she glossed over the issue I’d come in for and gave me a test I didn’t want — without even discussing it with me first. In my previous visit, she ordered me a mammogram and brushed off my attempts to discuss the exam’s harms and benefits. It’s clear we have a communication problem, and frankly I’m ready to fire her — but how? Am I obligated to tell her I’m switching doctors? (I’d feel badly if she found out by reading it in this column.) And what obligations does she have to me?….
Once you have decided to leave, be sure to request a copy of your medical records. You can have them sent either to you or directly to your new doctor. Ask that they include lab results and such things as MRIs, X-rays, EKGs and recent hospital records, Blackwelder says. If your doctor has sent you to a specialist, it’s a good idea to ask for copies of the consultation notes from these visits too, he says. Legally, the records belong to your doctor, but as a patient you have a right to a copy, says Rachel Seeger of the Office for Civil Rights at the Department of Health and Human Services. “ (E)

“Regardless of how many years you have been with the same doctor, there may come a time when you need to find a new one. Perhaps you are not comfortable with your current physician, or maybe the doctor that you have loved for years has died or retired. In some cases, your life may depend on firing and replacing your doctor…
Many people are somewhat intimidated by their doctors. You might consciously or subconsciously feel that the
“There are many things your doctor could do or not do, or say or not say, that may make you want to find a new doctor. These things may be different for each person and situation. Here are a few things you can look out for. You do not feel that your doctor is listening to you.You do not feel that your doctor believes you.Your doctor cuts you off when you are speaking. You feel rushed when you are with your doctor. You feel that your doctor acts superior to you. Your doctor insults you, instead of treating you.
While there are many reasons for wanting a new doctor, you do not need a specific reason for changing doctors. You may not be able to pinpoint why you want to switch to a new physician, but if you feel like you want to make a change, the reason does not matter.”” (F)

“… Patients ask me frequently, “Can my doctor dismiss me?” The answer is — yes it is legal and fair for a doctor to fire a patient under any circumstances. But there are also circumstances under which a doctor may not dismiss a patient….
The American Medical Association has established guidelines regarding when a doctor may fire a patient, based on its Code of Ethics. In addition, many states have laws about the circumstances under which a doctor may terminate a patient relationship.
The reasons a doctor may dismiss his or her patient are:Patient non-compliance (non-adherence). A patient’s rude or obnoxious behavior. Non-payment of bills. A relatively new reason for dismissal seems to be based on the type of insurance a patient has…
When a Doctor Cannot Legally Dismiss a Patient…Doctors may not discriminate based on race, color, religion, national origin, sexual orientation, gender identity or any other attribute that is nationally recognized as discrimination. The courts have ruled that a patient cannot be dismissed because he or she is HIV-positive…
Doctors may not dismiss a patient in the midst of ongoing medical care, called “continuity of care.” For example, a pregnant woman cannot be dismissed by her doctor within a few weeks of delivery. A cancer patient cannot be fired before his chemo or radiation treatments are completed. However, a patient who has been on a primary care doctor’s roster, but hasn’t visited that doctor in a year or two might be dismissed. That is not considered ongoing care. (G)

“Being old and sick in America frequently means a doctor won’t ask you about troublesome concerns you deal with day to day difficulty walking, dizziness, a leaky bladder, sleep disturbances memory lapses, and more.
It means that if you’re hospitalized, you have a good chance of being treated by a physician you’ve never met and undergoing questionable tests and treatments that might end up compromising your health. It means that if you subsequently seek rehabilitation at a skilled nursing facility, you’ll encounter another medical team that doesn’t know you or understand your at-home circumstances. Typically, a doctor won’t see you very often…
A complex set of forces is responsible. Some examples: Medical training doesn’t make geriatric expertise a priority. Care at bottom-line-oriented hospitals is driven by the availability of sophisticated technology. Drug companies and medical device manufacturers want to see their products adopted widely and offer incentives to ensure this happens. Medicare, the government’s influential health program for seniors, pays more for procedures than for the intensive counseling that older adults and caregivers need.” (H)

(A) Listening Is a Lost Art in Medicine. Here’s How to Rediscover It, Prabhjot Singh, MDNiyum Gandhi, https://hbr.org/2017/11/listening-is-a-lost-art-in-medicine-heres-how-to-rediscover-it
(B) Know when it’s time to fire your doctor, by Elizabeth Cohen, http://www.cnn.com/2016/10/07/health/fire-your-doctor/index.html
(C) Why I Almost Fired My Doctor, by BOB BRODY, https://www.nytimes.com/2017/10/12/well/live/why-i-almost-fired-my-doctor.html
(D) How to Fire Your Doctor, by Amber J. Tresca, https://www.verywell.com/how-to-fire-your-doctor-1942906
(E) How to fire your doctor. Rule One: Make sure you have another one lined up first, by Christie Aschwanden, https://www.washingtonpost.com/national/health-science/how-to-fire-your-doctor-rule-one-make-sure-you-have-another-one-lined-up-first/2014/01/13/44778c2e-76fb-11e3-af7f-13bf0e9965f6_story.html?utm_term=.3cb5b7baada3
(F) When, Why and How to Fire Your Doctor, by Michal Vilímovský, https://medlicker.com/1199-how-to-fire-your-doctor
(G) Can My Doctor Fire or Dismiss Me as a Patient? By Trisha Torrey, https://www.verywell.com/can-my-doctor-fire-or-dismiss-me-as-a-patient-2615017
(H) How older patients can dodge pitfalls entrenched in health care system, by Judith Graham, How older patients can dodge pitfalls entrenched in health care system, by Judith Graham, http://www.chicagotribune.com/lifestyles/health/ct-older-patients-pitfalls-health-care-20171128-story.html

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Note to Sen Collins: Look Around the Poker Table- If You Can’t See the Patsy, You’re It! *

Before she voted for the Senate version of the Republican tax bill, Sen. Susan Collins saw that Congress would soon be passing separate spending deals, and she had demands.
The Maine Republican laid out a series of conditions for her to support the final “conference committee” version of the tax proposal. Most notably, she wants Congress to pass two separate health care bills first….
It’s unclear how the separate health bills would become law before a final tax vote. Though Collins secured support from both President Donald Trump and Senate Majority Leader Mitch McConnell (R-Ky.), neither man controls the House of Representatives.
House Speaker Paul Ryan (R-Wis.) has suggested he doesn’t support the Collins demands, saying he wasn’t a party to her deal with McConnell. And Rep. Mark Walker (R-N.C.), leader of a group of lawmakers called the Republican Study Committee, said the conservative bloc had been promised by GOP leaders that the health bills would not be part of a must-pass spending package this month.
Collins wants Congress to pass the so-called Alexander-Murray deal — an agreement worked out between Sens. Lamar Alexander (R-Tenn.) and Patty Murray (D-Wash.) that would provide for “Cost Sharing Reductions” for Obamacare insurers — and another bill providing $2.25 billion annually for states to offset the high insurance costs of some individuals.
Without those measures signed into law, McConnell could just invite Collins to become the one remaining “no” vote Senate Republicans can afford, since their tax bill passed with 51 votes last Saturday….
It would be difficult for Republican leaders to appease Collins without betraying House conservatives.
On Thursday, they went along with a stopgap spending bill under the conditions that there would be no Alexander-Murray provisions in any of the other upcoming measures to fund the government. Ryan and House Republicans could very well pass another short-term appropriations bill in two weeks, have the Senate change the bill — because, after all, McConnell needs Democratic votes to pass that bill in his chamber — and then force Ryan and House Republicans to pass the Senate version or shut down government.
But no matter the ultimate conclusion, Collins is already being asked to accept more things on faith than she was supposed to. Earlier in the week, the House Freedom Caucus nearly derailed a vote to begin merging the separate versions of the tax legislation until leaders agreed to “decouple” the tax bill from the other spending bills, with Freedom Caucus Chairman Mark Meadows (R-N.C.) telling reporters that the final tax bill would now likely come next week, days before Senators vote again on a spending bill.
If that’s the case, Collins will once again be asked to vote for legislation she believes is harmful to Americans with the promise that Congress will mitigate their actions in the future.
If Collins objects, any one other Republican senator — with Bob Corker (R-Tenn.) continuing to oppose the bill — could sink the tax legislation. And other senators may hold up the process until Collins receivers firmer commitments. Sen. John McCain (R-Ariz.), for example, could have a problem with McConnell going back on his word.” (A)

“But it should be clear at this point, to Collins and to House conservatives, that someone is going to get hoodwinked. At least one GOP leader is going to have to go back on his word. And it should be clear at this point that these commitments Republicans are making are a lot looser than members of Congress think…
Republican Sen. Susan Collins of Maine says she would consider removing her support from GOP tax plans, saying in an interview she could change her vote if her proposed amendments don’t make it in the final version.
“I would (consider changing my vote),” she told CNN affiliate CBS WABI5 on Thursday. “I’m going to look at what comes out of the conference committee meeting to reconcile the differences between the Senate and House bill. So I won’t make a final decision until I see what that package is.”…
Collins, a moderate Republican, voted for the GOP’s tax plan last week despite having helped kill the GOP’s Obamacare repeal efforts earlier this year. Several aides told CNN that Collins made clear to Senate Majority Leader Mitch McConnell that she wanted to get to “yes” on the tax legislation, unlike with health care.
“There’s a real fear that the tax bill is going to trigger a 4% cut in Medicare,” she told CBS WABI5 in the interview. “I am absolutely certain that 4% cut in Medicare that I mentioned will not occur. I have it in writing from both the speaker of the House, Paul Ryan, and also Senator Mitch McConnell.” (B)

Meanwhile, it looks as though funding for another cost-sharing reduction (CSR) payments won’t make it into the next spending bill, according to The Hill. Republican Study Committee chairman Rep. Mark Walker said House leaders made that promise during a meeting Tuesday.
That is likely unwelcome news for Sen. Susan Collins, R-Maine. She agreed to vote for the Senate’s tax bill—which repeals the ACA’s individual mandate—after striking a deal with Senate Majority Leader Mitch McConnell to pass a bill funding CSR payments and her reinsurance proposal. The idea is that those bills might mitigate the negative effects of repealing the individual mandate—though some analyses have disputed that notion.
Collins said Friday that she might change her vote on the GOP’s tax overhaul if party leaders don’t include her amendments to that measure, which are related property tax and medical expense deductions, the Associated Press reported. Collins also noted that House and Senate leaders promised her they would remove the threat of a 4% cut to Medicare. (C)

“Sen. Lisa Murkowski (R-Alaska) is pushing back on Democratic attacks that she is undercutting ObamaCare, saying opponents are simply using “scare tactics.”
In a question-and-answer video posted on her YouTube page, Murkowski defended her vote for tax reform this month. Murkowski backed a bill that includes language repealing ObamaCare’s individual mandate.
“I think it’s important that people really look to what is included in this bill when it relates to the Affordable Care Act and to get beyond the scare tactics and the rhetoric that is designed to just instill fear and paranoia in people,” Murkowski said.
She notes that the only provision in the tax bill related to ObamaCare is the repeal of the requirement to have coverage or pay a fine.
“What this bill does is says if you can’t afford health-care coverage, or if you don’t see that value in it, we’re not going to fine you,” she said. “It doesn’t impact the ACA in any other way. If you receive a subsidy for your health-care insurance before this tax bill passes you will still be able to receive a subsidy after.”
Murkowski was one of three Republican senators who voted down a Republican ObamaCare repeal attempt over the summer, which included repeal of the mandate. She has drawn sharp criticism from Democrats this time for voting for the repeal of the mandate.
Opponents of her move argue that eliminating the mandate will have wider impacts, and that it could lead to a spike in premiums or insurers dropping out of the market once an incentive for healthy people to enroll is removed.
The Congressional Budget Office finds that premiums will increase 10 percent and 13 million fewer people will have coverage over a decade if the mandate is repealed.
Murkowski argued that subsidies available under the health-care law will encourage many people to remain enrolled in ObamaCare.
She also touted a bipartisan bill from Sens. Lamar Alexander (R-Tenn.) and Patty Murray (D-Wash.) as one that would help stabilize the market by providing funds for key insurer payments.
“It is my understanding that as part of the negotiation, not only has the Senate leadership committed that we will advance Alexander-Murray, but the president has indicated that support as well, so prior to the end of this year, I think we can anticipate that we will see that piece inserted as well,” Murkowski said.
Many House Republicans, though, are opposed to the bill, raising questions on if it can pass that chamber.
Experts say that Alexander-Murray alone is also not enough to counteract the premium increases from repealing the mandate, and that additional funding would be needed to bring down premiums.” (D)

“Marc Short, the White House director of legislative affairs, said the change for state and local tax deductions is “certainly being discussed.” But he said “the biggest challenge is the pay-fors” — that is, how to cover the revenue that would be lost by offering a larger deduction….
By Monday, Cohn added, “we’ll have a pretty final tax bill here, and we’ll know where we’re going to be.”
Short predicted that two GOP senators who have cited specific concerns about the legislation — Marco Rubio of Florida and Susan Collins of Maine are “going to be fine” in the end….
Collins has said she wants to see separate legislation passed to shore up health-insurance marketplaces if the ultimate tax bill repeals the individual mandate that’s part of Obamacare. The measures will almost surely face rough sledding in the House, however.
On Thursday, the White House didn’t commit to supporting the health-care bills Collins wants. Short said Friday that “if those reach the president’s desk he will sign them, but there’s some elements of that as far as the lobbying and whipping of votes that is out of our control.”” (E)

“Sen. Susan Collins, the Maine Republican whose vote was pivotal in pushing the GOP tax bill forward last week, thought she had a deal to bolster health care protections in exchange for her support.
But it’s now unclear whether her strategy to shore up part of the Affordable Care Act will prevail or that it would produce the results she anticipates.
The tax bill repeals the ACA’s fines for the individual mandate, which requires most people to have health insurance or pay a fine. Collins says she would vote for it if Senate Republicans promised to allow a vote on two other health bills….
The tax bill is now the subject of final negotiations between the House and the Senate. First, even if the bills pass the Senate, there is little to suggest that the House Republicans would go along. On Tuesday, House Speaker Paul Ryan, R-Wis., reportedly told other House leaders he was not a party to Collins’ health care deal with McConnell. Ryan had previously expressed opposition to restoring the cost-sharing payments.
In response to Ryan, Collins on Thursday signaled that she might not vote for the tax bill’s final passage.
But would Collins’ changes offset the elimination of the mandate? Some analysts question whether the bill restoring the federal cost-sharing subsidy payments could actually do more harm than good.
“It’s a mess,” says insurance industry consultant Robert Laszewski. Many states allowed insurers to raise premiums to make up for the loss of the federal cost-sharing reduction payments. So passing the law now, at least for 2018, would require insurers to make refunds to individuals and the federal government for those overpayments….
The elimination of the mandate penalties is permanent, but Collins’ bill would fund the cost-sharing and reinsurance programs for only two years. Because of that, says Timothy Jost, a former law professor and expert on the health law, “I don’t think it’s going to be much of a carrot” to encourage insurers to stay in the individual market…..” (F)

Health insurance companies know that an insurance market without the requirement that everyone get coverage will be worse for them and their customers. They just aren’t sure how much worse.
HuffPost contacted dozens of health insurance companies to ask them to assess the impact that removing the so-called individual mandate ― which Republicans in Congress are on the verge of doing as part of their tax bill ― would have on their businesses and their customers.

Fifteen companies responded ― and all warned that eliminating the mandate would force them to further raise prices, and could drive some insurers to leave the market altogether. Both of those outcomes would lead to fewer Americans having health insurance and destabilize an insurance market already plagued with problems.
Let’s assume for a second that you eliminate the mandate and so those healthy people decide to sit out, whether they need a subsidy or not, the pool shrinks,” said Jim Havens, senior vice president of individual and senior markets for Mountlake Terrace, Washington-based Premera Blue Cross.
“That means that the people left are people who either intend to use it or think they will be using it, which is going to make it more expensive,” Havens said. Premera is the sole insurer offering individual policies in Alaska and also operates in Washington state.
The biggest losers would be middle-class people who don’t get health benefits from their employers and make too much money to receive subsidies for private insurance from a health insurance exchange. They will see fewer choices and higher prices in the future.
People who live in sparsely populated regions are at the greatest risk of extremely high premiums, and of having no insurers doing business where they live because rural areas already are the toughest locations to make a profit.” (G)

*Quote attributed to Warren Buffet

(A) Susan Collins Never Had An Actual Deal On Taxes, by Arthur Delaney and Matt Fuller, https://www.huffingtonpost.com/entry/collins-tax-vote_us_5a2ac0d1e4b0a290f050378a
(B) GOP Sen. Susan Collins says she would consider changing her tax plan vote over amendments, by Daniella Diaz, http://www.cnn.com/2017/12/08/politics/susan-collins-republican-gop-tax-plan-amendments/index.html
(C) GOP lawmakers mull health insurance tax delay, by Leslie Small, https://www.fiercehealthcare.com/regulatory/gop-lawmakers-mull-health-insurance-tax-delay
(D) Murkowski pushes back on ObamaCare ‘scare tactics’, by Peter Sullivan, http://thehill.com/policy/healthcare/363975-murkowski-pushes-back-on-obamacare-scare-tactics
(E) Trump Backs Keeping State Income Tax Break With Cap, Cohn Says, by Toluse Olorunnipa and Jonathan Ferro, https://www.bloomberg.com/news/articles/2017-12-08/trump-backs-keeping-state-income-tax-break-with-cap-cohn-says
(F) Doubts Rise About Sen. Collins’ Strategy To Shore Up Insurance Market, by Julie Rovner, http://www.wbur.org/npr/569421827/doubts-rise-about-sen-collins-strategy-to-shore-up-insurance-market
(G) Health Insurers See Higher Prices And A Big Mess Ahead Without The Obamacare Mandate, by Jeffrey Young, https://www.huffingtonpost.com/entry/health-insurers-higher-prices-obamacare-mandate-repeal_us_5a272277e4b0c2117626a077

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“White House counselor Kellyanne Conway will be the point person for the Trump administration’s opioid crisis efforts…

President Donald Trump tapped Conway to help “change the perception” about opioids and reduce addictions and deaths, Sessions said at a press briefing about the Justice Department’s efforts to combat the crisis. Sessions said Trump had made the epidemic “a top priority for his administration, including every senior official and Cabinet member.”
Conway worked as a pollster before becoming Trump’s campaign manager, and she now serves as a White House spokeswoman and Trump surrogate. She has become notorious for defending some of Trump’s most blatant mistruths, and she pioneered the term “alternative facts” to excuse the president’s troubles with the truth.
She has no formal experience in drug policy or law enforcement. Conway has a law degree and started her own polling company, The Polling Company, in 1995, often consulting on consumer trends. She worked as an adviser for several Republicans, including Mike Pence and Newt Gingrich.
In the past, she has shared Sessions and Trump’s view on defeating drug abuse: Strict prevention programs. “The best way to stop people from dying from overdoses and drug abuse is by not starting in the first place,” she told Fox News in October. “That’s a big core message for our youth.” (A)

“The Justice Department on Wednesday said it is stepping up enforcement efforts to combat the opioid crisis.
Attorney General Jeff Sessions announced that the agency will dedicate $12 million in grants to help police target illegal manufacturers and dealers of prescription opioids, heroin and methamphetamine.
The department is also directing U.S. attorneys around the country to designate an “opioid coordinator” for each office, and the Drug Enforcement Agency will open a new field division in Louisville to cover Kentucky, Tennessee and West Virginia, where communities have suffered particularly high rates of opioid addiction.
“I’m convinced that our law enforcement efforts save lives, because they prevent new addictions from starting. By enforcing our laws, we keep illegal drugs out of the country, reduce their availability, drive up their price and reduce their purity,” Sessions said at a brief press conference at Justice Department headquarters.
Opioid addiction rates have skyrocketed in recent years, with more than 140 Americans a day dying from opioid overdoses, according to the Centers for Disease Control and Prevention.
The announcement suggests the Trump administration is prioritizing a law enforcement response to the opioid crisis even as questions linger about how it plans to approach the public health aspect of treating addiction.” (B)

“The President’s Council of Economic Advisors (CEA) recently issued a report stating that the economic costs of the opioid crisis have been greatly underestimated. When previous researchers crunched the numbers, they did not factor in the monetary worth of each life that is lost involving opioids.
According to economists, the value of each decedent’s life is called the “value of a statistical life,” or VSL. Several federal agencies use VSL to inform regulatory decision-making.
The CEA recalculated the previously reported economic cost of the opioid crisis so that it now includes a value for each human life lost involving an opioid. For that calculation, the CEA used the figure of 33,091 opioid-related deaths and 2.4 million people with opioid addictions in 2015. The cost was composed of $431.7 billion for the cost of fatalities, and $72.3 billion for the cost of non-fatal abuse and addiction.
In other words, there are now two financial consequences given for opioids: one that includes the loss of human lives (fatalities), and one that does not (abuse and addiction that does not lead to death).
The non-fatal costs are for health care, workplace, drug treatment, and criminal justice costs mostly, lost productivity and crime. Then there are the costs of fatalities.
According to the CEA report, the total cost of opioid-related deaths is estimated at $504 billion in 2015. Divide that by the number of opioid-related deaths — 33,091 — and we see that the CEA has assigned roughly a $15 million value to each life lost.” (C)

“A better explanation points to something uniquely American: the U.S. medical-industrial complex, which has facilitated the massive proliferation of prescription painkillers.
In the 1990s, doctors faced pressure to treat pain more seriously as “the fifth vital sign.” They turned to opioids, which pharmaceutical companies were pushing hard (and as recent lawsuits allege, in the name of profit) as a safe solution. The U.S. health care system equates quality of care with the ability of doctors and hospitals to deliver what patients ask for, incentivizing providers to pull out the prescription pad. In 2012, doctors wrote 259 million opioid prescriptions—enough to give a pill bottle to every adult in the country. Twelve states had more prescriptions than people. The Centers for Medicare and Medicaid Services even links reimbursements to patient surveys that ask whether “your doctors did everything they could to help with your pain.”
As the maker of OxyContin, Purdue Pharma has been pummeled by controversy since the opioid hit the market in 1996. The company has poured many millions of dollars into promoting Oxy, and made billions in return. But an increasing number of public officials and medical professionals see the revenues as tainted because they say Purdue has knowingly stoked the escalating epidemic of opioid abuse by consistently making false claims about a drug linked to thousands of deaths.
“This was the perfect storm — a push to ask for painkillers, higher dosing, more powerful medications and erroneous studies that said that these drugs were not addicting,” said Dr. Arun Nandi, chairman of emergency medicine at Stamford Hospital.” (D)

“The US Department of Health and Human Services (HHS) is moving ahead to address the opioid crisis via the power given by the public health emergency declaration issued by President Donald J. Trump in October, but it is looking to Congress to provide the funding, HHS officials said at a press briefing.
“We’re looking forward to hearing from Congress as to how they intend to address this,” said Acting HHS Secretary Eric Hargan at the briefing. He noted that the House has proposed $15 billion in funding and that the Senate has proposed $45 billion.
The Trump administration intends “to work closely with Congress to help develop those numbers further,” said Hargan, adding, “I think the fact that they put those kind of numbers in shows that the congressional leadership is taking this seriously, as is President Trump and his whole administration.”” (E)

“Opioid-driven deaths during hospital stays in the United States quadrupled between 1993 and 2014, according to a new study released Monday.
The study found that patients admitted to the hospital for opioid use skewed young — 39 years old on average — and white. From 1993 to 2014, the number of black and Hispanic patients admitted to hospitals for opioid or heroin poisoning remained fairly stable. But that rate among white patients doubled between 2007 and 2013; with about 30,000 cases, they were the “largest and fastest-growing share of hospitalizations” in recent years, according to the study published Monday in the journal Health Affairs.
Why are people dying with opioids in their bodies after they arrive at the hospital? Song said the data alone can’t answer that question, but he offered a few possible explanations.
The presence of fentanyl and heroin nationwide is growing in communities across the country, often at prices that are cheaper than prescription opioids, such as oxycodone, he said. And efforts to treat people where they are — in the field, or at clinics or urgent care facilities — could mean that hospitals tend to admit patients who “are higher risk and more severe,” he said….
Michael Botticelli, who served as drug czar during the Obama administration and currently directs the Grayken Center for Addiction at Boston Medical Center, said the study makes the case for more hospitals to adopt intervention and treatment programs to combat the nation’s ongoing opioid epidemic and rising number of overdose deaths.” (F)

“It’s become an almost daily routine: Some panel, discussion, summit, commission, hearing, project, or report claims to have the answer to America’s historically deadly opioid crisis. The latest pathetic “solution,” of course, is the (weirdly disputed) emergence of longtime Republican pollster, Donald Trump “alternative facts” adviser, and noted public health expert Kellyanne Conway as some kind of alleged “opioid czar.” I say alleged because even though Attorney General Jeff Sessions suggested last week that she had the gig, the White House later said she was merely continuing existing work on the issue.
Who’s telling the truth? …The time for talk is over. In the past three years alone, more than 100,000 Americans have died of opioid overdose. Mothers, fathers, sisters, brothers, children—a tremendous loss. Conway is close to President Trump and this news has been taken by some as a signal that he’s finally serious about addressing opioids. But what does that even mean when no new money is being appropriated, healthcare cuts may be on the way, and no actual “drug czar” has been named to coordinate strategy, among other glaring gaps in the administration’s response to this disaster?” (G)

President Donald Trump has donated his third-quarter salary of $100,000 toward battling the opioid crisis….
In October, Trump declared opioid addiction a “public health emergency.” But so far, the administration hasn’t asked for more money to fight the crisis, and the fund for public health emergencies has only about $57,000.” (H)

(A) Kellyanne Conway Will Run White House’s Opioid Crisis Efforts, by Melina Delkic, http://www.newsweek.com/kellyanne-conway-lead-white-house-opioid-crisis-efforts-726249
(B) Sessions Steps Up Enforcement Actions in Opioid Crisis, by Alan Neuhauser, https://www.usnews.com/news/national-news/articles/2017-11-29/sessions-steps-up-enforcement-actions-in-opioid-crisis
(C) Evaluating the CEA’s cost estimates of the opioid crisis, by DR. LYNN R. WEBSTER, http://thehill.com/opinion/healthcare/362398-evaluating-the-ceas-cost-estimates-of-the-opioid-crisis
(D) Big pharma’s role in the opioid crisis, by Paul Schott, http://www.stamfordadvocate.com/business/article/Big-pharma-s-role-in-the-opioid-crisis-12396414.php
(E) Trump Administration Looks to Congress for Opioid Crisis Funding, by Alicia Ault, https://www.medscape.com/viewarticle/889562
(F) Deaths during opioid-driven hospital stays have quadrupled, by Laura Santhanam
(G) https://www.pbs.org/newshour/health/deaths-during-opioid-driven-hospital-stays-have-quadrupled
(H) Trump Donates $100,000 Third-Quarter Salary To Fight Opioid Crisis, by Lindsey Pulse and Ethan Weston, https://www.newsy.com/stories/trump-donates-third-quarter-salary-to-fight-opioid-crisis/

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