Republican Health Reform Proposals

Now that the Florida primary is over and we await super Tuesday, it’s time to look closely at health proposals of Republicans. Unlike Democrats, they’re turning to market rather than governmental solutions. Governor Romney, of course, led the effort in Massachusetts to create a universal solution requiring every individual to buy insurance, but he now says that solution applies only to Massachusetts and shouldn’t be applied to other states.

Republican candidates want more options for individuals. They would create new deductions or tax credits for health insurance. Lower income people would get subsidies to purchase private insurance.

People could purchase health insurance across state lines, and regulations and mandates would be reduced to make health insurance less costly. Reduced premiums would bring new buyers into the market, expand competition, and force insurers and providers to offer more affordable options.

Here’s what the surviving GOP presidential candidates are saying.

- John McCain: "It is good tax policy to take away the bias toward giving workers benefits instead of wages. It is good health policy to reward having insurance no matter where your policy comes from. To use their money effectively, Americans need more choices."

- Mitt Romney, "The federal government needs to loosen regulations on the nation's health-insurance providers, increasing competition and thereby lowering patient costs. The right answer is less government, less regulation, more individual responsibility, and more of the market dynamics that propel the rest of our economy."

- Mike Huckabee: "I advocate policies that will encourage the private sector to seek innovative ways to bring down costs and improve the free market for health-care services. We can make health care more affordable by making health insurance more portable from one job to another, and making health insurance tax deductible for individuals and families as it now is for businesses."
The Republican presidential candidates want to give people the same tax benefit whether they purchase a policy on their own or they get it at work. They don’t want insurance tied to the workplace. Nor do they want individual mandates requiring everyone to buy insurance as Senator Clinton proposes. Senator Obama supports a mandate for children to get health insurance but not everyone. "The reason Americans don't have health insurance isn't because they don't want it, it's because they can't afford it.”
Major candidates of both parties support:

- More prevention

- greater use of electronic health records

- more information for consumers on choices and prices

- better chronic-care management

- medical malpractice reform. (assuming John Edwards has been effectively eliminated from the race)

- more consumer choice and control over health insurance

Barring a sweeping Democratic victory in the fall with control of Congress and the presidency and a veto-proof majority, complete transformation of the health system is unlikely.

Listening to Floridians About Health Care

Fort Worth, Florida - I’ve learned two things from engaging Floridians in conversation and listening to what they have to say.


One, conversations start with weather. Weather obsesses Floridians. It justifies their living here.. Once they learn you hail from the North, they respond, “How cold was it there?” “You must be so happy to be here!” Or, apologetically, “I’m so sorry about our cool (or overcast, or rainy) weather. It’s usually much nicer.”


Weather opens and closes conversations. It dominates everything in-between. There’s no escaping it. Weather is an obsession.


Two, health care preoccupies, flummoxes, and irritates them. Once they know you’re a doctor, verbal floodgates open. Seldom is heard an encouraging word. Of the health care system, they say, “It’s broken.” “It costs too much.” “It’s a mess.” Or, “I like my doctor, but the rest of it sucks.” Still, they can’t seem to get enough of it.


There’s no single complaint theme. This should come as no surprise. For health care, like Florida itself, is diverse. Florida, our 4th most populous state, has Crackers to the North, New Yorkers and Yankees to the East, Midwesterners to the West, Cubans to the South, and Immigrants, Snowbirds, Retirees, Canadians, Transients, and Veterans (2 million of them, mostly for McCain) Everywhere.


Here are four excerpts I heard on my Listening Tour.


• A 6o-ish woman, a PhD in French literature, a textbook writer, an industrial consultant to French companies in America, and a breast cancer survivor, complained, “My surgeon, my pathologist, and my internist don’t communicate with each other. In reformspeak, we call this “fragmentation” and “lack of coordination.” We say it can be eased electronically by EMRs, PHRs, and e-mail visits.

• A 42 year old married, woman housecleaner, mother of four, whose husband had lost his job, told me, “I had to drop my insurance because we couldn’t afford it.” In reformspeak, we call her one of the”working uninsured,” who comprise 82% of America’s 47 million uninsured. Democrats propose to solve this problem by pouring in more federal money and subsidizing care for all. Republicans say we can solve it through tax credits for all and market innovation.


• A 70 year old married former well-to-do businesswoman, informed me she and her husband have joined a concierge practice. They pay $1500 a year each for personal attention, 24/7 access, and other amenities. She and her husband are immensely satisfied with the care they receive. In reformspeak, depending on your political point of of view, we deem concierge care as “two –tier luxury care,” or “innovative practice design.”


• A 50-ish married, fully-insured Bed and Breakfast proprietress, related this story.
She awoke at night with intense painr rib cage pain. . Not knowing what to do or where to go, she hastened to an emergency room where herpes zoster was diagnosed. She added she has aortic stenosis and will have a valve replaced later this year. In reformspeak, we often say ERs are overcrowded with the uninsured, but the reality is the insured, particularly Medicare patients,. comprise the majority of ER patients. It’s a question of access during off-hours. This partially explains why retail clinics and urgicare centers are proliferating. As for her heart surgery, in reformspeak , we proclaim hospital costs have to come down, but we have yet to find a way to lower them. The problem is we just love those life-saving and lifestyle-saving hospital-based technologies.


Today is the Florida primary. Bringing down the cost of care and covering the uninsured will be on every politician’s lips. Meanwhile and hereafter, more retail clinics and urgicenters will sprout, more obstetricians and neurosurgeons will flee Florida for colder climes in search of lower malpractice premiums, and shortages of 120,000 nurses and 50,000 doctors will make most reform proposals impractical. What good is expanded coverage without access to care?

In a perfect health care world, which I described in an essay “2020: The View from 2006,”October 3, 2006, in healthleadersmedia.com, everyone will be insured, medical bankruptcy will be a historical curiosity, all will have a medical home rooted in a primary care practice, people will shed all bad habits, pricing and quality will be transparent to all, and freedom to chose the doctor and institution of one’s choice, will be unlimited.


That isn’t going to happen soon. Massachusetts universal health plan’s cost
overruns have mounted to $400 million, California’s plan will likely fail because of its $14 billion cost, San Francisco is promising to cover all, and the resilient U.S health system shows no sign of collapsing, Stay tuned.

Harvard Med

Lake Worth, Florida - I take along a book on my trips. For this trip, I chose Harvard Med: The Story Behind America’s Premier Medical School and the Making of America’s Doctors (Adams Media, 1996).


I’m not a Harvard med man. I went to Duke. But I knew the author, John Lagone, a journalist who died last year in his 70’s of lymphocytic lymphoma. John worked for newspapers and wrote 15 books on social, medical, and technology issues. One of his books, for the Smithsonian, The Way Things Work, became a best seller. John also reviewed scores of health-related books for the New York Times.


Harvard Med recounts a year in the life of a Harvard Medical School class. John describes the mix, backgrounds, skills, drives, and dreams of incoming students. He focuses on the culture of the school - its history, attitudes, biases, strengths, and ambience, “It is, “ he says, “and is likely to remain a haven for 3Ms – male medical magistri, gowned gurus who are far more scholar, researcher and specialist than empathetic, readily available healers – and for the students who want to emulate them.” It is not, he says again and again, not an ideal breeding round for primary care physicians.


In one chapter “Science is Easy, Humanity is Hard.” John notes how hard it is to insert compassion into course work. The problems, he observes, are dominance of science and technology, massive amounts of hard facts to be absorbed, sheer constraints of time, and realities of where rewards lie in our high tech health system. It is not an environment conducive to teaching primary care. Most training takes place in hospital acute care pressure cookers. Most outpatient training occurs in clinics at one of Harvard’s twenty hospitals, which serve poor and disenfranchised minorities many of whom are struggling to learn English. This may not be ideal training ground for caring for mainstream Americans.


Don’t misread me. John is a huge fan of Harvard Med, its eminence, its world class faculty, and its reputation as a research facility. He is just saying much of the Harvard students’ medical education occurs in a tertiary, indeed quaternary, referral hospital setting.


As I read John’s fine book, I’m reminded the more things change, the more the rhetoric heats up about health reform, the more things remain the same. The emphasis in American medicine remains on acute care, technological fixes, and research breakthroughs. In these areas reside the missionsof Harvard Medical School, and it does them superbly. But these missions leave little time for primary care. For aspiring primary care physicians, the rewards, incentives, peer approval, and personal gratification are not there.

Global Cooling

Fort Lauderdale, Florida - I’m down here to escape global cooling. Snow, ice, and frigid temperature grip almost 70% of the U.S. today. It seems like global cooling, but you and I and the rest of the intelligentsia know it’s actually the perverse effects of global warming. It just doesn’t feel that way.


When I left New England yesterday, it was 5 above – much warmer than Northern Minnesota, where it plunged to 36 below. I’m reminded of an essay I wrote some years ago, when I lived in Minnesota, “Warming UP Cold Statistics: Or, How to Talk to Floridians about Minnesota Winters.”


Here are a few tricks I mentioned when kibitzing with warm-blooded Floridians:


• Discuss Distances – Inform the aghast Floridian that International Falls is 310 miles north of the Twin Cities. To judge Minnesota weather on the basis of International Falls is ridiculous. It’s like comparing frost-prone Jacksonville to frost-free Miami, 345 miles south of Jacksonville.


• Emphasize the “Heat Shield” hovering over major Minnesota Cities. Big northern cities have big heat shields. The temperatures of these cities are much hotter than International Cities.


• Think High and Hot – Here are the hottest historical temperatures in the Twin Cities during winter months.

November, 1933 – 77 degrees
December, 1939 - 63 degrees
January, 1846 – 59 degrees
February, 1896- 63 degrees
March, 1910 – 83 degrees


• Avoid Speaking about Wind Chill Factor – Do not discuss the wind chill factor. Who wants to know a 20 miles wind on a 20 degrees day feels like 9 below and what it does to exposed flesh. The Floridian already knows enough about exposed flesh.


• Talk about the Discomfort Index - Instead of discussing the Wind Chill Factor, push the Discomfort Index. The higher the heat and humidity, the greater the Discomfort Index. Tell the Floridians an index of 75 is uncomfortable for most people, an index of over 80 is uncomfortable for everybody, when the temperature is 95 everybody is uncomfortable no matter what the humidity. Provide him with a chart showing him how to calculate the Discomfort Index. This chart has nothing to do with Minnesota weather. That’s the point. The Discomfort Index is a diverting maneuver.


• Tell him Minnesota has a “dry cold.” This is the kind of cold you don’t really feel (unless you go outside, of course). Besides, the Mean Absolute Hi8midity (whatever that is) reaches its lowest point in the coldest months. Florida, on the other hand, has a “wet heat” – the kind that drenches you with sweat and makes you feel uncomfortable (and attracts Yankees in droves).

• Unleash The Sunshine Quotient -_ Then there’s the Sunshine Quotient – the % of days with sunshine + number of clear days + Snow Glare Intensity factor. You can find these facts on google Remind your listener that in Minnesota sunglasses are an absolute necessity to protect against the blinding glare of Minnesota winters. Compare the Sunshine Quotient of the Twin Cities against major Florida Cities, use a Snow Glare Intensity factor of 100, and the Twin Cities wins hands down.

• Pay the name game – Pull out the Miami and Twin Cities telephone directories and look up cold and warm names. Miami has 72 winters, nine Shivers, 6 Colds, One Ice, 37 Snows, two Snowballs, 12 Blizzards, 45 Frosts, and One freeze. At the other pole, Minneapolis-St. Paul has 46 summers, four Springs, two Hotts, one Heater, 74 Beaches, and two Warms, two Warmings, One Sunn, 59 Sands, 10 Sweats, and 129 Palms.

These are the cold facts

More Medical Groups

In a recent post, I suggested a series of group names for certain specialists. Readers recommend these additions

A Scrotum of Urologists
A Clot of Hematologists
A Phalanx of Hand Surgeons
A Tarsus of Foot Surgeons
A Pedology of Pediatricians
A Premie of Neonatologists
An Elder of Geriatricians
A Grope of Sex Therapists
A Flaccid of ED Specialists
A Clan of Family Physicians
An Implant of Plastic Surgeons
A Conduction of Cardiologists
A Cohort of Epidemiologists
A Sample of Biostatisticians
A School of Deans
A Gonad of Fertility Specialists
An Eruption of Dermatologists
A Corridor of Hospitalists
A Plethora of Proceduralists
A Triage of ER Physicians
A Polyp of Colonoscopists
A Loci of Locums
A Finding of Researchers
An AA-Ha of ENT Specialists
An A-Choo of Cold Sufferers
A Cliché of Medical Writers
A Rejection of Medical Editors
A Trivia of Medical Bloggers

2008 Forecast for Managed Care

"Health plans often declare that they want to have good relationships with their physicians. But UnitedHealthGroup has at least 315,000 reasons to be extra nice. That number represents the 2007 slide the insurer experienced in employer-sponsored and individual memberships. The company attributed the loss, in part, to frayed relations with patients and doctors.”

Emily Berry, “Enrollment Drop has United Vowing to be Nicer,” American Medical News, January 14, 2008


I’ve never been a fan of managed care. Indeed, in 1988 in And Who Shall Care for the Sick? The Corporate Transformation of Medicine in Minnesota (Medica Medicus, Minneapolis), I predicted patients and physicians would ultimately rebel or drop HMO plans. This week UnitedHealthCare Group announced it lost 315,000 members in 2007 and wants to make amends with doctors. The bloom is off the HMO rose.


On January 31, 1:30PM -3:00 PM, The Executive Report on Managed Care and The Managed Care Information Center will sponsor a live 90 minute audio and Webinar conference, with these discussants:

• Jim Adams, Executive Director, IBM Center for Healthcare Management

• Peter Kongstvedt, M.D., F.A.C.P, Health/Managed Care Consulting Services, Accenture

• Gregory J. Pepe, Principal with the law firm of Neubert, Pepe & Monteith

Notice no representative of the practicing physician community is present at the table. It’s as if those who deliver the care don’t really count.

Issued to be discussed include:

• uneasy relationships with doctors.

• continued rebellion by doctors

• inadequate reimbursement

• increasing costs

• who is going to foot the bill,

• health benefit cost increases

• contracting and negotiation issues

• claim denials

• impact of provider pay-for-performance programs

• growth and effectiveness of consumer driven health plans

• controversial quality rankings of doctors

• transparency

• reform initiatives

• health plan consolidation.

You might want to put in your two cents at the end of the following agenda
Agenda
• Top managed care issues for 2008

• Emerging estrangement in the payer-physician arena

• Market forces and pressures leading to revolutionary change for health plans

• Will approaches to expanding coverage for all Americans be focused on individual coverage or employer-sponsored coverage?

• How entry of new health care business models might impact health plans

• changing role of the consumer

• increased focus on price and quality data transparency

• Proliferating physician ratings by consumers and health insurers

• Momentum of Pay-for-Performance into the private and public sectors

• Linking evidence-based medicine to P4P

• How physicians can successfully participate with P4P Measures

• New initiatives for improvement in quality

• Shifts away from payment for medical errors

• Need for IT support for new and disparate functions in health plans

• Resurgence of IPAs and PHOs as engines of change

This agenda will be followed by a live question and answer session. This is where you might want to weigh in.

For more information, visit http://www.healthresourcesonline.com/edu/mc08wc.htm or call
The Managed Care Information Center
PO Box 559, Allenwood, NJ 08720
1-800-516-4343

The Old Fray Lady and the Vast Gray Void

On January 15, 2008. the New York Times, known as The Old Gray Lady in journalist circles, published “Drug Approved, But Is It Real?” The Times piece spoke of Lyrica, a drug for fibromyalgia. The article set off a fibromyalgic firestorm. Some doctors aren’t so lyrical about Lyrica, for they say the drug treats a non- disease.


Two days later, the Times printed seven mostly angry letters to the editor under the title “Fibromyalia: The Pain is Very Real.” Doctors, fibromyalgic sufferers complained, don’t feel their pain. The pain, the letters said, is very real, even if no definitive diagnostic test exists.


Similar disorders, without specific tests to prove their existence, are out there. They include chronic fatigue syndrome, chronic Lyme disease, and restless legs syndrome, to name but a few.

In any event, here are my thoughts.


In health care, there looms a vast gray void,
An endless empty space some physicians avoid,

Some docs insist the void is fundamentally psychosomatic,
Others say there’s no void, with pain, disease is axiomatic.

Fibromyalgia isn’t black or white,
For no good test exists to shed light,

On what may be really there,
Or if there’s any there there.

Or whether it’s a disease or some mysterious syndrome,
Or something non-existent where certain minds roam,

Some say fibromyalia, chronic fatigue, and restless legs,
Need new drugs to defuse smoldering disease powder kegs,

Others say we should only pay for what’s evidence-based,
For what experts can prove without a doubt is data-encased.

But still it’s very difficult to be scientifically objective,
To ignore severe pain even when it’s considered subjective.

When patients are in obvious pain,
It’s hard to be in an oblivious vein,

To be scientifically rigorous,
When pain is unambiguous.

Ibuprofen,tylenol, et al
Don’t seem work at all.

In fibromyalia you may not believe
But pain you’re obligated to relieve.

Don’t feel like you’re just a nonscientific jerk,
It’s a Brave New World, it’s marketing at work.

In many ways, it’s the Old World Way,
When the Art of Medicine held sway.

Treating without really knowing may seem like nostalgia,
But remember: not all pain has a specific cause-algia.

Bundling Hospital Processes

A bundle, according to my dictionary, is a collection or group of things tied, wrapped, or held together. A hospital, for example, is a bundle of services held together by a hospital board, its administration, its employees, and a collection of doctors called the medical staff. Processes, of course, are a series of actions with a particular aim.


Bundled Bills


I’ve had experience bundling together hospital and physician fees. In the early 1990s, as chairman of a physician-hospital organization, I helped bundle together fees of independent physicians and a hospital for about 100 common hospital procedures. The idea was to create a collective bundled fee known in advance by insurers and consumers without touching the independence of doctors. If the cost exceeded the bundled fees, we had reinsurance in place to protect everyone involved.


Bundled Safety Procedures


Now I see by the January 16 USA Today “Bundling Hospital Processes May Help Prevent Infection” that hundreds of U.S. hospitals are putting bundles of safety procedures into place. The bundles are recommended by the Institute of Healthcare Improvement in Boston.


The bundle for preventing infection includes:


1. Monitoring antibiotic use before and after surgery

2. Stopping the use of razors at surgery sites to prevent nicks that might serve as portals of entry for bacteria.

3. Keeping patients warm during surgery

4. Monitoring blood sugar after surgery

5. Implementing vigorous hand washing and hygiene

6. Scrubbing skin with bactericidal agents and alcohol to further minimize infection.

The Institute of Healthcare Improvement recommends other bundles as well for preventing pneumonia in respiratory patients, urinary tract and blood borne infections in patient with catheters, confusion in medications and orders when transferring patients from one hospital site to another, protecting patients being resuscitated after a cardiac arrest.

Bundling of safety measures is not rocket science. It entails common sense, collaboration, alertness, and measurements to see how far hospitals are progressing toward the goal of eliminating infections and other safety hazards lurking in hospitals.


As physicians, we know hospitals can be dangerous places. We can help tie together bundles to protect hospital patients. But unfortunately, office-based practicing physicians can’t usually be two places at once. We’re just part of the bundle.

An Exercise in Medical Group Think

If you have any groups to add, feel free to do so.

A Community of Sermo Physicians
A Family of General Practitioners
A Palpitation of Internists
A Stent of Cardiologists
A Bypass of Heart Surgeons
A Vault of Gynecologists
A Stirrup of Obstetricians

A Differential of Diagnosticians
A Void of Urologists
A Pile of Proctologists
A Movement of Gastroenterologists
A Mass of Oncologists
A Rash of Dermatologists
An Augmentation of Breast Surgeons
A Lift of Plastic Surgeons
A Cast of Orthopedists


A Hive of Allergists
A Shot of Pediatricians
A Scope of Laryngologists
A Passage of Rhinologists
A Detachment of Ophthalmologists
A Retinue of Retina Specialists
A Breath of Pulmonologists
A Joint of Rheumatologists
A Vein of Hematologists
A Lobe of Neurosurgeons
An Ablation of Surgeons
A Circulation of Vascular Surgeons

A Bag of Anesthesiologists
A Scan of Radiologists
An Invasion of Interventionists
A Corridor of Hospitalists
A Plethora of Proceduralists
A Crisis of Critical Care Doctors
A Triage of ER Doctors
A Body of Pathologists

A Complex of Psychoanalysts
A Panic of Paranoids
A Split of Schizoids
A Kvetch of Hypochondriacs
A Congress of Sexologists

An Arch of Podiatrists
A Colony of Microbiologists
A Plague of Epidemiologists
A Helix of Geneticists
A Host of Parisitologists
A Batch of Virologists
A Dearth of Nurses
A Sleepwalk of Residents
A Pan of Orderlies
A Tray of Dieticians
A Pestle of Pharmacists
A Pharmacopeia of Nostrums
A Killing of Medical Insurers


A Brace of Orthodontists
A Wince of Dentists
A Plaque if Periodontists
A Canal of Endodontists

On Never, Never, Never, Never Paying for Never-Never Events, Nevermore, Qouth Medicare

Never give in, never give in, never, never, never, never.


Winston Churchill, Address at Harrow School, 1941


And my poor fool is hang’d! No, no, no life!
Why should a dog, a horse, a rat, have life,
And thou has no breath at all? Thou come no more;
Never, never, never, never, never!

Shakespeare, King Lear


Quoth the Raven, “Nevermore.”


Edgar Allen Poe, 1809-1849, The Raven


I see in the January 15, 2008 Wall Street Journal “Insurers Stop Paying for Care Linked to Error” health plans are joining Medicare in never, never paying for never-never events in hospitals.


Never-never events are preventable events that should never-never have occurred. The never-never preventable complications that should never, never have taken place include.


• Objects left after surgery – a sponge, clamp, a pair of scissors

• Surgical-site infections – surgical wound infcctions due to lack of hand washing or shaving the surgical site

• Blood incompatibility – a mismatched transfusion

• Urinary tract infections due to catheters – left too long without being changed

• Hospital acquired bedsores – those not present on admission

• Falls in hospitals – those occurring in patients not strapped in and allowed to walk without assistance or support.

• Letting patients wander off or disappear – as in the disoriented, confused elderly or Alzheimer’s patients

• Artificically inseminating the wrong donor with the wrong sperm

• Operating on the wrong patient

• Performing the wrong procedure

• Using contaminated drugs or devices

• Discharging an enfant to the wrong patient

• A mother’s death or a serious infection or serious disability following a low risk pregnancy

• A patient abduction or sexual assault

• Paying for a patient’s hospitalization after an avoidable never-never event.



Aetna is following Medicare, and WellPoint, UnitedHealthcare Group, Cigna, and the Blues will shortly follow. It’s understandable why this is happening. Preventable complications are said to cost Medicare and other health plans tens of billions of dollars, at least $10,000 for each avoidable event. There are 1.7 million hospital –acquired infections each year, and 99.000 die from these infections.


Never paying for preventable complications is a logical way to save money and to prevent deaths from never-never events that should never, never have occurred. At least, it seems logical to government and health plan bureaucrats who seek to encourage hospitals to launch prevention and safety programs..


These programs work. The Pitt Country Hospital program in Greenville, North Carolina, screened all admitted patients with nasal swabs for MRSA infections, and the incidence of respiratory pneumonias dropped by 67% and catheter-related urinary track infections by 60%.


Please note the incidence didn’t drop by 100%., This makes sense. You’re dealing with chronically ill or terminally patients with compromised immunity who are prone to infections who are susceptible to end-stage complications.


Michael Maves, executive vice-president of the American Medical Association, commented,


The concept of not paying for complications that are often a biological inevitability, regardless of safety procedures, is discriminatory and could be punitive to those patients at greatest risk.

Maves has a point.


You can never, never end all complications in seriously or terminally ill patients, no matter what safety measures you undertake. Complications are a “biologically inevitability” in certain patients, but not in all.


That’s why preventive programs are worthwhile. The rub comes when deciding whether a complication was a never-never event. That will require another set of federal and health plans rules to decide. Still, preventive programs are worthwhile as evidenced by Donald Berwick’s Healthcare Improvement Institutes 2006 campaign to save 100,000 lives, which ended up saving an estimated. 103,000 hospital patients. I could go on, but never, never mind. I never, never go beyond my alloted space.

Big Pharma – A Call for Balance and Fairness

This week the AARP Bulletin, a publication directed to over 40,000 Americans over 50, came across my desk. A Bulletin article Ties That Bind, opens with this paragraph,


For years, pharmaceutical companies have courted America’s doctors with an ever growing intensity, showering them with billions of dollars’ worth of gifts, consulting fees and trips to persuade them to prescribe to their drugs.


The article describes how,

• doctors have created the websites No Free Lunch and Pharmed Out to resist Big Pharma’s blandishments;

• the Institute of Medicine is drawing up guidelines for doctors to avoid conflicts of interest’

• medical schools and Congress are acting out against drug companies by restricting gifts and trips;

• Pennsylvania and South Carolina are hiring their own drug reps to “unsell” brand name drugs and to promote safety and efficiency;

• drugmakers are spending $7 billion a year to “win the hearts and minds of doctors” and another $18 billion and free drug samples;

The article paints a grim picture of an army of 101,000 drug reps descending upon unsuspecting office based-physicians, and asserts doctors are subconsciously vulnerable and gullible to marketing messages and financial inducements and other favors. .


All of this may be true to some extent, and it no doubt resonates with economic populists, who condemn Big Pharma as a major villain behind high health costs.


But is it fair to condemn Big Pharma out of hand without presenting a balanced picture?


The AARP Bulletin doesn’t mention the argument’s other side – that doctors in their offices are Big Pharma’s biggest customers and without them there would be no profit, that putting a new drug on the market costs $850 million, or that Big Pharma is by far the single largest source of innovative new drugs, employs huge numbers of people in states like Connecticut and New Jersey, produces the new drugs, like statins, that have significantly reduced heart attacks and strokes, and kept million of people out of hospitals; and supports somewhere between ½ to 2/3 of CME programs, which physicians are obligated to attend to stay in practice.

The piece quotes Jerome K. Kassirer, MD., former editor of the New England Journal of Medicine. He says doctors are being bought by Big Pharma. Since the early 1980s, when then editor Arnold Relman, M.D., warned of the for-profit medical industrial complex as American health care’s undoing, and his wife, Marcia Angell, MD, who later served as acting editor, the New England Journal has crusaded against for-profit health businesses, particularly Pharma. I find this attitude puzzling. even duplicitous, since the Journal would not exist without pharmaceutical advertising. If it‘s true to its beliefs, the Journal should simply refuse to accept pharmaceutical advertising.

We need to keep our balance when criticizing Big Pharma. It has its excesses, which should be addressed, but its successes too, which should be acknowledged. The pharmaceutical industry will remain a vital part of American health care economy, America’s largest single economic sec

Selective Contracting

As editor-in-chief of Physician Practice Options, a monthly newsletter devoted to practice efficiency, I sometimes run across someone with a nuts and bolts approach to practice management – someone who can explain their approach in a few well-chosen words.


There are many excellent practice management firms in the U.S., and I don’t favor one over another. This blog simply represents the thinking of one pragmatic practice management leader.


John McDaniel, President and CEO of Peak Performance Physicians, a physician practice advisory company in New Orleans, says physician are increasingly turning to selective contracting to manage their patient mix. McDaniel has worked with hospitals and physician groups across the United States, first as a hospital administrator of 15 years and for the last 20 years as a physician advisor.


According to McDaniel, five levers of profitability for physicians exist.


1) Reimbursement systems, where physicians review their coding proficiency, their management contracts, and their professional fee schedules.


2) Billing and collection processes – how to bill and collect more profitably and efficiently.

3) Accounts receivable management. Accounts receivable are the largest single asset of most physicians.


4) Operations improvement, basically anything within the four walls of the practice – scheduling to ancillary services.


5) Practice growth – how to position the practice to grow volume.


I asked McDaniel what innovative trends he is seeing these days among physicians. He focused on “selective contracting” in “mature practices” where physician are being more creative in patient scheduling as opposed to “first come, first serve.”


In certain markets with a high percentage of Medicare, Medicaid, or “poor paying” managed care organizations, the “first come, first serve” philosophy erodes profitability over time. It happens slowly, and doctors may not realize what’s happening until it’s too late.


McDaniel encourages practices to monitor their payer mix and the percent of patients who are Medicare, Medicaid, managed care, and private pay and to look at the charge/collection ratios among those payers. He says doctors should be more targeted in patients they want to encourage, and in some cases, discourage.


After doing the analysis, the practice can determine what percent of patients in each category they want. For example, if an internist is seeing 20 patients a day and wants Medicare patients to be 20% of the mix, he or she can schedule 4 Medicare patients a day.


When the fifth Medicare patient calls, presuming the problem isn’t urgent. that patient goes to the next Medicare appointment on a future day, That way the practice can balance its payer mix.


Some people may argue selective contracting is “rationing of care,” but McDaniel says it isn’t rationing per se because appointments are available to all. It’s really no different than the practices of airline, restaurants, or other businesses who strive for greater efficiencies. It is simply serving patients on a different basis and being more selective in their clientele.

Primary Care Practice – The State of Affairs

For the last five years or so, the argument has been advanced in many quarters that primary care – family practice, general internal medicine, and pediatrics – is on the verge of collapse because of low morale, low reimbursement, high overhead, low incomes, and low job satisfaction.


What follows are facts gathered by Merritt, Hawkins, and Associates (MHA) - for full survey results, see www.merritthawkins.com.


MHA conducted the survey for Physician Practice, a practice management publication with a readership of 300,000. MHA sent the survey to a random sample of 10,000 physicians – 4000 FP, 4000 IM, and 2000 pediatricians. The response rate was 44.1% FP, 32.3% IM, and 23.5% Peds. Because of space limitations, I have not, in general, split the responses by specialty. You can find that information at the MHA website. No all figures add up to 100% because of rounding. As you scan the income statistics, keep in mind Christmas bonuses on Wall Street this year averaged more than $1 million, senior partners in large law firms pulled down an average of $1.2 million, CEOs of the nation’s health plans earned a mean income of $10 million, and medical specialists rarely make over $1 million.

1. Years in practice -- 0-5 years, 14.5%, 6-10 years, 19.7% , 11-15 years, 21.2%, 16-20 years, 19.1%, 21+ years, 25.5%, No Answer, 0.6%

2. Type of practice – solo, 30.3%, two physicians, 9.4%, three of more, 60.3%

3. Busyness of practice – too busy, 34.6%, not busy enough, 16.9%, as busy as I want, 48.3%

4. Net income – excellent 8.7%, appropriate, 32.8%, disappointing, 58.5%, No Answer, 0.8%

5. Net income ($ in thousands) – 300 or greater, 9.5%, 275 to 300, 3.6%, 250-275, 2.2%, 225-250, 3.9%, 200-225, 5.5%, 175-200, 9.3%, 150-175, 11.4%, 125-150, 15.0%, 100-125, 17.8%, 0-100, 15.4%, No Answer, 5.5%

6. Net Income by specialty ($ in thousands)

0-100, FP, 18,2%, IM, 13,3%, Ped, 25.6%

100-125, FP, 13.5%, IM 11,4%, Ped, 12.8%

125-150, FP, 18.9%, IM, 20.0%, Ped, 6.4%

150-175, FP, 14.2%, IM, 17.1%, Ped, 7.7%

175-200, FP, 8.1%, IM, 11.4%, Ped, 8.8%

200-225, FP, 2.7%, IM, 4.8%, Ped, 12,8%

225-250, FP, 4.2%, IM, 4.8%, Ped, 5.2%

250-275, FP, 4.7%, IM, 1.9%, Ped, 3.,8%

275-300, FP, 4.7%, IM, 0.0%, Ped, 1.4%

> 300 FP, 10.8%, IM 15,3%, Ped, 15.5%


7. Overhead as % of income - 0-10%, 5.8%. 11-20%, 3.4%, 21-30%, 3.4%%, 31-40%, 9.2%, 41-50, 16.1%, 51-60%, 27.4%, 61-70%, 22.9%, 71-80%, 5.2%, 81-90%, 1.4%, 90-100%, 3.8%

8. Your overhead – able to support, 31.5%, not able to support, 13.6%, doubtful to support, 22.2%, hopeful to support, 32.7%, No Answer, 12.0%

9. Your socioeconomic status - lower middle class, 4.4%, middle class, 29.7%, upper middle class, 59.5%, upper class, 6.4%, No Answer 0.0%,

10. Your status in medical hierarchy – top dogs, 0.1%, equal partners 14.7%, junior partners, N.A., 2nd class, N.A..

11. Job market in five years – more robust, 31.2%, less robust, 35.0%, same, 33.8%

12. Severe shortage in five years – GP, 79.2%, IM, 67.5%, Ped, 58.0%

13. Primary care will eventually disappear – FP, 17.5%, IM, 15.9%, Ped 3.7%

14. Primary care destined to be taken over by PAs and NPs - FP, 27.3%, IM, 33.6%, Ped, 27.1%

15. Continue to pay vital role – FP, 39.0%, IM, 38.1%, Ped, 48.1%

16. Career satisfaction – very satisfied, 18.3%, somewhat satisfied, 43.0%, somewhat dissatisfied, 25.5%, very dissatisfied, 13.2%

17. If you had to do over – stay in primary care, 39.5%, become surgical/diagnostic sub-specialist, 38.7%, would not choose medical career, 21.8%

18. If you had financial resources – would retire today,44.7%, would maintain practice for a few more years, 55.3%

19. What reforms will happen – single payer, 36.5%, no major reform, 2.4%, market-driven, 68.4%

Summary

Primary care physicians will be in demand, most are ambivalent about their careers, most would not choose to become primary care physicians if given a choice, and most would prefer a market-driven system.

Bytes and Pieces from Boston

Boston, January 10, 2007 - I’m here to attend a poetry reading by my son, Spencer Reece, a nationally known poet. He recites at academic institutions and poetry festivals across the United States.

I’m here also to observe the health scene. Massachusetts considers itself U.S. health care’s academic hub and the leading state in universal coverage.

What follows are three observations.

1) Information Technology Not What It’s Cracked Up to Be – My host here is a chemist. He works for a national chemical firm. Part of his job is to persuade chemists to use “electronic notebooks,” the analog of EMRs, in the course of their work. Most chemists still prefer old paper notebooks. Next to my bedside sits The Social Life of Information (2000), a book by two information scientists at Stanford, long the hotbed for budding Internet entrepreneurs. Two of these are the Google founders. The book claims Internet information’s sheer outpouring exceeds society’s capacity to process it usefully. As I pondered the usefulness point, I thought of,

• the dot.com collapse of 1999-2000,

• limited successes of EMRs in doctors’ offices,

• disappointing market penetrations of WebMD.com and RevolutionHealth.com

• The trouble consumers are having digesting the massive diet of health misinformation on the Internet

We’re drowning in web growth, measured in trillions of megabytes. The data deluge is growing 50% a year, but our ability to apply is at the 5% to 10% level. This is an example of the old DI-DO (Data-In, Debris-Out) problem, more commonly referred to GI-GO (Garbage In-Garbage Out). You might ask what good is data if it doesn’t relate to human events. Events often move faster than the data. The unreliable polling data of the Clinton-Obama New Hampshire primary is a telling example of what I’m talking about.

2) The Yawning Hole in Medical Education - Sitting next to me at my son’s reading was Rafael Campo, MD, a general internist at Massachusetts General Hospital. He specializes in infectious disease and instructs Harvard medical students. Rafael is a poet and prize winning author of The Healing Art: a Doctor’s Black Bag of Poetry, and the Poetry of Healing: A Doctor’s Education, in Empathy, Identity, and Poetry. Rafael confided there’s a yawning hole in educational and humanistic yearnings of today’s students. ”Soul numbing managed care and mind numbing technology advances seem to have conspired to distant patients from doctors,” he has said. At the reception after the reading, I spoke to a writer and illustrator of children’s books. She said her daughter is an internist at one of Massachusetts General’s suburban outlets. Her daughter believes in taking precise notes and telling patients’ stories as a narrative. But the system, viz, managed care, technological documentation in bytes and dabs, and demands of processing patients quickly, do not lend themselves to narrative medicine and meticulous note taking. The moral to these two tales is simply this: absorbing new technologies and producing digital data doesn’t lend themselves to patient intimacy and to doctors telling patients’ stories as cohesive narratives.

3) Consumer Convenience and Access Trumps Academic Prestige. As I was railroading out of town, I picked up a copy of the Boston Globe and read the front page story, “In-Store Healthcare Wins State Approval.” It announced the Public Health Council and 8 members had approved the entry of CVS Minute-Clinics into the Massachusetts health care market. If things go according to plan, 100 to 120 clinics will open in CVS stores in the next five years. This news shocked the academic establishment, which has long monopolized Massachusetts with its not-for-profit hospitals and large affiliated medical groups. But according to one observer, it was “loud and clear” time-strapped consumer’s preferred quick access to convenient, less costly care, to waiting in line at academic medical centers. . Another Council member noted it was not the fault of CVS but of the system. “My issue,” he said of the clinics,” is what they say about the whole delivery system. The primary care delivery system in this country is dying. The reasons these things have become important is because of this big hole in the delivery system.” Another reason is that Massachusetts is in the process of covering 300,000 uninsured residents. Universal coverage without convenient access doesn’t mean much. The CVS message is that some sort of affordable access, even if less than ideal and less than comprehensive, should complement traditional care before the universal coverage train leaves the station.

No Tree Grows to the Sky

The health care cost tree has grown to the sky. U.S. health costs are unsustainable. I believe the U.S. health system will adjust. It will innovate and make changes to provide affordable care for its people. It has to. That’s what successful societies economies do.

Here are a dozen adjustments you are likely to see in the next five years.

1) The most significant change for reducing costs will deductibility of health premiums and other health expenses for individuals – in short, , across the board health deductions for all.

2) Portability of health plans across state lines for all health plans will become a reality. It may be accompanied by a reduced and more uniform state mandates.


3) Health plans will move to cover most pre-existing illnesses and high risk individuals. This is in the works at AHIP (American Health Insurance Plans). It will progress to avoid adverse political events.

4) Private health plans will start to cover more of the uninsured once they realize the uninsured population offers marketing opportunities: 85% are employed, ½ are aged 18 to 34. ¾ say they are in “excellent” or “very good health,” and 2/3 have college educations.

5) Health plans, patients, and physicians will switch to generic drugs. Indeed, most major payers will no longer pay for brand drugs if effective generics are available.

6) Retail and worksite clinics, and other care outlets, will proliferate. More entrepreneurial physicians and hospitals will join .to create more outpatient-based and convenient entry points into the system.

7) The “system” will close in on excessive and abusive compensation for health plan executives. The successful suit against Dr. William McGuire for stock backdating is the tip of the iceberg, It consisted of a civil fine of $7 million, $12.7 million for “ill-gotten gains,” and a forfeiture of options already issued.

8) Prescribing by pharmacists and office dispensing by doctors will increase. It will be done in the names of “convenience” and “cost reduction.” The strategies may be counterproductive and cost more than they save..

9) New information technologies – e- patient education sites, e-visits, and e-web videos – will change who patients and doctors interact. They may lower costs. These new approaches require broad band access but not necessarily EMRs, or EHRs.


10) The shift to outpatient care, spurred by consumer demand, changes in technology, and less invasive procedures, will accelerate. People will realize much hospital care, by its very nature, is unaffordable, partly because of high “facility fees.”

11) Prevention will take off for these reasons - public campaigns to promote awareness, new pharmaceutical products to prevent smoking and obesity, employers not hiring smokers or obese people, lower premiums for “clean” living, doctor rewards for performing preventive tests, Medicare’s decision not to pay for preventable “never events,” employer-based wellness programs.

12) The consumer-directed movement, defined as high deductibles linked to HSAs, will gain traction as employers, employees government, and consumers weigh cost-saving benefits of more selective, elective, value-based quality care.

I forecast costs, not the sky, will level off or fall. The sky’s not the limit. People want change, from the roots to the top of the tree. Changes are underway.

Political Realities Mug Mandated Coverage

It remains incredibly difficult for states by themselves to get all the uninsured covered,” said Robert Blendon, a Harvard professor of health policy and political analysis. “There just is not a consensus on who should pay.”

Health Care Expansion Hits Roadblocks, New York Times, December 25, 2007

Mark Twain said of Richard Wagner’s music, “It’s not as bad as it sounds.”

Similarly, “Mandated universal coverage isn’t as good as sounds.” All for one, one for all; unity among diversity; fairness. affordable costs; no medical bankruptcies; low drug prices; fewer ER visits; no more guilt about the “moral disgrace” of U.S. health care, no more uninsured or holes in the safety net,

It surely sounds good, and it has its truths, particularly on the safety net issue. Public hospitals provide 2% of care but absorb 25% of uncompensated care. At Grady Hospital in Atlanta, only 8% of patients are privately pay.

The utopian “sound good” scenario goes:

Big government fans say if the U.S. were like countries with single-payer mandates, costs might be 40-50% lower, everybody might be covered, and infant mortality longevity, and health statistics might improve

But U.S. political realities may mug “mandatory coverage.”

• Philosophical conflicts – “Mandatory” means government demands and commands.. This doesn’t sit well with those Americans who say mandates impinge on “liberties, “choices,” and “freedoms” in a free society where health care is part of the marketplace.

• Cost and Who Will Pay – In California, mandatory coverage’s price is estimated at $14.4 billion, the size of California’s current budget deficit. Who will pay? Taxpayers? Corporations and small businesses? Hospitals, doctors, and health plans? Imposing mandatory coverage on the present U.S, health system will entail massive expenditures. “Savings” so far suggested – preventive care, compulsory doctor computerization, and government negotiated drug prices – will take time to get in place.

• Fairness Fallacy - Under present premium structures, 25 year olds pay ¼ to 1/3 of what 55 year olds pay. The young may view mandatory higher premiums as a “rip-off.” Massachusetts is already having a tough go at tracking down 200,000 people, mostly young, who refuse to pay individual mandated premiums. Mandates suggested by Senator Clinton give no tax breaks to the young. Some say mandates exploit the young to pay for the old. In America where we believe the old should make way for the young. Significantly, Senator Obama, who caters to the young, doesn’t recommend “mandates, ‘ but “comprehensive affordable care.”. The main sdifference between Mr. Obama’s and Mrs. Clinton's plan is she would dictate that everyone have health insurance, while Mr. Obama's would only require the coverage of children.

• The Emergency Room Illusion - Some say lack of uninsured coverage is mainly responsible for crowded emergency rooms. This may not be so. Fully insured Medicare recipients are much more likely to go to the ER . “Frequent flyers” suffering from mental illness or substance abuse also commonly visit ERs. Mandates will not change where they seek care.

• “Moral Disgrace” Argument - John Edwards argues “a system that leaves 47 million Americans uninsured is a moral disgrace.” This argument neglects the immigration problem. Most , 75%, of the 2 million rise in the uninsured over the last five years occurs in five Border States – Arizona, California, Texas, New Mexico, and Texas. Of the 10 million immigrants who entered in the last 7 years, half were illegal. Also legal immigrants’ cultural unfamiliarity with U.S insurance means many go uninsured when they can afford premiums. Of the 47 million uninsured, 10 million have incomes of $75,000 or more. Many choose to spend their money elsewhere. Another 14 million are eligible for Medicaid of SCHIP and simply need to sign up. company. Mary McCaughey, former lieutenant governor of New York, concludes.

Mandating that everyone, including young adults, buy insurance, and then hiding a hefty, cost-sharing tax inside that premium is an unfair solution.

The foreign mandated coverage music, as applied to the U.S., sounds good, but so far it isn’t playing well in America.

1. Kevin Sack, Health Care Expansion Hits Roadblocks, New York Times, December 25, 2007.

2. Betsy McCaughey, the Truth about Mandatory Health Insurance, Wall Street Journal, January 4, 2008.

The Long Way Home

When my wife and I are out for a ride, she often says, “Let’s take the long way home.”


The long way home is along the shore, where we can see nature at work and witness the sun with its shimmering iridescent effects on the sea surface, the waves whipping up froth, the colorful sunsets lighting the evening sky, and cumulous cloud formations and vapor trails of planes.


I was thinking of our long way home the other day when we were returning from a visit with my brother-in-law. We were listening on the radio to Anton Dvorjak’s “Going Home” theme from the New World Symphony. The theme is derived from a Negro spiritual, and is often played or sung at funerals.


With his disease, a Lewy Body variant of Parkinson’s disease, in which mind and body slowly, then quickly close down, usually over a two year period, Jack is taking his own long way home. In his case, it’s a sad way home, for his mind remains clear while he is imprisoned in his own body – unable to speak, move, talk, or control his body functions.


Each of us, in our own way, are taking the long way home. Let’s enjoy the sights, the workings of nature, and our fellow man as we journey home. And let’s salute those doctors, nurses, and aides in convalescent homes who are escorting our loved ones home.

Notable and Quotable – “The Falling Down Professions”

By Alex Williams, January 6, 2007, New York Times, Sunday Styles Section

“As of 2006, nearly 60 percent of doctors polled by the American College of Physician Executives said they had considered getting out of medicine because of low morale, and nearly 70 percent knew someone who already had. “

“Dr. Yul Ejnes, 47, an internist in Cranston, R.I., said he was recently forced by Medicare to fill out requisition forms for a wheelchair-bound patient who needed to replace balding tires. ‘I’m a doctor,’ he said, ‘not Mr. Goodwrench.’ “

“But in the days when a successful career was built on a number of tacitly recognized pillars — outsize pay, long-term security, impressive schooling and authority over grave matters — doctors and lawyers were perched atop them all. “

“Now, those pillars have started to wobble.”

‘The older professions are great, they’re wonderful,’ said Richard Florida, the author of ‘The Rise of the Creative Class: And How It’s Transforming Work, Leisure, Community and Everyday Life’ (Basic Books, 2003). ‘But they’ve lost their allure, their status. And it isn’t about money.’ “

OR at least, it is not all about money. The pay is still good (sometimes very good). Still, something is missing, say many doctors, lawyers and career experts: the old sense of purpose, of respect, of living at the center of American society and embodying its definition of “success.”

“In a culture that prizes risk and outsize reward — where professional heroes are college dropouts with billion-dollar Web sites — some doctors and lawyers feel they have slipped a notch in social status, drifting toward the safe-and-staid realm of dentists and accountants. It’s not just because the professions have changed, but also because the standards of what makes a prestigious career have changed.”

“This decline, Mr. Florida argued, is rooted in a broader shift in definitions of success, essentially, a realignment of the pillars. Especially among young people, professional status is now inextricably linked to ideas of flexibility and creativity, concepts alien to seemingly everyone but art students even a generation.”

“Indeed, applications to law schools and medical schools have declined from recent highs. “

“The number of applicants to medical school, has dipped to 42,000 from 46,000 in 1997, although it has recovered from a low of 33,000 in 2003.”

“ ‘Students are focusing now on starring in their own creations, their own start-up businesses,’ said Trudy Steinfeld, the executive director of the Wasserman Center for Career Development at New York University. “

“ 'There’s a sexiness to starting something cool,’ she said. ‘Now we have people trying to start a Facebook or a MySpace. You might be working like a maniac, but it’s going to pay off in status. You’re going to be famous, providing something people are going to know and use all over the world.’

“Unquestionably, many doctors and lawyers still find the higher calling of their profession — helping people — as well as the prestige and money, worth the hard work. And the stars in either field are still that: commanding the handsome compensation and social cachet. But to others, the daily trudge serves as a constant reminder that the entrepreneur’s autonomy simply can’t be found in law or medicine.”

“Doctors face pressure. Complaints about managed care crimping doctors’ income and authority over medical decisions are nothing new, but the problems are only getting worse, several doctors said. “

“One doctor responding to the American College of Physician Executives survey wrote: ‘I find it necessary about once every month or two to stay in bed for 24 to 48 hours. I do this on short notice when I get the feeling I might punch somebody.’

“Increasing workloads and paperwork might be tolerable if the old feeling of authority were still the same, doctors said. But patients who once might have revered them for their knowledge and skill often arrive at the office armed with a sense of personal expertise, gleaned from a few hours on www.WebMD.com, doctors said, not to mention a disdain for the medical system in general. “

“ ‘If the topic comes up in cocktail party talk, you’ll hear nightmare stories from people as they’ve gone through the system — ‘they gave me the wrong pill,’ et cetera,’ said Dr. Gregg Broffman, 57, a former pediatrician who is now a medical director of a primary care group in Buffalo. ‘In terms of my own self-esteem, it feels like a personal attack.’ “

“EVEN the language of contemporary medicine has eroded the physician’s sense of majesty.”

“ 'What irritates me the most is the use of the term ‘provider,’’ said Dr. Brian A. Meltzer, an internist in Pennington, N.J., who now practices pro bono on the side, but works full time for Johnson & Johnson’s venture capital division. ‘We didn’t go to provider school.’ “

Obama and Huckabee Health Proposals

Iowa has spoken, and New Hanspshirelooms ahead. This is a good time to take a quick look at the health proposals of Iowa winners.

Governor Huckabee’s ideas are,

1. More emphasis on preventive care (His personal massive weight loss of 100 pounds or so, and Arkansas’ status as a national leader in preventing childhood obesity may offer clues to his thinking here)

2. Health care should remain in private sector, but needs improvement.

3. The system should feature more EMRs in doctors’ offices and hospitals. (who should pay isn’t said).

4. Health care should be portable from state to state.

5. Health insurance premiums for individual should be deductible, just as they are for corporations.

Senator Obama’s proposals are more nuanced but smack of economic populism, i.e. bringing down the big boys in health care, big health plans and big Pharma , and giving a bigger role to government.

1. Offering coverage for all by providing a cost savings of $2500 per family

2. .But not making universal coverage mandatory because doing so would be a wealth transfer from the young to the old, the young being a constituency he seeks to cultivate.

3. Compelling competition among health plans (just how is not clear).


4. Having health plans pay more for care and less for profits and administration.

5. Allowing Americans to buy drugs from abroad and let government negotiate drug prices at home for Medicare and Medicaid.


6. Following the lead of such European countries as Switzerland and Germany by offering universal coverall through a mix of market and government-based care.

7. Requiring parents to buy coverage for their children.


8. Requiring all employers of 15 more to provide health benefits or pay subsidies .

One of Senator Obama’s advisors is David Cutler, Harvard economics professor. He says Obama would “guarantee” universal comprehensive coverage by,

1. Having government pick up tab for expensive illnesses.

2. Focusing on preventive care by requiring coverage of scientifically –based preventive tests.

3. Improving quality by having hospitals and doctors publicly report outcomes and quality measures.

4. Requiring a paperless system.

5. Making generic drugs more available and more of the requirment of care.

6. Ending monopolizations of health plans and drug companies.

There you have it.

Doctor Bias

The perfect is the enemy of the good.

Voltaire


To be perfectly blunt, I tire of searches for the perfect doctor - perfectly balanced, perfectly equitable, perfectly consistent. I weary of stories about physician bias against blacks, ethnic groups, the poor, and the uninsured. I dread commentaries saying no bias was intended but must be considered.


“Nobody’s perfect,” goes the cliché, and doctors don’t pretend to be. We don’t change stripes between patients. We evaluate, diagnose, and treat patients we meet.


Part of the attitude that a bias lies under every medical rock dates back to a 2002 Institute of Medicine Report “Unequal Treatment Confronted: Racial and Ethnic Disparities in Health Care.” Of the report, Alan Flieschman, MD, senior VP of New York Academy of Medicine, said this in a 2002 NYT letter to the editor:

Doctors, hospitals and the institutions that represent the medical profession must be held accountable for correcting those parts of this problem that are within their control. Medical racism is unacceptable.

Realizing that preconceived notions about others exist in all of us is critical to eliminating social stereotyping and the resultant disparities in medical services. The overt or unconscious bias that a physician may bring to a patient encounter must be recognized and eliminated.

I concur, in theory. But the crusade against “overt and unconscious bias” can be overdone. Much of this so-called “bias” may simply be a sampling problem
Consider the following, based on three medical journal aritcles, and widely reported in the media.

• The January 2 Hartford Courant ran a story “Drug Bias Seen in ERs.” It says whites are more likely to get narcotics for pain than blacks and other ethnic minorities, and is based on a January 3 JAMA article ( Pletcher, el, “Trends in Opioid Prescribing by Race/Ethnicity for Patients Seeking Care in US Emergency Departments “ The JAMA study indicated narcotics were prescribed for 31% of whites, 28% of Asians, 24% of Hispanics, and 23% of blacks. For blacks, the reporter speculated, doctors feared, presumably due to “social stereotyping, “ that blacks were more likely to be addicts and to feign pain. Maybe the doctors were right. Maybe black addicts visit ERs more often to get fixes because they’re unknown to ER personnel whereas private doctors might be more suspicious of feigned pain.

• The January 3 issues of both the NYT and the WSJ carried articles citing a NEJM article indicating too many American hospitals take more than 2 minutes to respond to sudden cardiac arrest ((Chan, P. et al: “Delayed Times to Defibrillation after in-Hospital Cardiac Arrest, “ NEJM, January 3, 2008). When response times exceeded 2 minutes, survival plunged. Response times were slow when hearts stopped at night or on weekends, in patients with non-cardiac diseases, in hospitals with fewer than 250 beds, units without cardiac monitors, and in blacks. The NYT reporter was careful to point out that racial bias may not have been a factor because blacks tended to be in smaller hospitals. Still, the NEJM authors felt compelled to say,

“The association of black race with delayed defibrillation is not intuitively obvious and raises potential issues of disparities in care. Further studies are warranted to determine whether such variations are due to geographic differences in access to hospitals with more resources (such as more monitored beds) or whether they reflect actual differences in practice patterns according to race.

• The January 3 Boston Globe features “Drug Distribution System Faulted.” The article says doctors distribute more free drug samples to the “wealthy and insured” than to the “poor and uninsured.” The reporter, citing an article in February issue of The Journal of Public Health, is, in my opinion, is subconsciously using the phrases “wealthy and insured” and “poor and uninsured” pejoratively . He implies doctors are systematically biased against the disenfranchised. However, The lead author Sara Cutran, MD, is carefully and correctly points out,

“Doctors are truly trying to target samples to needy patients, but their individual efforts failed to counteract society-wide factors that determine patient care.”

These factors, of course, include the reality that the insured tend to see doctors in their offices, while the uninsured more often go to ERs and hospital clinics, where free samples aren’t usually distributed. The faulty distribution, therefore, is not due to doctor bias, but to society factors beyond doctor control.

To conclude:

Some insist doctors harbor an ingrained bias,
Against blacks, so critics in the main decry us,
I say doctors can only treat
Patients they see or meet,
To say otherwise is overly pious.

Give doctors a break. In this imperfect world, inequality may depend on clinical and social circumstances, not on bias.

WhyAmerican Health Care Reform is So Hard

I’ve been writing about American health reform for 30 years. It never gets any easier.


I started in the 1970s when HMOs bloomed in Minnesota, thanks to Paul Ellwood. Ellwood convinced Preside Nixon HMOs were the thing. . In 1973 the HMO act was born. The pace accelerated in 1976 when I attended an 8 week course on Health System Management at Harvard Business School. A single payer system seemed imminent, and Senator Edward Kennedy got government money to support the course so Harvard could meet the major players in the new system.. But reform was not to be. In 2005 I interviewed 42 national authorities for my book Voices of Health Reform. I concluded health care gridlock would continue because reform always geared someone else’s ox.


Health reform is hard for many reasons. We distrust centralized government. We believe in equal opportunity not equal results. We think the majority rules even though minorities may suffer. We see freedom of choice and access as God-given rights. No “socialized medicine,” rationing or queuing for us. We’re not a cruel people. We just don’t believe government is the answer. Markets and self reliance are.


We’re a vast continental nation with vast regional differences, but our reform ideas tend to be half-vast. We have a mixed population of 300 million. Our people include 31 million recent immigrants with different cultural expectations. This creates barriers and confusion. We have a history of individualism. Our Wild-West mentality creates the illusion that all things are soluble as long as we move to the horizon and seek new frontiers of cure.


We all hold strong ideas of what health care should be, especially when someone else pays for it. Given this sense of entitlement, we expect, even demand, the health care we think we need. Damn the expense.


We yearn for a political savior, but there is no savior. The problem is bigger than politics. It’s being hooked on technology, behaving as we please, rushing to satiate to relieve anxiety and stress, riding rather than walking, believing vitamins, immune system builders, herbs, hormones, and other nostrums will do the trick, and, if all else fails, turning to specialists for a quick fix.


We see the body as a machine. If the machine’s face or frontal knobs sag, lift them; if pipes plug, bypass them or put in Drano; if joints wear out, replace them; if organs fail, cannibalize other machines for substitutes. Stress body owner’s manuals, artificial hearts and parts, and mechanical devices. We can’t replace one organ , but we’ve got Al (Algorithm) and Art (Artificial Intelligence) working on it.


We’re opportunists. Lift ourselves by our own bootstraps. Talk of safety nets, as if life were a high-wire act, but don’t dig too deep in our own pockets to pay taxes to weave new nets or to sew up holes in old ones.


We’re capitalists. Solve problems by letting markets reign. Let Big Management and Big Ideas solve social problems. In the end, blame Big Government. But distrust Big Government. As a conservative society, we suspect no nation can support a robust growing economic and a generous welfare state at the same time. We cite Europe as an example. Health costs for Europe’s aging peoples are growing as fast or even faster than ours. Their economic growth has been half ours over the last 25 years. Their unemployment is twice ours over the same period.


These are some of the reasons health reform is so hard. Meanwhile, until reform comes, we’re living longer. Deaths from cancer, heart disease, and stroke, and our cholesterols, are dropping. Things could be better, but we’re getting healthier every day even without reform. So don’t despair. Hang in there. Americans and their doctors are doing something right.

Remaking American Health Care, Part 2, The Consumer-Driven Solution

In my blog before last, I described how George Halvorson, Kaiser CEO, would remake health care. That blog drew mixed opinions. Some top-down corporate control was bad. Others said it was about time doctors engaged in systematic improvement programs from on high.

Halvorson advocated a national system-wide data-driven revolution comparing how well doctors and hospitals perform, focusing on improving care for major chronic diseases, then allowing payers to bid on who performs best in terms of costs and outcomes. You can read details of his proposal in Health Reform Now! (Wiley, 2007).


At the end of my blog, I asked how you, America’s practitioners, thought of Halvorson’s approach.


Now I would like to ask how you react to another proposal, this one by Regina Herzlinger, Professor of Business Administration at Harvard Business School and author of Who Killed Health Care? (McGraw-Hill, 2007)..


Here’s what she said in an August Wall Street Journal piece “Where Are the Innovators in Health Care?”


“Luckily there is a solution, but there is only one: consumer-driven health care. Let’s take back our $2.2 trillion from the entrepreneur-suppressing status quo and allow consumers to reward those entrepreneurs who lower costs by improving health. Until we control our own health-care system, the entrepreneurs who could reform it – and it make our lives better – will continue to look elsewhere for opportunities . Who can blame them?”


She is referring to the 20 or so doctors enrolled in her “Innovating in Health Care” course at Harvard Business School. She says thy’re “ruefully driven to earn MBAs once they realize they innovate better as an entrepreneur than as a doctor.”


In “Who Killed Health Care? she argues health insurers, general hospitals, employers, the U.S. Congress, and academics have “killed” health care through a complex web of rules and regulations. What is needed, she says, a consumer-driven health-care system that will unlock those shackles to bring about a much-needed entrepreneurial revolution that will lower costs, improve care, and expand choice.


Do you agree?

Five Health Care Innovations: Shine Your Light in Different Places

Well, 2008 is here. It’s time to shine the light of innovation in different places, to do things differently, to look at medical practice in a new light.

In the 1980s, the Eveready, the company that makes those inexpensive red lamps and metal flashlights, then sold mostly to men in hardware stores, was in trouble. Ralston bought Eveready. A Ralston executive suggested Eveready change the color of lamps and flashlights from red to pink, light blue, and lime green and sell them to women in supermarkets. Sales took off. Same product, same light, different colors, different places.


For doctors, the moral of this tale is four fold:


• Bring in people from outside for new ideas.


• Place your services in different places.


• Paint your services in a different light.


• Think of where your patients’ convenience


Venture outside your practice box. Use your same training and expertise. Shine light of
That same knowledge in different places. Here are a few thoughts that have worked in the past and may work in the future.


1. Create and own your own retail clinic. Many medical groups are doing this as an extension of their practice or in partnership with retail outlets. Entrepreneurial companies are marketing franchises for physician-downed retail outlets. Rushed consumers, short on time and money, will appreciate it.


2. Think about approaching companies to set up worksite clinics. This is already happening. Primary care practitioners run these clinics, offer preventive services to employees, prescribe generic drugs, and create their own specialty referral networks. Employers will save money, and employees love the convenience.


3. Consider partnering with hospitals to set up a Big MACC (Multispecialty Ambulatory Care Centers), also called Big Boxes, in convenient suburban or rural settings, with ample parking and with shared receptionists, laboratory, x-ray and imaging, and pharmaceutical services. Place your practices in these New Big Boxes. Your patients will be impressed with the one-stop-shopping convenience.


4. Brainstorm about getting into the chronic disease game. It’s a known fact five diseases – diabetes, depression, asthma, depression, coronary artery disease, and congestive heart failure – gobble up 70% of total health costs. You are probably doing this already. But you might consider adding a new wrinkle or two – such as offering home house calls or monitoring electronically patients who are homebound. People want to be treated at home. Make it easy for them.


5. Fill prescriptions in your office. It’s convenient for your patients, cost them less, saves them time and driving, and makes for better compliance. Office prescribing is permissible in 36 states, and software is out there for you to check on drug interactions, prescribe from your office, and build and maintain your inventory. You’re using the same knowledge, you’re prescribing the same drugs, you’re profiting from your knowledge, and you’re making thing easier for your patients. If you find this commercial, unethical, or a conflict or interest, don’t do it. But keep in mind there’s a national movement propelling pharmacists prescribing , and it’s taking off in states like Florida.

Happy New Year!