What to Do Until The Messiah Comes

Brian Klepper, PhD, a well-known and insightful health reformer, asked me yesterday what I would say if I were to speak before a group of medical society executives. He is being kind. He doesn’t need my advice and will say what he wants to say.

Nevertheless, what came to mind was a country song. When I was growing up in Tennessee, there was a country song “Mother’s Not Dead, She Is Only A’Sleepin’, Patiently Waiting for Jesus to Come.”

When I think of the song, I think of some doctors in practice. Some are sleeping, patiently waiting for some miracle to rescue them from their doldrums.

• The bad news is: Jesus isn’t coming soon in the form of single single-payer , sharp updating of Medicare codes, or a consumer-driven overhaul of an entrenched system, which some have called a “calcified hairball.”

• The good news is the bad news may help doctors and their societies get down to the hard work of creating a new future As Peter F. Drucker, the father of modern management, declared, “ Innovation has to degenerate into work.”

What might his hard work be?

• First, doctors will need capital, not religious fervor, or righteous indignation. This capital may come from hospitals or health systems, venture capitalists, or grants from organizations like the Physicians Foundation for Health System Excellence. Doctors will need this capital to build infrastructure, install electronic systems, build new business models, and recruit new doctors.

• Two, doctors will have to look at themselves through the eyes of health care consumers and patients who want cheaper, better, convenient, and documented quality services delivered in the neighborhood . With gas at $5 a gallon that will be important.

• Three, physicians will have to prove to the public that they can create new business models – for disease managed care, medical homes, and worksite clinics – that coordinate care and guide patients to go where they need to go.

• Four, physicians need to design and develop systems of systematic innovation spelled out and agreed upon at regular meetings that allow physicians to arrive at an agreed upon approach to innovate and please patients , reward doctors, improve care, and achieve camaraderie.

• Five, physicians need to think through and prepare for the day when patient-owned and patient-controlled personal health records arrive. That day will come soon because Microsoft, Google, and Dossia (a consortium including Intel and Walmart) have entered the market. Think of PHRs as wikis – patient records that will need to be continually updated and edited by doctors and that may make medical homes a reality.

• Six, to attract doctors to your state, push for malpractice caps, as Texas has done.

• Seven, consider engaging patients by having your doctors “prescribe” videos – with voice, plain language, and anatomical illustrations- telling them exactly what to expect from surgery; Emmi solutions offer these videos which please patients and drop malpractice actions immediately.

Unlike the Mamma in the song, physicians can’t be patient much longer, waiting for Jesus to come. Do it now, and don’t be caught be a’sleepin’.”

High Tech/High Touch Care from Afar:

Technology systems to underpin living independently, or what some call “aging in place,” are still years from being rolled out in a big way, awaiting adequate financing for research and other incentives.

Ben Garvin, “High-Tech Devices Keep Elderly Safe From Afar,” New York Times, May 24, 2008

Facing growing cases of chronic illnesses and continuing nursing shortages, the health care industry is increasingly turning to home-based medical devices to keep tabs on patients.

Elena Cherney, “New Ways to Monitor Patients at Home,“Wall Street Journal, April 18, 2006

For patients and for doctors, traveling to see each other poses logistical problems – problems that can be overcome by traveling in cyberspace. With electronic communication, the elderly can now live alone without physical assistance, and patients and doctors can talk, observe, and listen to each other without being physically together.

.As John Naisbitt pointed out 25 years ago in Megatrends (Warner Books, 1982),
“High tech/high touch is a formula I use to describe the way we have responded to technology. What happens is that whenever new technology is introduced into society, there must be a counterbalancing human response – that is, high touch – or the technology is rejected? The higher tech, the more high touch.”

As it relates to the home, high tech/high touch is now being applied in two domains.

First, to the elderly who live alone?

Emergency response systems have been around for years, but motion sensors and remote monitoring systems are now available for $50 to $85 a month.

These systems will become commonplace as the 76 million baby boomers approach ages when Alzheimer’s, diabetes, failing eyesight, and sheer age threaten the ability to live independently. The population of those 65 years and older is 40 million today, and the Census Bureau says that will more than double, to nearly 87 million, by mid-century.

Jeremy Nobel, M.D, professor at the Harvard School of Public Health who co-wrote a study on the feasibility of such technologies. “We are at the beginning stages regarding the availability of such services and before business models are developed. I expect we’ll see a significant increase in the adoption of such systems in two to five years, and widespread adoption in 10 years.”

All that prevents these systems from being rolled out in a big way now are adequate financing by government and coverage by insurance companies.

And even that may not be necessary. An AARP survey found older people are willing to use high-tech devices at home, and to pay about $50 a month.

Second, to the sick elderly confined to their homes.

As I explained in my book, Innovation-Driven Health Care: 34 Key Concepts for Transformation (Jones and Bartlett, 2007), “The chief impact of Internet-based medicine will be decentralized care.” In a case study in the book, Randall Moore, MD, CEO of American Telecare, and Erin Denholm, CEO of Centura Health, wrote that readmissions to hospitals and ERs for patients with congestive heart failure dropped 95% when patients were monitored by remote bedside audiovisual devices controlled by patients. Though these devices, doctors and nurses could observe patients, talk to them, listen to their breath sounds, and record their blood pressure, weight, and blood oxygen.

Further, patients controlled the provider encounter and quickly learned to spot their own complications. Patients learned they could find help when they needed it, earned respect as individuals with knowledge of their own disease, could take control of their illnesses, could share information they deemed appropriate, and could self-coordinate their care without wasting time, money, and worry.
While remote care in now possible and available at low costs, payment for these services is complicated by state and national regulations and turf battles between providers.

A Call to the Uninsured and Underserved: The Case for Cash Only

Operator, please connect me to the health care uninsured and underserved in the USA.

Yes, I know there are 45 to 50 million uninsured. No, I don’t now how many consider themselves underserved, i.e., unable to gain intimate access to their doctors

Yes, I know the uninsured are a mixed bunch – 82% are employed, 50% are between 18 and 34, 75% say they’re in good or excellent health, 67% have college degrees, some are down and out, and others are between jobs.

The underserved are more affluent. They simply seek doctors’ undivided attention and quick access.

How am I going to pay for this call? I’m at a pay phone. I’ll pay cash. It’s a simple, convenient, and quick way to go, just as a paying for your health care often is.

Pause…..

Hello. Am I speaking to the uninsured and underserved? Good, I’d like to talk to you about the cash-only approach to paying for care.

I’ll speak to the underserved first. You may want to pay cash, roughly $1000 to $2000 a year upfront, in exchange for doctors responding to your every need. There are about 500 practices providing this level of service. You can find out where they are at the Society of Innovative Practice Design website (www.SIMPD.org). SIMPD is a physician organization promoting direct financial relationships with patients.

Now for you uninsured. You may want government to take care of you. Well, it might if Senators Clinton or Obama have their way. But their reforms will take years to wend their way through Congress, and reforms aren’t a sure thing. You need care now. Beside, Senator McCain might win, and that’s another kettle of fish. He says you can pay cash and deduct $5000 of annual health expenses.

Senator Clinton calls for an “individual mandate. “ That means you’ll have to pay for individual coverage... This mandate approach isn’t working well in Massachusetts because 1/3 of the uninsured are resisting paying their way. If you can’t pay, the government will pay for you. That involves paperwork to make sure you qualify...

What are your other options? Good question.

• Try Medicaid. It covers 59 million Americans, but you’ll have to sign up, and you should understand many doctors don’t take Medicaid patients because of low payments and paperwork. You may have to pay co-payment. Some consider being Medicaid patients a social stigma.

• Since 82% of you are employed, you could ask your employer to cover you with a high deductible plan with a health savings account. Why would your employer want to do that? First of all, it saves employers money. Health costs are only going up 2-3% for employers with HSA-linked plans, versus 8-10% for other plans. Yes, you may have to pay cash for care because of the high deductible. But the cash you pay is tax-deductible, and if you don’t spend it, it carries over until the next year and accumulates in your tax-free HSA account. It’s like a 401K plan.

• What about cash on the barrel-head for your care? This may not be a bad idea. Since 1/2 of you are in good or excellent health and probably only have minor ailments, paying cash when you see the doctor may cost you a lot less than paying for expensive premiums.

How does this work, and how do you find doctors who accept cash? Well, first of all, most doctors accept cash. Second, cash-only clinics are cropping up around the country, so ask your doctor, ask around. You’ll find someone. Thirdly, you might want to seek out a retail clinic at Walmarts, CVS, or Walgreens, or some other retail chain. Nurse practitioners generally run these clinics. They accept cash, and they charge $59 to $89 for treating minor illnesses. A word of caution, if you think you’re seriously ill, sees your doctor. Doctors run a few of these retail clinics, but not many yet. Lastly, you might want to seek out a national known chain of doctors called Simple Care. At Simple Care, patients pay cash for short ($35), medium ($65), and long ($95) visits. You can go to Simplecare.com to find if there’s an affiliated doctor in your town or region.

Will the cash-only approach solve America’s high cost crisis. Of course not. If you have a health problem requiring a high-cost solution –major surgery, cancer, a joint replacement, heart surgery – you will need insurance. Most of us don’t have the cash to cover the cost. A few of you might want to travel abroad for lower-cost treatment, but that’s not an option for most. If you want to lower your premiums, a high deductible HSA-plan may be the best way to go. If you have a minor illness you want treated quickly, try the options listed above, or ask your doctors if they would take cash. About 50% of doctors’ overheads are due to 3rd party payments, and many prefer to deal in cash. Cash is simple, direct, requires no 3rd party OK, and avoids credit-care woes and collection problems. Try it. You may like it. The doctor will.

God Bless the USA

Perhaps because it is Memorial Day. Perhaps it is because I simply believe words matter. Perhaps it is because I’ve lived in Tennessee and Minnesota, two states immortalized in the lyrics. Perhaps it is because the song stirs my soul. For whatever reason, here are the lyrics of “God Bless the U.S.A,” by Lee Greenwood, a frequently sung patriotic song

If tomorrow all the things were gone I’d worked for all my life,

And I had to start again with just my children and my wife.
I’d thank my lucky stars to be living here today,

‘Cause the flag still stands for freedom and they can’t take that away.

And I’m proud to be an American where at least I know I’m free.

And I won’t forget the men who died, who gave that right to me.

And I’d gladly stand up next to you and defend her still today.

‘Cause there ain’t no doubt I love this land,

God Bless the U.S.A.

From the lakes of Minnesota, to the hills of Tennessee,
across the plains of Texas, from sea to shining sea,

From Detroit down to Houston and New York to LA,
Well, there’s pride in every American heart,
and it’s time to stand and say:

I’m proud to be an American where at least I know I’m free.

And I won’t forget the men who died, who gave that right to me.

And I’d gladly stand up next to you and defend her still today.

‘Cause there ain’t no doubt I love this land,

God Bless the U. S.A.

In Remembrance of Military Doctors

"Things come from civilian medicine, and then we take it into the cauldron of the war and focus it, test it and evaluate it, and then use it many, many, many more times than the civilians have. And then whatever spits out in the end is better.”

Army Col. John Holcomb, M.D. commander of the U.S. Army Institute of Surgical Research, 2007

On this Memorial Day, it is time to remember, celebrate, and commemorate military doctors.

We sometimes forget military doctors have served in every American war since 1775.

We sometimes forget lessons learned and innovations developed by military doctors carry over to civilian life in operating rooms, trauma, and rehabilitation centers across the land.

We sometimes forget doctors in the Spanish-American war learned mosquitoes cause yellow fever, in World War I that transfusion saved lives, in World War II that penicillin and sulfa drugs were indispensable for treating infections, in Korea and Vietnam that prompt helicopter evacuations reduced death tolls, and in Iraq and Afghanistan that hemorrhage can be stopped on the spot by new types of bandages and drugs.

We sometimes forget that military medicine in times of war is very intense because of new treatment methods, recognition that time passed before treatment is the enemy of life. For the military physicians, there’s no wasted moments, no wasted movements, military treatment is very, very focused.

We sometimes forget we have a medical school, the Uniformed Services University in Bethesda devoted to educating and training doctors for military duty in peace and war.

We sometimes forget that 80% of our civilian doctors spent part of their education and training in Veterans Hospitals affiliated with teaching centers.

We sometimes forget our military hospitals – Walter Reed in Washington, over 190 Veterans Hospitals comprising the largest hospital system in the world, and military clinics q43 strewn all across the U.S. and over the world. Sometimes these hospitals even exist in the sky, during flights from Iraq to Germany.

We sometimes forget that the famed comedy series MASH (Mobile Army Surgical Hospitals) was based on a book MASH: A Novel About Three Army Doctors, was written by an Army surgeon, Richard Hooker, MD. With death and chaos of war, sometimes comes humor. But risk also comes, especially in wars without frontlines. Doctors, nurses, and other medical personnel in Balad in northern Iraq are ordered to carry firearms.

We sometimes forget that the managerial and leaderships experiences gained in the military carry over into civilian life. In the armed services, doctors learn to organize, to treat populations of patients, to train paraprofessionals. to function and work as teams, and to improvise and innovate.

So let us not forget on this day our heroes – military doctors

Two Points of View on Business and Health Trends

At a recent conference sponsored by a multinational company, I was asked to summarize how I felt about health trends, nationally and internationally.

I made two brief points:

1) It’s the culture, stupid! In America, people want the best, will demand they get it, and will reward lawyers if they don’t get it.. Since our founding 231 years ago, America has been a conservative, individualistic country that operates from the bottom-up , distrusts government, and is always looking for disruptive innovations over the next horizon, often but not always technological, sometimes organizationally, to solve their problems. . This isn’t true of other countries but must be taken into account if our economy is to continue to grow.

2) In health care, it’s all about efficient, useful information transfer. This will come as lower-cost, more convenient, simpler, easier-to-use Internet-based information disruptive technologies featuring patient-health consumer-physician partnerships facilitated by personal health records developed and distributed by companies like. Google, Microsoft, Yahoo, and retail organizations like Walmart. These activities will diverge from past practices and will require new market and strategic insights and stresses on what succeeds.

That’s as short and sweet as I can make it.

How Doctors React to Being "Managed"

Last week I blogged on how a former corporate medical affairs executive thought independent practicing doctors should be managed.

Among other things, he said corporations should,

• regard health care as just another product,

• deal only with doctors who comply with product specifications,

• judge doctors to whom to refer by judging value (cost/quality).

• pay only for evidence-based care.

Doctor readers reacted swiftly. My blog rating dropped sharply by 40%. Negative comments ensued. Being a messenger of bad news bore adverse consequences.

I’m not surprised how doctors reacted. Twenty years ago, I wrote in And Who Shall Care for the Sick? The Corporate Transformation of Medicine in Minnesota (Media Medicus) that managed care was doomed to fail. And in a second book, Managed Care Memor: A Physician’s Whistle-Stop Journey, 1983-2003 (Infinity Press, 2003), I elaborated on why managed care was failing. In essence, I said doctors think of themselves as professionals to be trusted, not as providers to be managed, or as cost-generating renegades to be reined in.

For years, I’ve argued with this medical executive that,

• You can’t manage care like other, more tangible products because medical practice is a subjective, complex interactive human activity;

• You can’t force doctors everywhere to comply with product specifications because care varies with local cultures;

• You can’t base payment solely on “evidence-based” care because more thant 50% of doctor visits aren’t evidence-based; visits are human-based, neighborhood-based, relationship-based, and circumstance based. .

• Ultimately, you can’t judge physicians on outcomes depend on how patients behave once they leave the doctor’s office, not on what the doctor does at the point of care.

• If you want to control costs, deal directly with physicians rather than through their human relations departments or through managed care surrogates, and make your case with irrefutable data.

Case closed.

A Major Disruptive Innovation = Doing Away with the Paperwork

“…Disruptive innovations – cheaper, simpler, more convenient…”

Clayton Christensen, Richard Bohmer, and John Kenagy, “Will Disruptive Innovations Cure Heallh Care?’ Harvard Business Review, September-October, 2000

I just attended a conference on strategic innovation. At a pre-proceedings greeting dinner, the group leader asked, “Name the most disruptive innovation that has changed society forever.” Or words to that effect.

The audience included senior executives of a global company and a handful of experts representing various spheres of economic activities affecting society and business. I was the “expert” on health care trends, a title I so richly deserve but so seldom get.

These answers, some profound, some trivial, came back:

“Television.”
“The Personal Computer”
“The Internet”
“Google.”
“E-mails”
“Post-It Notes”
“Bottled water.”
“Cellphones,”
“I-Pods”
“Boneless chicken wings.”

At my table in the rear of the room, a health care guy, I was in a jocular mood. So I threw out “virtual colonoscopy” as a disruptive innovation, or perhaps I should say, a non-disruptive procedure. I was there, after all, to talk of health care trends. One trend I foresaw was minimally invasive procedures.

That Damned Paperwork

Suddenly the mood turned serious among our little subgroup, and we collectively concluded that the single most disruptive innovation that could even happen, was, “Getting rid of that damn paperwork.”

Detailed paperwork – get down the demographics, note past and present diagnoses, record the history, state the chief complaint, list allergies and drugs, identify the person to notify in care of emergency, document the encounter, and above all, confirm who is paying – is the bane of patients and doctors alike.

Perils of Paperwork

Paperwork is, well, so complex, duplicative, time-consuming, and, so frequently irrelevant, to the task at hand. Finding out what’s wrong and what to do about it the case of the patient; practicing what you’re trained to do in a cost effective and timely manner, in the case of the doctor, the waste of everybody’s valuable time, and one of the singularly most inefficient aspects of the health system.

Patients indignantly ask, “How many times do I have to go through this routine?” Or, “Don’t you people ever talk to each other?” Doctors, in their turn, ask,” Why do I have to do this?” “what the hell does this have to do with being a doctor?” “Why hasn’t this been done ahead of time?” Or, “Why can’t I have all this information in front of me when I see the patient?”

The paperwork involved, as everybody with any sense at all, knows, is a giant invoice, rather than a communication document.

And, to compound the problem, EMRs, until now, have been nothing, more or less, than a huge electronic invoice. This may be about to change, and the pressure is coming from multiple commercial enterprises =- WebMD, Google, and Microsoft, and others – who see simplifying the problem as a giant opportunity to streamline the patient-doctor encounter in the form of personal health records, owned by patients, frontloaded with patient data, and designed to be continually updated by patients and their doctors – as the vehicle for transforming health care and making it more efficient.

Not a Sure Thing

Sure, personal health records have privacy, security, and data entry hassles and concerns. Sure, patients and doctors alike may find it complicated at first, as they did personal computers, the Internet, e-mails, and those damn EMRs. But, these records have the potential of dramatically simplifying the patient-doctor encounter and making it more convenient, satisfying , and productive. It may even help get rid of that damn paperwork.

Meanwhile, disruptive innovations have yet to “cure: health care, as I noted in the opening quote.

A Call to the American Public

Operator, connect me to all of the American public,
Yes, all 303 million of them under the USA rubric.

Yes, I know this call is out of the ordinary,
But times call for the highly extraordinary.

Who is calling? Sermo physicians working together.
We want to talk to Americans about making care better.

Pause...

Hello, American health care consumers and patients.
We American doctors want to show our impatience.

With high costs, excess paperwork, and long waits,
And huge malpractice costs for occasional mistakes.

Yes, we’re human and we occasionally do err,
And if we do, we insist you be treated fair.

We prefer to deal with you directly,
Rather than through 3rd parties indirectly.

We want to be your direct partner and guide,
We want you to know we’re on your side.

We believe costs of rules, regulations, and mindless standardization,
May overly restrict freedom, choice, and thoughtful individualization.

So keep an American Eagle eye out for our Open Letter,
With your help together we will make health care better.

Thousands of us want to shout what needs to be done,
to make our precious health care system better run.

Right now I can’t tell all.
But we plan to stand tall.

What these united doctors want to reveal
is now in An Open Letter still under seal.

Straight Talk with a Corporate Medical VP

Recently I ran across this statistic: 60% of health coverage is employer-based and 30% is government-based. This struck me. I felt government was on the verge of taking over, mostly because employers can’t keep up with health cost inflation, which has been 4.4 X of health inflation vs. general inflation. Yet I know employers are reluctant to accept government-regulated cae.

So I called a lifelong friend, formerly the VP for medical affairs of a major multinational corporation. He prefers to remain anonymous. He’s an internist who wrestled with health inflation demons for 13 years during his corporate life.

I asked him, how can Corporate America subdue the inflation beast?

Here are his answers, none of which are easy to do.

1) Overcome the entitlement mindset. He claims Health Resources departments think of themselves as dispensers of health care entitlements rather guardians of cost.

2) Manage care rather than finance it. Too often, he says, corporations simply pay for efficient use of unnecessary care.

3) Treat health care as simply another product: deal only with providers who comply with product specifications. Quality first saves money.

4) For major illnesses, contract with major institutions with known outcomes. Again quality first saves money.

5) Institute wellness and prevention programs. Focus on screening and controlling those things – BP, glucose, and weight – known to have adverse outcomes.

6) Pay only for evidence-based care, based on evidence generated from the medical literature and from specialty societies: reduce excessive care.

7) Be aware of consumer-driven care and shared consumer-cost responsibility but do not rely on them. Employers will be wary of intrusions into their financial and lifestyle worlds and are difficult to inform and educate about proper care.

8) Have the CFO, who is responsible for the corporate bottom-line, engage directly in conversations with local and national physician organizations to set standards to see what else can be done rather than going through the current chain of health care command -- HR departments, HMOs and PPOs, and health care consultants.

A Call to Aesculapius

Operator, please connect me to Greece
Who’s calling? My name is Dr. Reece.

What city? It’s a place called Mount Olympus
Who am I calling? His name is Aesculapius.

No, I confess I don’t know his first name.
With his fame, you don’t need a first name.

What’s my reason for calling?
Tell him the medical sky’s falling.

I desperately need his advice,
That reason should suffice.

Pause……

Hello, Aesculapius?

I’m delighted to speak to you
I want to get your point of view.

Down here the operative words are “hope” and “change,”
Which aren’t so good if you view them at close range.

Take the simple common matter of clinical priority,
Doctors now turn to technology as the first authority.

Instead of looking at the patient and taking a history
They turn first to scans and tests to solve the mystery.

Reflexive, senseless technologies drive up costs,
Tests become the boss and have an automatic gloss.

Did you order a CT and MRI scan, asks loudly the instructor?
Of course, says the intern proudly to the rounds conductor.

As if it’s not what you observe on the outside,
But what counts is what is seen on the inside.

Forget subjectivity,
Focus on objectivity.

At medical school, doctors learn practice management,
Rather than the ins and outs of disease management.

By the way, how is the doctor’s first advisor, Hippocrates?
Tell him his famous oath is now swinging in the breeze.

Doctors are now swearing different kinds of oaths,
At rules, regulations, and bureaucratic over-growths.

And at malpractice lawyers on the offensive,
Which makes doctors practice on the defensive.

If you happen to run across Sir William Osler,
Tell him the Art of Medicine has taken a detour.

Today we talk of medicine as being data-driven,
As if numbers, not humanity, were the only given.

Please forgive me, Aesculapius.
If my bias is overtly obvious.

This is simply my own rendition,
Of medicine’s current condition.

As I complete these bad-time, bed-side medical rounds,
I think of Mark Twain’s comment on Richard Wagner’s music, “It’s not as bad as it sounds.”

Of Doctors, Debt, and Time

I see by today’s May 15 Wall Street Journal that the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University will award full scholarships to all entering medical students to cover the $43,500 tuition but not the estimated $21,800 for living expenses, fees, equipment, and books.

The school is starting a five-year program to train physician investigators for academic careers. Medical student interest in academic careers has been flat for a decade, hovering around 15%, but dropped to 9.4% in 2007.

The program also addresses the problem of the high cost of medical education, which is $140,000 on average. Other medical schools – the University of South Florida and Yale – are also moving to address the problem of education debt.

Buried in the WSJ report is this statement, “Academic careers are very demanding in terms of time. Some students feel those kinds of demands would be difficult for them to meet while also trying to obtain some sense of work-life balance.”

I find this comment interesting because doctor critics too often ignore the whole concept of time spent becoming a functioning doctor – 11 to 16 years depending on specialty. time expended in seeing this 25 patients answering those 50 phone calls, and filling out those endless forms in the course of day.
Maybe those young doctors flocking to hospital employment and those 8 hour days and 40 hour weeks have it right – time is fleeting, life is short, and family relationships are sweet.

In any event, the words of Peter F. Drucker (1909-2006) come to mind.

“Time is a unique resource. Of the other major resources, money is actually quite plentiful. We long ago should have learned that is the demand for capital, rather the supply thereof that sets the limits of economic growth. People – the third limiting resources – one cannot hire, through one can rarely hire enough good people. But one cannot rent, hire, buy, or otherwise obtain more time.

The supply of time is totally inelast6ic. No matter how high the demand, the supply will never go up. There are no prices for it, and no marginal utility curve for it. Moreover, time is totally perishable and cannot be stored. Yesterday’s time is gone forever and will never come back. Time, therefore is in exceedingly short supply.

Time is totally irreplaceable. Everything requires time.

Primary Care Shortage in the Concrete

It is one thing to consider something in the abstract; it is quite another to experience it in the concrete. I’m reminded of the story of the couple watching their children playing in the newly laid concrete in front of their home. The father was furious, and his wife remarked “But, Dear, I thought you loved children.” “I do,” he said, “in the abstract, but not in the concrete.”

It is one thing to read the news in the abstract about the primary care shortage as seen through the eyes of the Council on Physician and Nurse Supply. This national organization was created in response to the emerging shortage of doctors and nurses, estimated to reach 200,000 doctors and 800,000 nurses by 2020. Based in the University of Pennsylvania's Consortium for Health Workforce Research and Policy, CPNS is supported by San Diego-based AMN Healthcare, the nation's largest healthcare staffing organization.

These shortages, the Council warns, may result in

• Inadequate access to care, particularly in rural and inner-city locations.
• Lack of emergency preparedness.
• Decreased ability to expand health care services, with negative effects on local and national economies.

But it is even more telling to look at the shortage through the eyes of a primary care physician. Charles Meyer, MD, editor of Minnesota Medicine and an internist in a four person group, puts the matter in concrete terms in the May issue of Minnesota Medicine, in an issue with the general them of “Doctors Wanted.”

“The forces threatening primary care are economic and practical – with astronomical medical school debt confronting disparate earning potential in medical specialties and 25-patient-50-phone-call days losing out to procedure –based practice. The evidence for primary care’s disappearance is mounting: stagnant or declining applications in primary care residencies, primary care groups searching for years to find a new partner, and individuals making call after call to find a primary care physician taking new patients. Our group of four internists has found the search for a partner to be like hollering into an empty tunnel. My son, healthy, insured, and 26 tried four family practitioners in San Francisco before he found one accept new patients. Staring my 60th birthday in the face, I wonder who will take of me as head into the age of pills and patient-hood.”

Stark Reality

How one sees reality depends on where one sits and where one stands. Representative Fortney “Pete” Stark, 76, a Democrat from California, sits as Chairman of the Ways and Means Committee. He stands as an unabashed liberal favoring a government-run universal health system at any cost and opposing anything that gets in the way.

He sees himself as a paternalist-in-chief, savior, protector, and guardian of health care of the American people. He sees market-based Health Savings Accounts (HSAs), designed by its backers to give people freedom to choose their care as a plot. That’s why he sees HSAs as something for “the healthy and wealthy,” “weapons of mass destruction,” and “country clubs for the rich.”

Stark sees doctors and hospitals as avaricious, self-referring, self-enriching allies bilking Americans of their right to “free” health care. To rein in doctors and hospitals, he has created a series of Laws, Stark I, II, and III, that create hard to meet conditions under which physicians can refer to hospitals or to facilities in which they have financial interests and which might lead to competitive advantage.

The provisions of these laws, which have evolved over the last 15 years or so, are so arcane, Byzantine, and contradictory that only skilled lawyers can parse them, which is probably the reason why health care lawyers are the fastest growing segment of the legal profession.

A little background. Stark represents southwestern Alameda County, a liberal district where he has been reelected 16 times. He is the first openly atheist member of Congress. He graduated from MIT in engineering and received an MBA from the University of California. He is the longest serving member of Congress from California. He has been voted its most liberal member for two consecutive years.

Stark is argumentative, testy, opinionated, and sometimes vulgar. He accused Nancy Johnson (R-Connecticut), who favored market-based health care, as a “whore for the insurance industry” and said her knowledge of health care was based solely on “pillow talk” with her husband, a physician.

Now Stark is at his market-obstructing tactics again. He is hobbling HSAs with another layer of bureaucracy. Here is how an April 19 WSJ editorial “Stark versus the Free Markets” sees the problem.

"This week, the House passed legislation that included a provision to require every HSA transaction be reviewed and verified as a legitimate medical expense. Democrats say this is to ensure that consumers are using their tax-free withdrawals for a knee replacement, rather than a new iPod. In reality it adds a layer of bureaucracy that could sharply reduce the appeal and cost savings of HSAs.”

”A key player here is Ways and Means Health Subcommittee Chairman Pete Stark, whose main purpose in politics is to give the U.S. a government-run health-care system. He is a known opponent of HSAs – once comparing them to ‘weapons of mass destruction’ – because they introduce more individual choice into the health-care marketplace."

Just how Stark came to see the world of physicians and hospitals as a greedy cabal is a mystery. We know in 1963, Stark founded Security National Bank, a small bank in Walnut Creek. Within 10 years it grew to a $100 million company with branches across the East Bay.

Part of that growth rested on transactions and loans with doctors and hospitals. Perhaps a few financial transactions gone sour. That may have skewed his view of the provider world. Perhaps the wealth derived from the bank converted him to an angry cadillac liberal with a guilt complex. Whatever the reason, Stark exemplifies righteous indignation at work against those who don’t share his world-view.

Who knows? But what we do know is his laws and his views stifle market innovation and costs physicians and hospitals a bundle of legal fees – and, indirectly, the American people, considerable expense and restricted choice.

Anyway, that’s the Stark reality as I see it.

A Call to My Mother

Operator, connect me to heaven.
The number is nine eleven.

This is a real emergency,
It’s Mother’s Day,
OK?
I have a sense of urgency.

I need to speak to my late mother,
Only she will do, and no other.

Pause…..

Hi, Mom,

How are you doing up there?

How are things down here?

Well, down here things are only fair.

What do I mean by that?
What’s the chit-chat?

Well, the American economy is in the ditch.
Some say the country is only for the rich.
The price of gas, believe it or not, is $4 a gallon,
which is bad, no matter what your mpg.
Everybody is complaining about health care,
and why family doctors are getting to be so rare.

Who is running for president?

A young fellow named Obama,
who had a nice Kansas Mamma.
And an old navy guy named McCain,
whose mother of 96 has no cane.

Do I miss you?

You bet I miss you, mother.
I’ll never have another mother
Someone who loves me unconditionally,
and anything else I do additionally.

You say that last rhyme was a real stretch,
One that didn’t really rhyme or quite mesh.

I suppose that is so, but like all the other good Mamas,
You‘ll forgive me, even if I go to bed with soiled pajamas.

Sorry, Momma, the operator says our time is nearly done,
I love you, I miss you, and I will call next year,
same time, same son.

Health Care and U.S. Employers – The Tail That Wags the Dog

A global U.S.U.S. manufacturer has asked me to talk on health care trends. The company has $10 billion in revenues, and 56% of its sales are outside the U.S. Asia is its fastest growing market.

The manufacturer already knows,

That for the last five years, health costs have spiked,

• 4.4 X faster than general inflation.
• 3.7 X faster than workers’ earnings

That premiums cost $14,500 to cover a family of 4.

That U.S. costs are crimping its ability to compete globally. As one CEO noted, “Less than half of our workforce is in the United States – but 95 percent of our health costs are.”

That U.S problems stem from deep problems.

• Fee-for-service pay, which leads to more services and an opportunistic culture.
• No consensus on infrastructure, standards, and transparency which makes it hard to put your arms around system variables or even to know what they are.
• Lack of reasons for consumers to change, due to cost insensitivity and sparse information to decide what’s best.
• Resistance to changing the status quo by special interests with lobbying clout in Washington. As one cynic remarked, “Everything changes but the status quo.”
• An aging and in some ways less healthy population, e.g. we lead the world in obesity rates with only a fat chance that will change.

Tail Waving Dog

This is a case of the tail waving the dog. Here the dog is U.S. employers who provide 69% of health care coverage, and the tail is health care, the single fastest growing uncontrolled cost in corporate America.

Employers started offering coverage 65 years ago during World War II as a fringe benefit in response to wage freezes. Little did they foresee unintended consequences of the tail growing so huge or swinging so fast and forcefully.

Or, A Butterfly in Brazil

Edward Lorenz, an MIT meteorologist who founded Chaos Theory and who died on April 17 this year, described the “butterfly effect,” the idea that a small disturbance like a butterfly flapping its wings in Brazil could cause a tornado in Texas. The flapping wings represents a small change in the initial condition of a system. This causes a chain of events leading to large-scale weather shifts.. Had the butterfly not flapped its wings, the final system might have vastly differed. Lorenz realized perfect weather forecasting was a fantasy. It required perfect knowledge of wind, temperature, humidity, and other conditions everywhere around the world at one moment of time. Even a small shift could lead to completely different weather.
This analogy applies to health care. In the U.S. care remains local rather than global, and no overarching federal system exists. No perfect knowledge of variable local conditions exists. Ending local or regional variation to lower costs and standardize care is still a pipe dream for 35 years even though Wennberg advocated it in 1972. . Even leading academic centers – models of idealism and progress – differ strikingly in costs and outcomes due to contrasting cultures. Finally, a new technology – like CT scans – can upset forecasting.

What Can Be Done Now

This company isn’t interested in metaphors or theories. It wants to know what can be done now. What are trends that might curtail tails wagging and butterfly wings flapping.

Here are a few trends that might benefit companies, not necessarily in this order, and with my opinion attached.

• Employers shifting to high deductible HSA/based plans to replace HMOs and PPOs (These new plans make up 7.5% of the market, but have grown slowly)
• Employer demanding politicians act in Washington and state capitals, or we go elswhere (reform is deadlocked, but in our shell-shocked economy, employers can break the deadlock)
• Health 2.0. Wider use of algorthims to spot “best” doctors and hospitals and to identify widely varying aggregate costs of disease episodes (These algorithms have revealed in markets like Los Vegas, that aggregate costs for disease episodes vary as much as 4X)
• Wellness and prevention programs (essentally band-aids marginally reducing costs)
• Worksite clinics and retail clinics to promote greater convenience and lower costs (This is well underway, with the entry of such retail giants as Walgreens, Walmarts and CVS into the market)
• Widespread EMR adoption with embedded guidelines ( I’m skeptical unless providers are cheaper, user-friendly systems and financial incentives).
• Performance based reimbursement ( more of a ripple than a wave)
• Larger integrated physician practices (unlikely unless integration is “virtual” and doesn’t totally disrupt office-based practices.)
• Greater transparency(Sounds good but will be slow because of competitive pressures and reluctance to share data)

Those are a few trends for lightening the load on the business enterprise.

Health 2.0 Versus Human 2.0: No Contest

So far, from this blogger’s vantage point, www.medinnovationblog.blotspot.com, it’s no contest.

The score is Health 2.0, 550, Human 2.0, 0.

Five hundred fifty Internet experts gathered in San Francisco in September 2007 to attend a Health 2.0 conference, orchestrated and led by Matthew Holt, health analyst,, impresario of the Health Care Blog, and by Indu Subaiyu, health internet guru and consultant.

They were leaders of the Internet band. They were dedicated to the proposition that the Internet will clean up, rationalize, and make transparent all of those forces that have contributed to the current U.S. health care imbroglio.

Health 2.0 will be a game changer for unraveling then clarifying the U.S. health system, which one health 2.0 participant called a “calcified hairball.”

All the Giants were there in San Francisco (where else, since the Baghdad by the Bay is cheek-to-jowl with Silicon Valley), Google, Microscoft, WebMD, Yahoo, Intel, Revolution Health, and Walmart, and other major players, including Sermo.com, a physician Internet player, and a host of emerging entrepreneurs, too. It was a grand event. It pulsated with excitement and anticipation of what was to come – empowering and connecting everybody in the health care community and beyond.

It is safe to say, at this autumnal event, health 2.0 became a rolling forward movement – a swirling whirling mish-mash of Internet companies, wikis, mash-ups, videos, bloggers, and assemblers of user-generated data – all designed to connect health care consumers, providers, and players in a seamless Web of data and ideas.

At the conference seldom was heard a dissenting word or whimper from the Human 2.0 community. But more on that later.

For those of you not in the know,

Health 2.0 is the next generation Internet with increasingly simple applications and simultaneously more sophisticated software allowing every widening access and use of information at the site of care by end-users, namely patients and doctors and everybody else connected to health care. A winning combination of evidence-based information, sophisticated algorithms, centralized data depositories, and user-generated data hold health 2.0 together

Health 2.0 is a computer contagion, spread both by physical contact with infected brethren and by remote but ubiquitous and instantaneous cybespace connections. Health 2.0 is an Internet typhoon, cyclone, tornado, hurricane, tsunami, or any other large scale data storm system, all wrapped up in one electronic bundle, laying bare, flattening and making transparent everything in its path.

Health 2.0 excites everybody, left and right brainers alike, because it is so damn logical, allowing you to see details on the ground, in the air, and from cyberspace. You can view and document all transactions in the aggregate, retrospectively and prospectively, but not always perspectively.

Then there are the pitifully weak forces of Human 2.0

Human 2.0 is the present and future generation of followers who say humanism – that system of thought based on values, characteristics, and intellect of human beings – will resist the logical and relentless encroachments of the computer and will allow individualism, creativity, and unbounded thoughts of humankind to flourish. Computers are not the do-all, be-all, and see-all. They are limited human tools, not magical machines.

Health 2.0 clearly outmatches and outflanks Human 2.0. The Health 2.0 folks and their machines are, after all, online, real-time, all-the-time, and they have data to back them up. They are linear, objective, and measure-driven.

Human 2.0 folks may say humankind and health-kind are too subjective to measure, too complex to pin down, too chaotic to yield to computation, too private and too personal to be exposed for the whole world to see, and too full of human hunches, intuitions, paradoxes, informal relationships, gossip, rumors, jealousies, secrets, variables, permutations, and combinations to categorize. Indeed, some of the Human 2.0 advocates are saying in hushed voices that the Health 2.0 enthusiasts are suffering from an advanced case of hardening of the categories.

The game is still young, but it appears Health 2.0 has all the forces of logic, scientific and management evidence, business opportunities, and information technologies on their side. Human 2.0 may have some human capital and human nature assets, but little else. Human 2.0 is …well, a little too human, a little too protective in hiding its secrets. foibles and inconsistencies. To err is human, and to be inconsistent.

Personally, I find consumers and doctors partially covered, more attractive than those with all assets transparent and exposed. I fear I am one of God’s diminishing few, and the game will inexorably go to Health 2.0.

But it’s not over until the Fat Lady, either bare or clothed, sings.

25 Things I've Leaned about the Physician Culture

1. People become doctors to serve patients, not hospitals or business corporations.

2. Patients are not “customers,” they’re individuals who need your help, even when that help may be expensive and experimental.

3. Physicians are “the patient’s advocate,” a protector and guide through a world fraught with obstacles to care.

4. Filling outforms frustrates doctors because paperwork takes time away from seeing patients: some doctors take hospital jobs because they can practice medicine rather than processing paper.

5. HMOs increase health costs by over-promising coverage, then restricting it, and requiring doctors to hire three to four employees to monitor it.

6. The basic promise of consumer-driven care is that empowers patients and weakens middlemen.

7. Physicians like consumer-driven care because they believe patients, i.e. health consumers, in control of their own money will tend to be more judicious in selecting their doctors.

8. Regulation has its place, but too much of it stifles innovation.

9. Doctors distrust malpractice lawyers because most suits are trivial, and avoiding these suits requires doctors to practice defensively.

10. The American culture demands the best, accepts nothing less, and rewards lawyers if they do not get it.

11. Diagnosis is a creative act based on experience and cannot always be guided by data.

12. Clinical protocols often fall short because no two patients are the same.

13. You see patients one at a time, and you don't feel responsible for "population health."

14. You are responsible and accountable for patients while they’re in your office and in the hospital, but you can’t control what they do once they’re not under your influence.

15. You realize patients spent 99 percent of their time outside your office, and you know ill health often stems from flawed life styles and rarely rests on your advice, which you are not paid for offering.

16. “Health care,” as administered by health professionals, is responsible for about 10% of a society’s health; the rest is genetics, environment, lifestyle, and cultural socioeconomics.

17. Investor-owned HMOs profit from maximizing marketing and minimizing care.

18. Physicians tend to distrust organizational activities. Your success has always been by dint of your individual effort, whether that effort has been getting good grades in college, doing well in medical school to qualify for the residency of your choice, or caring for sick patients in academic medical centers or inner-city hospitals.

19. Your rewards have come through working hard, mastering your specialty and impressing colleagues, not through participating in hospital, HMO, or corporate bureaucracies.

20. You dislike organizational politics. You detest meetings. You turn a wary eye toward any activity that takes you out of the operating room, off the wards and away from your office, for those locations are where you’re patients, your joy in doing well, and your income are.

21. What has any managed care organization, hospital or business corporation done for you? HMOs, in your mind, manage cost not care. Has any HMO medical director or health executive ever helped you care for a patient better? Has any HMO policy improved quality of care for your patients? Has adherence to clinical guidelines really helped you find the right answers to your patient’s problems? Has any managed care organization placed at your fingertips in the waiting room, at the “point-of-service,” an easy-to-use information system that saves you time by telling you what drug to use, what diagnosis to consider and or whether the patient can pay?

22. Everything that relates to the new competitive environment has discounted your fees, driven down your revenues, compelled you to hire more personnel to deal with HMO clerks or “Doctor Denial” HMO medical directors and forced you into organizations where autonomy is less, rules are stricter, income is lower, work is harder, and a production-line mentality is at work.

23. Doctors are tech-savvy; 99% have computers with broad band access; but at this stage most feel they don’t need EMRs with all the bells and whistles until EMRs become less expensive and more clinical relevant.

24. A computer in the same room situated between the patient and a doctor changes human dynamics between the two.

25. You’re a professional, not a "provider" to be ordered about. What do these health care executives and those on the other end of an 800 line know about practicing medicine anyway?

Health Care Fundamental

Life is short, but health care debates are long. During debates, there are highs and lows – suggestions for rebuilding the system from the ground up, innovations to better the system, reports and retorts for reform.

But underlying the sound and fury, one fundamental never changes: doctors are at the center of the system. Only doctors can “practice medicine,” and most patients like it that way.

When push comes to shove, people go to doctors for relief of symptoms and pain, to find what’s wrong, and for an expert opinion based on education and experience. Most people trust doctors, they know doctors have gone through an arduous educational process, they’re aware the system, for the most part, allows only
physicians to prescribe medications and to perform procedures.

And they know, in their heart of hearts, and in their left and right brains, that hospitals would not exist without doctors, that doctors are more to be trusted than health plans, and that other approaches to care by American doctors - whether by alternative practitioners, nurse practitioners, nurse doctors, physician assistants, or Internet advisors – have value but in the end, doctors are best suited to care for the sick. This is not to denigrate other approaches, but to note, for the most part, the American physicians will continue to care for most of the people, most of the time, in sickness and in health.

I was thinking of this physician-centered undamental when recently reading about the state of retail clinics and medical tourism.

• Retail clinics have grown from 125 to 963 in the last three years. That’s impressive, and they are projected to grow even further. Walgreens says it will open 240 more by the end of the year, and Walmarts plans to open 400 more under hospital sponsorship. But the bloom may be often the retail rose. 69 clinics have closed this year in 15 states, due in part to startup expenses $500.000 secondary to marketing, complexity of operation, and the 18 to 24 months needed to break even. Those are the tangibles but there are intangibles too – patients leery of places that don’t have “real” doctors, absence of a traditional medical environment, fear of malpractice, failure to cure or dissatisfaction with results, and the fact that some end up in doctors offices for a definitive opinion or treatment.


• Medical tourism has gained a lot of cachet in last five years because of the globalization movement. It’s been widely noted that wealthy foreigners flock to the U.S. for care at such places as Mayo, the Cleveland Clinic, and Hopkins, and that Canadians and other ration-refugees from nationalized systems, jump the waiting lines to come to the U.S., and that the U.S. uninsured or underinsured reverse traditional migration patterns by traveling to India, Hong Kong, Thailand, and Singapore for cost relief. According to a report by MacKensey estimated 60.000 to 85,000 went abroad for care, where 710.000 procedures were performed. The fundamental here is that these numbers represent a ripple not a wave, and that the fundamentals – fear of the unknown, legal problems, and lack of follow-up, will slow the growth of medical tourism.

Sometimes, it helps to be reminded of the basics.

Code Blue For Some Medical Specialists

The May 5, 2008, Wall Street Journal reports some medical specialists are feeling blue about flat incomes and growing income gaps between themselves and their procedural colleagues, with whom they must share equally in overhead costs in some groups.

There is nothing new about this, of course, but most news items on low physician incomes focus on primary care doctors rather than the pay cognitive sub-specialists. The article “Medical Specialists Hit by Growing Pay Gap” says the following specialists, who tend to do few procedures but engage in long workups of patients with complicated problems, are falling behind in incomes -- neuro-opthamologists, neurologists, endocrinologists, pediatric subspecialists, metabolic physicians, rheumologists, and pulmonologists.

Particularly hard hit are pediatric rheumologists. There are only 200 of them, but 400,000 new cases of juvenile rheumatology, lupus, and related diseases survace each year. Neuro-ophthalmologists are also in trouble. Of the 400 now practicing, 140 will soon retire in a decade or so, and only 20 physicians have taken neuro- ophthalmology residences in the last 4 years.

The article says the gap all about high tech/low tech, with the procedure-oriented high tech specialists - radiologists, gastroenterologists, invasive cardiologists, and orthopedic surgeons – has grown wider over the last ten years because of higher codes for procedures and the ability to see more patients in a shorter period of time

If You Think Health Care is Expensive Now

On Fox News Wednesday, Sen. Hillary Rodham Clinton told Fox News' Bill O'Reilly, "If we don't get universal health care, we will continue to bleed money." Funny. The more Washington politicians promise to control health care costs, the higher they go. As humorist P.J. O'Rourke famously said, "If you think health care is expensive now, wait until you see what it costs when it's free."

Clinton and Sen. Barack Obama both promise to provide access to health care for all Americans by mandating that employers provide or contribute to the cost of health plans for employees. Clinton would mandate that all uninsured adults buy health care, Obama has no "individual mandate." Both candidates would offer health care for all children and subsidies for adults, and would require insurers to cover everyone, regardless of health.

Somehow they propose to offer and subsidize more health care without raising costs for the majority of Americans who already have it.
What next? Consume more calories, weigh less?

Debra Saunders, “Paying for Health Care – Who and How?” San Francisco Chronicle, May 4, 2008

“If you think health is expensive now,” he was said to decree,
“Wait until you what it costs when it’s free.”

So spake humorist P.J. O’Rourke,
who was speaking of government pork,

Maybe was referring to soaring Medicare cost,
which has thrown the federal budget for a huge loss.

Or maybe he was simply trying to be funny,
about being free with other people’s money.

When you promise something for free,
People tend to go on a non-buying spree.

Just ask those poor automobile makers of Detroit,
Where unions first dollar coverage did exploit.

Or ask executives of health maintenance organizations,
who first promised comprehensive care for all well patients.

But soon found the young and well get old and sick.
And give your best-laid budgetary plans a nasty kick.

But when you’re a politician,
You can be a bit of a magician.

You can wave your rhetorical wand,
Of which you have grown fond.

And you can say you will keep everybody healthy,
By not spending their money but the cash of the wealthy.

No doubt in a perfect world health care ought to be a right,
The cost will not be light, a boomer’s budget blight.

Health Care’s Split Screen – Costs and Technology

Viewing America’s health care resembles looking at a split screen. On the left screen, you see a people struggling with costs and coverage and saving money. On the right screen, you see a nation obsessed with technology and making money.

Nowhere is this split screen better shown than in two stories in today’s May 4, 2008 Sunday New York Times.

• On the front page, column right, the column reserved for the big news of the day, runs this piece, “Even the Insured Feel the Strain of Health Costs.” It reports even those with insurance are having a hard time getting care and paying for it. Combinations of high premiums, limited coverage, high deductibles and co-payments, and soaring food and gas prices, are causing people to avoid seeing the doctor and paying for that $50 co-payment. The Times reporters offer no solutions, instead content themselves with hard luck stories from across the land about people unable to pay and small businesses unable to provide benefits. This brings to mind Benjamin Franklin’s maxim, “For want of a nail the shoe was lost; for want of a shoe the horse was lost; for want of a horse, the rider was lost.” So much for the bad news, now for the good news.

• On the front page of the business section appears another story, more upbeat, even glowing, about using of robots to perform surgery. It’s entitled, “Prepping Robots to Perform Surgery.” The lead paragraph sets the tone, “What do you call a surgeon who operates without scalpels, stitching tools or a powerful headlight to light the patient’s insides? A better doctor, according to a growing number of surgeons who prefer to hand over much of the blood-and-guts portion of their work to medical robots controlled from computer consoles.” The article proceeds to describe a bustling $1 billion segment of the health care industry, its heroes, premier companies, and Wall Street’s love affair with medical robots, hospitals’ obsessions to have the latest and best, and diseases organs that lend themselves to robotic fixes. Theoretically, robots will erase differences between good and bad surgeons. There’s only one dissenting note. Winifred Hayes, CEO of Hayes, Inc, a company that evaluates medical technologies, says, “The real story is that this is a technology that has been disseminated fairly widely prematurely.” She might have added robotic surgery is expensive and does little to ease angst of those on the other side of the split screen.

A paradox, according to my dictionary, is a statement or proposition that contradicts itself. Health care's greatest paradox is that technology and progress go hand in hand but so technology and costs which makes progress difficult.

Health Reform: Slippery Slope of Public Opinion

Philosophically, many Americans are suspicious of direct, massive government intervention.

Lawrence R. Jacobs, PhD, “1994 All Over Again? Public Opinion and Health Care, “New England Journal of Medicine, May 1, 2008

Finding how Americans feel about health care reform depends on how you ask the question.

Between 1991 and 2007, 90% of Americans in polls said the health system should be “completely rebuilt,” and another 70% felt the system was “in crisis.”

Yet seven polls between 1998 and 2007, found 41% to 58% of Americans opposed a single payer system, and 51% to 63% of Gallup polls conducted since 2001, indicate Americans prefer to maintain the current system. In essence, Americans like their doctors and hospitals but hate “the system.”

Finally, though 56% of Americans in an ABC News, the Kaiser Foundation, and USA Today favored government insurance over the current system, respondents quickly reversed course when asked specific questions: 64% became opponents when told a government system might reduce access), 49% when informed a government plan might limit choice of doctors, 36% to 40% when they learned government care might increase waiting or involve cost sharing.

Americans are clearly uneasy about the unintended consequences of government takeover. Yet, according to Gallup, many are dissatisfied with current coverage (20%), cost (40%), and quality (15%).

The polls have yet to address how many Americans would favor the Republican approach – removing tax subsidies for employer health benefits, giving $5000 tax breaks for all individuals to spend as they please, HSAs and high deductibles, increased consumer information with transparency, and heightened market competition. My bet is Americans will resist this market-based approach too, just as they show hesitancy over single payer.

As a conservative people, critical of both big business and big government, we distrust sweeping change, whether it come from the left or the right. In the coming presidential election, neither Democrats nor Republicans will be able to mobilize enough support for overreaching change for the incoming administration.

Conclusion? We’re likely to see 1994 all over again – with a slight shift to the left if Democrats win big, and a few marketplace tilts if McCain wins. Meanwhile Americans will still want to have their cake (access to superb critical care) and to eat it too (comprehensive coverage with little direct, personal cost).

Controlling Longevity in a Polyglot Nation

These days physicians are being judged on outcomes. The ultimate outcome, of course, is how long patients live. But where you live may not depend on health care, but where you live, your race, and what your income is. If you live in Appalachia, the Deep South, the Southern Plains, or Texas, you’re likely to live less long than if you reside in the upper Midwest, New England, or the West.

In many ways, judging doctors indiviudally or the health system as a whole on longevity data is silly, even irrelevant One can judge physicians on process - whether a doctor orders beta-blockers or aspirin on hospital discharge after a heart attack or whether a doctor checks a diabetic’s eye grounds or glycosylated hemoglobin during an office visit– but to judge doctors on final outcomes, e.g., deaths after myocardial infarction, other chronic disease, or obesity , is absurd because longevity depends heavily on such interacting variables as genetics, race, lifestyle, socioeconomic status, and geography what doctors say or do.

A recent Harvard study in the journal PLoS found significant declines for longevity of women in 180 of 3,141 counties in the U.S. The rising mortality was mainly due to smoking, COPD, lung cancer, obesity, and diabetes. The declines, in turn, were due to economic gaps between the “least deprived” and “most deprived,” the gap growingfrom 2.0 years to 3.3 years in women from 1983 to 1999. The gap for men rose to 5.4 years from 1.6 years over the same period.

These gaps, of course, are matters for public health experts to consider. What can be done in an increasingly polyglot society to prolong life? The answer would seem to be to increase the general level of prosperity and narrow the gap between least and most deprived.

Lengthening longevity is a tricky general proposition, but let's give ourselves a little credit, we’re trying to help people live longer on multiple fronts,

• More physicians are encouraging patients to get preventive tests and to eat right, exercise more, and stop smoking (Codes to pay physicians for these activities would help).

• A number of entrepreneurial health appraisal organizations across the U.S. have sprung up to evaluate health and to recommend programs for wellness and prevention.

• Employers are initiating wellness and preventive programs, providing onsite facilities to aid wellness, and rewarding patients for wellness (the reward for employers are healthier, more productive employees, and lower benefit costs)

• Certain doctors, such as Michael Roizen, MD, chief wellness officer of the Cleveland Clinic, have spent their life promoting wellness among the public at large. Roizen created the RealAge ® concept, wrote a #1New York Times bestseller, RealAge, started an executive health center at Northwestern Memorial in Chicago, and has written or co-authored 10 books for RealAge, Inc, a media corporation providing health information for consumers.

There's only so much doctors can do.

Kibitzing with Kibbe, or How to Unravel the Health Care Hairball

I spoke last week to David Kibbe, MD, MBA, e-health consultant extraordinaire. Kibbe, who served for years at the e-point man for the American Academy of Family Physicians, now independently consults with the Kings and Queens of the e-health realm, such as Microsoft and Google.

Although his job for a decade or so was to encourage physicians to enter the e-health arena, these days his main schtick is e-consumer-empowerment. He believes Microsoft, Google, Dossia (a consortium that includes Walmart and Intel), and others will turn health care on its head in a few short years, rather than a few long decades.

The tool of these a-giants will be consumer-owned personal health records, bearing information on their medical histories, medications, allergies, lab tests, x-rays, even images of EKGs, CTs, and MRIs. Another arrow in the consumer empowerment quiver will be web sites such as revolutionhealth.com, medcarecompare.com, outofpocket.com, and carol.com, which seem to be popping up everywhere..

Rather than blog you down with the details of our discussion, let me share with you with excerpts of some of Kibbe’s recent comments in a September 24, 2007 e-caremanagement blog.

Health 2.0 Deserves Careful Watching

By David Kibbe, MD, MBA

Thursday I attended a wonderful one day conference, entitled “Health 2.0 — User Generated Health Care .” One of the most interesting events of 2007. Held in San Francisco. I had a chance to talk with Adam Bosworth and Missy Krasner of Google, with Peter Neuport of Microsoft, and with David Brailer, among many others.
How to describe this event?

Imagine it’s 1995, and you spend 8 long hours with 500 other people looking at demonstrations, very brief, of about 40 companies who want to use the Internet and Web for e-commerce and other businesses aimed directly at the consumer. There is lots of enthusiasm, and lots of venture capital attention.

Imagine that in the mix of companies demo’ing their Web-based applications are four tiny firms: Google, Yahoo, Expedia, and Amazon.com . Along with 36 other companies and products. But remember, it’s 1995, and so you have no way to know which company or product will grow and go on to be successful businesses in 2000. (A lot of people in the audience don’t think Google will do very well, by the way.)

That’s what this was, except that the companies and products at Health 2.0 were all aimed at consumer health activities that offer interactive benefits to the user, and in some cases to providers. I saw some amazing products and services, but I have no way of knowing which ones will ultimately succeed and move into the mainstream.

There were several categories of panels for the demonstrations.

• The Role of the Consumer Aggregators, which included Google, Microsoft, WebMD, and Yahoo.
• Search in Healthcare, including Webstory and Kosmix.
• Social Media and Networking for Patients, including PatientsLikeMe and Sophia’s Garden
• Tools for Consumer Health, e.g. Vimo, which offers a way to purchase health care insurance online, and DNA Direct.
• Provider and Social Networks. e.g Sermo and Within3

It will take me some time to digest all of this. Here are some first impressions:

1) What I really, really liked was the way in which so many of these companies and applications helped the patient/consumer help himself/herself — to be better informed, to know their options, to take better actions, to hope and act in their own best interests. This is exciting, and very necessary, as physicians in primary care are already unable to meet the demands upon them for care delivery, and this imbalance/shortage is only going to get worse in the future. And it’s exciting because empowerment is the key to saving the individual out-of-pocket spending. As health costs continue to shift to the individual, Health 2.0 can really be helfpful.
Healing without information is indistinguishable from magic…..And magic in health care today is unsafe and very expensive!
We need an informed (empowered) health nation. Health 2.0 is leading that potential.

2) There are two issues that I would focus upon:

• We need to help people discover, collect, store, and utilize the relevant health information in digital (computable) format, e.g. the CCR and XML. Until we do that, none of these wonderful applications can be invoked at will without having to type in medications, diagnoses, or family history, etc. And that is going to impact adoption.

• We need to find ways to share the task of personal health data discovery and use — including all the repurposing of that data — between the individual and his/her providers. These applications and networks pose wonderful opportunities for patients and physicians to work together in completely NEW and DIFFERENT ways, some of which we saw yesterday, but for the most part hasn’t yet occurred