Notes of a Medical Technology Realist

I’m a realist about technology use in American health care. Given the American culture and its belief that solutions to complex problems lie in technology just beyond the next horizon, I believe it's difficult, indeed, nearly impossible, to effectively suppress technology use.

Those in power tend to believe they can control medical technologies, bring in experts to figure out what needs to be done, conduct large scale studies to assemble evidence to decide what to pay for, set pre-authorization standards to rein in abuses, and limit available technological installations.

This belief sounds logical. But in America these approaches may not work. Why not? The problem is that complex technologies and their uses and abuses are…..well, complex.

At the market level in a complex capitalistic society that believes in innovation and entrepreneurship and choice, there are simply too many interacting variables, vested interests, market-driven forces, permutations and combinations among interacting individuals and entities, connections at the edges of practices and inside and outside organizations, financial and emotional incentives and considerations, hospitals and doctors who see technologies as a means to increase marketing clout, bring in more revenues, enhance prestige, and improve care: and too much pressure to generate additional sources of money to compensate for decreased reimbursements, patient desire to access the best and the latest, hype and hope generated by ubiquitous media.

Complexity doen’t end there. Once the technological genie is out of the bottle, and hospitals, specialists, and supply chain companies taste fruits of technology, there’s no going back, no way to stop, step back, and re-assess hard evidence whether a technology actually works to improve outcomes..

Take the case of imaging. Once CT and MRI scans hit the marketplace in the early 1970s and doctors recognized computerized imaging was a superior technology that allowed doctors to look inside brains, hearts, body cavities, and joints, there was no retreat. Marketing forces were simply too powerful.

Howard Hiatt, MD, dean of the Harvard School of Public Health, wrote in 1976 in the Wall Street Journal that there was far too much medical technology, and there ought to be a National Technology Assessment Institute to establish irrefutable proof that medical technologies improved care before they hit the market. His idea never got off the ground. Imaging flourished. Indeed, by 2001, a survey published by Fuchs and Fox in Health Affairs, among 225 internists indicated the number one innovation over the previous decade was CT and MRI scanning.

Consequently, imaging, in all of its variations and configurations, has become the fastest growing single cost component of the health system, with growth rates
of 16% to 18% per annum.

Health plans and Medicare have tried to contain imaging growth without avail. This year Medicare drafted a proposal saying it would only pay for CT angiograms if a large scale study proved their worth in improving care. The proposal met with fierce resistance from cardiologists and industry CT suppliers and lobbyists.

Medicare backed down. Two comments on why Medicare blinked, cited in a June 29 New York Times piece, “Weighing the Costs of a Look Inside the Heart,” are worth quoting and tell the technology tale..

• Said Barry Straube, MD, Medicare’s chief medical officer, “There are a lot of technologies , services, and treatments that have not been shown to improve health outcomes in a definite manner,” in announcing Medicare had changed its mind and would pay for CT angiograms, designed but not proven to rule out heart disease and to identify calcified arterial plaques.

• Noted Dr. Redberg, University of California San Francisco cardiologist, “Once the train leaves the station, once the technology gets into the marketplace, we don’t get the evidence. We’re spending a lot of money on technology with unclear benefit and risk.” And so CT angiograms are destined to continue, in ever increasing numbers.

The Web of Ideas to Limit Technology Costs

Here, briefly, are pros and cons of a web of ideas, many based on the Web itself, to reduce and untanglesoaring costs of technologies and to curtail the thirst and dependence of American health providers and consumers on technologies.

• Place doctors on salaries to end incentives to use medical technologies for personal gain from self-referral. This is so-called Mayo Model. It has two problems – one, only 10% to 12% of American doctors practice in Mayo type environments; two, the economic success and growth of hospitals employing doctors depends of ordering technologies offered by the hospital, thereby increasing costs.

• Reward only technologies that are “evidence-based.” Sounds good, but evidence-based research is in its infancy and “evidence” too often rests in the eyes and spins of beholders, outcomes based on patient behavior and compliance, not on actions of doctors. Few treatments have “absolute” evidence of cost effectiveness and reside in that “vast gray void” devoid of scientific proof and more on incentives of doctors and expectations of consumers. Besides where is the evidence to pay for "social visits," which account of about half of patient visits to the doctor.

• Compel health consumers to pay for a growing portion of costs using health savings accounts, high copays, and high deductibles in a consumer-driven environment using health savings accounts, with unspent tax-free money carrying over to subsequent years in a 410J type of arrangement. Consumers spending their own money will spend it widely, conventional wisdom says. The trouble is it’s hard to wean paternalistic pundits, politicians, and policy wonks, and consumers off idea that health care ought to be essentially “free.”

• Develop sophisticated algorithms using artificial intelligence and predictive modeling and aggregate pricing techniques to identify those technologies that offer proof of value and avoids unnecessary duplications and medical expense. Requires widespread computer systems, “fully operative” electronic medical records and personal health record systems that talk to one another and are trusted and used by physicians and hospitals.

• Introduce a single-payer system, as in Canada or the United Kingdom, that minimizes administrative expense and controls technologic use and installations by fiat and command and control methods. In America, socialism and capitalism don’t always mix, particularly when they restrict freedom to choose and exercise options.

• Modify the malpractice environment to end practice of “defensive medicine” so doctors are not punished for failure to diagnose using advanced medical technologies . Believe this will happen, and I will be glad to sell you a time-share in North Dakota in January.

• Have physicians spend more time with patients and pay them well to patiently to explain risks and benefits and options of technologies versus less expensive and more conservative wait-and-see approaches. This is difficult in our fast-paced society looking for immediate answers and gratifications, often for life-style enhancement and advancement rather than diagnosis and treatment of life-threatening disorders.

Oh, what a tangled web we weave then we try medical technology costs to relieve.

Medicare Pay Cuts Imminent

Doctors Outraged;
Seniors See Prejudice against Aged;
Democrats Sense Potent Campaign Issue

“Time after time, Congress has jumped in at the last minute to block Medicare payment cuts to doctors. Will this be the time when time runs out?”

Jacob Goldstein,” Bill Blocking Medicare Pay Cuts to Docs Stalls in Senate,” Wall Street Journal Health Blog, June 27, 2008

“President Bush had threatened to veto the bill, in part because it would reduce federal payments to private Medicare Advantage plans, offered by insurers like Humana, UnitedHealth and Blue Cross and Blue Shield companies.”

Robert Pear, “Doctors Face Payment Cuts for Patients on Medicare, “New York Times, June 27, 2008

July 29, 2008 - On June 26, Tuesday, a handful of Republican Senators handed Democrats a campaign issue by voting against calling up a bill that would have blocked a 10.6 % cut in Medicare pay for doctors, thus killing it. Senate supporters fell two votes short of the 60 needed to close debate. The vote was 58 to 40. Senator Obama voted to block the bill. Senator McCain, who was campaigning, and Senator Kennedy, who is ill, did not vote
The House had voted overwhelmingly 355 to 59 to pass the bill the previous day.

Cuts are scheduled to start on Tuesday, July 1, while Congress is taking a July 4 recess, making a last minute reprieve unlikely.

On Campaign Trail

On the campaign trail, Democrats will argue Republican Senators’ vote favors big business, i.e. the private for- profit Medicare Advantage HMO industry and the unpopular President Bush. This tactic will anger 44 million Medicare recipients, a potent voting bloc, and 500,000 or so practicing physicians..

Physicians, and anyone else with eyes to see and minds to think, knows Medicare is the Sheriff of the health system and sets rules and precedents on health plan payments. Health plans obey those with the Medicare badge. Health plans follow Medicare in lockstep, especially when it benefits their bottom lines.

Consequences, Expected and Unintended

What are expected and unintended consequences of the Senate action?

On the “expected” side, you can expect

1) “Compassionate” Democrats will seize a wedge campaign issue against “Heartless” Republicans, who, they will say, care only for profit-making enterprises.

2) The senior vote. led by AARP and the like, will swing to Democrats,

On the “unintended” side, you can expect

1) Outrage among doctors and seniors: already Sermo.com has 1174 messages among doctors, some threatening to boycott Medicare and others saying they shut down practices to new Medicare patients.

2) Widespread protests among seniors, already upset about higher Medicine copays, increased premiums, and complaints of doctors about unfair Medicare restrictions and expenses.

3) Less access to primary care physicians, and specialists who conduct Medicare based practices.

4) Loss of morale among doctors, who will retire earlier, restrict access, cut Medicare services, and seek careers outside of private practice.

5) Cries of dismay among those unable to find a doctor and among doctors unable to afford to care for them.

6) These messages will become common, “Where have all the doctors gone?” “Will the last doctor in America please turn off the lights?” and among doctors, “We no longer accept new Medicare patients.”


In Short

This Medicare crisis will engage all politicians, Republicans, Democrats, and independents. This crisis will be about what you can expect, who will be the most politically correct. Expect an unprecedented wide protest among clinicians, who depend on Medicare to meet economic conditions. Expect outright outrage among Medicare patients, who depend on predictable physician relations. Expect campaign talk on what’s good for business ganders isn’t necessarily good for the physician and patient bystanders. Expect frequent reportage on the physician shortage. Expect Obama moral stigmas on McCain health plan market-driven enigmas. Expect a campaign battle for the minds the public who want choice and freedom and who aren’t mindless cattle. Expect patients to take sides on health plans versus doctors with whom their care resides

Disruptive Innovation Takes Time

While in route to a recent retreat to speak about disruptive healthcare innovations, I picked up a copy of Harvard Business Review on Managing Health Care, which contained several articles about disruptive innovation and the changing healthcare landscape.

As I read the book, two questions popped into my mind:

If disruptive innovations are so hot, why aren't they working to lower overall health costs?

And if prices are so high, why are hospitals in such hot water?

Health costs ballooned by 4.4 times the rate of general inflation from 2002 to 2007. In "Will Disruptive Innovations Cure Health Care?"—an article featured in the compilation—Clayton Christensen, who popularized the term "disruptive innovations" in The Innovator's Dilemma (Harper Business, 2000), explains why healthcare costs may remain so high:

"Nurse practitioners, general practitioners, and even patients can do things in less-expensive, decentralized settings that could once be performed only by expensive specialists in centralized, inconvenient locations. But established institutions—teaching hospitals, medical schools, insurance companies, and managed care facilities—are fighting these innovations tooth and nail. Instead of embracing change, they're turning the thumb-screws on their old processes—laying off workers, delaying payments, merging, and adding layers of overhead workers. Not only is this at the root of consumer dissatisfaction with the present system, it sows the seed of its own destruction."

Christensen's comments may be true, but the medical establishment is unlikely to change. Its leaders are heavily invested in specialized facilities, and specialists (two-thirds of all doctors) are accustomed to having things their way and of dictating who can do what to whom.

Resistance to Change
The healthcare establishment is strong. It has lobbying power. And it can always claim only it has the stature and legitimacy to deliver quality care and set standards. For these reasons, disruptive solutions have been slow to come and to bring down health costs. These innovations have been marginally effective.

Sure, there have been signs of progress. Since 2000, Congress has made high deductible plans with HSAs widely available, consumer-driven care has chugged ahead, hospitals have started to decentralize, doctors have invested in specialty hospitals and other physician-owned facilities, large employers have set up worksite clinics, big retailers—Walmart, CVS, and Walgreens—have gotten serious about retail clinics, medical tourism has been born, and some have became delirious about health 2.0 as the do-all and be-all to re-organizing our dysfunctional system.

And the hospital establishment has shown signs of failure and panic. The fear of failure is out there. Michael Sandnes, director of healthcare services for the Executive Sounding Board in Baltimore, writes in a recent column, "Is The Tidal Wave About to Wipe Out the Health Care Sector?":

"Many hospitals and healthcare facilities have come face-to-face with the reality that factors largely out of their control, like insurance reimbursement and government funding, will ultimately determine whether they survive—perhaps in a different form with a new owner or in a downsized facility—or shut down."

Hospital challenges include

Competition from freestanding, investor and physician-owned diagnostic and treatment facilities.
Cost and complexity of technology and IT infrastructure.
Constant need to improve quality and patient safety.
Labor supply shortages
47 million uninsured Americans.
Questions about not-for-profit status
Pressures on Medicare and Medicaid reimbursements.

There are signs hospitals are awakening to the reality the status quo will no longer work. Hospitals are rapidly decentralizing to form their own outlying facilities, or creating partnerships and alliances with physicians groups. A good example of hospital decentralization is partnering with Walmart to own, oversee, and staff retail clinics in the 400 retail clinics Wal-Mart plans to open in the next two years.

The role of physician leadership
As these disruptive changes are underway for hospitals, pundits tend to disregard innovations on the physician side of the equation, perhaps because of physicians' fragmented, disorganized, independent nature. In the managerial and venture capital world, physicians tend to be viewed as organizational mavericks and therefore may receive little respect.

This is a mistake. Physicians know that without physicians, hospitals would be nothing but empty shells of buildings with mediocre food. They also know physicians flooding into hospitals for employment may ultimately rise to top leadership positions, as they have at Johns Hopkins, Mayo, the Cleveland Clinic, Duke, Emory, and Health Partners in Boston.

Finally, physicians know the future lies in detached facilities—emergency rooms, diagnostic centers, surgicenters, big MACCs (multispecialty ambulatory care centers), imaging centers, surgicenters, specialty hospitals, specialized chronic care facilities—established and controlled by physicians, and in their own revamped, rewired, and retooled practices, delivering care outside established institutions.

These shifts are underway, but they sometimes lack overall physician leadership. Needed now are new business models, new ideas, and new innovations. Ideas for these may emerge of such knowledge exchange sites as Sermo.com, which now has 65.000 doctors submitting ideas and suggestions, or the Physicians Foundation for Health System Excellence, whose constituency consists of state medical society leaders representing 300,000 practicing doctors. New consulting firms, focusing on physician innovation, are springing up to provide new directions.

The physician culture as a whole must coalesce around central disruptive ideas that make healthcare more convenient, cheaper, better, and more adoptable by generalists and the public at large. Rather than turnaround firms, practicing physicians need organizations and leaders with market insights, strategic and development skills, and ability to help physician execute through innovation in rapidly changing markets.

I conclude with this cautionary note from Clayton Christensen, Richard Bohmer, and John Kenagy in the Harvard Business Review on Managing Health Care:

"If history is any guide, the established high-end providers of products and services are likely to be articulate and assertive about preserving existing systems in order to ensure patient-well being. Very often, however, their eloquence reflects concerns about their own well-being. Customers have almost always emerged from disruptive transitions better off- as long as the disruptions are not forced into an old mode, but instead enable better service to be delivered in a less-costly, more convenient contract."

Maybe in the end, those at the bottom of the healthcare food chain—patients and primary care doctors, will set the pace for change. But we're not there yet.

Massachusetts 2 1/2 year old Universal Coverage Pan

Observations about progress to date.

1. At its onset, Massachusetts was a state unusually positioned for universal coverage, a liberal populace, a low rate of uninsured (552,000 of 6.4 million, 8.6%) and the highest health premiums in the land, roughly 30% above the national average.
2. Other states are unlikely to follow Massachusetts because of different demographics, e.g., California has more uninsured, 6.7 million, than the entire Massachusetts population of 6.4 million.
3. Universal coverage is more expensive than originally projected and is growing faster than anticipated because of record and growing enrollments.
4. The plan has successfully newly insured 350,000 residents, 5.5% of the state population.
5. Universal coverage requires a large and complicated bureaucracy (The Connector, rules for tracking who gets subsidies and how much, tracking who is getting enrolled, and Medicaid tracking and adjustments).
6. Monthly costs per subsidized member are $352.43 per member.
7. The individual mandate is enforced through state income tax returns.
8. In 2008, the maximum penalty for not having insurance was $912.
9. In 2008, for most citizens health insurance is now considered affordable.
10. Universal insurance coverage is not the same as universal access, :many citizens are having difficulty finding a primary care physician and primary care practices are overloaded.
11. Cost control is an overriding issue (according to John Kingsdale, executive director of the Commonwealth Connector, “To maintain public and financial commitment. Controlling costs is 110% of the challenge over the next several years.”)
12. he legislature is considering new cost controls, and Blue Cross Blue Shield may initiate a plan combining payments combining pay-for-per-performance and capitation.
13. The Massachusetts experiment is a work in progress, is popular among the public and its politicians, and will continue as long as the State and the federal Medicaid program is willing to pay the ever-increasing bill
14. Universal health reform takes more time and more money than expected, evening an overwhelmingly liberal state with the best intentions of all participating parties.

Reference

Robert Stein brook, M.D. “Health Care Reform in Massachusetts – Expanding Coverage, Escalating Costs,” New England Journal of Medicine, June 26, 2008.

EMRs and Consumer-Internet Use

I have a confession to make. I don’t use ATMs. I don’t shop online. I don’t deposit online. I don’t go through electronic shopping center check-out counters. I don’t seek out doctors with EMRs for my personal care.

The New York Times, that fount of national health system wisdom, disagrees with me. In a June 24 editorial, “Our Pen-and-Paper Doctors,” the Times opines that every American doctor ought to have an EMR, just like doctors in Australia, New Zealand, the Netherlands, and Denmark do. The Times cites a Mass General survey of 2700 doctors and laments that only a “paltry” 4% of doctors have “fully functioning” EMRs. The Times concludes, “It is time to drag private physicians out of the paper age.” Presumably public doctors, bought and paid for and supported by government, would have EMRs.

In fairness, the Times does mention that American doctors think EMRs cost too much to buy and maintain, don’t fit their needs, and become rapidly obsolete. What the Times doesn’t say is that studies to date in the U.S. indicate no significant differences in quality, safety, outcomes, and productivity in doctors with or without EMRs.

Nor does the Times say anything about consumer Internet attitudes and actions. Surveys indicate consumers would like to communicate with doctors by e-mail and regularly surf the Net for information about signs and symptoms and treatment of disease.

But, as it turns out, consumers don’t pay much heed to doctor rankings and choosing a doctor. According to a 2007 survey of 1007 California adults, only 1-2% use doctor online rankings to choose or change doctors. Consumers prefer word of mouth referrals from friends, relatives, and neighbors and personal stories. When it comes to choosing doctors, the Internet is not yet that Great Global Positioning (GPS) in cyberspace for steering , influencing, and telling patients where to go for care.

I suppose it is contrary, ornery even irreverent, for me question the notion that this nation’s health system and its doctor choices, are not yet ready for e-prime time, or that our medical system doesn't have to run on Internet time, or that myself and 98%-99% of other consumers, still prefer to choose caregivers the old-fashi0ned way, word of mouth and local and regional reputations, rather than Internet rankings, but that’s what blogs are for – to keep readers and the Times in touch with reality.

References

1. New York Times editorial , “Our Pen-and-Paper Doctors,” June 24, 2007.

2. Pamela Lewis Dolan, “Patients Rarely Use Online Rankings to Pick Physicians,” AMedNews.com, July 23/30, 2008.

3. California Healthcare Foundation, “Just Looking: Consumer Use of the Internet to Manage Care,” Harris Interactive Survey of 1,007 adult Californias form Nov. 5 to Dec. 17, 2007

Poem Call to Babyboomers

Operator, please connect me to America’s babyboomers
Yes, those 78 million soon to be health care consumers.

All born after the year of nineteen forty six,
Now about ready to qualify for a Medicare fix.

Pause…

Hello, all you baby boomers
Have you heard the rumors?

That as you grow old and startto age
You’ll turn over a new health page.

That you will be much more demanding,
To avoid a life style crash landing.

That you will flock to cosmetic operations,
To lookyouthful for all possible occasions.

That you will seek new hips and knees,
To remain free of any over-use disease.

That at all costs you will avoid unseemly unsightliness,
No contacts or bifocals, but lasers to hid nearsightedness.

That you will come to doctors’ offices with e-downloads,
Gathered during your many trips down electronic roads.

That you will examine doctor data outcomes,
To comparison shop for the best value sums.

Most doctors know these rumors are misleading,
Indeed, that many are simply not worth heeding.

Like all patients you’re looking for best advice,
Not necessarily the best price or latest device.

Life, health, prevention, imagined and real disease
Are so complicated no single approach will all please.

Keep your faith in doctors, be reasonable.
For you they will do whatever is feasible.

In the end, it’s all about options and choices,
And about physicians listening to your voices.

For your care you deserve freedom and to be in charge,
To partner with doctors in a relationship writ large.

Practicing in Retail Settings

“Why didn’t I think of that?”
We live in a world of innovation overdrive, overloaded by consumer choice and excruciating tough commercial realities, realities that include the rapid commoditization of markets, technology shifts, margin pressures, and relentless fragmentation of consumer and business markets.

Erich Joachhimsthaler, Hidden in Plain View, Harvard Business School Press, 2007

Sometimes the obvious is in plain sight. But we may overlook the obvious because of current or perceived problems. Doctors live in a world where medicine has become a business. There is no better evidence of this than the opening of 1500 retail clinics in commercial outlets.

One of the maxims of innovation is;”Look at the opportunity not the problem.” Every problem presents opportunities.

• In U.S. shopping centers, the current vacancy rate is 7.6%. Because of the sluggish economy, the CoStar Group, a real estate information provider, expects 28% of new real estate space to remain vacant.

• In the physician office space market, costs are going up, especially in medical office buildings, adding gloom to the present picture of increasing overhead and flat or decreasing revenues.

Now would be a good time for physicians to consider moving into strip malls. Spaces are empty. Rents are negotiable. Foot traffic is heavy. Remodeling costs are modest. Parking space is ample. Patients are looking for convenience.

An article in the June 16 AMA News “Revitalizing Dead Space” quotes Kenneth Watson, president of Kenneth Watson & Associates in Miami , a health care real estate brokerage, “ Retail draws a tremendous amount of trips each per year. And with a medical office in a retail center, one person can see a physician while the family dines or shops.”

With the cost of gas, consumers are looking for one stop shopping opportunities. This has not gone unnoticed by Walgreen, CVS, and Walmart, all of whom are opening retail clinics at a brisk clip.. By the end of 2008, 1500 of these clinics are expected to be in operation. These retail chains see the opportunity of combining shopping, health advice, and prescriptions. Walmart has added a new wrinkle – having local hospitals operate these clinics. Academic centers are also into the act. Vanderbilt University Medical Center has yet another approach. It has a project, Vanderbilt Health at One Hundred Oaks, where it will house 16 medical clinics and support services in a vacant retail space at ½ the cost it would have taken otherwise.

Opening medical facilities in retail setting is not new. Lucien Wilkins, MD, a Wilmington, N.C, a retired gastroenterologist turned real estate entrepreneur, has long been in the business of promoting and building big MACCs (multispecialty ambulatory care centers) in prime retail locations in North Carolina.

Aaron Kohl, a medical office broker in Scottdale, calls combining retail with medical “A genius concept” – big lots on major roads, and more parking and visibility and access than congested medical centers, which tend to be inner cities .

There’s another factor as well. The health care industry is the most vibrant part of the U.S. economy, and brokers are more than willing to negotiate a favorable rate in blighted retail malls. In an aging population with all the publicity surrounding health care, medical growth tends to be recession-proof.

One caveat. I’m not certain retail clinics, run by nurse-practitioners, are the wave of the future. To date, only 7% of patients have visited them, and 65% have concerns about staffs without doctors. But these clinics may have paved the way for medical offices located in similar settings. There’s a place for retail clinics offering vaccinations, treating colds and warts and rashes, routine preventive tests, physicians exams for camps, sports, and school, but there may be even large place for doctors offering comprehensive care in similar locations.

Renegotiation of Health Care

I have a quixotic dream physicians can renegotiate conflicts with major health care stakeholders. Surely these stakeholders will listen to reason – to cost and time burdens imposed upon physicians with unintended consequences.

My dream harks back to a 1999 interview I conducted for The Physician Executive with Leonard Marcus, PhD, Director of the Program for Healthcare Negotiation with Conflict Resolution at the Harvard School of Public Health. Marcus published a book Renegotiating Health Care: Resolving Conflict to Build Collaboration (Jossey-Bass, 1999).

I know this may be a pipe dream. Our political system is built on conflict and resolution through compromise. Conflict is in our DNA. It’s by design. That’s why we have three arms of government, two political parties, adversarial hearings, partisan scandal investigations, overheated political campaigns, constant Congressional haggling, and periodic elections to turn the bums out. In the end, the result is usually uneasy compromise.

Why not health care too? Why not try to break the gridlock over health reform? Maybe physicians should seize the initiative and renegotiate conflicts by seeking sustainable innovations to dig our way of the present imbroglio?

The renegotiation of physicians with stakeholders in other major health care sectors might resolve a few of these issues. These stakeholders, after all, depend of physicians for their existence. Perhaps a little conflict will build resolution.

Conflicts with Stakeholders to Be Renegotiated

Managed Care - Underpayment, speed of payment, unrealistic physician rankings, excessive out-of-network payments, unknown reasons for including or excluding physicians from networks, more coverage of patients with pre-existing illness.

Hospitals - Balance between competition and collaboration, reasonable payment for ER coverage and committee duties, coordination between hospital and physician IT systems, recognition that physician-owned facilities may provide better more specialized care.

Government - Relief from overwhelming paperwork, reasonable Medicare and Medicaid payment formulas, common sense on “non-payment” of certain unavoidable complications, raising codes for primary care physicians and Medical Home incentives, simplifying Medical regulations, now running over 150,000 pages, subsidies for those who can’t pay, adopting Federal Employee Benefit Plan, now available to all federal legislators and federal employees (what’s good for the gander out to good for the geese).

Medical Device Industry – Bar codes for devices to track effectiveness, information on relative effectives of imaging technologies, attention to costs and policies effecting “supply chain of medical devices,” one of fastest growing medical costs; a little credit to innovative physicians for developing new devices and sorting out those that don’t work.

Drug Industry - Initiatives to reduce common generic drug costs, as Wal-Mart has done, regulations to monitor and control misleading Direct to Consumer ads and to limit TV ad time (how many of the virile healthy young men displayed in ads could possibly have ED?), acknowledgment among critics that drug firms support the lion’s share of CME in this country and that drug firms are not as “greedy”. The academic establishment doeth protest too much and too self-righteously about evils of drug marketing, physician –Pharma summits to reconcile differences.

Information Technology Industry – Realistic attitudes towards seamless interactive technologies not being the Holy Grail, understanding that data alone does not cover or render rationale all patient-physician interactions, work on common language and standards linking EMRs and PHRs, development of useful EMR software for different specialties with special needs and common situations, e.g., communicating with ER when you send patient, more attention paid to the expense of data entry.

The American Medical Association - A deeper knowledge that it is in trouble with its main constituency- America’s practicing physicians, who feel the AMA does not consistently act in their best interests, which may be why only one of four physicians belong to the AMA, why primary care physicians have only ½ and 1/3 the income of their specialty brethren, why many physicians have profoundly low morale, why 200 nursing schools are stepping into gap by a plan to produce more “nurse-doctors” to become the equivalent of primary care doctors.
The AMA does not get the credit it deserves for averting many potential legislative bad laws , but it should consider “U-turn” towards improving the lot of physicians.

And that’s just for starters

Aetna Re-Commits to Better Physician Relationships

Nearly five years ago, Aetna committed to working more closely with physicians following a class-action lawsuit settlement with multiple state medical societies. Aetna was one of many health plans accused of concosting schemes to underpay doctors.

Terms of the settlement included:

• Funding of a physician grant-making organization later called the Physicians Foundation for Health System Excellence.
• Forming a Physician Advisor Board to advise Aetna on coding and reimbursement issues.
• The creation of the Physicians Advocacy Institute to oversee compliance on coding and reimbursement issues.

Aetna also committed to:

• Allowing doctors to leave the network 90 days after giving notice.
• Allowing claims submission up to 120 days after the date of CAE.
• Making the fee schedule available. 90 days before any change
• Contracting without all-products or gag clauses.

What Aetna has done is to re-commit to these various changes on June 2, when its 5-year settlement with Aetna and other health plans will expire.

What is the lesson here? It is that confrontation between physicians and health plans can lead collaboration. In the case of Aetna, according to a survey conducted by Athenahealth, a claim processing firm, Aetna has moved to the top of the list as the health plan in paying claims accurately and quickly. The top eight firms, in order of ranking, are:

1. Aetna
2. Cigna
3. Humana
4. Medicare (Part B)
5. UnitedHealth Group
6. WellPoint
7. Coventry Health Care
8. Champus/Tricare

Meanwhile, the Physicians Foundation for Health System Excellence has been offering grants worth millions of dollars to physician organizations to help them improve the efficiency and quality of care. The Foundation is also conducting a survey of the nation’s primary care physicians and certain specialties to assess their socioeconomic and attitudinal status.

Could Tim Russert's Death Have Been Predicted or Prevented?

The question posed in the tile is unanswerable, but I put it to William Bestermann, MD anyway. Doctor Bestermann is medical director of the Vascular Medical Center for the Holston Medical Center in Kingsport, Tennessee. He has a long and deep interest in preventing vascular deaths and is considered an authority on the subject.

Through his work at Holston Medical Center and at COSEHC (Consortium for Southeastern Hypertensive Control), he has shown doctors using protocols to prevent, monitor, and minimize metabolic risk factors producing the vascular death epidemic can dramatically reduce the rate of sudden deaths in patients with diabetes, hypertension, and lipid disorders.

Bestermann believes diabetes, hypertension, and the various dyslipidemias are closely related and inhabit the same vascular universe, and simultaneous control of metabolic factors ( Hemoglobin A1c of less than 7.0, BP under 130/80, and LDL of 70 or less) sharply reduces vascular deaths. Further, he thinks this reduction can be implemented in any community with physicians willing to follow protocols focusing on metabolic control.

He expresses his philosophy and its results in my book Innovation-Driven Health Care in a chapter in a chapter entitled “New Practice Paradigm for Preventing Vascular Deaths.”

Here is what he said in response to my question: Could Tim Russert’s death have been prevented?

“I can’t say absolutely about prevention in his case,
But I can say chances can be minimized in similar patients.

A heart attack is not about blockage. It’s about plaque rupture. When the plague ruptures, it kicks off the clotting process. Russet’s autopsy showed fresh clot. He had a stress test six weeks before. A stress test is not a good predictor of sudden death. But Russet was diabetic, and have a high risk of sudden death from heart attack or stroke.

You can’t predict a heart attack based on a stress test. But you can anticipate a plaque rupture if blood pressure and metabolic factors like glucose and lipids is out of control. Only 7% of diabetics have excellent control of these factors.

Stabilizing those plaques so they don’t rupture involves precise control of blood pressure, diet, and medication. An article in JAMA in 2004 showed simultaneous control of blood pressure, diabetes, and cholesterol occurred in only 7% of patients.1A type II diabetic, like Russet, has an 82% chance of heart attach or stroke. Each of those things you control, you lower the risk by roughly half.

In a study reported in the New England Journal in February, a Danish group split 160 patients into two groups – 80 under tight control of blood pressure and metabolic factors, the other 80 uncontrolled.2After 7 years, there was a 54% reduction in heart attack and stroke. and a 60% reduction in other complications. So ethically, th Danes had to bring the usual care group into the tightly controlled group.

At 13 years, half the people in the usual care group were dead, twice as many as in the aggressive care group. In the group under usual care, there were 4 times as many heart attacks, 5 times as many strokes. 11 times the number of stents, 3 times as many amputations, and 6 times the number of dialyses. In the patients under usual care, there were 158 catastrophes, or two apiece, and there were a 1/3 that many in aggressive care.

Doctor Bestermann emphasized he did not know the details of how well Tim Russet’s vascular risk factors were controlled. He added you can not absolutely prevent, or even, predict a plaque rupture but you can “stabilize the plaque” through blood pressure, glucose, and LDL control, and vastly decrease the odds of rupture.

References

1. Sedan, et al, Poor Control of Risk Factors for Vascular Disease with Previously Diagnosed Diabetes, JAMA, Jan 21, 2004.
2. Geed, P, et al, “Effect of Multifactorial Intervention on Mortality in Type 2 Diabetes, NEJM, Feb 8, 2008

Infrastructure

I keep six honest serving men
(They taught me all I knew)
Their names are What and Why and When
And How and Where and Who

Rudyard Kipling, 1865-1936
The Just-So Stories (1902), The Elephant’s Child

What – Infrastructure is an organizational term referring to the system by which a company or a practice is organized and the services and facilities are present that are necessary to carry on economic activity. The terms “infrastructure,” “critical mass, ” and “scale” are sometimes used interchangeably.

Why - Because “infrastructure” appears often in the health care literature, as in, “ Solo and small practices lack the infrastructure to compete in a managed care environment.” It is seldom mentioned that these practices, making up 80% of all practices, are the infrastructure that make health delivery possible.

When - The term “infrastructure” is most often cited in two situations: 1) the necessity for installation of electronic medical record systems and other software as essential tools to make medical practice more efficient and safe and capable of documenting every clinical act and satisfying every payer and consumer; 2) common complaints among physicians that they do not have resources to document every transaction and satisfy everyone outside their practice, negligible or negative return of investment of EMRs , lack of clinical relevance of current EMR systems, and loss of productivity with EMR use.. The prevailing belief is, however, even among physicians, that sooner or later, all physicians will practice on Internet time using multiple information technologies. .

How - The most common ways of introducing IT and meeting stringent infrastructure requirements are to persuade partners and staff that IT is necessary to grow and thrive, join or build a larger group, wait and see if financial incentives from payers evolve to justify the investment, forget about it and become a hospital employee, or retire. A common belief is that bigger infrastructure requires a bigger superstructure; though a few IT physician pioneers have shown they can practice with smaller staffs.

Where - Infrastructure building, also known as overhead expense expansion is going on everywhere, large practices and small, hospitals large and small, and investment therein is difficult because expenses are rising at 3-5% per year, while revenues are flat or dropping. Pressures are building to become electronically connected to payers and consumers so all transactions and clinical acts will become transparent to all. The problems are two fold: 1) most infrastructures don’t talk electronically to one another; 2) most doctors and patients don’t trust current privacy, personal, and security protections, or indeed, total transparency and electronic tracking of all human interactions.

Who - Mostly advocates of a seamless, interoperable, transparent, complex world, who believe that world can be reduced to simplicity and costs can be cut with enough software, and who conceive of the world of health care as a monolithic machine powered by algorithmic cogs and greased by aggregated data of every financial transaction and every diagnostic or treatment act. What these advocates believe and conceive, they think they can achieve. Advocates come in all managerial and technological shapes and sizes, and share thing in common – a desire to get a byte of the health care apple.

Physicians, Business, and Marketing

Because its purpose is to create a customer, the business enterprise has two – and only two – basic functions, marketing and innovation. But none our institutions exists for itself and by itself. Every one is an organ of society and exists for the sake of society.

Peter F. Drucker (1909-2006). Management, 1974

Whether one likes it or not, medicine has become a business, thanks in no small part to managed care. As a business, it depends on marketing and innovation.

But physicians are notably edgy about the term “marketing,” often equating it with advertising rather than about making your services and skills known.. There’s an unwritten rule among physicians, “Thou shall not advertise.” You can put your name in the Yellow Pages, create a website to highlight your practice, speak before community groups, organize educational forums, let your local hospital advertise for you. But limits exist. Drug firms cross the line with Direct Consumer ads which invariably end, “Ask your doctor.” Doctors look upon these ads as distasteful, even though they may direct traffic to their door.

As a general rule, thou shall not blow your horn in any public media But there are all sorts of exceptions to the rule. Cosmetic physicians, plastic surgeons, surgicenters, and other physician-engaged enterprises can advertise, but not individual physicians, lest they offend their peers.
The most acceptable way for a physician to market, i.e., to make their services and skills known, is to establish an unassailable reputation. This may be done by affiliating with a prestigious hospital, writing a landmark paper, being listed in Top Doctors or Best Doctors, writing a book for the public, being frequently cited as a source by the media as best of breed, or simply impressing your patients and your colleagues by the quality of your work.

There are, in short, multiple roads to marketing glory, both high and low. David Zahaluf, MD, a practicing physicians , author the Ultimate Practice Building Group, suggests these ten marketing and practice building steps

1. Focus on the future.
2. Keep score on the financial yield of your marketing efforts.
3. Plan better, including for contingencies.
4. Work to the clock, be crisp, focused, and efficient..
5. Build championship teams by seeking help from the best people you can find..
6. Have high self esteem.
7. Take action.
8. Model what works for others.
9. Respect and learn from more successful people.
10. Invest in education.

There is no miraculous marketing magic in all of this, just hard work and solid performance and the understanding that your reputation is your best marketing tool.

Reference

Zahaluf, David, “Financially Successful Physicians,” Healthleadersmedia.com, June 12, 2008. For more information, see www.ULtimatePracaticeBuilding.com

Physician Access and Loss of Physician Civility

The Medical Payment Advisory Committee (MedPac) has recommended Congress increase pay to primary care physicians. In response, a consortium ciations representing 14 surgical specialty societies fired MedPac a letter protesting the pay increase would come out of their pay.

The physician payment system, you see, is a budget-neutral pie. The bigger one’s specialist’s slice, the smaller the other specialist’s portion of the pie. Surgical specialists are reluctant to give up even a small piece of their share of the pie.

This, to me, is an example of physician angst and loss of civility among physicians. What’s mine is mine, and what’s yours is negotiable, event I make two to three times what you make.

I’ve been observing the rise of physician angst for 30 years. In 1988, I wrote And Who Shall Care for The Sick? The Corporate Transformation in Medicine in Minnesota ( Media Medicus, Minneapolis). In the book I predicted HMOs and managed care, then in rapid ascendancy in Minnesota and elsewhere, would fail. Doctors, I said, would become angry and disillusioned, patients would revolt, physician ties with each other would become strained, and primary care fortunes would decline and fall, and specialists would prosper.

The HMO strategy was to uproot the structure of medical practice by creating a gatekeeper system, whereby referrals to specialists and hospitals would be controlled and limited. This strategy too has failed. Specialists have become richer, generalists poorer, and costs have continued to escalate. Through maneuvers by Medicare, and HMOs, which follow Medicare in lockstep, payers have applied the screws, cutting pay to primary care and specialties alike, while physicians in general have gamed the system in various ways to maintain their life system.

The consequences of this convoluted game has been “angst,” which my dictionary defines as a feeling of dread and anxiety, among primary care physicians and general surgeons who are in short supply and feel they are being shortchanged and potentially being driving out of existence.

I am not alone in my interpretation of events. Timothy Norbeck, who has been associated with organized medicine for 40 years, says physician morale is the lowest he has ever seen. He should know. As executive director of the Connecticut Medical Society, he led the charge amongst 19 state medical societies against HMOs by organizing an anti-racketeering civil action lawsuit against Aetna, and later other HMOs. The suit succeeded and resulted in a federal settlement which culminated in the formation of the Physicians Foundation of Health System Excellence, a 501C3 grantmaking organization dedicated to improving the quality and safety and economic efficiency of care. The Foundation has issued grants totaling $21 million to 41 physician organizations.

The Foundation is now in the midst of conducting a survey of America’s 270,000 primary care physicians and 30,000 specialists to apprise their socioeconomic status and the depth and breadth of their angst. Perhaps this survey will demonstrate to the American public, federal policy makers, and managed care executives that the angst of American physician is rooted in reality, and corrections need to be made lest the primary care shortage loom even larger and we lose the physician foundation of our current health system.

As we go through this corrective process, I hope as physicians and professionals, we will observe the rules of civility among one another. As I was leaving a luncheon the other day, the host handed me a little red book published by Applewood Books entitled George Washington’s Rules of Civility & Decent Behavior. It is a good read, and I recommend it.

The Doctor's Dilemma: The Parable of the Plumber

Occasionally I come across a passage in a book or article that is notable and quotable and captures the essence of one of American doctors’ many dilemmas. This passage is from Merritt, Hawkins & Associates Guide to Physician Recruiting (April, 2007). This recruiting firm is currently conducting a survey of all of America’s 270,000 primary care physicians for The Physicians Foundation for Health System Excellence.

Physicians are different from other professions by virtue of the ground rules of contemporary medicine. The ground rules are largely determined by the way in which medical services are paid for in the United States today. Medicare sets physician payment rates for a wide range of services categorized as Diagnostic Related Groups (DRGS). An orthopedic surgeon might be reimbursed $500 by Medicare for setting a simple bone fracture. Private insurance companies often set their reimbursement rates based on what Medicare pays.

The point is that physicians rarely set their own fees. Their fees are dictated to them by Medicare, Medicaid, HMOs, PPOs, and other third parties. The money reimbursed to them for services may have little or no relation to their cost of doing businesses. What can be more aggravating is that sometimes third parties also dictate what physicians can or can’t do for their patients, by declining to pay for services physicians may believe their patients need.

This is not the environment most of us work in. There is no “third party” barrier between the lawyer, the accountant, the computer programmer, the plumber, the mechanic and his or her coolants. They all set a fee, perform a service, and are paid directly by the person for whom they did the work. Imagine a plumber who fixes a pipe for a fee set by the government – a fee that does not meet the cost of his tools. The plumber then submits a bill- not to his client, but to an agency or insurance company. The agency or company then declines to pay the bill on the grounds that they do not cover this particular service under those particular circumstances.

It would be no surprise, under these conditions, plumbers became a generally cranky group – especially if they had to complete 11 to 15 years of post-college training to become plumbers.

Thoughts about Tim Russert and Heart Disease

Tim Russert was 58 when he collapsed and died of coronary thrombosis two days before Father’s Day. This is sad because his dad, known as Big Russ, the subject of Tim’s recent books Big Russ and Me, and the sequel. The Wisdom of Our Fathers, are still on best seller lists. And it is sad, too, his Dad is still alive andTim had just returned from Italy with his wife, after meeting with their son, to celebrate he son’s graduation from Boston College

Tim Russert had people and political gifts. He loved people, and they loved him. He was personable, generous, loyal, and full of insight. His love for people translated into his passion for politics and his deep understanding of how it worked, who would win and why, what defined leadership, where power resided, and when and when not to act. He had the Irish gifts of speech, humor, affability, and deep respect for family and religious values. He was a good guy and easy to like and trust.

But he could not contain his love and enthusiasm for his work and an abiding concern about the future of the nation. To him politics was a source of unending curiosity and a drive to know more. He could not contain his passions. Politics consumed him every waking hour. Before he died, he had slept only two hours the previous night, after returning from a trip to Italy.

Russert had some elements of a type A personality. Type A individuals are impatient, excessively time-conscious, highly competitive, and incapable of relaxation. They are often high achieving workaholics who multi-task and drive themselves with deadlines. Because of these characteristics, Type A individuals tend to be "stress junkies.” Type A traits may be desirable in a high-powered journalist seeking interviews with the high and mighty in D.C., but they may lead to heart attacks, especially in people like Russert, who was diabetic, had known coronary disease, and a stocky mesomorphic stature – traits common to coronary prone individuals.

Did his personality have anything to do with his death? I do not know. Nor do we generally know why in 30% of patients why die from heart attacks, sudden death is the first symptom.

Can sudden death from coronary disease be prevented? Yes, in those whose disease is symptomatic, or in those in which the underlying disease is otherwise spotted through stress tests, nuclear heart scans, ECGs, and use of technologies showing calcium in coronaries, and in whom preventive measures are taken.

Can we predict candidates for sudden death? Can we present them with evidence to change behavior? Can we put the “scare of death” into them?
Of course, doctors do it all the time. But maybe we can develop more convincing evidence than we do.

A new technology, called SHAPE(Superior Health and Pulmonary Evaluation ) developed in St. Paul, Minnesota and tested by the Mayo Clinic may help. It is a modified and improved coronary stress test consisting of minimal stress (stepping up and down 1 ½ steps), magnifying this small stress signal of this minimal stress into a cardiogram, breathing through a snorkel-like device to have pulmonary gases analyzed, and then using predictive modeling informtion from a massive data base gathered from hundreds of thousands of similar patients to predict the likelihood of hospitalization or sudden death from coronary disease.

This kind of objective predictive data may convience high-powered, driven, logical, skeptical individuals to stop smoking, take other preventive steps, and change their life-style. The beauty of this low-risk procedures is that it can be done anywhere, without the dangers of the treadmile and without the presence of a doctor should the subject collapse on the treadmill.

Would this approach have persuaded Russert to slow down? We will never know. Probably not. He may have felt he had to do what he had to do. Would it reduce the rate of sudden deaths among others? Maybe not. Coronary artery disease will remain a silent killer in asymptomatic individuals, even though the danger signs are there before sypmptoms develop. But SHAPE is worth a shot, once it receives final FDA approval.

A Bit of Fun and Good Sense

Here I play an old trick. It is great fun, and it will not take much of your time.

It is good to use for those of you who write about health care. You can give the facts, the good news, the bad news, and the dire trends. You can track high costs, those who can pay and those who can’t. You can tell of the the rise and fall of good and bad folk, the role of greed for those who crave riches and the hope of those who from costs want to be freed.

And you can do it fast. You save time for all. You can use it when you write blogs, poems, straight pieces, and prose for docs. MDs have time on the line and on their mind. They want their facts straight – no bells, no bows, no strings, no wind, no fog.

See if you can spot it. I do it now right under your nose. Have you known each word so far? Does what I write make sense? Do you know what I mean? I hope so.

You can say what you mean when you play this trick. You can be brief, terse, to the point, full of pith and good sense. Those who read you can not blame you for loose talk or long words that are hard to know. They will thank you. They may even think you are full of smarts.

Please read this piece once more. You will find all words have been of one syllable – except the last, of course.

As Winston Churchill, said, “Short words are best and the old words when short are best of all.”

Walgreen-CVS Retail Clinic Battle

Since Regina Herzlinger officially launched the consumer-driven health care movement with a 1999 conference at Harvard Business school and a subsequent magnum opus book Consumer-Driven Health Care: Implications for Providers, Payers, and Policymakers (Jossey Bass, 2004), health policy experts and practitioners have debated: is consumer-driven care a myth or a reality? Congress poured gas on the debate by granting wide access to HSAs in December 2004. HSAs have grown to 6.1 million HSA holders, considered slow by critics and fast by proponents.

So the debate rages. Truth be told, health care is part consumer-driven, part provider-driven, and part government-driven. Genetic-disease, Acts-of-God diseases like cancer, sudden catastrophic events, or traumatic accidents do not lend themselves to consumerism. On the other hand, routine checkups and preventive visits, certain cosmetic surgeries, laser corrections for nearsightedness, elective surgeries to improve lifestyle, and minor mishaps and illnesses fit neatly in a consumer-driven mindset.

The best example of a consumer-driven phenomenon is the explosive growth of retail clinics, now numbering somewhere between 1000 and 1500. These clinics reflect the reality of consumer-yearning for less expensive, more convenient, and more predictable costs in neighborhood and mall outlets. Retail clinics are a prime example of “disruptive innovations,“ whereby consumers gain access to convenient less costly care provided by nurse practitioners rather than doctors (although a few clinics feature primary care physicians.)

It is ironic to me that the major battle for retail clinic turf is being fought in Boston, home of the Bean and the Cod, major academic centers, and the highest health premiums in the U.S. Perhaps because of the latter. Boston consumers backed the entry of CVS MinuteClinics into the Hub market. The Mayor and the academic establishment fought CVS but lost. This did not go unnoticed by the chief rival of CVS – Walgreens. Walgreens is now seeking state approval of 16 retail clinics in Massachusetts stores. All told by the end of 2008, CVS and Walgreens may have 1000 or so retail clinics in the U.S., and 40 or so in Boston and its suburbs.

Rapid growth of retail clinics is facilitated by consumer hunger for change, by retail advantages of one-stop health-prescription shopping, and by the Internet. Nurse practitioners has an EMR and electronic protocols to guide them to more standardized and predictable care. These electronic gismos are no substitute for clinic judgment, but they help. It is safe to predict that other “disruptive solutions, “ such as information technology directed self-care and home care and remote electronic monitoring of chronic disease will rapidly rise to the forefront of new medical technologies. Hold on to your hats. Medicine is now running on Internet time. I predict no miracles but anticipate profound change.

What I Have Learned About Health System

• I have learned hospital and doctor rating systems are overrated.

• I have learned most health care critics focus on top-down national uniformity rather than bottom-up regional cultural diversity.

• I have learned those who complain about comparative U.S, health care longevity statistics rarely take domestic, street, and highway violence into account; if they did, they would learn our life spans are just as good as those of Japan or Europe.

• I have learned bad news about health system outsells good news.

• I have learned most doctors still gain patients through word of mouth rather than through the Internet.

• I have learned new technologies rarely cut cost of care.

• I have learned EMRs are irresistible but inadequate.

• I have learned a vast interoperable online real time system with everybody talking to each other and having secure privacy and security protection is an irresistible dream that doctors and hospitals resist.

• I have learned entry of Google and Microsoft into personal health market may change landscape by empowering patients, with the operative word being “may.”

• I have learned many doctors do not think the AMA acts in their best interests.

• I have learned the Medical Home concept appeals to all but may not have legs because of hassles of implementation and inadequate compensation.

• I have learned online innovations to inform patients do not work well unless doctors use them.

• I have learned doctors welcome practical innovations they can deploy in their offices but resist innovations requiring new business models or changes of location of their practices.

• I have learned the media regularly reports on the 45 million uninsured but rarely mentions the 250 million uninsured.

• I have learned physicians don’t like the third parties.

• I have learned physicians are ambiguous about universal EMRs, universal coverage, and universal Medicare.

• I have learned predicting futur trends is difficult because it involves the future.

• I have learned the Internet hastens the pace of medical change.

• I have learned CMS demonstration projects rarely demonstrate what they are supposed to.

• I have learned primary care is in a bad way, and its practitioners are not crying wolf.

• I have learned many physicians think EMRs are for someone else’s benefit.

• I have learned the greatest innovation of them all would be doing away with wasteful paperwork.

• I have learned practicing physicians yearn for a national organization that would provide them with practical benefits.

• I have learned America’s 800, 000 doctors lack a strategy of sustainable innovation that would put in the center of health reform.

• I have learned fragmentation is another word for individualism and ca , in some cases, be overcome through collaboration and partnerships..

• I have learned critics and rule makers of doctors have rarely spent any sustained time in doctors’ offices watching them work.

• I have learned ideology dominates heath reform thinking more than reality.

• I have learned the left thinks a paternalistic government made up informed bureaucrats will solve most health care problems.

• I have learned the right thinks a materialistic marketplace made up of informed consumers will solve same problems.

• I have learned both are right but mostly wrong.

• I have learned the Federal Employee Benefit Program which covers 10 million federal employees and Congress would be a good model for the rest of us.

• I have learned hospitals may have a superior organizational model to doctor organizations because of scope, community presence, access to capital, and hierarchical structure.

• I have learned many successful innovative health care models go to where the patient is rather waiting for the patient come to them.

• I have learned new physician business models evolve because of a desire to get around the 60 hour, 25-patient, 50-phone call, low reimbursement day.

• I have learned business models that lean too heavily on informed consumers making intelligent decisions without doctor help rarely work in real world..

• I have learned health care outcomes depend more on what happens outside the office rather than what patients were told inside.

• I have learned patient told they need surgery forget 80% of what they were told about the procedure within 10 minutes after leaving the doctor’s office.

Health Innovations and Venture Capital

Innovation and Venture Capital

Health care is the fastest growing sector of the nation’s economy. This has not gone unnoticed in the venture capital community. Last year venture capitalists poured $9 billion into health care projects.

The emphasis has shifted from speculative biotechnology ventures to more predictable ventures, many of which already have a track record and some capital already successfully invested.

These include:

• Wireless devices for monitoring cardiac arrhythmias. Wireless monitoring of patients with chronic disease – congestive failure, diabetes, and other disorders in which vital signs are important are good bets.

• New cardiac stress tests requiring minimal stress, simultaneous measure of cardiac and pulmonary functions, and software predicating chances of hospitalization or death. Traditional treadmill-based cardiac stress tests entail risk, the presence of a cardiologist, and do not integrate cardiac and pulmonary information.

• Hospital staffing companies that supply and recruit specialists for hospitals experiencing doctor shortfalls due to the physician shortage. This industry is a sure bet as young physicians and older physicians suffering burnout flock to hospitals for security, payments of malpractice premiums and education debts, and balanced life-styles, and as hospitals seek internal and external specialist coverage.

• Occupational health centers and worksite clinics offering convenient evaluation and treatment for industries. Employers are desperate to cut their health costs, please their workers, and recruit talent with new health benefits.

• New tests for cancer. Cancer remains the most dreaded disease, and new genetic developments may make it possible to prevent malignancy or to catch it when it is treatable.

• Specialized centers for treating patients with special problems – e.g. centers for accelerating wound healing. For years Regina Herzlinger has spoken of “focus factories,” where doctors focus on special diseases to special needs. This have been slow to develop because of payment quirks and regulations, but may be coming into their own.

Quandaries of Preventing Health Disease in Diabetes

High blood sugar as a toxin, the higher it is, the more it poisons the system. High blood sugar leaves a sludge in its path that plugs capillaries, arterioles, and blood vessels large and small. Bring down high glucose, and you can control the disease and its complications.

Unfortunately, tightly controlling blood sugar, keeping it constantly low as measured by a hemoglobin A1c of 7.0 or less, has its hazards too – episodes of hypoglycemia with occasional deaths.

At the American Diabetes Association in San Francisco – three studies featuring glucose control to prevent heart attacks – ACCORD from NIH, ADVANCE from Australia, and the Veterans Affairs Trial from Phoenix – reached four broad conclusions.

• One, the best way to reduce cardiovascular risk is lower cholesterol and blood pressure, but reduced blood sugar levels have little additional benefit.

• Two, avoid hypoglycemia. Episodes of hypoglycemia double risk of heart death and triple risk of death of any other cause.

• Three, aggressively controlling glucose levels early in the disease but not after having the disease for several years.

• Four, aggressive treatment helps prevent eye and kidney complications, especially if coupled with improved diet, exercise, and aspirin therapy.

To conclude, diabetes is a disease best viewed through the lens of complexity. It is the most studied disease in history, but remains a mystery. It is better controlled than uncontrolled. It is genetic in children and certain kindred, but acquired, most often as a result of obesity. It has highs and lows, and both are bad. It is one of the few metabolic diseases curable by surgery (gastric bypass for obesity). It is a cluster disease, often occurring with heart failure, heart attacks, and peripheral vascular disease, to name but a few. Treatment can be simple – exercise, diet, and aspirin – but more often involves pills to control the disease itself and its companion co-morbidities. Avoid it if you can; control as best you can.

Can Health Inequalities Be Narrowed?

I see by the June 5 New York Times “ Research Finds Wide variation in Health Care by Race and Region,” that the Robert Wood Johnson Foundation will fund a three year $300 million initiative to narrow health care variations by race and region.

According to the article, a black diabetic has five times the chance of having a leg amputated as a white person, and women in Mississippi have much lower mammography rates than elsewhere in the country.

The director of the project, Bruce Siegel, MD of George Washington University Medical Center, is under no illusions, “In my book health care is local, just like politics, so you’re going to see a lot of differences in what communities do?

Doctor Siegel might have added that experience to data indicate it is difficult to significantly narrow practice patterns and disease outcomes.

• Thirty five years ago, Wennberg at Dartmouth decried variations in practice for Medicare patients in different sections of the country “ Small Area Variations in Health Care Delivery (Science, 1973). He and his colleagues have repeated the message ever since Yet little has changed, even in leading academic centers. Doctors and health systems, it seems, respond to regional and local cultures rather than pledging obedience to national authorities.

• Today, according to a study of 22 European nations, socioeconomic inequalities in health care are more of a function of national cultures, education , income, socioeconomic differences, lifestyle, and alcoholic and nicotine use rather than national health systems promising equal care (J.P. Mackenbach et al, “Socioeconomic Inequalities in Health in 22 European Countries, New England Journal of Medicine, June 5, 2008).

For at least 20 years researchers have known national health systems, despite their social justice virtues, and managed care companies with care controls, have little to do with reducing death rates or extending life expectancies (L. Sagan, The Health of Nations; The True Causes of Health and Well Being, Basic Books, 1987, and D. Sather, and R. Pamies, Multicultural Medicine and Health Differences, McGraw Hill, 2006). Medical Care accounts for about 15% of the health status of any population, life style for 20% to 30%m, and other factors – poverty, inferior education, income differences, and lack of social cohesion – for the other 55%. This does not mean we should stop trying to narrow health care outcomes among various groups and across regions.

We certainly wish Dr. Siegel and the Robert Wood Johnson Foundation luck, but we caution them to keep their expectations now.

No two patients, no two doctors, no two regions, no two races, and no two cultures are the same, and they do not easily bend to cries for national uniformity, standardization, and top-down controls. Calls for uniform distribution of care throughout any society and for cooperation with government or health management authorities do not necessarily gain the obedience of health professionals or individual citizens who lack the larger herd instinct.

All You Really Need to Know About Health Reform

It’s Sunday. I’m feeling charitable. I’m willing to give everyone the benefit of the doubt in the health care debate.

Since I wrote Voices of Health Reform (2005), made up of 42 interviews with national health leaders, I’ve sought a compromise approach to health reform that fits the American culture. I’ve found it the book All I Really Need To Know I Learned in Kindergarten (Villard Books, 1988). Its author, Robert Flugham, says these are lessons he learned in kindergarten.

• Share everything.
• Play fair.
• Don’t hit people.
• Put things back where you found them.
• Clean up your own mess.
• Don’t take things that aren’t yours.
• Say you’re story when you hurt somebody.
• Wash you hands.
• Flush.
• Warm cookies and cold milk are good for you.
• Live a balanced life – learn some and think some and draw and paint and sing and dance some and play and work every day some.
• Take a nap every afternoon.
• When you go out into the world, watch out for traffic, hold hands, and stick together.
• Be aware of wonder – Goldfish and hamsters and white mice even the little seed in the Styrofoam cup – they all die. So do we.

Health Reform

Everything doctors need to know about health reform is in there somewhere and can be applied to health reform. The Golden Rule, love, basic sanitation. Ecology and politics and equity and sane living and realities of violence and dying.

In health reform and in the American culture,

• Share everything you can – your knowledge and your skills and your indignation over social and health injustices.
• Pay fair – you know life isn’t fair, but you can be fair.
• Don’t hit people – you never have, but do what you can to curtail and report domestic violence.
• Put things back where you found them – in healthy patients who have become ill, try to restore them to health.
• Clean up your own mess - do so yourself but also ask your patients and your nurse and your staff and your spouse what you can do better.
• Don’t take things that aren’t yours –this doesn’t apply to you, but protest if you think health plans and Medicare and Medicaid are taking money away from you for your patients and your practice for businesses and political reasons.
• Say you’re sorry when you hurt somebody – experience is showing doctors who admit and apologize for mistakes are sued less.
• Wash your hands – before and after you see a patient or do a procedure.
• Flush – There are others behind you.
• Warm cookies and cold milk are good for you – better than fried foods and hard drink.
• Live a balanced life – spend time with your family and yourself, live, learn, play, and enjoy the arts and other things your community has to offer.
• Take a nap every afternoon – or at least a prolonged break.
• When you go out into the world – take a realistic view of life and death and watch out for obstacles and opponents, and hold hands and stick together with your fellow doctors – together you can make a difference.

Clinical Pathology Innovations

Seek simplicity and distrust it.


Sir Alfred North Whitehead (1861-1947), Adventures of Ideas

What do simple folk do?
They must have a system or two.

Lyrics to “What Do Simple Folk Do?” CamelotAs a clinical pathologist, I believe in the simple things.

I believe

• In the power of the clinical mind to sort through relevant diagnostic possibilities at the point of care.

• In enhancing those powers that translating abnormal numbers into diagnostic possibilities.

• In the power of the Internet to generate lists of likely diagnoses, given patterns of abnormals, and age, gender, and chief complaint of patients.

• In the power of “chunking,” building larger diagnostic systems out of simple systems that work.


• In the power of commonsensical algorithms to predict health status based on a brief family history, age, sex, lipid values, blood sugar, height, weight, blood pressure, waist size.

• In the right of ordering clinicians to request and control the diagnostic information they receive. .

• In the concept that simple things are always more complex and risky than they seem but that does not mean the simple things should not tried.

I believe in these simple ideas and systems because I have done them in the real world in the laboratory. Further, I believe in an ideal world, it should be the duty of clinical pathologists to explore the health and disease implications of the information we generate.

In the 1970s and 1980s, our laboratory

• Attached paper slips called Diagnotes to abnormal results.

• Developed differential diagnoses based on age, gender, and abnormal patterns with the right diagnosis appearing in the top 5 possibilities over 80% of the time. With additional simple clinical information, I believe this 80% figure would climb to 95%.

• Suggested relevant follow-up studies.

• Predicted health status, the HQ, normal range, 75 to 125, on thousands of patients.

• Issued more than 6 million reports using these systems.

Why are these simple things not done on a larger scale?

• The mindset that the clinical pathologists’ duties stop at the lab door with issuing of a report.

• The mindset that using the Internet costs too much money in a competitive environment.

• The mindset that diagnostic information listed, not pursued, or ignored may result in lawsuits.

• The mindset that the problems inside the lab outweigh the opportunities looming outside.

I may be wrong, as I often am, but these are my simple-minded views which I express in more detail in my book Innovation-Driven Health Care: 34 Key Concepts for Transformation (Jones and Bartlett, 2007).

Anatomic Pathology Innovation

Cinda Becker, NYC Bureau Chief of Modern Healthcare, called yesterday to ask what I thought about the announcement that GE and the University of Pittsburgh Medical Center (UPMC) had launched a new business, Omynx.LLC, to digitize and revolutionize disease detection.

“Revolutionizing” anatomic pathology, a 125 year old practice based on glass slides overlaid with tissue sections from paraffin blocks, sounded like verbal overkill to me, but maybe not. GE and UPMC had each chipped in $20 million to form a company “improve the speed, efficiency of diagnosis, and interpretation of tissue report. The new company would form a “new digital platform to enable clinicians to share images to virtually interpret results using advanced algorithms, and reduce costs.”

The annoucment added, “Omnyx will be the first company in GE’s history to be formed with an academic medical center and represents a aim to accelerate ideas to market through enhanced co-development.”

This is what I told Ms. Becker after reading the full text of the announcement.

1) This is basically good idea with tough cases, though I’m dubious about routine mass “screening” of slides. Tough cases often involve sending slides by snail mail to outside experts with agonizingly slow waiting times.

2) Sharing digital images of slides with sharing of opinion would minimize chances of error and individual mistakes on a pathologist’s bad day.

3) The technological already exists for digitizing radiological images and in some cases, like Mayo, for sending tissue images. I saw no reason this technology couldn’t be extended to slides.

4) To me the larger story was the emergence of centers of innovation in multiple health care centers – UPMC, Kaiser, Virginia Mason, Northwestern Memorial, Vanderbilt, Health Partners, Mayo, Johns Hopkins, the Cleveland Clinic – and co-partnering with innovative corporations. It is no secret that medical centers has been stodgy and behind the curve in matters of systematic innovation across the enterprise.

A final cautionary note, which may be a function of my ignorance of the current state of anatomic pathology. Perhaps because I still believe in the power of the naked eye and the alert mind conditioned by experience, I’m a bit wary of talk about “advanced algorithms to interpret results “and “to screen large numbers of slides in search of small nests of cells.” These thoughts may apply to cytology sides, screening of fluids, and needle biopsy aspirations, but I find it difficult to envision how these new techniques would work with paraffin-fixed tissues.”

Obama , McCain Plans, Comparisons in a Nutshell

Now that Obama is in, and Clinton is out, it’s time to compare Obama and McCain health plans.


Individual Mandates

Obama: Require all children to be covered but delay adult mandates until health insurance is affordable for everyone

McCain: None

Health Insurance Access

Obama: Crate national insurance plan with benefits similar to those of federal employees plan. Establish entity to regulate prive plans and help American enroll in private coverage.

McCain: Create a national guaranteed health plan, with sliding scale perimiums, for people who can’t afford insurance.

Personal Tax Credits

Obama: None

McCain: A $2500 refundable federal tax credit for individuals and $5000 for all families to buy health insurance.

Medicare and Medicaid

Obama: Expand eligibility for Medicaid and SCHIP. Have the federal government negotiate drugs prices for Medicare Part D. Reduce subsidies to private Medicare plans.

McCain: Focus more attention on rewarding physicians and hospitals for managing care and treating chronic disease.

Summing-Up

Obama favors a more active role of government, which would initially cost $100 billion. McCain would rely on a free-market. Obama would heavily regulate health plans and drug companies. McCain would not. Obama would have government obligate health plans to cover those with pre-existing disease. McCain would place those with pre-existing illness in high risk pools in the states. Everything, it seems, is up for grabs. Nothing will be free for all.

Medical Homes - An Idea Whose Time Has Come?

Everybody knows patients yearn for the compassionate primary care doctor, Marcus Welby re-incarnated, to know, guide, protect, and empathize with them.

Everybody knows the health system is fragmented, meaning patients don’t know where to turn for general informed advice.

Everybody knows family physicians, internists, and pediatricians are in short supply.

Everybody knows the AMA/Specialty Society RVS Update Committee, RUC for short, has been criticized for undervaluing codes of primary care doctors, whose incomes are ½ to 1/3 of their specialty colleagues.

That’s why associations of family physicians, internists, and pediatricians promote the idea of a medical home, where doctors are paid more to coordinate care, collaborate with specialists, and serve as a clearing house of medical information.

But as always, DIITD, “The Devil is in the Details.”

Well, the Devils (CMS and RUC) have collaborated to offer these Details for a three year demonstration project involving 2000 physicians.

Here are the Details of the CMS-RUC proposal

Monthly Payment Tier 1 Tier 2 Tier 3

Physician $2, 364 $2,837 $3,346

Case Manager $5,145 $6,965 $8,841

Liability Insurance $190 $190 $190

EMR $0 $50 $97

Patient Education $97 $97 $97
Booklet

Month Total $7,796 $10, 139 $13, 489

Year Total $93,555 $121,671 $161,871

I have no idea of the preparation or paperwork tasks or money involved to qualify for participation in the Medical Homes project,But I’m sure they are not insignificant.

Walking in Doctors' Mocassins

Until you walk a mile in another man’s moccasins you can’t imagine the smell.

Robert Byrne, 1911 Best Things Ever Said, Robert. 1988

My name is Chief Moving Forward. I have gathered together you promulgators of federal rules and regulation; you promoters of guidelines, protocol, and science-based evidence; you proponents of pay-for-performance and outcomes measurement.

I invite you to spend one year walking in the moccasins of practicing physicians.

The Split

I have split you into two sections – those who will walk in the moccasins of specialists, and those who will spend your year in the offices of primary care physicians. For those among you who regard “walking in another’s man’s moccasins,” as too colloquial, think of what you’re about to do as “management while walking around.”

First, Specialists

Let’s begin with the specialists, and let’s start with a specialist who I interviewed last week. Dr. Melvin Seek is a 53 year old nephrologist who heads up an eight man kidney group in Ocala, Florida. Doctor Seek works 80 hour weeks, seeing patients, overseeing five dialysis units, covering 3 hospitals in Marion Country, which is about the size of Rhode Island, and serving as president of Healthy Ocala, a ten year old RHIO (Regional Health Information Organization) that sells personal health records to businesses.

Dr. Seek’s group has had an EMR for 8 years and finds it useful. He says, however, for most physicians, EMRs have been counterproductive – too expensive, too little ROI, too time-consuming, and of little value as a communication document between doctors and between doctors and patients. Instead EMRs have been a legal, documentation, and compliance document – a sort of giant invoice.

One of you please walk in Dr. Seek's moccasins for a week, and then advise how your various approaches can shorten his week, improve the quality of care, improve outcomes, and maybe even enhance his efficiency. I am sure he and other specialists would like to hear what you have to say and share your wisdom, after you’re spent time in their shoes.

Next, Primary Care

According to Frederick Bloom, Jr. MD, director of quality and performance improvement for the Geisinger Health System, “Studies have estimated that a typical primary care physicians would require about 10 hours per day to address all the chronic care needs, another 7 hours to address preventive care needs, and an additional 5 hours per day to meet the acute care needs of his or her patients.”

That totals 22 hours. Given this time-consuming reality, if a primary care doctor is to function optimally, he or she would need a team to whom to delegate. The trouble is, of course, 80% of primary care doctors practice in groups of 4 or less, run overheads of 50% to 70%, and already work 25-patient, 50-phone call days. This leaves scant time to meet or consider all requirements of protocols and guidelines.

While you’re in the doctors’ moccasins, I ask you to keep a notebook indicating in what percent of patients the diagnosis or treatment is “science-based,” or simply commonsensical and individualistic, based on the needs of the moment at the point of care.

Also I’m sure practitioners would like to know how your various approaches and measurements can be implemented in the time available, how they would cut overhead, achieve efficiencies , and improve outcomes.

Reporting Back

Once you’ve walked in the moccasins of specialists and generalists, I would like for you to consider revisiting and possibly revising how to make your approaches less time consuming, more streamlined, relevant, and user-friendly. You might also estimate doctor’s dollars per hour income, and compare it to your own once you’re put back on your own moccasins. This would help put matters in perspective and give you a sense of smell of what doctors go through.

Of Hospitalists, Intensivists, Criticalists, Proceduralists Surgicalists, Obstetrianists, Locumtenenists, and Nocturnalists

These days, every time you turn around, you run across new name for a new medical specialist, who is almost always hospital-based.

What’s behind this compulsion to create new specialists? It goes against traditional wisdom -- that we have too many specialists and too few generalists. The hidden reason may be that generalists want to become specialists and the road to that ambition goes through hospitals.

The creation of new specialists hinges on five trends;

1) The drive by hospitals to assure greater control, safety, and efficiency through hospital-based specialists. The movement towards hospitalists, intensivists, and criticalists has been going on for ten years. Having these specialists on site to respond to emergencies and other needs of patients make sense in many ways. On-site physicians can respond quickly in more standardized ways to problems and, as a bonus can shorten hospital stays. Another side benefit is that practicing physicians and other members of the hospital staff generally accept these new specialists. They offer relief from night and weekend calls, and doctors can have confidence their patients are in good hands.

2) Proceduralists are a refinement and spin-off of hospitalists – a subspecialty. They ensure safety and efficiency because they grow adept at doing common hospital procedures – lumbar punctures, central vascular.access cut-downs, tracheostomies, parancenteses and thorancenteses. They perform them repeatedly and well – and more safely than an inexperienced resident might..

3) “Nocurnists”are the new kid on the hospital specialist block, and the latest development, on the hospital safety front. Within the last two weeks, articles in the New England Journal and the Wall Street Journal, have commented on the work of David Shulkin, M.D., president and CEO of New York’s Beth Israel Medical Center , who observed that many critical cases are admitted at night, that these patients tend to have poorer outcomes, and that the hospital staff is at its lowest level at night. The outgrowth of his concerns was the creation of full-time physician “nocturnists,” who work only at night as a career. In some ways, “nocturnists” are mature versions of residents, who now work fewer hours because of new laws restricting them to an 80 hour week or less.


4) Then there is the physician shortage. It is now acknowledged that a physician shortage is upon us. To assure continuity of care and coverage, hospitals are increasingly turning to locum tenens, or locumtenensmists, and physicians, in their turn, turning to the locum field to escape the hassles of private practice, to work regular hours, and to have their medical practice premiums paid.

5) Finally, there is the new generation of young physicians. Most are trained in hospitals, and most feel comfortable in that setting. These young physicians seek a balanced life style, time-off, vacations, other fringe benefits, and professional support – all of which may be hard to come by in private practice.


References

1. D.J. Shulkin, MD, “Like Night and Day – Shedding Light on Off-Hours Care, New Englnad Journal of Medicine, pages 2091-2093, May 15, 2008.

2. Laura Landro, “Hospitals Move to Reduce Risk of Night Shift, ‘Nocturnists Fight Dangers Patients Face on Off-Hours, “ Wall Street Journal, May 28, 2008

Gloom for Improvement: A Poem Call for Unhappy Physicians

Operator, please connect me to all unhappy doctors in the United States,
Those who consider themselves and the system to be in desperate straits.

How do I know these doctors are so glum?
Well, I listen, and I’m not deaf and dumb.

And I read things in books, websites, and Forbes, 1-3
Everything about unhappy doctors the media absorbs.

How many of them, you ask, are practicing out there?
2/3s of them,500,000: I pull that number out of thin air.

Pause….

Am I talking to unhappy doctors practicing in the U.S.?
Those of you who consider everything as a unholy mess?

What I’m about to say is you for the good,
For you in the sisterhood and brotherhood.

You say America is going in the wrong direction,
And the economy is headed into a deep recession.

You say your revenues are flat,
And health plans are getting fat.

You say patients suffer from lack of access,
And country’s compassion is in recess.

Yes, I know the health system is full of unnecessary regulations,
Unrealistic patient expectations, and unfair doctor accusations.

Yes, I’m aware malpractice lawyers are on the offensive,
Forcing up costs and making you practice on the defensive.

Above all, I know this,
A notion no one can dismiss.

No one wants to have a doctor with low morale,
Not here, not there, not anywhere in any locale.

My message is; there’s always gloom for improvement,
You’re part of the physician empowerment movement.

Relax,
Face these facts.

Take a look at a physician networking site called Sermo.com
Physician outrage is ticking there like an undetonated bomb.

It’s about to explode in an Open Letter to the American Public,
Which will tell it is like for doctors in the American Republic.

Physician revival in on the way,
Soon to be shown in full display.

Through your collective voices warning of less access,
Congress will the Medicare payment cuts suppress.

Patients still trust you more than politicians
Whom they consider to be mere rhetoricians

Most of you remain at the top of the economic food chain,
Though practitioners are riding and idling in the slow lane.

And keep in mind you’re still in a noble profession,
And for the most part, you can still use your discretion,

So show good cheer,
Better times are near.

In short, be happy,
Be upbeat and snappy.

Let me be clear,
Have no fear,

Things are better
Than they appear.

1) James Merritt, Joseph Hawkins, and Phillip Miller, Will The Last Physician in America Please Turn Off the Lights? A Look at America’s Looming Doctor Shortage, Practice Support Resources, 2004.

2) Edwin, Leaped, MD, “Unhappy Physicians, Healthleadersmedia.com, May 21, 2008.

3) Tara Weiss, “Reasons Not to Become a Doctor,” Forbes, May 5, 2008.