Sunday, June 10, 2012

On the Road Again to Health Reform and Repeal: American Culture Misdirection
On the road again –
Just can’t wait to get on the road again.
Willie Nelson (born 1933),  Lyrics to On the Road Again
June 10, 2012 -   In two weeks, on or about  June 25, the Supreme Court will announce its long awaited, fateful decision on Obamacare’s constitutionality.
The odds are the Court will strike down the individual mandate but keep some of the rest of the law. “Even if the law is struck down entirely, “ says Pam Belluck in today’s June 10 New York Times, “it has already spurred some changes.”
It’s been a long and rocky road to the Supreme Court.   I  know this more than most.   In November 2006,  I launched the Medinnovation Blog,  “Where Health Reform, Medical Innovations,  and Physicians Practices Meet. “ Since then,  I have churned out 2130 posts, almost daily.   
In these posts, I’ve mixed serious commentary, light verse, historic quotes, and short tweets.  Out of this curious mix has come a book The Health Reform Maze (Greenbranch Publishing, 2011).  As the title implies, the road to reform and probable partial  repeal is a twisted maze , full of turns leading off-times  nowhere but sometimes somewhere.
What do I conclude from my roadrunner role?
Mainly  this: Obama has fundamentally  misunderstood and  misdiagnosed  American culture.  The culture is more center-right than center- left, more bottom-up than top-down.   
The late Eli Ginsberg (1911-2002),  a New York City health policy expert,  understood this better than most.  In his 1994 book The Road to Reform: The Future of Health Care in America (The Free Press),  he wrote
“Americans take pride in the fact that their society – including the health care system – is characterized by a pervasive pluralism. Government – federal, state, and local- does not dominate the economy, the educational system, or the health care delivery system. Most Americans oppose “big brother”; government should be guarded from dominating any critical aspect of their lives. There are advantages to pluralism – from stimulating innovation to avoid the intrinsic rigidities of bureaucracy.”

A year ago, on June 3, 2011,  I wrote the  post below  What I said then , that the practice of medicine and the health care system will never be the same again,  no matter where the road to reform  leads, still holds.

June 3, 2011

A Review of  Roadmap for Physicians to Health Care Reform, a 73 Page White Paper of The Physicians Foundation

June 3, 2010 – On June 1, The Physicians Foundation, a nonprofit representing practicing physicians in state medical societies, released a 73 page white paper explaining the impact of the health reform law, available at

The Foundation has existed for eight years. It results from a 2003 settlement of 19 medical societies with a handful of national health plans. It exists to advance the work of practicing physicians and to improve the quality of care in America. Through $28 million in grants and two national surveys of physicians, the Foundation has laid the groundwork to meet these goals.


This White Paper is a milestone. It culminates eight years of work. It expresses deep physician frustration, stress, and anxiety, largely gathered through two national surveys completed in 2008 and 2010. It is balanced, comprehensive, realistic, and, above all else, readable.

Organization and Revelations

The White Paper is organized into three parts:

• Health reform’s economic and budget framework

• The 2010 elections and the “reform of reform”

• Health reform provisions and for doctors and physician targets for reform

What does this White Paper reveal? It reveals hard truths about the cost and complexity of health care in America. It gives insight into the workings of the collective physician mind and the stresses on private practice.

It explains why many health reform provisions are so difficult for physicians to implement and indeed may be unworkable in the real world despite good intentions in policy-making circles.

Reform Provisions

These provisions include:

• Government “innovations, “ largely based on organizational restructuring into larger, coordinated groups such as accountable care organizations in which physicians fear losing their autonomy.

• An Independent Payment Advisory Board (IPAB), which many physicians do not regard as “independent.”

• Quality reporting and outcomes research, which many physicians regard as cookbook, protocol-driven, medicine.

• Physician fee adjustments, which means systematic fee reductions, abandoning fee-for-service medicine, and adopting capitated or bundled payments.

• Value-based purchasing for hospitals, which entails paying hospitals and their medical staff for outcomes and “population health,” which may or may not be within the physician’s control.

There are other issues as well, which are discussed from the patient, physician, and national perspectives. The overhanging cloud of possible health law reform repeal is also addressed in depth.

This book’s lead authors include Physician Foundation Officer – Lou Goodman, PhD, President, Tim Norbeck, Chief Executive Officer, and Walker Ray, MD, Vice-President; Kathy Means, manager of Old Creekside Consulting , an independent health care consultancy located in Fredericksburg, Virginia; and Ken Monroe, Chairman and CEO, a leading association management and professional services company.

Two Truths

In my opinion, the White Paper reveals two truths about health reform.

One: The health reform law is a disparate assortment of mandates, public insurance expansions, subsidies, and regulations that affect different groups of Americans, including physicians, in different ways and at different times. Whether one agrees with the law or not, or supports its various provisions, it will leave a permanent mark on how medicine is practiced in America.

Two: Whether health reform succeeds or fails depends on physician support and cooperation and availability of physician services because of the public’s widespread trust in physicians and visceral distrust of current reform policies. Without access to doctors, universal coverage could be meaningless. Physician understanding and reaction to the law are essential for improving care and access in America.

The Impact and Purpose of the Roadmap

According to Lou Goodman, PhD, president of the Physicians Foundation and CEO of the Texas Medical Association, “We believe that no matter what actions Congress takes to amend the ACA, the most direct provisions affecting physicians will endure in some form. The Physicians Foundation commissioned this Roadmap to educate physicians on those core elements, as well as to promote broader understanding of how private practice physicians will be impacted."

Tweet: : Whether health reform succeeds or fails will depend largely on physician support and access to physician services.

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