Tuesday, January 31, 2012

Democrats, GOP, and Public in Clash All by Themselves over Health Law

I often think it’s comical
How nature always does control
That every boy and every gal
That’s born in the world alive,
Is either a little Liberal,
Or else a little Conservative!

Sir William Gilbert (1836-1911), Iolanthe (1882)

January 31, 2012- According the latest Kaiser tracking poll, 73% of Republicans view the health law unfavorably while 62% of Democrats favor it.

That’s clear enough. But wait a minute. What does the public think?

Well, like the alcoholic who lurches from left to right to stay upright in the center of his gait, the public is tottering in a clash all by itself.

The Kaiser tracking poll indicates:

• Only 37% have a favorable view of the law.

• 44% have an unfavorable view of the Affordable Care Act.

• 31% want to expand the current law while 19% want to keep it in its current form.

• 22% want it repealed outright and another 18% want it replaced with a Republican alternative—a total of 40%, fewer than the 50% want to expand it or keep it as it is.

• 67% have an unfavorable view of the individual mandate requiring everyone to buy coverage, while 30% have a favorable view of the requirement.

• While 50% of those surveyed think the law should be kept or expanded, 54% say the Supreme Court should throw the mandate out, while only 17% say they think the mandate should be upheld.

To Summarize

To summarize, only 37% have a favorable view of the law, and 67% don’t like the mandate. But 50% think the law should be kept as it is or even expanded.

What to Do

What to do politically? President Obama says there’s no going back. Republicans insist it should be repealed and replaced. The schizophrenic public wants it repealed, replaced, and expanded in one fell swoop.

Republican Grab Bag

Republicans offer a free-market grab bag.

• Malpractice reform, which Democrats, whose #1 contributor is the Trial Lawyers Association, will never accept.

• Health Savings Accounts, which depends on consumer responsibility and wisdom, something which Democrats think ordinary people lack.

• Universal tax credits, which makes so much sense it will never fly.

• Individual ownership of plans, which leaves employers out.

• Selling plans across state lines with doctors and hospitals and health plans competing, which smacks of free market competition, anathema to liberal elites.

• High risk pools for those with pre-existing illnesses, which is popular but not among all conservatives.

• Continued closure of Donut Hole and coverage of young adults under parents plans, which everyone seems to like.

Solutions

Solutions? Let the Supreme Court decide. Let liberals argue gutting Medicare of $575 billion will save it. Let Conservatives argue changing Medicare through premium vouchers will save it.

Let the public decide in November as they stagger to the polls – Liberals to the left of them, Conservatives to the right of them, Moderates and Independents dead ahead of them.

Tweet: According to the latest Kaiser tracking poll, the public would like the health law repealed, replaced, and expanded – at the same time.

Monday, January 30, 2012

Tech-Led Health Care Boom?

There is always gloom for improvement.

Optimist's Maxim

January 30. 2012 – In health care and elsewhere, these are days of gloom, even doom. Costs are high, the future is uncertain, the SGR may cut doctor fees by 27.4%, physician shortages loom, reform may be unconstitutional. For the nation as a whole, the national deficit will soon exceed $16 trillion, more than the GDP, and the economy grew an anemic 1.7% in 2011. The bloom is off the U.S. rose.

In the face of all of this, Mark P. Mills, founder of the Digital Power Group, and Julio M. Ottino, dean of Engineering and Applied Science at Northwestern, say in today's Wall Stree Journal, "The Tech-Led Boom," that the U.S. is on the cusp of an unprecedented technologically-led economic boom.

These two high-tech prophets, who seem oblivious of health care gloom, predict three “three grand high tech transformations” are upon us and are centered in America - big data, smart manufacturing, and the wireless revolution.

Big Data - Virtually free computer processing power and data shortage make this transformation inevitable. The I-phone, they note, has computing power that shames IBM mainframes, the Internet is ascending into the “cloud,” and limitless data distribution with metadata analyses assures a medical revolution in outcomes, say they.

Smart manufacturing - Automation and information systems, they assert, will streamline supply-chain management, and in the process, will optimize product features, and will radically improve quality and reduce waste. Computer design and engineering will create new devices and products.

Wireless revolution – Soon most humans on the planet will be connected wirelessly – everywhere, everyone, all the time. This wirelessness will fuel economic growth in our youthful, dynamic, diverse culture. America, the authors claim, has “incontrovertibly powerful features “ – open mindedness, risk-taking, hard work, playfulness, anti-establishmentarism, a penchant for critical thinking, and more than half of the world’s top universities.

Given the proper political leadership, liquid financial markets, sensible tax and immigration policies, and balanced regulations , America will innovate and it will boom, for we are an exceptionally gifted and blessed nation.

Mills and Ottino conclude:

America’s success isn’t foreordained. But technological innovations circa 2012 are profound. They will engender sweeping changes in our society and our economy. All the forces are in place. It’s just a matter of when.”

I pray they are right. There is gloom for improvement in health care and elsewhere.

Tweet: Three high tech forces and U.S. strengths– big data, smart manufacturing, and wireless technologies – forecast a bright America future.

Sunday, January 29, 2012

Robots in Medicine

The world of the future will be an ever demanding struggle against the limitations of our intelligence, not a comfortable hammock in which we can lie down to be waited upon by our robot slaves.

Norbert Wiener (1894-1964), God and Golem, Inc. (1964)

January 29, 2012

About robots in medicine
I ponder
And I wonder
Are robots desirable
Are robots better
Will touching
Feeling
Listening
Smelling
Palpating
And Handling
Become obsolete
Will everything be
automatic
systematic
monochromatic
It is possible
Robots do things
The same way
Every time
Real time
Robots do not deviate
From the straight
And narrow
Algorithms think like robots
Robots are checklists of the mind
IBM might tell us
Robots are E-lementary
My Dear Watson
Robotic surgery is
Purportedly
And reportedly
Safer
More predictable
Less invasive
Produces faster recoveries
Reaches inaccessible places
Reduces hospital infections
Hospital marketers love robots
Specialists love new tech, high tech
The media and the public
Love breakthrough news
But I keep thinking
Humans design robots
And therefore
Robots have
Blind spots
And soft spots
And so I wonder
Will robots ever
Think outside the box
Are robots replacements
Or merely human assistants
Maybe, just maybe, robots
Being ever consistent
And error resistant
Will protect us from human terrors
And stretcher-bearers.

Sources

1. “What’s Wrong with the da Vinci Robot?”, Health Leaders Media, January 26, 2012

2. “Robot Cleaners a ‘Game-Changer’ for Hospital Infection Epidemic”, Health Leaders Media, January 27, 2012

Tweet: Maybe robots, being ever consistent and error resistant, will protect us from health care errors and human stretcher bearers.

Electronic Medical Records – Incentives and Pressures for Use Mount, Obstacles and Costs Shrink

The mind of man is more cheered and refreshed by profiting in small things than by standing at a stay at the great.

Francis Bacon (1561-1626), Of Empire


It’s been three years since Congress approved a nearly $30 billion plan to digitize health care records, yet much of the health care industry is still drowning in paper.

Shefali Kulkenn, “Bipartisan Report Highlights Gaps, Recommendations for Health IT, Capsules in KHN Blog, January 27, 2012

January 30, 2012 – When future historians write the story of electronic medical records, they will ask: What took so long? After all, they will say, EMRs reduce costs, duplications, and errors, improve quality, and are more efficient because they cut across specialty lines and allow physicians to review the complete patient record at one setting in one format.

Many physicians of today would respond: Well, maybe, but not yet, but that’s another story.

The answer to the historians, according to the Bipartisan Policy Center in a 43 page report, is delay in getting various EMR systems to talk to one another. As of now, the myriad of systems tends to create a Tower of Babel.

The report says other obstacles to routine use include lack of enthusiasm among consumers, privacy and security concerns, paucity of hard-pressed physicians’ and hospitals’ financial incentives to convert from paper to digital records, prohibitive costs, and the necessity to completely change practice dynamics.

Still, recently, in the last year, there has been an upsurge of EMR installations, with perhaps as many as 50% of physicians using EMRs in one form or another, usually as incomplete systems. There are a number of reasons, tangible and intangible, why this is so.

• Government carrot and stick financial incentives – 1% to 2% bonuses or punishments to install and use EMRs and to prescribe electronically.

• A sense of the inevitability of digitization, partly propelled by software advances, mobile devices, and the flowering of the social media.

• Subsidies of EMR systems by some health plans.

• Ease of adoption and use by new EMR business models, in which ads rather than physicians pay for adoption and in which software and hardware resides in “The Cloud” rather than onsite.

• Improvements in usefulness, e.g. speech recognition allowing voice entry of narrative summaries by physicians accustomed to dictating.

• Administrative pressures on acquired and salaried physicians in hospitals and physicians groups to use EMRs – or to practice elsewhere.

• Difficulties in recruiting young physicians, weaned on computers, and refusing to join practices without EMRs.

• Increasing awareness by some consumers that EMRs are a hallmark of practice excellence.

• Realizations by physicians that future practice survival and thrival will depend of digitization.

Tweet: Incentives and pressures to adopt electronic records are mounting while obstacles to use are shrinking.

Saturday, January 28, 2012

Heart Deaths, Medical Progress, and No Free Lunch

There is no such thing as a free lunch.

Milton Friedman (1912-2006), Attributed

January 29, 2012 – Lost in health reform debate is the fact that medical advances contribute mightedly to exploding health costs. In the sometimes hysterical debate over health costs, we have been distracted from factoring in costs of remarkable medical advances that have occurred over the last half century. Health inflation has a positive as well as a negative side. Medical progress exacts a heavy price, but in the case of heart disease, it is worth it.

In an article in the January 5 The New England Journal of Medicine, which celebrates the 200th anniversary of The Journal, “A Tale of Coronary Artery Disease and Myocardial Infarction,” Drs. E.G. Nabel and E. Braunwald put health reform and medical advances in perspective.

A figure in that article chronicles the steep decline in deaths per 100,000 population from 1950 to 2010. Death rates have declined is from 440 to 100 deaths per 100,000, a 4.4 fold or 773% decline, from 1950 to 2010.

Although the authors do not say so, this decline comes as the result of medical trials leading to costly medical procedures and treatment . For example,each bypass surgery in the U.S. costs $59,770, 32 million Americans take statins to prevent coronary artery disease, one statin, Lipitor, produced $7 billion in profit for its maker, and total cost of cardiovascular disease, the leading cause of death in America, is $475.3 billion each year.

The events leading to this remarkable decline include.

• 1954 – First open-heart procedure

• 1958 – Coronary arteriography developed

• 1961- Risk factors defined

• 1961 – Coronary care unit developed

• 1962 – First beta-blocker developed

• 1969-First description of CABG (Coronary Artery Bypass Graph)

• 1972 - NHBPEP (National High Blood Pressure Education Project)

• 1976 – First HMG CoA (3-hydroxy-3-methyl-glutaryl-COA) reductase inhibitor described

• 1979 – Coronary angioplasty developed

• 1980- First implantable cardioverter-defibrillator developed

• 1983- CASS(Coronary Artery Surgery Study)

• 1985 – TIMI 1 (Thrombolysis in Myocardial Infarction)

• 1985- NCEP (National Cholesterol Education Program)

• 1986- GISSI (Gruppo Italiano per lo Studio della Strpetochina i hell Ifarcto Myocardio)and ISIS-2 (International Study of Infarct Survival)

• 1992 – SAVE (Survival and Ventricular Trial)

• 1993 – Superiority of Primary PCI (Percutaneous Coronary Artery Intervention) vs. fibrinolysis in acute myocardial model

• 2002- Efficacy of drug-eluting vs. bare-medal stents determined

• 2002 – ALLHAT (Anti-hypertensive and Lipid-Lowering Treatment to Prevent Heart Disease Trial)

• 2007 – Benefit of cardiac resynchronization therapy in heart failure demonstrated

• 2009 – left-ventricular assist device as destination therapy in advancd heart failure shown to be effective

• 2009 – Genomewide association in early –onset myocardial infraction described

• 2009 – Deep gene sequencing for responsiveness to cardiovascular drugs performed

Tweet: Cardiovascular deaths have declined from 440 to 100 since 1950, thanks to medical advances, which carry a heavy price tag.

WASHINGTON REPORT for The Physicians Foundation

The Physicians Foundation seeks to advance the work of practicing physicians and to improve the quality of healthcare for all Americans.

Mission statement, the Physicians Foundation

January 28, 2012 - The ensuing report, compiled and written by Lee Stillwell, an Inside-the-Beltway consultant for the Physician Foundation, a non-profit organization representing over 500,000 physicians in state medical societies, tells physicians what to expect in 2012 – from now until the Supreme Court decision in June and November 6 election. Stillwell predicts political sniping, gridlock,and an agreement to disagree.

“It may have been a short and subtle message, but President Obama made it perfectly clear in his Tuesday State of the Union speech to Congress that he intends to protect his 2010 health care law now under attack in the courts and before Congress.

Obama limited direct mention of his historic legislation to a few sentences:

-- “I will not go back to the days when health insurance companies had unchecked power to cancel your policy, deny your coverage, or charge women differently than men…”

--“I’m a Democrat. But I believe what Republican Abraham Lincoln believed: That government should do for people only what they cannot do better by themselves, and no more. That’s why our health care law relies on a reformed private market, not government program.”

The message-- that the President had drawn a line in the sand about repeal of Obamacare-- was clear, but it already has been dismissed by the Republican Congress and the representatives of a host of states that are challenging the health care law right now before the U.S. Supreme Court.

And, all eyes now are looking forward to March when the court will hear oral arguments; and then to June, when a landmark ruling is expected before summer adjournment.

Surprisingly, the justices agreed to hear five-an-a-half hours of arguments from lawyers—the court normally limits time to no more than three hours.

The central provision to be considered is an individual mandate requiring Americans to buy health insurance by 2014, or pay a penalty. In addition to deciding if the mandate is Constitutional, the court also will consider if the rest of the law can take effect without that provision.

Expansion of the joint federal-state Medicaid program will be reviewed by the court with the states claiming the new law goes too far in forcing them into participation with a threat of a cutoff of federal dollars.

Lastly, the justices will decide whether a decision is premature because a federal law generally prohibits challenges to taxes until taxes are paid.

Earlier this month the Obama Administration submitted its first brief on the merits of the individual mandate, arguing it is an acceptable use of Congress’s taxing power and defends the policy under the Constitution’s Commerce Clause. Although the same tax argument presented by the Administration has failed in the lower courts, Justice Department officials say they still believe in it.

Meanwhile, GOP legislators already are moving to replace the law in June, according to Rep. Joe Pitts(R-Pa.), chairman of the House Energy and Commerce health subcommittee.

'We’ll have a window of opportunity to—with everyone looking—to explain that the Affordable Care Act is not fully implemented yet,' Pits said. 'A lot of people think it is. So we’ll use that opportunity in that window to discuss the full ramifications of the Affordable Care Act and what we’ll replace it with.'

Speculation about what will be included in such a package are malpractice reform, a tax break on health insurance to the employee instead of employer, creating high-risk insurance pools for people with pre-existing conditions, and allowing insurers to sell their products across state lines.

Pitts said the 'timing' for such a package is 'above his pay grade,' meaning leadership will make the call.

Speaking of leadership, Speaker of the House Rep. John Boehner(R-Ohio) told his GOP legislators in a close-door retreat in Baltimore last weekend that this year should be a referendum on the president’s policies, according to sources. The strategy for the House Republicans in the 2012 election year appears to be a minimalist agenda that is designed to be a referendum on Obama.

Consequently, it is no political surprise that Boehner said Sunday that the GOP may withhold support for the payroll tax legislation to force President Obama to approve the Keystone pipeline project just rejected by the Administration.

The GOP’s intention to be tough in negotiations with the payroll tax bill was obvious Tuesday at the first meeting of a bipartisan House-Senate Conference Committee tasked with finding $160 billion in revenue to pay for the one-year extension of the payroll tax, unemployment benefits and a provision that would prevent a 27.4 percent pay cut in Medicare fees for physicians.

Negotiators are far apart and many are skeptical that a deal can be reached before the end of February when the current two-month extension expires.

Now, the GOP-controlled House Rules Committee is moving much faster to cripple a provision in the health care law—repeal of the CLASS Act, a program designed in the law to handle long-term care. Administration officials put the program on hold because staff has not found a way to make it solvent. The committee voted to send legislation to officially repeal the CLASS Act to the floor for a vote next week. The bill is expected to pass the House but fall short in the Democratic-controlled Senate.

Four powerful Republican members of the House Ways and Means Committee also publicly poked the White House with a letter demanding hundreds of pages of memos, including those involving the White House Office of Health Reform and how it made decisions on health care legislation. The four Congressman included Fred Upton (Mich.), chairman; Cliff Stearns(Fla.), chairman, subcommittee on oversight and investigations; and health subcommittee chairman Pitts along with his vice chair, Michael Burgess(Tex.). The legislators seem serious about getting all of these documents, which were given to a reporter for a magazine article, and you can expect the political rhetoric to heat up.

Even the Administration’s decision to release the 2013 budget a week late-Feb. 13 instead of Feb. 6—is drawing incoming political flak from the GOP, who are loudly pointing out to media that President Obama’s budget has been late three of four years.

Expect little legislative or regulatory success this year and a great deal of heated political rhetoric tied to that Nov. 6 Presidential and Congressional election.”

Tweet: In State of Union. President Obama said there was no retreat on health law, and that it relied on private reform not government takeover.

Friday, January 27, 2012

Government Innovation, Electronic Inquisition, and Practice of Medicine

In America, innovation doesn’t just change our lives. It is how we make a living. Our free enterprise system is what drives innovation.

President Barack Obama, State of Union speech, 2011

In God we trust, all others use data.

W. Edwards Deming (1900-1993), American statistician

January 27, 2012 - As I write, The Health Care Blog and The Center of Medicare and Medicaid Innovation are co-hosting the Care Innovation Summit in Washington, D.C.

The events main speakers are:

• Rich Gifillan, Director of CMS Innovation Centers

• Todd Park, Chief Technology Officer at HHS

• Atul Gawande, MD, a surgeon, policy advisor, and author of Checklist Manifesto

• Don Casey, CEO, West Wireless Heart Institute

• Susan Dentzer, Editor-in-Chief, Health Affairs

• Marilyn Tavenner, RN, Acting Administrator of CMS

These speakers are government officials or supporters of top-down health reform. There is nothing wrong with that, of course, and what they advocate – a collaborative effort between government and the private sector to bring about innovation – is a good thing. And it is worth noting the CMS has launched a Innovation Advisors Program, designed to ultimately recruit 200 advisors from the private sector to help government bring about innovation.

Two Cautionary Notes

As the Advisory Innovation Program goes forward, I would like to insert two cautionary notes,

One, Government is generally poor at innovation. As I observed in The Health Reform Maze: A Blueprint for Physician Practices (Greenbranch Publishing, 2011), now available as an E-book, there are six reasons for this lackluster performance.

1. Government cannot manage failure.

2. It seldom abandons a project.

3. It is not gambling with its own money.

4. Its success is measure in good intentions not results.

5. It succeeds in growing too big to fail and too influential to stop.

6. It cannot go out of business, can print money to keep on going, and is propped up by taxpayer money.

Two, Government cannot solve all reform problems by acquiring, analyzing, transmitting, and paying for evidence-based outcomes. It is always tempting to say that data is objective, impersonal, and non-judgmental. But as everybody knows, studies can be structured to give one the results that one wants. This is especially true in the field of medicine, a combination of science and art – in which personal feelings, expectations, and life-death decisions are involved.

The Electronic Inquisition

With the rise of high speed, broad bandwidth, Internet-actualized capabilities, a quasi-religious belief that data will solve all problems is going on. If only government can collect enough data on enough doctors, hospitals, and other health care professionals,all will be well. The U.S. and private health plans will finally have enough data to judge who and what is good, who and what is bad, and who and what justifies federal payment. Data will somehow be the Holy Grail and the Final Enlightment.

In a economic and human sector as fluid, personal, emotional, individualistic, and unpredictable as medicine, this is dangerous thinking. Data alone is not enough to judge performance or assure satisfaction. That is why patient and doctor decision-making, sometimes independent of data, and why market-based behavior, based on freedom and choice, are equally as valuable and credible as data-based judgments.

Tweet: CMS Centers for Medicare and Medicaid Innovation are reaching out to the private sector to reach collaborative innovation decisions.

Thursday, January 26, 2012

What Prooccupies Physicians

Maybe the preoccupation with technologic progress has overshadowed our concern with human progress.


Wynton Marsalis (1961- ), American jazz musician

Physicians are preoccupied with health reform, their fate, and the fate of their patients.


Anonymous

January 26, 2012 – From time to time, I review the “stats” of my Medinnovation blog. Why? I want to know what essays of mine people are reading. Since most of my readers are physicians, it useful to review what they are reading so I can address their concerns in the future.

Here is a summary of the stats, in order of number of top blogs read.

Over Last Three Years


1. Is Practice Fusion’s “Free” EHR for Real?

2. Interviews, Physician Shortage

3. Primary Care Revolt: Replace the RUC

4. The Low Value of Primary Care in Eyes of Patients

5. The Future of Accountable Care Organizations

Over the Last Month

1. Is Practice Fusion’s “Free” EHR for Real?

2. The Time Has Come: Physician Productivity and Telemedicine

3. Health Reform: Does it Matter What the Public Thinks?

4. Health Care Future Bright for Nurses. Stinks for Doctors

5. Power of Humanistic-HIT Integration

Discussion

I do not want to put too fine a point on these results.

Basically the results show these proccupations.

• A preoccupation with installing the most efficient EHRs for as low a price as possible. Much of this preoccupation, no doubt, is due to how to respond to federal financial incentives for “meaningful use” and a sense that EHR use is inevitable. EHRs are also improving in their relevance and their use is being facilitted by lower installation costs and by processing in the “Cloud,” which makes onsite hardware and software on practice sites unnecessary.

• A preoccupation with the shortage of primary care physicians, their low morale, their perceived dismal future, and increasing their income and status.

• A preoccupation with how to bring about increasing productivity through the use new-fangled software that will allow, among other things, faster patient throughput and more virtual visits.

• A preoccupation with the continuing unpopularity of Obamacare, now at 58%, and Democrats’ dismissal or silence of this lack of popularity. As President Obama said in his State of the Address, “There is no going back.” He dismissed health reform in two sentences.

• A preoccupation with Accountable Care Organizations – what they mean, what to do about them.

Tweet:
Doctors are preoccupied with what to do about EHRs, the fate of primary care physicians, increasing physician productivity, and ACOs.

Wednesday, January 25, 2012

Greatest Challenge Facing Health Reform

The unhatched egg to me is the greatest challenge in life.

E.B.White (1899-1985), American Essayist

January 25, 2012 - Health reform’s greatest challenge resides in how the U.S. will supply enough physicians to care for the incoming wave of Medicare and Medicaid patients. How can government create and stoke the physician incubator enough to warm it and to hatch sufficient numbers of new physicians?

No single organization has a better grasp of how to rise to the challenge than the Physicians Foundation. This non-profit organization has achieved this grasp by conducting a series of national surveys on how doctors feel about reform and how they are likely to react to pressures imposed upon them.

Here Louis Goodman, PhD, President, and Timothy Norbeck, CEO, of the Physicians Foundation – in an article in the January 4, 2012 Physicians Digest, describe the challenging road ahead for America’s physicians and patients they serve. For more on the work of the Foundation, I invite readers to visit the Foundation website. Go to google and enter the Physicians Foundation, and its website will appear.

“This year promises to be a watershed year for healthcare in general, and for patients and physicians, in particular. No matter how the U.S. Supreme Court determines the constitutionality of the Patient Protection and Affordable Care Act (PPACA), 2012 will be a crucial turning point in the delivery of healthcare.”

“During the Congressional passage of the PPACA, White House advisors acknowledged that the economic forces in the legislation would accelerate physician employment by hospitals and larger physician groups. As mentioned in the “Roadmap for Physicians to Health Care Reform,” the “private” part of private practice for physicians is disappearing. "

"Currently, more than 80 percent of visits to physician offices have been to practices with five or fewer physicians. That will change drastically as more physicians feel pressure to move into larger groups or become employed by hospital systems. Through October of 2011, there have been 71 hospital mergers. All of this will change the face of the delivery aspect of health care, but a question remains: will it be for the better or worse?”

Present Physician Shortages

“Expert opinion is almost universal that there is a present shortage of physicians, especially those in primary care and those practicing in rural areas. This is a workforce problem that must be addressed now, but it seems to be lost in the debate over the PPACA. The Physicians Foundation recognizes the shortage problem and recently awarded a large grant to The Cecil G. Sheps Center for Health Services Research at the University of North Carolina at Chapel Hill to develop a dynamic web-based projection model that can be continually updated to track ongoing physician workforce needs across the country. Information gleaned from the UNC research will further enhance efforts to identify where physicians are most needed to support patients in a growing healthcare system."

"Thirty-six percent of practicing physicians are over age 55 and may retire by 2020. According to Physician Foundation surveys conducted by Merritt Hawkins in 2008 and 2010, fewer physicians are seeing Medicare patients or taking on new Medicare patients. With 10,000 baby boomers becoming eligible for Medicare every single day, the survey results do not bode well for access to care for Medicare patients.”

Why So Few Physicians?

“Why do we have fewer physicians seeing Medicare patients at the very time that we need more of them? First of all, the Sustainable Growth Rate (SGR) used to pay physicians under Medicare, singles out physicians for financial punishment in the form of payment reductions when volume of service increases. With an aging population and increasing numbers of chronically ill elderly people, of course the volume of services continues to rise."

"However, unless Congress steps in and acts promptly, Medicare physician payments are scheduled for an average reduction of 27.4 percent effective January 1, 2012. The Physicians Foundation joins all other medical associations and the AARP in warning of the dire consequences on patients’ access to care should this massive and unwarranted reduction go through. The fatally flawed SGR must be fixed and the aforementioned 27.4 percent scheduled reduction must be stopped.”

Reform Law from Physicians’ Viewpoint

“Much has been said about the PPACA, some good and some bad. We would like to address the legislation from a physician’s point of view. Physicians are extremely happy to have the American public insured and are delighted to have an end to the discrimination against their patients with pre-existing conditions. They also applaud the new focus on preventive care which should help lead to a healthier public. As for the downside to the legislation, there was no SGR fix and no tort reform. The PPACA also assumes a planned 30 percent reduction in physician fees scheduled under the SGR over the next three years."

"Furthermore, and this is something that is largely overlooked when discussing the legislation, any physician’s office which mistakenly and by mere accident improperly bills too much for a Medicare visit, is subject to potential liability under federal fraud and abuse statutes. Before the PPACA, intent to commit fraud was necessary for a charge of fraud to be made, but now even an innocent error can result in prosecution. Finally, and also overlooked by many, is the “translation” fee which must be paid by the treating physician. If a physician treats a patient who doesn’t speak English and requires a translator, the physician is responsible for the translation fee. In other words, the translator’s bill would probably exceed the physician’s reimbursement for the office visit!”

Physician Survey Results

“These issues and other pressures on physicians help explain some of the survey results from the 2010 Physicians Foundation Health Reform Research Study, and the numbers only become bleaker when comparing the results from our 2008 survey. Only one-quarter of physicians surveyed said they plan to continue practicing as they are; while half reported that they would adopt a style of practice different from the traditional full-time independent private practice model. Hence, the “private” in private practice is going, going, gone!”

“Clearly, increasing administrative burdens attributable to the PPACA requirements plus insurance, red tape and costly regulatory measures are having a likely negative effect on patient care. Sixty-three percent of physicians surveyed claimed that non-clinical paperwork has caused them to spend less time with their patients and 94 percent said that the time they devote to non-clinical paperwork has increased over the past three years. Ask any physician what he or she enjoys the most about practicing medicine and the response will be: “seeing, helping and interacting with my patients.”

"The increasing amount of regulations and paperwork are becoming a more formidable barrier to the joy of practicing medicine. Add to that the declining reimbursements and difficulty in sustaining one’s practice, the constant threat of liability, decreased time with patients and low or no bargaining power with insurers, it is not surprising to note that general physician morale is low and getting lower.”

Meeting Declining Health and Social Needs

“A recent Robert Wood Johnson Foundation survey of physicians indicated that four out of five physicians agreed that unmet social needs are connected to declining health for many Americans. By the same ratio, they also agreed that addressing patients’ social needs are just as important as addressing their medical conditions. An innovative Boston, Massachusetts organization called Health Leads interviewed local physicians about their needs in providing patient care. Many expressed frustration that they could not help their poor patients beyond simply providing medical care – with housing, nutrition (food) or other resources that could improve their health. Not only have these important issues been excluded from the health reform debate, they are largely ignored by policymakers.”

“With a substantial grant from The Physicians Foundation, Health Leads has been able to expand their efforts to train college student volunteers in five cities to “assist” physicians to “prescribe” food, housing and fuel assistance, or other resources for their patients – just as they do medication. Patients then take those “prescriptions” to the Health Leads Family Help Desks located in clinic waiting rooms, where the volunteers “fill” them by connecting patients with those resources. Most of the student volunteers (64 percent of who are pre-med students) end up choosing to go into primary care – another plus!”

“Generally exacerbating the overall workforce problem is the plight of medical students now coming into practice. Graduates, on average, carry a debt of $156,000 and payments of up to $2,000 a month! According to the American Association of Medical Colleges (AAMC), each member of the graduating medical school class of 2033 will face a $700,000 debt!”
“So what can be done to help physicians sustain their practices and have more time with their patients? An obvious place to start would be to fix the unfair SGR – and promptly! This Congressional and government inability to solve this problem reminds us of the late economist Milton Friedman’s observation on the inefficacy of government: If you put the government in charge of the Sahara Desert, he said, in five years there will be a shortage of sand."

"And so it is with the growing shortage of physicians. Congress should relieve physicians of onerous and time-consuming regulations and insurance red tape – which do not help patient care and only add to the cost of that care. It should create more incentives for physicians to go into rural areas and find additional ways for medical students to pay off their medical school loans. Build more medical schools and increase the number of the 25,000 residents and fellows completing their training every year.”

Finding the Money

Of course, the big question is: Where do you find the money to do all this? Throughout America’s history, that question has been asked many times. The obvious answer: If you have the will you can find the wallet. America always has, if the issue is considered important enough. It won’t be easy but healthcare delivery and its workforce are being challenged in a major way today, and it will only worsen tomorrow without Congress stepping up and addressing it. As noted in Shakespeare’s Henry VI: “Delays have dangerous ends.”

Tweet:
The greatest challenge facing the U..S. system is how to inspire America’s current physicians and to find the means to replace them.

Tuesday, January 24, 2012

Doctors Tend to Do Only What They Are Paid to Do or to Know

You get what you pay for.

Popular Saying

A thing is worth whatever the buyer will pay.

Maxim

January 24, 2012 - Why are doctors so reluctant to accept phone calls? Why do so few doctors use email? Why are doctors so slow in adopting electronic medical records compared to their foreign counterparts? Why do most doctors not know the price of drugs, how brand names compare to generics, and where in town to get the best deal? Why don’t they spend more time educating patients on the principles of good health and self-care?

The short answer, according to John Goodman, in his January 23 blog, “How Doctors Are Trapped, Part 2,” is that doctors, being reasonable economic beings, tend do only what they are paid to do or know. Goodman uses telephone consultation as an example.

“Medicare doesn’t pay for telephone consultations. Medicare has a list of about 7,500 tasks it pays physicians to perform. And talking on the phone isn’t on the list. Private insurance tends to pay the way Medicare pays. So do most employers."

"At a time when doctors feel they are being squeezed on their fees from every direction by third-part payers, most become much focused on which activities are billable and which are not. And most are going to try to minimize their nonbillable tasks.”

Considering that talking on the phone in response to patients can absorb as much as 25% to 33% of practice time, these physician attitudes make sense. The same sense applies for activities such as answering patient emails, learning and training staff to use electronic records, educating patients about self-care, and dispensing knowledge about where to find and use the most economical drugs.

Goodman concludes doctors are relatively helpless to alter the situation, given how they are paid and the constraints of repackaging and repricing their services.

These restrictions, Goodman asserts, are deleterious to effective reform, “Of all the people in the health system, none is more central than the physicians. Fundamental reform is almost inconceivable without physicians leading and directing the changes.”

Cost constraints about these time consuming but essential activities are not universal, nor do they necesarily add to costs. In Denmark, where health care costs half of what it does here, physicians are paid to talk on the phone, send and receive emails, install and use EMRs, educate patients, and facilitate referrals. Patient convenience is the goal.

Tweet: In U.S., 3rd parties don’t pay MDs to talk to patients by phone, to consult by e-mail, to use EMRs, to educate about drugs and health.

Monday, January 23, 2012

Liberal Views of Government and Health Reform

Only a completely ready state can permit the luxury of a liberal government.

Otto von Bismark (1815-1898)

January 23, 2012 – Liberal readers have complained my last blog on Newt Gingrich and his take on American history lacked balance. My blog, they said, was not "fair."

“Fair” is a liberal pejorative word. You will hear it often in President Obama’s State of the Union address Tuesday night.It will be the central theme of his talk.

Just to be fair and balanced, in this blog I shall quote three liberal contributors in yesterday's New York Times, that impeccable Grand Old Gray Lady of American liberalism.

One, Ezekiel J. Emanuel, MD, President Obama’s former chief medical advisor, in “What We Give Up for Health Care”.

"When it comes to health care, most liberals are committed above all to ensuring that every American has health insurance, the greatest achievement of the health care reform act passed under President Obama to finally erase the moral stain of the United States being the only major country without universal coverage…To protect education and workers’ pay, liberal must start to care about costs.”

Two, Philip Boffey, editorial writer of the New York Times, in “The Money Traps in U.S. Health Care”.

"Health reform is supposed to control costs, but there is no simple avenue of attack. Our aging population has played a role in driving up medical costs, but Germany, Italy, and Japan have much bigger percentages of elderly people while spending much less per capita on health care…The spread of health insurance, which shields patients from price sensitivity, has played a role in driving up our spending. But almost all other advanced nations cover virtually everyone, while we leave 50 million uninsured. Administrative costs are high here – no surprise given the hordes of clerks and accountants needed to deal with insurance paperwork. And technologic advances, which are sometimes beneficial and sometime not, cost a lot more than standard treatments. (Surprisingly, American doctors lag far behind their foreign counterparts in using electronic medical records, which can help prevent costly errors and duplications.”

Three, Thomas L. Friedman, Times Political Columnist, Commentator, and International Guru in “American Voters: Still Up for Grabs”

"I want to vote for a candidate who advocates an immediate investment in infrastructure that will create jobs and upgrade America for the 21st century – ultrafast bandwidth, highways, airports, public schools, mass transit.

Second,
I want to vote for a candidate who is committed to reforming taxes, and cutting spending, in a fair way. The rich must pay more, but everyone has to pay something. We are all in this together.

Third, I want to vote for a candidate who has an inspirational vision, not just a plan to balance the budget.

Finally, I want to vote for a candidate that supports a minimum floor of public financing of presidential, Senate and House campaigns. Money in politics is out of control today.

Obama is a ‘Kenyan socialist‘- who shocks the public by going radically responsible, radically honest, radically demanding and radically inspirational. Along the lines above, he will be our next president.

I hope it is Obama, because I agree with him on so many issues."

Denouement

There you have it – three liberals’ points of view. I trust that they have not left anything important out, and that I have been fair and balanced.

Tweet: Liberals espouse universal coverage, low costs, high taxes,fair taxes,EHR use,infrastructure spending, and care as delivered abroad.

Sunday, January 22, 2012

It's the American Culture, Stupid!

Something very fundamental that I wish the powers that be in the media will take seriously: The American people feel they have elites who have been trying for a half-century to force us to quit being American and some kind of other system.

Newt Gingrich, in comments on his South Carolina primary triumph

January 22, 2012 - In winning the South Carolina primary, Newt Gingrich put his finger on several important fundamentals:

1) We are a center-right, not a center-left nation, not only in South Carolina but arguably in the rest of the nation as well.

2) We are more conservative and independent than liberal (Gallup says 40% of us identify ourselves as conservative, 40% as independent, and 20% as liberal).

3) We dislike the 20% elite, members of the new upper class, telling 30% of members of the new lower class what to do and how to think(Charles Murray, “The New American Divide,” WSJ, January 21, 2012).

4) We prefer American capitalism to European socialism with capitalism's supposed inequities( as Winston Churchill famously remarked: “The inherent vice of capitalism is the unequal sharing of blessings; the inherent virtue of socialism is the equal sharing of misery.”)

5) The majority of us say we would rather have the current Medicare-Medicaid-private-based system to an Obama-Democrat centralized system ( by 51% to 38% in an average of national polls as compiled by Real Clear Politics).

6) A remarkable disparity in wealth and attitudes exists between elites who live in “Super ZIP codes” to economic effetes who reside in less affluent ZIP codes(according to Charles Murray, 11 of 13 D.C. Super ZIP residents have incomes in 99% bracket and 2 of 13 are in 98% bracket).

Put simply, the new upper class -highly educated and high income celebrities, managers, executives, politicians, policy experts, engineers, lawyers, salaried physicians, professors, journalists, and information IT content producers - think differently than poorer citizens on the streets, farms, small businesses, and check-out counters eking out a living. The latter tend to be high school educated blue collar workers, less skilled service workers, and other ordinary Americans with lower incomes. The lower class thinks differently on fundamental values like marriage, single parenthood, industriousness, crime, immigration, religion, and size of government.

President Obama is striving to bridge these differences by insisting on “fairness” and redistribution of benefits and income. He will argue in the State of the Union address that an activist government is the best means of promoting a prosperous and equitable society.

In health care, Obama seeks to overhaul the entire structure of the health system from the White House and Washington and make it more uniform. This will not be easy. We are a vast continental nation with marked regional differences and culture.

Obama faces four great obstacles to health reform. These obstacles start with the letter “C”- Culture, Complexities, Costs, and Consequences. The “Cs” are inner-connected and inner-tangled and have been building over a ong time, at least since 1970.

Getting hospitals and doctors and patients, indeed the entire medical-industril complex, to change direction – to focus on prevention and chronic care and self-care instead of the traditional way of doing things to government-oriented approaches– from a medical care to a health care system, will require radical philosophical and practical changes.

It will require changes from traditional ways of doing things - from switching from special interests to personal interests. These transitions will take time. It will require switching from elites running things to American people in the drivers’ seat.

It will take leadership – and a grasp of our culture and American historical traditions.

It will take painful tradeoffs between self- responsibility and government dependency – from attitudes of central entitlement to peripheral enlightenment.

American health care culture abhors “rationing,” by any other name, be it “evidence-based” or “outcome-based” care. Americans cherish choice and personal freedoms, quick access to the latest and the best, and proven life-style and life-saving technologies. Americans know they can see a specialist, to get elective surgeries, and to be treated for diabetes, cancer, and other chronic diseases quicker than in other countries. They prefer the 35% tax burden in the U.S. to the 55% tax load in Europe. These traits conflict with a centralized, command-and-control federal health care expansion.

Tweet: Center-right Americans don’t wish to be more like Europe. They prefer choice, freedom, and personal judgment to elite government control.

Saturday, January 21, 2012

Hospital Funding Cuts and Future Physician Hospital Employment

When men are employed, they are best contented, but on idle days they were mutinous and quarrelsome.

Benjamin Franklin (1706-1790), Autobiography(1731-1759)

January 21, 2012 – I am old enough to remember those days in Minneapolis in the 1980s and 1990s when managed care shut down half the hospital beds and left unemployed physicians in its wake, including me.

I am also old enough to recall those days in the late 1990s and early 2000s when hospitals acquired thousands of physician practices, lost a bundle of money on them, then let doctors loose to return to practice to fend for themselves.

I am young enough to know that hospitals are again employing physicians in record numbers, that young physicians, carrying heavy debts and craving balanced life styles, are flooding into hospital employment.

I am alert enough to know hospitals are a vibrant employment sector, having created 89,300 jobs in 2011, according to the Bureau of Labor Statistics.

I am smart enough to know that the hospital industry, facing an influx of 32 million federally-subsidized Medicare recipients in 2014 and a steady increase of roughly 4.5 million new Medicare eligible Baby Boomers each year until 2029, are feeling paranoid about Congress and hospital funding cuts.

The American Hospital Association says funding cuts now under consideration by Congress (HR3630) could cut hospital budgets by $61.4 billion over the next 10 years. These cuts, say the hospitals, would force hospitals to slash 278,000 jobs. The GOP Congress it seems, plans to take money from hospitals and use the money to cover the deficit created by extending the Social Security tax holiday and unemployment benefits and by applying the “doctor fix.”

How many of these projected 278,000 lost jobs would be physician jobs? If an “doc fix” indeed occurs, how many physicians will be able to remain in practice to see new Medicaid and Medicare beneficiaries? How will short-staffed hospitals be able to care for the tsunami of new patients in gvenment programs?

These are unanswerable questions that boggle the mind. Answers depend on the health of the economy and on the June Supreme Court decision and the November election.

Tweet: The AHA says HR 3630, a bill now in Congress would cut hospitals by $61.4 billion and force hospitals to lay off 287,000 employees.

Friday, January 20, 2012

Poisonous Politics of Health Reform

One man’s meat is another man’s poison.

Oswald Dykes, English Proverbs (1709)

January 20, 2012 – In John Iglehart’s article (“Confirming the CMS Nominee – Overcoming Poisonous Politics, NEJM, January 19, 2012)on the nomination of Marilyn Tavenner, RN, as the successor to Donald Berwick, MD, who was forced to resign by Republicans, Iglehart has this to say.

“Tavenner is no shoo-in. In May2007, President George W. Bush nominated Kerry Weems, who was acting CMS administrator, but Democrats refused to confirm him… Although Tavenner has demonstrated a capacity to head CMS, she may be locked in a similar politic vise – a reality of the poisonous partisanship of U.S. Politics.“

One bad act may deserve another, especially when one considers what Tavenner said of her predecessor, who Republicans reviled because of perceived socialistic leanings, Republican opposition should surprise no one.

Travener is on record as saying, “Our strategy is pretty much mapped out for 5 years. It’s called the Affordable Care Act..Don is…a great visionary, and we’re working on some great projects…I don’t see much change.”

As the English proverb states, “One man’s meat is another man’s poison.”

The Democrat’s meat is the Affordable Care Act, which Obama considers his historical legacy. The Republican’s poison is repealing the Affordable Care Act, which they believe personifies unaffordable Big Government.

Democrats and the Obama administration, with control of the Presidency and both Houses of Congress, poured salt on their meat by passing the ACA with questionable last minute legislative maneuvers,offering Medicaid largess to three wavering Democratic Senators,and virtually ignoring, even thumbing thier collective noses, at Republicans.

Obama rubbed even more salt into Republican wounds, who voted unanimously to oppose the bill, by making the recess appointment of Dr. Donald Berwick on July 7, 2010 while the Senate was out on recess.

According to Republicans, Obama also failed to "consult and consent." He did not develop any personal relationships or even to listen to GOP leaders. The GOP regarded the passage of ACA as an act of political arrogance. Passage of the Act against unanimous GOP opposition was as if to say,” By God, I’m the President and we control both Houses, and we are going to pass this damn thing, no matter what you or the public thinks. It is our historical and patriotic duty."

Obama and the Democrats poisoned the political well from the onset. In November 2010, The public reacted by voting in a Republican majority in the House by the most overwhelming margins since 1938. The new majority voted for repeal to no avail but vowed to defund, debunk, dismantle, and eventually repeal the ACA. But the Senate, controlled by Democrats, did not support repeal.

And so the matter of implementation or repeal is stalled until the Supreme Court announces its decision in June on the constitutionality of the individual mandate and other portions of the bill, particularly those applying to Medicaid, and until the November 2012 elections.

Tweet: Democrats and Republicans are locked in partisan poisonous debate over health reform and the nomination of a new CMS administrator.

Thursday, January 19, 2012

Health Reform and You

It requires an unusual mind to undertake the analysis of the obvious.

Alfred North Whitehead (1861-1947)

Your health is about you – not them.

Anonymous

January 19, 2012 - My wife and I went to a new primary care physician today. He shared his philosophy with us. It made abundant sense, and I would like to share it with you.

He said our health system costs too much because it’s obsessed with disease care not health care. It focuses too much on doctors and drugs and procedures, rather than on what you can do for yourself to stay healthy.

Your health should not be about them – the doctors and what they do- but about you, and what you can do for yourself.

Eighty percent of the problems he sees, he commented, are related to life-style, to lack of personal responsibility and lack of the sheer discipline it takes to maintain one’s health.

As he spoke, I reflected back on two introductory paragraphs of a 1992 book Staying Well: Your Complete Guide to Disease Prevention,by Harvey Simon, MD, a Massachusetts General Hospital internist.

Dr. Simon said:

“In my 25 years of medical practice, I have seen hundreds – perhaps thousands – of people die needlessly. And I cannot begin to count the thousands of patients I have seen suffering through illnesses that could have been prevented. As much as I love the practice of medicine I must confess that I’m growing a bit weary of patching up problems that never should have happened in the first place.

Nine of the ten leading causes of death in the United States are preventable. Only one of the ten, diabetes, is an inherited disease; all the others are affected much more by what we do than by who we are. And since diabetes can be controlled by diet, weight loss, and exercise, it is fair to say that changes in American life-style could control all of the ten leading American death styles
.”

In other words, as our new doctor said, “It’s about you, not about me.” Staying healthy requires hard work, concentration on what you must do, and goal setting.

In the beginning, it also requires record keeping to sensitize you to what you must do to stay healthy and to ward off those chronic diseases – obesity, hypertension, diabetes, heart disease – that kill so many Americans and cost so much, often until it is too late.

This record keeping should include recording how many minutes a day you devote to exercise. If your favorite exercise is walking, you should be walking on average 25 minutes a day. Write your minutes of walking each day, total it up, and take an average over a week or so.

Your records should also include the number of calories you’re taking in from eating and drinking. For a week, record everything you eat, every glass of wine you drink.

Then sign up for a website called myfitnessplan.com, enter the foods and drink you consume. The website, which has hundreds of thousands of foods with the calories for each food and drink, will calculate your calories per day.

Another thing, never eat after dinner before you go to bed. After dinner snacking adds calories and sends your body the wrong signals.

Finally, don’t depend too much on drugs to bail you out of your life-style induced problems and your indulgences. Drugs are an example of half-way technologies - treatments administered after the disease horse has left the barn.

Work on your weight and your exercise, and you may be surprised how soon you will no longer depend on those drugs for diabetes, hypertension, and symptoms of heart disease. You may also be surprised how quickly your drug and doctor bills go down.

Tweet: Life-style – over-eating and under-exercising - needlessly causes many chronic diseases and drugs required to treat them.

How Doctors Can Reduce Medical Errors, Lawsuits

January 19, 2012- Kevin Pho, MD, America’s number #1 physician blogger, wrote the following column for USA Today on January 18, 2012.

Kevin is a New Hampshire internist who was in the physician blogging scene in its early stages. His blog contains not only his blogs, but those of many other physician bloggers, including me. Today, for example, he ran my recent blog on "Hos Hosptials Are Gaining Leverage over Physicians."

By running other physicians blogs,Kevin follows the unwritten code of physician bloggers: Thou shall support and highlight the work of your fellow physician bloggers.

Here Kevin captures and aptly describes the fear of most physicians – an unjustified malpractice law suit.

Ask doctors what concerns them most, and chances are they'll say, "medical malpractice." A recent New England Journal of Medicine study found that 75% of doctors who practice psychiatry, pediatrics or family medicine will be sued during their career. Neurosurgeons, orthopedic surgeons and obstetricians have it worse, as virtually all of them will be sued before they finish practicing medicine.

The medical malpractice debate often pits physicians — who say the threat of lawsuits pushes them to order expensive, unnecessary tests — against lawyers who believe that lawsuits are needed to hold doctors accountable.
Obviously, no one wants medical mistakes. And no one, perhaps with the exception of lawyers, wants lawsuits, which put the victims, their families and the doctors involved through wrenching affairs.

How can physicians avoid the courtroom? If an error was made, many insurers advise physicians not to talk to patients. That's wrong. Physicians should disclose their mistake, apologize and, when appropriate and through mutual agreement, compensate injured patients.

Apology Laws

For more than a decade, the University of Michigan Health System has used such a program, and its incidence of malpractice claims has since dropped 36%.

This approach should be spread nationwide. Actually, in 2005, then-Sens. Hillary Clinton and Barack Obama co-sponsored the National MEDiC Act, which among other things would have implemented apology laws throughout the U.S.

Although the measure never became law, at least 36 states have passed legislation protecting apologies from being used against doctors in court.
Doctors also must create and maintain open lines of communication with patients, which is critical to preventing lawsuits in the first place.

Doctors have to better explain, and patients better understand, that not all adverse outcomes are due to physician errors. Although the Institute of Medicine's 1999 seminal report, "To Err is Human," concluded that medical errors caused up to 100,000 patient deaths a year, 90% of those deaths were attributed to systemwide procedural failures at medical institutions.

Nothing's Easy

Consider the seemingly simple task of dispensing a drug at a hospital. It's actually a complex process that requires five interdependent steps: ordering, transcribing, dispensing, delivering and administering. A poorly designed system can lead to an error in any of those steps, with a potentially deadly outcome. Bad outcomes can also occur despite proper patient care. A colonoscopy can be performed correctly, for instance, yet complications such as a bleed or a tear in the colon can still unexpectedly occur.

Finally, fewer lawsuits might lead to better medical treatment. A 2011 study from the Journal of the American College of Surgeons found that doctors who had been sued were more prone to burnout, depression and suicide, and, in turn, often make significantly more mistakes.
There's no panacea for eliminating mistakes, but a starting point is clearly communication. Better doctor-patient exchanges improve medicine, and when patients and their families are kept in the loop, they also are less likely to pursue a lawsuit. And, then, if errors are made, doctors should apologize and work with the patient and, when necessary, their lawyer, to find a compromise.

Tweet: Transparency is the key to an open, trusting and healthy doctor-patient relationship.

Wednesday, January 18, 2012

The Limits of Health Reform Intervention

All I want is a warm bed, a kind word, and an unlimited life and power.

Anonymous

January 18, 2012 - Capsizing of the giant Italian cruise liner brings to mind the gigantic revising and upsizing of the U.S. health system and limits of health reform. Expert guidance systems may not keep you off the rocks when human beings are involved.

The unfinished business of health reform is a story about limits of government intervention and federal power. Everything in human affairs has limits. The health system is no exception. In health care and medical care, which are not the same thing, as in everything else, the sky is not the limit, measures of outcomes is not the limit, estimates of costs is not the limit, wisdom of the elite is not the limit, wonders of medical technology is not the limit, power of federal intervention is not the limit, human folly, abuse, and overuse is not the limit. The human condition and human nature are the limit.

The limits are human desire to live another day in the best health and the best functional condition one can, the desire to have access to the best medicine has to offer, the dream of participating in a free and open society that doesn’t limit one’s actions or behaviors, and above all, something that few ever mention – acknowledging the limits of human biology. These are the limits.

• Human longevity has limits, somewhere around 110 years in the best of times, provided one’s mind remains intact. To pretend or predict otherwise is foolish, even if one blindly believes in gnomes and genomics.

• Human reproduction has limits, somewhere around 45 for women, unless, of course, one wants to prolong the reproductive cycle with artificial intervention, which, after all, is artificial even superficial for most of humankind.

• The human brain has its limits, somewhere around 5 minutes without oxygen, somewhere around an IQ of 200, and everywhere when it comes to foresight, judgment, and reasonableness.

• The human vascular system, which supplies oxygen, the stuff of life, to our vital organs, has limits - every pathologist knows the years deposit lipids on arterial walls, stiffens the vessels, and mankind is as old as his arteries.

• Human behavior – its wants, flaunts, haunts, and taunts – has limits. Humans will always do what they do to pursue happiness, pleasure, and power.

• Human cultures have limits and are set in stone by the time one reaches adulthood and beliefhood. Witness the world’s great religions, belief systems, hatred, bigotry, and conflicts and conflagrations that ensue.

• Human disease has limits. Most human diseases have mysterious origins and limited fixes, although it is incumbent for medicine to probe the mysteries and to create the cures when nature allows.

• Human benevolence has its limits. There is never enough money or resources to do what needs to be done, and there is always malevolence lurking around every corner, across every border, and in minds of adversaries.

• Human technology has limits. Technology can create artificial intelligence, but it always just that –“artificial”; it can amass data to guide us to more rational solutions; it can connect individuals to one another; it can disconnect them from corporate and political masters; but it cannot basically alter human conditions and limitations, nor can it intervene to reform everything human.

Tweet: As in everything human, health reform has limits of intervention.

Tuesday, January 17, 2012

Coding: Hardening of Health Care Categories

Coding is the bane of the doctor class.

Anonymous

January 17, 2012 - Health reformers complain bitterly and condescendingly about inefficiencies and costliness of fee-for-service. FFS, they say, encourages doctors to do more – often one step, one test, one visit, one procedure at a time – to generate more income.

Why not, they go on, bundle fees for one episode of illness, one swath of services surrounding one hospital procedure, one illness with all of its ramifications?

What these critics overlook is this reality: the arcane, byzantine, sclerotic coding system covering 7500 tasks imposed by Medicare and private health care sycophantic payers compels doctors to behave the way they do.

The coding system pays doctors for one task per visit. The patient may have multiple problems, known is federal slang as “co-morbidities,” but doctors are only paid to code for one thing or one visit at a time. There is no code for telephone calls or emails, or other tasks or knowledge that be required to address myriad problems.

The coding system, in other words, traps doctors into charging a certain way. John Goodman, founder of the National Center of Policy Analysis, explains the trap this way in “How Doctors are Trapped” in a January 12, 2012 The Health Care Blog.

Every lawyer, every accountant, every architect, every engineer — indeed, every professional in every other field — is able to do something doctors cannot do. They can repackage and reprice their services. If demand changes or if they discover a way of meeting their clients’ needs more efficiently, they are free to offer a different bundle of services for a different price. Doctors, by contrast, are trapped.”

Goodman continues:

“In addition, Medicare has strict rules about how tasks can be combined. For example, “special needs” patients typically have five or more comorbidities — a fancy way of saying that a lot of things are going wrong at once. These patients are costing Medicare about $60,000 a year and they consume a large share of Medicare’s entire budget. Ideally, when one of these patients sees a doctor, the doctor will deal with all five problems sequentially. That would economize on the patient’s time and ensure that the treatment regime for each malady is integrated and consistent with all the others.”

Under Medicare’s payment system, however, a specialist can only bill Medicare the full fee for treating one of the five conditions during a single visit. If she treats the other four, she can only bill half price for those services. It’s even worse for primary care physicians. They cannot bill anything for treating the additional four conditions.”

“Since doctors don’t like to work for free or see their income cut in half, most have a one-visit-one-morbidity-treatment policy. Patients with five morbidities are asked to schedule additional visits for the remaining four problems with the same doctor or with other doctors. The type of medicine that would be best for the patient and that would probably save the taxpayers money in the long run is the type of medicine that is penalized under Medicare’s payment system".

FFS may be inefficient because of the coding system’s “one-task-at-a- time” mentality. The system permits no flexibility, no consolidation of services, no way of repricing services to fit the total task at hand – or the totality of time, effort, and knowledge that goes into addressing the clinical and social situation.

Tweet: The physician coding system pays doctors for one-task-at-a- time rather than the time, energy, and knowledge required for the total task.

Monday, January 16, 2012

The “Specious” 30% Argument for Health Reform

Spe-cious - Seeming to be good, sound, correct, logical, etc without really being so, plausible but not genuine.

Dictionary definition of specious

I dare say that I have worked off my fundamental formula on you that the chief aim of man is to frame general propositions and that no general proposition is worth a damn.

Oliver Wendell Holmes, Jr. (1841-1935), Letter to Pollock, written on November 22, 1920

January 16, 2012 - I do not know exactly where the argument started that the U.S. health system “wastes” 30% on “unnecessary” care. Yet I read about this waste everywhere I turn.

The proposition that health care is 30% unnecesary waste and emblematic of rampant inefficiecy may have begun with John Wennberg and his colleagues at the Dartmouth Institute of Health Policy and Clinical Practice. Using Dartmouth’s Medicare Atlas maps, Wennberg et al showed a 30% regional difference in Medicare costs. They logically assumed the U.S. spent 30% too much treating chronic disease for the elderly, and presumably for everybody else as well. The New England Healthcare Institute, McKinsey, and Thomson-Reuters took up the 30% torch. The flame was passed to the Obama administration, whose experts, such as Ezekial Emanuel, MD, and Donald Berwick, MD, have perpetuated the 30% proposition.

It is, of course, true that humankind – individually, in groups, businesses, governments, hospitals, physicians, and patients - vary by at least 30% in their efficiency, performance, output, and outcomes. If one believes that people and organizations should be homogeneous, this 30% difference is indeed unnecessary, off-putting, even alarming.

It is alarming that 30% of Americans are overweight, incomes across the U.S. vary by +/-30% (some way 99%), only 30% of our doctors are primary care practitioners, 30% of Medicare money is spent on the last illness, 30% of us either drink or smoke too much, doctors consume 30% of money spent on health care, hospitals take another 30%, 30% of the population is responsible for at least 90% of health costs, only 30% of employers have wellness or prevention programs, government programs pay for 30% of the population but spend 50% of health care monies.

It’s not only alarming. It’s a shame. Theoretically, we could erase these 30% differences by.

• Offering coordinated, continuous, evidence-based care for the chronically -ill across the health care spectrum.

• Bundling and budgeting care for hospitals and physicians and paying only for outcomes.

• Paying doctors more for maintaining health and less for ordering tests, doing procedures, treating illnesses, and warding off disabilities, life style dysfunctions, and even prolonging life.

• Compiling massive data bases to show unequivocally what works and doesn’t work and paying only for what works.

• Doing away with fee-for-service for doctors to destroy the Greed Monster.

• Eliminating poverty, which causes people to be sick until it’s too late to treat them “parsimoniously.”

• Minimizing “individual differences” by paying for statistical averages of “populations.”

A Crying Shame

Yes, it’s all a crying shame. If we could only do away with human expectations, doctors doing what they are trained to do, if only we would do what is good, sound, correct, and logical, and if we could only eliminate that feckless thing known as human nature, all would be well.

Tweet: Patients misbehaving, wanting the best, doctors doing what they do, costs the U.S. 30% more than it should.

Sunday, January 15, 2012

A 2009 Prologue to Health Reform

What’s past is prologue.

Shakespeare(1564-1616), The Tempest


January 15, 2012 - Back in 2009, a year before the Accountable Act passed, I wrote the following in Obama, Doctors, and Health Reform: A Doctor Assesses the Odds for Success (IUniverse).

Buyers managed to stay away from the book in droves, so I will not hurt if I repeat now what I said then about my book
“It’s a history lesson. There’s no mystery to history. It’s the present and future that’s obscure.

When Medicare and Medicaid passed in 1965-1966, the Johnson Administration assured us the combined programs’ cost wouldn’t exceed $9 billion. Now, 43-to 44 years later, the cost approaches $1 trillion, may double in five more years, and threatens to bankrupt government.

What’s the lesson?

There are four lessons.

One, if you think health care is expensive now, just wait until we have “free” government care. Anytime you have a government program, people will fine ways to “game” the system, driving up costs. The government will have to decide selectively what it can pay for, not how it can pay for everything. Rationing is inevitable, but it will be called paying for “priorities’ or “evidence-based” medicine.

Two, when you expand coverage, you invariably spend more money. As sure as dawn follows darkness, expanded government coverage will drain the federal treasury.

Three, money, even federal money, isn’t unlimited. No tree, no fee, grows to the sky. There’s no free lunch and no free-for-service. If you’ll pardon a couplet of clich├ęs.

Four, complexity science and chaos theory is at work. A butterfly flapping its wings in Brazil can cause a tornado in Texas, and 5% of foreclosed mortgages in California can Bring down Wall Street, even the world economy,. The same forces are work in health care.

Do you detect a note of cynicism?

No, what you detect is realism based on experience. The only long term solution is to make people pay something out-of-pocket for health care, with a cap on unaffordable catastrophic and with unspent tax-free money set aside for retirement.

But that will not happen in a society like ours accustomed to entitlement, and a mindset among politicians that health consumers can’t be trusted to fend for themselves, to interact with their doctors, and to take personal responsibility. It goes without saying that politicians don’t think doctors can be trusted to do the right thing either- if money is involved.

Tweet: If the history of Medicare and Medicaid is prologue, the future affordability of these programs is in doubt.

Saturday, January 14, 2012

Big Doings in South Carolina – Politically, Economically, and Medically: the Coming Health Care Crunch of 2015

The South shall rise again.

Anonymous

January 14, 2012 - As a doctor raised in Tennessee, educated at North Carolina (Duke), receiving post-graduate training in the East (Hartford Hospital and Harvard Business School), steeped in managed care in Minnesota, and exposed to the real world in a doctor-short state of Oklahoma, I would like to comment on a conversation I had with Allen Wenner, MD, a family physician in Columbia, South Carolina.

South Carolina is big in the news these days. The South Carolina Republican Primary takes place this week. It may determine the Republican candidate for President. Multinational corporations - Michelin, BMW, and Boeing – are establishing factories in South Carolina. Medical systems are engaged in changing the medical culture.

South Carolina has a culture characterized by low taxes, a low rate of unionization, high unemployment, and socially conservative values. South Carolina is a quintessentially Red State.

But is some ways, South Carolina is a progressive medical state ahead of the times. In an article in Health Leaders Media “Nudging Physicians towards Accountability.,“ Ellis Knight, MD, Senior VP of Palmetto Health, a multi-hospital system seeking to create an accountable care organization, says ACO-creation is progressing but encountering slow going. “To really bring physicians into your business model, “he says, “requires a lot more than a contract and a paycheck. It is changing a culture that has been long-standing and well-entrenched, and that is never easy.”

But easy or not, big-time change is coming – bulldozed and propelled by Obama health reform Medicaid policies , economic pressures to lower costs, ubiquity of the Internet, and the coming in 2014 of 50 million new Medicaid beneficiaries and baby boomer-eligible Medicare recipients (2011-2029).

According to Allen Wenner, MD, a family physician In Columbia, South Carolina, founder of Instant Medical History.com, a number of fundamental changes will be necessary to adjust to the tremendous volume of new patients: paying doctors for email and virtual visits, allowing patients to enter their own data electronically from home or the reception room, and telemedical monitoring of lab results and other data.

Here in a blog submitted from randaloats.com,An EHR website, is how Allen Winner foresees healthcare in 2015, which is not far away.

What Will Health Care Look Like in 2015?

Guest post by Allen R. Winner, M.D.


"I am sitting here quietly listening to Pandora Radio while I work. I am thinking how it will totally change how people listen to music. I am listening to a music channel that is totally customized and specific for my listening tastes. This transformation is more dramatic than other changes. I think that is what is happens - each change is bigger than the last. Pandora Radio will send Satellite Radio the way of the Satellite Phone. It will downsize the Clear Channel listeners to people who do not have internet or drive an older car without an input jack. Radio stations will become essentially worthless.

Amazon transformed how people bought books bankrupting Books a Million and finally Borders. Now the Kindle, Nook, iPod are transforming reading again. Verizon announced it will no longer publish a phone book in many markets as search engines have replaced them. The same thing is happening to how people watch television as networks become less valuable and streaming via Netflix becomes the video standard.

Transformations all come to medicine last. Medicine is the last industry to computerize information, but the transformation is likely to be the most dramatic, although the digitalization has started, the workflow transformation has not occurred. Many providers still act like the computer is paper under glass. As more and more medical systems become digital, then the evolution of medicine it will occur. With 49,000,000 million US citizens getting health care insurance at the same time growing millions of Baby Boomers are seeking care while patient satisfaction with care is already at generational lows, 2015 could be the time for real health care change. The Meaningful Use incentives will be over and the medical system will be divided into two tiers - those that are still paper-based and those that are totally paperless. The former will fade like mom and pop grocery stores as these doctors grow old with their patients.

The question becomes what will happen to health care delivery. The web enabled handheld device will play a critical role in changing health care. It will become the front door to the medical practice. 3G Doctor is an example of how patients will interact with the health care system. No longer will patients call up and get an appointment.

The patient will complete an expert interview, Instant Medical History™, as described by Bachman in his study of e-visits.

(1) The clinician will review the information before deciding on the plan:

1) come to the office;

2) go to ancillary service;

3) have a test;

4) conservative management;

5) go to specialist;

6) get treatment and schedule appointment later.

The clinician will be at least twice as productive. Perhaps 50% of current office visits will be virtual, as safe,(2) and preferred by patients.

Care will be home centered with many point-of-service lab devices in the patient's bathroom. The current outdated reimbursement schemes that prevent this today will fail as population based payment renders quantity based payment obsolete. Home prothrombin devices will render Coagulation Clinics unneeded. These skilled coagulation nurses will manage ten times the number of patients using web devices like smart phones.

Home blood pressure readings will be the standard. Diabetes will be a home health disorder. In-home video and clinical measurement devices connected to smart phones will allow new management of chronic medical issues.

Face-to-face visits will be far more complex with two or more clinicians and others video conferencing about patients. Specialists will no longer have brick and mortar offices.

They will have procedure suites and offices in hospitals where they can carry out virtual discussions. The primary care physician will manage the details of the treatment plan."

(1) Bachman, John, http://www.mayoclinicproceedings.com/content/85/8/704.full

(2) Munger, Mark http://www.mayoclinicproceedings.com/content/83/8/890.full

Tweet: In 2015, physicians will be paid for virtual visits and e-mail communications with patients and care will be centered and controlled by mobile devices.

Friday, January 13, 2012

Sermo, Pareto, and Palestrant Road Show

I have entered on an enterprise which is without precedent.

Jean Jacques Rousseau 01712-`78), Confessions


December 13, 2012 - Daniel Palestrant, MD, surgeon-turned entrepreneur and founder in 2006 of Sermo.com, a physician networking site with 130,000 members, is leaving Sermo with Sermo’s medical director to launch a new startup. par80.

He is taking his idea, using sophisticated software to facilitate direct referrals between physicians, on the road by promoting it heavily on Twitter, Facebook, Linkedin, and other webstie.
.
The par80 idea rests on principles set forth by Valfredo Pareto (1848-1923), an Italian economist. The Pareto principle (also known as the 80–20 rule, the law of the vital few, and the principle of factor sparsity) states 80% of the effects come from 20% of the causes. Pareto observed in 1906 that 20% of people 80% owned 30% of the land in Italy and 20% of the pea pods in his garden contained 80% of the peas.

Palestrant’s departure surprised many. Palestrant had said his body, heart, and soul was devoted to Sermo. Perhaps Sermo’s growth has stalled. In any case, here’s how Palestrant explains his new venture.

“Above all, Pareto teaches us that efficiency comes from effectively matching supply and demand. A “pareto optimized” system maximizes the benefits that any group of people can receive from a limited amount of resources. For this efficiency to occur, there needs to be as few intermediaries as possible between the reciprocal parties and a clear, transparent understanding of the goods or services being provided.

Therefore, ALL markets (and efficient economies) have these two features in common:

1. Transparency - The ability for the goods or services to be understood by all parties, also known as “price discovery.”

1. Liquidity - Direct interaction between both parties, which is critical because it allows both parties to adjust relative to one another and minimizes the friction caused by intermediaries.

When a system does not have these features, almost as a rule, opacity replaces transparency and the multiple intermediaries replace liquidity. These outcomes benefit incumbents, rather than the broader good.

Hence, par8o.

As physicians we can see that we have strayed far from Pareto’s insights, which has resulted in the exact opposite of an efficient system (and our patients are suffering for it). There are so many intermediaries in the healthcare system today, that only a small fraction of our nation’s healthcare spending actually goes to the people providing the care. Furthermore, the AMA’s CPT coding system has turned physicians into a commodity. It makes absolutely no sense that my sister (who is just finishing her radiology residency) and my father (who has had an immensely successful 30+ year career as a radiologist), should both get paid the same amount for reading an X-Ray. No law firm pays the first-year associate the same amount as the senior partner, because higher value is placed on greater experience. As physicians we have allowed ourselves to be commoditized.

par8o is the catalyst to help that happen for both physicians and our patients.”

My Interest

Why does Palestrant’s new venture intrigue me? Partly because of my familiarity with Palestrant. I have interviewed Palestrant for this blog in the past, and I have devoted two chapters to him:

• One, “View of a Surgeon Turned Physician Social Worker, “ in my 2009 book Obama, Doctors, and Health Reform.

• Two, in “Sermo.com – Physician Social Networking” in The Health Reform Maze (2011)

From these writings, I have learned Palestrant staunchly advocates tort reform, streamlined/simplified billing, and minimizing, even eliminating, 3rd party intervention in physician-patient affairs. He foresees physicians opting out of Medicare at an accelerating rate and moving quickly to cash-only practices. He is no fan of Obamacare or the American Medical Association. He supports physician independence, trust, and self-reliance.

Palestrant believes in free enterprise and physician entrepreneurship. He knows how to obtain venture capital , having created two successful venture-capital backed companies. His strategy appears to be to obtain more venture capital by hyping his track record and his new venture in social service networks like Facebook, Twitter, and Linkedin. He is not giving many details on either his software or his business model. I do not understand where the revenues will come from to support Par80, but I suppose that will come in time.

Tweet: Dr. Daniel Palestrant, Sermo.com founder, is starting par80, founded on the Pareto Principle: 20% of people produce 80% of results.

Thursday, January 12, 2012

What People Are Predicting, Favoring/Opposing, and Reading

The Good News is the Bad News is Wrong.

Title of Book, by Ben Wattenberg, 1984

January 12, 2012

News #1 – What People are Predicting (Intrade.com)

• Mitt Romney to win South Carolina Primary, 73.9%

• Newt Gingrich to win South Carolina Primary, 23.9%

• Rick Santorum to win South Carolina Primary, 5.0%

• Ron Paul to win South Carolina Primary, 1.3%

• Mitt Romney to win Republican Nomination, 86.5%

• Mitt Romney to be elected President, 42.8%

• Barack Obama to be elected President, 51.0%

News #2 – What People Favor/Oppose (RealClearPolitics.com)


• Obama Job Approval, 45.3%/49.8%

• Congress Job Approval, 13.0%/83.0%

• Direction of Country, Right/Wrong, 28.3%/65.7%

• Democrat/Republican, 43.2%/42.2%

• Obama-Democrat Health Plan, 37.8%/49.6%

• Repeal of Obama-Democrat Health Plan, 49.8%/41.7%

News #3 – What Medinnovation Blog Readers are Reading in 2012

• Power of Humanistic-Technology Integration,16%

• The Time Has Come: Physician Productivity and Telemedicine, 14%

• The ACO Divide: “Pioneers” Vs. Private Practitioners, 14%

• Is Practice Fusion’s “Free” EHR for Real?, 12%

• Humpty Dumpty, Alice, and the SGR, or, Waiting for the Dough,9%

• Difference between Health Care and Medical Care,9%

• CMS Suspends Prepayment Reviews,7%

• Health Care Bright for Nurses.Stinks for Doctors, 7%

• Health Care Polls: Does It Matter What People Think?, 6%

• Should Doctors Be “Parsimonious” About Health Care?, 6%

Tweet: Good News-people engaged politically. Bad News – healthcare going to hell. Things will be OK when economy recovers and we figure out what to do.

Wednesday, January 11, 2012

Pinning Physician Bankruptcies on the Tail of the Federal Mule

A federal mule, sometimes called a fule, is the offspring of a male donkey and a female elephant.

Fakipedia

A federal mule is an animal with long funny ears.
It kicks at anything it hears.
Its back is brawny and its brain is weak.
It’s just plain stupid with a stubborn streak.
And, by the way, it loves to be a power fool,
And grows up to become a federal mule.

Lyrics, slightly altered, Swinging on a Star

January 11, 2012 - This blog’s thesis is that the federal government is like a mule. In fact, that may be why it is sometimes called a fule, short for federal mule. It is the offspring of a donkey and an elephant. It has no pride of ancestry and no hope of posterity. It breeds by artificial cash insemination. It grows in size after each breeding selection and each election. The fule is no fool. It never dies. Its breeders grows wealthier each year. Its back is brawny. Its brain is weak. It can be stupid with a stubborn streak. It is massive. It has a small brain. It has the capacity to trample most of us under its feet, often without knowledge or concern of the consequences.

Take physicians. It controls their economic and clinical destinies. Each year, it dictates the fees they are to receive the next year. It has no idea from year to year what these fees will be, making financial planning for physicians a tricky, prickly, daunting task, sometimes leading to bankruptcies.

To be specific, take the fees the mule pays :

• for cancer drugs, and what oncologists must pay to buy these drugs and to administer them to patients;

• for imaging reading or equipment – which constitute the income of radiologists and/or other physicians who read images and own the equipment.

• For fees to cardiologists, who insert stents and need the equipment to read where to put the stents.


• for fees to primary care physicians, who make up 30% of all American physicians, and who care for perhaps 70% to 80% of health care needs. The RUC (reimbursement update committee), a hybrid creature of the AMA and CMS, that sets the fees for primary care doctors.

Sit back and think what happens if the federal mule, arbitrarily, capriciously, and dramatically doubles or triples costs to obtain and administer cancer drugs, or cuts the fees by one-fourth to one-half for cardiologists, radiologists, and primary care physicians.

Then ponder this article from the January 6, 2012 CNNMoney News.

Doctors Going Broke

Doctors in America are harboring an embarrassing secret: Many of them are going broke.

This quiet reality, which is spreading nationwide, is claiming a wide range of casualties, including family physicians, cardiologists and oncologists.

Industry watchers say the trend is worrisome. Half of all doctors in the nation operate a private practice. So if a cash crunch forces the death of an independent practice, it robs a community of a vital health care resource.

"A lot of independent practices are starting to see serious financial issues," said Marc Lion, CEO of Lion & Company CPAs, LLC, which advises independent doctor practices about their finances.

Doctors list shrinking insurance reimbursements, changing regulations, rising business and drug costs among the factors preventing them from keeping their practices afloat. But some experts counter that doctors' lack of business acumen is also to blame.

Loans to make payroll: Dr. William Pentz, 47, a cardiologist with a Philadelphia private practice, and his partners had to tap into their personal assets to make payroll for employees last year. "And we still barely made payroll last paycheck," he said. "Many of us are also skimping on our own pay."

Pentz said recent steep 35% to 40% cuts in Medicare reimbursements for key cardiovascular services, such as stress tests and echocardiograms, have taken a substantial toll on revenue.

"These cuts have destabilized private cardiology practices," he said. "A third of our patients are on Medicare. So these Medicare cuts are by far the biggest factor. Private insurers follow Medicare rates. So those reimbursements are going down as well."

Pentz is thinking about an out. "If this continues, I might seriously consider leaving medicine," he said. "I can't keep working this way."
Also on his mind, the impending 27.4% Medicare pay cut for doctors. "If that goes through, it will put us under," he said.

Federal law requires that Medicare reimbursement rates be adjusted annually based on a formula tied to the health of the economy. That law says rates should be cut every year to keep Medicare financially sound.

Although Congress has blocked those cuts from happening 13 times over the past decade, most recently on Dec. 23 with a two-month temporary "patch," this dilemma continues to haunt doctors every year.

Beau Donegan, senior executive with a hospital cancer center in Newport Beach, Calif., is well aware of physicians' financial woes.

"Many are too proud to admit that they are on the verge of bankruptcy," she said. "These physicians see no way out of the downward spiral of reimbursement, escalating costs of treating patients and insurance companies deciding when and how much they will pay them."

Donegan knows an oncologist "with a stellar reputation in the community" who hasn't taken a salary from his private practice in over a year. He owes drug companies $1.6 million, which he wasn't reimbursed for.

Dr. Neil Barth is that oncologist. He has been in the top 10% of oncologists in his region, according to U.S. News Top Doctors' ranking.
Still, he is contemplating personal bankruptcy.

That move could shutter his 31-year-old clinical practice and force 6,000 cancer patients to look for a new doctor.

Changes in drug reimbursements have hurt him badly. Until the mid-2000's, drugs sales were big profit generators for oncologists.

In oncology, doctors were allowed to profit from drug sales. So doctors would buy expensive cancer drugs at bulk prices from drugmakers and then sell them at much higher prices to their patients.

"I grew up in that system. I was spending $1.5 million a month on buying treatment drugs," he said. In 2005, Medicare revised the reimbursement guidelines for cancer drugs, which effectively made reimbursements for many expensive cancer drugs fall to less than the actual cost of the drugs.

Tweet: The federal government sets the price for cancer drugs and for fees paid to cardiologists radiologists, and primary care physicians.