Friday, November 30, 2012

Health Reform -Thank God It’s Friday
We call this Friday good.
T.S. Elliot (1888-1965), Four Quartets

November 30, 2012

For physicians this particular Friday is a good day.

Thank God, another sad week has passed  away.

Why do doctors about this week feel sad?

After all, what about this week was so bad?

Well, Congress on the Sustainable Growth Rate (SGR) again stalled.

They can’t decide whether a doctor Medicare pay cut  should be installed.

If Congress does nothing a 27 percent doctor pay cut  on 1/1/13 will  ensue.

This dreary prospect definitely  tends to make physicians feel blue.

If that unlikely reimbursement reduction should occur,

Many doctors would stop seeing Medicare patients all concur.

Failure to avoid that montrous thing called sequestration,

Would cause  another 2 percent drop in  doctor pay cessation.

Another thing, for you not in the know,  Obamacare is still very much on hold.

Thirty states don’t want  to run exchanges so more Medicaid patients can enroll.

Then too , of course, there’s the Obama gigantic tax proposal.

If you make $250 K, it’s more money down the federal disposal.

Don’t forget the incessant chatter this week  about going off the financial cliff.

If we go down that abyss, a recession will follow which is nothing at which to sniff,

Obamacare is still unpopular, unsustainable, and uncertain ,

It is no done deal,  it is still too early to lower the federal curtain.

And so for this week: it's TGIF - Thank God it's Friday,

Maybe the Almighty wiill make next week more alrighty.

Thursday, November 29, 2012

Preventing Venous Thromboembolism (VTE) in Hospitals
To prevent clots or to bleed, that is the question.
November 29, 2012 - Today’s subject is how hospitals can prevent venous thromboembolism VTE), a leading cause of hospital deaths. Physicians may be indirectly responsible for some of these deaths because the underestimate the danger of clotting and overestimate the risk of bleeding through use of heparin or other anticoagulants.
According to Greg Maynard, MD, of the Division of Hospital Medicine at the University of California. VTE is perhaps the single greatest cause of morbidity and mortality in U.S. hospitals.
· accounts for 350,000 to 650,000 hospital cases each year

· causes 100,000 to more than 250,000 deaths

· occurs mostly in hospitals

· leads to 10% of hospital deaths

· accounts for many hospital readmissions.

VTE risk factors are present in as least one of every two hospital patients.

The risk factors are:
- any over age 40

- immobility

- congestive heart failure

- stroke

- paralysis

- spinal cord injury

- polychythemia

- severe COPD

- anesthesia

- obesity varicose vein
-high estrogen states
-inflammatory bowel disease
- nepthrotic syndrome
- thrombophlebitis

Endothelial damage


-prior VTE

- central vein line

- trauma

Since these conditions are so common, it makes sense to have set orders for anti-embolic stocking and intermittent pneumatic compression for most bed-ridden patients and anticoagulants for those are high risk. Those at high risk include patients undergoing hip or knee replacements and those with deep venous thrombosis.

How to institute and implement these preventive steps is easier said than done. No comprehensive prophylactic model exists. A number of solutions have been suggested.

- An electronic alert system based on risk factors in chart.

- Team education

- Standardized orders

- Periodic audits to alert physicians and staff to complications
There is no perfect preventive system, but most systems that have been introduced have led to a 40% to 45% reduction in thromboembolic episodes and deaths.

Tweet:  Venous thromboembolic (VTE) cause 10% of hospital deaths.  As many as 40% to 45% ov VTE events can be prevented through systematic preventive measures.

Wednesday, November 28, 2012

101 Letters from Kaiser Chairman and CEO To Kaiser Employees
Letters are among the most signifiant memorial a person can laeve behind them.
Johann Wolgang von Goethe (1749—1832)
November 28, 2012 -  George Halvorson, chairman and CEO of Kaiser Permanentate since 2002,  has published  a book of 101letters he wrote to employees ( he prefers to call them “people” and “colleagues”) he has written each week  since September 27, 2007.   The letters are delivered every Friday to every Kaiser employee.

 In his letters,  Halvorson  cheerleads  for Kaiser – praising the organization for every award received, for every increase in health status of Kaiser patients,  for every documented increase in quality or outcomes,  for every step forward in information technology, for every measurable achievement leading to  decreases in mortality or morbidity.
Halvorson candidly tells us  why he writes these letters.
“I do love writing letters..  For me writing letters creates a lovely mindset. I am constantly looking for good things to celebrate. I  definitely believe that I now know quite a bit more about us  as an an organization and as a care system had I not been consistently writing these weekly celebration letters.”
Halvorson has much to  celebrate. Kaiser has cut HIV-AIDS mortality rates in half, reduced pressure ulcers by 60 percent,   prevented the number of broken bones in seniors by 30%, and dramatically reduced death rates for sepsis,  heart attacks, cancers, and diabetes while connecting members and caregivers with electronic records, allowing patients to get their medical records and to email their doctors by IPhone, Android, and other Smartphone., and  teaching the world how to provide patient-focused , electronially  connected team care resulting  in measurable and continuously improving medical outcomes.
The letters are personal,  pithy, and uplifting. The letters have proven to be an effective means of communicating to "colleagues" in a health plan and hospital system that generates $50 billion in revenues  and which has  9 million members, 200,000 caregivers,  and 600 owned sites. Halvorson thinks big by constantly  emphasizing improvements, large and small,   that make a big difference in people's health and survival..

Tweet: For five years,  Kaiser Chairman and CEO, has written weekly letters of celebration to the 200,000 caregivers who make up  Kaiser Pemanente.

Tuesday, November 27, 2012

Donald Hall (born 1928), Poet, Caregiver, and Sickness Student
"Dying is simple," she said.
"What's worst is… the separation."
When she no longer spoke,
they lay along together, touching,
and she fixed on him
her beautiful enormous round brown eyes,
shining, unblinking,
and passionate with love and dread

Donald Hall,  “The Last Days,” except from poem in his book Without,  dedicated to his beloved wife, Jane Kenyou  (1947-1995), a fellow poet
November 27, 2012 -  I’m just back from a 2 day trip to Wilmot, New Hampshire, Eagle Pond Farm to be precise.  I travelled there with my son, my wife, and two friends to visit Donald Hall,    truly a man of letters, poet laureate of the United States from 2006 to 2007, and winner of multiple literary prizes.
Before going ,  I read two of Hall’s recent books, Unpacking the Boxes, A Memoir  of a Life in Poetry (2008), and The Best Day the Worst Day: Life with Jane Kenyon (2005).
In these two books,  Donadl Hall describes own illness (carcinoma of the colon, with liver metastases,  partial liver resection, and 20 year cure) and those of his young wife, 19 years his junior,  who suffered from a severe manic-depression bipolar disorder , partially controlled by antidepressive  agents, and lymphoblastic leukemia, which was treated with bone marrow transplant and a host of chemotherapeutic drugs.
What struck me about his books was not only his storied literary career (he knew the greatest poets and writers of his time and helped found The Paris Review), but  his harmonious interactions  with and understanding of  the medical profession, his extraordinary grasp of the clinical details of illness, and his dedication as a compassionate caregiver to his wife, with her painful,  exhausting, stormy,  and nerve-wracking  illnesses.  His memories of her are a touching tribute to a fine human being and a great poet.   Hall's book  sell well to this day.   Donald has not giving up the writing life.  He now has an essay running  in Playbook and still appears in variety of other well known publications.

Monday, November 26, 2012

Four Wild and Virtually Crazy Ideas Involving Disruptive Innovation and Creative Destruction and Health Reform

Virtual reality (VR) is a term that applies to computer-simulated environments that can simulate physical presence in places in the real world, as well as in imaginary worlds.

Here’s to the crazy ones, the misfits.
The rebels.
The troublemakers.
The round pegs in the square holes.
The  ones  who think differently. They’re not fond of rules and
They have no respect for  the status quo.
You can quote them , disagree with them,
Glorify, or vilify them
The only thing you can’t  do
Is ignore them.
Because they change things.
They push the human race forward.
And while some may see them as
The crazy one, we see genious
Because they people who are
Crazy enough to think
They can change the world.
Are the one who do.

Think Different,, Apple, 1998

November 26, 2012
Here are four wild and crazy ideas that border on creative destruction and disruptive innovatation.  You may love or hate these ideas because they change the status quo.

One, pay doctors for time spent on the phone or answering emails.

Two,  pay doctors spent monitoring  patients with remote monitoring devices and for changing those devices if necessary.

Three, pay doctors for virtual visits  via Skype and other virtual visitation devices.

Four,  deduct expenses  for  doctors who  do  charity work for free.

Sunday, November 25, 2012

A Morning’s Work on Health Reform

Reform that you may preserve.
Lord Macaulay (1800-1859), Debate on the First Reform Bill
November 25, 2012 -  I spent the morning working on the foreword and  introduction to my new book,  The Physicians Foundation: A New Voice of American Medicine.
The book will be out in a week or two.
Here is the tentative foreword foreword and introduction

The Physicians Foundation – A New Voice of American Medicine
With this Survey of America’s Physicians, The Physicians Foundation has endeavored to provide a “state of the union” of the medical profession. The survey was sent to over 630,000 physicians – or over 80 percent of physicians in active practice – and represents the Physicians Foundation’s efforts to provide as many physicians as possible with a voice.
A Survey of American Physicians, The Physicians Foundation, September 24, 2012
This second little book in as series of 12 books on health reform consists of Medinnovation interviews and blogs relating to the Physicians Foundation over the last five years.

My title A New Voice of American Medicine is testament the fact that the Physicians Foundation is relatively new. The Foundation is a nonprofit, non-lobbying organization founded in 2003 as the result of a settlement between 19 state and country medical societies and major HMOs.
The Foundation is acutely aware that American Medicine is in state of profound transformation. The Foundation’s voice is objective, analytical, rational, and nonpartisan. It fears the legacy of health reform will be a deep and lasting shortage of physicians with limited access for patients.
The Foundation’s mission is to advance,  defend, and salvage  private practice. This is a worthy cause. Private physicians provide 80% of America’s health care. Indeed, private physicians are the very foundation of American medicine. The Foundation issues grants, commissions white papers, does research studies, and conducts far-reaching surveys on the state and direction of American Medicine.

One voice for the Physicians Foundation  that is particularly compelling is that of Phillip Miller. Vice-President of Communications for Merritt Hawkins and Associates.   This national recruiting firm is close to the ground and to reality.  It speaks ever day to physicians seeking a job and to hospitals, medical groups, and other organizations seeking physicians.
Phillip knows the lay of the physician land, and he is beautiful writer. He has written a series of books on physicians – their needs, wants, and  dilemmas   His books include Will the Last Physician in America Please Turn Off the Lights, A Look at the Looming Physician Shortage, In Their Own Words: 12,000 Physicians Reveal Their Thoughts on on Medical Pratice in America.
Three  years or so ago,  I put the Physicians Foundation in touch with Phillip for the purpose of conducting a national survey of physicians.   Philip helped Merritt Hawkins survey 100,000 physicians  The survey appeared in October 2010.  Phillip served as the principal  author. 
Here is his summary of the White Paper based on the survey.   His summary captures perfectly the quandary in which  practicing physicians find themselves. The White Paper, prophetically, is entitled Health Reform and the Decline of Physician Private Practice.  An alternative title might have been American Physicians – Victims of Their Own Success.   In any event, here are Phillip’s words  

The words will serve nicely as an introduction into the works of the Physicians Foundation.
“Like society itself, medical practice has been evolving rapidly in the United States over the last 50 years, in response to technological, economic, demographic, political and related influences.  Passage of the Patient Protection and Affordable Care Act (“health reform”) promises to acceleate this evolution in a variety of ways.
The Physicians Foundation called upon Merritt Hawkins and an Advisory Board of healthcare experts to assess how health reform is likely to affect practices in the United States.

This White Paper reflects the results  of Merritt Hawkins and the Advisory Board’s analysis.
"1)Health reform is comprised of two elements” “Informal reform,” (i.e. societal and economic trends exerting pressure on the current healthcare system independent of the Patient Protection and Affordable Care Act) and “formal reform," (i.e. The provisions contained in the Act itself).
2)The current iteration,  both formal and informal, will have a transformative effect on the health system.  This time, reform will not be a “false dawn,” analogous to the health reform movement of the 1990s but will usher in substantive and lasting  changes.
3)  The independent private physician private practice model will be largely, though not uniformly replaced.
4)      Most physicians will be compelled to consolidate with other practitioners, become hospital employees, or align with large hospitals and health systems for capital, administrative, and technical resources.

5)      Emerging practice  models will vary by region – one size does not fit all.  Large, Accountable Care Organizations (ACOs), private practice medical homes, large independent groups, community health centers (CHCs), concierge practices, and small aligned groups will proliferate.

6)      Reform  will drastically increase physician legal compliance and potential  liability under federal fraud and abuse statutes.  Enhances funding for enforcement, addititional latitude for “whistle blowers,” and suspension of government’s need to prove “intent” will create a compliance environment many physicians will find problematic.

7)      Reform  will exacerbate physician shortages, creating access issues for many  patients. Primary care shortages and physician maldistribution  will  not be resolved.  Physician will  need to redefine their roles and rethink delivery models  in order to meet rising demand.

8)      The imperative to care for more patients, to provide higher perceived quality, at less cost, with increased reporting and tracking demands, in an environment  of high potential liability and problematic reimbursement, will put additional stress on physicians, particularly those in private practices. Some physicians will  respond by opting out of private practice or by abandoning medicine altogether, contributing  to the physician shortage.

9)      The omission  in reform of a “fix” to the Sustainable Growth Rate (SGR) formula  and of liability reform will further disengage physicians from medicine and limit patient access.  SGR is unlikely to be resolved by Congress and will probably be folded into new payment mechanisms  within the next five years .

10)  Health care reform was necessary and inevitable.  The impetus of informal reform would likely have spurred many of the changes above, independent of formal reform.  Net gain in coverage, quality and costs are to be  hoped for. But the transition will be challenging  to all physicians and onerous for many.”


For physicians, the future is not what it used to be.  For the present,  as revealed by the Physicians Foundation's research, and White Papers, the majority of physicians have responded unfavorably to the passage of health reform and  are experiencing  increased patient loads with decreased financial viability.  They are altering their practices to reduce patient access, and are taking steps to minimize 3rd party influences through  hospital employment, part-time work,  locum tenens,  or concierge practices.  What the future holds no one knows for sure,  nor do we know the fate of Obamacare. 
What follows in this 2ns book in a series on health reform  are  interviews conducted and blogs written over the last five years into insights the Physician Foundation. has contributed to knowledge of the reform process.

Tweet: Private American medical practices are in a state of decline and transition to other models of health care delivery.

Saturday, November 24, 2012

Thursday, November 22, 2012

Books– New Voices of Health Reform: The 3 R’s-Rhyme, Reason & Reality. A Modern History of Reform
November 20, 2012 -I am now engaged in the process of producing a series of books. These books are collections of my Medinnovation blogs on specific subjects written over the last six years.
The first of these books Physicians, Poetry & Humor is now available.It may be ordered by calling Bronwen Blaney at the RJ Julia’s bookstore in Madison, CT, at 1- 203-245-3959 and asking for a single or multiple copies of the book.It sells for $12.95 + 6% sales tax + shipping charge.The books will be 175 to 250 pages long.
Other books which have been completed but are not yet available include:
·Physician Culture & American Culture
·The Physicians Foundation – New Voice of American Medicine
·Primary Care & Specialty Care
·Medicare& Medicaid- Where Now?
·Medical& Health Care Innovation
·Electronic Health Records – Boon or Boondoggle
·Physician& Hospital Relationships
·Malpractice& Tort Reform- Physician Hot Button Issue
·Accountable Care Organizations – Who is in Charge?
·A Book of Health Reform Book Reviews
I will be announcing the availability of these books as they go online and are available in paperback. The first book, Physicians, Poetry & Humor would be an ideal oChristmas book for physicians or patients concerned about health reform
Richard L. Reece, MD

Of Wealth, Health, and Cash-Only Practices
Ah, take the Cash, and let the Credit Go.
Edward Fitzgerald (1808-1883), The Rubaiyat of Omar Khayyam
Cash-payment is not the sole nexus of man with man.
Thomas Carlyle (1795-1881), Past and Present
November 24, 2012 -  In the rarified world of social welfare reform,  it is anathema to use the words  “health,” and “cash” in one sentence.  It is one or the other. “Cash” smells of “cold-hard cash,”  “cash-and-carry.”  It distracts from the world of human needs and the social determinants of health.
Instead what people deserve, say advocates of the all-encompassing social welfare state, are conditions in which all people can be healthy, including equal opportunities for “education, housing, employment, living wages, access to health care, access to healthy foods and green spaces, occupational safety, hopefulness, and freedom from racism, classism, sexism, and other forms of exclusion, marginalization, and discrimination based on social status.” (Wilkinson, R, Marmot M., “Social Dterminants of Health – The Solid Facts, 2nd Edition, Copenhagen: The World Health Organization, Regional Office for Europe, 2003).  Overly generous social welfare programs in socialist countries with aging populations and low birth rates are a huge factor in bringing their  economies of these countries to their knees.
No mention in the WHO report is made of “profit,” “prosperity,” and “economic growth,” as the engines that make possible  this utopian state of affairs.   And no mention is made either in this week's New England Journal of Medicine (Jennifer K. Cheng, MD, “Confronting the Social Determinants of Health – Obesity, Neglect, and Inequity, November 22, 2012) of these factors.   Instead the latter article ends with a quote from Theodore Roosevelt, “The welfare of each of us is dependent fundamentally upon the welfare of all of .”
While one can hardly disagree with any of these sentiments,   the fact remains that all of us, including physicians,  have to pay our bills.  In the case of physicians, we somehow have to compensate for 15 years spend in education and training outside the economic mainstream,  paying for crushing medical school debts in the neighborhood of $150,000 to $200,000, the cost of malpractice insurance and complying with onerous government regulations.
One  physician response to the wealth and health problem,  i.e. cash-only practices,  is clearly brought out in  a yesterday New York Times piece (Paul Sullivan, “Wealth Mattters: Dealing with Doctors Who Take Cash Only,” November 23, 2012). 
The author describes the case of his 4 month old sleepless daughter.   A pediatrician drove an hour from his practice to see the little girl, spent an hour with the baby and her parents,  spent another hour returning to his practice, and submitted a bill of $650 not covered by insurance.  The insurance company would have paid $285.
The reporter says he and wife liked the doctor and the attention,  but he wondered what motivated doctors to go to cash-only practices,   The reasons  he cites are higher income, more time with patients,  lower overhead,  more patient satisfaction,  greater cash flow, and less third party harassment.    The problem for patients, of course, is more out-of-pocket cash, and increasing lack of affordability of  health care.
From 30,000 feet the problem  of cash-only and concierge practices,   which involves less than 10% of doctors but is growing,  is social reform versus economic reform, or put another way, health risks versus economic risks.
Stanford Owen, MD, an internist in Gulfport, Mississippi, who practices cash-only medicine, summed up the situation.  Dr. Owen says he is happy and feels that he is practicing family medicine the way his father and grandfather did. “Primary care is the least pay, the most work and the most responsibility,” he said. “Under this model, you can make a good living. You won’t get rich, but neither did the doctors in the 1960s.”
Tweet:  Primary care doctors are switching  to cash-only medicine to avoid low 3rd party pay, to make more money, and spend more time with patients.



Friday, November 23, 2012

  Americans and Their Medical Machines

The real problem is not whether machines think, but whether men do

B. F. Skinner (1904-1996), Contingencies of Reinforcement(1969)

If you are designing a machine, you had better think of everything, because a machine cannot think for itself.

B. Zimmerman, C. Lindberg, P. Pisek, Edgeware: Insights from Complexity Science for Health Care Leaders, 1998

Preface: From time to time, I review my blogs to see what past blogs readers are reading.  Here is a current favorite, from May 9, 2010.

Obsession with medical technologies and machines characterizes American’s cultural expectations. We tend to think of our bodies as perpetual motion machines, to be preserved in perpetuity. If the face of our machines sag, we lift its faces up. If our pipes clog, we roto rooter them out or stent them. If impurities gum up our machinery, we filter them out. If our joints give out or lock up, we replace them. If we want to remove something in the machine’s interior, we take it out through a laparoscope. If the fuel or metabolic mix is wrong, we alter the mix or correct the metabolic defect with drugs If anything else goes wrong, we diagnose it and rearrange it electronically.

We are reluctant to let nature take its course. We rely on half-way technologies and machines to do the job of keeping us looking young, active, functioning , and alive. This fixation on machines and technologies is the big reason American health care is 50% more costly than that of other nations. With rapid access to machines and our reliance on them, we deliver a different product than other countries – more technologies and more machines, faster and more often. Our belief system is : Give a specialist a machine, and he or she will do the job, and we or the government will pay for it.

We love machines - heart lung bypass machines, dialysis machines, heart rhythm machines, imaging machines, Internet-run machines, ventilation support machines to keep us alive at the end of life. . Patients and lawyers expect us to use these machines, doctors constantly innovate to produce more machines, and we tend to use them – no matter what the cost.

Go to a cardiology convention, and you will witness display after display of heart rhythm pacemakers. Go to an orthopedic convention, and you will think you are in an industrial exhibit, with new devices as far as the eye can see and the mind can comprehend. Go to an orthopedic operating room, and you will hear the sounds of hammers and chisels and rods being inserted. Go to a hospital convention, and much of the chatter will be about new technologies and machines that attract more patients and more specialists, reverse the ravages of disease, and to enrich the bottom line.

The latest and most talked about machine in hospital marketing and in the hands of surgical specialists such as urologists, heart surgeons, and gynecologists is the da Vinci surgical robot, a $1.4 million machine named after Leonardo da Vinci. It is designed to be less invasive, to cut blood loss, to minimize complications, to increase hospital market share and revenues, and to attract both patients and specialists to hospitals.

The price is high, $1 million to $2.25 million per machine depending on the model, $140,000 a year for maintenance, and $1500 to $2000 per procedure for replacement parts. The manufacturer of da Vinci, Intuitive Surgical, Inc, must be doing something right. Last year it had a profit of $233 million on sales of $1.05 billion. It is deployed in 853 hospitals, large and small.

But, as with all medical machines, da Vinci is not infallible . It relies on the expertise and experience of its physician users (See Wall Street Journal, May 5, “Surgical Robot Examined in Injuries.”)
The human body is not a machine, and not all of its problems and eccentricities , given the individualities and variabilities of the human condition, lend themselves to automatic or flawless operation and correction. Complications happen. Human judgment is still required.

Obamacare Hits Fast Food Business-Owners
Fast Food Nation: The Dark Side of the All-American Meal.
Title of 2002 book by investigative journalist Eric Schlosser on social consequences of fast food
November 23, 2012 -  The Patient Affordability Care Act (aka Obamacare) stipulates that on January 1, 2014: Every full time employees must be provided with comprehensive medical coverage if the company employs more than 50 full-time workers.
To fast food corporations and fast-food franchise owners, who operate on razor-thin margins,  this stipulations hits like a profit-killing thunderbolt.  How do you stay in business in a competitive marketplace, when this stipulation would dramatically increase your expenses for providing health benefits. “Comprehensive” government  sanctioned health benefits, are, by definition,  more expensive than currently provided in private plans.   

If you do not choose to provide government approved plans,  you will be fined $2000 for each full-time employee.  For Appleby’s in New York City along, this would cost $600,000.  For Applebys nationwside for th other firms like Papa Johns, Dennys,  McDonalds, Burger King, and Wendy’s, the cost would be enormous, in the billions of dollars.
If you are a business planner for a fast food restaurant chain, what are your option?
·          Roll back expansion

  • Do not hire more full time employees.  

  • Reduce thousands of employees to part-time, under 30 hours each week.
·         Raise prices, as Papa Johns has done by increasing the price of its pizzas.
If you are a worker for these chains, your options are:
·         Pay for your own health insurance with your greatly reduced income.

·         Work for multiple fast food restaurants.

·         Go on Medicaid, for which you may now quality and accept the fact that not enough doctors accept Medicaid patients and he benefits are less than private plans.
When Obamacare passed, it was no doubt done so with good intentions.
Unfortunately,   as Samuel Johnson observed, “The road to hell is paved with good intentions” and adverse consequences for those it was intended to help – lower incomes, paying for one’s health insurance,  or going on Medicaid, if you qualify.   Good intentions have consequences.
Tweet:  The Obamacare provision that businesses with more than 50 full time workers must offer comprehensive health  benefits has adverse consequences