Friday, January 31, 2014

Are  Obama and ObamaCare  Losers?

Show me a good loser and I’ll show you a loser.

Knute Rockne (1888-1931), Notre Dame football coach

Winning isn’t everything, it’s the only thing.

Vince Lombardi (1913-1970) Green Bay Packers football coach

To begin by comparing football coaches and the game of football to a U.S. President and his political program  may be a tacky thing to do.   But who cares, it's Super Bowl time.

Besides, President ObamaCare is a very competitive person, the winner of two presidential elections, and I’m sure he will welcome the comparison because he believes he will win in the end..

At the moment, Obama and ObamaCare look like potential  losers, and Obama isn’t acting like a good loser, as he vows to lash out  against his opponents as obstructions  to going foreword  by going around them with unilateral executive actions. The other team is blocking his forward progress.

Characterizing President Obama as a loser, or as a lame duck,   is premature.   But it’s hard to argue with polls.   They show Obama in the high thirty or low forty percentages for most approval measures.  And there’s no quibbling with the most recent Kaiser Family Foundation poll.  Kaiser, an editorially independent organization, with no political ax to grind,  found the uninsured , who Obama has vowed  to help,  have an unfavorable view of ObamaCare by a 2:1 margin (47% to 23%).   Among all Americans, the poll finds,  the sentiment is also negative, 50% to 34%.

What’s gone wrong?  No doubt news that 5 to 10 million health plans being cancelled hurts.   So do stories of skyrocketing premiums and deductibles. Unquestionably  the botched rollout plays a role.  So too does ignorance of the law.  More than half say they are unaware of the subsidies.  Sixty eight percent  of uninsured haven’t even  bothered to sign up. Only 11% of those enrolling were previously uninsured.  Forty percent of those who tried to enroll failed.    More than half of those polled  have said they have more negative than positive stories about ObamaCare.   Bad news sells better than good news, which may be why ObamaCare is such a hard sell.

None of this bad news deters the Obama administration which has recruited thousands of ObamaCare explainors and translators.  It has spent $1.4 million in launching a good news publicity campaign,  featuring such celebrities as exercise guru, Richard Simmons,   Hollywood  celebrities , NFL stars, and other visible elites to sell the program,  all without avail, at least among the young (18-34) who so far represent only 20% of those signing up instead of the expected 40% needed to prevent an adverse selection death spiral.

Among those fleeing from and distancing themselves from the law are Democrats seeking reelection in red states,  the uninsured, independents, Republicans,  union leaders,  the young,  Hispanics, Tea Parties, and growing numbers of women,  A motley crew, you say. Perhaps, but collectively they represent a sizable chunk of voters.

To make matters worst,  a December Gallup poll indicates 72% of Americans regard Big Government as the greatest threat to the U.S.,  and a Fox poll this week found 74% of us think we're still in a recession, five years into the Obama Presidency. Add to these numbers those who see themselves as targets of Obama,  the famous 1%, the upper-middle class, Southern states, charter schools, private businesses, politically active conservatives, the Catholic Church, doctors driven out of Obama networks, and the Little Sisters of the Poor, and Obama has a problem on his hands (Daniel Henninger, "Obama's State of Disunion," Wall Street Journal, January 30, 2014).

Of course, it is not over until the voters vote,  Fat Lady sinks,  or the Old Gray Lady (The New York Times) and the other media elite run up a White Flag, which will never be. 

It’s a long, long way from February to November. But as of now, Obama and ObamaCare look like losers, and not good losers at that  as Obama  lambasts the obstructionists and evil-doers among us.

Tweet:   As we end January and enter February ,  Obama and ObamaCare  look like potential losers in November.

Health Reform  Plan’s Acronyms

A  word formed by using initial letters of a legislative act or a series of words.


PPACA stands for ObamaCare,
Patient Protection Affordable Care Act,

That controversial Democrat health law,
That rubs the GOP's  and  public's emotions raw.

CARE stands for GOP’s Patient Choice, Affordability,
Responsibility, and Empowerment Act,
CARE shows how to the law Republicans react.

Supposedly these competing acronyms capture,
The essence of the  pro- and con- legislature.

Both claim to be sweeping and comprehensive.
Both are to other side deeply offensive.

Both claim to greatly lower health care cost.
Both aim to demonstrate who is the boss.

Both claim to widen access to the poor,
Both represent what  parties stand for.

Both claim their Acts offer intelligent choice,
Both say they listen to the consumer voice.

One claims only government knows what’s best,
Only, says the other, if it passes market test,

Obama says ObamaCare shows he cares.
GOP says CARE will test how with voters that fares.

PPACA  has those dreaded mandates,
Keys to eventual ObamaCare’s fate.

CARE claims mandates are unnecessary,
It does away with them as accessory.

Obama claims you can keep doctors and plans,
CARE assures you can keep them in your hands.

Tweet:   The acronyms PPACA and CARE represent competing health care reform philosophies, one government-driven, the other market-driven.

Thursday, January 30, 2014

Is Solo Private Practice Obsolete?

Driven from every corner of the earth, freedom of thought and the right to private judgment in matters of conscience direct their course to this happy country as their last asylum.

Samuel Adams (1722-1803), Speech, 1776

Is solo private practice obsolete? 
Is it feasible in this age of nearly universal  3rd party payment, government intrusion, mandatory compliance , required documentation of every doctor-patient encounter, and constant  calls for coordinated team care ?  

These are the questions I  pose in this blog post.     

And they are the questions I’ve been asking myself  as I prepare for a talk before the Association of American Physicians and Surgeons (AAPS).    

My answer is:  Yes, it is possible to conduct a solo private in this technological age. Ironically, disruptive computer innovations make it feasible.

APPS defends private practice. It believes the doctor-patient relationship is a confidential one-on-one private matter.  AAPS  maintains the patient should pay the doctor directly at the point and time of care.  The doctor and the patient should agree upon the fee, not the government or some other 3rd party.   And lastly, when government and other 3rd parties, intervene, the intervention destroys the relationship and threatens the future of private practice.

Is this belief system realistic? 
Not in  3rd party eyes.   They argue for the collective and individual patient good,  data is necessary to judge health care “value”-  the best outcomes for  money expended.  They insist health care has become so complicated and sophisticated only a team of professionals,  using experts’ guidelines based on population studies,  acting in concert, deploying  the latest data, can offer optimal  care.   

In short, in  the words of Edward Deming (1900-1993), American statistician and quality control guru, “In God we trust, all others use data.”

This is a persuasive argument, and I do not disagree with it.    But there are other sides to it -  loss of personal privacy,  limitations of personal choices,  restrictions of  individual clinical judgment, release of personal data for all the world to see,  desiccated  dehumanization of  the patient-physician relationship,   and physician demoralization.    

Physicians often go into medicine with the belief that their experience and their knowledge of the patient in face-to-face encounters gives them the right  to do what they think is best for the patient,  without having  to justify their actions through endless paperwork, countless  phone and online calls asking permission to order a test or do a procedure, and being second-guessed at every turn.

This belief system has produced a movement towards return to individual practices.    This return is  a reaction against  becoming employees of large organizations,  of spending 25% of their time on paperwork,  of being judged and paid for data on “value” and “performance,” and of sacrificing their independence for the benefit of organizations, 3rd parties,  and the collective good of the “system.”
In a larger sense, what physicians are doing is decentralizing n in an age of  centralization and consolidation.   

Returning  to individual private practices is a difficult thing to do. It requires giving up revenue streams from 3rd parties, losing  loyal patients who depend on 3rd party payment,  taking financing risks,  entering  into a brave new world of individual care rather than coordinated care, listening to  critics harping and moralizing  that   it is the wrong thing to do because it creates a two-tier system  between those able to pay and those unable to pay for physician services.

But thousands of  physicians are  doing it. They are  downsizing into solo  direct-pay practices.  They are doing it  with the help of the Internet. They are shedding the need of large staffs  necessary to deal with the documentation, regulations, restrictions, and hassles that accompany 3rd party payment.  

 In the words of Clayton Christensen and his colleagues at Harvard Business School,

 “Nurse practitioners, general practitioners, and even patients can do things in less-expensive, decentralized settings that could once be performed only by expensive specialists in centralized, inconvenient locations. If the natural process of disruption is allowed to proceed, the result will be higher quality, lower cost, more convenient health care for everyone.”

Either alone, or with help of s nurse practitionesr, physician assistants, or other medical assistants,  and with routine  and imaginative use of the computer,  including email communication,  physicians are now able to practice in  smaller,  more personal,  more patient-friendly settings.

Here, in a previous blog post,  is how I described the process of disruptive innovation, decentralization, and individualization works 

Gordon Moore, MD, a family doc, working alone, but on the faculty of the Institute of Health Improvement, has come up with and implemented,  this Wild and Crazy Idea - that One Doc Working Alone in One Room, with no support staff and nothing but a computer with Internet access to keep him company, can revolutionize solo practice, by making it more productive, profitable, and fun.

Sure, I know it sounds crazy.  But he backed and documented  the theory and work of his practice in a medical journal article, “Going Solo: One Doc,  One Room, One Year Later.”

In one year, he did the following:  

Maintained open access scheduling, meaning he saw patients on the day they called; took his own call, reduced other access barriers, developed deep and personal relationships with his patients by spending 30 minutes with each one of them; reduced his patient load  from 25 to 30 to 12 patients each day; operated without support staff, in one room of 150 square feet, averaged $65 per patient visit, and expected to take home $155,000 a year

Thanks to a lean IT system and low overhead. He did this with high patient satisfaction rates,
and a high percent of quality goals met. He built his unorthodox practiceon these four basic principles:

1) Access. Patients have unlimited access to the care
and information they need when they need it.

2) Interaction. Interaction between the patient and care team is deep and personal.

3) Reliability. The system exhibits high reliability in that it provides all and only the care known to be effective.

4) Vitality. The practice has vitality: happy employees, a spirit of innovation, and financial viability.

Along the way as he practiced these principles, he developed and articulated these philosophical axioms.

Interaction is not the price we pay to submit a claim.It is the essence of what we do.”
Tweet:   With imaginative computer use,  it is possible  to run a profitable, productive solo practice satisfying to practitioner and patient alike.

Wednesday, January 29, 2014

The Raw Numbers and How Hard It is to Change American Health Care

Everybody is America is soft, and hates conflict.  The cure for this, both in politics and society, is the same. Give them the raw truth.

John Jay Chapman (1862-1933),  Practical Agitation (1898)

President Barack Obama left no doubt Tuesday night what his Obamacare sales technique will be: loud voice, lots of confidence and no apologies.

Don’t dwell on the scratches on the hood. Just tell the customer how good it will feel to rev the engine and drive the car off the lot.

David Nather, "Despite Troubles, Obama Embraces Health Law, Politico, January 29, 2014

Yesterday I interviewed Jane Orient, MD, executive director of the 5000 member Association of American Physicians and Surgeons (AAPS). She said 3rd parties  pay for 85% of care. Yet  she advocates that physicians  chuck 3rd parties and rely exclusively on direct pay from patients.  

 Last night I listened to  President Obama’s State of the Union address, in which he begged Americans to sign up for his health law so that every American would have 3rd party coverage.

These two events got me to thinking about the raw numbers and why health reform is so difficult in America without 3rd parties.
Let’s look at these raw numbers.

There are, in round numbers.

·         315 million Americans
·         1 million physicians
·         5000 hospitals
·         500,000 physicians hospital employees
·         50 million Americans in Medicare
·         60 million Americans in Medicaid
       36 million AARP members, a prime source of Medicare supplemental plans
·         160 million Americans covered by private plans
·         A health industry spending $2.6 trillion annually
·         Total U.S. government spending $3.8 trillion
·         An economy of $16.6 trillion
·         A national debt of $17.3 trillion
·         A health insurance industry with revenue of $663 billion

       If I may paraphrase the late Senator Everett Dirksen of Illinois, "A trillion here, a trillion there, and pretty soon, we're talking about real money."

E    Each of these entities or sectors or phenomena,  whatever you wish to call them,  has its lobbies, champions, critics, and  entrenched interests.   Put them in a national  mixing container, shake them up, turn it upside down,  and what do you have  -  the raw truth  that although we have a mixed pluralistic system  it is also very ery hard to change, reform, or transform.  

I thought of the raw truth and the raw numbers as I contemplated what I should say in a talk I’m scheduled to give before the Association of American Physicians and Surgeons (AAPS)/   This is a very conservative group that considers ObamaCare  an obamanation, if you’ll pardon an abominable pun.    AAPS wants a strictly one-on-one relationship between patient and doctor with patients paying doctors directly.  It calls this direct pay medicine. 

Direct pay doctors are a fringe phenomenon, representing 1 of 2000 doctors,  yet they may be emblematic of a larger change – two tier medicine.  In two tier medicine,  the government is one tier. It provides care for the basic necessities.  It is often characterized by less than optimal care with long waiting lines and restricted or rationed services for those who cannot afford to pay.    

The second tier, provided by the private sector,  provides additional care with better care faster access, and more time with physicians  for those able to pay.
John C. Goodman, a conservative economist who considers himself the father of health savings accounts, encourages patients to shop for care and to pay for routine services out of  pocket, describes the situations of patients in these two tiers:

“ In one system, patients will be able to see doctors promptly. They will talk to physicians by phone and email. They will have no difficulty scheduling needed surgery. If they have to go into a hospital, a "hospitalist" (who reports to them and not to the hospital administration) will be there to make sure their interests are looked after. They may even have an independent agency that reviews their medical records, goes with them when they meet with specialists and gives them advice on every aspect of their care."

"In the other system, waiting times will grow for almost everything-  to get appointments with physicians, to get tests, to obtain elective surgery, etc. Patients may find that they don't have access to the best doctors or the best hospitals. They may find that the facility where they are treated does not have the latest technology. In terms of waiting times and bureaucratic hassles, health care for these patients may come to resemble the Canadian system. It may become even worse than the Canadian system."

"The evolution toward a two-tiered system was already under way before Barack Obama became president. But ironically, the Affordable Care Act (Obamacare) is accelerating the pace of change. “

The evolution has many facets. Less than 50% of doctors are now accepting Medicaid patients and in Texas,  less than 60% of patients are seeing Medicare patients. More and more Employers and employees are embracing health savings accounts,  with patients paying more of the bills, but paying lower premiums and accepting higher deductibles.  

 And there is a movement towards direct pay medicine and some of its hybrids – concierge medicine, retainer, medicine, cash only medicine. Advocates of government  deplore this trend. They say they are immoral, favor the rich, and are non-egalitarian.  Yet two tier systems exist at the margins in all developed countries.   

 Insurance companies resist the trends as well, for it dries up a source of new customers and threatens the very concept of managed care,  that its experts know best what it good for its customers and protects them against excessive care.   

And government? Well, progressive government's very reason for being is providing entitlement programs to retain political power.

Will the second tier grow?  Will more physicians choose to enter direct pay practices?  Will more choose  not to  accept Medicaid and Medicaid patients?  Yes, but there will be sharp limits. 

 Just look at the raw numbers. Ninety percent of  physicians depend of 3rd parties for their cicnoems. The number of Americans who depend on Medicaid and Medicare will grow from 110 million to 150 million by 2020.  Employers will continue to cover 160 million Americans, although the numbers may diminish slightly. The number of physicians employed by hospitals will grow.  Hospitals will depend on Medicare and Medicaid for more than 50% of their revenues.  

Self-interests, perhaps I should say, entrenched interests, will protect their turf.   In Minnesota, where I am speaking before AAPS, UnitedHealthGroup is the state’s largest employer.  System wide,  it has over 100,000 employees, covers 70 million people, and has over $7 billion in revenues.  United and other health insurers are not going to go gently into that good night of independent practices stripped of 3rd pqartie,s , now will the federal government.

Tweet:  Raw numbers indicating the size, scope, and revenues of major health are players preclude any major return to independent medical practices.