Tuesday, May 31, 2016

ObamaCare Legacy: The Good, The Bad, and the Ugly
This is a must read collection of essays that gives the good, the bad, and the ugly of the new health care law.
Jacket blurb on my 2011 book,The Health Reform Maze,  by Donald J. Palmisano, MD, former president of American Medical Association and author of On Leadership
The Good, the Bad, and the Ugly was the title of 1966 movie starring Clint Eastwood and Eli Wallach.   The film was called a Spaghetti Western, or Macaroni  Western because  it was produced, directed, and put to music by Italians.  The flick  had good guys, bad guys, and ugly guys, often acting out of character.   The good guys had noble intentions but were cunning, deceitful, and acted unexpectedly: the bad guys had their good sides; and the ugly guys did brutal things against defenseless people.  
In any event,  in my 2011 book, published the year after ObamaCare was passed,  I predicted 8 trends :  1) the rise and possible fall  of ACOs; 2) consolidation  at every level of the health system; 3) bundled payments between hospitals and doctors; 4) decline of private practice; 5) decentralization of care with dominance of local markets; 6) evolution of  concierge medicine; 7) the electronic revolution ; 8) patient involvement in care,
ObamaCare triggered these trends.   Now the time has come to evaluate the good, the bad, and the ugly effects of the health care law.
The Good -   20 million people have been removed from the number of insured – 12.7 million in health exchanges and 7.3 million in Medicaid, reducing the percent of uninsured from 15% to 10%;  coverage of those with preexisting conditions and  young adults on their parents’ plans has been assured.
The Bad -  The cost, roughly $ 1 trillion has exceeded estimates  and raised taxes for all;  the administration has failed to deliver on its promises of cutting premiums,  increasing quality, and improving outcomes;  premiums will soar 20% or more in 2017 and quality and outcomes have not significantly changed; 13 to 23 co-ops established by the administration have failed with more to come;  major insurers, led by UnitedHealth have pulled out  of health exchange markets;  widespread physician shortages have intensified with decreased access to doctors and narrowing of choices of doctors; somewhere between 10% to 50% of  doctors are not accepting Medicare, Medicaid, and ObamaCare patients. 

The Ugly  - Increasing numbers of middle income people can no longer afford  premiums, deductibles, and co-payments; Jonathan Gruber, an MIT economist said by many to be architect of ObamaCare,  has revealed that the Obama administration knew from the start people would be unable to keep their doctors and health plans;   The VA system, though not part of ObamaCare,  has besmirched the reputation of government as a competent health care manager  of large populations of needy people;   despite two Supreme Court decisions upholding the constitutionality of ObamaCare  recent lower court decisions questioning the legality of  hospitals that participate in ACOs to continue to be charitable institutions  and the legality of unilateral  subsidies for health exchange  without House approval has cast a cloud over the future  of ObamaCare. Good, bad, and ugly weather lies ahead.

Monday, May 30, 2016

The Power of Trump Twitter
Brevity is the soul of wit.
Lately  I’ve been doing a lot of tweets on twitter.  Twitter’s power is its brevity – say what you have to say in 140 characters or less. 
My tweet today was – Come One! Come All! Welcome to the Twitter Free-for-All Brawl! See the latest Trump news break!  See insults being cast.
Compared to Donald Trump,  I’m a mere twit.   I’ve done 1312 tweets and have 67 followers.  He’s tweeted 32,100 times, and he has 8.54 million followers.
Donald Trump uses Twitter to keep his name in front of people every hour of every day.   He often tweets 12 times a day, sometimes  more.   He’s also on Instagram and Facebook.  He uses the power of the social media to agitate, motivate, and promote, to settle old scores, and start new ones.  
By doing so, he keeps his name constantly before voters,  foregoes costly, conventional methods and unleashes free, urgent,  and visceral messages to  his followers, many of whom will retweet them to friends.    He uses tweets to keep alive endless feuds, to stroke egos,  to criticize the media.    He is the master of pithy putdown  and virtuoso of the tweet. 
He is known for his direct and indirect  slights on his political rivals, for giving them derogatory nicknames,  and for articulating what his followers are thinking.   Trump is in command of the Art of the Insult and use of nicknames are a concise counterpunch.
Below are 6 of his recent tweets.
·         Does President Obama ever discuss the sneak attack on Pearl Harbor in Japan.  Thousands of Americans died.

·         I find it offensive  Goofy Elizabeth Warren, sometime referred to as Pocahontas, pretended be Native American to get into Harvard.

·         The Inspector General’s report on Crooked Hillary Clinton is a  disaster.  Such bad judgment and temperament cannot be allowed in the W.H.

·         The protesters in New Mexico were thugs who were flying the Mexican flag.  The rally inside was big and beautiful, but outside criminals! 

·         Crooked Hillary just can’t close deal with Bernie Sanders.  I have knocked  out 16 very smart and very good candidates.  Hillary doesn’t have it. 

·         I broke all-time records for most votes gotten by Republicans  by a lot – and with many states to go.
Apparently it is difficult for rich person to be modest, or a modest person to be rich.  Whether his lack of modesty will propel him into the White House remains a billion dollar question (the cost of a general election campaign), but  given his success with Twitter,  I wouldn’t bet against him.  As Dizzy Dean, the winning St. Louis Cardinals pitcher, said after winning 28 games,  "If you can do it, you ain't bragging."

Sunday, May 29, 2016

Saving Soul of Medicine
I owe my soul to the company store.
Lyrics of song,  Sixteen Tons, most memorably sung by Tennessee  Ernie Ford in 1955
Physicians are struggling to save the soul of medicine.  They feel they owe their allegiance and  skills  to  patients, not to the corporations  or hospitals,  not to CMS (Centers of Medicare, Medicaid, and ObamaCare),  not to the VA,   and not to insurers, all of whom set the rules of payment for roughly half of all Americans and dictates the rules of patient engagement.
For physicians this struggle poses problems of the soul, defined as the principles of life, feeling, thought, and action in man, the spiritual and moral part of man as distinct from the physical part.
Serving Three Masters
How do you serve three masters, your employer, your government, and your patients?  How do you serve as the prime deliverer of these services without sacrificing your soul? 
At What Point
At what point, does the profit of your employer or payer become more important than your desire to give patients the best medicine has to offer? 
At what point, does servicing your own debt (the average debt of physicians entering practice is about $200,000) become the force that drives you and compels you to follow the wishes of those who employ you and pay your bills? 
At what point is enough enough?  And you feel you must go on my own to serve yourself, your family,  and your patients better? 
At what point, do you heed the words of Matthew 16: 26, “What is a man profited, if he shall gain the whole world and lose his soul.”
Daunting Dilemmas
These are daunting dilemmas. 
The dilemmas involve choices between morals and markets,   socialism and capitalism, economic prosperity and  economic stagnation, government control and individual liberty, idealism and  reality.   Physicians find themselves between a rock and hard place, tormented by tortuous ambiguities and convoluted  contradictions.
Do you owe your soul to a government health law, designed to cut your fees to below Medicare, which is 80% below private fees? 
Do you owe your soul to your employer, usually an integrated hospital system or a large medical group, whose profit may depend on how well you perform and follow directives?
Past Writings
I have thought about these dilemmas for years, first in a 1988 book And Who Shall Care for the Sick?  The Corporate Transformation of Medicine in Minnesota,   in 2005 in Voices of Health Reform- Interviews with Health Care Stakeholders at Work: Options for Repackaging American Health Care, in a 2009 book Obama, Doctor, and Health Reform: A Doctor Assesses Odds for Success,   in 2011 in The Health Reform Maze: A Blueprint for Physician Practices, and finally in 4300 blogs and tweets in Med innovation and Health Reform. Com (2006 to the present).  
No Easy Answers
The answers are not easy.  Universal coverage is noble, but it is proving to be unaffordable when superimposed on the current entrenched system.   Given the nature of the federal bureaucracy, government care is inherently inefficient and interferes with the doctor-patient relationship. 
Anytime government undertakes anything on a massive scale, it becomes entrenched permanent, and dependent on its constituents.  
If you defy the government, elected by popular vote, you are labeled as unpatriotic or immoral.  
If you act in your own self-interest, you are considered  greedy and ignoring the collective interests of the nation. 

If you do not accept Medicare, Medicaid, or ObamaCare exchange patients because   you cannot afford their reimbursements levels and stay in practice, you are said to be inhumane and self-serving.
Saving the Soul of Medicine, the Whyte Way
In 2007, I interviewed David Whyte, an English poet then living in Washington State.    Whyte earned his living by serving as a consultant to health care corporations, using poetry as physician soul-saving tool. 

Whyte believed physicians were losing their souls to business matters, and he sought to help corporations help physicians regain their souls.     In his heart and soul, Whyte believed government health care, as practiced in Britain and Canada, was the answer in physician-soul saving.
Here was his reasoning:
The health service in Britain, just as in Canada, has lots of difficulties, but it is astonishingly cohesive glue for the whole of society. Neither country would ever swap it for the system we have in the U.S. “

“The National Health Service gives you the sense of being part of a greater society, that you are not just part of an anthill with people climbing over one another. There is a social contract that admits to a greater bond with one another than our ability to pay up. If things go wrong, there is a safety net. “

“Society has made a contract whereby you will be taken care of no matter what your financial background or particular circumstances; that is an immensely powerful idea. I'm not sure the conditions would ever be right in the United States for that to come to pass, because the mindset, the vested powers and the individual expectations are so different. “
As   consultant to major health care corporations, David believed poetry was a potent humanistic weapon for saving souls.  By hiring David, corporations sought to escape fetters of an overly managed and rigid hierarchal pyramid. Corporate leaders sought to bring humanity to employees and caregivers to render them more creative, adaptable, and dedicated.  Corporate leaders sought  feedback and ideas from people on care frontlines, for they were  true arbiters of quality coupled with humanity.
When Whyte used that word soul” in the workplace, he was encouraging physicians to have a sense of participation in the particular work or the organization, a sense of texture, color, intrigue, and surprise. For most human beings, that was  an important question to ask and an important journey to follow.
American physicians, particularly those in heavy managed care areas, he felt,  were losing their souls in the name of profit. How do they regain their souls?  He did not mention the soul of corporations or their need for profit.
Whyte said the soul of medicine was on trial.  There was no coherent voice speaking up for the spirit of medicine, and the spirit of what doctors stand for. The American Medical Association had not spoken to the soul of medicine.

Doctors, he added, were trained in a hierarchical way. Because people's lives were at stake, there were always people who know better how to deal with those vulnerable thresholds of health. Doctors were therefore constantly deferring to someone else or to the great hierarchy of knowledge throughout the system.
Something Had to Change
Something, he thought,   had to change. No one was happy with the system.  He quoted Oscar Wilde who  said of a certain person, 'He has no enemies but is intensely disliked by all his friends." It applied, unfortunately, to American health care. It was hard to find anyone who will speak up for the U.S. health system with any enthusiasm.

Whyte noted we had almost 45 million uninsured people.  No society could afford to disenfranchise so many of its members. We were surely approaching a bridge that we would  have to cross, where everyone sould  have to give up something, somewhere, and that bridge was  probably not too far ahead of us.
Not Convinced
I am not convinced that the answer to moral problem of the uninsured lies in universal government  coverage.    A government system breeds bureaucracy, is inherently inefficient, discourages innovation, and inevitably involves rationing with long waiting lists, as exemplified by today’s VA waiting lists.
For these  reasons, and because of the impersonal nature and  higher costs of any government  system,  a dual system is emerging. 
One will be an impersonal  government-related and run system, like Medicare, Medicaid, the VA, and ObamaCare.  The other will be for patients and physicians, who seek affordable liberty and choice, personal care, and efficiencies and amenities , beyond the reach of government.

Or there may be a cross-over between systems.    Pete Sessions (R) and Dr. Bill Cassidy (R) have just introduced a House bill that allows patients to stay in or leave  ObamaCare  health exchanges.  As premiums and deductibles rise, they can go to a market based system with $2500 in tax credits (plus $1500 for each child) to purchase private insurance or to put their money into health savings accounts.
Perhaps poetry, with its capacity to make the complex simple  and its power  to evoke the best in the human  soul and spirit ,  is the answer.   Perhaps computers and the Internet and social websites will breed efficiencies , promote individual choice, and  give every patient a portable medical record to carry from doctor to doctor.
 But perhaps not.   Government and health care corporations  have turned to algorithms and data and artificial intelligence to manage doctor-patient relationships,   but  there is nothing poetic about data. Government and managed care are  not poetry,   but bureaucratic  prose (regulations and  mandates)  and  prose run mad.

Friday, May 27, 2016

Are G.O.D. (Good Old Days) Coming Back?
In G.O.D we trust, all others use data.                              
This blogger’s play on words
Forgive me.   I have a weakness for creating acronyms critical of well-intentioned but misguided government interventions into the health system.
W. Edwards Deming (1900-1993), a statistician, was famous for saying, “In God we trust, and all others use data.”  Deming was referring to data as the only reliable way to measure quality and gauge continuous improvement.
His statement was a forerunner of the current measurement craze over algorithmic data as the best and only means of controlling health care quality and containing costs.  This management mindset has popularized and characterized the movement towards evidence-based care, pay-for-performance pay for physicians, and data-based population health as the way to improve outcomes and decrease costs.
This movement has met resistance among physicians, who insist you can’t judge physicians by numbers alone, and patients, who would rather not have the details of their care and illnesses exposed to the world through personal data exposure to the government or anybody else.
A study of electronic records by the California Health Association of 1587 adults found that 15% said they would lie to conceal information “if the doctor had an electronic record,” and another 33% would “consider hiding information .” Another study , conducted by GE, the Cleveland Clinic, and Oshner  Health System said 13% of patients fibbed about exercise,  9% about diets,  9% about taking their medicine,  7% about drinking,  7% about smoking,  4% about taking  illegal drugs, and 4% about unprotected sex (Medinnovation and Heath Reform,  “Survey; Patients May Lie if Electronic Records Are Shared,” April 17, 2010),
Which brings me to the news of the day.    Kaiser Health News reports that A 41 year old psychiatrist says 55% of psychiatrists now charge patients directly  rather  going through 3rd parties (“A Doctor Yearns for a Return to the Time When Physicians Were Artisans” and “Doctor House Calls Saving Medicare Money.”  Doctors and patients alike are seeking more private, personal, home, decentralized,  confidential  care based on mutual trust, outside the reach of electronic health records.
The Good Old Days  are , of course, unlikely to return, given the penchant for  the importance  of  time spent documenting   over time spent doctoring.   Asgovrnment continues to cut  provide pay,  doctor  consolidation  will roll on over the next decade, and federal and private insurers will insist on data  rather than on trust between doctors and patients to do the right thing.  “The future “, as Yogi Berra noted,” ain’t what it used to be.”
However, there’s a search out there for more personal care, based on trust between patient and doctor without intrusion by data-seeking computers.   Patients want refuge  from the  digital revolution, where nothing is hidden and everything is known about the personal habits,  illness details, financial status, and health care shopping patterns of patient.  Doctors are seeking to escape from expenses, irritations,  and delays of hassles  and prohibitive overheads imposed by 3rd parties,   Patients yearn for a more trusting , confidential relationship between them and their doctors and more eye-to-eye contact with a personal doctor, absent an interposed computer, recording every detail of the encounter.     Total transparency is overrated .   Some things should be kept private

Memorial Day and A Sense of History
Memorial  Day commemorates veterans killed in defending  America.   Memorial Day  celebrations depends on  historical knowledge  – on a sense of history of America’s wars – the Revolutionary War, the Civil War,  World War I, World War II,  the Korean War, the Vietnam War,  the Afghanistan and Iraq Wars,  and Yes,  on  current conflicts against ISIS, which has yet to be called a War.
The Young and Knowledge of History
Yet,  if you listen to young people being interviewed on the streets,   they have little  knowledge of history.   They have no sense of when these wars were fought,  who the combatants were, what issues  led to the conflicts,  and what the economic consequences were.  History has lessons to teach, but they seem unaware of them.
This  is too bad.   As Abraham Lincoln intoned in its 1862 Annual Message to Congress, “Fellow citizens, we cannot escape history. We of this Congress and this administration  will be remember in spite of ourselves. No personal significance or insignificance can spare one or another of us.” History has legacies.
This warning applies particularly to the young,  aged 18 to 34, who are now the largest voting demographic segment of the U.S. population. 
How Will History Judge Clinton, Sanders, and Trump 
How do millenials  think history will judge the policies of Hillary Clinton,  the  status quo of the last eight years, which  has featured withdrawal  from the Middle East wars with attendant  uptick  in chaos and terrorism, and a stagnant economy?
Will the failed histories ofsocialistic economies  be repeated in  the  promises of Bernie Sanders,  whose idealism favors government control over individual  liberties,   with “free” health care and college tuitions for all ?
Will Donald Trump  prevail, with his  capitalistic promises of  making America great again, by  negotiating  deals favorable to America, by  wiping out  the deficit,  and by declaring war on ISIS and  radical Islam?
Is Government Up to the Job
Is government  under any of these leaders up to the job of controlling  wars,  restoring social justice,  and  guaranteeing peace? 
Big government has not proven it can manage  economic failure.   It cannot keep within a budget when it comes to cutting back on  “free” entitlements.      It seldom abandons a project if it conflicts with its ideology.  It is not gambling with its own money, but  that of the taxpayer.  Its success is measured in good intentions, not results.     It succeeds by growing too big to fail and too influential to stop.   It can’t go out of business, can print money to keep going , and is propped up by taxpayer money. It  has not proven effective in avoiding wars or terrorist outbreaks.   And it failed to restore economic growth
Until Now
At least until now.    Now we have populist  uprisings against government on both the left and the right because its self-serving corruption  and its failures to deliver on its promises. 
Only history will tell  if government,  as now constituted and now controlled by the Establishment,   is up to the job of avoiding wars, keeping the peace,   restoring prosperity, and expanding affordable health care? .  
History is not optimistic.







Wednesday, May 25, 2016

The Status Is Longer Quo: What It’s All About and Where It’s All Headed?
A physician friend asked what to expect in the near future.
I said, ”The status is no longer quo.”
”What does that mean,” he replied , where are we headed, and where does that leave me?”
It means  the information age has turned the world of politics and the world of health care upside down  and downside up.
Uprooted Political Establishment
It means the traditional political establishment , which has shaped health care policy in the past,  is being uprooted.   No matter who gets elected, it is likely that the individual and employer mandates will soon be gone and that electronic health records and physician payment policies  will  be altered.  
It is now apparent that ObamaCare doesn’t lower costs,  limits choice, and makes premiums, deductibles, and co-pays unaffordable for most of  the  unsubsidized middle class.   The middle class is mad as hell and may turn out in droves to do something about their economic plight and about perceived political corruption at high levels of government.
It means things are in flux.  It means things will never be the same again. 
On the Social Scene 
On the social scene,  it means minorities and elites are threatening  to become the majority.  It means blacks, thanks to a black president, will continue to  vote as a solid block.   It means white male workers  will also vote en mass the other wwyal  It means concern for the future exceeds nostalgia for the past.
 It means a resurgence in national pride,  middle class angst, and the silent majority.   It means more social unrest, with increases in crime  and declines in morality.   It means anger among workers  who have been displaced by the global economy and the information technology revolution.  It means a realignment of our culture, with more emphasis on identity politics, whether you’re black, white, Hispanic, Oriental, Islamic,  mixed, homosexual,  female, white male, or veteran.
On the Medical Scene
On the medical  scene,  it means a clash between data algorithms and human rhythms and desires.   It means  the emergence of possible ObamaCare alternatives,  such as market-based competitive care backed by Republicans.   And, at the same time, it means   a call for possible universal care as advocated by  Bernie Sanders and the millenials.   It means young physicians, in search of economic security and a balanced life style,  will go for hospital employment  or  higher paid specialties .  
It means widespread primary care shortages, and public unrest as growing numbers of physicians , facing federal budget cuts, unacceptable payment schemes, government interventions in patient relationships,  tell prospective patients,  “Sorry, we don’t take Medicare, Medicaid, or ObamaCare.    It means significant numbers of physicians will opt for  direct cash practices  outside the reach of 3rd parties to escape hassle factors.   
It means two simultaneous  movements are occurring ,  more hospital and big group consolidation,  and more care outside of hospitals in more private, personal , focused care, and concierge settings. 
 It means  more home care,   more IT monitoring of chronically ill patients in their homes,   and more home care visits. It means significant numbers of patients will delay physician visits,  seek alternative medical options,   treat themselves, or not take medications are prescribed.  Care will be delayed,  symptoms and illnesses will be neglected,  and care, when required, will be more expensive.
On the positive side,  it may mean people will concentrate more on prevention,  seek to stay fit,  monitor their fitness with electronic devices,  eat the proper foods, maintain a normal weigh, smoke less,   and avoid  excessive alcohol consumption and addictive drug an pot use. And at the federal level,  it may mean medical scientists at the National Institutes of Health, though genetic manipulation and immunotherapy,  will finally find effective ways to combat and cure multiple types of cancers.

Tuesday, May 24, 2016


Observations of  and on  Richard “Buz”  Cooper
In January of this year,  Richard “Buz” Cooper, MD,  a renowned oncologist and health care analyst, died of pancreatic cancer.   Cooper was known for this straight talk.   He believed poverty and delayed treatment for the poor was a major cause for high health costs, not  physicians overuse of care engendered driven by fee-for-service.  
I had the privilege of knowing  Doctor Cooper and wrote the following blogs  on his work.   I have edited them for brevity but sought to retain the essence of the man.

Doctors Don't  Drive Up Costs: Poverty Does

I am a big fan  of Richard “Buz” Cooper, MD, Professor of Medicine and Senior Fellow in the Leonard Davis Institute of Health Economics at the University of Pennsylvania.  

He is a  fine, clear, and direct writer.

He firmly grasps what drives up health costs.  

Recently Dr. Cooper made a presentation before an audience of physician workforce consultants at Merritt Hawkins,  and I could not resist reprinting this piece by Phillip Miller, VP of communications at Merritt Hawkins, the national physician recruiting firm.

Cooper  turns the conventional wisdom of elite policy wonks on its head by saying, in essence, it isn't  “overdoctoring” that drives up costs; it’s sick poor patients who show up in the later stages of their illnesses in economically unstable parts  of the country – like the American South,  remote rural areas, and  inner urban cities.

For  Cooper,  poverty and economic instability is  a short, simple, and reasonable explanation for cost variations across the U.S.

Do Doctors Really Drive Up Health Care Costs?

By Phillip Miller

The “experts” are wrong. They are simply flat wrong.
That’s the only conclusion I believe a reasonable person can draw after reviewing the data and analysis compiled by Richard “Buz” Cooper, M.D., an oncologist and an internationally noted authority on physician supply and health care utilization studies.

Dr. Cooper recently presented his case before an audience of physician staffing consultants at Merritt Hawkins.
His topic was current physician workforce trends, including why there are regional variations in both physician supply and in health care costs.

The conventional wisdom is that regional variations in cost are driven by variations in how physicians practice. Health care is provided relatively inexpensively in the upper Midwest, the argument goes, because physicians practice efficiently and keep utilization down.

 In other regions, by contrast, physicians “over-doctor,” driving up costs.

In the run-up to health reform it was repeatedly stated by policy makers and analysts that $700 billion, 30% of all health care spending,  could be saved if physicians would only practice like they do in the upper Midwest and other low cost regions.

Control how physicians practice and you can control healthcare spending, is the underlying basis of much of today’s health care policy.

But as Dr. Cooper clearly shows statistically, doctors don’t practice more efficiently in the Midwest. They practice more efficiently in economically stable parts of the Midwest. They also practice efficiently in economically stable parts of Manhattan, Los Angeles, and just about everywhere else.

Dr. Cooper observes health care costs are 82% of the national average in prosperous parts of New York City. Literally blocks away in less privileged areas, health care costs are three times the national average per capita, even though the hospitals and medical staffs serving patients from both areas are the same.

Places where health care costs are thought to be high, such as much of the Northeast, are actually comparable to the Midwest and other low costs areas when you compare apples to apples, i.e., one economically stable population to another.

Though Dr. Cooper conceded  ample waste and inefficiency in the health care system exists, he argues  economic disparity, not physician practice patterns, drives health care utilization and therefore health care spending.

Poorer people are sicker and cost more to treat than do more economically stable people by a large margin. Therefore, the key to lowering health care costs is to reduce poverty and increase wealth. Standing over the shoulders of physicians telling them how to practice is not the answer.
This seems like a straightforward argument, but it is not widely accepted in health policy circles.  The problem of rising health care costs derived mostly from how physicians practice, or mostly a result of economics? Or is there another driving force?
The principle driver of variation of health costs is economic instability and poverty,  not physician “overdoctoring.”
Some physicians, hospital administrators, and legislators appear to have succumbed to a behavioral bias.

Jason Sutherland, Ph.D., Elliot Fisher, MD, and Jonathan Skinner, Ph.D., Dartmouth Institute for Health Policy and Clinical Practice, “Getting Past Denial – The High Cost of Health Care in the United States, “ New England Journal of Medicine, September 24, 2009

It took me a while to figure out what the Dartmouth authors meant by “Getting Past Denial.” They never say explicitly what they mean. In effect, the Dartmouth policy wonks are saying fee-for-service incentives move doctors to “do more” to maximize profits.

In another article in the same NEJM edition, Arnold Relman, MD, former editor of the New England Journal, says it more directly, “Most doctors are paid on a fee-for-service basis, which is a strong financial incentive for them to maximize the elective services they provide (“Doctors as the Key to Health Care Reform,” NEJM, September 24).
Opines Relman, what we must do to bring down costs and improve quality, is "pay group physicians a salary for providing patients with the best, most cost-effective care, within the limits of a publicly determined budget.

Richard “Buz” Cooper, MD, professor of medicine at the University of Pennsylvania and a senior fellow in the Leonard Davis Institute of Health Economics at Penn. Cooper has directly challenged the Dartmouth premise and Relman.   Cooper  disagrees.   He  doesn’t thin,  regional cost differences in the 30% range stem from overuse of “discretionary resources” by specialists and subspecialists in high spending regions, but are secondary to poverty and higher spending for delayed diagnosis and higher spending on sick patients.  

Cooper maintains levels of sickness, socioeconomic and cultural differences, and cost of doing business in different sections of the country must be taken into account and that Medicare spending is not representative of health care spending as a whole.

Cooper has issued three reports to this affect, one in association.

One, “Physicians and Their Practices Under Health Care Reform: A Report to the President and The Congress,” prepared on behalf of The Physicians’ Foundation, and distributed to members of Congress, the White House, and the media, on September 8, 2009.

Two, “Regional Variation and the Affluent-Poverty Nexus, Journal of the American Medical Association, September 9, 2009

Three, “Wrong Turn on Health Reform, “ Washington Post, September 11, 2009.

30% “Savings”

The differences between the Cooper and Dartmouth and Relman  positions are important.  Peter Orzag, Obama’s budget director, buys  the Dartmouth argument that erasing regional differences could reduce “waste” by 30%, and generate enough savings to cover the uninsured.

You may not be aware of the Cooper-Dartmouth debate because Dartmouth has chosen to cloak its differences with Cooper and followers through euphemistic language and by  not mentioning Cooper by name. This is an academic put-down.

A perfect example of the Dartmouth approach is in full display in a September 24 NEJM article “Getting Past Denial – The High Cost of Health Care in the United States. “

The Dartmouth authors never mention Cooper. Indeed, they never explicitly say what “Getting Past Denial,” means.  One can infer what they mean when they when they talk of overuse of “discretionary resources ” by doctors “who have succumbed to behavioral bias.” I would argue “behavioral bias” effects everyone, wonks as well as practitioners. As George Orwell famously said, “ no one is genuinely free of political bias.”

From their figures and tables, however, what Dartmouth means is clear. After admitting that health status and income may be minor Medicare factors, they move to their statistical "Quintile" argument.

In one figure, “Quintiles of Care Intensity,” a colorful bar graph shows that “regional factors” have 5 to 20 times more impact than health, income, and race on costs in annual per capita regional Medicare spending from the least to most intensive quintiles.

In a table, the Dartmouth triumvirate shows these differences as one moves from intensity quintiles 1 to 5: impatient days per beneficiary, 1.4 to 2.1 days, up 50%; physician visits per beneficiary, 10.7 to 14.5 days, up 35%; MRI use per 100 beneficiaries, 16.6 to 21.9; CT scans per 100 beneifciaries, 46.9 to 61.4, a 31% increase.

The Dartmouth authors conclude, “We should recognize that so much discretionary care is provided in the United States that we would easily expand coverage without increases in taxes or rationing care – as long as we couple coverage expansion and broadly implementing successful reforms in payment and delivery systems.”

Presumably these reforms entail progressing towards integrated salaried group practices operating on a capitated basis without fee-for-service incentives , through they never say so. That would be too direct and impolite. Instead readers are subjected to a high-level hatchet job questioning the integrity and motives of physicians in high-spending Medicare regions
I would like to bring to your attention three reports by Richard “Buz” Cooper, MD, professor of medicine and principal of the Leonard Davis Institute of Health Economics at the University of Pennsylvania.

One, “Physicians and Their Practices Under Health Care Reform: A Report to the President and The Congress,” prepared on behalf of The Physicians’ Foundation, and distributed to members of Congress, the White House, and the media, on September 8, 2009.

Two, “Regional Variation and the Affluent-Poverty Nexus, Journal of the American Medical Association, September 9, 2009.

Three, “Wrong Turn on Health Reform, “ Washington Post, September 11, 2009.

Opportune Time

These reports come at an opportune time in the wake of these events: President Obama’s speech before Congress on September 9; his campaign stops across the country to rally his followers, the first today in Minneapolis; the taxpayer march on Washington today of 100,000 people ; and 10,000 physicians assembling in D.C. the same day to protest Obama health care policies. These events follow the raucous town hall meetings of August.

The Physicians Foundation

I believe Dr. Cooper’s report before Congress. supported by The Physicians Foundation, a 501C3 non-profit organization representing 650,000 practicing physicians in state and local medical societies, lends perspective, context, and rationality to the otherwise emotional debate over health care.

Contents of Three Cooper Reports

Perhaps the objective way to present the contents of Dr. Cooper’s three reports is to use his words summing up their contents.

One, the “Cooper Report,“ to the President and Congress is a 53 page document. Here are Dr. Cooper’s words about its contents with a list of its other authors,

“Our report is intended to inform the discussions of health care reform about the deepening physician shortages, the needs of physicians' practices in a reformed health care system and the effects of poverty and other social determinants on health care utilization and outcomes. Its conclusions are that, without adequate numbers of physicians, the health care system cannot function; without adequate attention to the structure of physician practices, the system cannot function efficiently; and without adequate attention to the pervasive effects of poverty and other social determinants, it cannot function economically.”

“ We hope you will find this to be useful as the critical issues that it addresses are discussed in the months ahead.

Two, Dr. Cooper’s summary of his JAMA article

The affluence-poverty nexus offers a number of insights.

First, it reconfirms the complex interplay between individual and communal dynamics in determining health care utilization and outcomes.

Second, it demonstrates that when total expenditures rather than expenditures from Medicare or any single source are considered, regions with more health care inputs have better aggregate outcomes.

Third, it suggests that while health care reform has the potential to narrow regional differences in wealth and health care resources, a substantial degree of variation is likely to continue for many decades. Fourth, it provides evidence of the high costs borne by the health care system because of poverty and its associated social determinants."

“As the United States confronts difficult fiscal choices, there should be no illusion about the relationship among physician supply, health care spending, and outcomes. Nor should there be uncertainty about how poverty affects health care utilization. The reality is that more is more and that poverty leads to less, and the false assertion that "more is less" should not detract from efforts to ensure that the United States will have an adequate supply of physicians for the future.“

Three, excerpts from the September 11 Washington Post Op-Ed piece.

“President Obama pledged on Wednesday that ‘reducing the waste and inefficiency in Medicare and Medicaid would pay for most’ of his health-care plan. This echoes remarks from Peter Orszag, his director of the Office of Management and Budget, who has claimed that one-third of health-care spending, more than $700 billion, is wasted annually.”

“Those Orszag comments come straight from the Dartmouth Atlas, which announced that the United States could save 30 percent of its health-care expenditures if high-spending regions were more like low-spending ones. But this can't be how we'll pay for reform. The numbers are too good to be true.”

“Orszag has argued that if Medicare spending could be as low in Newark as it is at Mayo, the nation could save billions. But this theory doesn't hold up in practice.

Consider: One-fourth of the folks in Newark live in poverty, compared with less than 10 percent of those in Rochester. And national surveys show that poor people consume more health-care resources -- 50 to 75 percent more than average.

They are sicker and they stay sicker, despite the best efforts of physicians and hospitals. Mayo is a fine institution, but it isn't more cost-effective than other hospitals in its home region, nor are its operations in Jacksonville, Fla., and Phoenix more cost-efficient than other hospitals in those cities. So why would it be more cost-effective in Newark?”

“To really achieve health-care reform, and find a way to pay for it, the president will have to give up on the Dartmouth suggestion and grapple with some painful truths.

First, medical care is inherently variable in different regions of the country -- socio-demographic differences matter.

Second, more is more and less yields less -- the best care is the most comprehensive care, and it costs more. Finally, poverty is expensive -- the greatest "waste" is the necessary use of added resources when coping with patients who are poor. If we want a technologically advanced, socially equitable health-care system, we will have to organize our finances accordingly. There is no quick fix. That's what we should be talking about.

Reece Take

Four of the interrelated central themes in my book Obama, Doctors, and Health Reform are:

One, the next big political health care crisis will be lack of access to doctors. This will be aggravated by 78 million baby boomers entering Medicare in 2011 and a dramatic expansion caused by millions of uninsured citizens entering the market.

Two, the growing doctor shortage, expected to peak at 150,000 to 200, 000 in a decade;

Three, government policies that systematically pay doctors less each year, this year scheduled to be a 20% cut;

Four, doctors declining to accept new Medicare patients because Medicare fees will make it difficult to maintain and sustain practices.

Although incremental reform is essential and necessary, the health system is too complex to reform, re-engineer, and overhaul in one fell swoop. Medicare is not a good model on which to reform health care. For two reasons. It has no cost controls. It is not representative of the system as a whole'

Health Care Waste or Paying for the Sick Poor?,

“As he raced through the U.S. Capitol this fall, Dr. Richard “Buz” Cooper, a 73-year-old University of Pennsylvania medical school professor, didn't mince words. He denounced as “malarkey” a reigning premise of the health care debate -- that one-third of the nation's $2.5 trillion in annual health spending is unnecessary -- and said that the idea came from “a bunch of clowns.”

“The harsh language underscores Cooper's disdain for highly regarded work -- as close to a sacred cow as anything in health care -- developed over two decades by the Dartmouth Atlas of Health Care. The work by Dartmouth Medical School researchers shows huge geographic variations in the amount of care that hospitals and doctors provide, with spending in some areas running three times as much as in others. Dartmouth argues much of the high spending is due to extra procedures and tests that often don't help patients, but bring in more money for doctors and hospitals.”

“The argument has been embraced by President Barack Obama's administration and several lawmakers, who have repeatedly said that the nation could save as much as $700 billion a year -- if only doctors and hospitals in high-spending areas, such as Philadelphia, Los Angeles and Chicago, would end their profligate practices and adopt the thriftier ways of say, the Geisinger Health Systems, based in Danville, Pa. The House has inserted provisions in the health bill that could punish high-spending hospitals in Philadelphia and elsewhere, while rewarding low-spending facilities in places such as Albuquerque, N.M., Madison, Wis., or Portland, Ore.”

The Poverty Factor

“But Cooper and some allies say that would be a disaster and hurt efforts by doctors and hospitals to care for the poor. Cooper says the Dartmouth research doesn't take into account the high cost of helping the impoverished, who often spend more time in hospitals because they don't have people to care for them at home and often return to the hospital when they can't afford needed medications. “

“There is abundant evidence that poverty is strongly associated with poor health status, greater per capita spending, more hospital readmissions and poorer outcomes,” he wrote in an Oct. 24 post on his blog. “It is the single strongest factor in variations in health care and the single greatest contributor to 'excess' spending.”

How much of U.S. health spending is waste?

How much of this spending is poverty-based?

The Dartmouth people says unwarranted waste is 30% of health care.
Cooper says caring for the poor is something hospitals have to bear.

Dartmouth says eliminating excessive regional variation,
Will be the American health system’s economic salvation.

Professor Cooper of Penn says this is unadulterated malarkey,
Dartmouth studies are the work of a statistical sharkey.

But who is right and who is wrong,
You can argue that query all day long.

But when you have a sacred cow to gore,
It helps if you do it to protect the poor.

Richard “Buz” Cooper, MD, now Co-Chair of the Council of Physician and Nurse Shortages at the Leonard Davis Institute of Health Care Economics at the University of Pennsylvania, and formerly Dean of the Medical School at the University of Wisconsin at Milwaukee – gets it – in 2001 he and his colleagues in Wisconsin wrote groundbreaking Health Affairs article “Economic and Demographic Trends Signal an Impending Physician Shortage.”

In it, they pointed out experts misjudged such factors as America’s population explosion, economic growth with discretionary income pouring into health care, desire for access to specialist-oriented technologies, and created unprecedented demand were behind the physician supply deficit.
Cooper said it was simple: as the economy grows, the nation spends more money on health care.

Linda Aiken, PhD, professor of nursing at the University of Pennsylvania and Cooper’s co-chair at the Council of Physician and Nurse Shortage gets it – she says there is a double whammy because of a an accompanying shortage of nurses of an even greater magnitude than the doctor shortage.

Cooper and Aiken believe in the next 15 years, there may be a 150,000 to 200,000 shortfall in doctors, and an 800,000 nursing shortage.
Where Experts Go Awry
How could this be in a nation of policy and health manpower “experts?”

The answer, according to Cooper, is two-fold:

One, the experts simply underestimated the dramatic increase in the U.S. population, our proclivity to spend more on health care, our embrace of new technologies, and the capacity of people in a democracy to get what they want.

Two, the experts had flawed mindsets.

 Experts at the Council of Graduate Medical Education, who determine the numbers of medical students and resident doctors, and government policy wonks have long believed, wrongly, that we have too many doctors, with more doctors we spend too much money, excess health care spending is bad for the economy, we should organize and discipline physicians so we need fewer doctors, not more;

If people would only behave themselves, fewer doctors would be needed; and we make up doctors shortages by substituting physician extenders for doctors.

Instead it turns out, Americans want to see more doctors, not fewer, and health care is good for the economy – a clean industry, a major employer, often the biggest industry in town, and the only growth sector in the economy.

Policy wonks and federal policymakers don't get it. As result of their missed estimates and flawed mindsets, federal wizards neglected the health care human infrastructure by putting caps on the number of medical students and the number of residency slots.

The problem with expert wizardry is that no matter what your scenario – more efficient, higher quality care, and more federal money poured into care; or more health insurance with expanded care; or more preventive counseling, more information technologies, and more comprehensive, coordinated care, you need more doctors.

What Will Not Work

At this point, having existing doctors work harder will not work; nor will persuading patients they should not have access to what they need or cannot afford. Nor will turning over care to nurses, midwives, LPNs or orderlies. Nor will redirecting care so doctors will be paid only within a federal system, in other words, only reimbursing them if they see Medicare and Medicaid patients.

The Problem

Well, what about single payer or Medicare for all? Here is Cooper’s response to that solution.

The problem with Medicare for all is the Federal government runs Medicare. It will sink health care. It is too capricious; it is too politically driven, too bureaucratically onerous. Physicians hate Medicare. They like the reimbursement when it comes, but it carries too much regulation, so much inefficiency– caring for Medicare patients is a terribly inefficient process. The view of the Federal government is that if they are paying the bills, they should make a whole bunch of rules, well, that just doesn’t work.

They spend all their time looking for the rotten apple in the barrel. There are rotten doctors, everybody knows that. But good doctors are exposed to such scrutiny and such arbitrary action; they are scared to death to take care of Medicare patients. So Medicare for all, in my view, is the death of health care in America.

The Answer

The answer? Listen to the people. Lighten up on federal rules. Lift the caps on the number of residency programs and medical schools. Rebuild the nation’s physician and nurse infrastructure.