Medinnovation

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

2012-01-31T12:19:00.002-05:00

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

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

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

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

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

The Kaiser tracking poll indicates:

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

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

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

• 22% want it repealed outright and another 18% want it replaced with a Republican alternative—a total of 40%, fewer than the 50% want to expand it or keep it as it is.

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

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

To Summarize

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

What to Do

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 Republicans insist it should be repealed and replaced. The schizophrenic public wants it repealed, replaced, and expanded in one fell swoop.

Republican Grab Bag

Republicans offer a free-market grab bag.

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

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

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

• Individual ownership of plans, which leaves employers out.

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

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

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

Solutions

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

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

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

Tech-Led Health Care Boom?

2012-01-30T10:48:00.005-05:00

There is always gloom for improvement.

Optimist's Maxim

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

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

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

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

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

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

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

Mills and Ottino conclude:

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

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

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

Robots in Medicine

2012-01-29T14:45:00.001-05:00

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

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

January 29, 2012

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

Sources

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

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

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

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

2012-01-29T07:00:00.000-05:00

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

Francis Bacon (1561-1626), Of Empire

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

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

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

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

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

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

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

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

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

• Subsidies of EMR systems by some health plans.

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

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

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

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

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

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

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

Heart Deaths, Medical Progress, and No Free Lunch

2012-01-28T13:42:00.006-05:00

There is no such thing as a free lunch.

Milton Friedman (1912-2006), Attributed

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

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

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

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

The events leading to this remarkable decline include.

• 1954 – First open-heart procedure

• 1958 – Coronary arteriography developed

• 1961- Risk factors defined

• 1961 – Coronary care unit developed

• 1962 – First beta-blocker developed

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

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

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

• 1979 – Coronary angioplasty developed

• 1980- First implantable cardioverter-defibrillator developed

• 1983- CASS(Coronary Artery Surgery Study)

• 1985 – TIMI 1 (Thrombolysis in Myocardial Infarction)

• 1985- NCEP (National Cholesterol Education Program)

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

• 1992 – SAVE (Survival and Ventricular Trial)

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

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

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

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

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

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

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

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

WASHINGTON REPORT for The Physicians Foundation

2012-01-28T06:45:00.001-05:00

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

Mission statement, the Physicians Foundation

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Government Innovation, Electronic Inquisition, and Practice of Medicine

2012-01-27T10:56:00.002-05:00

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

President Barack Obama, State of Union speech, 2011

In God we trust, all others use data.

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

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

The events main speakers are:

• Rich Gifillan, Director of CMS Innovation Centers

• Todd Park, Chief Technology Officer at HHS

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

• Don Casey, CEO, West Wireless Heart Institute

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

• Marilyn Tavenner, RN, Acting Administrator of CMS

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

Two Cautionary Notes

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

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

1. Government cannot manage failure.

2. It seldom abandons a project.

3. It is not gambling with its own money.

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

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

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

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

The Electronic Inquisition

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

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

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

What Prooccupies Physicians

2012-01-26T06:48:00.000-05:00

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

Wynton Marsalis (1961- ), American jazz musician

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

Anonymous

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

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

Over Last Three Years

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

2. Interviews, Physician Shortage

3. Primary Care Revolt: Replace the RUC

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

5. The Future of Accountable Care Organizations

Over the Last Month

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

2. The Time Has Come: Physician Productivity and Telemedicine

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

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

5. Power of Humanistic-HIT Integration

Discussion

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

Basically the results show these proccupations.

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

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

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

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

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

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

Greatest Challenge Facing Health Reform

2012-01-25T10:07:00.004-05:00

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

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

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

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

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

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

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

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

Present Physician Shortages

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

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

Why So Few Physicians?

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

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

Reform Law from Physicians’ Viewpoint

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

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

Physician Survey Results

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

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

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

Meeting Declining Health and Social Needs

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

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

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

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

Finding the Money

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

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

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

2012-01-24T10:55:00.004-05:00

You get what you pay for.

Popular Saying

A thing is worth whatever the buyer will pay.

Maxim

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

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

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

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

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

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

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

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

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

Liberal Views of Government and Health Reform

2012-01-23T06:55:00.002-05:00

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

Otto von Bismark (1815-1898)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Denouement

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

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

It's the American Culture, Stupid!

2012-01-22T12:39:00.004-05:00

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

Newt Gingrich, in comments on his South Carolina primary triumph

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Hospital Funding Cuts and Future Physician Hospital Employment

2012-01-21T13:15:00.002-05:00

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

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

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

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

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

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

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

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

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

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

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

Poisonous Politics of Health Reform

2012-01-20T08:11:00.002-05:00

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

Oswald Dykes, English Proverbs (1709)

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

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

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

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

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

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

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

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

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

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

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

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

Health Reform and You

2012-01-19T12:56:00.002-05:00

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

Alfred North Whitehead (1861-1947)

Your health is about you – not them.

Anonymous

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

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

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

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

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

Dr. Simon said:

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

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

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

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

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

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

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

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

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

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

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

How Doctors Can Reduce Medical Errors, Lawsuits

2012-01-19T07:27:00.002-05:00

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

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

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

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

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

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

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

Apology Laws

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

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

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

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

Nothing's Easy

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

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

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

The Limits of Health Reform Intervention

2012-01-18T09:17:00.004-05:00

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

Anonymous

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

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

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

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

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

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

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

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

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

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

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

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

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

Coding: Hardening of Health Care Categories

2012-01-17T13:54:00.001-05:00

Coding is the bane of the doctor class.

Anonymous

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

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

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

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

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

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

Goodman continues:

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

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

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

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

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

The “Specious” 30% Argument for Health Reform

2012-01-16T10:36:00.005-05:00

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

Dictionary definition of specious

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

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

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

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

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

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

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

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

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

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

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

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

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

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

A Crying Shame

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

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

A 2009 Prologue to Health Reform

2012-01-15T06:49:00.001-05:00

What’s past is prologue.

Shakespeare(1564-1616), The Tempest

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

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

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

What’s the lesson?

There are four lessons.

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

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

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

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

Do you detect a note of cynicism?

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

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

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

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

2012-01-14T16:12:00.002-05:00

The South shall rise again.

Anonymous

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

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

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

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

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

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

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

What Will Health Care Look Like in 2015?

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

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

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

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

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

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

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

1) come to the office;

2) go to ancillary service;

3) have a test;

4) conservative management;

5) go to specialist;

6) get treatment and schedule appointment later.

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

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

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

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

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

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

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

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

Sermo, Pareto, and Palestrant Road Show

2012-01-13T09:46:00.000-05:00

I have entered on an enterprise which is without precedent.

Jean Jacques Rousseau 01712-`78), Confessions

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

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

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

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

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

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

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

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

Hence, par8o.

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

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

My Interest

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

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

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

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

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

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

What People Are Predicting, Favoring/Opposing, and Reading

2012-01-12T07:53:00.007-05:00

The Good News is the Bad News is Wrong.

Title of Book, by Ben Wattenberg, 1984

January 12, 2012

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

• Mitt Romney to win South Carolina Primary, 73.9%

• Newt Gingrich to win South Carolina Primary, 23.9%

• Rick Santorum to win South Carolina Primary, 5.0%

• Ron Paul to win South Carolina Primary, 1.3%

• Mitt Romney to win Republican Nomination, 86.5%

• Mitt Romney to be elected President, 42.8%

• Barack Obama to be elected President, 51.0%

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

• Obama Job Approval, 45.3%/49.8%

• Congress Job Approval, 13.0%/83.0%

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

• Democrat/Republican, 43.2%/42.2%

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

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

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

• Power of Humanistic-Technology Integration,16%

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

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

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

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

• Difference between Health Care and Medical Care,9%

• CMS Suspends Prepayment Reviews,7%

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

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

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

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

Pinning Physician Bankruptcies on the Tail of the Federal Mule

2012-01-11T10:18:00.006-05:00

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

Fakipedia

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

Lyrics, slightly altered, Swinging on a Star

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

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

To be specific, take the fees the mule pays :

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

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

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

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

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

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

Doctors Going Broke

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The Time Has Come: Physician Productivity and Telemedicine

2012-01-10T12:34:00.002-05:00

Time is totally irreplaceable. Moreover, time is totally perishable and cannot be stored. Yesterday’s time is gone forever and will never come back.
Peter F. Drucker (1909-2005)

January 10, 2012 - This blog’s genesis is three-fold: one, an article I read by Phillip Betbeze “Telemedicine as Talent Strategy” in today’s HealthLeadersmedia.com; 2) an interview I conducted in May, 2010 with Ron Pion, MD, chairman of Telemedicine Associates in Los Angeles , titled “The Internet Lifts All Boats”; and 3) frequent Skype conversations I’ve been having with my son, who lives in Madrid, Spain.

From these encounters, I predict: new sophisticated Internet technologies may be key to enhancing physician productivity.

For the physician, there may be no more “dead time” or “windshield” time sitting in one’s car travelling to remote locations to examine patients.

For the patient, there may be no more time needed to be physically present, travelling to a distant location, and spending time away from home or your home town.

Yes, I’m aware of the problems – the impersonal nature of it all, possibilities of overuse and abuse, how, when, and whom to reimburse , difficulties of electronically replacing the physician examination, and, above all, the “virtuality” of it all.

But I am persuaded from my own Skype experience – the intimate "feeling" of talking two-feet away to a loved one face-to-face; the exploding and frightening shortage of doctors and nurses; and the telemedicine tale as told by Betbeze that these obstacles can be overcome – in real time, by real physicians, by real patients, in real circumstances.

Betbeze describes the clinical experiences of Don Chomsky, MD. a cardiologist associated with Saint Thomas Heart in Nashville, which is part of Ascension Health, a multi-hospital system. Chomsky,backed by a technology system developed by Cisco, the Cisco HealthPresence System and supported by the American Hospital Association, has been experimenting with seeing and examining patients electronically.

The idea is to make real-time visits remotely in hospital outreach clinics. The difference between the Nashville approach and previous approaches is the sophistication and clarity of the Internet-transmitted images, via large High-Definition television screen, and in the physical presence of a nurse practitioner or other mid-level practitioner with the patient.

According to Dr.Chomsky , with the able help of a midlevel practitioner, he can listen to the heart and lungs, look for leg swelling, examine the neck vessels, peer into ears, and look for other tell-tale physical signs just as well as if he were actually there. It is, he says, “frightfully intimate,” and he adds, patients are just as satisfied with the new encounter of the Internet kind as he is.

Tweet: Cardiologists in Nashville and elsewhere are now conducting real-time visits remotely for hospitals via Cisco’s HealthPresence System.

Hospitals Gaining Leverage over Physicians

2012-01-09T11:07:00.002-05:00

Most hospital managers have never had the power to exert leverage over their most valuable resource, the physician, who, after all, admits the patients who make the hospital’s economic existence possible in the first place.

Richard L. Reece, MD, And Who Shall Care for the Sick? The Corporate Transformation of Medicine in Minnesota, 1988

January 9, 2012 - So I wrote in introducing a chapter in my first book in 1988. I hastened to add, however, at the close of that chapter, these admonishments,

1) The economic powers of the hospital is shifting from those who provide care – to those who pay for it – government and business.

2) This shift is forcing hospital administrators and medical staff to discuss how to use hospitals wisely without destroying quality.

3) Hospitals and physicians are losing their monopolies on inpatient services both had taken for granted – diagnostic testing, surgery, emergency care, and even routine deliveries – and now must consider investing together in alternative delivery systems outside the hospital.

4) Administrators of voluntary hospitals and private physicians are beginning to understand that the health care marketplace can be cruel – forcing them to depend on one another and compelling them to sit down together to decide future priorities.

At this point, I could chortle, quoting Lord Byron,” Of all the horrid, hideous tales of woe, is that portentous phrase, ‘I told you so’.” I could even cite my book as proof I was right from the very beginning.

But alas, I overlooked something elemental. The course of events over the last 24 years has shown that hospitals are steadily gaining leverage over physicians, not the other way around.

These events include: increasing complexity of the system, need to negotiate complicated contracts, systematic decline in physician reimbursements, growth of mega-hospital systems, persistent growth in malpractice premiums, utilization reviews requiring physicians to justify testing and procedures, demands for expensive information technology systems, and the growing awareness that teams of experts are necessary to manage technologies, to market services, and to deal with rules and regulations of health reform.

A Fragile, Malleable Thing

Leverage is a fragile, malleable thing.

It depends on public trust. And , as the late Peter F. Drucker (1909-2005) observed, this trust in increasingly invested in large organizations,

“Every single social task of major impact is increasingly entrusted to institutions which are organized for perpetuity and which are managed by professionals , whether they be called “managers,’ “administrators,” or ”executives.”

It depends on management. As Victor Fuchs, a Stanford economist and proponent of universal health care, noted,

“The most significant battleground is between practicing physicians and management. By that I mean inevitable clash between a fiercely independent profession and a management system system that seeks firmer control over what physicians do.”

It depends on who owns whom. In the last 5 years, there has been a precipitous decline in physician-owned practices, from 75% to less than 50%. Much of this decline can be attributed to physicians, who - weary of overwork, dropping incomes, practice hassles, loss of autonomy, and malpractice worries - have become hospital employees. When someone else pays your salary, you do they want you to do – or else. I have a technophobic internist friend, whose practice was bought out be a hospital chain. The chain insisted he enter all patient data into an EMR. He retired.

It depends on administrative competence. To function in today’s competitive environment with its rules, regulations, and legal and government compliances, one needs an administrative team with the means of acquiring capital, marshaling technological resources, implementing information systems, auditing performance, continuously improving quality, coordinating care, and negotiating and dealing with public and private bureaucracies. Most private practices cannot do this myriad of tasks without organizational backup.

It depends on politics. It depends on June Supreme Court decisions on Obamacare, on November elections outcomes, on local and regional elections, and on hospital-physician politics.

It depends on physician leadership and personal options. Collaborative physician-led integrated hospital and health systems tend to be successful. But so too do independent and entrepreneurial physicians who own their own facilities, who drop out of third party arrangements to create cash-only or concierge practices, and who seek other medical careers or new ventures offering more convenient, improved, and less expensive care.

Tweet: Leverage is shifting control from physicians to hospitals, but exceptions exist when physicians decide to control their own destinies.

Hits, Hips, Joints, and Nails

2012-01-08T12:57:00.005-05:00

A hit, a very palpable hit.

Shakespeare (1564-1616), Hamlet

This hitteth the nail on the head.

John Heywood (1497-1580), Proverbs

January 8, 2012 - A golden rule of writing goes: “If you have a nail to hit, hit it on the head.”

Today I have two nails to hit, if you prefer, two hits to nail.

One, Medicare health costs are not going to go down because the public, current Medicare beneficiaries or beneficiaries to be, will not willingly allow access to high-tech surgeries to be restricted.

This A.M. I met for coffee with 5 other male Medicare recipients. They spoke glowingly of the pain-free outcomes of their joint surgeries. The final score was 6 impaired hips, 4 impaired knees, and 1 impaired shoulder repaired. All agree they would have their joint procedures over again, the surgeries freed them of pain, and Medicare was a wonderful thing.

Two, tomorrow’s health costs will be higher than today's.
Yesterday I spoke via phone with Steve Jacob, a Texas health care journalist who has written a new book Health Care in 2020, with this subtitle “Where Uncertain Reform, Bad Habits, Too Few Doctors, and Skyrocketing Costs Are Taking Us,” Jacobs concluded by 2020, 20 cents of every dollar will be spent on health care, there will not be enough doctors, or nurses, to provide care, 4 of 10 deaths are self-inflicted, and 30% of all medical care is of no benefit to the patient.

When I pressed my coffee mates. they said their problems were not self-inflicted, their pain was not imaginary, their results were imminently satisfactory, and they, not their doctors, influenced them to have the joint procedures done.

Tweet: If you have a bad hip, knee, or shoulder, consider having it fixed to relieve the pain. Chances are, you will become pain-free.

Screening Smokers and Weeding out the Wretched

2012-01-07T14:39:00.000-05:00

The wretcheder one is – the more one smokes; the more one smokes, the wretcheder one becomes.

George Maurier (1834-1896)

Smoking is a shocking thing- blowing smoke out of one’s mouth into other people’s mouths, eyes, and noses, and having the same thing done to us.

Samuel Johnson (1709-1784)

January 8, 2012 – Smoking has always been considered a vile, disgusting, wretched habit. What has changed are four things: one, recognition that it causes chronic disease with premature death, eight years before non-smokers, two, it is now socially unacceptable; three, it has become economically unbearable, for the nation as a whole, for employers, and for individuals; four, one cannot smoke at work, in restaurants, or inside or outside public places.

Increasingly, smokers have nowhere to go or do what they have to do to satisfy their habit.

In spite of all this, 20% of Americans continue to smoke. Either we enjoy it, are addicted to it, or accept the consequences. Smoking has become the # 2 New Year’s Resolution, #1 being losing weight, and # 2, by stopping smoking. #1 rarely works, with a 98% failure rate, #2 is only a little better, with 96% failing to shake the weed.

According to a 2010 National Survey of Drug Use and Health, among people who smoked cigarettes a year prior to the survey 4.1% stopped, more women stopped than men, stopping went up with education and income; and cessation rates varied by state, with 6.8% stopping in Vermont by only 1.8% ceasing in South Carolina. Yet smoking is the #1 preventable cause of death and disability.

Some of us are lucky. Given enough incentives, we can stop cold turkey. In my case, these incentives included : 1, being a doctor and knowing better; 2) witnessing hospital wards full of gasping ex-smokers with tracheostomy tubes and oxygen tanks; 3) having a mother die of lung cancer from addiction to Lucky Strikes; 4) being married to a nurse who demanded I increase my life insurance or stop; 5) incurring the wrath of my fellow physicians, who no longer openly smoke; or 6) being considered a socially unacceptable wretch.

Now, from a January 6 USA Today report, “Employers Ban Not Only Smoking But Smokers Themselves “ comes these discouraging words for smokers,

“As bans on smoking sweep the USA, an increasing number of employers – primarily hospitals – are also imposing bans on smokers. They won’t hiring applicants whose urine tests positive for nicotine use, whether cigarettes, smokeless tobacco, or even patches.”

It used to be bad breath, yellow fingers and teeth, burn holes in your clothes, now it is your urine that gives you away.

And last year, two-thirds of employees with 300 or more workers offered smoking cessation programs and 31% of smaller companies did so. And if you don’t stop, 12% of companies with over 500 employers raise your premiums and 24% with more than 20,000 workers do the same. And the new health law requires that new health plans screen adults for tobacco use and provide free top-smoking programs.

Tweet: More employers are screening applicants with urine tests for nicotine, offering smoking cessation programs, & raising rates for smokers.

Mirror, Mirror, on the Wall, Who is the Fairest of Them All?

2012-01-07T08:07:00.003-05:00

Culture doesn’t save anything or anyone, it doesn’t justify. But it’s a product of man: he projects himself into it. He recognizes himself in it; that critical mirror alone offers him his image.

Jean Paul Sartre (1905-1980), Les Mots (1964)

January 7, 2012 –The question in the blog’s title is an easy question to ask and a hard question to answer.

After all, the Occupy Wall Street crowd is crying the top 1% are taking the bottom 99% for a ride; most of the top politicians – Senators, Congresspersons, the President himself -are millionaires; the top K Street lobbyists have joined the millionaire's club; American CEOs average more than $10 million in income and benefits; the top college presidents and top college coaches are making more than $1 million each, as are the top hospital administrators and top medical specialists; talking heads on the left and right are pulling down 6 figure incomes; movie stars, sports stars, and celebrities are making out like billionaire bandits; Mitt Romney is outspending his impecunious rivals; even the President makes $8 million and has $1 billion in his campaign war chest, which he is gleefully using to lambast the Rich.

Life Isn't Fair

Life isn’t fair. One fifth of America’s children live in poverty, 15 million of us are unemployed, and money has become the mother’s milk of politics - and everything else - in American life.

What We Can Do

How can we correct this deplorable, dreadful, despicable , delusional situation?

We can attack the Have’s as exploiting the Have-Not’s. We can say Capitalism is a terrible thing. We can become Populists. We can proclaim our political opponents as the unscrupulous Party of the Rich. The Rich can give away their Gains, as Warren Buffett and Bill Gates propose to do.

We can embrace that oft-repeated cliché, and create a compassionate government that commits itself to “leveling the playing field,” wherever and whatever that field happens to be and however tilted it happens to be, as long as it is tilted in our direction.

We can become priests, clergy persons, low-paid healing and helping professionals, unpaid volunteers, or members of the military or Peace Corps.

Or, I suppose, we can be honest. We can admit money is how humankind keeps score. Money is how we reward those with talent, intelligence, skills, years devoted to educating and bettering themselves, entrepreneurial savvy, and other abilities, allowing some to rise, and others to fall.

We call this a Meritocracy. We call this a Democracy. We call this America. We allow people to pursue their dreams, to rise and fall, to rise and risk again, while protecting those who fall.

We can acknowledge, to use George Orwell’s famous phrase, that “some are more equal than others.” We Americans are human beings with skills, faults, and differences. Viva la differences!

Tweet: American capitalism allows human differences to exist. We permit people to chase their dreams, to rise and fail, to rise and risk again.

Humpty Dumpty, Alice, and the SGR, Or, Waiting for The Dough

2012-01-06T08:25:00.003-05:00

“When I use a word, “ Humpty Dumpty said in a rather scornful tone, “It means just what I choose it to mean- never more or less.”
“The question is, “ said Alice, “whether you can make words mean so many different things.”
“The question is,” Said Humpty Dumpty, “which is to be master – that’s all.”

Lewis Carroll (1832-1898), Through the Looking Glass

January 6, 2012 - On the current health reform scene, the Obama administration is Humpty Dumpty, vowing to turn the health system upside down, Alice is the status quo, the word is "SGR", and the question is which is to be the master – government or the markets – that’s all.

Right now an uneasy calm exists before the storm – how to pay doctors enough to keep them in practice – preoccupies Washington. The issue at hand, set to be solved in 2 months, is how to fix the Sustainable Growth Rate (SGR), which calls for a 27.5% cut in Medicare pay to doctors.

A doctor pay cut of that magnitude is unthinkable. The cut would cause as many as 50% of doctors, the exact figure is unknowable but it is large, to cease accepting new Medicare patients. One-third of Texas doctors already no longer accept new Medicare patients. Lack of access to doctors would inflame seniors who cannot or could not find a doctor. Seniors, of course, are the single most reliable voting bloc. Two-thirds oppose Obamacare. Not fixing the SGR would be equivalent to pouring gasoline on a smouldering political fire in a windstorm.

Thus the battle is joined – who is to be the boss - the Obama administration, which leans towards government control, or the Republicans, who favor market competition.

The Obama administration’s approach, if I may oversimplify, tends to be socialistic – doing away with fee-for-service, bundling bills in packages determined by government, herding doctors in government sponsored and subsidized accountable care organizations to “save” money in the names of efficiency and quality, controlling ultimate doctor pay through a government-run Independent Payment Advisory Commission, pre-auditing physicians suspected of overusing procedures, and in Massachusetts, contemplating whether to make acceptance of government –based patients a condition for practicing medicine.

Republicans counter by proposing open competition across state lines by health plans, introducing health savings accounts on a widespread scale, maintaining Medicare Advantage plans, voucher or premium support plans allowing patients to choose between traditional Medicare and private options, and allowing patients to privately contract outside of current Medicare boundaries.

In the end, this struggle boils down to who shall have the most political clout- those who tout the virtues of a more equitable distribution of government benefits and entitlements, or those who say the market is more efficient in distributing the more expansive benefits of a dynamic capitalistic society.

Both sides insist it is the principle, and not the money, that counts. Let’s not kid ourselves, given the looming mounting exploding $15 trillion national deficit, it’s the money. I’m reminded of the play, Waiting for Godot, in which the two protagonists are waiting for someone called Godot, who neither of them knows to arrive.

Under current circumstances, a more appropriate title might be Waiting for the Dough. To occupy their time, the two antagonists swap talking points, blame one another, play political games, anything to try to figure out how to pacify doctors, who may bolt out of Medicare, and seniors, who may punish them at the polls no matter what they do.

Tweet: In the next 2 months, Obama, Democrats, and GOP must decide how to pay doctors to keep them in practice seeing Medicare patients.

CMS Suspends Medicare Prepayment Reviews

2012-01-05T10:30:00.001-05:00

January 6, 2012 - Yesterday I reported CMS had started on January 1 prepayment reviews of questionable cardiac, joint replacement, and spinal fusion procedures. Scratch that. Today CMS, after receiving many negative comments, has suspended reviews until further notice.

Tweet: Sometimes trial balloons, even federal trial balloons, are shot down or go down in stormy weather.

Should Doctors Be ‘Parsimonious’ About Health Care?

2012-01-05T10:11:00.003-05:00

Parsimony requires no providence, no sagacity, no powers of combination, no comparison, no judgment.

Edmund Burke (1729-1797)

January 6, 2011- Kaiser Health News struck a verbal nerve when it reprinted the following story by Rob Stein of NPR News. Use of the word “parsimonious” provoked a discussion on the meaning of that word.

Here is a shortened version of the story followed by a brief verse discussing the significance of “parsimonious” care.

The American College of Physicians, the second-largest U.S. doctors’ group after the American Medical Association, with 132, 000 internists, in the latest version of its ethics manual, says doctors should be more “parsimonious” in use of tests and treatments.

“The cost of health care in the United States is twice that of any other industrialized countries and we are not providing care to as many people as they do in other places, and we don’t even have as good outcomes,” said Dr. Virginia Hood, president of the group. “So given that, we really have to look at ways of doing things better. Every time you prescribe something for a patient or subject them to some kind of investigation there’s a risk of harm,” she said in a telephone interview. “So the concept of doing less is actually a really good concept, not a negative concept.”

As a result, the sixth edition of the College’s ethics manual includes this passage:

“In making recommendations to patients, designing practice guidelines and formularies, and making decisions on medical benefits review boards, physicians considered judgments should reflect the best available evidence in the biomedical literature, including data on the cost-effectiveness of different clinical approaches.”

Hood argues that considering cost-effectiveness would do far more than just help protect patients from costly and potentially dangerous tests and treatments they don’t really need:

“We also have to realize that if we don’t think about how resources are used in an overall sense then there won’t be enough health care dollars for our individual patients. So while concentrating on our individual patients and what they need we also to think on this bigger level both for their benefit and for the well-being of the community at large.”

Dr. Ezekiel Emanuel of the University of Pennsylvania calls the statement “truly remarkable” for taking on the sensitive issue so directly.

Emanuel has advised the Obama administration on health policy and has long advocated this way of thinking. It’s a position that provokes strong resistance from those worried about the federal government rationing health care.

And even those who support the concept in theory are alarmed by some of the language used, especially this part:

“Parsimonious care that utilizes the most efficient means to effectively diagnose a condition and treat a patient respects the need to use resources wisely and to help ensure that resources are equitably available.”

The word “parsimonious” strikes some as worrisome, almost Dickensian. “It’s going well beyond just giving advice to physicians about just being cognizant of the fact that we should use resources efficiently,” said Dr. Scott Gottlieb of the American Enterprise Institute. “I think that that’s generally accepted in medical practice right now.”

For Gottlieb, a parsimonious approach to medicine “really implies that care should be withheld. There’s no definition of parsimonious that I know of that doesn’t imply some kind of negative connotation in terms of being stingy about how you allocate something.”

For her part, Hood defended the wording, arguing the college simply means that efficient health care is good health care — both economically and medically. “Parsimonious is a good word in the sense that it means that you use only what’s necessary,” she said. “I don’t see particular problems with that. Maybe it has some connotations where people think frugality or being parsimonious is the same as being mean or inadequate. But I don’t think that is the real meaning of that word.”

“If you say certain things will not be cost-effective, they’re not worth the money, well that’s rationing, particularly if some patients might benefit or simply some might desire it whether they benefit or not, whether it benefits them or not. So that’s where this all becomes a real viper’s pit,” said Daniel Callahan of the Hastings Center, a bioethics think tank.

Here is my tongue-in-cheek take on the use of “parsimonious” in health care.

Use of the Word "Parsimonious" in Health Care

When one says health care should be more “parsimonious,”

Is that the right use of the word or is that use “erroneous”?

Will that use be in lawsuits widely considered as “felonious”?

Rationing fear mongers will fume that will be “acrimonious”.

Reformers will deem that use with their intent as “harmonious”.

Personally I think we’re all being a bit too “sanctimonious”.

Tweet: In its ethics manual, The American College of Physicians says internists should be more “parsimonious” in ordering tests and treatments.

Prepayment Audits: Medicare Rationing by Procedure, Region, and Physician

2012-01-04T09:57:00.003-05:00

Government is a poor manager. It is, of necessity, large and cumbersome. It must administer public funds and must account for every penalty. It has no choice but to become “bureaucratic ” Every government is, by definition, a government of forms. This means high costs. For “control” of the last 10 percent of phenomena always cost more than the control of the first 90 percent.

Peter F. Drucker (1909-2005), The Daily Drucker, 2004

January 5, 2012- Picture yourself as a Medicare manager charged with preventing budget overruns by limiting overuse of medical procedures. As such, you are sensitive to media reports, such Dr. Atul Gawande’s article “The Cost Conundrum “ in the June 1, 2009 New Yorker on the overuse of cardiac procedures in McAllen, Texas, and two front page Wall Street Journal pieces on March 29, 2011 “Medicare Road Reveals Troubling Trail of Surgeries” and April 13, 2011 “Hospital Bars Surgeon from Operating Room,” based on abusive overuse of spinal fusions by a Portland, Oregon surgeon.

What would you do? You would turn to your massive Medicare data bank to find what procedures were costing too much. Those would be heart,joint replacement, and spinal fusion procedures. You would use that same data to identify physicians who stand out as doing more, many more, procedures than their colleagues. You would see what regions of the country where excessive number of procedures occur. And you would ration those procedures by reviewing costly and overdone procedures, region, and physician, before the procedures were done and by not paying for them.

Starting January 1, 2012

That is exactly what started to take place on January 1, 2012. On that date, CMS launched its Medicare Prepayment Claim Reviews, a demonstration project that will be conducted over the next 3 years.

Medicare will require pre-payment audits for hospital stays for certain cardiac care replacements, and spinal fusion believed to be “improper” under the Recovery Audit Prepayment Demonstration Act of 2010. Recovery Auditors will focus on high-cost cardiac, joint replacement, and back procedures in 7 states with high rates of “improper payments ”in states said to be prone to fraud and abuse (Florida, California, Michigan, Texas, New York, Louisiana, and Illinois) and in 4 states with high claims volumes for short hospital stays (Pennsylvania, Ohio, North Carolina, and Missouri) for a total of 11 states.

The following procedures will be audited before payment is rendered in the 11 states.

226- Cardiac defibrillator implants without (w/o) cardiac catheter with (w/) major complications or comorbidities (MCC)

227 – Cardiac defibrillator implants (w/o) cardiac catheter w/MCC

242 - Permanent cardiac pacemaker w/MCC

243 – Permanent cardiac pacemaker w/CC

244 – Permanent cardiac pacemaker w/CC or MCC

245 – Automatic implantable cardiac defibrillator (AICD) generator procedure

247 – Percutaneous cardiovascular procedure w/drug eluting stent w/o MCC

251- Percutaneous cardiovascular procedure w/o coronary art stent 1/o MC
253 – Other vascular procedures w/CC

264 – Other circulatory system procedures

287 – Circulatory disorders except acute myocardial infraction (AMI) w/cardiac catheter w/0 MC

458 – Spinal fusion except cervical w/spinal curve, malign, or 9+ fusion c/0 CC
460 – Spinal fusion except cervical w/o MCC

470 – Major jo9int replacement or reattachment of lower extremity w/o MCC

490 – Back and Neck procedure except spinal fusion w/CC/MCC or disc device /neurostimulator.

Reducing Improper Payments

Through these audits and other efforts , CMS hopes to reduce improper payments by $50 billion, cut errors by half, and recover $2 billion in improper payments. Whether a large and cumbersome bureaucracy like Medicare will succeed in its efforts, and how much it will cost to reduce overpayments is unknowable. It is, however, worth observing that control of the last 10% of any government phenomena always costs more than control of the first 90%.

Tweet: On 1/1/12, CMS launched a 3 year project in 11 states to prevent payments for improper heart, joint replacement, and spinal fusion procedures.

Where The Tall Corn Grows

2012-01-03T17:44:00.002-05:00

January 4, 2012 - It’s a little known fact, but I was born in Iowa along with my twin sister, in a town called Bedford,a stone's throw from Clarinda, where Glenn Miller, the famous band leader, and Johnny Carson, the famous comedian, were born.

My father and mother were born in Iowa. So were all of their immediate relatives. So was my brother. So were Buffalo Bill, Herbert Hoover, John Wayne, and Michelle Bachmann. Where I fit into this galaxy of American heroes is a problem to ponder for the nation’s historians.

I bring these facts to your attention in the wake of results of the Iowa cauci, the plural for caucuses, which rhymes respectively with Hawkeye, the state bird, and ruckuses, the unofficial name for the state’s first political primary ‘s noisy squabbles.

Iowa ,by the way, is a nightmare for poets, because the only word that rhymes with Iowa, is Kiawha, the name of an island in South Carolina. But South Carolina will have its own primary soon, which will give poets among us some hope for reason to rhyme.

Speaking of corn, not the political corn in the Iowa caucuses or the corny humor derived from that corn, but real corn, which grows tall in Iowa.

Did you know the Iowa corn industry has a website called ethanol.com, that Iowa corn produces 30% of nation’s ethanol, creates 50,000 Iowa jobs, and reduces oil imports by 128,000 barrels a day?

Did you know that Mark Twain said, “You tell me where a man gets his corn pone, and I’ll tell you where his opinions are.”

This leads me to other lesser known facts. Iowa is the only state whose name starts with two vowels. The word Iowa comes from the Ioway people , a tribe of American Indians.

Iowa is a geographically a square state. This may be why elites consider its hardworking, small town people with small town values square, and, heaven forbid, as evangelical, as first person domesticated rural rather than plural person sophisticated urban.

In actual fact, Iowa derives more than twice its income from manufacturing rather than agriculture. Iowans have among the highest number of high school graduates and the highest SAT scores in the nation. Iowans may be square, but they are not dumb, no matter what their media lessers say.

Yes, Iowa has its eccentricities. Iowa has a law against throwing stones, a law repeatedly violated in the recent campaign by all the candidates, except Newt Gingrich even though he had more than enough stones in his pockets and his knapsack to throw.

Here is another strange fact. My distant relative, Maynard Reece, is the only artist to win the Federal Duck Stamp competition five times, which proves all Reeces are not quacks.

But enough about Iowa. You’ve heard enough bout Iowa to last you another four years.

Until then, Go Hawkeyes! Go!

Tweet: Iowa, a small square state of 3 million citizens, is full of corn, little known facts, and intelligent citizens with minds of their own.

Uncertainties, Mysteries, Doubts, and Challenges of Accountable Care Organizations

2012-01-03T07:27:00.002-05:00

I mean Negative Capability, that is, when Man is capable of being in uncertainties, Mysteries, doubts, without any irritable reasoning after fact & reason.

John Keats (1795-1821)

January 3, 2011 - The uncertainties, mysteries, doubts, and challenges facing implementation of accountable care organizations (ACOs), just launched this January, are not to be understated.

Consider this statement by the three authors of “Building the Path to Accountable Care,” (New England Journal of Medicine, December 29, 2011).

Its three authors, Elliot S. Fisher, MD, of the Dartmouth Institute for Health Policy and Clinical Practice, Mark B. McClellan, MD, of the Brookings Institute, and Dana G, Safran, Sc.D. of Blue Cross Blue Shield of Massachusetts, state:

"Implementation is still at an early stage. We have preliminary information about the actual performance of many ACOs and no strong evidence on which features are most likely to lead to success in specific circumstances or how ACOS can be integrated with other reforms intended to promote accountability and high-value care. On the basis of the growing set of ACO experiences and the intensive public comments regarding the Medicare ACO program, we have identified five key challenges and possible approaches to overcoming them."

In other words, the three do not know precisely what to expect.
They list these challenges.

One, providing timely data and useful performance measures to support case management and quality measures to improve care within the ACO own setting. Builders on ACO may be blind to care other ACOs provide. It is a venture into the unknown.

Two, overcoming transition costs to support investments needed to start up ACOs and to provide funding for poorly capitalized groups. ACOS are expensive to set up from scratch. How expensive no one knows.

Three, gaining Medicare population support for a new kind of care that at this point means nothing to Medicare patients. Medicare recipients may perceive ACO as stinting on care and forcing them to switch doctors or hospitals.

Four, learning what works and doesn’t work and using what is learned to inform policy and practice. ACOs are a learning experiment. Where and how they end up no one knows for sure.

Five, clarifying the path forward and how to create an unknown alternative to fee-for-service and to give physicians some idea whether ACOs will provide them with an adequate income and a new and satisfying practice experience.

The reason of the authors give for building ACOs is that fee-for-service payments for non-ACO practitioners will undergo an “inexorable transition “ which “will almost certainly see continued cuts in payment rates.”

Inside-the-ACO-Box Thinking

The problem with the authors’ assumptions is this. They are thinking exclusively inside the ACO box. They are avoiding obvious questions.

Why should 90% of doctors who practice outside ACOs accept the idea of a risky experimental model? The model may not provide them with adequate income. It may impinge on their practice freedoms and incomes. It may force them to practice ACO-type medicine on their non-Medicare patients. It may compel them to change existing practice patterns and to junk existing practice management systems, which are based on fee-for-service systems. It is difficult to change practice stripes between patients in the same practice. What are the consequences if the ACO fails? What are the anti-trust risks if the ACP succeeds?

How does the ACO model anticipate dealing with these physician options?

Physicians may choose not to join the ACO, not to accept new Medicare patients, to retire, to enter concierge or other direct-cash practices, to pursue medical careers outside of clinical practice or outside of medicine.

What happens if the Supreme Court overturns Obamacare in part or as a whole? And what will take place if Republicans win the presidency, the House, and the Senate – and repeal Obamacare?

There are simply too many uncertainties, mysteries, doubts, and challenges for most physicians to contemplate before embarking on an ACO.

Therefore, many, if not most physicians, are likely to adopt a “wait-and-see” attitude. This srikes me as the prudent thing to do.

Tweet: ACO implementation is full of uncertainties, mysteries, doubts, and challenges and may lead to wait-and-see attitude by most physicians.

Power of Humanistic-HIT Technology Integration

2012-01-02T08:06:00.005-05:00

It is in Apple’s DNA that technology is not enough – it’s technology married with the liberal arts, married with the humanities that yields us results make the heart sing.

Steve Jobs (1955 -2011), Inventor of Apple Computer and Developer behind IPad, IPod, and IPhone, Interview with Forbes, 2011

January 2, 2012 - I have a confession to make. I am a humanistic-HIT technology flip-flopper.

As you know, “flip-flopper” is a term derisively applied to politicians who change their opinion in the face of new information or political opportunities. For this conversion to new realities critics deride politicians as crass opportunists – as snakes in the political grass.

But, in my opinion, these late blooming conversions may also be a sign of maturity - Mitt Romney deciding Obamacare has its faults, Newt Gingrich abandoning the individual mandate, or even Barack Obama transforming himself from a political unifier to a political divider by attacking a do-nothing Congress.

In my case as a clinical pathologist through the years, I stoutly maintained that human use of information technologies was more important than the technology itself.

• In the 1970s, I came out with the idea of Diagnotes, list of diagnostic possibilities attached to abnormal lab tests, with the idea that the human mind could separate the wheat from the chaff.

• In the early 1980s, I used an early version of the Internet to organize lab reports into UNIPORTs (Unified Presentation of Relevant Tests), which displayed patterns of abnormal results into differential diagnoses, which doctors could sort through and choose the pick of the litter.

• In the mid-1980s, I developed a report called the Health Quotient, a computer algorithm converting ordinary body physical measurements, clinical historical information, and certain lab tests, into the HQ, the analogue of the IQ, except it applied to physical health rather than intellectual measurement.

• After 2007, in a book Innovation-Driven Health Care (Jones and Bartlett) and Medinnovation Blog, I insisted the primary value of Health Information Technologies resided in their humanistic value rather than in the technological achievements.

Certain developments have caused me to change my mind. I have slowly come to believe the technologies themselves contribute more to humanism than humanism itself.

These developments include:

• The use of clinical algorithms to convert the histories of patients into human narratives.

• The deployment of sophisticated computer applications to accurately digitize human speech into language speakers and readers recognize and understand.

• The application of computers to aggregate seemingly random information into integrated bodies of information with diagnostic, prognostic, and treatment import at the point of care.

I have, in short, become a believer that health information technologies yield humanistic opportunities beyond what I imagined.

In his book, Adventurers of a Bystander(1978), Peter Drucker (1909-2005), presented two prophets as representative of a technology-driven world.

--One, Buckminster Fuller (1895-1983) “Synergy means behavior of whose systems unpredicted by the behavior of its parts”;

--Two, Marshall McLuhan (1911-1980) “The new electronic interdependence recreates the world in the image of a global village/"

Drucker's message was this:

Suddenly, in the 1960s, technology was seen as a human activity; formerly it was always known as a "technical" activity, carried out by God knows whom or what, presumably by "elves in the Black Forest." Technology moved from the wings of the stage of history to which the “humanist” had always consigned it, and began to mingle freely with the actors and even, at times, to steal the spotlight. The first response to such a change in awareness is always violent rejection. It would be so much easier if the change could be made undone.

If only we could return to the nice “humanist” world in which ideas, values, aesthetics, and knowledge are disassociated from such grubby things as how people make a living, produce their tools, and above all in which they are divorced and disassociated from how men work.

And finally, David Blumenthal, MD, MPP, neatly wraps it all up the case for Health Information Technologies:

Information is the cornerstone of good clinical care and vital to all the objectives of our health care system. It is inconceivable that the health system will indefinitely resist a force that is transforming modern civilization and that offers almost infinite promise for improved and more efficient care.” (David Blumenthal, MD, MPP, “Implementation of the Federal Health Information Initiatives, New England Journal of Medicine, December 22, 2011).

Tweet: The greatest innovation in the 21st century will take place at the intersection between the humanities and information technology.

I Interview Myself for 2012

2012-01-01T12:34:00.001-05:00
It is not a train wreck or an earthquake but an interview.

American Poet, John Berryman (1914-1972) The Image (1962)

January 1, 2012

Q: Can we talk frankly?

A: There’s no other way we can talk.

Q: What do you think will happen in 2012 in health care?

A: Three things. A Supreme Court decision. A Presidential election. A physician electronic revolution.

Q: I understand the first two, but what about the third?

A: Physicians can’t do much about the Supreme Court or the Election. The Supreme’s decision and the state of the economy will determine the election outcome. The November election will be watershed event for health care and physicians’ future.

The election,by the way, will hinge on two issues: 1) income redistribution vs. economic growth; and 2) government control vs. market freedom and individual liberty.

Q: You evade my question.

A: You nailed me on that one. The world and health care now move on Internet time, and we physicians might as well get used to it and capitalize on it.

Q: How?

A: By recognizing that:

One, young Baby Boomer physicians and those who follow are weaned on HIT, will accept nothing less, and will only join practices that have it.

Two, new electronic record business models will be “free,” will not require on-site installation of EHR systems, and electronic functions will be carried out in “The Cloud” on Internet browsing farms.

Three, payers, both public and private, will reward and pay more for physicians with fully-functioning electronic medical systems, and will subsidize such systems.

Four, so-called mobile “medical apps” will proliferate and make it nearly impossible to practice without a receptive EHR system capable of interfacing with these apps.

Q: Wow! That’s a mouthful, or perhaps I should say a snoutful. Which reminds me: Why do you lead off your blogs with quotes from poets, literary, or historical figures, and why do you sometimes end them with doggerel verse?

A: Because there is rarely anything human that’s new under the sun that hasn’t been said better before. And because you can sometimes say things better and shorter in verse, particularly things you oppose that government tries to impose, than in prose.

Q: There you go again – recklessly, fecklessly, impetuously alliterating. Get back on track. What advice do you have to offer for your fellow physicians for 2012?

A: Innovate. Go for an electronic future. Come up with electronic ideas to electronically engage your patients - through email, blogging, tweeting, facebooking, websites, medapps, electronic monitoring, telecommunications, social networking, even Skype.

Seek venture capital to create your own new physician electronic business model that make things cheaper, better, and more convenient.

Who knows? Maybe your entrepreneurial ideas will free you up to spend more time with patients – addressing their needs and wants in more human terms.

Tweet: In 2012, Supreme Court decision and elections- are beyond doctors’ control – but electronic communication with patients, is not.

2012 Self-Care Ventures Tsunami

2011-12-31T07:44:00.004-05:00
Trust thyself: every heart vibrates to that iron string.

Ralph Waldo Emerson (1803-1881),Self-Reliance

All writing is communication. Creative writing is revelation. It is Self escaping into the Open.

E.B. White (1899-1985), The Elements of Style, 1974

December 31, 2011- It’s here at last – Goodbye 2011! Hello 2012!

What will be the big news in 2012? It will be venture capitalists, entrepreneurs, and consumers escaping into the Open by supplying new services to self-reliant individual consumers.

Why?

Think about it. The U.S. is a consumer-based economy. There are 310 million consumers, versus 500 hospitals, 1500 or so health plans, perhaps 900,000 doctors, 5 million other health care profesionals, and maybe 10,000 healthcare supply chain companies.

Think some more. The Internet has converted consumers into self-reliant individuals looking for free information on health care at the best price and advising each other through social media how to best find and use that information.

Think again. Markets are gravitating from brick and mortar to online, from inside hospitals and doctors’ offices to outside sites, from corporate sites to individual sites, from institutional care to self-care, particularly care administrated, orchestrated, and applied in homes, by consumers themselves rather than health care professionals. The U.S. is decentralizing from group, authority, and institutional decision-making to individual decision-making on a massive scale.

Call it what you will - Health 2.0, Health 3.0, self-care, home-care, self-reliance, patient engagement, patient communication, consumer education, disruptive innovation, wellness movement, fitness frenzy, even ATM health care- it is here to stay. It will surely grow. Economic forces -lower costs, greater convenience, more transparent information, and better outcomes - are in the drivers seat.

These consumer-based revelations have not escaped the attention of venture–capitalists, who are in the business of capitalizing on massive consumer-based social and commercial trends – such as Facebook, Twitter, Google, Skype, Kindle, and, of course, IPad, IPod, an IPhone, with “I” standing for either "I"nformation or "I"ndividuals.

That said, here are a few of my favorites.

• Instant Medical History – This clinical software allows patients to enter their demographics, chief complaints, symptons and history from their home computer or a laptop in the reception room before entering the exam room. Shortening the otherwise tedious history taking process.

• Emmi Solutions – The Chicago-based company preaches and practices “patient-engagement” by allowing patients to preview all aspects via videos of a procedure they are about to undergo or the consequences of a health problem they may have.

• Practice Fusion – This San Francisco EHR company has changed the EHR revenue model by having advertisers, not physicians. pay for installation, functioning through “Cloud” browsers rather than office-based systems, and meeting “meaningful use” CMS criteria, thus allowing physicians to have a “free” and “user-friendly” EHR.

• All those companies and start-ups who permit self-reliant consumers to test on their own for pregnancy, lipid levels, other blood content measurements, blood pressure fluctuations, weight gain or loss, and telemonitoring and audiovisual monitoring of patient appearances, vital signs, heart rhythms, unexpected complications, and other body functions.

Tweet: In 2012, Smart venture capitalists will support entrepreneurs and start-ups catering to and empowering health and disease-conscious consumers.

Survival At Any Cost – Why Health Costs Rarely Go Down

2011-12-30T06:59:00.002-05:00
There is a land of the living and a land of the dead, and the bridge is love - the only survival – the only meaning.

Thorton Wilder (1897-1975), The Bridge of San Luis Ray (1927)

December 30, 2011- I knew a surgeon, John Najarian of the University of Minnesota, who did organ transplants. “Dick, “ he said to me, “I never knew a patient who didn’t want to live another day.”

To patients, in other words, medical care is all about survival

I thought of John as I read an article in today’s New England Journal of Medicine entitled “The Savings Illusion - Why Quality Improvement Fails to Deliver Bottom-Line Results.” Its four authors, from the Dartmouth Institute for Health Policy and Clinical Practice, maintain quality care rarely saves money because of structure of medicine is designed to save lives.

That’s what we doctors are here for – we love to save lives, and that’s what patients want – they would love to live another day.

I did not completely follow the logic of the Dartmouth people until Stuart Gitlow,M.D., writing in an AMA website “Take Back the Professional Advisory Group,” explained it to me. The Advisory Group, a provision of Obamacare, is designed to have the last word on lowering doctor pay, and Congress cannot override its decision.

Doctor Gitlow’s decision is simple – and profound.

Everybody wants to survive another day – at any costs. Sink or swim, live or die, and survive or perish- when it comes to living or dying- money is no object.

Here is Doctor Gitlow’s explanation.

“What these authors ignore is that the expected healthcare cost is infinite. That is, humans have one priority that outweighs all others - survival. Survival is more important than housing or eating. And survival in later years can be achieved only at increased cost.

Housing does not have an infinite cost - there is a basic need for shelter which can be met inexpensively. Food does not have an infinite cost - there is a maximum food intake for any one individual. Survival, on the other hand, not only can cost as much as one is willing to spend, but we want to spend as much as possible so as to live as long as possible in as healthy a manner as possible.”

“If I have $1000 to spend, and I can choose to spend $500 on my house and $500 on my food, but I'm dead, that was poor planning. I'd much rather spend $1000 on healthcare and live in a shelter eating table scraps. “

“The goal of any one person is, therefore, NOT to reduce healthcare costs but rather to increase them.”

“Each time I hear that healthcare costs are taking a larger percentage of each dollar spent, I am pleased, for it is certainly my perspective that the bulk of my future expenses should go toward my survival and my family's survival.”

“One day, perhaps this will change. Perhaps we will discover the gene/s responsible for aging of cells, and determine a method of turning aging off. I wonder how we might approach that fork in the road for then the equation would change - healthcare would be inexpensive but the supply of people would be infinite. Other factors would then become limiting.”

Tweet: The goal of doctors and patients is not to reduce health care costs, it is to survive.

Ten Health Care Forecasts 2012

2011-12-29T08:17:00.001-05:00
The most reliable way to forecast the future is to try to understand the present.

John Naisbitt

Weather forecast for tonight: dark.

George Carlin

December 29, 2011 - Here we are at the end of the year. It is time for my annual health care forecast.

• One, it all depends on the election - If we have a Democratic President and Congress, it’s Obamacare, full-speed ahead. If Obama wins and has a Republican Senate, it’s slow go – with reduced funding and slow implementation. If its Republican government at all levels, it’s Obamacare repeal and time for alternative plan.

• Two, it depends on the June Supreme Court announcement of its decision on the individual mandate, the whole plan, and Medicaid implementation. My forecast is that the mandate will be overturned 5-4.

• Three, it’s beginning to look like Romney. I think he stands a 50:50 chance of beating Obama. If he does, each state may have its own approach to care , can handle its Medicaid population as it sees fit, and can have its individual mandate if it wants.

• Four, hospitals, doctors, and health plan will continue to rapidly consolidate, with some owning each other, with dominance of local and regional markets, with negotiating power, with higher prices, and with anti-trust issues.

• Five, as new revenue models offering “free” EHRs, computing off-site in “the Cloud,” and hand-holding facilitating “meaningful use” bonuses, EHR use will take off like wild-fire.

• Six, more and more physicians will exit from practices depending on 3rd party revenues and will go to concierge, retainer, and direct-cash practices.

• Seven, hospitals, physicians, and insurers will enter retail markets to snare business from individual consumers, who will become an increasingly larger part of insurance market.

• Eight, primary care shortages will grow, concern about their future will escalate, and more nurses and physician assistants will be trained and recruited to fill the gap.

• Nine, accountable care organizations will be very much in the news as the ten “pioneer” ACOs hit the streets on January 1, 2012, and other providers wait and see if outcomes improve and savings eventuate.

• Ten, venture capitalists, sensing openings in the vast health care industry, will be actively searching to find entrepreneurs, including physicians, who have marketable ideas on how to make care cheaper, better, more convenient, and more “disruptive,” i.e., useable for less sophisticated folk below the specialist level.

Tweet: Herein are 10 forecasts for health care as envisioned by a physician.

Hip Implant Failures

2011-12-28T12:18:00.003-05:00
The widespread failure of all-metal hips may cost taxpayers, insurers, and employers billions of dollars in coming years.

New York Times, “Hip Implants’ Common Failures Brings High Costs ,” by Barry Meier, December 28, 2011

December 28, 2011 - Today’s New York Times’ front page, left column , article on the failure of all-medal hips replacements is a cautionary-tale on the limits of technology.

Beware, the tale warns, what patients wish for and what medical device manufacturers and doctors deliver.

One-third of 250,000 hips replaced last year, and 500,000 of all hips implanted to date, are of the all-metal type. News of widespread failures of all-metal hip failures have set off a flurry of medical of more than 5000 lawsuits and complaints so far. with more surely to come.

The problem with these all-metal hips seems to be that the all-metal surfaces grind against one another, causing a shrapnel release of tiny metal parts which damage adjoin tissues and the joint itself.

With orthopedic surgeons,

It’s no longer pedal
to the metal.

It’s backing off from the all-metal hip joint,
No more can they to its use point or anoint.

All-metal hips have become an Achilles heel,
A non-fatal condition that does not heal.

Its past use puts them in a fettle,
With potential lawsuits to settle.

Tweet: Unexpected failures of all-metal hip implants will cost taxpayers, patients, employers, and orthopedic surgeons plenty.

Health Care Future Bright for Nurses. Stinks for Doctors.

2011-12-28T08:24:00.003-05:00
The trained nurse has become one of the great blessings of humanity, taking a place beside the physician and the priest, and not inferior to either in her mission.

Sir William Osler, MD, (1849-1919), Aequanimatas

December 28, 2011 – The following blog appeared a few days ago in The Health Care Blog.

The author, Merrill Matthews, resident scholar at the Institute for Policy Innovation in Dallas, Texas, beautifully sums up the plight of primary care physicians and the bright road ahead for nurses. This post originally appeared at Forbes.

The systematic downing of physician incomes under Obamacare, projected to reduce Medicare doctor pay to less than that of Medicaid by 2019, may come back to haunt Democrats politically as tens of thousands of doctors exit from clinical medicine and as tens of millions more Medicare and Medicaid recipients enter government entitlement rolls.

Matthews Blog

"There are lots of losers in President Obama’s effort to remake the U.S. health care system, and chief among them are the doctors. But there are also winners, especially nurses and physician assistants (PAs). Indeed, nurses and PAs win big in part because doctors lose badly."

"Surveys repeatedly show doctors are fed up with low reimbursement rates from Medicare and even lower from Medicaid, which have increasingly led doctors to no longer see new patients in those government-run plans. For example, a recent Texas Medical Association survey found that “34 percent of Texas doctors either limit the number of Medicare patients they accept or don’t accept any new Medicare patients.” Even more do not accept patients with Medicaid."

"Then there’s the heavy-handed regulations and requirements from both government and private health insurers. Complying with all those requirements and paperwork creates expensive and time-consuming administrative burdens. And to top it off, there’s the looming shadow of a high-cost lawsuit if things don’t turn out well."

"And that’s all before ObamaCare kicks in, which will exacerbate every one of those problems. So it’s little wonder that there are physician shortages, especially in lower-paying primary care, and those shortages are only going to get worse if ObamaCare succeeds in getting an estimated 32 million more Americans insured."

"The increased demand for medical care and lower reimbursements—which is one of the primary ways ObamaCare will try to hold down costs—is a recipe for a mass exodus of doctors willing to practice medicine. As Physicians Practice reported in August from its physician survey: 'Nineteen percent say they plan to move to another position in the same field. An equal amount says they plan to leave medicine—not to retire, but to pursue something new.' "

"So who will provide the needed care if the doctors exit? Enter the nurses and physician assistants."

"If ObamaCare withstands the Supreme Court challenge and Republicans fail to “repeal and replace” it, more nurses will be called on to provide more care that historically has been provided only by physicians—a trend that is already happening."

"As the PBS NewsHour reported last May: 'The scope of what nurses can do medically has also been growing for the past decade, at a time when the pool of primary care, or family doctors, has been shrinking. … And more and more are working on their own, especially in poor inner-city neighborhoods and rural areas, where there are few doctors in private practice.' "

"The U.S. Bureau of Labor Statistics (BLS) predicts that the registered nurse (RN) will be the fastest growing profession between 2008 and 2018. And the profession is financially rewarding. The BLS estimates that the average salary for a registered nurse in 2010 was $67,720, or $32.56 an hour. In 2009 the average salary was $63,750, or $30.65 per hour. That’s about a 6 percent increase in a bad economy when millions of Americans were just thankful to have a job."

"However, as in all professions, some segments do better than others. A recent survey of 3,000 nurse practitioners conducted by “Advance for NPs and PAs” found full-timers earned $90,770 in 2010. But nurse practitioners in emergency departments earned on average $104,549. Good salaries considering that Medscape reports that nearly half of family physicians, with all their additional training and educational expenses, made between $100,000 and $175,000 in 2010."

"Because ObamaCare will never bend the health care cost curve down—as the president repeatedly promised it would—something will have to give. And doctors’ reimbursements will be on the amputation table."

"Those payment cuts will surely be politically messy. Just look at the current fight over Medicare reimbursements. Yes, Congress is trying to stop the scheduled 27 percent cut in physician reimbursements—part of a 1997 law that says if Medicare grows faster than a certain rate, physician reimbursements must be cut to balance it out. Because Congress postpones the cut every year, the scheduled cut keeps getting bigger."

"That means doctors have received no significant Medicare increase in more than a decade, even though their costs to provide care go up every year. In effect, the Medicare reimbursement problem has resulted in a 20 percent cut in inflation-adjusted dollars. But what is an unacceptable cut for physicians could be an attractive increase for lower-earning nurses and PAs, many of whom are willing to take the lead on providing more comprehensive care."

"While it may make sense to expand nurse and PA responsibilities, that decision should be made from the bottom up, in the context of doctors and nurses looking for ways to provide quality patient care at a reasonable cost. It should not be the result of top-down micromanagement and price controls that leave health care providers scrambling to find a way to exist under Washington-imposed regulations. Yet that’s exactly what ObamaCare will do."

Tweet: Future prospects for physicians are bleak, while fortunes of nurses and physician assistants are bright.

Physicians Venture out of Practice, Seeking Capital

2011-12-27T11:04:00.005-05:00
Begin, be bold, venture to be wise.

Horace, 65BC - 8BC

December 27, 2011- Luis Pareras, MD, PhD, MBA, of Barcelona, Spain, and I are contemplating writing a book on physicians seeking venture capital to escape the fetters of practice and to launch innovative ideas.

Dr. Pereras is a venture capitalist. He lives in Europe. In Europe, aging populations, plummeting birth rates, and soaring costs makes it hard to sustain overly generous social welfare states. I live in the U.S, where, to a lesser degree, a similar situation is emerging.

Here Medicare is approaching bankruptcy. Medicare is the single biggest contributor to our growing budget deficit. In Europe, centralized bureaucracies often smother innovation. This may soon be the case in the U.S. Europe and the U.S. are inextricably interlocked sectors of the global economy - economically. clinically, but not always culturally.

Nevertheless, both physicians in Europe and the U.S. are unhappy because government is cutting their pay and ramping up regulations to make national ends meet. Some physicians in Europe and the U.S are turning to venture capitalists to get the money required to launch start-up health –related enterprises. Others rely on their own finances or angel investors.

Of Wikipedia’s list of 91 notable venture capital firms, only 8 (8.8%) are headquartered in Europe, 4 in London, 2 in Germany, 1 in Paris, and 1 in Moscow, while 78 (85.7%) are in the U.S., and 4 elsewhere (2 in Singapore and 2 in Israel).

In the U.S, 41 are in California, 13 in Massachusetts, 7 in New York, 5 in Texas, 3 in Pennsylvania, 2 in Connecticut, 2 in District of Columbia, 2 in Virginia, with single firms in Kansas, Washington State, Colorado, Maryland, and Rhode Island.

Why such a book? The reasons are complicated and overlapping. Physicians are by nature entrepreneurial. They often rely on other people’s money. Many physicians want to escape from negative practice environments – mounting bureaucratic burdens, declining reimbursements, increasing expenses, decreasing autonomy and practice satisfactions.

Some physicians are willing to take entrepreneurial risks, to roll the dice with their reputations and their own money, or money from relatives or angel investors. Some are seeking refuge from overheads imposed by 3rd parties, public and private, Still others are entering concierge practices or practices requiring only direct-cash transactions. Many believe that once they are freed from 3rd parties, they can provide cheaper and better care through “disruptive innovations.”

But how? How does one change one’s practice? How does one access venture capital, the financial oxygen required by startup enterprises? Where are the best sources of reliable venture capital? What are the economic and control tradeoffs between individual entrepreneurs and investors? What is the process by which one embarks on an alternative career? In Dr. Peraras’ excellent book, Innovation and Entrepreneurship in the Health Care Sector: From Idea to Funding to Launch ( Greenbranch Publishing, 2011, 460 pages), he has described the process in detail.

Dr. Peraras and I envision a smaller book – full of concrete case studies illustrating why entrepreneurial physicians have either succeeded or failed in new ventures. We want to tell where physician entrepreneurs got their money. We want to describe the pratfalls, beartraps, and opportunities lurking out there . We want to interview these entrepreneurs. We want to ask them the lessons they learned. We will list notable venture capital firms. We will take note of health care trends barreling down the health care pike.

An instructive example of what is going on the venture capital field appeared recently in an interview with Rebecca Lynn in the December 11 edition of HealthLeaders Magazine. Ms. Lynn, a partner in Morgenthal Ventures, a venture capital and private equity firm in Menlo Park, California, had this to say.

“Some argue the healthcare industry is innovation-proof. It is risk adverse. It is too slow – even unwilling to change. It is too complicated and regulated to change.”

She disagrees.

“Change will come from outside entrepreneurs unfettered by the status quo – who can tame the healthcare data beast and who are willing to try new ideas – such as outsourcing some care to patients themselves.”

“The only way to get the data is through an EMR…that’s automatically populated by your physician, by the labs, and by the pharma companies. The data’s got to be in the cloud, and it has to be free.

'One thing we’ve learned is that doctors pay for nothing. It’s not a slam against doctors. It’s just a fact of life.”

“That’s why our firm invested in PracticeFusion – a free web-based EMR with an open application program interface that grants access to other applications.”

“Start-ups must get creative when it comes to revenue models. Offer a product that’s free, and it will take off like wild fire.”

“Patients have proven they are capable of tending to their own health care issues . Diabetics manage to measure their insulin levels, and women take pregnancy tests at home all the time…The trends to passing to patients some of the responsibility of their own care will continue – from ordinary lab tests to in-home medical devices and technologies such as blood pressure cuffs, glucose meters, and smart scales.”

“We cannot afford the healthcare industry as it stands. You hve to look at ways to deliver better care, increase efficiency, reduce readmissions, and reduce costs. That’s why healthcare has to be readmitted.”

Tweet: A health care innovation revolution is at hand. Physician entrepreneurs with venture capital access will lead that revolution,

Everything You Ever Wanted to Know about Tweets, Tweeting, and Health Reform

2011-12-26T04:04:00.004-05:00
Tweet - An online comment of 140 characters or less (65 characters)

Tweet definition ( 17 characters)

December 27, 2011 (18 characters) People ask me why I tweet.(26 characters).

And tweet I do, incessantly, with 715 recent tweets to my credit.(71 characters)

Why do I tweet? (16 characters)

I tweet because I like brevity.(31 characters) Truth be known, my favorite limerick is: (36 characters)

Seek brevity.

with a touch of levity. ( 36 characters)

In short,

Be terse,

for nothing is worse,

than verbal longevity.( 64 characters)

I tweet because I like aphorisms, succinct opinions,and short truths.( 71 characters)

I tweet because we live in a world of sound bites, bullet points, and talking points. (85 characters)

I tweet because I like bare-bones commentary. (46 characters)

I tweet because people these days have shorter and shorter attention spans, approching zero in isolated cases (119 characters)

I tweet to promote my medinnovation blog and my book, The Health Reform Maze. (73 characters)

I tweet because nothing is so sweet as a short single English declarative sentence. (83 characters)

I tweet because my hero, Winston Churchill said: “Short words are best and the old words when short are best of all.” (117 characters).

Tweet: Everything you ever wanted or needed to know about tweets and tweeting but were afraid to ask.(94 characters)

Christmas Pause

2011-12-23T06:17:00.004-05:00
It’s time to pause and to celebrate.

Anonymous

December 23, 2011 - This will be my last blog until after Christmas.

This Christmas I will be thinking of my two sons who can’t be with us. One will be selling goods for Brooks Brothers in New York City during their peak season. The other is an Episcopal Priest in Madrid, Spain, where he serves as an assistant to the Anglican Bishop of Spain.

I asked my priest son, who is in Spain on a one year Amy Lowell Fellowship, awarded to an American poet each year, to name his favorite Christmas poem. He nominated James Merrill’s “The Christmas Tree.”

James Merrill (1926-1995) wrote this poem just before his death, with full knowledge he was dying. The poem celebrates life and Christmas.

My son tells me in Spain people dig up their Christmas trees, preserve them in pots, then replant them when the two week Christmas celebration ends on January 6. That seems fitting. It gives the Spanish nearly a year to regrow, renew faith, and spirituality. Perhaps we Americans should have an annual ritual of uprooting, repotting, and replanting.

I am grateful to you, my blog readers, as I try to explain the transformation and reformation of medicine and health care, which I pray will better our physical, spiritual, and economic health.

Christmas Tree by James Merrill

To be
Brought down at last
From the cold sighing mountain
Where I and the others
Had been fed, looked after, kept still,
Meant, I knew--of course I knew--
That it would be only a matter of weeks,
That there was nothing more to do.
Warmly they took me in, made much of me,
The point from the start was to keep my spirits up.
I could assent to that. For honestly,
It did help to be wound in jewels, to send
Their colors flashing forth from vents in the deep
Fragrant sable that cloaked me head to foot.
Over me then they wove a spell of shining--
Purple and silver chains, eavesdripping tinsel,
Amulets, milagros: software of silver,
A heart, a little girl, a Model T,
Two staring eyes. The angels, trumpets, BUD and BEA
(The children's names) in clownlike capitals,
Somewhere a music box whose tiny song
Played and replayed I ended before long
By loving. And in shadow behind me, a primitive IV
To keep the show going. Yes, yes, what lay ahead
Was clear: the stripping, the cold street, my chemicals
Plowed back into Earth for lives to come--
No doubt a blessing, a harvest, but one that doesn't bear,
Now or ever, dwelling upon. To have grown so thin.
Needles and bone. The little boy's hands meeting
About my spine. The mother's voice: Holding up wonderfully!
No dread. No bitterness. The end beginning. Today's
Dusk room aglow
For the last time
With candlelight.
Faces love lit,
Gifts underfoot.
Still to be so poised, so
Receptive. Still to recall, to praise.

Tweet: I shall pause writing this blog until after Christmas to celebrate the season and to reconsider the meaning of life and health

A Pre-Christmas Proposal to Bring Down Medicare Costs

2011-12-22T10:03:00.000-05:00
Bundled payments, also known as episode-based payment, episode payment, episode-of-care payment, case rate, evidence-based case rate, global bundled payment, global payment, global package payment, package pricing, or packaged prices..have been proposed as a strategy for reducing health costs, especially in the Obama administration.

Wikipedia

December 22, 2011- Ekekiel Emanuel, MD, PhD, (born 1957), former associate professor at Harvard Medical School, bioethicist at NIH, and Obama health advisor, and, as of September 2011, a Professor at University of Pennsylvania Medical School and Wharton and regular New York Times contributor, expresses these opinions in a December 19 in a NYT’s Opinionator column entitled “For Medicare, We Must Cut Costs Not Shift Them.”

“The Affordable Care Act already created a mechanism to reduce spending in Medicare to the growth in gross domestic product plus one percentage point. Starting in 2020 the Independent Payment Advisory Board is required to submit proposals to cut Medicare spending if the growth in spending exceeds that level. However, the board is specifically prohibited from rationing care, raising taxes or premiums, increasing cost-sharing, restricting benefits or modifying eligibility — thereby protecting beneficiaries. Its proposals become law unless Congress or the president votes to institute other reforms that save as much money.”

"What should be done about Medicare? To address the root of the cost problem, we must change how we pay doctors and hospitals. We must move away from fee-for-service payments to bundled payments that include all the costs of caring for a patient, thereby encouraging providers to keep patients healthy and avoid unnecessary services. Medicare should announce that it will make this change by Jan. 1, 2022, and that it will begin by switching to bundled payments for cardiac and orthopedic surgery within one year and for cancer patients within five."

"Premium support will not reduce the government’s costs without shifting those costs to older people who can’t afford them. Only a plan that transforms how we pay doctors and other health care providers can do that.”

Tweet: Ekekiel Emanuel, MD, PhD, Obama health advisor, says to cut Medicare costs we pay doctors for episodes of care rather than FFS.

The ACO Divide: "Pioneers" Vs Private Practitioners

2011-12-21T08:16:00.004-05:00
The independent, private practice model will be largely, though not uniformly, replaced. 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.

The Physicians Foundation, “Health Reform and the Decline of Physician Private Practice, “ A White Paper Examining the Effects of the Patient Protection and Affordable Care Act on Private Practices in the United States, October 2110

December 21, 2011- This week Health and Human Services announced with considerable fanfare 32 "Pioneer" Physician Organizations that qualified after competition to become “Pioneer” Accountable Care Organizations (ACOs). These ACOs will begin their work on January 1, 2012 and are designed to save Medicare $1 billion over the next 5 years by boosting quality while improving outcomes and reducing costs.

These 32 organizations, selected from among 80 applicants, hail from 18 states. They now care for 880,000 Medicare beneficiaries. Six of the fledgling ACOs are from California, 5 from greater Boston, 4 from Minnesota, and 3 from Michigan.

The 32 "Pioneers"

The “winning” organizations, if you want to call them that, include:

Allina Hospitals and Clinics (Minneapolis), Atrius Health (Massachusetts), Banner Health (Phoenix), Bronx Accountable Care (New York City), Brown and Toland Physicians (San Francisco), Darrtmouth Hitchcock ACO (New Hampshire and Vermont), Eastern Maine Health Care System(Maine), Fairview Health System (Minneapolis), Franciscan Alliance (Indianapolis), Genesys PHO (Michigan), Healthcare Partners and Medical Group (Los Angeles and Orange County), Healthcare Parnters of Nevada), Heritage California ACO (California), ISA Medical Group (Orlando-Tampa), Michigan Pioneer (Michigan), Monarch Healthcare (California, Orange County), Mount Auburn Cambridge IPA (Massachusetts), North Texas ACO (North Texas), OSF Healthcare System (Illinois), Park Nicollet Health System (Minneapolis), Partners Health (Massachusetts), Physicians Healthcare (Denver), Presbyterian Health System(New Mexico), Premier Medical Network (Southern California), Renassiance Medical Management Company(SE Pennsylvania), Seton Health Alliance (Central Texas), Sharp Healthcare System (San Diego), Steward Healthcare System (Massachusets), TriHealth System (Iowa), University of Michigan (SE Michigan).

These organizations hardly represent U.S. physicians as a whole. Many are in the most progressive cities in the more liberal states of the U.S. – in California, Massachusetts, Minnesota, Michigan, and New England.

Great swaths of the U.S., 32 states in all, have no ACO representatives.

These states include those in the far West (Hawaii, Alaska, Oregon, Washington State, Idaho, Montana, Utah, Wyoming), the Midwest and Southwest (North and South Dakota, Nebraska, Oklahoma, Missouri, Ohio, Kansas), the entire South (North and South Carolina, Georgia, Alabama, Mississippi, Tennessee, Kentucky, Arkansas Louisiana, Virginia, West Virginia), parts of the East (Connecticut , Delaware, Maryland, New Jersey).

These organizations do not include physicians and health systems that care for 47 million other Medicare recipients. Moreover, many of the “pioneers” are hardly that. They are well-established groups with salaried physicians and the infrastructure, finances, and administrative teams to handle the bureaucratic demands of ACOs.

It may be, of course, that 88% to 90% of physicians who practice outside of these “pioneer” ACOs, will see the light and invest money, time, and energy and will take the risk of creating these new organizations. It may also be that prestigious organizations like Mayo, the Cleveland Clinic, the Marshfield Clinic, Geisinger, academic medical centers, like Duke, Johns Hopkins, and prestigious New York and Pennsylvania centers, and other intergrated medical school-centered systems, will join the reformation and climb upon the ACO bandwagon.

It will be a waiting game to see if the 32 “pioneers” can produce results envisaged by Washington CMS and HHS planners and founders of these early ACOs.

Maybe, just maybe, other physician organizations will cross the Great Divide between private practice in fragmented solo or small groups to an organizational Nirvana. It will take more time, more experiments, more results, and more federal incentives.

When one uses the term “Accountable Care Organization,” a fundamental question arises. ”Accountable to whom?” To the federal government? To the experts and managers who designed these organizations? To the organizations who implement them? To the defined populations of the elderly they serve?

Tweet: Health and Human Services has announced 32 “pioneer “ medical organizations have agreed to become experimental ACOs, starting in January 2012.

Presidential and Health Reform Odds

2011-12-20T12:03:00.002-05:00
It’s unwise to bet against the House, the President, and the Law, but you might get lucky.

Anonymous

December 20, 2011 - In 2009, I wrote a book entitled Obama, Doctors, and Health Reform: A Doctor Assesses the Odds for Success (IUniverse).

The book comes to mind as I assess the current odds on the Presidential race and health reform repeal as set forth by these two sources.

One, Intrade.com, which portrays itself as the world’s leading prediction market, with political odds as seen by the wisdom of crowds, viz, people betting on outcomes.

 Mitt Romney to be Republican presidential candidate, 67.1% chance

 Newt Gingrich to be Republican presidential candidate, 9.9% chance

 Jon Huntsman to be Republican presidential candidate, 5.3% chance

 Ron Paul to be Republican presidential candidate, 8.3% chance

 Rick Perry to Republican presidential candidate, 2.6%

 Barack Obama to be re-elected as president, 50.6% chance

Two, Real Clear Politics, favorability odds.

 Obama job approval, approve 45.8%, disapprove 50.0%

 Congressional approval, approve 11.3%, disapprove 83.7%

 Country going in right direction, 23.0%, wrong direction 71.2%

 Obama and Democrats health plan, approve 36.4%, disapprove 49.8%

 Favor repeal of health plan 49.7%, against repeal, 39.3%

Conclusion

Odds favor Mitt Romney as Republican candidate for President, and President Obama as eventual winner. Odds indicate Most Americans disapprove of health reform law and desire its repeal.

Tweet: Odds indicate Presidential election in November may depend on Supreme Court decision in June on constitutionality of health reform law.

What Doctors Think about Health Reform

2011-12-19T15:16:00.002-05:00
D.C. stands for Darkness and Confusion.

Anonymous

December 19, 2011- Lee Stillwell, an inside-the-Beltway health care consultant, writes a periodic Washington Report for the Physicians Foundation (physiciansfoundation.org, a non-profit 501C3 organization representing over 500,000 physicians in state medical societies.

In my opinion, Stillwell's reports accurately mirror attitudes, fears, and perceptions of the ACA (Accountable Care Act. aka, Obamacare). It has now been 21 months since the Act's March 23, 2010 passage. The nation's citizens, including its physicians, remain divided on the wisdom and consequnces of its passage.
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We are about to end the year, much like it started. There has been a great deal of noise and few results toward the goal of creating a new healthcare system that has increased quality and value for the consumers and drastically reduced costs to government.

Repeal or retention of Obamacare and overhaul of Medicare/Medicaid as part of the need to control healthcare spending will remain a top priority of both Democrats and Republicans as we leave 2011 and head into 2012.

Even though the need to control healthcare spending grows by the minute, Congress will adjourn without addressing the problem.

An annual report from the Medicare Office of the Actuary estimates health care spending by 2020 will double and federal, state and local governments will pay half –50 percent—of the cost. The report indicates health care spending will average 20 percent--of the nation’s GDP in 2020, up from 17.6 percent in 2010.

Looking at those numbers in another way, health care spending will almost double to $4.6 trillion from $2.6 trillion in 2010. And, health care spending in 2020 will cost $13,710 for each man, woman, and child in America, up from a 2010 per capita cost of $8,327.

Surprisingly, the analysis concludes that President Obama’s health care law only plays a modest role in growing costs, even though it provides 30 million uninsured Americans with insurance coverage. Blamed are the increasing numbers of aging Americans and the high cost of medical innovations.

Obviously, such statistics and the mounting political rhetoric about the urgent need for drastic action have made the public very nervous. They rightly fear that medical care will cost more and their access and choices for treatment will be less. Consequently, health care and the economy will be defining issues in the upcoming Presidential primaries and next year’s November election.

Matter of fact, disenchantment with Obamacare—the Affordable Care Act (ACA) passed March 23, 2010-- continues to grow. A recent Associated Press poll shows support for his law has dropped to 29 percent with 49 percent opposing it. Also, only 15 percent believed that government should be able to force citizens to purchase health insurance while 84 percent say “not.” The U.S. Supreme Court will determine the fate of this individual mandate, which is part of the Obama bill, this coming year.

These polling numbers make the Republican political strategy for 2012 obvious. They plan to be very visible in their efforts to appeal the law. Remember, the GOP-controlled House’s first legislative effort this year was to pass a repeal of Obamacare, which went nowhere in the Democratic-controlled Senate.

Expect more of the same in 2012. Insiders say the GOP focus will be on repeal of two provisions in the Obama law—the Independent Payment Advisory Board (IPAB) and the CLASS Act.

The Obama Administration had put the CLASS Act, the health care law’s long-term care provision, on hold because staff at the Department of Health & Human Services (HHS) couldn’t find a way to make the program solvent. Therefore, the GOP contends it should be repealed and is moving legislatively forward to do so.

Republicans warn that the IPAB, a 15-member board, has too much power. The law authorizes it to make reductions in provider payments if they increase too fast. Congress could overrule the panel, but only with a super majority in the Senate, or by devising an alternate plan that saves the same amount.

A political solution for both of these provisions is possible, but there appears no likely outcome in 2011 for the greatest of the challenges facing the nation’s health care system: Medicare reform.

Political observers believe Medicare reform only comes from a bipartisan plan. Subsequently, there is a great stir in the capital over a development this past week that saw a bipartisan legislative proposal to revamp Medicare come from two unlikely individuals--Rep. Paul Ryan(R-Wis.) and Sen. Ron Wyden (D-Ore.).

Ryan, chairman of the House Budget Committee, was the chief sponsor last April of a budget resolution which passed the Republican-controlled House with a provision limiting the federal government’s Medicare spending while requiring seniors to pay for coverage and eliminated the traditional fee-for-service option.

The Senate ignored Ryan’s proposal, which upset many of the nation’s seniors. And, it should be noted, 34 percent of the seniors 60 or older regularly vote. And there now are 47 million Americans on Medicare.

The new Ryan-Widen plan expands choice by permitting private health plans to compete with the government for seniors. The new system, which would start in 2022, also would include a premium support system intended to lower the costs of private plans by comparing them to Medicare. Providers and drug companies would face reduced support if spending rose more than one percent GDP.

Reaction was predictable. House Speaker John Boehner(R-Ohio) called it a bipartisan idea worthy of consideration. House Minority Leader Nancy Pelosi (D-Calif.) charged that the plan shows the GOP want Medicare to “whither on the vine.” White House Press Secretary Jay Carney called the plan radical and GOP Presidential candidates Mitt Romney and Newt Gingrich praised the plan.

None of the comments appeared to deter Widen and Ryan from promoting their plan, which still lacks cost projections and other key details. The men don’t intend to introduce the legislation until after the November 2012 election, only putting the proposal out there now as a marker for discussion.

Their timetable makes sense. A divided Congress, and reelection-anxious President, seems destined to avoid a real solution in 2012-- until after November’s results. By then, spiraling deficits, threatening the nation’s economic wellbeing, will force all the politicians to address the matter. For better or worse, we finally can look into a crystal ball— in 2013 for sure--and see our health care system dramatically transformed and reshaped to meet budgetary challenges.

Tweet: Retention or rejection of the health reform law preoccupies physicians. The law's fate remains uncertain.

12 Common Medicare Scams

2011-12-19T10:30:00.006-05:00
To scam Medicare is not to give a damn for taxpayers. Money is money whether you earn it or steal it.

Anonymous

December 19, 2011- Christine Seivers of medicalbillingandcoding.org sent me the following list of common Medicare scams. I have edited and shortened her copy to fit my blog. Her blog was sent out on December 18.
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1. The Poser Scam

One common way to scam Medicare is to pose as a Medicare employee, a practitioner, or insurance representative. These fraudsters call, email, or send letters asking for personal information that includes bank, Social Security, and Medicare numbers.

2. The Healthcare Reform Scam

Healthcare reform is on the lips of everyone these days, and scammers are using it to cash in. Many adults don’t know what the new health care legislation actually entails. That’s just the way criminals want it. It makes many Americans easy targets for scams, like those that claim to sell "healthcare reform insurance" that purportedly protects seniors from any losses to their Medicare or any fines they make incur from not meeting guidelines.

3. The Free Lunch Scam

There is no such thing as a free lunch. Scammers in low income areas are taking advantage of the neediest Medicare recipients by drawing them in to fake health care clinics with promises of free food or gifts. Once they have the victim where they want them, they get Medicare numbers through coercion and then use them to commit Medicare fraud.

4. The Kickback Scam

Scammers might offer you a cut of the take in exchange for your Medicare number, but they won’t put it like that. If anyone ever promises you any gift or monetary rewards for your Medicare number, decline their offer immediately. You’ll be drawn into the scam, and could face criminal charges for your role.

5. The Refund Ripoff Scam

As part of the Affordable Care Act, many senior Medicare recipients may be eligible to receive a refund from the government of $250 to help cover their prescription drug costs. Criminals have pounced on these checks as an opportunity to make some extra cash and scam some Medicare numbers at the same time. Many call seniors and tell them that they need to confirm Medicare numbers to send out the checks. Medicare numbers are like credit card numbers: they should never be given out to strangers over the phone.

6. The Imposter Employee Scam

.Anyone can claim to work for the government. Some criminals looking to scam those on Medicare will call or even come to the home of recipients asking for personal information like Medicare numbers and bank accounts. Never trust someone who calls or visits you out of the blue looking for information of this kind.

7. The Free Medical Supplies Scam

Exchanging medical supplies, which are usually of very low value, for Medicare numbers is not a bargain, it’s a scam. If someone tells you that an item is free but they just need your Medicare number for their records, you’re better off buying the items on your own.

8. The Not Usually Covered Scam

If something isn’t covered by Medicare, it isn’t covered. Period. If your provider or someone you don’t know tells you that an item isn’t covered but they know how to bill it so you won’t have to pay, that might sound great. But it’s also fraud and can get you, and that provider, in a lot of trouble.

9. The Extra Equipment Scam

Those with diabetes, arthritis, and sleep problems are frequent victims of this scam. Salespeople will go to homes of those they know suffer from these conditions and try to get them to buy extra equipment, often things that they really don’t need. It sounds great because these extra items can be billed to Medicare and you won’t have to pay a thing.

10. The New Card Scam

Another way scammers are taking advantage of new health care regulations is by telling seniors that in order to keep receiving benefits or get their refund checks they’ll need to get a new Medicare card. This simply isn’t true.

11. The Medical Decisions Scam

Some unscrupulous insurance agents have been taking advantage of Medicare policy holders. Some are sending out release forms that allow agents to make decisions on their behalf. Never, ever sign anything without reading through it first and making sure you understand it. If it’s confusing, get a friend, family member, or lawyer to look over it before signing.

12. The Fancy Tests Scam

Some doctors and nurses are at the center of Medicare frauds. They make their money from scamming Medicare by scaring or coercing patients into getting unnecessary and expensive tests. Your medical provider should never use pressure or scare tactics to get you to consent to any medical decision, it’s just unethical. If you feel this is going on, get a second opinion.

A Verse for Medicare Scammers

You don’t have to go on the lam,
When Medicare is so easy to scam.
You nee a Medicare and street number,
And you can be cool as a cucumber,
For the Feds are in deep slumber.

Tweet: Scammers defraud Medicare of $60 billion a year through these 12 schemes.

Medicare Reform and New York Times Editorial

2011-12-18T13:30:00.009-05:00
Coulda, shouda, oughta

Saying of those who know how things could, should, and ought to be

December 18, 2011 - I enjoy reading New York Times’ editorials. The editorials tell you how things could, should, and ought be in opinions that are fit to print and in a world that’s fit to live in.

The editorials are predictable. They adore the Democratic party, abhor the Republican Party, and deplore anything that distracts from Big Government’s mission.

Take today’s editorial, “Working with Medicare: Reforms Could Save Hundreds of Billions of Dollars – without Scrapping the System.”

Here the operative word is "could", but the implied "should" and "ought to" are not far behind.

The editorial says:

1. It is “skeptical” that the latest Medicare proposal advanced by Paul Ryan (R- Wisconsin) and Ron Wyden (D-Oregon) suggesting a blend of today’s Medicare system blended with a private option of premium support would work(Anything that changes present Medicare, scheduled to go broke in 2016, is verboten).

2. Medicare insurance is superior to private insurance (even in face of the fact that Medicare is decimated by $60 billion of fraud and abuse while this is rare with private insurance).

3. Medicare “could save" $112 billion to $135 billion by deeply discounting drugs from those evil private drug companies (never mind that this might bankrupt many durg firms).

4. Medicare pays too much, much more than needed for a “reasonable profit" to provide good care” to providers and “could save" $40 billion by paying skilled nursing facilities and nursing homes less and $200 billion more by aggressively managing coordinating all care ( presumably a D.C. bureaucrat should decide what constitutes a "reasonable profit").

5. Raising the Medicare entry age from 65 to 67 “could save" $125 billion, but it’s a bad idea “only if the health reform law remains in place” (In other words, Medicare is sancrosanct and cannot be changed in any way).

6. Real costs savings “could" occur if incentives are removed from doctors to perform more tests and procedures (no mention is made of patient and malpractice pressures to do these tests and perform these procedures).

7. Medicare “could save" $30 billion with a $550 annual deductible , a 20% copay for all service, and a cap on out-of-pocket spending, but it’s a bad idea unless it would protect the poor( part of the "poor"are families of four making up to $108,000).

8. Medicare means testing for those making over $85,000 a year "could save" $50 billion in ten years and $200 billion if it rasised premiums for everybody, but “that seems risky” ( What"risky" means is not explained).

9. The real solution is the reform law “that makes a start by reducing doctor pay and pay for Medicare Advantage Plans , that “could save" $400 billion and even more if followed by pilot projects promising to reduce Medicare costs even more ( If only those greedy doctors and Medicare consumers desiring options would play ball, all would be well).

10. No matter what, “Medicare still works better than most private plans and offers the best hope for promoting wider reforms"(translated: the New York Times believes the health reform law and Medicare should be left alone, even if headed towards bankruptcy. In time, 10 years, it believes the new law will cut costs , preserve, and improve the health system).

Tweet: The New York Times, in a predictable editorial, says Medicare could, should,and ught to save Medicare by saving billions of dollars.

Gingrich on Health Reform

2011-12-17T18:01:00.003-05:00
It is not enough to have a good mind. The main thing is to use it well.

Descarte (1596-1650)

One man who has a mind and knows it can always beat men who haven’t and don’t.

George Bernard Shaw (1856-1950)

December 17, 2011 - When I think of Newt Gingrich, I think of a mind at work and at play. He has a good mind, even a grandiose mind, and he is always playing around with new ideas. He has a mind rich in experience,brimming with political anecdotes and historical lore.

But, say critics, it is a fickle and opportunistic mind. Six years ago, he was for the individual mandate, now he is against it. Now he is backing off his support of electronic records.

Some say these changes of position represent grandiosity, even pomposity, but Gingrich supports say these shifts speaks more of virtuosity. Gingrich can, admirers say, out-think and out-talk other politicians in tense situations, like debates.

On some issues – like electronic medical records and a comparative effrectiveness research – Gingrich claims he is steadfast. Data, he opines, enriches the mind, expands mental horizons, and corrects biases.

Of Obama's stimulus package of $787 billion in 2009, with $27 billion targeted for EHRs, Gingrich told the New York Times that same year, “The president should be applauded for making this a vital priority and a key part of his economic stimulus package.” Today Gingrich is against Obamacare.

Of EHRs, Gingrich declared, “A Republican Congress that’s serious will pass an electronic records for every American.”

In Human Events, he wrote, “In our country the road to humanity begins with something called comparative effectiveness research.”

Of his backing of EHRs and comparative effectiveness research,Gingrich asserted, “Initially, they’ll be rejected. Let’s be clear: This is not a city that likes innovation. It’s not a city that likes to think deeply. It’s a city that memorizes a handful of phrases and uses them in nine sound bites.”

Now there’s a man who knows how to pose as a Washington outsider, while making his fortune through insider contacts. Gingrich collected consulting fees at the Center for Health Transformation, which he founded, by serving as spokesperson for clients like Siemens, GE Healthcare, Allscripts, MedAffinity, and Microsoft and other firms selling, developing, or pushing EHRs.

Gingrich a man who knows his own mind. He reserves the right to change his mind, depending on new knowledge. Flip-flopping, changing one'v view in the fact of new information, can also be interpreted as the mark of a mature mind.

Tweet: As a presidential candidate, Newt Gingrich has an on and off record of support for EHRs.

Weapons of Mass Distraction

2011-12-16T07:44:00.009-05:00
Nevermore!
Edgar Allen Poe (1809-1849), The Raven (1845)

December 16, 2011 –The media this week carried stories about distractions caused by mobile devices for drivers, doctors,and politicians.

The National Highway Safety Board announced plans to ban smartphones for drivers, medical authorities said computer use among doctors and nurses potentially harms patients, and Herman Cain withdrew from the Republican race because of distractions caused by irresponsible bloggers.

In cars nevermore use of smart phones,
It turns drivers into distracted drones.

In operating suites, nevermore IT devices,
It causes surgeons to make wrong slices.

In the political arena nevermore blogging,
Partisan blogs cause needless pettifogging.

Multitasking is simply too distracting,
For tasks requiring one to be exacting.

The moral is:

Excessive use and abuse of mobile apps
Causes too many of us to lapse.

Tweet: Do not tweet while in the driver's seat.

The Future of Hospitals

2011-12-15T13:06:00.009-05:00
It may seem a strange principle to enunciate as the very first principle in a Hospital that it should do the sick no harm.

Florence Nightingale (1820-1910), Notes on Hospitals (1859)

Hospitals in their present form will not disappear, but their role will change dramatically.

Anonymous

December 15, 2011 - A world without hospitals as they now exist is an improbable thought. Yet it is well underway.

The health system is shifting from expensive hospital specialist-dominated care to more affordable primary care and to home-based self-care. General hospitals will, of course, continue to exist as bedrock large employers in most communities and as providers of the last resort, but they are shedding their brick and mortar mentalities and facilities.

Powerful Centrifugal Forces

Powerful centrifugal forces are pulling patients out of hospitals and ERs. These forces are economic,sociological,and technological. They are turning hospitals inside out. They are shrinking centralized facilities and enlarging outpatient outreach activities.

The forces are focusing on cardiovascular and oncological diseases. They are being unfurled under the health reform banner, but there is more to it than that. It is survival of the fittest and the biggest. Government at all levels is driving change. Hospitals are moving aggressively into outpatient and retail arenas. Large and small employers are seeking refuge from high costs; physicians are searching for autonomy; and consumers are questing after lower costs, more convenience, more empowerment, more personal care.

Fear of hospital-acquired infections and other hospital safety hazards are factors as well. All parties are focusing on simpler solutions to reduce complexities of care. People want more care outside of institutions. They prefer to walk-in rather than be carried-in for care.

Christensen's Disruptive Innovations

Here's how Clayton Christensen, a Harvard Business School professor who wrote The Innovator’s Dilemma in 1997 and who coined the term “disruptive innovation,” describes events. Christensen considers himself an innovator. He co-founded Innosight, the Innosight Institute, Innosight Ventures, and Rose Park Advisors and Venture Capital Group.

Christensen views the fundamentals and sequence of transformational events this way.

• Its essential change elements are: 1) investments in diagnostic technologies that simplify care outside hospitals, e.g. ultrasound in hands of doctors in their offices; 2) business model innovations, such as retail and walk-in clinics; 3) creation of more integrated fixed-fee health systems along the lines of Intermountain Healthcare, Kaiser, and Geisinger, while phasing out of variable and traditional fee-for-service care.

• A transition to simpler care aided by technologies and provided by less sophisticated personnel outside of hospitals – in doctors’ offices, outpatient settings, retail clinics, and in patients homes using telemedicine monitoring and communication.

In the Christensen scheme of things.

• Doctors would relinquish simpler tasks to allied health professionals.

• General hospitals would convert to integrated systems.

• Payers would merge with providers.

• HSAs with high deductible plans would gain ground, capturing as much as 50% of health plan market by 2014.

• Patients would take more responsibility for their own care – self-care would go mainstream.

According to John Peabody, MD, PhD, and Vice-President, of Sq2, a future- focused health care consulting firm, much of what Christensen is predicting and advocating for hospitals, is already taking place.

Peabod's Forecastes for Hospitals

From 2011 to 2021, Peabody projects for hospitals:

• Inpatient loads to drop 3% while outpatient work will increase 32%.

• Cardiovascular and cancer inpatient care, hospitals’ two profitable service lines, to decrease by 27% while outpatient care will go up by 19%.

• Outpatient work for pneumonia, the scourge of the elderly, to spike by 23% while inpatient care for pneumonia to plunge by 48%.

• Hospital outpatient outpatient and ambulatory visits to increase by 24% and 40% respectively.

References

1. Managed Care, A Conversation with Clayton Christenson, DBA, January 2010.

2. Sg2’s Disease-Based Forecast Predicts Dramatic Increase to Outpatient Health Care Services over the Next Decade, January 5, 2010.

Tweet: Health system will shift from costly hospital care to less costly outpatient care provided by integrated systems over the next decade.

Can Hospitals Exist without Doctors?

2011-12-14T11:29:00.004-05:00
One cannot run a hospital without doctors, and one cannot run one with them.

Peter F. Drucker (1909-2005)

December 14, 2011- Yesterday Kaiser Health News ran a piece “Hospitals Clash with House Republicans on Medicare Cuts.”

The article revived these questions:

• Are hospitals friends or foes of independent physicians?

• Will the future of hospital-doctor relationships be one of cooperation, collaboration, or cooptation? (On the last bullet point, "cooptation" means hospitals take over the practice of medicine).

• What is the role of hospitals in health reform – hospitals after all have already agreed to $155 billion in Medicare cuts under Obamacare?

But I digress. What is the hospitals’ problem with the Republican legislation? What is the big deal? The Senate will probably not even take up the bill up anyway.

Simply this: Hospitals would have to pay $17 billion of the $38 billion required for the “doctor fix, ” a 2 year reprieve from the 27% Medicare doctor pay cuts.

How? Starting in 2013, the bill would lower hospital Medicare payments government now pays for uncollected bills, copays, and deductibles and for the administrative costs devoted to collecting these unpaid items.

Hospitals say this additonal cost burden would be devastating. Uncollectibles are soaring because of the recession, diminished state Medicaid funding, and a 2% cut due the “sequester” in the wake of the failed budget bill.

The hospitals’ hostile reaction to the Republican legislation raises these questions.

. What is the basic attitude of hospitals toward independent doctors, who may practice largely outside the hospital environment but who may depend on hospitals for their work and livelihood?

• If the 27% cut goes through, can hospitals live without doctors who will no longer accept Medicare or Medicaid patients?

Answers to these questions may be moot, i,e.not relevant in the present practice environment.

• Many of the doctors who cease or cut back on practices will be older independent doctors who practice outside of hospitals.

• Many will go into cash-only practices, concierge practices, walk-in clinics, and urgent care centers outside of the province of hospitals.

• Many, especially younger or mid-career doctors, will become hospitalists, ER physicians, or employees of hospital-owned practices.

• Academic centers or large hospital systems or doctor driven- systems already employ 10% to 12% of physicians.

. Many primary care doctors will work for government-sponsored Community Clinics, which already care for 20 million Americans.

• Some of the practice vacuum will be filled with physician extenders – nurses, nurse practitioners, and physician assistants.

• Many doctors may be working within the context of accountable care organizations (ACOs) - in which doctors will be paid to care for large defined populations of Medicare patients and will be required to follow a series of complicated bureaucratic rules.

Tweet: Hospitals oppose Republican bill giving doctors 2-year reprieve from 27% cuts but which lowers hospital Medicare payments by $17 billion.

Blurred Future of U. S. Health Care

2011-12-13T03:35:00.008-05:00
Power-worship blurs political judgment because it leads, almost unavoidably, to the belief that present trends will continue.

George Orwell (1903-1950), Raffles and Miss Blandish, (1944)

December 13, 2011 - These days news of the future of health care's big transformations are coming fast and furious.

Why? Because pressures to cut costs are transforming business models. It is becoming survival of the biggest- a contest between bigger and bigger power-mongers. WSJ’s Anna Mathews says the future of health care is “blurred” – in the sense hospitals, physicians, are consolidating into bigger and bigger amorphous blobs. So amorphous, it’s hard to tell who is running the show.

If you’re big, amorphous, and dominate a market, you’re harder to push around, even by Big Brother. After all, patients have to get their care somewhere, and if you’re the only game in town, where are patients going to go? And what can government do? If present trends toward consolidation continues, you tend to believe you will have the power to negotiate the best deals. In the end, I suppose it will come down to Trust vs. Anti-Trust, and to the question: will govenrment be able to slay the monstrosities it created?

Anna Mathews of the WSJ describes the power of consolidation in a December 12 Marketplace Section of the Journal in an article entited "The Future of U.S. Health Care," with a subtitle of "The Lines are Blurring Between Insurance Companies, Hospitals, and Other Health-Care Providers."

She points out that:

• the percentage of 800,000 doctors who own their own practices will drop from about 50% in 2000 to 33% in 2013;

• hospitals are “bulking up” by acquiring other hospitals, with the number of acquisition climbing from 35 in 2002 to 82 in 2011;

• big insurers, like Aetna, are creating jointly marketed health plans with hospitals, in essence acting like integrated companies;

• accountable care organizations, made up health-care providers conjoined at the hip, are coordinating the care of defined groups of patients and sharing the savings - 15% of hospitals say they currently have an ACO in place, and that number may grow to 80% BY 2015.

• Insurers are buying health care providers at an accelerating rate.

-- On June 8, 2011, Wellpoint announced it would buy the CareMore Health Group for slightly less than $800 million;

--On August 31 the United Group’s Optum said it would buy Monarch HealthCare, a 2300 doctor association in California;

--On October 24, Cigna disclosed plans to acquire Medicare carrier HealthSpring for $3.8 billion;

--On November 1, Highmark announced a deal to acquire West Penn Alleghany Health System and said it would pump $475 million into the hospital group;

-- On some future date, Humana says it will buy SeniorBridge which provides care for complex chronic conditions.

So It Goes

And so the health care acquisition Merry-Go-Round goes. Where it stops no one knows. As one player observed, “Who knows? Right now, it’s all a blur.”

Building, bulking, bulging, and blurring into big boundary-less behemoths seems to be health care’s Master Plan “B.”

To "B' or not to "B", that is no longer the question.

Tweet: Lines are blurring between insurance companies, hospitals, and doctor groups as they bulk together to cut costs and dominate markets.

Frugal Health Reform Innovation

2011-12-12T11:05:00.010-05:00
He who does not economize will agonize.

Confucius (551-479 B.C.)

Preface: Anthony Regalado, business editor of the MIT Press’ Technology Review (http://www.technology review.com/business/39216) sent me the following article, which will appear in Technology Review today.

The author of the article is Eric J. Topol, Chief Academic Officer of Scripps health. It is an important contribution to the health care innovation debate. Topol is also author of The Creative Destruction of Medicine: How the Digital Revolution Will Create Better Health.

Medicine Needs Frugal Innovation, December 12, Technology Review

A low-cost pocket ultrasound device can see into the human heart. So why do so few doctors use it?

In the history of medical innovation, advances in technology have been inextricably linked to increases in cost. But we are at a unique moment in which the insular world of medicine is about to be penetrated by the remarkable digital infrastructure. Think about the cost of computing. Over the past two decades, cost has been relentlessly reduced while capacity and performance have dramatically increased. How and when can this trend reach the practice of medicine, where costs often go up with little real improvement?

Let's consider the icon of medicine—the stethoscope draped around the doctor's neck or in the pocket of a white coat. Invented by René Laënnec in 1816, the stethoscope didn't see routine use by the medical community for another 20 years. The lag in acceptance reflected the conservative nature of physicians, who objected to having to learn heart sounds and let an instrument get between their healing hands and the patient.

Now, nearly 200 years later, economic forces are greatly slowing the adoption of a powerful replacement for the stethoscope in cardiac medicine. Instead of listening to the heart of a patient, I can now watch it on a device no bigger than a cell phone—a high-resolution miniature ultrasound probe. In fact, in my clinic I have not used a stethoscope to examine a patient's heart for the past two years.

Why would I listen to the "lub-dub" of heart sounds when I can actually see everything relevant about the heart in real time? Exquisite ultrasound images of the heart muscle—showing its contraction, its thickness, the size of the chambers, the valves, the sac around the heart—can all be obtained within seconds as part of a routine physical examination. I can share and discuss the images with the patient as they are being acquired, put video recordings in the electronic medical record, and send them to the patient or referring physician. The up-front cost of the pocket ultrasound device is about $7,700, but there is no extra cost for an unlimited number of readings.

That makes these small devices a formidable challenge to business as usual in American health care. Each year in the United States more than 20 million echocardiograms (ultrasounds of the heart) are performed, and so are a similar number of abdominal and fetal ultrasound examinations. Each of these diagnostic procedures is done in a dedicated laboratory setting, either in the hospital or in a doctor's office, with expensive equipment—and a combined professional and technical charge of $1,000 to $2,000. The math is straightforward. If a pocket ultrasound device were incorporated into routine physical exams the same way we use a stethoscope, several billion dollars in unnecessary charges would be saved each year.

Therein lies the rub—and the explanation for why many low-cost innovations are being held back in medicine. Those savings would represent a critical hit to revenue for doctors and hospitals. It's not just that doctors, like those who refused to use the stethoscope, are intrinsically conservative. The American health-care model of billing "medicine by the yard" creates economic disincentives to cost-saving technology. In contrast, pocket high-resolution ultrasound has been rapidly adopted and hailed as a breakthrough in countries such as India, China, and Brazil.

This represents just a single, simple example of how frugal innovation—the idea of coupling engineering creativity with lower costs—could be achieved if patient care in the United States were not determined by reimbursement rules. We now have wireless sensors that can help us diagnose sleep apnea by capturing all the relevant data for sleep studies—respiratory rate, oxygen saturation of the blood. The data can easily be captured for less than $100, right in a patient's home. But instead, the medical community keeps using $3,000-per-night hospital sleep labs to make the diagnosis.

I believe a great inflection is coming in medicine: advances in technology will finally help us override the reimbursement issue and topple the economic models that physicians, insurers, and hospitals still cling to. This moment will arrive as medicine is opened to the digital infrastructure of mobile wireless devices, pervasive connectivity, ever-expanding bandwidth, cloud and supercomputing power, and the Internet.

Superimposed on these digital capabilities are the ones specific to health care—genomic sequencing, biosensors, advanced imaging, and health information systems. It will all lead to what I call "high-definition man": a panoramic, granular profile of an individual's molecular biology, physiology, and anatomy.

Medicine, in short, has the potential for better technology at a much lower price, but don't look to the medical profession, government, or the life-sciences industry to make the change on its own. I believe the change will come when consumers demand it. The Arab Spring and the Occupy Wall Street movement have shown the influence of social networks as a way to express citizens' demands. Don't be surprised if health care is occupied next.

Fitting and Proper Close

It is altogether fitting and proper that I close with this perverse verse.

When with new technologies, you no longer need a stethoscope,

You can use new technologies as an endoscopic periscope,

To see with what diseases you must cope,

At the other end of the diagnostic rope.

Technologies,unfortunately,can be abused,

And simple human observations underused.

The Great Health Reform Picture Show - As Seen Through Medinnovation's Complexity Lens and Physicians' Eyes

2011-12-12T04:32:00.024-05:00
The Health System, From Top-Down to Bottom-Up, As Seen Through Lens of Cultural Complexity

Substitle of Book, Obama, Doctors, and Health Reform, 2009

December 12, 2011 - One purpose of this blog, which now has 2064 entries over the last 5 years, is to illustrate the complexity of health reform.

Here I have chosen to show how doctors react to reform's complexity by showing what they are reading in the Medinnovation blog.

What follows are the top ten Medinnovation blogs read by doctors over the last 36 months.

As you read the title of these ten blogs, keep in mind that the Accountable Care Act, aka Obamacare, passed 20 months ago on March 23, 2010. One of these blogs, preceded the ACA, nine occurred after its passage.

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

May 23, 2010, 2537 Hits

This is by far most visited blog, by a factor of 2.5:1. The goals of universal physician/hospital EHRs are to document, monitor, control, and decide how to pay for tens of billions of annual patient-doctor-hospital transactions through the miracle of Health Information Technologies.

Achieving these goals is powered by $27 billion federal dollars and complicated by 186 EHR companies vying for the business. Practice Fusion Inc has grown 7-fold to 130,000 physician-users over the last year by simplifying EHR installations, transactions, use, and price. Practice Fusion is just one of these EHR companies. Other EHR firms are also growing rapidly.

Doctors know EHRs are inevitable but are waiting to see how effortlessly, cheaply, effectively, and efficiently they can get on the right side of the Digital Divide without disrupting their practice or losing revenue while still qualifying “meaningful use” bonuses.

2) Interview, physician Shortage - Interview with Richard "Buz" Cooper, M.D., Professor of Medicine at the University of Pennsylvania

Jan 24, 2009,1,194 Hits

This is an interview with “Buz” Cooper, MD, U Penn professor of medicine, who predicted large doctor shortages long before anyone else. In the interview, he gives reasons for the shortage. Cooper says health reform is on a collision course with shortage of doctors. Contrary to popular belief,engendered by Dartmouth Institute that provider greed leads to regional differences in Medicare costs, Cooper believes highest costs occur among poorest patients, whose costs are high care because prevention,diagnosis, and treatment are often neglected until late in disease.

3) Primary Care Revolt: Replace the RUC

Apr 17, 2011, 1107 Hits

This is an under-the-radar account of a revolution going on out there. It is a revolt of primary care physicians against the AMA and CMS. It is a request for parity with specialists. It is a movement to replace how primary care practitioners are paid. The RUC, Reimbursement Update Committee, or the Relative Value Reimbursement Value Committee, is dominated by specialists. These specialists, say the Primaries, ovwerwhlmingly set Medicare fees for doctors. RUC is a creature of the AMA. CMS endorses its decisions over 90% of the time. Primary care societies claim RUC fee schedule favors specialists and says its list of members should be reconfigured to give primary care specialists more of a voice.

4) The Low Value of Primary Care Doctors in Eyes of Patients

Jul 1, 2010, 971 Hits

Sometimes it is painful to discuss the obvious, especially when the obvious goes against your grain. But here goes. Primary care is in a bad way. Only 2% of medical students are picking primary care specialties. The number of primary care doctors is dropping. And over 90% of costs stem from specialty care. Primary care disarray, unhappiness, and low morale comes from these obvious causes : low reimbursement, long work hours, and as Rodney Dangerfield, might say, “We get no respect.” This in face of the fact that policy types and payers, like IBM, are calling for a rejuvenation of primary care as the salvation of American medicine with its cost, coordination, care improvement, and efficiency problems.

5) The Future of Accountable Care Organizations

Jan 26, 2011, 607 Hits

This was an interview with Bill DeMarco, a health care consultant for more than 30 years and an advisor on Accountable Care Organizations (ACOs). The subject of Accountable Care Organizations (ACOs) accounted for only 10 pages of the 2700 page health reform bill. Yet ACOs were then the buzz, the rage, the hottest 3-letter acronym since sliced bread, and the most talked about subject in hospital board rooms, medical staff lounges, and the medical talk circuit, and consultant enclaves. I am cautiously pessimistic about the future of ACOs. My views on ACOs are available in an e-book , Pros and Cons of Accountable Care Organizations (www.practicesupport.com).

6) Comments on Yesterday’s Value (Outcomes/Cost) Blog

Dec 31, 2010, 474 Hits

I posted this blog on the value of measuring outcomes of various diseases based on cost. The Health Care Blog, probably the most widely read of blogs pertaining to health care policies, reran my piece. In my blog,I expressed skepticism about the practicality of value determinations based on outcome measurements on a broad scale across the medical care spectrum. I closed with these questions. Here are the comments from readers of The Health Care Blog.

I ended my blog with these questions.

1. Is overall health care value measurable?

2. Are the organizational, societal, and individual costs required to make this value measurement worth it?

3. Will the measurement of value unify ideological factions competing to advance the cause of health reform?

I had my doubts.

7) Why Doctors Don't Like Electronic Health Records

Oct 7, 2011, 455 Hits

On September 27, 2011, An article of mine appeared in the Technology Review, an MIT Press publication. The Health Care Blog, the most widely read health blog, reran it on October 9, and it immediately drew 26 responses.

Here is the gist of the article.

A physician argues that electronic patient records raise costs, decrease patient visits, and make poor communication tools.

Why are doctors so slow in implementing electronic health records (EHRs)?

The government has been trying to get doctors to use these systems for some time, but many physicians remain skeptical. In 2004, the Bush administration issued an executive order calling for a universal "interoperable health information" infrastructure and electronic health records for all Americans within 10 years.

And yet, in 2011, only a fraction of doctors use electronic patient records. There at least 10 good reasons doctors resist EHR use.

8)Health Reform: Look at Massachusetts First

May 2, 2011, 347 Hits

If you doubt the likely effects of health reform on health care, says Kevin Pho, MD, in its widely-read blog, Kevinmd.com, "Look at Massachusetts first." In its stab at universal coverage, now four years old, Massachusetts has seen these consequences: overcrowded ERs, longer waiting times to see doctors, more than 50% of primary care doctors closing practices to new patients, and the highest health care premiums in the nation.

So much for lowering health costs and expanding access. And all of this in state with more primary care physicians per capita than any other state, in a state with fewer uninsured than any other state, and in a state with an individual mandate and a health plan said to be a model for Obamacare.

These, of course, all factors in Mitt Romney's baggege as a Republican Presidental candiate. He must explain to conservatives and the public at large the rationale of his support for the individual mandate and why and how Romneycare differs from Obamacare, His answer is that ech state is entitled to its own brand of health care, and the people of Massachusetts like their plan by a 3:1 margin.

9) Accountable Care Organizations (ACOs): California or Bust.

Sept 16, 2010, 1 268 Hits

I am skeptical in this blog about the futue of ACOs.

Why was I skeptical?

I suppose one reason is that I have been down the road before as a founder of the Physician Hospital Care Organization, later the Integrated Care Organization, in the 1990s, both now defunct because of mutual physician-hospital distrust and conflicting competitive goals.

Secondly, California’s business and health care climate, politically and in health care, are not representative of the U.S. as a whole.

Thirdly, California is a budgetary basket case, with a budget deficit of $20 billion.

Fourthly, I am dubious of the Congressional Business Offices estimate that ACOs will save $4.9 billion over 10 years through a limited pilot program.

I may have been wrong, but, given the complexity of the final ACO rules, enthusiasticlly endorsed by CMS administration by CMS Administator Donal Berwick, before Republicans forced his resignation, and almost universal rejection by the hospital, physician, large health system communities, there was room for skepticism.

10) Doing Better and Feeling Worse: Why Aren't Doctors Feeling Better About The Future?

Nov 29, 2010, 231 Hits

Why, if health care will be the next engine of growth and will consume ever more of the GDP, are doctors feeling so glum about the future? If you doubt how they feel, I invite you to read Health Reform and the Decline of Physician Private Practice (Merritt Hawkins. October 2010).

This feeling of dread is not new. In 1977, John Knowles, MD, a Massachusetts General internist who became the President of the Rockefeller Foundation, edited a book Doing Better and Feeling Worse: Health in the United States (W.W. Norton and Company).

The problem then, as now, was the system was doing better in improving health outcomes but doing worse in controlling costs, and many of the bad things, in both the economic and health realms, that happen to people were beyond the reach of medicine. The health system didn’t have all the answers.

To take a leading example, why can’t we contain demand and control health costs?

That, of course, is this year’s $2.7 trillion question - the estimated cost of the ACA from 2014 to 2024.

According to Regina Herzlinger, PhD, a tenured professor at Harvard Business School, the problem is we don’t let consumers, spend their own money. pick their own providers, drive the system.(Who Killed Health Care? America’s $2 Trillion Medical Problem – and the Consumer-Driven Cure (McGraw Hill Companies, 2007).

Dr. Herzlinger identifies the five “killers” of a consumer-driven system as:

1. Health insurers, who insure the death of cost control through their dysfunctional culture.

2. General hospitals, which kill cost-control through their building of centralized. Ever-expanding empires of care.

3. Employers, who doom consumerism because they generally give their employees the “choice” of only one plan.

4. The U.S. Congress, who spur cost growth through lavish entitlement program riddled with fraud, abuse, and overuse.

5. Academics who contribute to the death of consumerism because of their elitist, technocratic, superior attitudes.

“Sadly, “comments Herzlinger, “on the federal government level, representatives from Republicans and Democrats have quaffed deeply form the Beltway Kool-Aid well. Neither believes in the power of innovators and consumers to reshape markets. Neither is in the-small-is-beautiful camp. Both believe the more oversight of health care by the government and academies is the solution. Both believe that big-is-beautiful.”

She goes on, “The federal government has not only specified what should be measured but also the protocols that health care providers must follow. These monopolistic powers are cloaked in the pseudoscientific mantle of ‘evidence-based.” The title implies that the guidelines are shaped by intelligent saints devoid of a shred of self-interest or vanity, guided only by ‘evidence’”

Small wonder doctors are glum. Everyone else, other than themselves and their patients, think they know what is best about the practice of medicine and the health care business. The health reform law effectively squelches health savings accounts which encourage consumers to shop for what they consider to be the best deal and doctors to compete for the consumers’ dollar. Rules and regulations forbid doctors to creatively re-design their practices and repackage their services. Medicare laws prohibit patients and doctors from privately contracting with each other. Prices keeps rising as regulations keep growing.

Medicine, it seems, is too important to be left to doctors and consumers. Trust us, is the mantra. We’re from the government and other large institutions, and only we know what is good for you and yur health.

Tweet: Health reform is fiendishly complex. I offer these 10 most widely read Medinnovation blogs as evidence.

Health Reform Blogs, Fishes in the Sea, and Needles in Haystack

2011-12-11T06:00:00.006-05:00
Findability is a term for the ease with information contained on a website can be found, both from outside the website (using search ) and by users already on the website.

Wikipedia

December 11, 2011 - How hard is it to find something on health care reform or innovation on the Net?

It isn’t easy. Consider the number of results listed on Google for the Internet containing information on:

• Health care reform, 192 million

• Health care innovation, 5 million

• Health care findability, 800,000

Finding health reform Internet information is a little like finding a specific species of fish in the ocean (230,000 species at last count), or a needle in the Internet blog haystack (70 -100 million blogs and doubling every 6 months).

So how do you assess the “findability “ of your blog?

According to clickz.com, you follow this formula.

One point for 5 keywords for your blog on first result page for top five major search engine blogs: Google, Yahoo!. Bing, Ask, and Aol.Search.

If, for example, the keywords for medinnovation were:

• Medinnovation/ehrs,

• Medinnovation/ health reform,

• Medinnovation/health innovation,

• Medinnovation/physicians,

• Medinnovation/hospitals,

Medinnovation would have 237 points.

According to clickz.com, this would give Medinnovation a high rating.

Points Ratings

200+ Yes, Master!

100-199 Extraordinary

50-99 Target Zone

20-49 Good

0-19 Thank God,we found you!

Of course, by putting medinnovation in front of the subject matter of my blogs, I have stacked the odds in favor of finding my blog in the Internet haystack.

But so what? I only have one fish to fry, one fish in the Net, one fish in giant kettle of blogs, and one fish in the sea of the blogosphere.

In closing,

Needledum and Needledee

Agreed to tattle about the Internet battle!

For Needledum said Needledee

Has put his blog too high in the Blogosphere saddle.

Tweet: To find how to find health reform information on EHRs, reform, innovation, physicians, and hospitals, read 12/11/11 medinnovation blog.

My Top Ten HIT Parade

2011-12-10T10:28:00.003-05:00
“What are the bugles blowin’ for?” said Files-on-Parade.
“To turn you out, to turn you out,” the Color-Sergeant said.

Rudyard Kipling (1865-1936),Ballads and Barrack Room Ballads(1892-1893)

December 10, 2011 - For the uninitiated among you and those of you on the other side of the Digital Divide, HIT stands for Health Information Technologies.

The Top Ten HIT Hits

1. Practice Fusion Update: “Free” EHRs and “Cloud Com... December 5, 2011, 65 Hits

2. Consequences of 2012 Elections on Health Reform…December 3, 2011, 42 Hits

3. Health Reform Christmas Books, December 8, 2011, 34 Hits

4. Is Practice Fusion’s “Free” EHR for Real?...May 23, 2010, 30 Hits

5. The Physicians Foundation Helps Poor Find Social Services ...December 8, 2001. 30 Hits

6. Book Review: Keys to EMR/EHR Success: Selecting and Implementing... December 7, 2011, 28 Hits

7. Differences between Health Care and Medical Care…April 22, 2009, 26 Hits

8. Cleveland Clinic Unveils Top 10 Medical Innovation... November 22, 2011, 25 Hits

9. Hospital Systems Enter Walk-In Markets…November 22, 24 Hits

10. Book Review: Time to Sell? Guide To Selling A Physician Practices ... December 6, 2011. 21 Hits

Tweet: Today's medinnovation blog shows its top ten hits.

Addition to Christmas List of Health Reform Books

2011-12-09T13:30:00.002-05:00
Edgeware is a thinking approach. This is not a program that you roll out in organizations with banners and coffee mugs. It is a new way of thinking and seeing the world – and, hence, a new way of working with real organizational and health care issues.

Edgeware: Insights from Complexity Science for Health Care Leaders, by Brenda Zimmerman, Curt Lindberg, and Paul Pisek, VHA, Inc, 1998

December 9, 2011- When I suggested a list of Christmas health care books in yesterday’s blog, I forgot to mention one of my favorites, Edgeware.

Edgeware is a 1998 paperback of 228 pages. You can buy it new on amazon for $26.49 and used for $4.69.

No, Edgeware is not about kitchen knifeware. It’s about health care’s complexity. It’s about taking and handling risks at care’s cutting edge.

Though Edgeware predated the health reform law by a dozen years, Edgeware's lessons apply to dealing with complexities at the edges of today’s health law.

Edgeware sets forth these principles.

• View your system through the lens of complexity – Health organizations are not like a machine or military organization. Reform is about dealing with complex, often fickle, human beings.

• Build a good-enough vision with minimum specifications - The government’s mistake is trying to implement a sweeping vision with maximum specifications. This mistake may bring down ACOs, EHRs, and the IPAB Indepedent Payment Advisory Board),

• When life is far from certain, lead from the edge. Balance, intuition, planning, and risk, giving honor to each. Government reform tries to lead from the center and gives no honor to what is intuitively wrong at the edge.

• Tune your place to the edge, fostering the “right” degree of information flow, diversities and differences, with power considerations inside and outside the organization – Don’t try to control everything, deal separately with contentious groups, seeking comfort with each.

• Uncover and work with paradox and tension – These are natural with sweeping reform. Live with them.

• Go for multiple actions at the edge- rather than being absolutely certain before you do anything. Uncertainty is the name of the reform game. Health care uncertainties are a big reasons businesses don't hire.

• Listen to the shadow system- gGossip, informal relationships, rumors, and hallway conversations – They are powerful and may dictate future actions.

• Grow complex systems by chunking – These systems emerge from links of simple systems that work well independently.

• Mix cooperation and competition - This will always be true with hospitals and physicians. You cannot force competiton. It doesn’t work.

Tweet: Health reform follows the principles of complexity science. Learn how to adapt to complexity by reading the book, Edgeware.

The Physicians Foundation Helps Poor Find Social Services

2011-12-08T11:45:00.001-05:00
For the poor always ye have with you.

John 12:8

December 8, 2011 - 'Tis the season to turn our thoughts to the poor, and what we can do for them, short of massive government welfare programs.

These thoughts on the poor have not escaped the attention of John Commins, an editor of HealthLeaders Media. He wrote a piece today called, “Primary Physicians Link Social Barriers to Poor Health." In it, he cited an online survey of 1,000 primary care physicians, including 310 pediatricians, on behalf of the Robert Wood Johnson Foundation.

The survey found that:

• 85% of physicians say unmet social needs are directly leading to worse health for all Americans.

• 85% of physicians say patients' social needs are as important to address as their medical conditions. This is especially true for physicians (or 95%) serving patients in low-income, urban communities.

• 76% of physicians want the healthcare system to cover the costs associated with connecting patients to services that meet their social needs if a physician deems it important for overall health.

• Only 20% of physicians feel confident or very confident in their ability to address their patients' unmet social needs.

• Physicians said that if they had the power to write prescriptions to address social needs(italics mine) these would represent 1 out of every 7 prescriptions they write— or an average of 26 additional prescriptions per week.

These findings will come as no surprise to the Physicians Foundation, a charitable 501C3 organization representing at least 500,000 physicians in state medical societies.

On May 13, 2011, I wrote the following blog, which I reprint in full, on a $1 million grant to Health Leaders, Inc, addressing to the very needs of the poor the survey describes, especially the bit about what physicians would do if they had the power “to write prescriptions to address social needs.”

In 22 pediatric and prenatal clinics, newborn nurseries, emergency rooms, and community health centers in six cities across the U.S., physicians now have that power – a power that is likely to spread as Health Leads expands to other cities across the land, thanks to generosity of the Physicians Foundation and the physicians it represents.

May 11, 2011 Medinnovation Blog

The Physicians Foundation Awards $1 Million Grant to Health Leads

Yesterday the Physicians Foundation, a charitable organization representing physicians in state medical societies nationwide, put its money where its heart is.

The Foundation awarded a $1 million grant to Health Leads, a Boston non-profit to help it expand from its current base of six cities to other locales across the land.

The Physician Foundation-Health Leads collaboration is a natural partnership. Both the Physicians Foundation and Health Leads are organizations who think “outside the box” to help vulnerable citizens find resources outside the mainstream of care.

Physicians often find themselves trapped in a box, unable to help patients find food for their stomachs, heat for their homes, transport to medical facilities, jobs to supply the money to pay for care, decent homes in safe neighborhoods. These basics are simply beyond the reach of the current health system or the current reforms designed to improve care.

Health Leads works in 22 pediatric and prenatal clinics, newborn nurseries, emergency rooms, and community health centers in six cities across the U.S. Last year, Health Leads trained and deployed 660 college volunteers to connect nearly 6,000 low-income patients and their families to the resources they need to be healthy. By providing a transformative experience for hundreds of college volunteers, Health Leads is producing a pipeline of new leaders who will have both the conviction and the skills to transform health care from the bottom-up.

How does Health Leads make this transformation possible ?

• One, by giving doctors the power to “prescribe” food, shelter, job training, and transportation by writing prescriptions to find these resources.

• Two, by recruiting college volunteers to serve at Health Desks in various health care settings to direct patients and families to community resources, in the process serving as a training ground for health careers and as a sort of domestic Peace Corps.

In the hospitals and health centers where Health Leads operates, doctors can “prescribe” food, housing, or other critical resources—just as they would medication. Patients take their prescriptions to the clinic waiting room, where Health Leads’ college volunteers are ready to connect them to these resources. Nearly 60 percent of Health Leads patients secure at least one critical resource – receive food, get their heat turned back on, find a job – within 90 days of getting their “prescription.” All patients receive ongoing follow-up until their needs are met.

“As we continue to identify new ways to enhance healthcare delivery, we are extremely proud to fund the ongoing efforts of Health Leads,” said Dr. Walker Ray, Vice President of The Physicians Foundation and Chair of the Research Committee. “In a system that is massively overburdened by strained resources, innovative models that foster collaboration between college volunteers and physicians can have real impact on our nation’s healthcare.”

The Physicians Foundation’s funding will help Health Leads expand its operational capabilities, allowing the organization to serve significantly more patients. By developing an information technology infrastructure to enhance tracking of patient outcomes and by hiring additional program managers and staff, Health Leads will be able to deepen engagement with physicians and clinic partners.

“Health Leads is grateful for the assistance of The Physicians Foundation in helping us to build the capacity we need to scale our program model over the next four years. Since we received their funding, we have been able to serve more than 2,600 patients, putting us on track for an increase of more than 60 percent over last year,” said Rebecca Onie, Co-founder and Chief Executive Officer of Health Leads.

“We have also launched discussions to build an evaluation partnership with the Mayo Clinic Center and rolled out a new client database to all of our sites that will enable us to better track and report client outcomes. The Foundation's support has been invaluable in helping us make significant progress on these strategic goals."

Tweet: The Physicians Foundation, a doctor organization, has awarded a $1 million to Health Leads, to help patients find food, housing, & jobs.

Health Reform Christmas Books

2011-12-08T07:31:00.010-05:00
Some books are to be tasted, others to be swallowed, and a few to be chewed and digested

Francis Bacon (1561-1626), Essays

December 8, 2011 -These are books I recommend as gifts for those engaged in health reform. I have written some of them. I know the authors of most of them. I have read all of them.

1. Obama, Doctors, and Health Reform. Richard Reece, 290 pages, IUniverse, 2009, paperbck. $17.12, Ebook $9.99,1-800-228-4467, or amazon. A doctor’s prediction on odds for success of health reform.

2. In Their Own Words: 12,000 Physicians Reveal Their Thoughts on Medical Practice, Philip Miller, Louis Goodman, Tim Norbeck, soft cover, 2010, $11.66. What doctors really think about health reform.

3. Doctor in the House: A Physician Turned Congressman, Michael Burgess, hardcover,2010, $16.43. A view from top-down from someone who has practiced from bottom-up.

4. Sailing Seven “Cs” of Hospital Physician Relationships, James Hawkins and Richard Reece, paperback, 68 pages, $17.95. What practice and hospital-doctor relationships looked like before we had Accountable Care Organizations.

5. The Health Reform Maze: A Blueprint for Physician Practices, Richard L. Reece, 290 pages. Greenbranch Publishing , 800-933-3711, $48.50. Describes the way it is, fiendishly complicated, not the way it ought to be, understandable for ordinary mortals.

6. Innovation-Driven Health Care: 34 Concepts for Transformation, Richard L. Reece, 375 pages, hardcover, Jones and Bartlett, $101.95. It’s never too late to innovate.

7. The Heart of Power; Health and Politics in the Oval Office, David Blumenthal and James Morone, 2009, hardcover, $35.17. The view from Massachusetts General and Harvard Medical School.

8. Remedy and Reaction: The Peculiar American Struggle for Health Reform, Yale U. Press, 324 pages, 2011,hardvoer, $17.49. A balanced book by long-time advocate for reform.

9. Inside National Health Reform, John McDonough,California Milbank books, 2011, hardcover, 339 pages, $22.60. By a Democratic insider.

10. Why Obamacare is Wrong for America, Grace-Marie Turner et al, Broadside-Harper Collins, 259 pages, 2011, paperback, $10.94. How health care law drives up costs, puts government in charge, and threatens constitutional rights.

11. The Truth about Obamacare, Sally Pipes, Regnery Publishing, 2011, paperback, 274 pages, $6.28 paperback, $8.23 Kindle, By a passionate Canadian expatriate who is president and CEO of Pacific Research Institute.

12. Health Care Reform Now! A Prescription for Change, George C, Halvorson, John Wiley & Sons, 2007, 361 pages, hardcover, $16.28. By CEO of Kaiser, a systems thinker and supporter of structural change.

13. Time to Sell? Guide to Selling a Physician Practice: Value, Options, Alternatives, Randy Bauman. 2011, 124 pages, $86.50, Greenbranch Publishing, 800-933-3711. Important because reform pressures are driving physicians out of practice into the arms of hospitals.

14. Road to Reform; The Future of Health Care in America. Eli Ginzberg, The Free Press, 216 pages, 1994, $4. A reminder that more things change the more they remain the same by a veteran of failed Clinton reform.

15. And Who Shall Care for the Sick? The Corporate Transformation of Health Care in Minnesota, Richard L. Reece, 278 pages, 1988, $46.97. A blast from the past by one who was present at the birth of United Healthcare and who predicted doctor shortage.

16. Consumer-Driven Health Care: Implications for Providers, Payers, and Policymakers, Regina Herzlinger, 2004, 892 pages, 43.33, This is still the bible of those who espouse market-driven reform.

Tweet: Christmas is wonderful time to give thoughtful gifts, especially if those gifts require thought.

Book Review: Keys to EMR/EHR Success: Selecting and Implementing an Electronic Medical Record, second edition, by Ronald B. Sterling, CPA, MBA, Greenbranch Publishing, 2011,292 pages, $139,1- 800-033-3711

2011-12-07T12:26:00.001-05:00
It ain’t over until the Fat Lady sings – until the EHR is installed, functioning, supported, useful, and showing positive results with patients and doctors.

Veteran Physician EHR User

December 7, 2011 - Among technology advances, none is more complicated or uncertain than selecting and implementing electronic medical records.

In 2004, President Bush committed the nation to universal EHRs. The aim, then, as now, was to develop electronic tools to pay physicians based on outcomes, quality, coordination of care, and wellness, rather than just on volume.

According to John Hamalka, MD, CIO at Harvard Medical School, EHRs are essential if the nation is to address “waste”- overtreatment, insufficient coordination of care, excessively complicated administration, overly burdensome rules, and fraud (“The Promise of Electronic Health Records,” Health Care Blog, December 6, 2011). One way to do this, asserts Hamalka, is to compare physician performance electronically.

Unfortunately, a 2011 CDC survey indicated that in 2010 only 10.1% of physicians had “fully functional EMRs/EHRs.” Margalit Gur-Arie, an HIT expert, speculates fully-functioning EMRs will double to 20% in 2012, but no one knows for sure.

One factor driving EHR adoption is the federal government’s “meaningful use” initiative. This initiative will pay physicians a 2% bonus for implementing EHRs and impose a 2% penalty for not adopting EHRs, if doctors comply with a series of complicated rules.

Whatever transpires, selecting an EHR, implementing, living with it, and maintaining it remains a complicated, prolonged, and expensive process.

Enter the book Keys to EMR/EHR Success,Selecting and Implementing an Electronic Medical Record, by Ronald Sterling President of Sterling Solutions, Ltd (www.sterling –solutionns.com). The author’s goal is to help physician practices capitalize on technology to improve patient service, clinical operations, and financial results.

The book’s thesis is that physicians underutilize computer systems. At the same time, Sterling recognizes that installing EHRs is a complicated process requiring checklists, understanding of what’s involved, meeting staff, physician, regulatory, and procedural requirements, and negotiating fine print issues.

His message is: nothing worth doing with EHRs is easy. It takes hard work and systematic analysis.

The complexity of the EHR task is reflected in the book’s 12 chapter headings.

1 – Should I Invest in an EHR?

2 – Evaluating an EHR Investment

3 – Your Practice Management System and an EHR

4 – Compiling a Practice Focused List

5 – EHR and Malpractice Risk

6 – Selecting Products to Review

7 – Reviewing Products for Your Practice

8 – Making a Final Decision

9 – Negotiating a Contract

10 – Implementing an EHR

11 – Activating an EHR

12 - Supporting an EHR

Appendix: List of EHR Vendors.

The list of 186 EHR vendors contains vendor phone numbers and websites. The list will be useful to physicians considering purchasing an EMR system.

Readers will find the chapter on “Negotiating a Contract” fundamental and essential, It addresses the nitty-gritty of what can go wrong in a practice of your size and characteristics. In a 17 page table, the author recommends what to ask for and to specify.

My suggestion for the next edition would be that it more fully discuss physician negative experiences with EHRs and obstacles to EHR use, and that it highlight recent advance and refinements – such as speech recognition entry into EHRs; new business models, such as EHRs made “free” through advertiser’s support, and EHR support for physicians facilitating meaningful use adoption.

Tweet: Keys to EMR/EHR Success is a useful book for physician considering installing EHRs in their practices.

Home Monitoring to Cut Hospital Readmission Rates

2011-12-07T08:39:00.001-05:00
One’s home is the safest refuge.

Anonymous

December 7, 2011- I was speaking yesterday to a consultant for troubled hospitals. She told me community hospitals are in dire financial straits.

One reason, she explained, was financial penalties CMS being imposing on hospitals for readmissions taking place less than 30 days after discharge. Many of these readmissions occurred because of preventable complications occurring in homebound patients.

Hospital CEOs said they did not have human or technological resources to monitor these patients at home.

I pointed out that companies like American Telecare in Minneapolis had developed audiovisual devices transmitted over ordinary phone lines in which patients could monitor themselves. These devices had significantly sslashed readmissions. Yes, she said, that's true, but those devices had to have medically trained personnel on the other end responding to the patients, and that cost money hospital did not have.

So goes the debate over remote monitoring. On the other side of the hospital-home divide is the argument presented by the Home Care Technology Association of America, as reported by Jessica Marcy in in yesterday’s Kaiser Health News

“Home care technology can play a critical role in keeping patients out of hospitals and at home, but many providers believe new policies should be used to encourage its adoption.

Advocates for those changes were on Capitol Hill yesterday to push for legislation that would expand the use of such technology, which allows home health agencies and nurses to remotely monitor a patient’s vital signs, like heart activity and blood pressure, and be able to flag troubling symptoms before they become medical emergencies.

Such technology is important as people live longer with more chronic conditions and seek to stay in their homes, the advocates told congressional staff at a presentation sponsored by Philips Healthcare, the National Association for Home Care and Hospice and the Home Care Technology Association of America. It also could be critical as Medicare prepares to penalize hospitals next year for frequently readmitting patients within 30 days for heart failure, heart attacks and pneumonia.

'We have to come up with other solutions to manage these chronic conditions outside the expensive acute care setting,' said Mark Szewczyk, the general manager of remote patient monitoring at Philips Healthcare, a company that provides diagnostic, treatment and preventive care products including many for home health. 'Telehealth and remote monitoring are really going to be solutions in the future. The reimbursement and policy piece is what we’re waiting to catch up.'

Medicare and most private insurers do not reimburse for home health care technology despite its increasing use among providers. Legislation pending in Congress seeks to expand the use of telehealth under Medicare by providing incentives to home health agencies that use it in rural and underserved urban communities and can demonstrate savings. Sen. John Thune (R-S.D.) introduced the Fostering Independence Through Technology (FITT) Act last March with eight co-sponsors.

The bill creates pilot programs and other implementation procedures for efforts to demonstrate health savings and performance targets.

Participants at the event are pushing for its passage this year, believing it might be likely as more lawmakers seek bipartisan cost-saving solutions.

'You wouldn’t need a FITT Act if Medicare wasn’t out of sync with today’s medical needs,' said Suzanne Mintz, president and CEO of the National Family Caregivers Association. 'The fact that Medicare doesn’t cover it is a sign that Medicare was designed as an acute care program for people who didn’t have many years to live.'

About 90 percent of seniors have at least one chronic condition and about 77 percent have two or more, according to Szewczyk.

Home health agencies are increasingly investing in such technology despite limited resources and the lack of reimbursement because they believe it will provide future cost savings. Telehealth sales are growing at an average of about 35-40 percent a year, Szewczyk said.

Speakers at the Hill meeting also noted the support that such systems can provide to patients and their families. 'Family caregivers, despite their numbers, feel very isolated,' Mintz said. 'The idea of being connected to a nurse who can react on the spot … has a very powerful effect.' “

Tweet: Remote home health monitoring devices can help reduce hospital readmissions, thereby decreasing financial penalties on hospitals.

Book Review: Time to Sell? Guide To Selling A Physician Practice: Value, Options, Alternatives, 2nd edition by Randy Bauman, Greenbranch Publishing, 2011, 124 pages, $86.50

2011-12-06T11:07:00.007-05:00
Trends, like horses, are easier to ride in the direction they are going.

John Naisbitt, author of Megatrends (1982) and Mindset! (2006)

December 6, 2011- Every once a while, a book on the nuts, bolts, and realities of current physician trends catches my eye and hits my gut.

A Time To Sell? is such a book. The author, Randy Bauman, is president of Delta Health Care. For 25 years, Bauman has advised physicians and hospitals on how to ride current trends.

What impresses me about the book is Bauman’s gift of getting to the meat of the matter – the Whys, Whats, and Whatnots in the headlong horse race of physicians to sell to hospitals. There is no horsing around here. He accurately describes the trends and mindsets of physicians and hospitals as they race to reach deals to survive pressures of health reform.

Here, for your consideration, are quotes from the book:

• ”The trend is unmistakable – physicians continue to sell their practices at a feverish pace. In my role as a practice consultant, I can tell you this trend is taking on tsunami proportions. “

• “I see more and more physicians disillusioned with private practice they are reconciled to selling or merging their practice, and making the best deal they can.”

• “One physician hit the nail on the head when he told me,’I always have to remind myself that’s it never as good as it seems on the best days and never as bad as it seems on the worse days. That’s how I keep my perspective.”

• “In many ways, what happens as physicians sell their practices to hospitals is analogous to a shotgun wedding in which both parties rush down the aisle without sufficient time to plan their life together. And that is where the trouble begins. The reality sets in soon afterward that what has been created is an unmanageable monster.”

The book is more than sound bites. It consists of 10 chapters on what to expect, what to do, what not to do, and what items to check off before you do a deal.

The 10 chapters, with takeaway points at the end of each chapter are:

1. Why Sell?

2. Preparing Your Chapter for Sale

3. Choosing the Right Hospital Partner

4. Valuation – What is Your Practice Worth?

5. Compensation

6. Deal Structure

7. Negotiations

8. Operational and Post-Sale Issues

9. Making It Work

10. Options Other Than Selling

Tweet: Before physicians sell their practices to hospitals, they should stop to consider: this may not be a deal made in heaven.

Practice Fusion Update: “Free” EHRs and “Cloud Computing” Are for Real

2011-12-05T06:44:00.009-05:00
What is reasonable is real, that which is real is reasonable.

Georg Wilhelm Hegel (1770-1831), Philosophy of Right (1821)

December 5, 2011 - Twenty months ago, May 23, 2010 to be precise, I wrote a blog “Is Practice Fusion's ‘Free’ EHR for Real?” In the blog, I described the economic model of Practice Fusion, a San Francisco-based startup.

From the physician’s point of view, Practice Fusion’s model was reasonable, it had advertisers instead of physicians pay for the EHR, no installation of hardware was required at the practice site, physicians could use their own computers for data entry, physicians did not need to learn the ins and outs of software, and computing was conducted offsite in “the cloud,” i.e., offsite,by Internet browsers.

In the words of Practice Fusion’s CEO, Ryan Howard,

“The product is provided to physicians fully subsidized. It’s not a “take now, pay later” or get half of the product now and then pays for the rest of it. Every feature that’s included with the product in any capacity is offered at no cost, so it’s truly free. It’s offered with support, training, and hosting. It’s the only totally free model on the market.”

The beauty of it was that you could use your own computer and somebody else – people and businesses who wanted access to physicians to sell them products – paid the freight for the EHR. In other words, someone else, not physicians, was paying the bill, thus removing expense, one of the major obstacles to EHR adoption.

I was skeptical of Practice Fusion's approach, but open to persuasion. At the time, Practice Fusion was fairly far down the line of EHR vendors physicians used.

Vendor Physician Users Practices Used in 2010

Epic 45,000
AllScripts 40,000
eClinicalWorks 40,000
GE Centricity 35,000
NextGen 35,000
SOAPWare 30,000
Practice Fusion 18,500
Eclipsys 11,000
Sage Health 10,000 .
Greenway Medical 6,000

I do not know where Practice Fusion ranks now, but it has moved up. It now has 130,000 physician-users, serves 25 million patients, and has 130 employees. It has experienced a 7-fold increase in business.

Practice Fusion has venture capital money, which always helps with a rapidly growing company. Its venture capital investors - Felicis Ventures, Glynn Capital Management, Founders Funds, Western Technologies, Artis Capital Management, Morganthal Ventures, and angel investor, Scott Banister, have invested more than $36 million in Practice Fusion.

Why do these investors have such faith in Practice Fusion?

I suspect there are four main reasons.

• The future belongs to high-speed, wired Internet in physicians’ offices. You can no longer practice without the Internet. More than 90% of physician practice have high speed access, and they are adopting smart phone and other mobile apps at breakneck speeds. Moreover, young physicians come from a generation accustomed to video games and IT applications, and they are reluctant to join any practice that does not have an EHR.

• “Cloud computing,” defined as delivering computing as a service rather than a product ,whereby shared resources, software, and hardware are provided over a network (like the electricity grid), is catching on fast. Physicians are not necessarily interested in mastering nuances of software and hardware or in installing and being trained in their use. They just want to “plug in” into a system, get results, do business, grow, and prosper.

• The U.S. government is putting up $90 million, at $44,000 per physician, in the form of financial incentives if doctors use EHRs that met “meaningful use criteria.” Practice Fusion has developed a systematic approach, which consists of a lot of hand-holding and support, to help doctors qualify for meaningful use bonuses.

• EHRs, through a combination of vendor companies like Practice Fusion offering “free” or “low-cost” services and modifications of existing EHRs using more sophisticated voice recognition and patient entry software are making EHRs more user-friendly and useful to use. Furthermore, a whole new IT industry sub-sector has sprung up – companies training and introducing “scribes” into physician practices. These scribes, often aspiring young people interested in a medical career, enter the patient’s data and history and record the physicians findings, in the process humanizing EHRs and making them more practical to use.

Tweet: EHR vendors, like Practice Fusion, are growing fast by offering “free,” low-cost, government subsidized wireless Internet services.

Doctor Donald Berwick's Parting Shots

2011-12-04T13:06:00.005-05:00
The mind travels faster than the pen; consequently writing becomes a question of learning to make occasional wing shots, bringing down the bird of thought as it flashes by.

E.B. White, The Elements of Style, Macmillan, 1992

December 4, 2011 - As I read the title of Robert Pear’s NYT’s piece, “Health Official Takes Parting Shot at ‘Waste”, I thought of E.B. White’s comment on style.

Like White, Donald Berwick, forced to resign this week by Republican opposition as administrator of CMS, is a notable and quotable stylist. He has written a number of memorable books and speeches filled with eloquent thoughts- pro-government, pro-patient, pro-hospital safety, and anti-market - which he says were wrongly used against him.

His admirers consider him the American health system’s potential savior; his critics as its potential destroyer, the apostle of “socialized medicine.”

Here are some of Doctor Berwick’s parting shots on the “extremely high level of waste,” as exemplified by overtreatment of patients, failure to coordinate care, administrative complexity, burdensome rules, and fraud.

• “Much is done that does not help patients at all,” Dr. Berwick said, “and many physicians know it.”

• “I came with an agenda, I wanted to try to change the agency to be a force for improvement, covering one out of three Americans.”

• It’s a complex, complicated law. To explain it takes a while. To understand it takes an investment that I’m not sure the man or woman in the street wants to make or ought to make.”

• “We are a nation headed for justice, for fairness and justice in access to care,”

• “We are a nation headed for much more healing and much safer care. There is a moon shot here. But somehow we have not put together that story in a way that’s compelling.”

• “Government is more complex than I had realized. Government decisions result from the interactions of many internal stakeholders — different agencies and parts of government that, in many cases, have their own world views.”

• “The decision is not whether or not we will ration care — the decision is whether we will ration with our eyes open.”

• Berwick added, “Republicans have completely distorted my meaning. My point is that someone, like your health insurance company, is going to limit what you can get. That’s the way it’s set up. The government, unlike many private health insurance plans, is working in the daylight. That’s a strength.”

Tweet: Dr. Donald Berwick, resigning as administrator of CMS, takes parting shots at government complexities and distortions by Republicans.

Heath Reform: Costs, Demands, and Coffee In Old Saybrook

2011-12-04T12:30:00.000-05:00
As long as we have an aging population; sick patients who want to live a little longer; evolving technologies, and doctors devoted to those technologies, and consumers demanding them, costs will rise.

“Costs and Demands,” Section in The Health Reform Maze, Greenbranch Publishing, 2011

December 4, 2011 – Every Sunday, I have coffee with my friends at the River Mart Convenience Store on Main Street, In Old Saybrook, Connecticut. Across the street from River Mart are the Fire Station, the Town Hall, and the Katherine Hepburn Cultural Arts Center. Not far down Main Street is Walt’s, the neighborhood food store, where everybody knows somebody worth knowing in this seaside town of 10,000.

This morning six of us gathered to gossip over coffee. I shan't disclose our ages. Just let me say, we were long in the tooth, rich in life’s experiences, and living and feeling well thanks to modern medicine.

• One was an ex-CEO, who has had both knees replaced and who has undergone three lithotripsies for kidney stones.

• Two was a retired machinist about to have the first of two cataract procedures.

• Three was the old sea dog who has had two rotator cuff repairs.

• Four was the sea dog’s son, who has a thyroid cancer cured and a rotator cuff fixed.

• Five was a former printing company employee, who has recently had a cardiac pacemaker and a defibrillator implanted.

• Six was a retired physician now bearing two stents after a myocardial infarction.

What did these six share in common? They believed in the wonders of modern medical technologies. They had all benefited from these technologies. Specialists,armed with these technologies, treated them all. Medicare and health insurances shielded them from true costs of care. They had little sense whatbottom-line costs were for government, nor did they care. They took it, as a given,they would have quick access to similar technologies and to specialists who provide them at somebody else’s dime, should they need either to survive and thrive until their dotage or death.

And so it went, and so it will be.

As I recite this tale of health costs, demands for care, and coffee talk, consider what government is up against as it tries to rein in costs by denying procedures.

• Does government ration care for those who have come to expect it?

• Do government bureaucrats and experts, not doctors or patients, know best?

• Does government lower specialists’ pay or money expended on each procedure?

• How does government keep news of medical technology triumphs from spreading, as citizens talk over coffee about their own experiences and those of friends, relatives, and neighbors?

• How do you convince the public that one man’s new-found cure and feeling of wellness is another man’s waste?

A Take-A-Way Walk-A-Way

I walked away from this morning’s coffee hour thinking: 1) most of us don’t care deeply or knowledgeably about health care cost issues, as long as we get the best care for ourselves; 2) Coffee talk is a great stimulus for spreading the health care technologies.

Tweet: Coffee and talk of positive health care outcomes are great stimuli for more health care demands, costs be damned as long as you get yours.

Consequences of 2012 Elections on Health Reform

2011-12-03T15:07:00.002-05:00

The consequences for Americans will be huge.

David Blumenthal, MD, MPP, “2012- A Watershed Election for Health Care, “ New England Journal of Medicine, December 1. 2011

December 3, 2011 – In the New England Journal of Medicine two days ago, Doctor David Blumenthal, of Harvard Medical School, former Health Information Coordinator for President Obama, speculated on the consequences of three outcomes of the 2012 elections.

• OUTCOME #1 – Status quo (Obama reelected, Democratic Senate).

“Continued implementation of ACA coverage and delivery of reform provisions, barring Supreme Court decision to overthrow entire law. Consequences – Reduced rates of uninsured patients in America, aggressive implementation of ACA health reform provisions.”

My comment - I agree with Blumenthal that this is unlikely election outcome. However, I do not think aggressive implementation will succeed. States will go slow because of oppressive Medicare burdens and businesses will be slow to hire because of uncertainties of ACA-imposed expenses. Businesses have already dropped 4.5 million from coverage in anticipation of Obamacare. Furthermore, care access will become political criss as doctor shortage worsens as 48 million more Americans become Medicare eligible from 2011-2014 and as 34 million more enter Medicaid in 2014.

• OUTCOME #2 – Obama reelected. Republican House and Senate.

“Even if Supreme Court upholds law in entirety, political stalemate leads to compromise that reduces funding for coverage expansions, slows implementation of health exchanges, and reduces funding for health system reform. Consequences: maintenance of near pre-ACA levels of uninsured Americans; no substantial growth of levels.”

My comment: Reasonable bet that Obama will win and lose Congress. Blumenthal does not mention that private sector will adjust by offering lower cost care in cash-only settings and by reducing # of uninsured through HSA plans (1/3 of those who sign up for HSAs were previously uninsured). He also fails to say problem not exclusively # of uninsured, but dramatic cost increases imposed on the insured.

• OUTCOME #3 - Republican government, Republican House and Senate).

“Repeal of coverage provisions of ACA, without replacement. Retention of system-reform provisions that do not require federal expenditures (value-based purchasing, demonstrations of patient-centered homes. Resumption of pre-ACA rates of growth in number of uninsured Americans. Federal health system reform activities that are similar to pre-ACA activities.”)

My comment: Blumenthal neglects to mention that some Republican measures - universal vouchers, shopping across state lines, market competition, malpractice reforms, and Federal Health Benefit –type system for all- may reduce costs and number of uninsured.
Tweet: 2012 elections will be huge event for health reform with consequences, some good some bad, for all Americans, depending on your politics.

Tweet: The 2012 election will be watershed event for health care with huge consequences for every American.

Observations on Obesity and New Medicare Policy to Cover It

2011-12-02T06:07:00.005-05:00
We are digging our graves with our own teeth.

Thomas Moffett (1820-1908), Irish Poet and Educator

December 2, 2011 – Medicare has announced it will cover obesity screening and counseling as a free preventive service.

Under the new rules, physicians will be paid to screen and counsel beneficiaries with a Body Mass Index (BMI) of 30 or more. The counseling can take place once a week for a month, then every month for 5 more months. Patients who lose 6.6 pounds or more at the end of 6 months will be eligible for 6 more counseling sessions. This is Medicare's 6-6-6-6 plan.

As things now stand, 30% of Medicare patients have BMIs of 30 or more. Many private plans cover bariatric surgery for the morbidly obese (BMIs of 40 or more), which is found in 2% of men and 4% of women, but they do not pay for screening or counseling.

Will the new CMS policy bring down obesity rates and slim waistlines?

The answer is unknowable at this point. But politically, it may not matter. Government success is measured in good intentions, not results. It is a good thing to pay doctors to advise on obesity, which leads to diabetes, heart disease, hypertension, sleep apnea, and high health costs. And it is a good thing always to offer “free” preventive services.

Who knows? An ounce of preventive counseling may be worth a pound of flesh and ward off a future disease. Given the scale of the obesity epidemic, it’s worth a government try.

I suspect, however, CMS has bitten off more than it can chew. Its good intentions remind me of the maxim: seek simplicity but distrust it.

Everybody knows these simple obesity rules.

• Eat less, move more, weigh less.

• More calories in, less calories out, more weight on.

• Choose veggies, eschew salt,carbs, sweets, red meat, and fats.

• Obey the law of small portions.

Besides, everybody knows inside every fat person there is a thin person wildly waving to get out. And , of course, everybody knows obesity is a mental state brought on by bad habits, boredom, low self-esteem, and disappointment.

But what few say, not often enough, is that obesity is a complex multidimensional cultural problem brought on by:

• Ubiquitous marketing of fast foods and sugary drinks.

• Poverty and distance from stores selling convenient fresh foods.

• Sedentary life styles accompanying video games, TV, on-line computer sitting.

• 2-3 automobiles per American family.

• Lack of sidewalks and walking paths.

• No more recess and time for outdoor games.

• Habits of the human heart which celebrate and congregate around tables of food.

• Sheer pleasures of tastey foods, beautifully served, and accompanied by animal spirits.

As H.L. Mencken (1880-1956) sagely observed, “For every complex problem there is an answer that is clear, simple, and wrong,” which may be why the Center of Disease Control reports that 98% of all attempts to lose weight fail.

Still, as the French say C’est quoi l’expression,, loosely translated as "It is worth a try."

Tweet: Medicare has announced it will cover screening and counseling for obesity as a free preventive service.

Prostate Cancer – Multiple Choice Disease with No Right or Wrong Answers

2011-12-01T07:23:00.006-05:00
Want to elect there is but me,
‘Tis Hobson’s choice take that or none.

Hobson’s Choice

December 1, 2011 - As I was reading the November 24 issue of the New England Journal of Medicine containing these articles – “Prostate-Cancer Screening – What the U.S. Preventive Services Left Out,” One Man at a Time – Revolving the PSA Controversy,” “Stratifying Risk – The U.S, Preventive Services Task Force and Prostate-Cancer Screening,” and “Screening for Prostate Screening” - I was thinking of PSA screening for prostate cancer as a multiple choice question.

As a patient you live uneasily with a borderline PSA – even knowing full well prostate cancer is a slow growing disease, and you may die with something else. Or you may panic – knowing this could be the start of something big, bad, and ugly. Or you can’t live with the thought of harboring a malignancy- so you want it cut.

So you begin to investigate the myriad of noninvasive techniques for ablating prostate cancer - hormones, seeds, cryotherapy, cyberknives, plain old radiation, or that new wunderkind IMRT (Intensity-Modulated Radiation Therapy).

You fantasize about life without sex. You try to decide whether a needle biopsy with its possible complications - infection, impotence, incontinence - is worth the risk.

Or you go back to your primary care doctor, who most likely will advise watchful waiting. If you choose biopsy, he may refer you to a urologist fora biopsy, If positive, he may put you on hormones to knock back the testosterone, or send you to a radiation oncologist, who may implant radioactive seeds or start various forms of external radiation, or you may end up in the hands of a surgeon, who believes he can take it out without causing impotence or incontinence.

Or, if you’re a doctor like me, you may read the NEJM articles in search of rational answers.

• The first article, “Prostate-Cancer Screening – What the U.S. Preventive Services Task Force Left Out, “ points out that the Task Force recommendation against routine PSA-screening is a good thing, but it doesn’t end the confusion.

• The second, “One Man at a Time – Resolving the PSA Controversy,” says “we must ensure there is no more routine, indiscriminate screening- and no washing our hands of responsibility we must help put the controversy to rest ...one patient at a time.”

• The third, “Stratifying Risk- - The U.S. Preventive Services Task Force and Prostate-Cancer Risk,” says doctors should take risk factors – e.g. cancer in blood relatives, race, and so forth, into account, before dismissing the value of the PSA, so “screening should be made on an individual basis by an informed patient and his clinician, after weighing the patient’s individual risk factors.”

• The fourth, “Screening for Prostate Cancer,” a case study, stresses shared-decision making between patient and doctor based on values and risks of potential consequences with an eye on criteria for biopsy referral – age, family history, findings on rectal, PSA characteristics, and co-existing conditions.

In other words, deciding whether to screen for prostate cancer, biopsy and what to do with a positive biopsy, is still a multiple choice question.

Tweet: PSA Screening is controversial – to screen routinely, not at all, or just with positive risk factors – is the multiple choice question.

The Doctor Fix and the Balloon Metaphor

2011-11-30T07:54:00.002-05:00
Language is nothing but metaphor

Anonymous

November 30, 2011 – It’s here. Tis the season to battle over the annual doctor fix. The battle is more intense this year because of the super-committee's failure. The problem, as always, remains - how to fix the stupid macroeconomic Sustainable Growth Rate Formula (SGR) concocted in 1997 by Congress, but bypassed every year for the last ten years.

The “doc fix’, for the uneducated among you, is a temporary postponement of a legislatively mandated act- the SGR. If enacted this year, the SGR would cut doctor Medicare pay by 27.4%, or 29.4% if you throw in the 2.0% automatic cuts resulting from the super-committee's failure.

The SGR says the health inflation rate should be same as the general rate of inflation, although it never is because entitlement programs keep blowing up the federal balloon because people think health care is free, when it isn’t.

The trouble with SGR is if you cut doctors by 27.4%, you puncture the Medicare balloon. Doctors pull out of Medicare en masse. The balloon collapses because there are no more doctors to provide free care.

Back to health care as a political balloon. There are two schools of thought.

One, health care is a wonderful, infinitely inflatable balloon. It is a lifesaver, a rising boon for all citizens, a new new deal for which every progressive has waited a lifetime.

Two, health care is the Hindenburg. It is a socialistic death trap. It is death by mandate and will come crashing down to earth, gushing political debt gas as it falls.

These metaphors are both over-inflated. But I believe in the metaphor of the health system as a balloon, which when squeezed simply bulges out somewhere else.

You see these bulges in Medicare physician pay. Push down Medicare physician fees, and physicians will see more patients in less time, invest more in self-referral technologies, order more tests for which they know they will be paid, and practice more defensive medicine to avoid higher malpractice premiums.

Perhaps you could deflate the balloon by having doctors be rewarded only for good outcomes based on “evidence”, have them take more risks through ACOs for budget overruns, halt self-referrals and pay from pharmaceutical companies, reform malpractice, pay more for time spent with patients rather than for technologies.

And maybe, just maybe, you could puncture the balloon by paying for federal programs through vouchers, or block Medicaid grants to states, or private care through health savings accounts with high deductibles.

Don’t expect too much. The federal balloon still contains a lot of hot air, the government balloon is still rising, and balloons are still infinitely elastic and expandable.

I close with an Ogden Nash verse which I ought to apply to this blog.

One thing that literature would be
greatly the better for
Would be a more restricted employ-
ment by authors of simile and
metaphor.

Tweet: The Sustainable Growth Rate and the failure to fix it is a superb example of the balloon metaphor, squeeze it and it bulges out elsewhere.

Debut of Health Reform Maze Cover and Video

2011-11-29T19:24:00.005-05:00
November 29, 2011 - Today marks the debut of the picture of the cover on my new book, The Health Reform Maze; A Blueprint for Physician Practices (Greenbranch Publishing) on this blog. The book is about the amazing maze of U.S. health care and how physicians seek to navigate its twists, turns, rocks, and shoals.

As you can see on the right side of this blog, the book cover features a box containing a diagram of the labyrithic, byzantine, fiendishly complicated maze of the new health system as set forth in the new health care law- variously known as the Patient Protection Affordability Act, The Affordability Act, or simply as Obamacare.

The diagram shows the maze of possible bureaucratic interactions of the President, CMS, the health exchanges, Congress, 159 different agencies, health plans, doctors, and patients.

On the top left of the maze is the President, at the top right of the maze is the Congress, in the middle of Secretary of Health and Human Services, at the bottom left of the maze are physicians, at the bottom right of the maze are patients. The positioning of these people znd entities explains why the new health system is a "top-down" system.

At the upper left of the box you enter complicated innards of the system. As yet there is no exit

On the right side of the blog is a 2 minute video. In it, I speak of the filled and unfulfilled promises of the Accountable Care Act.

Keep these promises in mind when voting next November.

Workers, Reform Yourselves, Or Pay the Piper

2011-11-29T08:03:00.005-05:00
For behavior, man must learn it, as take diseases, one or another.

Francis Bacon (1561-1626), The Advancement of Learning

November 29, 2011 – Well, it come down to this – Be Well, Stay Well, Or Else. One of these Or Elses could be Farewell.

Learn to be well, behave yourself, stop smoking, cut down on the drinking, keep your weight down, lower your cholesterol, or else pay more for health care coverage.

Or else means you may not be hired, you may have to pay a higher health care premiums, deductibles and copays. You may not even be able to keep your job, and you may become persona non grata to your employer and your co-workers.

At least that’s how I read the story of “What’s End Game for Wellness,” as told by John Commins in the November 28 issue of HealthLeaders Media.

Commins cites a NYT report this month this month saying a growing number of employers are telling workers who smoke, are overweight, or have high cholesterol to pay a larger share of their health care costs.

The Times article says policies imposing financial penalties on employees' poor health choices have doubled to include 19% of 248 major U.S. employers. Benefit consultants Towers Watson projects a doubling of that number again next year.

According to Commins,

“ We are seeing a surge in the wellness movement – the idea that employees should take greater responsibility for their health or pay the consequences.

"At face value it seems reasonable. Why should the rest of us pay for your lousy lifestyle choices? However, the wellness movement also has huge potential for abuse and discrimination. It also raises troubling questions about who gets thrown overboard, and where we draw the line on employer intrusions into our personal lives.”

Much of this understandable, of course. Since 2001, family premiums have increased 113%, compared with 34% for workers' wages and 27% for inflation. And smokers and the obese cost employers and their co-workers a lot of money. Unhealthy habits, even gluttonous, behavior is one reason premiums rose 9% rise in 2011 to $15,073 for a family of four.

But then comes the Big Brother question. How much can and should government, which covers 30% of Americans and employers who cover 55%, intrude into personal behavior of insured Americans? I have not included the 15% uninsured, said by some to be the unhealthiest, and sometimes the most misbehaving of them all.

A second question is: how can you change an individual whose behavior is shaped by the culture in which he or she was born. We are all creatures of our culture, and American culture promises we can behave as we please as long as we don’t harm others. The harming others problem becomes relative when misbehavior of one individual raises costs to the employer and fellow workers.

Farewell,Be Well, and Stay Well

Tweet: Some 20% of employers this year, and perhaps 40% next year, are making wellness a criteria for health premiums charges.

For Health Reform Success, Follow the Culture!

2011-11-28T10:22:00.005-05:00
As the American culture goes, so goes America. It’s the culture, stupid!

Bobby Jindal, Governor of Louisiana, Speech, American Values Summit, October 12, 2011

November 28, 2011 - I have spilled more ink than most on the pitfalls, pratfalls, and bear traps of health reform – in Obama, Doctors, and Health Reform (IUniverse, 2009), The Health Reform Maze (Greenbranch Publishing, 2011), and 2044 Medinnovation blogs (2007 to present).

In these various verbal outpourings, I have been consistent about one point. To succeed, health reform will have to satisfy and meet beliefs inherent in American culture.

We have all heard the negative litany of health care problems – skyrocketing costs, medical bankruptcies, U.S. businesses paying twice that of foreign counterparts, uneven quality, 50 million without insurance, too many specialists, too few family physicians, mediocre health outomes compared to other nations.

What we have not heard is how the American culture operates and how we think.

• We distrust centralized federal power.

• We revel in virtues of self-improvement.

• We seek freedom of individual choice.

• We believe in equality of opportunity for all citizens.

• We prefer a multipayer to a single payer system.

• We reject a federal- imposed individual universal mandate.

• We want to make our own health decisions in concert with our doctors.

• We seek immediate access to medical high-tech.

• We believe market-based institutions and public-based institutions (VA, Medicare, Medicaid, Tricare) can co-exist.

• We consider regional diversity a good thing.

These cultural roots and beliefs may be exceptional, regrettable , counterproductive, conflicting, and wasteful , but they create a climate of freedom and opportunity that draws millions of immigrants and entrepreneurs to our shores.

But how to resolve problems of cost, access, and unevenness these cultural beliefs create, and how to design a system consistent with these beliefs,that is a horse of a different color.

I like the solution suggested by David Dranove, a professor of health industry management at Northwestern’s Kellogg School of Management. In The Health Care Blog, “The Constitution Is Not a Turkey", he recommends Congress give each state block grant conditioned on expanding health coverage. No expansion, no grant.

Let Massachusetts be Massachusetts, Texas be Texas, and so on down the line. Let states learn from one another. Keep the feds out of it. This approach, says Dranove, would be constitutional, conservative, constructive, consistent with each state’s culture, and put everybody’s pet theory to the test.

Tweet: Let Congress give each state a grant conditional on each state expanding coverage. This would be constitutional and culturally acceptable.

Physician Doom and Gloom over Sequester and SGR

2011-11-27T11:38:00.000-05:00
November 27, 2001

Physicians are crying doom and gloom over the “sequester,”
2% Medicare cuts starting in 2013 and allowing SGR to fester.

This translates to 2% cuts annually through 2021,
Added to 27.4% SGR cuts starting next January 1.

If the do-nothing Congress does nothing,
And continues to its partisan impasse cling.

This will lead to the worst of improbable possibilities,
Closure of hospital facilities and physician hostilities,

Fewer doctors accepting Medicare patients.
In the good old U.S.A, the richest of nations.

Surely something is amiss.
We can do better than this.

Tweet: The Super Committee's failure may lead to a "Sequester",resulting in Medicare physician cuts of 2% and a 27.4% SGR cut.

Medicare and Black Friday

2011-11-26T16:48:00.003-05:00
Black Friday thought: Medicare is imploding while Medicaid is exploding.

Anonymous

November 26, 2011- Black Friday has come and gone.

For retailers "Black Friday" was the day after Thanksgiving, the point at which retailers begin to turn a profit, i.e., go into the black.

For shoppers “Black Friday,” was a wild and crazy hunt for bargains, starting for most at the stroke of Midnight and going on all day Friday.

For Medicare recipients, Black Friday meant something different.

Black Friday for Medicare Recipients ends on December 7 this year. That's the day Medicare deadline signups loom.

There’s plenty of Medicare shopping to do over Thanksgiving weekend and beyond. Seniors have only two weeks left to choose a new Medicare Advantage or prescription drug plan, if they want to change from their current ones.

Medicare’s open enrollment deadline was pushed up this year, from Dec. 31 to Dec. 7, as part of the 2010 federal health reform law. The earlier deadline is meant to ensure that beneficiaries are properly enrolled and get their new membership cards by the start of the plan year Jan. 1.

That’s why you see many TV ads, mailers and events calling attention to it. Few callers to the groups’ helplines are asking about the deadline; talk is now almost entirely about picking a plan.

Many Medicare beneficiaries might still be unaware of the December 7 date The “four C’s” of picking a plan are cost, coverage, convenience, and customer service.

Go to Medicare.gov to judge the relative merits of various Medicare plans, including Medicare Advantage and Medigap policies. People often forget about customer service, in particular. It’s important to evaluate the responsiveness of your Medicare provider, as well as to consider other providers and their ratings.

Medicare’s official website features a plan comparison tool, which includes the star ratings that CMS awards based on quality factors such as rates of hospital readmission.

Depression Friday

Black Friday Is also Depression Day Medicare Recipients. The color black also connotes depression, as in a black mood. It’s no secret Medicare recipients are the age group most opposed and most skeptical to the Accountable Care Act.

Many, 2'3s to be precise, are in a black mood if you can judge by polls of seninors who oppose the bill. The law requires cutting over $500 billion out of Medicare and eliminating many of the benefits of Medicare Advantage Plans.

There are other objectionable features as well.

Here is a list of black features of the Accountable Care Act (Obamacare) composed by Jeffrey H. Anderson, former senior speechwriter for Secretary Mike Leavitt at the U.S. Department of Health and Human Services.

• It’s 2,700 pages long, so few people really understand it and its consequences.

• It has caused 4.5 million Americans to lose their employer-sponsored health insurance and be dumped into Obamacare “exchanges.”

• It loots Medicare. The CBO projects that during the overhaul’s real first decade (2014 to 2023), nearly $1 trillion would be siphoned out of Medicare and spent on Obamacare.

• It costs twice as much as the deficit commission is trying to “save.” The CBO says that Obamacare would cost an estimated $2.5 trillion during its real first ten years.

• It raises, rather than lowers, health costs. The Medicare chief actuary says that Obamacare would increase health costs by hundreds of billions of dollars by the end of this decade.

• It massively expand sMedicaid, at a time when our national debt is $15,000,000,000,000.00 and is about the size of our entire gross domestic product, Obamacare would provide a colossal expansion of Medicaid — expanding it to cover many of the middle class.

• It establishes the IPAB. The Independent Payment Advisory Board (IPAB) is a version British National Institute for Clinical Health and Excellence (NICE), the British rationing agency .

• It politicizes medicine and amases unprecedented power and money in Washington at the expense of Americans’ liberty.

Tweet: Black Friday is a good time to start seriously thinking about picking a Medicare plan and for considering the consequences of health reform.

The World of Health Care Venture Capital

2011-11-25T16:07:00.010-05:00
He ventured neck or nothing – heaven’s success
Found, or earth’s failure.

Robert Browning (1812-1889), A Grammarian’s Funeral (1885)

November 25, 2011- Luis Pareras, MD, PhD, MBA, of Barcelona, Spain, and I are thinking of writing a book on the world of health care venture capital – how , when, why, where, and and for whom, it works.

We sense physician entrepreneurs are searching for access to venture capital to back their ideas and make those ideas become reality. Unfortunately when you stick your neck out, some ideas you conceived as heavenly fall to earth and fail. Perhaps we can help prevent the fall.

It is our contention that health care venture capital is a world-wide phenomenon, that physician entrepreneurial innovators are worth encouraging, and that "disruptive" health care startups may help relieve the pressure of national health costs by lowering costs and improving practices.

Make no mistake about it. Venture capitalists across the world generate much of the capital – the financial oxygen – required to go public and succeed on a broad scale.

Much of the venture capital activity is centered in the United States, Of the 91 venture firms listed in Wikipedia, 78 are in the US, followed Europe, China, Israel,India, and Singapore with 24 based in multiple countries.

In th U.S., 46 venture firms are concentrated in California, 25 in Menlo Park alone. Massachusetts has 16 venture capital firms. Other states - Minnesota, Texas, New York, Connecticut, and Virginia - are also beehives of venture activity.

Why the concentration of venture capital firms in the U.S.? according to Peter Drucker (1909-2005), the U.S. economy, until recently, outpaced the European economy, growing at a rate of 3-5% per year until about 2005, while European growth rates were stagnant at about 1%. Today the U.S. is in the same no growth funk as Europe.

According to Drucker, the basic reason for the U.S. entrepreneurship success is that in the decentralized U.S. economy, decisions are based on proximity to the market and rapid response to changes while European centralized, socialized economies render market response difficult and slow.

The U.S. says Drucker has switched from a centralized managerial economy to a decentralized entrepreneurial economy while Europe has not.

Critics of the Obama administration maintain that the current slow U.S. growth stems from our drift toward the European model of doing business, centralizing health care, and hog-tying health care enterprises with government regulations and onerous business taxes.

This may be, but health care in the U.S.added 300,000 jobs in 2011, and health care's vibrant growth makes it an attractive sector for venture capitalists.

One way out of the slow growth trap for the U.S. economy as a whole is revitalizing entrepreneurship and innovation. The optimal place for creating new businesses and getting money to launch them is still the U.S.

Foreign entrepreneurs know this, which is why they come to the U.S. to be educated in U.S. universities in science, technology, engineering, and mathematics, then stay here to start up companies backed by venture capitalists, particularly in places like Silicon Valley. And, if these entrepeneurs are not granted visas or green cards, they return to their home countries – such as India, China, or Isreal – to set up startups and gain venture capital.

One reason for writing a book on physician innovation and entrepreneurship is to educate doctors about the process of obtaining venture capital.

Venture capital provides capital to early-stage, high-potential, high risk, growth startup companies.

Venture capital funds make money by owning equity in the companies it invests in. They may be interested in physicians who have ideas about a novel technology or new ways of organizing doctors.

Physicians may gain capital through angel investing, relatives, or personal resources, or from a local bank. But given the current clamp-down on lending to companies without a track record, obtaining money to go public is difficult. Venture capital is attractive for new companies with no operating history that are too small to raise capital in the public markets and have not reached the point where they are able to secure a bank loan or complete a debt offering.

Venture capital is also associated with job creation (accounting for 21% of US GDP). Every year, there are nearly 2 million businesses created in the USA, and only 600–800 get venture capital funding. According to the National Venture Capital Association, 11% of private sector jobs come from venture backed companies and venture backed revenue accounts for 21% of US GDP.

In closing, I offer this astute observation by Peter Drucker on why some countries' economies grow and others do not (Innovation and Entrepreneurship,Harper & Row, 1986:

And yet it is most unlikely (I am tempted to say impossible) for any counry to be innovative and entrepreneurial in high tech without having an entepreneurial economy. High tech is indeed the leading edge, but there cannot be an edge without a knife. There cannot be a viable high-tech sector by itself any more than there can be a healthy brain in a dead body. There must be an economy full of innovators and entrepreneurs, with entrepreneurial vision and entrepreneurial values, with access to venture capital , and filled with entrepreneurial vigor.

Tweet: Venture capitalist backed small businesses account for 21% of GDP, and many of these new business are in health care.

Brief Update and Medinnotion Blog and New Book, Health Reform

2011-11-23T15:23:00.002-05:00
November 23, 2011- I shall be devastatingly brief. My blog is now getting more than 1000 hits on some days. I am entering some blog contents on twitter as tweets.

I now have a video on Youtube about effects of health care law. To view the video, click on Health Reform Maze after googling YouTube. Have a happy and gluttonous Thanksgiving.

Richard L. Reece, MD

Thanks for Thanksgiving, Ben and Abe

2011-11-23T08:40:00.010-05:00
There is one day that is ours. Thanksgiving is the one day that is purely American.

O’Henry, aka, William Sydney Porter (1862-1910)

November 23 for November 24, 2011

Thank you, Lord, for the privilege of living in the U.S.A.
I want you to know things here are still mostly A.O.K.

Oh, as a doctor, I have a few complaints,
Mostly because of government constraints.

I like Thanksgiving because it is brown,
Which is by far the best color around.

Thanksgiving is as brown as burnt toast.
Thanksgiving evokes a brown turkey roast.

Speaking of freshly cooked warm turkey,
I like it much better than cold beef jerky.

Ben Franklin, electricity's inventor - sage on the $1 bill,
Composed Poor Richard's Almanac and believed in free will.

Ben proposed the wild turkey as our national symbol.
The wild turkey roamed across the land free and nimble.

Wild turkeys may not soar with the eagles.
But at least they are nobody’s pet beagles.

I prefer majestic wild turkeys to domestic tame turkeys,
In my way of thinking wild turkeys are nobody’s lame lackeys.

They have minds of their own.
They are nobody’s pet drone.

Abraham Lincoln proclaimed Thanksgiving a national Holiday,
Thank you, Abe,for your proclamation for Thursday turkey day.

Tweet: Here is my Thanksgiving day turkey poem, which some may call a turkey of a poem.

Hospital Systems Enter Walk-In Markets

2011-11-22T11:52:00.004-05:00
Fortune is like the market, where many times, if you can stay a little, the price will fall.

Francis Bacon (1561-1626), Of Empire

November 22, 2011 - In today’s WSJ Health Blog, Laura Landro writes an excellent column on why hospitals, drug stores, hospital systems, and physician groups are establishing more and more walk-in clinics in retail settings.

Among other things, Landro had this to say:
>
“For patients with immediate medical needs, a growing number of walk-in clinics and freestanding emergency rooms offer an alternative to hours-long waits in the hospital emergency department, today’s Informed Patient column reports.”

"‘Hospital systems feel they need to stop losing these walk-in patients with minor injuries and illnesses to new players,' Tom Charland, chief executive of consulting and research firm Merchant Medicine, tells the Health Blog.' "

“ 'With new models of care envisioned under the new health-care law including bundled payment systems that reimburse for episodes of care rather than for each service, hospitals 'will be responsible for the total cost of patients, so it is in their interest to send them to the lowest-cost provider,' Charland adds.”

“Hospitals are also watching Wal-Mart, which is seeking partners to push into the primary-care market by expanding the quick-service clinics it already runs.”

“Freestanding emergency rooms are also growing in popularity, as health systems find that they can help relieve the burden on primary hospital emergency rooms and draw patients who might have trouble getting to the main hospital ED.”

“While many of the freestanding ERs are owned by hospital systems, some are being built by independent companies that aren’t bound by some of the same regulations as hospitals — such as seeing all patients regardless of ability to pay.”

“Insurers also may not cover all services at independent freestanding emergency rooms. States are now wrestling with how to regulate such facilities.”

Here was my comment on Laura Laundro’s perceptive column:

Nice piece. As I pointed out in my November 10 Medinnovation blog, "Health Care Moves Into Retail Spaces," there's another dimension to this. Hospitals, doctors, and insurers are moving into these spaces because increasing numbers of people are signing up for individual policies featuring health savings accounts with high deductibles . These individuals tend to be sensitive to price, and they are looking for care bargains and the convenience of one-stop shopping. Also insurers have realized to sell these poliicies, one-on-one contact works better than marketing to groups.

Tweet: Hospitals, physicians, and health insurers are moving into retail spaces because that's where individual care buyers congregate in search of one-stop bargains.

Cleveland Clinic Unveils Top 10 Medical Innovations for 2012

2011-11-22T09:02:00.004-05:00
It is never too late to innovate. You can always do better

Richard L. Reece, MD, Innovation-Driven Health Care: 34 Concepts for Transformation, Jones and Bartlett, 2007

November 22, 2011 - Before I became wrapped up in health reform and its consequences, I intended this blog to be about medical innovations. I still think innovations may be the salvation of reform, if oppressive government does not quash innovation. But that’s another story. Today’s story is about the important technological innovations, as conceived and executed by the Cleveland Clinic.

The Top 10 Medical Innovations for 2012, as seen by the Cleveland Clinic, are:

10. Genetically Modified Mosquitoes to Reduce Disease Threat: Researchers are now exploring new avenues to fight mosquitoes, starting in the laboratory where scientists manipulate the DNA of the insects.

9. Novel Diabetes Therapy: SGLT2 Inhibitors: Most diabetes medications work by affecting the supply or use of insulin. This helps move glucose into the cells. But now there is a new class of drugs ready for prime time called sodium-glucose co-transporter 2 protein inhibitors, or SGLT2 inhibitors. These drugs represent a paradigm shift in diabetes treatment. They reduce blood sugar in a totally new way – by causing it to be excreted during urination.

8. Harnessing Big Data to Improve Heath Care: Health care data requires advanced technologies to efficiently process it in reasonable time, so organizations can create, collect, search, and share data, while still ensuring privacy. In this way, analytics can be applied to better hospital operations and tracking outcomes for clinical and surgical procedures. It can also be used to benchmark effectiveness-to-cost models.

7. Active Bionic Prosthesis: Wearable Robotic Devices: About 9 out of 10 amputations involve the leg, from the foot to above the knee. Thanks to remarkable advances in prosthetics research in the last decade, space-age plastics and carbon-fiber composites have been engineered to help restore function. Now comes the computerized bionic leg with its microprocessors and computer chips that can rival the functionality provided by biological limbs.

6. Implantable Device to Treat Complex Brain Aneurysms: A new minimally-invasive procedure can safely and effectively treat brain aneurysms without open surgery by implanting an FDA-approved device directly into the artery. Consisting of a flexible braided mesh tube made of platinum and nickel-cobalt chromium alloy, this device can be delivered by catheter and used to block off large, giant, or wide-necked aneurysms in the damaged internal carotid artery.

5. Increasing Discovery with Next-Generation Gene Sequencing: The best way to get to the root cause of serious illness is to sequence a person’s genome. Leading geneticists envision a day soon when everyone’s genome will be sequenced and included as a routine part of their medical records. Next-generation sequencing machines can help achieve this goal in the near future with the wider dissemination of faster and affordable sequencing machines.

4. Medical Apps for Mobile Devices: Medical apps have several significant advantages: reliable medical information is always up to date, doctors can answer patient queries quickly by accessing data without every leaving the patient’s bedside, and many medical apps also have interactive features that help doctors choose appropriate screening tests for patients and calculate a patient’s risk of developing a host of diseases.

3. Concussion Management System for Athletes: Head injuries are now such a major medical concern in sports that special patient management tools have been developed. Used by athletes, they instantly detect brain injuries at the moment of contact, and provide patient-specific guidance about when athletes can return to play without risk of further harm. The novel Concussion Management System includes a special assessment tool that is used to establish an athlete’s baseline cognitive and motor skills at the beginning of his or her athletic season. This is the first tool that objectively and accurately assesses cognitive and motor function simultaneously.

2. CT Scans for Early Detection of Lung Cancer: With the introduction of low-radiation-dose spiral computed tomography (spiral CT), a high-tech scan can generate a series of detailed cross-sectional images of the lungs that are used to create a three-dimensional image. These scans can not only identify tumors earlier, but also spot them when the tumors are smaller and more treatable by surgery. Surgery is the best treatment for most types of lung cancer.

1. Catheter-Based Renal Denervation to Control Resistant Hypertension: Today, one in three adult Americans has hypertension, which puts them at significant risk for strokes, heart attacks and kidney failure. In fact, hypertension is the No. 1 risk factor for death in the world. Now, a new 40-minute catheterization procedure, called renal denervation, is approaching resistant hypertension in a new way – by targeting the renal sympathetic system, which consists of the small nerves that carry signals between the brain to the kidneys. Disruption of these nerve fibers has resulted in improved blood pressure levels, while also showing promise in treating chronic kidney disease, insulin resistance, and heart failure.

Tweet: As practiced by the Cleveland Clinic, Health care reform and health care innovation go hand in hand.

A Dozen Health Care Uncertainties for 2012

2011-11-21T11:39:00.002-05:00
Health care roses may not be cheaper by the dozen in 2012.

Health Care Florist

November 21, 2011- Cheryl Clark, senior editor for HealthLeaders Media,today delivered a bouquet of 12 reasons for health care uncertainty in 2012 in “Twelve Uncertainties Hovering Over Healthcare.”

Clark is the California correspondent for HealthMedia Leaders. California the site of the Tournament of Roses and the home of Gertrude Stein, who wrote that memorable line, “ A rose is a rose is a rose.” Health care roses next year by any other name might not be as sweet.

Enough word play.

Here are Clark’s dozen roses.

1. Super Committee on Deficit Reduction – A no-go. 2% automatic cuts across- the-board start in 2013.

2. Sustainable Growth Rate Repeal – Another no-go. 27.4% cuts for physicians scheduled for January 1, 2012.

3. Supreme Court on Accountable Care Act Constitutionality – Could be yet another no-go,this time for Obamacare. Decision scheduled for June.

4. Hospital readmissions - A thorn in Medicare’s side. Hospitals await CMS decisions on how to interpret and penalize excessive readmissions in 30 days after discharge.

5. More civil and criminal penalties on physicians – Fighting fraud and abuse is a good thing, but not if it makes most doctors feel like criminals awaiting public hangings.

6. More aggressive health plan premium reviews – The Obama administration has met the enemy, and it is those evil health plans who want to stay in business and satisfy stock holders.

7. Who will lead CMS? By end of year, it won’t be Donald Berwick, who is persona non grata among conservatives who see him as leader of the socialized medicine band.

8. Patient-Centered Outcomes Research Institute – This 21 member panel created by ACA will recommend what doctors can do and be paid for based on“ evidence.”

9. Meaningful use - In second quarter of 2012, CMS will announce details of how doctors will be rewarded or punished for installing and using EHRs, come October 1, 2012.

10. Accountable Care Organizations – Sometime this year CMS, FTC, and anti-trust division of Department of Justice will try to assure ACOs don’t dominate markets, skimp on services, and pressure enrollees to influence choice of providers. May not be important since few hospitals and doctors will elect to become ACOs.

11. Physician Payment Sunshine Act – Designed to limit influence of drugs, devices, and supply manufacturers on physicians and hospitals. Advocates claim little sun must shine on undue influences ; critics say it’s just another bureaucratic cloud.

12. Value-based Purchasing Payments Incentive – This is about CMS offering 1% hospital incentives for dropping mortality rates for heart attacks, health failure, pneumonia, and infections and hospital acquired conditions – falls, pressure sores, and infections.

Comparing health reform uncertainties to roses,
May not be best to show what goes on under our noses.
Butthe Affordable Care Act has its thorns,
And it doesn’t hurt to seize roses by their horns,
To show what challenges the future poses.

Tweet: The health care law has created profound uncertainties affecting all providers of health care, most increasing bureaucratic rules, penalties, and incentives.

The Supreme Court and the Future of Health Care

2011-11-21T07:03:00.003-05:00
The Supreme Court holds health care's future in its hands.

Anonymous

November 21, 2011 - The best source of information on the future of health care and of physicians is the Physicians Foundation (physiciansfoundation.org). This nonprofit organization was founded in 2003 to settle a lawsuit brought by 19 state medical societies against major health plans.

The non-partisan non-profit Foundation seeks to improve the practice of medicine by its practitioners and their patients. It does part of its work by awarding grants to physician groups and other organizations, such as Health Leads.

Health Leads allows physicians to “prescribe “ social services. College volunteers, most destined for a future in health care as physicians and other health care professionals, then help poor families gain access to food stamps, housing, jobs, social services, and medical transportation.

The Foundation also conducts national surveys of thousands, even hundreds of thousands of practicing doctors. These physicians are the backbone of health care's delivery system. Through its surveys, the Foundation determines physician morale, economic status, plans for the future, wants, needs, expectations, and frustrations.

The Foundation publishes results of its surveys to guide physicians, and it publishes the Washington Report. Lee Stillwell, a veteran inside-the- Beltway consultant and journalist closely allied to the medical profession, writes the report.

Here are excerpts of his November 21 Washington Report.

Finally, after 20 months of arguments between the Obama Administration and Congress about the viability of the massive health care law, the U.S. Supreme Court dramatically has moved to determine the fate of the legislation that impacts every American’s medical treatment.

The Court last Monday (November 14)surprised the political community, which has been involved in never-ending bickering about Obamacare, with an announcement it would decide the legal fate of four issues which are at the heart of the law.

The case likely will be heard in March 2012, and a decision announced later in the summer at the height of the Presidential and Congressional campaigns!

The high court set the oral argument at five and one-half hours, longest time in more than 45 years. The court also picked two outside veteran attorneys—H. Bartow Farr 111 and Robert A. Long-- to argue certain components of the law that would not be covered by the other lawyers in the case. Many believe the decision will be the most crucial ruling made by the justices since the Bush vs. Gore decision almost 11 years ago, sealing George W. Bush’s election win.

The importance of a case that will decide the future of health care for all Americans led to an unusual request to televise the oral argument—the first time ever in the history of the court. The plea to permit TV coverage was made by Brian P. Lamb, chief executive officer (CEO) of C-SPAN.

“We believe the public interest is best served by live television coverage of this particular oral argument,” Lamb said in the letter. “It is a case which will affect every American’s life, our economy, and will certainly be an issue in the upcoming presidential campaign."

From my viewpoint, Lamb, who has support for the idea from members of Congress, makes a valid argument. There is no doubt that this issue will determine the future of medical treatment for all Americans.

The Court certified four questions for review in the Patient Protection and Affordable Care Act (PPACA), signed into law by President Obama on March 23, 2010:

--Is it Constitutional for the federal government, who wants to increase coverage to 50 million uninsured Americans, to mandate that everyone is required to have health care coverage by 2014?

--If an individual mandate is unconstitutional, does the entire statute fall or stand?

--Is it unconstitutional for the federal government to require the states to pay extra funds for expanding Medicaid to a bigger pool by 2017?

--Should a legal decision be put off until 2015 when the first taxpayers would be forced to pay a penalty for not having health insurance?

Cases accepted by the court are National Federation of Independent Business v. Sebelius, No. 11-393; Florida, et al., v. Department of Health & Human Services, No 11-400; and Department of Health & Human Services v. Florida, et al, No. 11-398.

The legal battle finally reaches the Supreme Court after four very different rulings at the Circuit Court level. The 11th Circuit Court of Appeals, Atlanta, ruled the mandate unconditional; the Sixth Circuit, Cincinnati, and the District of Columbia Circuit, upheld the mandate; and the Fourth Circuit, Richmond, dismissed the suit as premature, stating the challengers had to wait until the mandate takes effect in 2014.

All nine justices –John Roberts, Antonin Scalia, Anthony Kennedy, Clare Thomas, Ruth Bader Ginsburg, Stephen Breyer, Samuel Alito, Sonia Sotomayor, and Elena Kagan—appear ready to participate in the ruling.

The stakes are high and the health care community waits with great anticipation. A ruling against the individual mandate would cripple the intent of the law. Without it, many would avoid the insurance until they get sick, dramatically driving up insurance premiums.

If the court throws out the entire law, many already implemented provisions that benefit millions could be jettisoned, including young people staying on their parents’ health plan until 26 years of age and the effort to close the doughnut hole for seniors-the gap in prescription drug coverage.

However, the biggest surprise was the court agreeing to look at the law’s Medicaid expansion. Supporters of PPACA fear an adverse ruling will kill the effort to expand Medicaid. States in their suit said the expansion amounts to an unconstitutional coercion. Under the law, cash-strapped states would be required to cover all residents with incomes up to 133 percent of the poverty level, adding an estimated 17 million participants.

Obviously, any legislative effort to repeal the law now will take a back seat until the Supreme Court makes a decision. However, the twists and turns of the market place guarantee that the health care community, which cannot afford to wait for a decision, will continue to transform itself the best way it can to survive in this uncertainty.

Tweet:The Supreme Court holds health care’s and physicians’ future in its hands. It hears ACA’s case in March and announces results in June.

Liberal Pessimism over Supreme Court and Obamacare

2011-11-20T14:18:00.002-05:00
A glass half-empty.

Pessimists' Operating Philosophy

November 20. 2011- Lately I cannot help but notice an air of pessimism among liberal commentators about the upcoming Supreme Court decision over the constitutionality of the Affordable Care Act, an oxymoronic title for what otherwise has come to be called Obamacare by critics and advocates alike

In a book review "Hillarycare: The Sequel," in the November 20 NYT of Remedy and Reaction: The Peculiar American Struggle Over Health Reform, Timothy Noah, senior editor for the liberal New Republic, concludes his review on this pessimistic note.

Should the Supreme Court chuck Obamacare, health policy will be back to Square 1, and Obama’s presidency will be instantly transformed from a substantive success to a substantive failure. I fear that Justices Roberts, Thomas, Scalia, Alito, and Kennedy may find that possibility too tempting to pass up.

Tweet: Liberals are increasingly pessimistic about prospects of the Supreme Court chucking Obamacare.

Will Bundled Care Save Health System a Bundle?

2011-11-20T14:12:00.001-05:00
This will save you a bundle.

Common Marketing Premise and Promise

November 20, 2011 - In his NYT Op-Ed today, Ezekiel Emanuel, MD, former Obama advisor and now vice-provost and professor at Penn, argues that bundled payments for episodes of care, e.g. diabetes, heart failure, and hip replacements, will save a bundle for taxpayers and patients.

Since 2009, he reports, Medicare has bundled payment for 37 cardiovascular and orthopedic procedures, with preliminary data indicating savings of 10% and improved quality of care. Therefore, we should “ make the program mandatory for all hospitals beginning January 1, 2013, eliminating fee-for-service for the procedures.”

Fee-for-service, Dr. Emanuel maintains, incentivizes specialists to give more services than needed in a fragmented and inefficient manner, while bundled payment delivered by coordinated groups would be more efficient and keep patients healthier. Besides, specialists and hospitals, “ lose money if they keep the chronically ill healthy,” as if greed drives specialists to do what they do.

If only, he pleads, we could roll all caregiver payments into one bundle to pay all health care players into one neat, all- encompassing bundle, we could prevent events like 20% hospital; readmissions of chronically ill patients from occurring.

Not so fast, Dr. Emanuel, these readmissions are usually very sick patients, suffering from chronic irreversible illnesses developed over a lifetime, not curable by one hospital admission.

Furthermore, many revert to old behavioral and dietary habits that got them into the hospital in the first place, and 40% of them do not fill or take their prescriptions. Complications consequently happen under the best of payment models or treatment conditions when you’re old, sick, and forgetfull

Changing the payment system isn’t going to restore them to health or prevent readmissions.

What patients need, according to Emanuel, is “high touch medicine” and “concierge medicine” offered up by teams of caregivers anticipating every human need, thereby preventing complications . Politician say we need, he says, “a health care system rather than a sick care system. They are right, and high touch medicine and bundled payments are the best ways to catalyze that change.”

Maybe. But, in my opinion, Emanuel mischaracterizes “concierge medicine,” and “high touch medicine, “which iin the eyes of doctors, is more about individual doctors devoting more time with individual patients and escaping the bureaucratic restraints of government medicine.

As for saving money, it has yet to be proven that herding patients, doctors, and hospitals into organizations offering bundle care saves money.

Tweet: Read Doctor Ezekiel Emanuel’s NYT Op-Ed piece ,“Saving by the Bundle,” to learn how Obamacare proposes to save money and improve care (11/20).