Sunday, August 2, 2015

Conservatives: Aim at the Heart, Talk about the Pocketbook!

The big problem for Republicans in the 2016 elections, as Arthur C. Brooks, president of the American Enterprise Institute, says in his new book, The Conservative Heart: How to Build a Fairer, Happier, and More Prosperous America (Broadside Books, 2015), is that the left has a monopoly on compassion and empathy.

The solution for conservatives, according to Brooks, is to speak less from the head and more from the heart, and aim more at the pocketbook.

Talk about fighting for the middle class, expanding incomes, increasing job opportunities, and unleashing free enterprise. Be seen as fighting for people rather than against policies.

This is easy to say, hard to do.

It does not lend itself to 30 second sound bites.

Here is my try at a 30 second sound bite.

“Are you happier than you were last year?"

“Do you feel America’s economic system is fair?”

“Are you having difficulty finding full-time job with health benefits?”

“Do you feel safe as you once did in America?”

With pauses, that is a 30 second sound bite, Not only that, it would fits nicely on 4 bumper stickers.

Wednesday, July 29, 2015

Empowering Consumers to Prevent Disease

Today I have 2 items on my reading list:

One, “How to User in a New Era of Preventive Health Care, by Elizabeth Holmes, founder and CEO of Theranos, a consumer health-technology and medical –laboratory services company, Wall Street Journal, July 29, 2015. In her piece, she states, “Laboratory tests drive 70% if all clinical decisions. They’re used to determine whether a patient should start taking medication and, if so, which one, They help doctors decide whether a patient should undergo medical procedures or be admitted to a hospital. And they’re used to identify an individual’s risk of developing health conditions such as diabetes or heart disease,” She concludes “ People should be able to get any lab test on their own. Waiting for symptoms to a doctor’s order may be too late.”

Two, the second is Start-Up Nation: Story of Israel’s Economic Miracle, by Dan Senor and Saul Singer, two journalists who report on the Middle East (A Council of Foreign Relations Book, 2009). The authors say of their book. “If there is one story that has been largely missed despite the extensive media coverage of Israel, it is that key economic metrics demonstrate Israel represents the greatest concentration of innovation and entrepreneurship in the world today.”

It might be argued that Silicon Valley, where Ms. Holmes hangs out, has an even greater concentration. The Obama administration has largely missed the power of innovation and entrepreneurship in reforming health care. CMS has an innovation center, but it mostly concentrates on developing Accountable Care Organizations and other organizational concepts that save the government money. And it levies a 2.3% tax on medical innovation companies’ profits.

I would like to pick up on Ms. Holmes idea and extend it.

Why not empower consumers to order their own battery of lab tests in a consumer-friendly setting, couple that order information with age, gender, vital signs and physical information (BP, pulse, weight, height, and blood Oxygen, and symptoms if any, and generate a report for consumer’s eyes only, using current available algorithms, to indicate the patients degree of health for their age and gender.

The report could be something called the Health Quotient ( normal range 75 to 125), the analogue of the IQ, and could indicate in plain language the state of their health, how to interpret the results, what to do if anything, and whether to consult with a physician. The consumer would own this report and could use it as a barometer of their health and whether it contains useful information to prevent disease. For this idea to work, consumers would have to be able to access the tests and vital data in accessible locations at an affordable price, which I believe could be in the $50 range. They could then use the report to present to their physician.

Sunday, July 26, 2015

Magnitude of U.S. Health Care

When you think of the magnitude of American health care, and old, healthy and sick, insured and uninsured, legal and illegal, employed and unemployed, rich and poor but mostly middle class.

America spends $3 trillion on health care, $9375 per person.

The government at CMS (Centers for Medicare and Medicaid), spends over $1 trillion for its Medicare 55 million and Medicaid programs 70 million, $8000 per enrollee.

Americans spend $1.05 trillion on hospital care, and $0.75 trillion on physician care.

Of the money spent, $1.5 trillion comes from government, $1.5 trillion from private sources, and government share is growing.
There are roughly 300,000 primary care physicians in U.S, one for every 100 citizens , and roughly 200,000 nurse practitioners and 100,000 physician assistants, with the numbers of these midlevel practitoners expected to double in next decade.

For U.S. citizens without ready access to primary care physicians, non-emergency room alternatives for routine care include retail clinics in pharmacy and grocery chains, 1900, one for every 16,800. Americans, and urgicare centers, 6400, one for every 5000 Americans. Most retail clinics and urgicenters are in heavily populated centers, not in rural areas.

Of total Americans employed, 9.0% are in health care, the largest single employment sector. One of every 8 Americans is employed in health care. Hospitals employ over 6 million Americans and over 200,000 physicians.

Saturday, July 25, 2015

What Will the ObamaCare Legacy Be?

When President Obama steps down in 2016, what will be the legacy of his signature domestic program? What will ObamaCare leave in its wake? What will be its lasting effects?

One, will it be consolidation of insurers and hospitals into giant entities
? Larry Robbins, who runs Glenview Capital Management LLC, a hedge fund, thinks so. In 2010, after ObamaCare passed, he and his partners bet the health care system was going to change, with more people gaining coverage, and insurers and hospital merging and gaining power to help government manage the new system. It was apparent government could not manage the system alone. Robbins and his partners began to invest in big insurers and big hospital systems and clung to their thesis that they system was going to change big time through two presidential campaigns, congressional shoot-outs, two midterm defeats for Democrats, and two Supreme Court cliffhangers.
Their bet has paid off handsomely. Only three giant insurers remain – United, Anthem-Cigna, and Aetna-Humana. Hospitals are merging into giant chains. Glenview now owns shares in seven huge health insurers and hospital operators with these values of holdings and year-to-date changes in stock price in 2015: Humana $926.7 million +28.6%, Tenet Heathcare, $863.6 +15.2%, Anthem $759.5 million +23.5%, Community Health Systems , $712.3 million +9.2% HCA Holdings, +27.2%, Aetna $395.2 million, +26.1%, and Cigna $274.6 +50.0%.

Legacy lessons? As big government grows bigger, it’s easier for government to manage and control the system through bigger players delivering the health care goods, namely big insurers and big hospitals. Consolidation, in other words, is the ObamaCare legacy endgame.

Two, will the legacy be growth in government coverage and decline in employer coverage? Will coverage of employees under ObamaCare, with its mandates that all workers be covered, all plans have comprehensive “essential” benefits, or suffer onerous penalties, and force employers to drop or shift risks by offering only high deductible health plans? This is not only possible but probable. Since 2005, the percentage change in annual enrollment by coverage type has been;

• Medicaid, + 52.2%, 69.7 million people

• Medicare, + 31.1%, 54.1 million people

• Individual, including Medicare supplemental and health exchange plans, +25.4%, 25.2 million.

• Employer sponsored plans, -3.5%, 172 million

In other words, government sponsored and mandated plans dominate U.S. health care and are the fastest growing health market segment.

Three, will big government break the back of the medical profession by consolidating it and by deemphasizing autonomy and minimizing personal individual patient attention and cutting fee-for-service reimbursement by transforming to a system based on “value,” i.e, managerial and computer-judged population outcomes geared to lower prices as managed by teams using big data and online algorithms paying for by bundled services across the continuum of care?

Four , will the legacy be further fragmentation of the system with government controlled clinics, retail clinics, hospital-owned urgent care centers and other decentralized outpatient facilities, and private physicians in consumer-focused outpatient diagnostic and treatment centers, offering convenience and greater consumer satisfaction and fighting for market share in a two-tier health system, designed for those who can pay or not pay?

Five, or is it possible that ObamaCare will falter and break up in the shoals and on the shores of economic and reality
because of broken ObamaCare promises, out-0f-control costs, loss of patient choice and freedom, public distrust, and political defeats at the presidential and congressional ballot boxes?

Only one thing is certain. The Republicans cannot beat something, ObamaCare, with nothing, complaints and criticism of ObamaCare, without a unified alternative that covers more people at less cost with more choice.


Six, will it be all of the above, implemented in one way or another?
Probably, and maybe that’s the way it ought to be in a multicultural democracy that desires individual choice, quality options, and personal freedom with privacy.

Thursday, July 23, 2015

Physician Pride and Autonomy

That the Accountable Care Act has wounded the pride of doctors and eroded their autonomy there is little doubt. Patients with primary care physicians are flocking to retail clinics staffed by nurse practitioners and physician assistants and to urgent care centers when they have no primary care doctor. Politicians are saying only the government, not physicians, can be trusted to deliver care. Doctors are rushing into hospital employment because they cannot afford to maintain private practices because of low reimbursement and government regulations . Americans are being told that only comparative data generated by computers can be trusted, not clinical judgment and experience, as a basis for paying physicians and judging “value” of services. Doctors are being replaced by nurse practitioners and physician assistants, or teams of other care professionals, to provide “coordinated care across the continuum.”

To make matters worse, there is no unifying national organization representing physicians to respond to these challenges to physician pride and autonomy. The American Medical Association is no longer respected and has declining membership. Organizations like Sermo, the Physicians Foundation, medical societies and academies represent different physician constituencies, and groups like the American Association of Physicians and Surgeons, or the Free Market Medical Association are regarded as too conservative.

The American public is confused. They consistently disapprove of ObamaCare, usually by double digit margins. They want to see a doctor but are having a hard time finding one. More than one-third are now enrolled in Medicare (55 million), Medicaid (70 million), health exchange plans (10 million), and at least one half receive government benefits in one form or another the VA, food stamps, disability payments, Social Security.

It is in this setting that a new physician organization, the United Physicians and Surgeons Association (UPSA), has been formed to address physicians dilemmas. UPSA will meet in Keystone, Colorado, on July 24-26 at a physician summit meeting to consider physician options and how to respond to ObamaCare, which appears to be here to stay, to bundled payments for episodes of care rather than fee-for-service, to declining physician reimbursements and regulations, to online virtual relationships between patients and doctors, to the constraints of hospital employment and its high costs for patients, to walk-in clinics as an option to physician office visits, to how to use new social media and mobile device innovations to improve care and convenience and market their services, to market -based alternatives, such as direct ambulatory primary and surgical care devoid of 3rd party involvement, to and high deductible savings accounts, in which patient mus pay up to the amount of the deductible. In the age of a rapid changing culture in which physicians are considered as just another market commodity, and which are sometimes viewed with irreverence, there is no single magical answer to these various challenges. Thee are only niches to be filled, and alternative consumer-friendly markets to be developed.
Convenient Ambulatory Retail Care


If you have any interest in the powerful expansion of retail ambulatory care, as delivered by nurse practitioners and physician assistants in pharmacy and supermarkets, I invite you to read two articles in the July 23 issue of the New England Journal of Medicine:

“The Expansion of Retail Clinics- Corporate Titans vs.Organized Medicine,” by J.K. Iglehart, national correspondent for the Journal.


“Convenient Ambulatory Care – Promise, Pittfalls, and Policy, “ by three authors from the New York City and Health and Hospitals Corporation.

The articles messages are unmistakable: walk-in clinics in pharmacies and supermarkets, now numbering 1900 and owned by corporations and staffed by nurse practitioners and physician assistants, and walk-in clinics, 6400 of them, staffed by family physician and emergency room physicians, and owned by various health care entities, are growing like topsy.

Together ambulatory care setting visits account of one third of health care spending. Why the rapid growth of wall-in clinics? The reasons are varied, but walk-in clinics appeal to health care consumers. They can expected lower prices, extended hours, to be seen immediately, low-acuity care, immunizations, some preventive care, and insurance coverage, and they do not require a primary care physician to get care.

Here are the main players in the commercial market.

CVS, clinic name – MinuteClinic, 980 clinics


Walgreens, clinic name – Heslthcare Clinic, 400 clinics



Kroger, clinic name – the Little Clinic, 159 clinics



Target, clinic name – Target Clinic, 80 clinics (on June 15, 2015, CVS acquired Target pharmacies and clinics, which will be rebranded as MInuteclinics)



Most of these clinics share information and referrals with primary care physicians. Urgent care centers have relationships with health care organizations such as EpicCare, various proprietary hospital system, eClinicalWorks, or Athenahealth.

Walmart’s is also in the ambulatory game. The huge retail chain has announced it will operate “Walmart Care Clinics,” in conjunction with QuadMed to arrange for community-based physicians to provide clinic oversight. Walmart now runs 17 clinics in Texas, South Carolina, and Georgia.

Overall, CVS with 7600 stores, WalGreens with 8200 stores and Walmart with 4500 stores, have plenty of room for expansion of retail clinics.

A number of medical organizations – the American Medical Association, the American Academy of Family Physicians, and the American Academy of Pediatrics have questioned retail clinics quality of care. The Academy of Pediatrics have been the most strident, saying retail clinics are an “inappropriate source of primary care for children because they fragment children’s health care and do not support the medical home.”

According to J. Hwang and Mehrotra, writing in the Harvard Business Review in 2013, retail clinics, despite their rapid growth, have failed to transform health care because of regulatory and reimbursement barriers. Nevertheless Iglehart observes, “changes in policy under the ACA, a loosening of state restrictions on nurse practitioners’ practice, and the movement toward value-based car won’t erase all the obstacles facing retail clinics, but the train has definitely left the station.” Whether retail clinics will contribute to the ACA “train wreck,” a term coined by Max Baucus, former Democratic senator from Montana and now ambassador to China, or transform health care is for history to judge.