Sunday, November 23, 2014

My Favorite 12 Sources of Health Reform Information

There is no accident in our source of reading.


Francois Mauriac (1995-1970), Memoires Interieures (1958)

You can tell a man’s bias by his sources, and what he picks from those sources. We are all creatures of habit. It is my habit to scan these 12 sources before I sit down to write a blog.

1. Real Clear Politics - This blog features a cross section of political opinion. I like its average of polls on Obama approval ratings, direction of country, and health care law popularity.

2. New England Journal of Medicine - I am lifetime subscriber. I read its “Perspective” section. Each weekly editons contains four to five articles, which generally support ObamaCare.

3. Wall Street Journal - Most widely read newspaper. Conservative. Arch opponent of ObamaCare mostly because of its conservative ideology and its baleful effects on economy.

4. New York Times - Editorial board is fierce advocate of ObamaCare. Board’s comment today, “Republicans are not interested is improving the Affordable Care Act. They are bent on destruction” is typical. Other writers, like Robert Pear, are more balanced.

5. Grace Marie Turner, Galen Institute - Conservative, Opposes ObamaCare. Favors market-based approach. Writes for various publications.

6. KevinMD.com - Calls himself “the social media’s leading voice. “ Internist. Blog features his opinion plus other physician’s comments and blogs, including mine.

7. The Health Care Blog - Comes out of San Francisco. Has many physician blogs. Tends to be liberal and supportive of managed competition as seen from left coast.

8. Kaiser Health News - A daily compilation of health care news from major news organizations. Also has longer reports by its editorial staff.

9. Health Leaders Media - Has solid editorial staff who write what health care leaders, often hospital based think. Also contains list of clickable articles on health issues from elsewhere.

10. Washington Post - Mix of articles, pro and con on ObamaCare, as seen from inside the Beltway. I am fond of reading Charles Krauthammer and George Will columns.

11. Fox News - Dominant Cable News TV channel. Source of hard news. Critical of Obama administration and ObamaCare.

12. Myself - Whatever comes into my head. Tends to be center-right, pro-democracy, pro-voter, pro-market driven and patient centered care, pro-physicians, and pro-innovation. As E.B. White said in Elements of Style, “All writing is communication. Creative writing is revelation – it is the Self escaping into the open. No writer remains incognito.”

Saturday, November 22, 2014

Surgical Safety and Quality in Hospitals and Ambulatory Surgical Centers

Clearly quality, like beauty, is in the eyes of the beholder.

Humphrey Taylor, Chairman of Harris Poll and Harris Interactive, in The Health Care Blog

On the public's eye , safety has moved from and center since the recent death of 81 year old comedian Joan Rivers in a New York City ambulatory surgical center (ACS) from a seemingly minor biopsy procedure of her vocal cord.

Her unexpected death has raised this question: Are ambulatory surgery centers as safe as hospital surgical suites, where theoretically, resuscitation teams and resuscitation equipment are more available? This has lead to articles like “Quality and Safety in Ambulatory Surgical Centers” (Cheryl Clark, Health Leaders Media, November 18. 2014).

The question may be irrelevant. Hospitals are moving quickly to set up ambulatory surgical centers of their own, often in joint ventures with physicians, outside of hospital walls, in response to public demand, dangers of hospital-borne infections such as Clostridia Difficile, MRSA, and other antibiotic organisms, healthy consumers flocking to ambulatory centers, and hospitals suffering from competition from physician-owned ambulatory surgery centers.

The rapid formation of ACSs is made possible by faster, better anesthesia, less invasive procedures with small incisions, greater efficiencies and lower costs, public awareness that hospitals are dangerous places, and the simple reality that most surgeons prefer to operate in ACSs, when the patient is able, younger, needs a less complicated procedure , requires only a short length of stay, or has limited funds.

There’s another factor as well. Safety is not the same thing as quality.

Safety is freedom from occurrence of risk , injury, and complications.

Quality is a different animal. It resides in the eyes of the beholder- the patient, the physician, the supplier, the insurer, and the government overseer.

• Patients who use ACSs define quality as getting as much care as you get – the more the better, especially when it quicker, simpler, cheaper, more direct, more personal, friendlier, with more bedside matter, more amenities, such as valet parking; more modern facilities . That’s why consumers tend to prefer detached new ACSs over older centralized hospitals.

• Employers who send patients to ACSs look upon these centers as getting more bang for the buck for employees and retirees, as offering quicker, more direct care for common procedures for otherwise healthy workers, without building a corporate team to deal with the complexities of an overly complicated system.

• The Institute of Medicine and other judgmental organizations regard quality as avoidance of medical errors and implementation safety systems, which are invisible but necessary.

• Surgeons who work in ACSs think of quality as good outcomes, happy patients, a hassle-free environment, lack of restrictions and obstacles to care, greater efficiencies with more time for the job to be done and less time devoted to paperwork, your choice of surgical tools and nurses devoted to your cause, and less worry about how you’re to be paid with direct pay for what is done.

• Drug companies equate quality with use of their latest brand name drugs , a high level of compliance, and strict adherence to drug regimens, and access to physicians who use their drugs and influence other physicians.

• Government technocrats, policy makers and wonks, public health advocates believe quality resides in population health measures, wellness with avoidance of smoking and obesity, high immunization rates, longer life expectancy, and wider use of data and evidence-based medicine.

These health care stakeholders are like the Six Blind Men of Indostan, who, after feeling the various parts of the health care elephant, have their own impressions of what constitutes quality. Each is his own way is right, each is partly wrong, and each has a limited view of quality or the system as a whole.

Friday, November 21, 2014

President Obama’s Immigration “Shadows” Speech

All of us take offense to anyone who reaps the rewards of living in America without taking on the responsibilities of living in America. And undocumented immigrants who desperately want to embrace those responsibilities see little option but to remain in the shadows, or risk their families being torn apart…You can come out of the shadows and get right with the law.

President Obama, in November 20 speech promised to pull five million undocumented illegal immigrants “out of the shadows.”


As I listened to President Obama’s speech last night, I thought of a quote from Homer’s Odyssey, “Himself a shadow , seeking shadows.”

After his humiliating and decisive midterm rejection, Obama is a shadow of his former promising self, who was going to transform America and transcend partisan politics. He is limping into his second term, beset by a public that opposes his policies and who is asking for compromise.

Besides, Obama needed a bold stroke to redeem himself with his progressive political base. He felt he needed to act dramatically , some say brazenly, to confront the Republicans while winning Hispanics over for future Democrats. His apparent strategy is to cast blame on the GOP as the party who keeps immigrants furtively hiding in the shadows , out of the bright sunlight of American mainstream life.

The reaction to the speech, which as usual, was eloquent and powerfully delivered was mixed along party lines. What impact it will have is, well, shadowy. It puts Republicans in a dilemma how to respond and not to overact. But they will be in power come January, and they are likely to pursue one or all of three options: pass an immigration act of their own, underfund the Obama proposal, or sue the President for executive overreach.

In reading the various commentaries, the comments of David Gergen, a senior political adviser at CNN and now at the Harvard School of Government and adviser to four presidents, most impressed me.

Gergen begins his commentary: “There is something deeply troubling about President Obama’s decision to grant legal safe haven to unauthorized immigrants by executive order… It isn't the underlying policy that is troubling. Just the opposite. We have known for years that we would never deport some 11 million people from our midst. Many have become hard-working, productive members of our society, and Congress, working with the White House, should long ago have provided them a safe pathway out of the shadows.”

Gergen then ticks off his oncerns.

The immigration problem is not an emergency. It has been around for decades. While the President's impatience is understandable and his anger at Republican intransigence is well placed, that does not justify abandoning traditional ways of addressing hard public problems.

It is against the spirit of the Constitution. It certainly violates the spirit of the founders. They intentionally focused Article One of the Constitution on the Congress and Article Two on the president. That is because the Congress is the body charged with passing laws and the president is the person charged with faithfully carrying them out.

It is a bad way to start with new Congress. The midterm elections were a clear call for a change of course in Washington, starting in the White House. A new Wall Street Journal/NBC poll finds by 53-40%, Americans feel positive about the election results; by 56-33%, they want Congress to set policy for the country, not the President; by 57-40% they favor a pathway to citizenship for illegal immigrants but by 42-32%, they disapprove of Obama overhauling immigration through executive order. We have an action from the White House that will cast a dark shadow over prospects for legislative cooperation.

The President action has no direct effect on ObamaCare for undocumented immigrants. But in the future, it might ease their access to Medicaid, “The Sleeping Giant of ObamaCare.” For more information on the latter, see Kevinmd.com, where my blog on “Medicaid – the Sleeping Giant” appears tomorrow, November 22, 2014

Thursday, November 20, 2014

Health Reform: It’s The Diversity, Stupid!

It’s the Economy, Stupid!


James Carville, President Clinton Adviser, 1992


Since James Carville created his 1992 slogan, political slogans ending with “Stupid!” have gained political currency.

“Stupid!” is usually a positive rallying cry, but since Jonathon Gruber said ObamaCare passed because of the stupidity of American voters, Republicans claim “It’s the Stupidity, Stupid!” is one reason ObamaCare passed. We are a nation of whites, blacks, browns, yellows, blues, and reds, and it wise to be color blind but to keep in mind whites are still a majority of the mix.

“It’s the Diversity, Stupid!” would be a more appropriate reason why ObamaCare is faltering and may fail.

Previous Presidents have hailed diversity. John Fitzgerald Kennedy said in a 1963 address,” If we cannot end our differences, at least we can help make the world save for diversity.

In 1988, in his acceptance speech, George Herbert Walker Bush declared, “ We are a nation of communities, of tens and tens of thousands of ethnic, religious, social, business, labor unions, neighborhoods, regional and other organizations, all of them varied, voluntary and unique. A brilliant diversity spread like stars like a thousand points s of light in a broad and brilliant sky.”

When President Obama and Democrats passed ObamaCare, they made a critical mistake. They ignored diversity. The passed the law against unanimous Republican opposition and majority public opinion.

They forgot about diversity – the mainspring of American democracy. They forgot the majority of American people rule. They forgot we are a nation of the balance of constitutional powers – checks and balances, center right versus center left.

This forgetfulness may be why ObamaCare is in such danger. It caters the left while ignoring the right. It gravitates towards government control, away from private contributions. It does not acknowledge we must balance excellence, access, choice, and cost.

This balance is fragile. I wrote about it nearly ten years ago in a now forgotten book , Voices of Health Reform: Options for Repackaging American Health Care (Practice Support Resources, 2005).


The book featured interviews with 42 major health care stakeholders.

It ended with this overall conclusion,

“Our health system is a creature of our culture. When asked what Americans believe, Gary Orren, a professor of political science at Brandeis, who polls for the New York Times and Washington Post, said,

“A good place to start is to remember we are pro-democracy and anti-government. It comes down to ideas that are essentially anti-authority and tend towards self-regulation.

‘If there is an American creed, it might begin.

One, government is best that governs least.

Two, majority rules.

Three, equality of opportunity.’

“This seems about right to me. It explains why Americans prefer local health systems, why they reject federal government-mandated universal coverage with rationing, why they prefer they prefer pluralistic payment systems, why they allow market-based and public-based institutions to co-exist and compete, and why they permit doctors to behave democratically, seeking their own locales to practice, often acting independently of hospitals, health plans, and government, and making their own decisions , free of fetters of others.

Democracy is a messy business.”

President Obama, when unilaterally passing laws or issuing executive decrees, should keep in mind the American creed, culture, and diversity.

Wednesday, November 19, 2014

Corporate Corruption of Medicine

Make hay while the sun shines.

English proverb

There’s a disturbing trend out there.

It goes by different names – one-size-fits-all, population health, and corporate care.

It shares the notion that large corporate entities can force doctors to act in the financial interests of the corporate organization.

In a New York Times opinion piece (”How Medicine Is Being Corrupted”, November 18, 2014), Pamela Hartzband. M.D. and Jerome Groopman, M.D., husband and wife and professors at Harvard Business School, nail the problem.

“Financial forces largely hidden from the public are beginning to corrupt care and undermine the bond of trust between doctors and patients. Insurers, hospital networks, and regulatory groups have put in place rewards and punishments that can powerfully influence your doctor’s decisions.”

Among these are:

• Contracts that “pay for performance.” If doctors meet certain metric targets, e.g., lowering blood pressure or cholesterol, they are rewarded with bonuses or high placements on insurer website. If they fail to meet these targets, payments are reduced or they are given low website ratings.

• Insurers reward or punish patients by giving higher or lower co-payments doctors for using specific drugs or doctors or doctors for following certain pathways for treating patients.

Insurers, and government officials, contained that “it is obsolete for the doctor to approach each patient as an individual, Medical decisions should be made on the basis of what is best for the population as a whole.”

This, argue Hartzband and Grooper, is not only wrong but immoral. It ignores clinical judgment and patient preference, and it may harm the patient.

Power, say the two authors, now rests in the hands of insurers and regulators, and in the minds of patients , in part because they rely on information provided on corporate websites.

Hartzband and Grooper propose as a solution a new public website, similar to the one provided for Physician Sunshine Act, which exposes financial ties between pharmaceutical companies and doctors. The new website would reveal the hidden coercive forces that specify treatment and limit choices for doctors and patients.

Perhaps it is time for a little sunshine on corporate interests as they make hay at the cost of patient and doctor choice. by forcing doctors and patients to follow corporate dictates on treatment.

Tuesday, November 18, 2014

What Is Gruberism?

Maybe it is Gruberism: the belief that everybody else is slightly dumber and less well-motivated than oneself, and therefore politics is more about manipulation than conservation.

David Brooks, “Obama in Winter” New York Times, November 17, 2014


Just what is this concept called Gruberism?

Well, to begin, it’s a tried and true neologism.

It’s getting done what needs to get done,

It's how the health law’s language was spun.

It’s being thought of as an objective outsider,

When you’re in reality a subjective insider.

It‘s conning the gullible public on this fact,

A tax on them isn’t a tax when it’s a tax.

It’s being called a detached analyst,

When you’re a biased political catalyst.

It’s believing you’re smarter than the herd,

After and above all, you’re an academic nerd.

It’s thinking your motives are nobler than most,

As you collect millions on healthcare.gov's gold coast.

Gruberism is a political hot potato.

It has become a media rotten tomato.

Gruberism was once a healthcare algorithm.

Now it is a leaking digital aneurysm.

It's being a former Democratic party hero,

Where now his recognition nears zero.

Gruberism is not knowing Gruber

When he turns out to be a party pooper.