Friday, August 28, 2015

The Truth about Doctor Demand Dilemmas

As scarce as truth is, the supply has always been in excess of the demand.

Josh Billings (1818-1885)

As the physician shortage grows, technology advances, and government-subsidized care expands, the truths of the law of supply and demand become evident.

The demand side of the supply and demand equation states says that as the quantity of a good demanded falls, the price of the good rises.

Costs of care are rising, as premiums spike, often by 20% or more. Demand for physician services is growing. This demand stems from an aging population with more chronic diseases, technologies proven to alleviate those diseases, physician shortages across the board, expanding government programs - Medicare, Medicaid, and health exchange plans, more physicians not accepting those in government subsidized plans.

The truth is that the physician shortage is growing. It stands at 50,000 today and may exceed 100,000 by 2015. How could this be? Physicians are among the top 5 % in income, with top-earning specialists making $300,000 or more, and primary care doctors pulling down $150,000 or more. And physician recruiting firms report doctors finishing residencies get 100 or job offers, mostly from hospitals or large physician groups. These jobs generally come with health benefits , malpractice coverage, time off for vacations, and help paying off educational debt.

What’s not to like about becoming a physician? Well, as a recent “summit at the summit” meeting of physicians sponsored by United Physicians and Surgeons highlighted, there’s a lot not to like, including intervention into the patient-physician relationship, loss of physician autonomy, unreasonable credentialing requirements, unnecessary installation and use of dysfunctional electronic health records, time and effort spent searching for arcane IDD-10 codes to get paid, and second guessing at every step of the authorization of procedures and billing process.

The truth is that many, if not most physicians, are unhappy campers on the federal camping grounds. The truth is that health care has become a huge national business, consuming nearly 20% of GNP. The truth is that health care has consolidated into massive entities, with government, insurers, and large integrated health systems at the controls, rather than independent physicians in scattered practices. The truth is that costs of entitlement programs are becoming unsustainable, that something must be done to control costs, and that those controls begin with controlling physicians. The truth is that it is difficult, if not impossible for government, to dictate and monitor care from the top-down in a system involving billions of transactions at the bottom of the system.

The truth is that physicians are seeking ways through, out, and around the demands being placed upon them. These ways include becoming more efficient by using more physician assistants, nurse practitioners, and data scribes; opting out of the system by foregoing 3rd party participation and contracting directly with employers and patients; and going around hospitals and other competitors, by creating more focused, efficient, convenient physician-owned and directed facilities.
Where the physician Merry-Go-Round stops no one knows.

Thursday, August 27, 2015

ObamaCare Doctrine : No Risk, Everyone Gains, Except for Those Paying Higher Premiums and Deductibles

The ObamaCare doctrine is this: if you end the financial risk for caring for the sick and the needy, if insurers and government guarantee equal access to all regardless of their age, gender, and pre-existing medical conditions, all be well.

The problem with this ideological doctrine is that it doesn’t work very well in the real world. It may work well for the subsidized poor (3% of the population) and those who have neglected care because of costs, but it doesn’t work very well for for-profit insurers, who are beholden to stakeholders, and for the middleclass, who must bear the burden for health care without risks.

Risk is an essential pre-condition of the capitalistic society. Investors and entrepreneur are wary of anyone who urges action in which they incur no risk. You take your chances, and you accept the consequences.

With ObamaCare, consequences of accepting all comers for insurance coverage and guaranteeing that all comers will receive standardized, comprehensive coverage without regard to financial risk, has been and will continue to be increased premiums and deductibles.

It should be no surprise, then, that major insurers in some states have raised premiums in the health law’s third year, despite the ObamaCare’s insistence it will force states to justify these increases. Insurance regulators in multiple states have approved premium increases as “justifiable” because of the hefty increases needed to cover higher –than expected claims for sick people who signed up for health exchange plans.

Among the state raising premiums above 20% are major insurers in Tennessee, North Carolina, Maryland, Idaho, Oregon, and Kentucky. The problem is keeping insurers in business and staying financially sound while providing insurance. Five major insurers – Blue Cross and Blue Shield of Rhode Island, Medical Mutual of Ohio, MVP Health Care, Anthem, and Blue Cross of Michigan 0 have proposed raising premiums by more thatn 10%.

Requiring companies to allow anyone to buy policies, regardless of medical history, age , or gender comes at a cost. The Obama administration says people should shop around, but this is difficult in states where the major insurer dominates the market and where shoppers cannot cross stateliness in search of a better deal.

Tuesday, August 25, 2015

On Moving the Physician Movement Forward

There are always two parties, the party of the Past, and the party of the Future, the Establishment and the Movement.

Ralph Waldo Emerson (1903-1882), Notes on Life and Letters of New England

On July 20-26, 2015, a new physician organization, the United Physicians and Surgeons (UPSA), held a conference, dubbed the Summit at the Summit, in Keystone, Colorado.

The conference featured over 40 speakers. Speakers represented many physicians and physician organizations, both bearing workable innovative ideas. The conference was designed to restore physician autonomy, protect the patient-physician relationship, and reset relationships between overreaching government and corporate entities.

Conference attendees were enthusiastic about this physician Movement to restore the voice of medicine.

But inevitable questions arose: Where do physicians go from here? How do we sustain the movement? Where will funding come from? What form will the Movement take? How will physicians inform hundreds of thousands of fellow physicians and millions of their patients about grievances of physicians, their ideas for the future, and what can be done to improve quality and convenience and confidentially of care?

The challenges are daunting. Private practice and ownership of those practices are declining. Fee-for-service reimbursement is shrinking. Government and the public tend to trust large integrated organizations more than individual physicians. Physicians are not united. They are splintered into numerous state and specialty societies , and many owe their allegiance to their hospital employers. Older and younger physicians think differently, as do male and female physicians, as do specialists and primary care physicians. ObamaCare health exchange plans offering subsidies to 11 million patients already exist. And last, but certainly not least, there is no widely accepted organization, like the American Medical Association, whose membership has dropped from 85% to 15% of physicians, to represent practicing physicians. Given these realities, how do physicians maintain the momentum of the movement?

The Physician Movement has no single driving force. It reflects the general dissatisfaction of physicians of how the system is evolving and where it is going. The Movement is diverse. It will be composed of direct care practices devoid of government and insurer oversight. It will consist of groups of physicians complying with rules of the Establishment. It will feature collaborative ventures between hospitals and physicians, physicians and employers, and physicians and patients.

There was no shortage of ideas at the conference – direct patient care (concierge medicine and all-cash surgery centers), a moratorium of electronic health records, expedited ICD-coding, credentialing changes, independent practice associations competing with corporate entities, physician unions, new forms of health insurance, and national alternatives to ObamaCare should it be repealed or replaced.

The hottest ideas at the moment are to disseminate videos of the various speeches presented at the conference for distribution, to create 30 minute videos for other physicians and the public at large explaining the need for a physician movement.

I have an idea of my own: to transcribe the 40 speeches given at Keystone into a single Kindle e-book for sale to larger audiences.

Finally, I believe physicians need to spend more time developing collaborative ventures with hospitals and insurers and employers without compromising the principles of any of the participants. One form this could take would be bundled pricing for disease episodes or hospital admissions with discounted fees for physicians and hospitals with back-up reinsurance should the total fee exceed estimates. This could be workable alternative to Accountable Care Organizations, which have not worked well because of government regulations. Another form rapidly evolving are primary care practices offering bundled services for a fixed retainer price.

Hospitals and insurers are not going away. They are twin pillars of the current system. Work with them but keep your distance and maintain your core patient-protection principles.

Encourage development of physician-owned and directed focused, efficient, and convenient ambulatory diagnostic, treatment, and surgery centers, The future will be outside hospital walls in convenient community locations.

Meanwhile we physicians should reaffirm our commitment to the principles of individual freedom and choice, to the sanctity of the patient-physician relationships, and to limited government and corporate intervention. But we should distinguish between what we cannot alter, what we must accept, and what we should embrace. We should help design principled reforms that can win majority support to include a diversity of opinion.

For more information on the work and progress of the United Physician and Surgical Association, see
Obama: First Class, Intellect. Second Class, Temperament

America is still the best country for the common man. The common people feel at home here. America is still an ideal country who want to realize their capacities and talents.

Eric Hoffer (1898-1983), In Our Time (Harper & Row)

It was Justice Oliver Wendell Holmes, who observed of President Franklin Delano Roosevelt.

“Second class Intellect, First Class, Temperament.”

By temperament, Holmes meant political instinct or predisposition, doing what comes naturally.

President Obama has a first class intellect, honed by an unusual ethic heritage, a tight circle of progressive advisors, Harvard law school training , and a commitment to organizing minorities to overcome past social and economic inequities, but his temperament – for the America’s center right culture his political instincts may be lacking or off-base.

Nothing, he seems to think, can stand in his way - not Congress, not Republicans, not the Constitution, not peace and prosperity, not international terrorist disarray, not traditional allies, not public unpopularity of his health plan, not compromise with his principles. He has the power, and the glory will be the success of his vision to achieve equal outcomes for society and America’s place in the world.

By Guess and by God and by Obama and the power of sheer political will, he will transform America.

Obama’s mindset brings to mind Eric Hoffer (1898- 1983), the longshoreman philosopher. Hoffer’s take on the presidency was the last thing we need as a president is an intellectual. Intellectuals think of themselves are part of a superior educated minority, a cut above ordinary mortals. Intellectuals see the world in their terms. They think they have the answers and an end product that will right the wrongs of mankind.

There is nothing special about America. It is not a Shining City on the Hill as portrayed by Reagan. It is not exceptional. It is merely one of many nations. And when push comes to shove, it must accede to the wishes of its adversaries and placate them.

But common people do not see themselves or America that way. They think America is a special place. They distrust intellectuals. They are always striving, looking for individual ways up and out of the trap called life. They distrust big government , big taxes, and big regulations that hamper their freedom, cramp their life style, and violate their sense of manifest destiny.
They are interested in the individual good as well the common good and see the two as going together. They believe in innovation and entrepreneurship as a way of rising above it all.

For President Obama, the principled intellectual, the irony of the contradictions between intellectuals and the common man, is that Obama is for the common man.

Monday, August 24, 2015

Tom Coburn, Foe, Critic, and Friend of Obama

On the CBS program, 60 minutes, retired conservative Republican senator, Tom Coburn, of Oklahoma, said he was “proud” America had twice voted for Barack Obama as President. The vote showed America was a great country, largely free of the racial bigotry of which it is accused. Although a frequent foe and critic of Obama, Coburn said he was also a friend of Obama and had worked with him on many issues. Obama, Coburn added, is a serious man, not a glad hander, who deals easily with members of the opposition.

Sunday, August 23, 2015

Trump: Mastering the Art of Cooking the Books of Political Correctness

Donald Trump says the two best selling books of all time are: number one, The Bible, and number two, The Art of the Deal, composed by Donald himself. By citing The Bible, he appeals to Christian Evangelicals, one of his core constituents. By referring to The Art of the Deal, he promotes himself.

The Art of the Deal , part memoir and part business advice, was published in 1987. It stayed on the New York Times best seller list for 51 weeks. It sold over 1 million copies. It may not be the best selling business book of all time, but it shows that Trump has mastered the art of self-promotion. He is leading the polls among evangelicals, Republicans, conservatives, college-educated, the silent majority and people who have never voted before. To his critics, who label him as a self-aggrandizing blowhard, he says in a self-quote on this week’s Time Magazine cover, “deal with it.”

Trump has turned the political world and conventional wisdom upside down. How has he done it? Well, among other things, he has attacked “political correctness,” defined as avoidance of expressions perceived to exclude, marginalize, or insult groups of people who are perceived as socially disadvantaged or discriminated against.

It is, for example, politically correct to say that immigrants are poor, beleaguered souls who flow across the border or die trying, seeking a better life for themselves and their children. “Calling undocumented immigrants ‘illegals’, says Emily Bazelon in the August 13, 2015, politically correct New York Times Magazine, “implies that they are less than human and undeserving of fair treatment. ” Nonsense, says Trump, many illegal immigrants come to commit crime, rape, and pillage.

It is politically correct to protect immigrants with minor crime records from over-zealous, biased, conservative public officials in sanctuary cities. Send them back to their home countries, says Trump.

It is politically correct to say that there exists a war on women in corporate board rooms and in health care facilities. Ridiculous, observes Trump, the U.S. worships women, who are among the best treated and most accomplished in the world and they deserve better than late term abortions with selling of fetal body parts.

It is politically correct to say that the police have declared war on unarmed blacks. Patently untrue, counters Trump, black on black murder is a far greater problem. Policemen are among our best citizens. We need to respect them more, not less, and we need more of them enforcing the law, not less.

It is politically correct to say politicians have the best interests of their constituents at heart. Not true, observes Trump, they only have their own self-interests and getting re-elected at heart, and act in the best interests of their biggest contributors.

And so it goes. Asked if Trump had crossed the line with his language and his attack on politically correct language, Carl Tomanelli, 68, a New Hampshire police officer, commented, “People are starting to see, I believe, that all this political correctness is garbage, and I think he is echoing what a lot of people feel and say(“Why Trump Won’t Fold: What Polls and People Say,” New York Times, August 23, 2015).