Wednesday, August 20, 2014

Health Reform Law Under the Dome

Here’s one for the old dome.


These days the word “dome” is much in the news.

To begin, there is the Stephen King science fiction novel Under the Dome and the CBS TV series based on the novel. The plot concerns what occurs in a small Maine town, when town's inhabitants try to cope with the calamity of being suddenly being trapped under a dome, cut off from the outside world by an impassable, invisible barrier that drops out the sky.

Then, there’s Israel’s “Iron Dome.” That’s the mobile electronic defense system, consisting of 10 mobile radar units guided by a sophisticated computers that permit the Israeli government to identify the precise site from which Hamas rockets were launched, to show the rockets’ trajectory and direction, and to shoot down those rockets that would land in populated areas.

Of course, there’s always the Teapot Dome, a generic term referring to any political scandal that take place.

Finally, there’s all the capital domes in Washington, D.C. from whence all health laws flow. Well, not all.

There’s all those state capitol domes, 30 of which Republican governors or state legislatures control. These states have their own sets of health care laws, have jurisdiction over health plans in their states, and, according to the wordage of the Affordable Care Act, are the only government entities, that can offer subsidies to those enrolling in the health exchanges. The states can also decide whether or not they participate in the federally funded Medicaid program. Twenty six states have decided to participate.

As noted in Stephen King’s novel, this state of affairs - a dome dropping out of the sky cutting off citizens from the real health care world - causes confusion and dissension. The confusion and dissesion exists not only between the federal government and the states but also among the inhabitants of health care community itself.

As Tip ONeil , the late Democratic leader of the House of Representatives, observed,” All politics is local.”

It has been said “All politics is local.”

By one who was partisan and vocal.

Who will win, those who remain at home?

Or those who roam in U.S. capitol dome?

Who will prevail: state locals or U.S. bicoastals?

Tuesday, August 19, 2014

Retreat from Social Welfare Utopia

To arrest a downward movement is the utmost to which a Utopia can aspire, since Utopias seldom begin to be written in any society until after its members have lost their expectation and ambition of making further progress and have been cowed by adversity into being content if they can succeed in holding the ground which has been won for them by their fathers.

Arnold J. Toynbee( 1889-1975 ), A Study in History

Yesterday I joined a meeting of twelve senior citizens. The group was discussing how to best use Internet technologies to their advantage.

they learned I was a doctor, the meeting quickly deteriorated into an exchange concerning government’s role in health care. The seniors unanimously distrusted government – its motives and its methods. The language was sometimes profane and was flavored with dark conspiracy theories, such as the government will withdraw all cancer treatment for those over 75. I tried to correct their misconceptions but to no avail.

It was clear to me that ObamaCare had lost its momentum among these small group of seniors. And so, I maintain, have social welfare reforms across the globe. It was always Utopian to believe governments could provide universal health care to all citizens without adversely affecting private economies, or antagonizing demographic subgroups receiving government assistance, and such has proven to be so. Governmentcan giveth, but it cannot taketh away.

Everywhere social welfare states are struggling to goose their economies and salvage their nationalized health systems without giving away the goose that laid the golden social welfare egg.

Everywhere these states are turning to the private sector for help. In Britain, NHS-funded hip and knee replacements by private doctors have increased by 19%. The Swedish government is aggressively introducing private market forces to improve access, quality, and choices. In the U.S, the government has agreed to spend $17 billion, mostly for private referrals, to shorten VA waiting lists to prevent veterans from dying on the VA waiting list vine.

The reality is, as Scott W. Atlas, MD, physician and senior fellow at Stanford University’s Hoover Institute, says,

“The key goals for health reform -reducing spending, preserving personal choice and portability of coverage, promoting competition in insurance markets, and maintaining excellence in medicine – do not require government to directly provide insurance or health care.” (Scott W. Atlas, “Where ObamaCare Is Headed, WSJ, August 14, 2014).

How to preserve these goals without government? It has become obvious bloated governments cannot, at the same time, resuscitate the economy, generate jobs, micromanage health care, and change health care behavior and health care choices of individual citizens through individual and employer mandates.

One answer is to let consumers, using their money, through health savings accounts, to take responsibility for their own health and to choose their own doctors and health plans after being fully informed through transparent pricing, transparent information about quality, and transparent competition among care providers.

In other words, give consumers sufficient information, trust consumers to choose the best providers and to make the right choices for their health. Let the marketplace and consumers decide. Meanwhile, the U.S. government is struggling to hold its ground on the safety net gains it has won for Medicare and Medicaid patients without alienating 85% of the population who must pay for those gains by giving away some of their benefits to others. Only economic prosperity can lift all boats, and economic prosperity is something governmeent is not good at.
Chronic Disease Costs

The total medical care costs for people with chronic disease accounts for 70 percent of the nation’s health care expenditures.

George Halvorson, Chairman and CE of Kaiser Foundation Health Plan and Hospitals, Health Care Reform Now! John Wiley and Sons, 2007

When I read this comment in the New York Times:

“ In a policy change, the Obama administration is planning to pay doctors to coordinate the care of Medicare beneficiaries amid growing evidence that patients with chronic illness suffer from disjointed, fragmented care ( Robert Pear, “Medicare to Start Paying Doctors Who Coordinate Care, “ NYT, August 11),

I immediately thought of George Halvorson's work at Kaiser. George contends it takes systems thinking and systems implementation – cooperation and collaboration among physicians and health plans – to coordinate care.

In his book Health Reform Now! Halvorson cites a list of five chronic diseases that make up these costs.

1. Diabetes

2. Congestive heart failure

3. Coronary disease

4. Asthma

5. Depression

To these I would add cancer and chronic obstructive lung disease.

Halvorson notes it is not only these disease, but the co-morbidities that go with them. Chronic diseases come in clusters. Most patients have two or more of these diseases at the same time. It often takes five or six different doctors to take care of them, an even more if the patient comes down with an intervening related acute event, a myocardial infarction, a stroke, kidney failure, or gangrene requiring amputation.

These complications demand coordination, cooperation, collaboration, and unexpected costs. To minimize and rationalize these costs, Halvorson says we need to face four hard truths and to focus more on managing the chronic disease to avoid acute episodes.

These hard truths are:

One, costs are unevenly distributed 91% of the population accounts for 70% of costs).

Two , care coordination deficiencies exist (many doctors don’t communicate with other doctors).

Three, economic incentives significantly influence care (if you are not paid to coordinate care, you may not do so).

Four, systems thinking, coordinating care of chronic disease among doctors and hospitals and others may not be on the radar screen (instead we tend to concentrate on acute events, which are more dramatic and demanding of more atte4ntion.

Given these truths, CMS may be on right track when, starting in January 2015, they will pay doctors $42 for coordinating care of chronically ill Medicare patients. Unfortunately, this CMS move, like many government programs, may be subject to misinterpretation, malfunction, and abuse. It depends, for example, on doctors having electronic health records that communicate with other doctors’ electronic records. This is not yet the case in America. One doctor’s EHR may not communicate with another doctor’s EHR, and the hospital’s EHR does not talk to the multiple EHRs of its medical staff.

Monday, August 18, 2014

Transcending ObamaCare

To rise about or go beyond the limits of; to outdo or exceed in excellence.

Definition, To transcend

I have spent the morning trying to get my arms around Avik Roy’s “Transcending ObamaCare: A Patient-Centered Plan for Near-Universal Coverage and Permanent Fiscal Coverage, “ a white paper published by the Manhattan Institute where Roy is a senior fellow.

I have not yet grasped the full sweep of Roy’s proposal. Small wonder. The executive summary is 11 pages, and the report itself is 61 pages.

In essence, as its title suggests, “Transcending ObamaCare” goes beyond ObamaCare. It does not suggest repealing the law but in gutting it and restructuring it.

Roy says ObamaCare has four major problems:

One, it makes health insurance unaffordable for middle-income Americans.

Two, it causes long-term fiscal instability, i.e. cost overruns, for the U.S. budget.

Three, it dramatically expands Medicaid, with poorest outcomes of any health care system in the industrialized world.

Four, it spends over $2 trillion in the next decade but leaves 23 million lawful U.S. residents without insurance.

Roy proposes “ The Universal Exchange Plan,” or simply “The Plan.”

The “Plan” does not call for a full or formal repeal of the ACA. It has roots in the marketplace plans of two wealthy nations – Switzerland and Singapore.

These two countries have market-oriented plans offering universal coverage at a fraction of U.S. costs. Switzerland spends 45% of what we do and Singapore 25%. Switzerland fully subsidizes low income individuals, moderately subsidizes middle-income individuals, and gives no subsidies to high income individuals. Singapore funds catastrophic coverage for all citizens and reroutes a portion of payroll taxes through health savings accounts to pay for routine medical expenses.

The key reforms for Avik Roy’a “plan” include.

1. Repeals ACA individual and employer mandates.

2. Frees exchanges from most federal regulations.

3. Combats hospital monopolies.

4. Moves Medicaid enrollees and retirees into reformed exchanges.

Avik Roy projects his plan will:

1. Reduce 30 year budget debt by $8 trillion.

2. Reduce 3o year spending by $2.5 trillion.

3. Make Medicare Trust Fund permanently solvent.

4. Reduce private sector premiums.

5. For Medicaid population, improve public access by 98% and medical productivity by 159%.

6. By 2025, increase coverage by 12.1 million above ACA levels.

I do not know if “The Plan” will work as proposed, if it will be acceptable politically for the next administration or for the public at large. But Avik Roy impresses me. Liberals consider him “thoughtful;” he is author of “The Apothecary,” Forbes widely read health policy blog; he writes regularly for The National Review and a number of other major publications, and he was educated in molecular biology at MIT and in medicine at Yale University School of Medicine.

Sunday, August 17, 2014

President Obama – Lame Duck or Dead Duck

Lame duck – an elected official, often powerless in the final term of office.

Dead duck – a person or thing beyond help, redemption, or hope

Is President Obama a lame duck?

Or is he destined to be a dead duck?

Does his lowly job approval rating,

indicate his power is quickly abating?

Will the ACA see its final death knell?

Only the November midterms will tell.

Should he happen to lose the Senate.

He’ll veto repeal in New York minute.

We’ll know at his desk the buck stops,

And we’ll know health law’s repeal flops,

But then again, will he be a lame duck.

Or will he be a political dead duck

Saturday, August 16, 2014

Health Reform Game Changer: Interview with Mitchell Brooks, MD, Orthopedic Surgeon, Dallas, Texas

The chess-board is the world, the pieces are the phenomena of the Universe, and rules of the game are what we call the rules of Nature.

T.H. Huxley (1894-1963), A Liberal Education

Doctor Mitchell Brooks, an orthopedic surgeon who has practiced in Dallas for 30 years, is a man of deep convictions and fundamental beliefs.

He believes Americans consider health care a right, ObamaCare is wrong for America because of its adverse consequences, downsizing of our hospitals can be a health reform game changer, reform ought to focus first on the patient, catastrophic insurance is essential, and life is short and ought to be preserved at all costs.

These beliefs stem from his diverse life experiences: growing up in Brooklyn, college education in Toronto, Canada; medical education at the Medical College of Virginia; a spinal surgery fellowship at Bellevue; visiting lectureship at the University of Cardiff in Wales; private practice in Massachusetts and Texas, legal and compensation consultant for law firms, a leader in a real estate development company, associate for Directions International, an international management consulting firm, and recipient of a heart transplant in 2007.

He is perhaps most proud of his work at an innovator and designer of a 45,000 square foot “jeep hospital,” which he believes will be capable of providing 70% to 80% of the surgical procedures now performed in traditional hospitals at 30% of the fixed costs with much greater convenience.

Q: Why Dallas?

A : Before I came here, I was practicing in Massachusetts. The governor at that time, Michael Dukakis, basically told physicians “It’s my way, or the highway.” I chose the highway. I did a market study of states that were physician-friendly, and Texas came out number one.

Q: You had a heart transplant in 2007. Based on that experience and your multifaceted career, what would you say your working philosophy is?

A: My working philosophy is:

One, as a physician, we have very special responsibility because people trust us. That comes first. It is paramount. It is the raison d’etre for what we do. When patients lie prostate on the operating table, they are absolutely vulnerable. Most patients know little about health care. It is our job to teach them.

Two, I received nothing from the government to be educated. Government should not be able to tell me what I ought to be paid.

Three, because I set my own fees, I have to give value, and value-added services for those fees. That includes pre-operative, operative, and post-operative care. To me the most important thing is the history, and only I can take that. You can’t do a history on a drive-by visit. Your PA can’t take that history It may take an hour and a half to get a good history.

Q: You have said a lot of people who write about health reform don’t write about it from the patient’s point of view. What is that point of view?

A: It depends on the patient. It is incumbent upon us to educate the patient. The patient is your customer more and more these days because of the high deductibles. You have to put yourself in the patient’s shoes, where I have been, and find out what the patient wants and what the patient needs. That determines who you approach the patient and the manner in which you make suggestions. If the patient thinks their wants and needs are attended to, it is incredible what happens. I have been practicing orthopedic surgery since 1982, and I have never been sued. I am very selective. If the patient is not a good fit for me. I will see them for the first time, and I won’t charge them for the visit. I will suggest they see another doctor.

Q; You frequently appear on Fox News and Fox Business. Among other things, you talk about why the young invincible are not flocking to ObamaCare, why ObamaCare is killing the middle class, how innovation will reduce health costs, why ObamaCare has so many unintended consequences, and why the doctor shortage will surely worsen.

Have these media appearances been productive for you?

A: Yes, they have. The appearances have permitted me to get information out to a large number of people, and it has allowed me affect change. Change one person’s mind, the saying goes, and you have changed the world. I seek to get people to see things through a different set of eyes. I don’t want people to change their minds. I want people to think about something in a different manner. I think that’s critical in changing health care.

Q; You have been critical of the health law because it “robs the middle class.”

A: Absolutely. Because of the changes in ObamaCare and the way the law was written, of the various classes in our society – lower, middle, and upper class – the middle class is going to be hurt the most. The income taxes are going to hurt them the most, the hidden taxes are going to hurt them the most, the higher deductibles are going to hurt them the most, the stifling of the economy is going to hurt them the most, and ObamaCare approaching reform from the supply side rather than the demand side will hurt them the most. They have done that in Canada and Great Britain, and it doesn’t work.

I’ll let the statistics about cancer survival in Great Britain, and the waiting lists to be seen by a doctor or have a treatment speak for themselves, In Buffalo, New York , Canadians flock across the border to get their CT scan or MRI. In Ontario, the largest province in Canada 54% of the budget goes to health care. That is unsustainable. And it results in rationing. Call it what you will, it is what it is.

Q: You spent time in Wales. What did you bring away from that experience?

A: One of things I came away with was a design for a self-pay sports medical clinic. What I also took away was a good knowledge of the British system. When you consider my experience there, as a general practitioner, in Canada, in Massachusetts, my experience as a patient paying up to $60,000 for a heart transplant, those experiences give me a very special perspective of what works and doesn’t work, both from a patient’s and a physician’s perspective. I look at things from my own and my patient's perspective, and that is critical.

Q: You have made a number of talks about the importance of innovation, and one of your personal innovations is something called “The Jeep Hospital.” Why is that such a big innovation? What does this innovation bring to the table?

A: It retools the idea of a hospital as a “factory.” People pretty much agree the present hospital system, where everything is done in big hospitals, is outdated. Yet all of these bricks and mortar are constructed, and have to be paid.

But wait a minute, even given the embedded costs, do we really need beds anymore? More than 70% of surgical procedures done in the U.S. are done on an outpatient basis. Why do we need complex buildings of 100 of thousands of square feet,where you are charged for parking with detailed instructions of how to get to the ER or a doctor’s office, where you spend a substantial amount of time to get into and out of out of a complex hospital system. It may take an hour to two to navigate the complex, and that is productive time. Like their doctors, patients are busy people, and they need as much productive time as they can get.

That’s silly. If you take the same “factory”, redesign, decentralize, and downsize it, and apply it to 70% or more of surgical procedures, soon to be 80% or even 90% of surgeries you can do the same procedure at 20% to 30% of the fixed costs, and you reduce hospital costs by 35%.

The change I am suggesting is threatening. It represents what Joseph Schumpeter ((1883-1950) called “creative destruction” and what Clayton Christensen of Harvard Business School now calls “disruptive innovation.”

The analogy is the United States automobile industry in the 1970s and 1980s. The industry had to change to meet foreign competition.
The hospital industry is where the automobile industry was in the eighties. When interest rates go up, occupancy goes down, and Medicare and Medicaid payments get squeezed, hospitals will start falling like a stack of cards.

Only the large systems will be left standing. Of the 3500 current separate small hospitals, perhaps 700 of the larger systems will survie , which I personally believe was one of the goals of the Affordable Care Act.

I don’t care what the government wants. It is our government, our money, and our taxes. Government derives its power from us. If we don’t vote, we have no power. I believe if the private sector can offer a better product at a lower price with added-value and more convenience, we have something that is a game-changer, and people will vote for it.

Dr. Brooks can be contacted at