Costs - In the Abstract Not The Concrete

A husband and wife watch their children play in the newly laid sidewalk.. The husband fumes, his neck veins distend, his eyes bulge, his mouth froths. His wife confronts him, “But Dear, I thought you loved children.” He replies,” In the abstract, not in the concrete!”


Lowering health care costs is like that. In the abstract, given current trends, we must lower costs. Peter Orszag, director of the Congressional Budget Office, and Philip Ellis, his senior analyst (NEJM, Nov. 8, 357:1885-2007), put is this way,


“The long-term fiscal balance of the United States will be determined primarily by the future growth of health costs. If cost per enrollee in Medicare and Medicaid continued to grow at the same rate as they have over the past four decades, federal spending on the two programs alone would increase from about 5% of the gross domestic product to about 20% by 2050- roughly the share of the economy now accounted for by entire federal budget.”


So, constrain costs we must.

But how?

One, in the abstract, generate more information about treatment effectiveness and align incentives. In the concrete, this is behind P4P programs, yet to be broadly tried (or proven).


Two, in the abstract, expand federal disease management programs and coordinate care to reduce costs. In the concrete, Medicare disease management demonstration programs have been found to improve care but not reduce costs.


Three, in the abstract, “target” specific diseases, e.g...diabetes and heart failure, which cost the most and pay more to those who reduce costs. In the concrete, end fee-for-service reimbursement to remove incentives, and then reward salaried groups of physicians.

Four, in the abstract, have consumers themselves ration care by requiring them to pay more and by giving them tax incentives to seek less care. In the concrete, given deep roots and expectations engendered by the entitlement mind set, this is politically difficult.

In the abstract, it boils down to finding what works, targeting high-cost patients on whom it works, and paying physicians more who make it work. If all else fails, there’s always the “R” word – rationing. Maybe, in America, land of abundance, voluntarism, and innovation, we won’t step in that concrete.

U.S. Health Care, According to The New York Times

In the movie Patton, when asked if he reads the Bible, General Patton replies, “Every God-Damn day!”


I might answer the same if asked if I read The York Times. Its reporting on health care is simply too important not to be missed, and its editorial page, which faithfully reflects its ideological beliefs.


New York Times reporters do an excellent job reporting health care news and physician activities, though they’re sometimes critical about doctors using technologies for personal gain.


The Times Op-Ed page is something else again. It has never met a single payer scheme it didn’t like, claims most developed countries have vastly superior health systems, tirelessly thumps health planks of Democratic presidential candidates, and never misses a chance to criticize the “lagging U.S. health system” (lagging is The Times favorite word for describing our system).


Health Care Reporting



Let’s first consider The Times health care reporting. Take the Nov. 6 edition.


It presents a profile on Col. John Holcomb, the army’s top trauma surgeon, who, among other things, is said to conduct overly-aggressive clinical trials on the battlefield, and is fond of quoting the statistic, that, among U.S. civilians, trauma leads all diseases in terms of life-years lost, more than heart disease or cancer. That’s useful statistic to keep in mind when comparing national health systems, for if one takes trauma and violence into consideration, U.S. longevity statistics are comparable to any other country.



It reports on withdrawal from the market of Bayer AG’s heart drug, Trasylol, on basis of Canadian and NEJM studies suggesting the drug increases death rates among heart. dialysis, and stroke patients.



It tells the tale of Susan Wicklund, M.D., an abortion doctor as told in her forthcoming book, This Common Secret: My Journey as an Abortion Doctor (Public Affairs).



It announces the Times Health Guide which contains information on more than 3000 health care topics.


There reports are balanced straight reporting.


Op-Eds


Now let’s look at The Times editorials and one Op-Ed column, that of Paul Krugman, as evidence of a newspaper with its ideological blinders on.

Here’s the opening of Krugman’s Nov.9 column,

“Health Care Excuses,”
“The United States spends far more on health care per person than any other nation. Yet we have lower life expectancy than most other rich countries. Furthermore, every other advanced country provides all its citizens with health insurance; only in America is a large fraction of the population uninsured or underinsured.”


“You might think that these facts would make the case for major reform of America’s health care system — reform that would involve, among other things, learning from other countries’ experience — irrefutable. Instead, however, apologists for the status quo offer a barrage of excuses for our system’s miserable performance.”


No mention is made here that European nations like The Netherlands and Switzerland are turning to consumer-driven solutions, or that if one removes violence and accidents from the statistical mix, U.S. longevity is just as good as any other country; or that many countries with universal coverage lack access to life-saving high technologies, have overt rationing, feature long waiting lines, allow many patients to die while waiting or after being sent home to put their affairs in order, or that socialized systems can’t simultaneously have generous social welfare benefits and robust economies.



An Oct. 31 editorial “America’s Lagging Health Care, “The Times editorialist, says our “fragmented” system (code for lack of universal coverage) is sub par and substandard, performs poorly compared to other nations, causes Americans routinely to go without care, and fails to afford access to primary care physicians – all cited in a survey by the Commonwealth Foundation, its favorite think tank. Nothing is said of contrary points of view by think tanks like the Cato Institute, the Hoover Institute, the Manhattan Institute, or the American Enterprise Institute.


The culture of The New York Times editorial staff and
Its Op-ED contributors, idealistic and admirable as it may be, doesn’t necessarily represent fit the facts or represent the opinions as seen by others.

Those Radical Republicans

To hear people talk, you’d think Democrats are more radical health reformers than Republicans. After all, “everybody knows” Democrats want more government power and control with universal coverage based on single payer, and Republicans want the unfettered status quo.


Right? Wrong!


No major Democratic candidate espouses single payer. Instead, they’re pushing more government expansion and universal coverage , not single payer. They’d retain current employer tax breaks. None envision single payer, Canadian or European style. They know that’s not in the American cultural or political DNA,.


The Republicans, on the other hand, want to break from the employer-based system in which not only employers, but everybody else, individuals and the self-employed alike, get tax breaks. Republicans speak od universal fully –refundable federal tax credits, high deductibles, lower premiums, and consumers carefully spending their own tax-free money.


The Democratic approach of retaining the current breaks for employers only, say the Republicans, is deeply flawed for three reasons.


1. Costs rise because employees aren’t paying out of pocket and are shielded from true costs and therefore are careless in how they spend their health care dollars.


2. People lose insurance when they switch jobs and thereby may be chained to jobs they don’t really want or enjoy..


3. Exclusive employer-based coverage keeps millions of individuals from buying insurance because of lack of tax breaks available to individuals and consequent unaffordable high premiums.


Democrats may claim universal tax credits would be reckless because it would cause the current employer-based system to unravel, which it already is. Employer-based coverage has dropped from 69% to 60% of employees covered over the last 5 years or so.


“Our proposals,” i.e, the Democratic proposals, are more incremental, less radical, and less threatening because it keeps things they way they are. The Republicans, Democrats will surely argue, are the true “radicals.” Universal tax breaks would end our current employer-based health system as we know it.

Democrats are right. Republicans are the radicals. Republicans seek to alter the status quo—employers, health plans, and other third parties managing, massaging, monitoring, overseeing, or second guessing patient-physician transactions based on the patient’s perception of the value and worth of the transaction.

That, my friends, is radical. It depends on self-reliance, good information, intelligence, and trust -- qualities in short supply in this partisan world.

AMA: A Sleeping GIant Rouses

The AMA is becoming a more visibly activist organization.


The AMA recognized it was losing its membership grip and its clout as a national organization. Only about 1/3 of doctors belonged. Many felt the AMA no longer represented their point of view.



It was becoming known as a muscle-bound bureaucracy. In the public’s mind, the AMA was often thought of as a doctors’ union, protecting physician’s pocketbooks, rather than representing the public’s best interests. Furthermore, its voice among the major media and the public at large was seldom heard loud and clear on reform issues.



The AMA still has power – its journal is a first-class scientific publication, it helps create and profits from the codes by which doctors are paid, it has a strong voice in doctor training programs and in medical school affairs, and it’s a powerful lobby inside the Beltway.



The AMA’s job isn’t easy. It represents a varied, often cantankerous, mostly conservative profession made up of 191 recognized specialties, some independent, others moving to the beat of their employers or their own specialty societies.


The sleeping giant is now aroused.


The AMA has launched a public relation’s campaign, “Voice for the Uninsured.” It will reach primary care voters, crowds in football stadiums, civic and business groups. It will feature podcasts and will be on MyFace. It will run full-page ads in Time, Newsweek, and US News and World Report, and it will blanket the Metropolitan Center train station in Washington, D.C., with ads.


The AMA is encouraging members to call U.S. senators to avert drastic cuts in Medicare payments, cuts totaling 40% over the next 9 years under current law, starting with 10% cut on Jan. 1. 2008. What other profession, what member of the U.S. Congress, would put up with such pay cuts?


The AMA has sent an AMA Connect Survey online to its members asking for their opinions on four resolutions to be presented to its House of Delegates on four major issues


1) Whether the AMA should back a federal tax credit or other financial approaches to help doctors pay for purchasing and implementing electronic health records.

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2) Whether the AMA should amend HIPPA and similar regulations


3) Whether the AMA should foster legislative initiatives permitting and protecting doctors’ use of off-label drugs demonstrated to be reasonable and necessary for care


4) Whether the AMA should develop a mechanism allowing state medical societies to rank t health plans’ performance for transparency and informed decision making.


The AMA has signed an agreement with Sermo, Inc, through its website, sermo.com. Together the AMA and Sermo encourage physicians to express their unvarnished opinions about diagnostic, social, reform, health plan hassles, Medicare payment, and practice-management issues.


Out into the Open


The AMA giant has crawled out of its cocoon by reaching out to the public and its members, by launching campaign to address the uninsured issue, by asking its members to contact their senators, and by systematically encouraging members to exchange views with each other and categorizing issues that concern doctors.

Doctor Shortages - What's It All About, Alfie?

What’s it all about, Alfie?

Is it just for the moment we live?

What’s it all about when you sort it out, Alfie?

Are we meant to take more than we give?

Or are we meant to be kind?

And if only fools are kind, Alfie?

Then I guess it's wise to be cruel.

And if life belongs only to the strong, Alfie,

What will you lend on an old golden rule?

As sure as I believe there's a heaven above, Alfie.

I know there's something much more.

Lyric to Alfie, 1960’s popular song


Suddenly people want to become doctors.


I see by the latest two issues of the American Medical News that becoming a doctor is back in vogue.



The Oct.22 -23 issue runs this piece “We Have More Students, Now What?” Anticipating population growth and doctor shortages, Florida is adding four medical schools with total class sizes of 515 new students, and California is planning two schools with 192 new students. The “Now What?” part is whether Congress will fund residences to support these new students once they finish medical school.


The Nov. 5 article , “Record Number Vied for Medical School Slots, ” notes medical school applications for 2007-2008 boomed, with 31,496 applicants for allopathic schools and 11, 500 for osteopathic schools. Now only were there new applicants, but they had the highest MCAT and grade point averages on record. So much for the notion that medicine is no longer attracting the best and the brightest.


What’s it all about?


1) It’s about the imperfect art of predicting physician workforce demands. Maybe it’s all supply and demand. In the early 1980s, experts said it was excess supply. In the early 2000s, those in the know said it was excess demand. They predicted shortfalls of 50,000 by 2010 and 200,000 by 2020. Today, Florida says it will fall 6000 doctors short by 2012, and California estimates a 5,000 to 17,000 shortage by 2015. I’d like to think it’s more than supply and demand.


2) It’s about health reform and next election - about how generous the next administration will be in funding medical residencies. The Council of Graduate Medical Education (COGME) – the organization Congress set up to track workforce trends, financing, and training issues – has lost its funding. This has resulted in a disconnect between the nation’s need for more medical residents and the government’s drive to reduce costs of residency training.


3) It’s about the natural cyclic mood and meaning swings
of young people as they prepare for the future.It’s their growing economic awareness of the physician shortage. Now they seem to feel is a good time to step into the breech. It’s the realization that there’s something beyond materialism – altruism, giving back, wanting to help others, and a renaissance of the arts, religion, and spiritual needs.


I can vouch for the latter first hand. My son, Spencer, a nationally known poet and author of forthcoming book on becoming a priest. Spencer has been in retail for 10 years. He has decided to become an Episcopal priest focusing on hospice. When I asked,”Why are you doing this? “ Spencer replied, “Dad, the dying want to know they made a difference. The living seek inspiration, hope, and meaning to their lifes. Maybe I can help show them how.” Maybe he can. And maybe those crowds of young people entering medicine at this critical time can too.


How do you – you physicians out there in the trenches – account for this renewed passion to become doctors?

Hospital doctor relationships - Physicians and Hospitals: Priorities and Bottom Lines

Interview with Mike Martin, Publisher, Practice Support Resources, Inc, Independence, Missouri


Q: Mike, how long have you been a medical publisher?


A: 21 years.


Q: Your father, I know, was president of the Missouri Medical Society You cut your medical teeth there, and you’ve been working both sides of the hospital-physician aisle ever since.


A: I started out as nursing home administrator, then a physician practice administrator, then a physician recruiter, then in hospital administration, and finally I started publishing writings related to my experiences.


Q: What’s going on across the medical landscape?


A: Physicians and medical practices are seeking ways to empower themselves to manage themselves efficiently and to get the best reimbursement. It’s a constant struggle, and they’re seeking to identify the right sources to master the business side of medicine. There’s a perpetual battle between the business side of medicine and all the rules and regulations.


Q: What are the most common ways physicians seek to “empower” themselves?


A: Over the past 10 years, physicians most commonly reached out to hospitals. That outreach failed miserably because hospitals failed to recognize the business side of practices is run completely differently than the business side of hospitals. Doctors are saying, “Hospitals don’t understand and don’t work with me the right way.” Now the doctors are looking at everything from study programs on business to MBAs to how-to manuals to see what they can learn for themselves.


Q: You publish a lot of paper products – manuals, books, and instructional materials. Do physicians find this material more useful than electronic approaches, such an EHRs and Internet applications?


A: In the past electronics haven’t been user-friendly. It seems to take years for electronics – EHRs, the Web, appointment scheduling, e-prescribing – to catch on. Most doctors don’t find electronic products user friendly, efficient or effective. Physicians are waiting until electronic products become useful. During the interim, physicians will continue to use paper resources to get their jobs done.


Q; Doctors are so busy, they seem to prefer pithy manuals to electronic menus. So, during the waiting period, I suppose they’re buying items like coding and other how-to-manuals?


A: That’s right – how-to-manuals sell big. There’s a lot of ponderous academic publications with one chapter after another, but doctors like their information short, swift, and sweet. Doctors want something to the point about how-to bill, collect, manage, and train my staff to get timely payments. They like checklists and guidelines. They want to use material they can apply right now.


Q: You have an alliance with the Practice Management Institute in Texas, which is devoted to training office staffs.-- field growing rapidly under the radar. Do you find that to be true?


A: Yes, it amazes me there are these good training programs out there, and doctors fail to take advantage of what I call “real training” for a medical practice. That’s the biggest problem I’ve seen in 25 years of practice management -- lack of training of the office staff.


Q: You mentioned earlier that hospitals and doctors have a fundamentally different view of the world. How so?


A: The goal of physicians to deliver quality care to patients. That’s what they’re trained in, and that is their focus. The business part is just something they have to put up with. On the hospital side, business comes first and running profitably and efficiently. Patient care and quality are important but are secondary concerns.


Q: What preoccupies hospitals these days in their relationships with doctors?



A: Competition with other hospitals and with doctors. They fear something will take their market share away, another hospital, a joint venture, a medical group going from one hospital to another. I’ve seen a resurgence of buying practices to allay these fears and to buy loyalty.


Q: What are your best selling publications?


A: They always relate to the bottom line – collecting, coding, how-to-manuals – anything that cuts through the management challenges, rules, regulations, Medicare and Medicaid bureaucracies. Learning the so-called “coding game,” its changes and nuances, is a non-stop exercise. Physicians are also looking at cost and efficiency measures, but it always comes back to billing, collecting, and coding.


Q: Speaking of the bottom-line, we’ve reached to the bottom-line of this interview. Thank you.


Publication information on Physician Practice Management and Physician-Hospital Relations can be viewed on the Practice Support Resources, Inc. website www.practicesupport.com. For publications related to this topic, see Sailing the Seven “Cs” of Hospital Physician Relationships, The Voices of Health Reform, Innovation-Driven Health Care, And Who Shall Care for the Sick?