Limits of Technology - Limits of Medical Intervention

Cholesterol Lowering and Obesity Control


The U.S. government estimates the mean cholesterol of the typical adult American has dropped to 199 from about 210 a decade ago. This drop is attributed to increased public awareness of dangers of high cholesterol levels, to 60% of 70% Americans knowing their cholesterol levels, and to millions of Americans being on statins such as Lipitor, the all-time best selling drug, with $80 billion of prescriptions sold in the last 20 years.


But while we may be winning the fight to lower cholesterol, we’re losing the battle against obesity. According to the Center of Disease Control and Prevention, the average weight for men in the U.S. increased by 24 pounds from 1960 to 2002, with similar increases in women. We’re fast becoming a nation of fatties.


In a book review of Obesity : Epidemiology, Pathophysiology, and Prevention, CRC Press, 2007), Margo Denke, MD, of the University of Texas in San Antonio, remarks,


Obesity is an appropriate target for intervention, and one would have thought that almost any weapon would help to make us a worthy opponent of the enemy. But clinicians have been humbled by obesity. Each new inroad researchers have made into understanding the mechanism of obesity appears to been met with yet another battalion in the enemy’s army. Our efforts to manage obesity have been soundly defeated.


Today men are consuming 7% more calories, and women 24% more calories than in yesteryear. Food is often downed as an afterthought, as an escape from the pell-mell rush of American life. Labor saving devices, fast food consumption, large restaurant portions, sedentary time before TV and computer screens, lack of exercise, and door to door car transit – all beyond physician control – make for formidable obstacles to overcome.

The answer to obesity comes down to social and personal responsibility, often among parents. Adolescent obesity is on a rampage and will almost certainly overcome the benefits of lowering cholesterol in reducing coronary artery disease (“Adolescent Overweight and Future Adult Coronary Disease,” NEJM, December 6, 2007).

Maybe the pharmaceutical industry will come up with a blockbuster drug to defeat obesity, as Merck and others are striving to do, but chances of developing such a drug based on new chemical manipulation seem remote, as the industry lays off chemists (“As Drug Industry Struggles, Chemists Face Layoffs,” Dec. 11, WSJ, “Big Pharma Faces Grim Prognosis, Dec, 6, WSJ), as the industry fails in its quest to find new wonder drugs like Lipitor based on reshuffling of existing chemical compounds.

Perhaps doctors will find a way to quell the epidemic through patient education and counseling, but I doubt it. As we all know, the problem is cultural and societal, not medical. The question is; How can doctors help persuade people from digging their graves with their own teeth? I don’t have an answer, or a set of answers, do you?

U.S. Health Care System - Is American Health Care Manageable?

I see in the December 13th New England Journal of Medicine that Alain Enthoven, the Stanford economist who inspired Hillary Clinton’s failed managed-competition plan in 1993-1994 is at it again. This time he’s proposing America emulate the Dutch plan (“Going Dutch—Managed-Competition Health Insurance in the Netherlands”).


Enthoven’s thoughts brought to mind something I wrote back in 2005 in Voices of Health Reform after interviewing 42 “experts” on health reform.


Americans, I said, are individualistic, pro-opportunity, pro-democracy, and anti-government. These attitudes, I added may explain why Americans:


• prefer local health solutions,


• reject federally-mandated coverage with inevitable rationing,


• feel capable of making their own health care decisions,


• seek equal opportunity access to high technologies,


• prefer pluralistic payment systems,


• allow market-based and public-based institutions to co-exist and compete,


• let doctors, hospitals, and health plans act independently from government..


Elites run our dominant institutions. Their opinions don’t necessarily coincide with those of the general public. Liberal elites think we ought to have universal mandatory coverage with government making basic decisions; conservative elites think we ought to have a market-driven care with patients and doctors making decisions.. Elites on both sides control media information supplied to citizens.


Personally I wonder if this mix is manageable and if it can possibly end with a “unitary” health system. Meanwhile the rest of the civilized world wonders why affluent America doesn’t have a system that covers everyone.


Recently I ran across a book The Eagle’s Shadow: Why America Fascinates and Infuriates The World (Farrar, Straus and Giroux, 2002). The author, Mark Hertsgaard, a well-traveled journalist who has interviewed countless foreigners what they think about America, says the following reflects what others think of us.


1. America is parochial and self-centered – In health care, for example, we don’t necessarily care what others think of us.


2. America is rich and exciting – Our health system interests them because it generates most of the world’s new innovations in the realm of acute care and “medical miracles.”


3. America is the land of freedom – That’s why so many foreign physicians come to America to train and to practice, and once here, often stoutly defend America’s approach to health care.


4. America is an empire—We are hypocritical, dominant, and domineering, not our most endearing traits.


5. America is naïve about the rest of the world – Two oceans insulate us, we listen, only to our own media, and we don’t speak other people’s languages.


6. American is philistine – We;e materialistic to a fault and indifferent to the rest of the world.


7. America is the land of opportunity – We attract 85% of the world’s immigrants and generate much of the world’s wealth (and its pollution).


8. America is self-righteous about its democracy - We think we have all the answers despite our many faults.


9. America is the future - America’s arts, movies, news, Internet, and technologies set the pace for the rest of the world.


10. America is out for itself – We may proclaim ourselves as generous but down deep we’re greedy.


A national health policy might settle a couple of things. There might finally be unity in health care in the American Republic, and the old theory of states having the right to impose mandates (There are more than 1000 in individual states, including 83 in Minnesota alone) might wither away. Also people ought to able to shop across state lines for health policies anywhere in the union as advocated by the Council for Affordable Health Care (“A Health-Care Solution,” WSJ, December 12, 2007). This would do away with such abominations as the cheapest family health plan costing $20,000 in New Jersey while being available at 1/3 that cost in neighboring Pennsylvania).


My own view is we’ll muddle along. We’ll manage. In the end, we’ll do the right thing –having choice and affordability for all.


Is American Health Care Manageable?

I see in the December 13th New England Journal of Medicine that Alain Enthoven, the Stanford economist who inspired Hillary Clinton’s failed managed-competition plan in 1993-1994 is at it again. This time he’s proposing America emulate the Dutch plan (“Going Dutch—Managed-Competition Health Insurance in the Netherlands”).


Enthoven’s thoughts brought to mind something I wrote back in 2005 in Voices of Health Reform after interviewing 42 “experts” on health reform.


Americans, I said, are individualistic, pro-opportunity, pro-democracy, and anti-government. These attitudes, I added may explain why Americans:


• prefer local health solutions,


• reject federally-mandated coverage with inevitable rationing,


• feel capable of making their own health care decisions,


• seek equal opportunity access to high technologies,


• prefer pluralistic payment systems,


• allow market-based and public-based institutions to co-exist and compete,


• let doctors, hospitals, and health plans act independently from government..


Elites run our dominant institutions. Their opinions don’t necessarily coincide with those of the general public. Liberal elites think we ought to have universal mandatory coverage with government making basic decisions; conservative elites think we ought to have a market-driven care with patients and doctors making decisions.. Elites on both sides control media information supplied to citizens.


Personally I wonder if this mix is manageable and if it can possibly end with a “unitary” health system. Meanwhile the rest of the civilized world wonders why affluent America doesn’t have a system that covers everyone.


Recently I ran across a book The Eagle’s Shadow: Why America Fascinates and Infuriates The World (Farrar, Straus and Giroux, 2002). The author, Mark Hertsgaard, a well-traveled journalist who has interviewed countless foreigners what they think about America, says the following reflects what others think of us.


1. America is parochial and self-centered – In health care, for example, we don’t necessarily care what others think of us.


2. America is rich and exciting – Our health system interests them because it generates most of the world’s new innovations in the realm of acute care and “medical miracles.”


3. America is the land of freedom – That’s why so many foreign physicians come to America to train and to practice, and once here, often stoutly defend America’s approach to health care.


4. America is an empire—We are hypocritical, dominant, and domineering, not our most endearing traits.


5. America is naïve about the rest of the world – Two oceans insulate us, we listen, only to our own media, and we don’t speak other people’s languages.


6. American is philistine – We;e materialistic to a fault and indifferent to the rest of the world.


7. America is the land of opportunity – We attract 85% of the world’s immigrants and generate much of the world’s wealth (and its pollution).


8. America is self-righteous about its democracy - We think we have all the answers despite our many faults.


9. America is the future - America’s arts, movies, news, Internet, and technologies set the pace for the rest of the world.


10. America is out for itself – We may proclaim ourselves as generous but down deep we’re greedy.


A national health policy might settle a couple of things. There might finally be unity in health care in the American Republic, and the old theory of states having the right to impose mandates (There are more than 1000 in individual states, including 83 in Minnesota alone) might wither away. Also people ought to able to shop across state lines for health policies anywhere in the union as advocated by the Council for Affordable Health Care (“A Health-Care Solution,” WSJ, December 12, 2007). This would do away with such abominations as the cheapest family health plan costing $20,000 in New Jersey while being available at 1/3 that cost in neighboring Pennsylvania).


My own view is we’ll muddle along. We’ll manage. In the end, we’ll do the right thing –having choice and affordability for all.




I see in the December 13th New England Journal of Medicine that Alain Enthoven, the Stanford economist who inspired Hillary Clinton’s failed managed-competition plan in 1993-1994 is at it again. This time he’s proposing America emulate the Dutch plan (“Going Dutch—Managed-Competition Health Insurance in the Netherlands”).


Enthoven’s thoughts brought to mind something I wrote back in 2005 in Voices of Health Reform after interviewing 42 “experts” on health reform.


Americans, I said, are individualistic, pro-opportunity, pro-democracy, and anti-government. These attitudes, I added may explain why Americans:


• prefer local health solutions,


• reject federally-mandated coverage with inevitable rationing,


• feel capable of making their own health care decisions,


• seek equal opportunity access to high technologies,


• prefer pluralistic payment systems,


• allow market-based and public-based institutions to co-exist and compete,


• let doctors, hospitals, and health plans act independently from government..


Elites run our dominant institutions. Their opinions don’t necessarily coincide with those of the general public. Liberal elites think we ought to have universal mandatory coverage with government making basic decisions; conservative elites think we ought to have a market-driven care with patients and doctors making decisions.. Elites on both sides control media information supplied to citizens.


Personally I wonder if this mix is manageable and if it can possibly end with a “unitary” health system. Meanwhile the rest of the civilized world wonders why affluent America doesn’t have a system that covers everyone.


Recently I ran across a book The Eagle’s Shadow: Why America Fascinates and Infuriates The World (Farrar, Straus and Giroux, 2002). The author, Mark Hertsgaard, a well-traveled journalist who has interviewed countless foreigners what they think about America, says the following reflects what others think of us.


1. America is parochial and self-centered – In health care, for example, we don’t necessarily care what others think of us.


2. America is rich and exciting – Our health system interests them because it generates most of the world’s new innovations in the realm of acute care and “medical miracles.”


3. America is the land of freedom – That’s why so many foreign physicians come to America to train and to practice, and once here, often stoutly defend America’s approach to health care.


4. America is an empire—We are hypocritical, dominant, and domineering, not our most endearing traits.


5. America is naïve about the rest of the world – Two oceans insulate us, we listen, only to our own media, and we don’t speak other people’s languages.


6. American is philistine – We;e materialistic to a fault and indifferent to the rest of the world.


7. America is the land of opportunity – We attract 85% of the world’s immigrants and generate much of the world’s wealth (and its pollution).


8. America is self-righteous about its democracy - We think we have all the answers despite our many faults.


9. America is the future - America’s arts, movies, news, Internet, and technologies set the pace for the rest of the world.


10. America is out for itself – We may proclaim ourselves as generous but down deep we’re greedy.


A national health policy might settle a couple of things. There might finally be unity in health care in the American Republic, and the old theory of states having the right to impose mandates (There are more than 1000 in individual states, including 83 in Minnesota alone) might wither away. Also people ought to able to shop across state lines for health policies anywhere in the union as advocated by the Council for Affordable Health Care (“A Health-Care Solution,” WSJ, December 12, 2007). This would do away with such abominations as the cheapest family health plan costing $20,000 in New Jersey while being available at 1/3 that cost in neighboring Pennsylvania).


My own view is we’ll muddle along. We’ll manage. In the end, we’ll do the right thing –having choice and affordability for all.

Coding, Physician Payment - The RUC (RVS Update Committee) Ruckus

RUC is short for RBVS Update Committee. Aticles have surfaced recently questioning whether the AMA has overloaded the RUC (whose members are not known) with subspecialists. Consequently, say critics, subspecialists may be rewarded at the expense of generalists.1-4

Here is what Dr. John Goodson, a Mass General Internist, says about the matter.

I am starting to believe that the distortions of physician reimbursement orchestrated behind the scenes by the shadowy RUC are one of the main reasons US health care is in such a mess. We had posted about the RUC, based on some important articles published this year that first brought its machinations to light (1, 2,3) 4

The story of the RUC often reminds me of conspiracy theories. They (we never really know who they are) determine the fate of the world (or at least the economy). The RUC has disproportionate power and has apparently taken a reasonable idea (RBRVS) and may have corrupted it.

I don’t have the knowledge to judge the merits of Goodson’s argument.
Here’s t the AMA says about the RUC’s composition:

Composition of the RVS Update Committee (RUC)

The RUC represents the entire medical profession, with 23 of its 29 members appointed by major national medical specialty societies including those recognized by the American Board of Medical Specialties, those with a large percentage of physicians in patient care, and those that account for high percentages of Medicare expenditures. Three seats rotate on a two-year basis, with two reserved for an internal medicine subspecialty and one for any other specialty. The RUC Chair, the Co-Chair of the RUC Health Care Professionals Advisory Committee Review Board, and representatives of the AMA, American Osteopathic Association, the Chair of the Practice Expense Review Committee and CPT Editorial Panel hold the remaining six seats. The AMA Board of Trustees selects the RUC chair and also the AMA representative to the RUC. The individual RUC members are nominated by the specialty societies and are approved by the AMA.


I do know this. Primary care is on the verge of collapse, and its practitioners are taking a series of steps to reinvent themselves - same day access, no phone trees when calls are made to the office, email consults, EMRs, and group visits. In high volume, low margin practices, these steps may not be enough if (and this is a very big if ) if reimbursement is skewed against primary care.

1. Bodenheimer T, Berenson RA, Rudolf P. The primary care-specialty income gap: why it matters. Ann Intern Med 2007; 146: 301-306..

2. Maxwell S, Zukcerman S, Berenson RA. Use of physicians' services under Medicare's resource-based payment system. N Engl J Med 2007; 356: 1853-1861.

3. Newhouse JP. Medicare spending on physicians - no easy fix in sight. N Engl J Med 2007; 356: 1883-1884.

4. Goodson JD. Unintended consequences of Resource-Based Relative Value Scale reimbursement. JAMA 2007; 298(19):2308-2310.

Medicare, Specialty Hospitals, Doctors and Hospitals - Congress Tries to Tie Medicare Cuts and Specialty Hospital Ownership

A December 9 article in the Washington Post, “Limits Weighted on Physician-Owned Hospitals: Lawmakers Seeing, Curbs on Specialty Facilities to Attach Provision to Medicare Bill,” indicates Congress are trying to tie together a 10.1% cut in Medicare fees, due to be voted on January 1, 2008, with the moratorium on physician owned specialty hospitals.

Congress is playing with market dynamite.


If Medicare cuts go through, AMA surveys indicate 30% of physicians may either close their practices to new Medicare patients or cut back on services. This is the market at work. If physicians can no longer afford to accept Medicare patients, they will simply stop accepting new patients. The cut may have political consequences as well as the rising gorge of aging baby boomers are unable to find a physician who will see them.


If the specialty hospital moratorium is renewed, the market consequences are less clear. The community hospital lobby argues specialists are ‘cherry picking’ profitable heart and orthopedic patients, thereby depriving hospitals of much needed revenue to treat less profitable patients. Specialists, who now “own” some 180 hospitals across the land, argue specialty hospitals provide better care of higher quality with better outcomes, and represent the market at work.


Senator Grassley, R-Iowa, who opposes doctor-owned hospitals, argues:

"My motivation for seeking reforms over a long period of time is the effect that specialty hospitals have on community hospitals when specialty hospitals pass the buck on emergency care and cherry-pick based on profits rather than patient needs."

Pete Stark, Democrat Representative from California, no friend of doctors, weighs in “The major hospitals are more or less being cannibalized.”

On the other side of debate are these statements:

"To say that competition in the hospital business is bad goes against all the factual information that we have," saya William G. Plested III, immediate past president of the AMA, which opposes ownership restrictions. "We have all kinds of data that show that if you have a specialty hospital open up, the first thing that the general hospital will do is to try to improve their quality to compete."

Badr Idbeis, co-founder of Kansas Heart Hospital and president of Cardiovascular Hospitals of America, complains traditional hospitals use their muscle to lure patients, negotiate exclusive agreements with insurers, and pressure doctors not to send patients elsewhere.

Idbeis says physician ownership will lure the best minds to medicine and ensure patient care trumps bureaucracy. Kansas Medical Center has at least one nurse for every four patients, he says, and the hospital has little administrative overhead.

"America made its greatness allowing the market to decide what works and what does not work," he said. "Obviously patients are getting very good care in our hospitals. We should let the market decide what's good and what's bad."

What do doctors outside the specialties involved in owning these facilities think about this issue? My take is that Medicare cuts, which involve all physicians, should not be tied to specialty hospital ownership, which involve only a few specialists.

Limits of Technology, Internet - Medicine Doesn't Run on Internet Time

The world now runs on Internet time.

Andy Grove, founder of Intel

Clinical medicine doesn’t run on Internet time. Health care needs are so intimate, strong, varied, and diverse with so many permutations and combinations that personal care has yet and may never yield completely to the Internet or to be dramatically improved by it.

My skepticism makes me one of a diminishing few. Others think the Internet will transform medicine. To explain how this might happen , IT professionals use the term “Killer Apps.” A Killer App, short for Killer Application, refers to any computer application of power, originality, or market reach that turns the world upside down.

Prime examples of killer apps include the Internet and Google. The latest example may be the laptop itself. If you’ve been following the news lately, you’ve no doubt heard of Nicholas Negroponte. He’s founder and chairman of the One Laptop per Child non-profit association.

Negropante believes dirt-cheap laptop computers, distributed to illiterate children in the developing world, will be a world-wide boon to education and a blessing to mankind. In the health care realm, some believe universal laptops, in the hands of Internet savvy clinicians, may revolutionize medicine But, in a foreword to Unleashing the Killer App, Negroponte cautions Internet applications are often simultaneously understated and over-hyped..

You can appreciate his comment about understatement when you consider the hoopla about electronic medicine. Consider EMRs, EHRs, e-prescribing, telemedicine, and clinical monitoring of patients with chronic disease. Yet, for most doctors not much as changed in the clinical trenches. The most evident change in clinical medicine has been CT and MRI scanning. Internists have voted these computer-guided imaging devices as the number #1 clinical innovation over the last 20 years.

As far as hype goes, we have yet to see the clinical fruits of the computer-assisted stem cell revolution, individualized treatment of disease based on genomic analysis, diagnostic support systems, applications of predictive modeling on clinical practice, or even the much touted consumer health care sites such as WebMD or Revolution Health, Most so called killer apps, in the form of sophisticated algorithms, has been applied to streamlining managerial monitoring and “tiering” of clinicians. Until the killer apps have a more direct application to clinical medicine itself, I shall remain skeptical.

Physician Leadership, The Physicians Foundation - Who Speaks for Doctors?

You’re a physician. Who, in your opinion, speaks for you?

The AMA? Theoretically, that’s the way it supposed to be. But AMA membership is slipping, and its cumbersome bureaucracy is slow to respond and hard to penetrate. Two-thirds of American doctors don’t belong, perhaps because the AMA has been relatively ineffective in matters of inadequate Medicare reimbursement, national tort reform, and rules and regulation battles with CMS and health plans.


State and local medical societies? These societies are closer to members than the AMA and are more focused on local and state issues. It was 19 state medical societies who succeeded in legal actions in 2003 against national health plans , which culminated in Aetna and Cigna providing over $150 million to form the Physician Foundation of Health System Excellence, dedicated to improving the overall health system and settling fee disputes between health plans and physicians.

Specialty medical societies? These societies represent the clinical, business, and political interests of their specialty members and hire lobbyists to work for them. But because there are some specialties (190 at last count), their overall impact tends to be diluted and drowned out in the cacophony of voices, each representing their own view of what’s best for their specialty and the nation as a whole. Probably the MGMA, a practice management organization said to represent 300,000 doctors should be included in this category.

Organizations employing physicians – large group practices, academic medical centers, and hospitals – These organizations are powerful and employ somewhere between 10 – 20 percent of physicians, but they do not, for the most part, speak for independent physicians, 70% of 80% of whom practice in groups of 10 or less. In the case of hospitals, they may be real or quasi-competitors of doctors.

Pharmaceutical companies - Relationships between Big Pharma and physicians have soured over the last ten years, because of direct consumer advertising, overly-aggressive sales reps, under the table payments to doctor consultants for drug or device promotion, rising drug costs, and a generally negative image in the media and among politicians. Physician-Pharma relationships may change as the fortunes of the Big Pharma decline politically and as the result of failing to produce new block-buster drugs (“Big Pharma Faces Grim Prognosis: Industry Fails to Find New Drugs to Replace Wonders Like Lipitor, “ WSJ, December 6. 2007).

I believe physicians will increasingly speak more for themselves through social networking websites such as Sermo.com, which will categorize and organize their points of view in such a way as to make them known to the wider public and to those who rely on physicians for their livelihoods. It’s becoming increasingly clear that for any practical reform to be achieved physicians will have to be at the bargaining table.

You physicians out there. Please let us know who you think speaks for you