Electronic Health Records, E-medicine - Obama's E-Based Health Reform Push

One tactic Obama used successfuly to win the presidency was mobilizing support and money over the Internet. He raised a record $750 million and kept e-mail addresses of millions who contributed to this campaign over the past two years. Now Obama has became an e-health reform organizer, perhaps an extension of his knowledge gained from Internet fundraising and his community organizing efforts.

Current E-Reform Efforts

Now he is an engaged in an extensive Internet campaign promising to provide universal coverage by the end of his first term. The dimensions of this e-campaign are becoming evident and include.

1. The Obama Biden website which says.

- Obama will make affordable and accessible health care for all

- Obama will lower health premiums by $2500 per year per family

- Obama will promote public health

In addition, the web site asks for comments (it claims to already have over 10,000 suggests and offers free access clicks to Obama videos on health care.

2. Regular Obama Facebooks, with videos featuring Obama talking health care
Basic Promises

Clicking Away

Through these instantly accessible e-sites, Obama can efficiently click away again and again at his basic promises and premises.

- Savings through prevention, EMRs, chronic disease management, medical homes

- Expanding coverage through private and government-run health plans

- Making large businesses cover employees or pay a fine


- Mandating that health plans accept those with pre-existing illnesses

- Having government negotiate Medicare drug prices


- Reforming health care as an integral part of his economic salvage plan

Prospects for Success

Given his election margin (53% vs 47%), large Democratic majorities in the House and Senate, his successful Internet deployment during the presidential run, his cache of millions of email addresses from supporters, the presence of personal computers in 80% of American homes, and his promise of $2500 premium savings for the typical American family, Obama’s electronic mobilizing tactics for health reform may succeed. I would not bet against it. The only things that might prevent Obama-health reform are the economy, the soaring federal budget deficit, and the Department of Health and Human Services current $708 billion budget, 25% of federal spending and on brink of bankruptcy, but Obama is not one to let billions, even trillions of dollars, standin his way. Let the the government printing presses roll.

Medical Home Badwagon: Expectations and Assumptions

When people jump on the bandwagon, they get involved in something that has become very popular. The term “bandwagon” is usually applied to politics but spills over into other fields. It is also called the herd instinct, or going for the apparent winner.

Various Sources

Have you heard of the wonderful one-hoss shay that was built in such a wonderful way? Logic is logic. That’s all I say. Now in building of a chaise, I tell you there is always somewhere a weakest spot.

Oliver Wendell Holmes (1809-1894), The Deacon’s Masterpiece, or the Wonderful One-Hoss Shay, a Logical Story

Expectations are high. States, health plans, and the Medicare program are making substantial financial bets that implementation of the medical homes will lead not only to improved care but also to long-term savings, largely by reducing the number of avoidable emergency room visits and hospitalizations for patients with serious chronic illness. Some see the medical-home model as a means of reversing the decline in interest in primary care among medical students and residents, and others argue the broad implementation would reduce health care spending overall.

Elliot Fisher, MD, MPH, “Building a Medical Neighborhood for the Medical Home,” New England Journal of Medicine, September 18, 2008

Beware of assumptions! Whatever you assume to be possible, or impossible, may not work in the real world.

Unknown Source

When I think of the Medical Home, a concept introduced by the American Academy of Pediatrics in 1967, but now rapidly gaining speed and traction, two images spring to mind,

• One, a bandwagon.

• Two, Oliver Wendell Holme’s Wonderful One-Hoss Shay, which ultimately collapsed because of minor defects in its construction.

Bandwagon

Everybody is jumping on the medical home bandwagon. And for good reason. It’s so damn logical. Health costs are out of control. Countless studies show primary–based systems are politically popular, cost less, satisfy patients, and achieve better quality and outcomes. Besides, American primary care physicians are unhappy with the present system, and so are American patients. It’s time for a change. The problem, logic says, stems from our specialty-dominated, fragmented system and growing shortages of primary care physicians.

Why Not

Why not, then, create a new approach where primary care physicians form a medical home, and with the help of a newly hired care coordinator, and a team of providers operating under the guidance of the doctor, offer continuous, comprehensive, coordinated care of chronic diseases (the 4 C’s of medical homes).

Logic Builds Momentum

The logic of this approach explains why everybody is enthusiastically leaping on the medical home bandwagon.

Leapers include,

• Medicare and CMS, who are paying for a three year demonstration project, to be completed by 2010, to see if this new wagon works , has wheels, saves money on hospitalizations, and makes for a sustainable growth rate for health costs.

• The Obama administration, which has vowed to reform health care and save money through more primary care physicians, prevention, EMR use, and chronic care management – the medical home pillars.

• Major primary care associations – the American Academy of Family Practice, The American Academy of Pediatrics, The College of Physicians, and The America Osteopathic Association –have joined forces under the umbrella of the Patient-Centered Primary Care Consortium to issue a set of Joint Principles and are churning out white papers on medical homes.

• State legislators, who have taken the lead from state medical societies and the Physicians’ Foundation, and are endorsing Medical Home demonstration projects in at least 20 states. The numbers grow each month.


• Academic institutions, such as Johns Hopkins and the University of Rochester, who are pouring money and other resources into building and testing medical homes.

• The American Medical Association, the American Association of Medical Colleges, and societies of medical directors and state medical society executives, all of whom have bought into the concept.


• NCQA, who think medical homes contribute to improved medical care.

• Even the health plans, especially Aetna and the UnitedHealthGroup, who would like to serve as intermediaries in the process, selecting what doctors qualify for being medical home participants and what they will be paid.

Almost Everyone

Almost everyone, in other words, across the political spectrum has concluded medical homes are a significant leap forward and are willing to climb aboard for a bandwagon ride. The key phrase here is “almost everyone.” Forming and paying for medical homes is very much a political process, where “almost everybody” may not include those who want a piece of the action or feel their economic status is threatened.

Assumptions

It is assumed, of course, coordinated, comprehensive, continuous care of chronic disease in an aging population is an overwhelmingly logical thing. I agree, but it may be useful to examine medical home assumptions.

I am reminded of the story of the economist stranded on a desert island with fellow castaways. The castaways are surrounded by thousands of miles of ocean, but areblessed with cases of canned goods from their sunken ship. But, alas, they have no way of opening the cans.

The group turn to the economist for an answer, and he says, “First, assume a can opener.” We’re assuming here that medical homes will serve as can openers to save the system.

The cans, however, may be cans of worms. Perhaps it’s time to examine the assumptions which might cause the wheels of the Wonderful One Hoss Shay, known as Medical Homes, to come off.

• The first assumption is that there are enough primary care physicians to make medical homes enough of a reality to make a difference reforming the system. The stark truth is that a desperate shortage of primary doctors already exists, most medical students and residents shun primary care, and we have no idea how many primary care doctors would bother to go through the paperwork to qualify or to build the infrastructure ( an EMR and an a hired coordinator are mentioned as necessary medical home ingredients) or to undergo the scrutiny of being audited for quality or complying with performance compliance markers. Venture capitalists, alert entrepreneurs, and major corporations like Walgreens sense a primary care vacuum and are moving fast to set up primary-care based worksites in major corporate sites having sufficient numbers of employees.

• The second assumption is that new payment platforms would help create and sustain medical homes and recruit primary care doctors through a more lucrative “blended” payment system – fee-for-service, a capitation fee for managing a patient panel, and patient-centered bonuses for rapid responds to same day visits and email or phone to patients. Whether this scheme is workable in the U.S. is unknown, as is how much money will be required to win the hearts and minds of primary care doctors or whether money alone is the “turn-off” for medical students or residents considering primary care.

• The third assumption rests on the notion that every medical home physician will have an EMR and will be able to talk, refer, and send complete electronic patient information to, other entities in the medical neighborhood, clinical colleagues, hospitals, pharmacies and other care providers. This is a giant leap of faith since only about 15% of physicians currently have EMRs and PHRs are in their infancy. It may be this barrier can be overcome through federal subsidies for EMRs, requiring physicians to meet connectivity standards, and rewarding collaboration through payment increases, pay for performance bonuses, and shared savings, but, in my opinion, the system is at least a decade away from this electronic utopia.

• The fourth assumption is that primary care physicians will be comfortable with “managing” the medical affairs of each member of their panel, making the data entries required, and massaging and responding to the data involved in determining the outcomes of a population health model. Many doctors, weary and wary of paperwork and third party hassles, may respond by choosing to opt out by rejecting Medicare and Medicaid participation, retiring, going into concierge, cash-only, locum tenens practices, seeking employment outside the medical home, or seeking medical careers unrelated to direct patient care.

• The fifth assumption is that patients would welcome such a model. In his popular blog, KevinMD, Kevin Pho, says many patients will be annoyed by being asked to be in a medical home, when they only have one symptom or one disease that may not need to be “managed.” Also 20% of Americans move each year, and may not be looking for a personal physician or a medical home. Finally, keep in mind that most people who frequent emergency rooms do so because the emergency rooms are “there,” not because they are uninsured, underinsured, or lack a primary care doctors (Myna Newton, et al, “Uninsured Adults Presenting to U.S Emergency Departments, “ JAMA, October 22-29, 2008).

• The sixth assumption is that the medical home is a politically and financially neutral concept. This isn’t the case. Nurse practitioners, nurse doctors, physician assistants, and other medical specialists will lobby to set up their own Medical Homes, if for no other reason, than to make up for the primary care shortage. Another, probably more important factor, may the resistance of specialists. Organized medicine, now dominated by specialists, is aware that Congress’s present Sustainable Growth Rate (SRG) is supposedly revenue neutral, meaning if you reward primary care physicians through Medical Homes, you take away from specialists.

Conclusions

The medical home movement is logical and is intended to correct the current costly fragmented specialist dominated system by creating “homes” for patients with chronic disease to receive more coordinated and comprehensive care at less cost with better results. Medical homes are currently riding a political bandwagon, but the assumptions that the system will be transformed by the promising medical home concept remain politically and pragmatically untested. That is why multiple demonstration projects are underway. Meanwhile let us hope for the best and pray that a fundamental shift in the system towards more primary care occura. Making medical homes a reality will take hard work and political arm twisting.

Physician culture -Doctors are Human

Be thou as chaste as ice, as pure as snow, thou shall not escape calumny.

Hamlet

Surprise! Surprise! Doctors are not as pure as the fresh driven snow, as chaste as vestal virgins, as invincible as knights in shining armor, as saintly as Marcus Welby, as susceptible to the lure of money as ordinary mortals, as immune to fatigue as Lance Armstrong, or as happy as clams.

• Pure and chaste we are not. Their overall divorce rates are 10% to 20% higher than the general public, and 37% higher among female doctors, partly, I suspect, because of infidelity.

• Invincible we are not. Physician suicide rates over the last 49 years are 28 to 20 per 100,000, well above the general public rate of 12 per 100,000.

• Saintly we are not. A few are even arrogant, abusive, and disruptive (“Arrogant, Abusive, and Disruptive – and a Doctor,” New York Times, December 1, 2008).


• As susceptible to the lure of money we are not. After all, 4 of 5 graduating medical students choose specialties, where the pay is 2 to 3 times that of primary care doctors. And many receive money from health-related companies as consultants and lecturers and advisors (“Cleveland Clinic Discloses Doctors’ Industry Ties, New York Times, and December 2, 2008).

• As immune to fatigue as Lance Armstrong, we are not. The Institute of Medicine has just released a report saying to avoid mistakes from fatigue, medical residents should work no more Thant 16 hours without a taking a 5-hour sleep break, should have one day offer a week, and should have at least 2 back-back-days off each a month ((“Medical Residents should sleep after 16 hours, experts say, Washington Post, December 3, 2008).


• As happy as clams we are not. According to a national survey of primary care doctors conducted by the Physicians’ Foundation released on November 18 to all the major media, 78% of physicians say medicine is either ‘not longer rewarding’ or ‘less rewarding,’ while 76% say they are at full capacity or overextended. Only 6% describe the more colleagues as ‘positive,’ and 42% describe the morale of colleagues as either ‘poor’ of ‘very low.’ “

Why Newsworthy?

Why is all of this newsworthy? Two reasons: 1) we have overstated our case as a noble profession, somehow free of ordinary mortals’ faults; 2) we are victims of our success, leading to overblown expectations of the miracles of medical science.

Corrective Measures

Are there corrective measures we can take to re-establish our humanity? Yes, of course.

• We can admit and apologize for our mistakes immediately.

• We can be open about our financial arrangements and ties.


• We can treat nurses and other care team members respectfully.

• We can follow these rules in a hospital setting: 1) Ask permission to enter the room: wait for an answer; 2) introduce ourselves- show ID badge; 3) shake hands; 4) sit down and smile if appropriate; 4) explain our role as a member of the health care team; 5) Ask how the patient feels about being in the hospital.(“The Six Habits of Highly Respectful Physicians, New York Times, December 2, 2008).


• We can anticipate those moments of human truth when seeing patients in the office; calling the office, making an appointment, receiving directions, meeting the receptionist, waiting in reception, waiting in exam room, meeting the clinicians, giving a history, having an examination, having an invasive procedure, giving a lab specimen receiving discharge instructions, leaving the organization, obtaining test results, receiving a bill.

• We can manage expectations for surgery and procedures by giving patients to a free interactive online expectation of exactly what to expect during and after the procedure (see emmisolutions.com).


• We can acknowledge the importance of ten simple rules for meeting patient expectations as set forth by the Institute of Medicine: 1) Care should be continuous; 2) care should be customized for the patient; 3) patients should be source of control; 4) knowledge should be shared and information should flow freely; 5) decisions should be based on evidence; 6) safety should be a given; ; 6) transparency is necessary; 7) patients need should be understood and anticipated; 9) waste and duplications should be continuously reduced; 1)) cooperation among clinicians is a priority.

• We can be warm human beings.

Physician Recruiting, physician demoralization, Physicians, Physician shortage, Foundation- Unhappy Doctors Provide Roadmap for Recruiting, Retention

Prelude: Doctors are unhappy, and hospitals plan to take advantage of this unhappiness. The following is from the December 2 issue of Healthleadersmedia.com edand is sn editor for that publication.

A just-released and comprehensive survey from The Physicians' Foundation of more than 12,000 primary care physicians in the United States found some troubling—but not entirely surprising—results. America's primary care physicians are very, very unhappy.

Anyone in the physician recruiting business would be advised to take a look at the survey, which was compiled this summer, because it provides a good roadmap for recruiting and retaining.

"This is not necessarily a bad-news survey. It's a great retention tool. Now you know what is frustrating them and you can do something about it," says Kurt Mosley, vice president of business development for Merritt Hawkins & Associates, the physician recruiting firm that compiled the survey for The Physicians' Foundation.
"If I were a hospital HR director, I would have the key findings up. I would circulate them with all the senior leadership, and I would ask ‘how do we fix this?' If this is occurring in our hospital let's do something about it. Let's do focus groups in our hospitals to find out how our physicians feel," Mosley says.

First of all, the source of the primary care physicians' dissatisfaction is not just money, although low Medicaid/Medicare reimbursements were among the top concerns. What jumps out is the overwhelming sense of frustration. Physicians feel they spend too much time on paperwork, to the detriment of their patients; they're tired of hassling with insurance companies over claims discrepancies; and they're very concerned about the financial viability of their practices. They are demoralized.
Here are some key findings from the survey, which has a margin of error of less than 1%:

• 49% of primary care physicians say they will reduce the number of patients they see over the next three years.

• 63% of physicians say non-clinical paperwork has caused them to spend less time with their patients, and 94% say that non-clinical paperwork has increased in the last three years.

• 82% say their practices would be "unsustainable" if proposed Medicare reimbursement cuts were made, with 65% saying they lose money on Medicaid, and 36% saying they lose money on Medicare. Another 33% have stopped seeing Medicaid patients, and 12% have stopped seeing Medicare patients.

• Only 17% of physicians describe their practices as "healthy and profitable," while 45% say they'd retire if they could afford it.

• 78% of physicians say medicine is either "no longer rewarding" or "less rewarding," while 76% say they are at full capacity or overextended. Only 6% describe the morale of colleagues as "positive," and 42% describe the morale of colleagues as either poor or very low.

Mosley says he's surprised by the denial within the healthcare industry over the plight of primary care physicians, even as healthcare already faces a growing shortage of primary care physicians. "What's really unnerving to me is when we talk to state hospital associations and they are unaware of it," he says. "This problem affects everybody. If you don't have primary care physicians you don't have anyone feeding your specialists."

The primary care physician shortage could be exacerbated by the move toward the medical home model, which is supposed to be directed by those same physicians.
Some issues are beyond the problem-solving ability of hospitals and their HR departments. There isn't much you can do to improve Medicare/Medicaid reimbursements. For many primary care physicians, however, the primary focus isn't just money.

"A lot of the medical administration of America tries to solve everything with money and that is not necessarily the case," Mosley says. Obviously, you have to provide competitive financial compensation, but the Physicians' Foundation survey shows primary care physicians care more about issues like burdensome paperwork, adequate support staff and ancillary services, collegiality with fellow physicians, and even mundane issues like parking.

Those are issues any hospital can address.

So take note HR directors. Physicians are unhappy. They're telling you why. Are you listening?
________________________________________
John Commins is the human resources and community and rural hospitals editor with HealthLeaders Media. He can be reached at jcommins@healthleadersmedia.com.
________________________________________

Managed Care, Future - Salivating About Health Reform

TUESDAY, DECEMBER 2, 2008

Prelude: Today, while organizing my library, I ran across Tom Peters’ book The Circle of Innovation (Alfred Knopf, 1997). Tom cheerleads for innovation as the key to survive and grow and is fond of such sayings as “Whatever made you successful in the past won’t in the future,” “It’s the end of the world as we know it,” and “You can’t shrink your way to greatness.” Tom is a freewheeling irrepressible enthusiast. He often uses italics, cartoons, capital letters – whatever it takes -to drive home his points. This is an updated version of a blog I wrote in September 2007.
Business innovators salivate about fixing health care. They look upon physicians as throwbacks, far behind other industries in adopting innovations to modern times for consumer use, marketing, and organizing integrated units to treat common procedures (hernia repair, joint replacements) and diseases (diabetes, heart failure, COPD, asthma).

Here are a few of his slightly edited thoughts onwhat he sees as the path to a Health Care Nirvana

• Use physician's assistants for routine work.

• Support home care to the maximum.

• Stop 100,000 + needless hospital deaths.

• Stress alternative therapies and wellness-prevention programs.

• Realize demanding "boomers" will determine health care’s future.

• Focus on women as the decision makers, movers and shakers of the system.

• Know "patient-consumer-driven" will change the game.

• Reduce incentives for unnecessary tests through malpractice caps and other means.

• Acknowledge outcome-based medicine is a must!

• Embrace evidence-based medicine as a terrific idea!

• Recognize the Life Sciences Revolution will make the "info revolution" look like small beer!

• Radically increase "best practices" use—inculcate in Med school.

• Push the imperativeness of the Medical School "revolution" —outcome-based medicine, emphasis on wellness & prevention.

• Get information to patients!(Detailed hospital-by-hospital, disease-by-disease, doc-by-doc success records a must—despite controversy).

• Upgrade information technologies throughout the entire system, starting with acute-care institutions.

• Hail the Mega-, integrated-information computer networks – e.g. WebMD.

• Move heaven and earth to implement electronic health records!

• By hook or crook, institute basic universal care , starting with kids, "market-based" as much as possible—but acknowledging it’s not a "perfect market."

• Deal with the enormous HMO perception problem, which is unrealistic. HMOs are necessary

• Blitzkrieg patient/customer/citizen education (e.g., re "outcomes-based health care," "Get the most for your health care dollar").

• Support "Healing-centric"care , e.g. Planetree hospital healing model.

• Emphasize front-to-back "customer care " practices, will cut down on malpractice claims among other things.

• Develop integrated specialized units from common procedures (hernia repair) and common diseases (diabetes).

• Shorten the FDA approval process.

Physician Problems In Implementing Peters’ Vision

• Peters’ solutions don’t address several “monster issues.”

• Who will pay primary care physicians, already in short supply and overloaded with patients, to spend time counseling patients about wellness and prevention?

• If wellness and prevention strategies work, who will care for and pay for elderly patients who survive to die a “natural death?

• Who will protect doctors against predatory lawyers, should demanding boomers not get what they demand from doctors?

• How are patients and their doctors to deal with and master the vast array of new technologies promising better health and greater longevity?

• How can you judge and punish doctors for poor outcomes, when most of those outcomes are due to patient non-compliance outside the physicians’ office?

• Who is going to pay for all of those EMRs, which cost roughly $15,000 to 30,000 per physician per year to implement?

• And how is the federal government going to round up and punish all of those citizens who don’t pay for mandatory insurance?

Peters’ solutions are idealistic, but are they realistic in a world where physician resistance to technologic incursions into the patient-doctor relationship, the right to misbehavior in a democratic society, and death, even death delayed by prevention and wellness, are inevitable?

Summary

Tom Peters, business innovation guru, offers his multifaceted program for fixing the U.S. health care system. It combines, among other things, universal coverage, prevention and wellness programs, “best practices” and “evidence-based” education starting in medical school, and universal adoption of electronic health records by physicians. Sounds a little like Obama’s solutions.

My question are: Given the likely $1 to $2 trillion federal deficit for 2008 and the severity of current year long recession, where is the money coming from? And where are the primary care physicians coming from who will be required to implement these ambitious programs? And how will they be paid? And who is going to write the interfaces for these EMRs, now numbering over 100, so the various EMRs can talk to one another?

Will Peter’s principles work? Medinnovation concludes it’s idealistic but not realistic. Maybe Peters should have a saliva test.

Physicians Foundation, the Physician Shortage - Who Will Speak for Independent Physicians?

Talk to the chief executives of American’s prominent health –care institutions, and you might be surprised what you hear: When it comes to medical care, the United States isn’t getting its money’s worth…A high-performance 21-st century health system, they say, must revolve around the central goal of paying for results. That will entail managing chronic diseases better, adopting electronic medical records, coordinating care, researching what treatments work, realigning financial incentives to reward success, encouraging prevention strategies, and, most daunting but perhaps most important, saying no to expensive, unproven therapies.

Ceci Connolly, “U.S. ‘Not Getting What We Pay For’ Many Experts Say Health-Care System Inefficient, Wasteful.” Washington Post, November 30, 2007

November 31, 2008

As we approach the Obama administration’s dawn, health care institutional leaders, think tank experts, and politicians recently gathered in Washington, D.C. to pronounce what needs to done to fix the system. The Washington Post reports leaders from Mayo, Kaiser, Virginia Mason Medical Center, the UnitedHealth Group, and other institutional leaders have announced their fixes.

No Complaint

I have no complaint about the exeutive’s conclusions or opinions issued therein. I note, however, that leaders representing independent physicians were not there to give their point of view. Practitioners presumably were too swamped taking care of patients and trying to meet the bottom line.(“Bottom Line Blues,” American Medical News, November 27. 2008). They rarely have the time or money to spend attending august gatherings.

One Quibble

My only quibble is that those who go to reform meetings rarely represent clinicians in the trenches – those who deliver over 80% of the care. Instead those who go represent the “adminisphere” of institutions, those administrating the affairs of large organizations run, not practicing physicians outside those institutions.

Modest Proposal

I have a modest proposal - that we strive to place practicing physicians at the reform table. As everybody knows, the Clintons’ 1994 reform effort ignominiously collapsed for want of those who delivered the care. In retrospect, one reason why was absence of practicing physicians and practicing hospital administrators in the Clinton task force of more than 1000, composed mostly of Congressional staff, academics, and policy wonks. The Clinton proposed a universal managed competition system that few understood, that was so complex, so unrealistic, and so fraught with managed care jargon that Harry and Louise had an easy time shooting it down.

This Time Around

This time around, we are told, things will be different. The reform stars, says the Post, will be aligned,” Among physicians, insurers, academics, and corporate executives from across the ideological spectrum, there is remarkably broad consensus on what ought to be done.”

A Spoilsport Speaks

I don’t want to be a spoilsport, but I’m not so sure. Health plans, private Medicare plans, device manufacturers, pharmaceutical firms, and others who profit from the status quo will have lobbyists willing and ready to challenge reform assumptions and will not be taken by surprise. Independent physicians, weary of harassments and low reimbursements from Medicare and Medicaid and private plan followers, are leery of government efforts that infringe upon their autonomy and sovereignty.

Escalating Physician Shortage

Let us not forget the looming physician shortage at the primary care entry level of patients into the system. Universal coverage without primary is access is meaningless. Just ask Massachusetts citizens.And if Congress follows its formula for cutting Medicare by 21% in June 2009, we will have a political donnybrook of unimaginable dimensions on our hands. If that cut occurs, it is likely 1/3 of physicians will no longer accept new Medicare or Medicaid patients. The outcry from the disenfranchised but entitlement-minded populace will be thunderous.

No Single Organization Represents Independent Clinicians

As things now stand, no single organization speaks for independent practicing physicians.
• Not the AMA, which now has only 1/5 of physicians as members, which is perceived to be on side of specialists in its coding system, and which has failed in such things as broad malpractice reform, the bête noir of most doctors.

• Not the MGMA, whose 2800 members are made up mostly of practice managers of groups,


• Not the Medical Group Association, which is comprised of the multispecialty megaclinics of America, who care for about 10% of Americans.

• Not the Association of American Medical Colleges, representing teaching hospitals, academic medical centers, and whose mission is serve and lead the academic medical community.


• Not the New England Journal of Medicine, a liberal publication - the voice of academic medical community and advocates of government mandated universal coverage.

• And certainly not America’s Health Insurance Plans (AHIP), 1300 strong, which serve as surrogates for American business, cover 200 million Americans, and whose policies are not necessarily in the best interests of independent physicians.
Who Speaks for Independent Practitioners
As I see it, three organizations are rising to represent the voice of frustrated independent practicing physicians who want a voice at the health reform table and who seek to change the shape of American medicine.

• Sermo.com – This is a social networking website formed two years ago. It is open to physicians only and has about 100.000 participating doctors. Its purpose are to let doctors openly communicate with each other to present cases, learn from each other, give early evidence of adverse drug reactions or positive drug effects, voice their complaints, suggestions, and observations about the current health system, and to unite on the issue of reform.Sermo physicians are not happy with system, tend to favor consumer-driven care, harbor a deep angst against health plans, and do not believe EMRs represent the Holy Grail that will lead the system onto higher ground. Sermo participants are in the late stages of issuing an Open Letter to the American Public signed by 10,000 physicians about their grievances.

• The Patient-Centered Primary Care Collaborative (pcpcc.net) – Paul Grundy, MD, an IBM physician executive, deserved credit for being the moving force behind this collaborative. As a buyer of care worldwide for IBM, he had observed that countries with a broad primary care base have higher satisfaction, higher quality, and better outcomes than the U.S. The organization, now about two years old, is coalition of primary care organizations (America Academy of Family Physicians, American College of Physicians, American Academy of Pediatricians, and American Osteopathic Association), major employers, consumer groups, quality organizations, and health plans. Its main purpose is to advance primary care and increase its numbers to improve care, sustain the system, and change the mode of compensative physicians. Irrefutable evidence shows a broad primary care base cuts costs, improves care, and enhances outcomes.

Though multiple initiatives at the state and federal levels, the PCPCC is pushing the concept of the Medical Home, led by primary care physicians and their teams, to offer coordinated comprehensive care at one location. These initiatives are running into political resistance from some quarters and are at the lift-off stage. Given the tyranny of the status quo and profitability of entrenched special interests, progress may be fitful and slow, but is nevertheless underway.

• The Physicians’ Foundation - The Physicians’ Foundation created in 2003 as the result of a successful claims action suit against major insurers is a grantmaking foundation with assets of $98 million. The foundation represents state and local medical societies, which have a much larger membership than the AMA, perhaps because they are closer to the ground and know intimately the concerns of their members.
The Foundation seeks to improve care delivered by its members through grants and through surveys highlighting their problems. It has issued grants worth $22 million to 41 member organizations, often relating to EMRs, but found members were ill-equipped to implement these systems and to use them in a productive way with adequate return on investment or improvement in practice quality. On November 18, the Foundation released results of a national survey mailed to 270,000 primary care physicians and 50,000 specialists.

The survey, released to national news media, received wide exposure. It indicated a deep loss of moral among primary care physicians, with 78% of respondents saying a shortage of physicians existed, 49% saying in the next three years they planned to reduce the number of patient seen or to retire, and 60% indicating they would not recommend medicine as a career to young people. Through this survey and other efforts, the Foundation hopes to persuade policymakers that something has to be done to address the concerns of primary care doctors and to ward off an impending and escalating physician shortage.

Such a shortage no doubt will create a political crisis. The Foundation believes compensation methods for rewarding primary care doctor’s needs to be overhauled, and the 21% cut in Medicare fees, scheduled for June 21, 2009, must be averted.