Sunday, September 30, 2007

Effect of culture -Health Reform and American Culture

Health Reform and American Culture:
Good Intentions, Unknown Consequences

“Almost daily, we're bombarded with apocalyptic warnings about the 47 million Americans who have no health insurance. Sen. Hillary Clinton wants to require everyone to have it, big companies to pay for it, and government to buy it for the poor.”

John Stossel, “Our Crazy Health-Insurance System,” September 26, 2007

James Carville, sparkplug of President Bill Clinton’s 1992 winning presidential campaign, proclaimed, “It’s the economy, stupid!” The slogan worked, and 12 years of Republican presidential reign ended. If Carville were to come up with a similar slogan for Hillary Clinton in her universal health reform campaign, it might be, “It’s the culture, stupid!”

She may be following that advice. Her new health care initiative promises no new federal bureaucracy, open choice of doctors and hospitals, leaving alone those happy with existing plans, punishing HMOs by forcing them to accept high risk patients, and, for starters, spending $100 billion to $125 billion more each year of government money to help cover the uninsured and fix the system..

The big problem is that she and other presidential candidates offer few convincing suggestions on how to significantly lower costs – the major U.S. health care issue. The candidates have put forth the usual cost-lowering list – EMRs to end errors and increase efficiency, preventive care, wellness programs, better coordination of care, and government negotiating Medicare drug contracts – none of which are likely to seriously dent inflation, which could cause Medicare to run out of money by 2017 if current projections hold.

The candidates are smart enough to avoid those cost cutting measures the American culture might reject -- limiting use of expensive new technologies, cutting reimbursements to badly needed doctors and hospitals, which employ 10% of Americans, or forcing people to use HMOs.

American Culture

Just what is American culture? One would have to be either a skilled anthropologist or an American historian to answer. But basically our culture dates back to attitudes of our founding fathers, who sought to avoid European aristocracy models and a centralized American government. So they created a Constitution with system of checks and balances. Add to that our culture is our belief in unlimited horizons of opportunity, fostered in part by the opening of the West, the natural resource riches, and our belief in American exceptionalism, and you have a picture of our culture.

Our health system is a creature of our culture. When asked what Americans believe, Garry Orren, a professor of political science at Brandeis, who polls for the New York Times and Washington Post, said, “A good place to start is to remember we are pro-democracy and anti-government. It comes down to ideas that are essentially any-authority and tend towards self-regulation. If there were an American creed, I think it might begin: one, government is best that governs least; two, majority rule, and three, equality of opportunity.”

Shattering the Creed?

Unremitting health inflation and vast numbers of uninsured may shatter this creed. But the creed explains why, up until now, at least, Americans prefer local or regional health solutions and choice, quick access to high tech procedures without waiting lines, why they have rejected federally mandated universal coverage since 1912, why they feel capable of making their own health decisions, why they allow market-based and public-based institutions to co-exist and compete, and why they have been reluctant to significantly raise taxes to pay for the have-nots.

What could happen now to overcome this culture of individualism and choice is the perception that the problems are so big – read 47 million uninsured and health inflation three times overall inflation - only government can handle it.

Monster Questions

But under any health reform proposal, whether market and government based, these monstrous problems will rear their enormous heads. not necessarily in this order.

• Where will the money come from to finance health care services – an open-ended demand fed by an aging U.S population, swollen by 78 million boomers set to qualify for Medicare in 2011.? It certainly won’t come solely from taxing the rich,” who already shoulder 70% of the overall tax load. Nor will it emanate from tax increases, when it’s been shown government revenues, now at an all-time high, increase with tax reductions, not tax increases. Individual mandates forcing everyone to buy insurance may be partial answer but not for the poor, who must be subsidized.

• Where will new physicians, or their replacements, come from? Already projections are we’ll be 50,000 doctors short by 2010 and 200,000 by 2020? Maybe physician assistants and nurse practitioners and international graduates will fill the gap, but its likely new federally-financed medical schools will be necessary to meet the needs of our immigrant-fed swollen population, likely to reach 350 million by 2020.

• How will reform prevent for-profit HMOs, with investor stakeholders, from charging higher premiums, after being forced to accept high risk patient’s raises costs and cuts profits? Whether we like it or not, 85% of HMOs are for-profit, and these HMOs are responsible for administering care for most private planes and many Medicare and Medicaid plans. As far as I know, profit still drives U.S. capitalism. The same profitability argument might apply to drug companies, whose financial stability may be threatened by low-balling government negotiated drug prices. Will government allow reasonable profitability for the drug industry – one of the bulwarks of our economy?

• Who will pay physicians, already in short supply and overloaded with patients, to spend time counseling patients about wellness and prevention? So far government and the private sector haven’t shown any inclination to come up with the money. Maybe employer-based wellness and prevention programs will help.

• If wellness and prevention strategies work, who will care for and pay for elderly patients who survive to die a “natural death? At home and in nursing homes? As everybody knows, our Medicaid system is already stretched to its budgetary limits paying for nursing home care.

• Who will protect doctors against predatory lawyers, who may thrive should demanding boomers not get what they demand from doctors? So far, the presidential candidates have chosen to avoid the $30 billion to $50 billion problem of “defensive medicine” and frivolous malpractice suites, the threat of which is driving many doctors to early retirement or denial of risky drugs, tests, or procedures.

• How are patients and their doctors to deal with and master the vast array of new technologies promising better health and greater longevity? It’s fine to claim predictive modeling, clinical protocols, and policing of those who don’t practice evidence-based medicine will streamline and improve the system - but who will enforce the rules and who will pay for the systems required?

• How can one judge and punish doctors for poor outcomes, when these outcomes are often due to patient non-compliance outside the physicians’ office? For example, 30% of patients never fill their initial prescriptions, and as many as 50% don’t opt for refills. Who will educate these patients, and how will we identify and punish the non-compliers who refuse change their bad habits or comply with doctors’ orders? Do we make smokers, drinkers, over-eaters, and non-exercisers ineligible for work – or do we make them social pariahs? In a democracy, we do neither.

• Who will pay for all of those EMRs, which cost roughly $15,000 to 30,000 per physician per year to implement? And how we reward doctors and their staffs for the time, effort, and upkeep of these systems and for the expense of entering the data to meet all those quality indicators to make them eligible for pay for performance rewards?

• How will the federal government round up and punish citizens who don’t pay for mandatory insurance? The IRS, despite its vast regulatory apparatus, only collects 85% of taxes it levies. And perhaps 20% of drivers never pay auto insurance, though it’s mandatory in most states.

In The End

In the end, I suspect some patch-work system, comprised of both federal and private elements, and covering more citizens, will evolve. It’s likely the reformed system will permit stratification of care, meaning if you have the means, you’re likely to be able to gain access to the care you want. And it may even shrink the number of uninsured through some combination of higher taxes, near universal coverage, individual mandates, and employer-based fines and taxes. Trickle-down regulation may partially circumvent or pacify most those who expect much and enjoy the freedoms of the American culture, but don’t count on it.

Saturday, September 29, 2007

Medical homes - Home Sweet Medical Homes

A recent AMA Medical News story, “New Orleans Grows Into Medical Testing Ground for Medical Homes: Physician Leaders Believe that Lessons Learned There May Be Used to Establish the Primary Care Model Elsewhere, “ AMA News, September 24, 2007), tells the tale of new medical homes in New Orleans.

The principles of medical homes include personal physicians providing first contract and continuous care, coordinating care across the health care spectrum, using information technologies, and making care more accessible and quicker through open scheduling.

Citizens now may seek medical help in 20 clinics in Greater New Orleans. Katrina has destroyed many hospitals and their ERs, which previously provided care. In their place, physicians at Tulane and elsewhere have created clinics built around the concept of medical homes... Last March the AAFP, American College of Physicians, American Academy of Pediatrics, and the American Osteopathic Association jointly supported the patient-centered medical home concept, which integrates primary care practices and coordinates care using electronic medical records.

New Orleaneans can now get care at these clinics, among doctors, nurses, and staff they have come to know in local neighborhoods. Medical homes are evidence of a possible primary care renaissance, which is long overdue and badly needed.

A recent AMA Medical News story, “New Orleans Grows Into Medical Testing Ground for Medical Homes: Physician Leaders Believe that Lessons Learned There May Be Used to Establish the Primary Care Model Elsewhere, “ AMA News, September 24, 2007),
tells the tale of new medical homes in New Orleans.

The principles of medical homes include personal physicians providing first contract and continuous care, coordinating care across the health care spectrum, using information technologies, and making care more accessible and quicker through open scheduling.

Citizens now may seek medical help in 20 clinics in Greater New Orleans. Katrina has destroyed many hospitals and their ERs, which previously provided care. In their place, physicians at Tulane and elsewhere have created clinics built around the concept of medical homes... Last March the AAFP, American College of Physicians, American Academy of Pediatrics, and the American Osteopathic Association jointly supported the patient-centered medical home concept, which integrates primary care practices and coordinates care using electronic medical records.

New Orleaneans can now get care at these clinics, among doctors, nurses, and staff they have come to know in local neighborhoods. Medical homes are evidence of a possible primary care renaissance, which is long overdue and badly needed.

Friday, September 28, 2007

Health Care Innovation at WalMart

As a physician, soon or late you’re likely to have a Wal-Mart’s employees as a patient – some with and some without coverage, perhaps some referred to you by a nurse-practitioner at a Wal-Mart retail clinic, or maybe some needing a $4 prescription.

Wal-Marts and its affiliate Sam’s Club now have about 3100 stores in the U.S. – an average of about 60 in any given state. Walmart stores and subsidiaries hire 1.34 million Americans. Among other things, Walmart’s and Sam’s Clubs now sell more groceries than any other grocery chain, and most of its stores have pharmacies, which make it competitive with CVS and Walgreens and other giant pharmacy retailers.

Last year Wal-mart launched its $4 generic drug program covering about 2000 generics, and it recently announced for the public it is adding 24 new generics, mostly for $4 but $9 for birth control clinics. Under its new health plan, its employees will have access to even more generics. The new health plans for employees will features grants of $100 to $500, premiums as low at $5 a month, elimination of hospital co-pays, deductibles of $500 to $2000 – all in all 50 ways you can slice and dice health care plans according to your needs.

I’m not a na├»ve Wal-Mart backer. I’m aware of relentless Wal-Mart attacks by others for the Walmart stress on cheap foreign products, its low wage scales, its lack of coverage for 57% of employees, claims of sexism, and its reputation as a destroyer of small businesses.

But I’m also acute conscious of its reputation as the most innovative (and largest) retailer in the World. Since its founding in 1962 in Rodgers, Arkansas, Wal-mart has taken the retail world by storm. It will have revenues in 2007 of $351 billion with a new income of $11.3 billion.

It has done this through various innovative strategies – “hit ‘em where they ain’t” placement of stores in rural and suburban locations, a systematic worldwide “just-in-time” computerized inventory system, bulk purchasing in Sam’s Clubs, pharmacies in most stores, $4 generics, and most recently the introduction of nurse-practitioner-run retail clinics in hundreds of its stores.

As much as 40% of its pharmacy business now features its $4 generics, which it claims has changed the “name of the game” and is profitable while cutting $610 million in overall health costs.

Wal-Mart’s health strategies are not without critics. Some claim, for example, that a $2000 deductible is a King’s Ransom for employees that average $20,000 in income. But others – such as Ron Pollack of Consumers USA and Dr, Helen Darling of the Washington Business Group – find the Wal-mart approach promising.


Soon or late, as a physician you’re likely to be touched in one way or another by Wal-Mart’s eeping health care innovations. So, for your information, Walmart and its subsidiary, Sam’s Clubs, now have 3100 stores with 1.34 million employees in the U.S. Walmart is now the world’s largest corporation with revenues of $351 billion. Walmart is rapidly opening retail clinics in multiple outlets, rolling out new high deductible health plans for its employees, and filling $4 prescriptions for over 2000 generic drugs and $9 prescriptions for birth control agents.

Thursday, September 27, 2007

Doctor Shortage, effect of culture - And Who Shall Care for the Sick?

I had a delightful lunch this week with Robert Gifford, M.D., former associate dean at the Yale Medical School and developer and former administrator of the general medical section at Yale. On a part-time basis, Bob now teaches medical students ethics and physical diagnosis, and serves on the medical school admissions committee.

In the course our conversation, Bob noted,

“There’s a sea change out there among medical students, and those applying for admission. More than half the applicants are women, a surprising number of the men
are foreign-borne, and essentially none of them want to go into primary care, preferring instead such specialties as dermatology, anesthesiology, and radiology, all of which offer a more balanced life style.”

Bob wasn’t complaining. He was observing. His observations bring up fundamental questions. How can the U.S. increase the supply of primary care physicians who, after all, care for most of the chronically ill?

Federal subsidies for medical school and post-graduate training? Forgiveness of debt? Increase in Medicare payments for primary care? Narrowing of pay schedules between primary care doctors and specialists? Replacement of doctors by physician assistants and nurse practitioners? Racheting up professional and monetary incentives to enter primary care? Increasing the respect and status for primary care specialists among medical school faculties?

If you have any ideas on how to solve or ease these problems or answer these questions, please comment. I have my own opinions, one of which is that managed care has alienated doctors and made the profession less desirable for ambitious young Americans.

For general background reading on this subject, I recommend Big Doctoring in America: Profiles in Primary Care, by Fitzhugh Mullan, MD. 2004, University of California Press; and for specific information on demand, supply, salaries, and recruiting incentives for primary care, see Merritt Hawkin,s & Associates Guide to Physician Recruiting, by James Merritt, Joseph Hawkins, and Phillip Miller, Practice Support Resources, Inc, 2007.

Wednesday, September 26, 2007

MedicaInnovations, general -Salivating about Health Care Reform

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).

The other day when 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.

Here are a few of his slightly edited thoughts on 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 Implementing Peters’ Vision
Peters’ solutions don’t address several “monster issues.”

• Who will pay 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? at home and in nursing homes?”

• 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?


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

Tuesday, September 25, 2007

Clinical Innovations - Eight Top Medical Technologic Innovations

Many, perhaps even most, medical innovations fall into the realm of technology. That’s why I’m listing the top eight technological/medical innovations selected by the WSJ among hundreds of applications (”2007 Technology Applications: Ahead of the Pack,” Wall Street Journal, September 24, 2007).

1) Novartis/Speedel, Switzerland - For Tekturna, an anti-hypertensive drug that controls hypertension by blocking an enzyme that controls the condition. The WSJ judges picked this as the gold medal winner among 800 applications because hypertension afflicts one billion people. One of every three adults suffers from hypertension.

2) Genaco Biomedical Products, the U.S. unit of the Netherlands – For a new technology for identifying infectious organisms using a single test. Especially useful for quickly identifying dangerous infectious agents in hospital settings.

3) Shire, U.K./US - For Elaprase, a treatment for Hunter syndrome, a rare and fatal disease in children caused by failure to make a critical enzyme. Elaprase replaces the enzyme and reduces liver and spleen swelling.

4) Abbott Laboratories, U.S. - For Humira, a self-injectable treatment for Crohn’s Disease.

5) Schering- Plough, U.S. - For Noxzfil, a treatment for life threatening fungal infections.

6) SEQaul Technologies, U.S. – For Eclipse, a portable 17-pound unit that provides concentrated oxygen for patients afflicted with chronic obstructive lung disease and other lung ailments. Operates with rechargeable batteries or other external battery sources.

7) Fonar. U.S. – For developing the upright MRI, which among other things, alleviates claustrophobia of supine patients.. Also used to scan a baby sitting on the lap of the mother.

8) Kyphon, U.D, Dr. James Zucherman of St. Mary’s Medical Center of San Francisco – For X-Stop – a titanium device implanted to treat symptoms of lumbar spinal stenosis.

Monday, September 24, 2007

Physician Mindsets and Culture - Ten Indications of Physician Restiveness and Cohesion

1. Physicians are intellectually restless, politically edgy, and full of angst about their future.

2. Physicians prefer terse brevity to verbal longevity when discussing current practice conditions.

3. Physicians feel most secure in telling stories of difficult diagnoses, obscure cases, and unknown clinical causes.

4. Physicians dislike being lecturing by others about how to conduct clinical and business practices.

5. Physicians often express skepticism about radical health reform, either from the left or the right.

6. Physicians regard information technologies – either from data mining algorithms or electronic medical records – as overrated.

7. Physicians distrust large integrated systems that reduce them to protocol-following functionaries.

8. Physicians question the value of retail clinics, off-site clinics, and disease management systems in which they do not directly participate.

9. Physicians remain wary of managed care, regarding it as unwelcome, intrusive, ill-informed, and obsessed with cost not quality.

10. Physicians. albeit heterogeneous, represent brotherhood and sisterhood, a common culture supportive and understanding of each other.

Sunday, September 23, 2007

Clinical Innovations - Ten Thoughts (and Afterthoughts) About Medical Innovation

During a listless moment, I jotted down ten thoughts for a talk I’m developing on medical innovation.

1. Innovation is about trying, testing, rejecting, and selecting new ideas that make a difference.

(To holding the line, don’t give too much reverence).

2. Innovation is the special province of surgeons (esp gadget-prone orthopedists) and IT physician types.

(Both of whom think gadgets or algorithms can correct most health care blights).

3. Innovation is about the future, not the past.

(The past is not always built to last).

4. Innovation is about opportunities rather than problems.

(Don’t get too hung up on the old emblems).

5. Innovation ideas often comes from outside rather than inside.

(Savings come from inside, revenues from outside).

6. Innovation separates good practices from also-rans.

(Also-ran rarely own a Benz).

7. Innovation distinguishes U.S. health care from the rest of the world - 80% of Nobel Prize winners are from the U.S., and so do most technologic advances.

(Doctors in other countries with socialistic systems have fewer incentives to take more chances).

8. Innovation may offer services cheaper, better, and more convenient, but it can be disruptive.

(To the practice routine, it may be revolutionary and violently eruptive.)

9. Innovation may be the salvation of U.S. health care; in the process saving us from the mediocre.

(And from the managed care broker).

10. Innovation requires physician champions and leaders.

(Who serve as chief innovators and idea breeders).

Saturday, September 22, 2007

Physician Business Ideas - Practice Tips and Tools on Personal Productivity

One of the jobs of a blogger is to promote other bloggers. That’s what I’m doing now by featuring an interview with Joshua Schwimmer, creator of, which appeared recently in Medscape General Journal.

Doctor Joshua Schwimmer is a busy New York City nephrologist. He's also a researcher, amateur photographer, father, and prolific blogger. How has he accomplished so much? He shares his secrets on his Web site,, and in this interview with Nicholas Genes, MD, a blogger in his right, Dr. Genes' blog is a digest of the developments in the life of an emrgency room physician.

The Interview

Dr. Genes: Why have you started writing this blog? Why "The Efficient MD"?

Dr. Schwimmer: The Efficient MD is the third blog I've written, and each serves a slightly different purpose. The first is Kidney Notes, an informal collection of interesting links related to medicine and technology. The second is Tech Medicine, a more in-depth exploration of technological issues of interest to healthcare professionals and nonprofessionals alike. While writing Kidney Notes and Tech Medicine, I also became interested in innovative ways of learning and helping physicians improve their efficiency to better care for patients. Putting my notes on personal productivity in one place seemed like a good idea, and Efficient MD became the third blog. To be clear: I'm not "The Efficient MD." That's just an ideal, and I need as much help as anybody.

Dr. Genes: I think some people might view "efficient blogging" as an oxymoron, because blogging has a reputation (in some circles!) of being something of a time waster. Why blog?

Dr. Schwimmer: Good question. At some point, every blogger (who isn't making a living blogging) probably asks themselves, "Why the hell am I doing this? Is it really worth my time?" The way I see it, writing a blog is like having a dog. It takes energy and time and constant attention, but if it's your thing, the rewards can be enormous and intangible.

In my case, blogging has made me a more efficient writer. It's introduced me to a variety of opinions, ideas, and people that I might not have otherwise encountered. And it's provided me with some unusual opportunities, like being featured in the Google Annual Report; appearing on a conference panel about the future of healthcare with physician executives from Microsoft and IBM; and, of course, being interviewed here.

Blogs are also a remarkably efficient tool for recording your thoughts and sharing them. What doctor doesn't have advice and reference material they'd like to share with friends, colleagues, current or potential patients, or their future self at some later date? Blogs are one way of making this easier. And in a few years, why shouldn't inexpensive mobile phones or PDAs have evolved to the point where blogging -- that is, the mobile sharing of information and media with small or large groups -- is second nature to most people?

Dr. Genes: Regarding efficiency, don't most healthcare providers pick up efficiency tricks in the process of their training? In other words, couldn't you say that all MDs are pretty efficient?

Dr. Schwimmer: Sure. Given the vast amounts of information most healthcare providers need to absorb and process, no provider would be able to get through their day without using some clever tricks to improve efficiency. But in my experience, most doctors come up with these tricks only in order to survive. On rare occasions do people step back and look at systems of practice in order to improve them. Harold Barrows, in Developing Clinical Problem-Solving Skills, calls this "metacognition." Barrows' book in particular I recommend highly to medical students and to anyone interested in thinking more deeply about the way they think about patients and their problems.

Just as physicians devote their careers to taking care of patients, other professionals devote their careers to helping people work better. If you listen, they can provide lots of useful advice. For example, I know many physicians who are undeniably brilliant but whose desks are a mess of papers, lab reports, and charts. Things get lost. They can't find anything, and it definitely reduces their efficiency. There's a simple device that can solve this problem called an inbox. But using inboxes properly is not as intuitive as you might think. It seems so simple, and it doesn't seem like it's something you need to be taught to use. As a result, many people don't use inboxes, or don't use them well.

The one book that might provide physicians with the biggest benefit in the shortest time is The Successful Physician by Marshall Zaslove. It's a wealth of tips and advice for improving clinical practice. Another book I recommend is Getting Things Done (GTD) by David Allen. GTD is a method that I personally find useful. It involves collecting undefined items, processing them to figure out what needs to be done, then organizing the "next actions" to be taken into contextual lists. (I provided a "mindmap" of the GTD system on my blog.) Using the methods in books like The Successful Physician and Getting Things Done can potentially help healthcare providers be more productive in half the time. I'm not exaggerating.

Dr. Genes: Join Dr. Joshua Schwimmer this week as he methodically organizes the best of the medical blogging world into the weekly Grand Rounds, hosted this week at

Reece Comments

Probably no single subject preoccupies physicians more than personal productivity – how to get through the day with the most work done with the least distractions. As you know, there’s plenty of advice – delegate to others, stuff the circular file, don’t get interrupted by phone calls, shun meetings. There’s even a book on the subject, which Dr. Schwimmer mentions, – The Successful Physician – A Productivity Handbook for Practitioners (Aspen, 1998). Now there's a blog telling you how to get through your day efficiently and effectively. I recommend it.

Friday, September 21, 2007

Physician Business Ideas, worksite clinics - Some Doctors Now Practicing at Worksites and in Stores

Innovation for doctors comes in many forms. One form is simply moving elsewhere to practice. If the move for primary care physicians results in greater income, less hassle, no malpractice premiums, primary care physicians may be attracted and tempted to make the move. If they treasure their autonomy, they may not be interested.

At the risk of being repetitive, here’s what I said in my Sept. 5 blog about the move to worksite clinics.

More than 100 of the nation’s 1,000 largest employers now offer on-site primary care or preventive health services — forecast to exceed 250 by the end of 2007. Companies opening or expanding these clinics include Toyota, Sprint Nextel, Florida Power and Light, Credit Suisse and Pepsi Bottling, and a small company in Florida called MyCareTLC, which plans to franchise these clinics across multiple corporate settings.

According to MyCareTLC, these clinics are projected to save as much as 45% to 50% in health care expenses for employers.

How? Well, it’s claimed company doctors onsite can conveniently assess the situation, prescribe generic drugs on site, follow best practice guidelines, and refer to pre-selected specialists, judged by data mining to be the best performers, the most quality oriented, and the most economical.

Furthermore, employees need not travel to see a doctor for routine care, pay no co-pay, receive generics at cost, and they and their families can be coached on healthy living and preventive care.

The clinics have an EHR integrated with an online editing and publishing service containing best practice information and evidence-based data on 200 clinical conditions, updated daily. In addition, the clinic and its doctors have access to information from a data-mining company which identifies high risk individuals, high performance physicians to whom to refer, and offers clinical advice and strategies to employers, purchasers, and patients.

Why would these clinics attract primary care doctors?

• First, they’re hassle-free. No worries about billing and collection and arguing with health plans.

• Two, the company will be pay 30% more than what MGMA reports as the mean income for primary care physicians.

• Three, an EHR system integrated with best practice guidelines and diagnostic support information is in place.

• Four, patients are on site, so no practice marketing is necessary.

• Five, a bevy of free-generic drugs are available on site, so drug costs drop to zero for most patients.

At least, that’s what MyCare clinic backers envision, and we’ll have to wait and see what happens as this innovation is rolled out across the country.

Doctors in Retail Outlets

Now we have another new wrinkle on the practice site block. It’s called Medical Marts, and it puts primary care doctors inside stores, as reported by Bruce Japsen in the September 20 Chicago Tribune ( “Medical Marts' Retail Clinics Putting Doctors inside Stores.”)

The physician-staffed retail clinic model has officially opened its doors in the Chicago area.

Medical Marts opened physician-staffed retail clinics in the Chicago suburbs this month in Aurora and St. Charles, with plans to open a third in Algonquin by the end of the month. All are located in Meijer supercenter stores, but Medical Marts is working with other retailers and plans to open two clinics in Kmart stores in Rockford before Nov. 1.

Medical Marts staffs its clinics with two full-time primary-care physicians, and two full-time medical assistants or licensed practical nurses. Las Vegas-based Medical Marts has avoided the criticism of retail clinics opened by the likes of Wal-Mart Stores Inc. and Walgreen Co. staffed by nurse practitioners. Medical groups such as the American Medical Association say clinics' nurse practitioners should have direct access to a physician and referral systems so patients with severe medical issues can be treated elsewhere.

"Our clinics are as one would find in any newly constructed, state-of-the-art medical facility, generally with three exam rooms, a procedure room, nurses station, reception area, physicians office and washroom," said Dr. Kenneth Richmond, a Wilmette physician and vice president and chief medical officer of Medical Marts. "The reception areas are purposely small, as patients are seen upon arrival. Should the physician be occupied, patients are given a pager, given time to shop, and paged when the physician is ready to see them."

Medical Marts clinics are open seven days a week, from 8:30 a.m to 8:30 p.m Monday through Friday, 8:30 a.m. to 6:30 p.m. Saturday and 9:30 a.m. to 5:30 p.m. Sunday.

Three year old Medical Marts hopes to open 400 clinics in retail outlets across the country by the end of 2009. The company has opened seven in Utah in Shopko stores, with four under construction in St. Louis and Virginia.

There are at least 600 retail medical clinics staffed by nurse-practitioners in the U.S., according to Merchant Medicine, a Minneapolis-based research and consulting firm. CVS/Caremark Corp. subsidiary, MinuteClinic, leads the pack, with more than 250 retail clinics, followed by Walgreens' subsidiary Take Care Health Systems, with 55 clinics. Sixteen separate companies now operate retail health clinics, and the number of clinics may reach 10,000 by 2011 or 2012,

What’s the significance of moveable primary care practices?

• One, innovation is alive and well in America’s employer-driven and consumer-directed health system and bears watching and responding to.

• Two, corporate employees and health care consumers are receptive to receiving care outside the traditional office settings.

• Three, when it comes to cutting costs and offering convenience, employers and entrepreneurs can be very innovative and effective in transforming the health care practice landscape.


Corporate worksites and retail stores are now employing primary care physicians on salaries to manage clinics in their facilities. For some primary care physicians, these new practice settings are attractive because of lack of hassles in billing and collections, relief from dealing with managed care carriers, regular hours and fringe benefits, availability of electronic medical records and access to diagnostic support services. But these types of practices may not be for doctors who wish to retain their autonomy and to be free of corporate fetters. For most physicians, practicing at worksites and in stores will remain a fringe phenomenon, and the overwhelming number of physicians will choose and prefer independent practice.
For full story, see

Thursday, September 20, 2007

Employer-Driven Reform Storm Hits Connecticut

“Reform will occur only if America’s non-health care business leaders recognize that it is a critical concern for them and us. By pooling their influence, they could overwhelm the health care lobby and drive changes that re-establish American health care’s stability and sustainability.”

Brian Klepper, PhD, Director Center for Practical Health Reform, Letter to Editor, New York Times, September 19, 2007

Sometimes a storm hits where we least expect it. Sometimes it’s a surprise because we misread climatic events, or because we called the storm by the wrong name, like consumer-driven care rather than employer-driven care.

In retrospect employer-driven care in the name of consumer-driven care should have been obvious. Employers pay for 54% of health costs. And employers are reluctant to give up their health care role. This is true even though high health costs hurt them badly,in the pocketbook and on the bottom line, as GE and Ford will attest. If employers are to hang onto health care as a workplace incentive, and to afford it and remain competitive, they will not sit back and do nothing. They will do something, and they will choose tools they know best how to deploy - in this case, information technology – to contain costs and control quality.

Fairfield County in Connecticut is perhaps the most affluent county in America. Health care costs there, as in much of the Northeast, are 20% above the national average. Many of the nation’s most affluent employers and richest citizens live there in Greenwich. More than 2000 doctors, most of them doing well, practice in the county.

So why should the Fairfield Country Medical Association, in conjunction with nine orthopedic surgeons, rear up and file a class action lawsuit against United-Healthcare and Cigna?

The suit says these health plans use computer algorithms inappropriatey to crunch claims data to steer patients to less costly doctors. Not so, say the plans. We’re simply using data to direct patients to the most “efficient” doctors --those who practice who follow best practices and who provide care at reasonable costs.

What’s behind this storm? It’s basically about health plans using sophisticated computer algorithms to capture data from multiple sources – doctors’ offices, hospitals, labs, imaging centers, outpatient surgery and diagnostic centers. rehab facilities, and pharmacies – to put together a coherent picture of what “episodes of care” really cost. This health IT exercise goes by the names of “connecting the dots,” data mining, predictive modeling, or Health 2.0 and defies precise definition.

Whatever you call it, it’s about employers getting their arms around health costs and rational care delivery. It’s said to be about delivering “transparent” information about costs and quality and outcomes to consumers, but it may be more about supplying employers with predictable cost information. Health plans, who are surrogates for employers, have leaped upon the “consumer-driven care” bandwagon because the plans have the technology to drive the bandwagon – to bring data together from multiple sources, analyze it, and focus it to judge, select, reward, or punish individual doctors and to determine what a given episode of care costs in a given city or region.

From the doctor’s point of view, much of this claims data crunching is unfair because it’s opaque. The health plans’ algorithms, you see, are “proprietary,” another word for secret black boxes inaccessible except to those who build them.. Doctors don’t know until it's too late why they’re rejected for a “select,” “preferred,” “premier, ”or “premium’ network.

But a storm it is. I became acutely aware of the size, ferocity, and direction of the storm while interviewing Jeff Hogan, a regional manager for the Rogers Benefit Group, a Minneapolis-based furn with 71 regionnal offices. Hogan is located in Farmington, Connecticut, and sells health care benefit programs to mid-mid-sized and large businesses throughout the Northeast. He tells me he can hardly keep up the demand of high-deductible health plans linked to HSAs.

Hogan says employers all over Connecticut are dumping HMOs and PPOs for high deductible plans because of the promises of cost savings and measurable quality, and health plans are happily developing the IT tools to justify the switch.

Here is a sample of what Hogan is talking about in his own words.

There’s a tremendous increase in the technological functionality of software supporting employer-sponsored and consumer-directed products--- online tools for employees, online populated personal health records for employees, online health risk assessments that grade employee's health, and online price and quality transparency tools directly linking price and review doctor's and hospital services.”

“Behind the scenes, health plans are introducing
sophisticated data mining tools reviewing EVERY claim for unwarranted practice deviation, contraindications across 35 disease processes. The plans then reports back to employers the return on investment.”

Hogan believes employer-driven care, mediated by health plans and directed towards consumers, has taken on a life of its own and will take the reform movement by storm.


Employer-driven care, in the name of consumer-driven care, is gathering momentum in sections of the country where costs are high. The principal tool of employers, and health plans representing them, is data-mining of claims from multiple sources to identify cost-efficient providers, who, the plans say, follow best practices. This data is then used to separate doctors into “premium” ,“preferred”, “select, ” or “tiered” networks which employers will use. Doctors in Fairfield County Connecticut and Washington State are suing health plans because doctors claim the plans are using costs, not quality, to rank them. Furthermore, the doctors assert the software being used to judge them is “proprietary,” secretive, and opaque and known only to the health plans. What’s transparent to consumers and employers isn’t transparent to physicians, who believe data mining is about cost nor quality.

Wednesday, September 19, 2007

Market reforms - Health Reform Simplified and Explained

What follows are three soucces explaining the current state of health reform.

1) Washington Post, September 18. 2007

Health-Care Scorecard

Clinton Edwards Obama Guliani Romney

Seeks to insure Yes Yes Yes No no Americans

Requires all Yes Yes No No No
individuals to
buy insurance

Requires small No Yes No No No
bsinesses to
isure employees
o pay tax

Requires large No No No Yes Yes
bsineses to
insure employees or
pay tax

Provides tax No No No Yes Yes incentives for

2) New York Times, September 18, “Hillary Clinton, from Revolution to Evolution, ” Bt David Brooks

David Brooks, moderate columnist for NYT, says Hillarycare is a huge step forward from 1993 – simpler, reassuring in that nothing about radical change, in touch with Americans’ values of choice and individual freedom, retains private care as heart and soul of system, offers take credits so people can afford care, and is evolutionary rather than revolutionary

It is, says Brooks, a “communitarian” approach – getting individuals, the federal government, insurers, doctors, and patients – go together around a big table to reach a consensus.

But, adds Brooks, communitarianism, has weaknesses. One, state governments. She limits the role of state governments, the usual source of legislative innovation, thus centralizing power.

Two, health plans, her bete noir. She commands health plans to cover everyone, no matter how sick. Health plans will surely find ways around her commandments.

Three, patients. If costs, say for MRIs, are lowered, patients will simply demand more MRIs, or anything test or procedure.

Four, posterity. What Hillary wants, says Brooks, will create a tidal wave of debt, something our children will have to absorb.

Brook concludes: “There are still complexities in the health system that no loya jirga, no matter how smart, can fully anticipate and control.” ( loya jirga is a large gathering or grand council held in Alfghanistan, Uzbekistan, Turkenstan, and Mongolia, held among competing tribal leaders, to reach consensus on difficult issues. There are not time limits on a loya jirga, and tribal leaders may deadlock and not reach consensus for years.)

4) Wall Street Journal, “Republicans Can Win on Health Care,” By Karl Rove

In his Op-Ed piece, Karl Rove claims Americans will be unable to trade freedom in selecting doctors and hospitals for government security, which, he says, leads inevitably to poor quality, inefficiency, rising taxes, and rationing.

Here’s Rove’s formula for a market-driven, consumer-oriented health system

• Level the tax paying field – Let all people, employees of large corporations and small businesses, and self-employed individuals, get deductions for health care.

• Give tax-free savings for health care, to be carried over year to year, i.e health savings accounts.

• Make health premiums portable from job to job, and state to state.

• Arm and empower consumers by letting doctors, hospitals, and health plans compete for their business.

• Pool risks of individuals, small business group in order to lower costs.

• Aim for price and quality transparency for patients.

• Stop junk lawsuits.

Tuesday, September 18, 2007

Goverment vs Market reform - “Killers” on Both Sides of the Aisle

“Killers” is becoming the operative word for describing the U\.S. health system. The health system, it seems, has “killers” on both sides of the aisle, the two sides being #1, the inefficient, costly health system itself; and #2 diseases that make up the leading causes of death.

In aisle #1, according to Regina Herzlinger (Who Killed Health Care? America’s $2 Trillion Problem – and the Consumer-Driven Solution (McGraw-Hill, 2007) – are five killers – the health insurers, the general hospitals, the employers, the U.S. Congress, and the elite Policy Makers.

In aisle #2, according to a 14 part NYT series, “Six Killers, ” are heart disease, cancer, stroke, chronic obstructive lung disease, diabetes, and Alzheimer’s disease.

As physicians, there may not be a lot we can do about the aisle #1 killers. But aisle #2 is our responsibility, and the responsibility of our patients, and you may want to read the advice and information NYT reporters are giving its readers. I’m not a fan of the NYT editorial page, but on the whole I find their medical reporting to be sound, albeit occasionally slanted against doctors.

See for list of 14 articles on six killer diseases.

Articles in the Six Killer Series

1) Looking Past Blood Sugar to Survive With Diabetes. August 20, 2007
By GINA KOLATA,. Largely because of a misunderstanding of the proper treatment, most diabetes patients are not doing what they should to protect themselves.

2) Tips to Help Patients Manage Their Care, August 20, 2007
By DR. JOHN BUSE, director of the Diabetes Care Center at the University of North Carolina, Chapel Hill, says everyone with diabetes should know.

3) ) An Increase in Diagnoses May Not Mean a Higher Rate of the Disease, a Survey Shows, August 20, 2007., By GINA KOLATAIt may just be that more people are learning they have diabetes, not that the number of those with it is increasing.

4) Obesity May Be Only One Piece of Diabetes Puzzle, August 20, 2007,
By GINA KOLATA. Researchers are struggling with a fundamental question. Why does high blood sugar lead to any of the diabetes’s complications — heart disease, stroke, nerve damage?

5) Cancer Patients, Lost in a Maze of Uneven Care, July 28, 2007,
By DENISE GRADY, Treating cancer can be very complicated, and it is difficult for even the most educated patients to be sure they have the best care.

6) Doing Battle With the Insurance Company in a Fight to Stay Alive, July 29, 2007,
By DENISE GRADY. A glorious blend of forces came together to save Gordon Hendrickson’s life; only his insurance company tried to stand in the way.

7) Push Hard for the Answers You Require
By DENISE GRADY, July 29, 2007, How can people with cancer make sure they are receiving the best treatment?

8) Lost Chances for Survival, Before and After Stroke, May 28, 2007,
By GINA KOLATA. From prevention to diagnosis to treatment to rehabilitation, a stroke is a litany of missed opportunities.

9) Cost Put a Stroke Treatment Out of Reach, Then Technology Made It Possible. May 28, 2007,
By GINA KOLATA, Doctors at Martha’s Vineyard Hospital knew the drug tPA had been shown to work for stroke, but they had not been giving it to their patients.

10) Steps Toward Reducing Risk , May 29, 2007,
The deputy director of the National Institute on Neurological Disorders and Stroke lists five things everyone should know about strokes.

11) Lessons of Heart Disease, Learned and Ignored, April 8, 2007,
By GINA KOLATA, The toll from the nation’s No. 1 killer could be reduced if the medical system delivered care that is known to make a difference.

12) How It Happens: It’s Not a ‘Plumbing Problem’, April 8, 2007
By GINA KOLATA, Doctors also fight the popular misconceptions about the causes of heart disease.

13) What I Wish I’d Known, April 8,2007
Naomi Atrubin, a survivor of two heart attacks, shares the lessons she has learned.

14) Answers to Questions About Heart Disease, April 17, 2008
By DR. ELIZABETH NABE, director of the National Heart, Lung and Blood Institute, answers readers’ questions about heart disease.

Monday, September 17, 2007

Limits of technology - A Data-Doubting, Technologically-Incorrect Tale

The appropriate question is not whether there are uncertainties about epidemiological data, rather it is whether the uncertainties are so great that one cannot draw useful conclusions from the data.”

John Bailor, MD, National Academy of Science, as quoted by Gary Taubes, in “Do We Really Know What Makes Us Healthy?” New York Times Magazine, September 16, Sunday, 2007

"You have to realize that physicians have been trained four years in med school, then three to seven years in post-graduate training. The funny thing is that they want to take care of patients. They don't want to become specialists in creating medical records. They look at the medical record as an incidental cost of doing business. Many EMR programs act as if the medical record is the whole point of the patient encounter. It is just not."

Bruce Landes, MD, President and CEO, Southwest Physician Association, a 1300 member Dallas IPA, as quoted by Gary Baldwin, in “EMR Pushback, September 14, Healthleaders Magazine

I’m not alone, but I’m in the minority in doubting the infinite power of data and IT-technologies to transform and better the quality of American medicine and the health of the American public. IT is a tool, but it’s not a driving force that will radically change the overall behavior and practice styles of American physicians or the life and health styles of their patients.

I have an ongoing debate with Brian Klepper, PhD, a good friend, an astute health care analyst, and a pragmatic idealist. Brian says, among other things that,

• IT technology data gathering companies, using sophisticated algorithms and predictive modeling to connect the data dots between all players, will dictate the future of health care.

• The data will be gathered from multiple sources, i.e, patients, doctors, health plans, Medicare, Medicaid, hospitals, labs, imaging centers – anybody who diagnoses, treats, tests, dispenses medications – or pays for care.

• IT technologies are now in place to translate the data into market-driven and government-regulated rules that will impel doctors to follow best practice guidelines, evidence-based medicine, and quality indicators – that can be used as leverage to judge and reward high performance physicians.

• Doctors will abandon solo or small group practices to join or form large groups, corporate health clinics, multispecialty groups, in order to afford the IT infrastructure to serve as credible physicians, to be rewarded as such, and to gain access to diagnostic and therapeutic support systems to practice competent, let alone, quality medicine.

• Reliance on data will drive down costs and will change the nature of private practice by phasing out fee-for-service, which encourages overuse, and phase in salaried physicians working in teams for organizations , which will encourage compliance to best practices, and removes incentives to do more.

• At some point, more likely sooner than later, doctors will be forced to install electronic medical or health records or their online equivalents, to gain access to best practice guidelines, patient health records, and diagnostic support information.

• In the names of quality and economy, major players – employers , consumers, physicians, hospitals, health plans, labs, imaging centers – will accept data as the best and most reliable means to restabilize the system before the need for managing the eminent baby boomer chronic disease boom sets in, which will force the need for data and enforce doctors to follow what the data says and where it leads them.

• Attention to and compliance with details of best practice protocols will systematically and sometimes dramatically increase overall population health and outcomes from chronic diseases.

In other words, to use Brian’s words, “ To improve the system, we have to grab all the data wherever we can, establish two levels of medical records – personal and clinical, practice evidence based best practices, use available diagnostic support tools, and get the patients, physicians, and payers on board.”

To back up his argument, Brian referred me to a blog, e-Care, written by Vince Kuraitis, MBA, who has spent 19 years in the technological trends, and who serves as the principal and founder of Better Health Technologies, Inc, a health technology consulting firm.

Basically Kuraitis says the technologies and strategies of Google Health, headed by Adam Bosworth, VP of Google and head of Google Health, hold the key to the future.

Kuraitis, deciphering clues from Bosworth’s speeches, says the Google Health strategies are:

1. To improve and refine the current Personal Health Record to make it a comprehensive data repository gathered from everyone who ever diagnosed, treated, prescribed, or paid for patient care.

2. To give every patient, who will own their own records, an internet website, a URL, which will empower them by giving them ownership and control over their record by giving them the power to decide who can enter and extract data from it..

3. To develop data gathering mechanisms making that up to date at the “speed of light,” at the instant it is generated.

4. To develop standards to make the record interoperable and accessible and enterable by all and friendly to all, including patients and doctors.

5. To make the Personal Health Record so universal, i.e. to create such a critical mass and to be so “populated,” to have so much compelling clinical information, that its acceptance will be inevitable.

6. To deal with and overcome the “disruptive potential” from patients, consumers, physicians, employers, health plans, hospitals, labs, and imaging facilities .

Google Health, says Kuraitis, will overcome the basic problem of widely scattered health information and lack of suitable standardized formats. The result will be better patient care and lower costs, all for the great benefit of humanity.

I’m sorry, Brian, but as noble and logical as your argument is, I’m not buying in its entirety, in parts perhaps, but not overall because I contend the response, use, and abuse of privileged health care data will be, well, human.

First, total transparency is not something all health care players will buy. It’s simply not part of human nature to tell all or reveal all – in politics, daily life, human interaction, or business affairs, indeed in all domestic and foreign affairs..

Second, total data gathering, while it may be technologically feasible , is intrusive, and will be resisted, no matter how sanitized, making the time frame for its adoption prolonged and painful.

Third, data can be manipulated, like statistics, and never tells the whole story of the nuances of human interactions or the considerations that go into health marketplace transactions.

Fourth, competing health care organizations will not be wont to reveal their data to each other, which, I believes, is why most RHIOs (Regional Health Information Organizations) will either fail or be DOA.

Fifth, I remain skeptical that assiduously following best practices, meeting quality indications, or rewarding doctors for performance, while desirable, will significantly improve outcome, maybe marginally, but not significantly. Many undue outcomes are due to untoward patient behavior or reversion to old deeply entrenched habits once patients are outside the reach of physicians. In a democracy, physicians can offer evidence to persuade patients to change, but they cannot compel change.

To conclude, Brian argues for the way things ought to be in a perfect world. I seek to describe the way things are in the real world and how likely they are to be. He may be motsly right, but I am not totally wrong.


Health data and information aren’t everything. Human response is important too. A dictum of the ecology of technology is this: for every technologic or information-based advance there’s a humanistic counter response. Data alone or blind belief in it will not improve care or outcomes. Nor will total transparency, intrusive rules, comprehensive data banks, salaried physicians, sophisticated clinical algorithms, or real or virtual groups practices. Improving care will take time and human understanding of the physician and American culture.

Sunday, September 16, 2007

Clinical Innovations - Office Dispensing, Retail Clinic Prescribing, and Conflicts of Interest

Times are changing and may require different prescribing methods by doctors. Many consider doctors profiting from prescribing as a conflict of interest. Yet thousands of retail clinics, featuring prescribing nurse practitioners, are being set up for the express purpose of offering convenient prescriptions at the point of care. Is that not too a conflict of interest? Or is it just entrepreneurs finding a niche to provide convenience for time-pressed consumers? If that’s the case, why can’t profit-pressed physicians offer a similar convenience?

Growth of Retail Clinics as Competitive Threat to Doctors

Retail clinics are exploding at Walgreen’s, CVS, Osco, Wal-marts, Target, Duane Reade, and other commercial outlets. There may be 10,000 of these nurse-practitioner staffed clinics by 2010. These clinics represent a competitive threat to doctors, since surveys show 12% of patients going to these clinics say they plan to use these clinics for their care rather than doctors.

According to Scott Nystrom, MD, medical director of Physician Total Care, Inc, a Tulsa-based company providing drugs and software for physician office dispensing,
Retail store walk-in clinics certainly provide convenience but the underlying motives to this movement beg comment.

The spirit of in-store clinics, Nystrom says, is to move the prescription writer (not a physician) to the pharmacy effectively creating point-of-care dispensing. For the store, it puts the patient in a retail environment where the entire process is focused primarily on generating retail sales not health care. For physicians, the competitive response is to move the process of dispensing back into the physicians‘ offices where it originated.

In Innovation-Driven Health Care: 34 Key Concepts for Transformation, I have a chapter entitled “Physician Office Dispensing Stages a Comeback.” In that chapter, I said the typical physician, seeing 20 patients a day, averages writing 30 prescriptions and refilling 30 more. Writing these prescriptions take knowledge and time, and the process of refilling them may cost $5 to $7 in direct and indirect costs.

Facilitating Office Dispensing

Physician Total Care and other companies facilitate office dispensing by purchasing prescription medications in bulk, repackaging them into individual prescription sizes for physicians, who then dispense these medications by using company software.

This process provides convenience for patients, (who don’t have to drive to pharmacies to have the prescription filled), assures greater compliance (30% of patients never have their first prescriptions filled, and as many as 50% don’t have them refilled), lowers prescription costs by as much as 50%, and provides most common generic and brand name drugs. Furthermore, it allows the dispensing physician to earn up to $6 per prescription, which may amount to $180 per day.

Office Dispensing Not for Everyone

Office dispensing isn’t for everyone. There are those who say doctors shouldn’t profit from prescribing because it represents a conflict of interest. Furthermore, seven states (Massachusetts, New Jersey, New York, New Hampshire, Texas, and Utah) don’t allow office dispensing.

There are other reasons doctors may choose not to dispense as well: hesitancy to change existing office patterns, fear of being perceived as overly “commercial”,: lack of office space to store drug inventories, balking at buying these inventories, reservations about upsetting cordial relationships with local pharmacists.. For these reasons, only about 10% of doctors dispense from their offices.

The Other Side of the Argument

Nystrom argues. The current retail pharmacy method of getting medication to patients is inefficient.

In 2006, pharmacists dispensed more than 3 billion prescriptions and placed over 900 million prescription-related telephone calls which cost the industry $280 billion, primarily for office staff and physician time as well as the telephone and fax charges. Each pharmacy call back costs physicians’ practices $5-$7. With the average physician writing 30 prescriptions a day and handling another 30 requests for refills, the costs escalate rapidly. The estimated 20 pharmacy related phone calls per day costs $20,000-$28,000 annually. In general, physicians are oblivious to this cost center. By moving dispensing into the physician’s office, this overhead can be cost shifted to better serve patients as well as create additional income.

Office dispensing respects patients’ time and increases patient medication compliance. Furthermore, only physicians possess the authority to substitute therapeutically equivalent generic or brand name medications of differing drug class. As a result, their cost saving generic use rates reach levels not attainable by any industry strategy. In 2006, the average generic prescription cost was over $88.00. Payers have increased generic substitution nationally to 63%. Stimulating higher generic prescription rates through higher co pays on branded drugs and limiting formulary may have the unintended consequence of deceasing compliance. Dispensing physicians achieve an 85% generic substitution rate with an average medication cost for both branded and generic drugs of $37.20. Without direct physician involvement, increasing generic prescription rates remains impractical. Physician dispensing prescriptions cost half the national average. The potential cost savings for payers and consumers is staggering.

The number of retail clinics staffed by nurse-practitioners who write prescriptions may reach 10,000 by 2010 in multiple retail outlets. These clinics offer convenience, lower costs, and quick access to prescriptions at the outlet. Twelve percent of patients patronizing these outlets say they plan to use them as substitute for their doctor and as their main source of care.
Some doctors may choose to partially counter the competitive effect of retail clinics by dispensing medications in their offices, in the process, offering convenience, lower costs, ease in refills, and lower overhead costs. The estimated 20 pharmacy related phone calls per day costs $20,000-$28,000 annually, which is nothing to sneeze at if you’re an economically stressed physician trying to meet a bottom-line.

For full story, see

Saturday, September 15, 2007

U.S. Health Car System - Should the U.S. Health System “Go Dutch?”

To “Go Dutch” means paying one’s own expenses. Two reasons the new Dutch health system these days is attracting so much attention are 1) It obligates Dutch individuals to buy or pay health care premiums. 2) It resembles the universal coverage plans now underway in Massachusetts and California.

Besides, this tiny densely populated country of 16.6 million, which rescued itself from the sea though a massive national engineering project and is home of three of world’s largest companies – Royal Dutch Shell/Shell Group, Royal Phillips Electronics, and Unilever, has shown itself capable of organizing and administering huge social and business enterprises. Why not health care too?

System Comparisons

Here’s how the three plans – Dutch, Massachusetts, and California compare.


Netherlands, 16.6 million, Massachusetts. 6.5 million, California, 36.5 million

Date Started

Netherlands, Jan. 1, 2006, Massachusetts, Last year, California, proposed but stalled in legislature.

Individual Citizens

In all three plans, each individual citizen must buy or pay premiums.


Netherlands, must offer coverage to all, in Massachusetts, may limit coverage for pre-existing illness, In California, must offer coverage to all.


Netherlands, don’t need to offer coverage, Massachusetts. must offer coverage, California, must offer coverage or pay penalty

Idea Behind Dutch Plan

The idea behind the Dutch plan is to offer private coverage for all, but to put a lid on costs. Last year, under the plan, health costs dropped from 4.5% to 3.0% versus the drop from 8.0% to 6.1% in the U.S. In the Netherlands, all adults must buy, and all insurers must offer premiums, no matter what the pre-existing illness, though premiums for high risk individuals are adjusted for “risk equalization.” Insurers are expected to compete on premiums, consumers will be told real costs, and hospitals will be pushed to lower costs.

More Detail

Here’s more detail on Dutch plan, which took 4 years to develop.

The new system has the following characteristics:

• All individuals must be insured.

• All individuals purchase health insurance on the private market.

• Individuals can choose to get their health insurance through their employer–if the option is available–but the employer doesn’t have to offer health insurance. If the employer does not offer health insurance or if an individual is unemployed, then they must purchase insurance on the private market.

• Health insurers are free to charge each individual any price they please for health insurance. Of course, market forces limit the price that the insurers can charge the consumers before they switch to another plan.

• The cost of health is more transparent to consumers since they see the price they are charged for health care.

• The state subsidize health insurance. “Insurers get risk-equalization payments for patients with about 30 major diseases.” Thus, people who are sicker receive a larger state subsidy than healthy individuals.

How the Dutch View Their System

You might be interested in how the Dutch look at their new system. Here is how a report from the University of Leiden on how the Dutch see themselves.
Overall, the health care system the Netherlands is of a good quality. It is a mix of public and private, whereby the government closely monitors private activity.

Waiting lists

Unfortunately, we have a shortage of doctors and specialists. This means patients may have to wait a long time for treatment.

On top of this, there is also a shortage of general practitioners (GP's). Generally, you can only see a GP by appointment (unless there is a an emergency, of course!).

Where to find a GP/dentist

In the Netherlands, it’s normal to have your own GP and dentist. General practitioners can be found in every town and city. Dentists are to be found in almost all cities.

Every big town has at least one hospital. Specialists are usually employed by hospitals.

Please note that you should first contact your GP before going to the hospital.


In general, Dutch doctors are reticent about prescribing medications. The theory is that, if the patient is a healthy person, the body will fight the disease itself.
So, do not be surprised that they will not prescribe penicillin if you have a cold.


Dutch health care is very expensive. Therefore, it is essential to have a good medical insurance. In fact, medical insurance is required by law. Make sure you read all the rules that would be applicable for you, especially if you are considering to take a part-time job.

Will the Dutch System Work in The U.S?

Matthew Holt, a well-known health analyst who worked closely with Alain Enthoven, the mastermind of “managed competition, “ the Clinton plan that bombed in 1994, thinks so.

Here are a few things he has to say in his September 7 blog, which followed a favorable WSJ report entitled , “In Holland, Some See a Model for U.S. Health Care System, Private Insurers Compete, But All Get Coverage.”

The Netherlands is probably has the most advanced health care financing system in the world.

How so? It's essentially Enthoven's original managed competition idea in action (circa 1987). Even the Wall Street Journal thinks good things. The key is you need to ban underwriting, and implement risk adjustment (not that it's easy but it is doable) between plans. Then you have to give the insurer and the insured incentives to realize that the way that population health is managed has ramifications for both the population's health and its wealth. Then you get rational trade-offs made at a population level.

Can it happen here? I think so, unless you think that Americans cannot handle rational choice. Of course the people who claim to value choice in health care here can't abide by the concept of the rational structure that the Dutch have put in place which allows choice to be made about the right things.

My Opinion

What do I think? Not in its entirety, not everywhere in the U.S., and not soon. We’re much more heterogeneous than the Dutch. We’re have nearly 20 times more people. Managed competition has already failed once, having crashed in 1994. Besides, under the Dutch plan health plans control physicians and consumers. Dutch doctors, by the way, vigorously opposed the current plan. It may be a market in terms of health plans, but it’s not a true market for doctors and consumers.
Still I find the Dutch plan interesting in that it may conceptually gets America conservatives over the hump that all single payer plans are run by faceless bureaucrats in a centralized, all- powerful centralized command-and-control centers without any sense of markets.

The Dutch plan contains some solutions. It offers choices of hospitals and doctors. Consumers now know what things cost. Private health plans compete. The U.S, has to get over the ideological notion that all universal coverage plans represent “socialized medicine,” conducted in gray government buildings, without third parties, without choice, without access to the latest technologies, and in process leveling rather than elevating care.

Maybe, in the end, we’ll find the right formula for ensuring access, maximizing access to the best, and moderating costs. Maybe, as Winston Churchill noted, “You can always trust the Americans. In the end, they will do the right thing, after they have exhausted all the other possibilities.” I hope so.


On Jan. 1, 2006, after 4 years in the making, the Netherlands, a nation with a population of 16.6 million, implemented a new health system requiring all individuals to buy or pay health premiums, private insurers to offer coverage regardless of pre-existing illness, premiums to be adjusted for risk, consumers to be made aware of costs, and not requiring employers to offer coverage. Since the plan’s inception, health inflation has ebbed from 4.5% to 3.0%, compared to a drop in the U.S. from 8.0% to 6.1% over the same period.

Will America “Go Dutch”? Not soon, in my opinion, because of the U.S.’s diversity, our regional differences, our partisanship, our size (land mass and population), our distrust of private health plans, and our preference for consumer and physician market competition. But the Dutch plan shows European governments can be innovative and aren’t averse to private competition.

Friday, September 14, 2007

U.S. Health Care System - A Conservative Journalist’s Report on American Health Care Airs Tonight

John Stossel, 1969 Princeton graduate and one of the few conservatives in the American media will report tonight on the pros and cons of the American health care system, on 20/20. The program will air at 10 PM EST on 20/20. It is called "Whose Body is It - Anyway?"

I’m personally aware he has spoken to Michael Moore, the controversial documentary filmmaker, Dr. Edward Hill, former AMA president, Regina Herzlinger, professor of business at Harvard Business School, Grace Marie Turner, founder and president of the Galen Institute, and John Goodman, economist and head of the National Center for Policy Analysis. No doubt, he has spoken to others as well.

Stossel will compare the U.S. system and others around the world, and will look at U.S. innovations. Included will be a segment is a view of health care in Cuba, featuring filmmaker Michael Moore, Miami-based Cuban activist Jose Carro and George Utset, who runs an anti-Castro Web site. Also Stossel will interview Harvard Business School professor Regina Her linger; and Canadian physician David Gratzer, author of “The Cure: How Capitalism Can Save American Health Care.”

The U.S. is in the midst of a national political debate on health reform. Unaffordable costs and 47 million uninsured spark the debate. The debate centers around these questions: Who shall dominate the system – the government or market forces? What is the proper role of each? How do we cover the uninsured? How do we bring down costs? There are signs things are changing; health premium inflation dropped from 8.0% to 6.1% last year, members in high deductible plans rose 30%., the number of uninsured rose by 2 million, and a half a dozen states have universal coverage plans in the works.

Thursday, September 13, 2007

Medicare To Ban Doctor Referrals to Hospital-MD Joint Ventures

Everybody knows,

• Hospitals account for 50% of total health spending and doctors account for 25% of total spending.

• Procedures cost at least 50% more in hospitals than in doctors’ offices because of Medicare pays “facilities fee” and needs revenues for cross-subsidization of money-losing services.

• Hospitals are scrambling to decentralize into ambulatory facilities to offer more convenient access to patients and preserve outpatient revenues.

• Hospitals can’t be everything to everybody, and can’t effectively manage a large range of specialized activities for every specialty with equal efficiency.

• Hospitals are interested in hospital-physician joint ventures to share costs, keep specialists loyal to the hospital, and to share profits.

• Hospitals are threatened by doctors running efficient “specialty hospitals,” which might siphon off profits from general hospitals.
• Hospital CEOs would rather share “half-a-pie” rather than “no pie at all.”

• The public thinks hospitals and physicians ought to cooperate and collaborate for the common good of patients and the community.

Everybody, it seems, except Medicare officials, Office of the Inspector General, and Representative Pete Stark who are bent on preventing hospitals and doctors from innovating and “colluding “ for mutual profitability.

At least, that’s what a Sept. 12 WSJ piece “Medicare Moves to Cut ‘Self-Referral’ Practice: Proposed New Rules the Rise of Doctors Sending Patients to Centers They Own.” Physicians, McKinsey data indicates, are profiting to the tune of $8 billion/year by sending patients to facilities doctors own, often because of increased efficiencies and excellent outcomes achieved by focusing on specialized procedures.

Not so, says Medicare, profit-mongering doctors are referring to themselves and doing unnecessary procedures because of their ownership stake and “creating incentives for over-utilization and corrupting medical diagnosis.” That is the main reason why, Medicare says, the money expended on imaging(CT and MRI) increased from $9.6 billion in 2003 to $13.7 billion in 2006.

In any event, Medicare is taking dead aim to joint ventures between doctors and hospitals and the shared investments and profits that ensue from MRIs, CTs, endoscopies, and outpatient and diagnostic surgery units.

• Never mind that anticipation of the Medicare joint-venture ruling is causing doctors and hospitals across the land to cancer joint ventures activities that cuts costs and create convenience.

• Never mind that primary care doctors and specialists alike are flocking to hospitals for employment.

• Never mind that hospitals account for almost 50% of excessive 2003 costs in the United States, relative to its wealth, compared to othe developed countries (Carlos Angrisano, et al, “Accounting for the Cost of Health Care in the Untied States, McKinsey & Company, McKInsey Global Institute, January 2007).

• Never mind that hospitals and doctors, working separately, may not be able to afford the public wants or demands and will go elsewhere to get.

• Never mind that hospitals can’t afford to lose the services of specialists who may abandon the hospital ship to keep their own economic boats afloat.

In a “perfect world,” you see, in the eyes of Medicare and their lawyers, hospitals and doctors should have a completely arms-length relationships, even though everybody knows that’s an impossible situation to sustain for long because of the intertwining, intimate, and interdigitating nature of the relationship. But no matter. To Medicare officials and their legal advisors, “pursuing the perfect” is preferable to “preserving the good” that could be achieved by realistic collaborative joint ventures.

Wednesday, September 12, 2007

Blogging, general - The Best Health Care Blogs and Where to Find Them

Here, for better or best, in sickness and in health, are my picks for the best health care blogs and blog aggregating sites. Most good bloggers are also blog aggregators. i.e. they refer to other bloggers and their comment sections contain entries from other bloggers.

Read their blogs, and you’ll inevitably come across other bloggers. Good bloggers are by nature incestuous – they interconnect intimately with other bloggers. Indeed, the blogosphere is a collective term encompassing all blogs and their interconnections. Bloggers exist together as a connected community(or as a collection of connected communities). That’s why blogging has become a form of social networking – of consulting and commiserating with fellow professionals.

I haven’t included my own blog in the following list of best blogs. That wouldn’t be kosher.

1. Health Care Blog (

Matthew Holt, this blog’s creator, is a British-born health care analyst and futurist, with 14 years of experience in U.S. health care. He spent time with Alain Enthoven and at the Institute for the Future and hangs out in San Francisco. He started his blog in 2003 and speaks with an authoratative, acerbic, and humoros voice on everything imaginable under the health care sun – policy, technology, and life on the mean streets of health care businesses.

2) Val Jones and the Voice of Reason (see

Val Jones, MD, a Canadian-born psyhiatrist, has been senior medical directors of Revolution Health, Inc, Steve Case’s consumer website, since it began. You can catch her blog on the Revolution Health website and also subscribe to her Best of the Blogs newsletter. Val triples as a website professional executive, a personal blogger and an aggregator of other people’s blogs. At her blog, she give links to the 35 blogs she trusts and reads. She’s a bottom-up person who believes doctors and consumers hold their health destinies in their own hands.

3) The Doctor Weighs In (

Patricia R. Salber, MD, is an emergency room physician who has held numerous executive positions for health care organizations, including Kaiser and the College of Emergency Room Physicians. She and her husband, Dov Michaeli, an oncology researcher, live in San Francisco. She started her blog, now known at TDWI, several years ago to share her thoughts on fat, fitness, health, and longevity. Recently her blog has offered more diversified fare by featuring blog hosts such as her husband, Brian Klepper, PhD, a nationally known health reformer and analysist, and William Bestermann, an internist who implements“best practice” techniques in a large multispecialty group to avert or minimize cardiovascular catastrophes.

4) Kevin, MD (www.
Kevin Pho, MD, a practicing family physician in his 30s at the Nashua Medical Group in New Hampshire is widely considered to the dean of medical bloggers. Among fellow bloggers, he is a hero because of his generosity in citing their blogs, many of which he reads daily. His self-effacing and candid comments on the true and sometimes ugly faceof American health care have captured the attention of the media and public as well. In the process, he has made his personal blogging profitable by attracting a number of paying sponsors.

5) (

This isn’t a blog, but it attracts a number of bloggers, including myself. is the brain child of Daniel Palestrant, MD, a general surgeon in Cambridge, Massachusetts, who thought doctors ought to have a free-wheeling online forum, accessible only to licensed physicians, where they could exchange their views as to what they really thought was going on in American health care and where they could share views of fascinating cases, technological issues, and matters of health reform. is an example of a new phenomenon in the Internet world known as social networking where doctors and others can consult and commiserate with each other. Only doctors licensed to practice can participate in
I conclude with a list of other blogs, and blog aggregation sites worthy of your attention.

• - features latest news of technological innovations transforming the health system.

• Google reader and google blog searcher – Google has unleashed the blogosphere by making it possible for anybody to create their own blog free of charge.

• – Everything you ever wanted to know about medical blog content and how to start a blog.

• www. – This is an emerging social network of physicians empowering physician relationships with other health care sectors.

• www. - a biweekly compendium of the best of health blogs. More than two dozen health infrastructure, insurance, technology, and managed care bloggers participate by contributing their best recent blog postings to a roving digest, with each issue hosted at a different participant's blog. For participants, it's a way to network and share ideas, and for those readers who don't live in this space every day, it's a way to sample some of the latest thinking and the "best of the best."

• And here are other medical blogs that come heavily recommended.


Physicians may find the following blogs and websites useful - www.thehealthcareblog,com, www. containing Val Jones and the Voice of Reason blog, www.the,, and Most of these blogs are also blog aggregating site, meaning you can find other timely blogs mentioned in them. Other medical and health care blogs are also listed. Health care blogging represents a new Internet phenomenon – social networking among professionals so they can consult and commiserate with each other in an innovative, rank, soul-searching, non-judgmental,and no-holds barred fashion.
See for full story

Tuesday, September 11, 2007

Hospitals and Doctors - Hospital-Physician Culture Gap

I just received the following email in response to “Five Physician Mindsets,” now appearing in The writer, an operational consultant, addresses the problem of the cultural gap between hospitals and doctors. She is right on target and has given me permission to reprint her email.

Dr. Reece,

Very nicely written. Succinct while raising many of the issues out there.

I'd like to humbly add that there are two categories you might consider adding. The first is the mistrust of senior management, especially in hospitals, by most physicians. There is a war going on out there. Physicians feel these executives have no experience with the 24/7 responsibility of someone's life and the deep accountability necessary with care. My husband, an internal med doc in a large hospital in Nashville has said the executive team has consistently failed in just about every endeavor to help. The failure gap widens.

The second mindset is within senior management and their opposition to changing organizational structure and processes in ways that would benefit doctors. Operational and financial deficiencies are widespread, and senior teams are engrained in a culture of ignore it and it will go away. None have been willing to build real accountabililty among themselves. They are insular, protected, and thus ineffective in leading operational change.

Combining the mindsets of mistrust on behalf of doctors, and insular protection of non-accountability on behalf of executive leadership results in collaborative barriers that are nearly impossible to overcome.

I always find it fascinating that in all the thousands of articles I read on the healthcare climate, the word "patient", or more appropriately, the focus on the patient is lost to the pressing complexities of the industry. As an operational consultant, we rarely focus on the patient, per se. Thanks for considering my thoughts.

Susie Gile-Daniels, MBA, RN
Portland, Maine

Ordinarily I don’t reprint what I’ve written in the past, but following the email I feel moved to reprint a portion of article “ I wrote back in May, 2003.

Hospital Culture vs. Physician Culture

Recently I heard Dick Davidson, head of the American Hospital Association, speak on "Fixing Our Broken Health System." He spoke of money pressures on hospitals. He asked for political support to bolster Medicare funding. Community healthcare, he said, converges at America's 5,000 hospitals. Hospitals are obligated to take all comers, their doors are open 24 hours a day, and meeting expenses of federal regulations is overwhelming many of them.

Davidson sees hospitals as the center of healthcare in most communities. All care roads converge there – preventive care, health promotion services, high-tech care, oncology care, outpatient care, and increasingly, low-tech primary care delivered by hospital-employed physicians. The hospital culture sees itself as being everything to everybody – as a place of convergence and integration for hospitals and physicians. Unfortunately, the hospital’s role as an indispensable community asset has become difficult. Medicare and Medicaid cuts, costs of the uninsured, and computer infrastructure demands are cracking hospital financial foundations and shredding the safety net for needy patients.

Meanwhile the physician culture – more fragmented, more introverted, and less hierarchical than the hospital culture – is experiencing its own angst, stemming from downward pressure on incomes, reduced reimbursements, sicker patients requiring more time, rising costs of doing business, unaffordable malpractice rates, HIPPA, and increased competition from physicians employed by hospitals.

Will hospital and physician cultures, both experiencing difficulties, converge into strategic partnerships? Or will they diverge into competing entities? Will they integrate or disintegrate? Hospitals hope for convergence and integration. Some health observers and stakeholders, including powerful specialty groups, foresee divergence and disintegration.

• Regina Herzlinger, Ph.D., professor at Harvard Business School, says "focused factories," specialized centers of excellence dealing one disease, will eventually replace hospitals that provide comprehensive care to all comers. "I don't think we can develop one vertically integrated, relatively convenient system that provides care for every conceivable disease for every patient,” she says. “It's just not realistic."

• Jeff Goldsmith, futurist, has written: "As health systems integrated structurally, they disintegrated culturally. The gap between professional and managerial cultures that existed during most of the 1980s and early 1990s widened into a chasm by the late 1990s. Professionals of all stripes – not merely physicians, but nurses, technicians, social workers and others – saw their practices increasingly commoditized and marginalized by the growing corporate ethos in their systems; professionals lost contact, physically and spiritually, with the 'adminisphere' – the tiny handful of people running their systems."

• Daniel K. Zismer, Ph.D., principal of a healthcare consulting firm in Minneapolis, says: "More hospital CEOs will lose their jobs over physician relations than for any other single reason over the next several years. Organized groups of physicians in certain specialties that also happen to be critical to the success of hospitals have business strategy alternatives, which, if pursued, can have devastating consequences for hospitals, which in turn, threaten the jobs of health system CEOs."

• In Columbus, Ohio, Michael Curtin, Mount Carmel Health Systems board chairman, reacted to news that Columbus orthopedic surgeons were building a specialty hospital by saying, "You cannot stand by and watch people rip out whatever profitable veins there are for a community facility." Mount Carmel and OhioHealth, another Columbus hospital system, plan to deny privileges to doctors investing in New Albany Surgical, an orthopedic hospital. Carl Bears, M.D, investor in the physician hospital, explains physician investors' rationale: "To gain control over how a hospital is run, you have to be an investor." And Robert E. Tabbies, M.D., an Oklahoma City neurosurgeon, part owner of the Oklahoma Spine Hospital, says: "For physicians, control and decision-making power translate into a more satisfying and rewarding professional life and increased revenues in the time of declining medical reimbursement, and many patients demand personalized treatment especially when it involves specialty care and surgery."

What can a hospital CEO do to influence physicians to become strategic partners, rather than competitors of hospitals?

Well, first, the CEO should understand the essence of the physician culture.

1. Physicians in a single specialty, though considered conservative and slow moving, speak from the same page. They know each other well, have similar practices, have a common language, and unite behind common business purposes. When uneasy or suspicious of hospital motives, they can move with astonishing speed to form competing entities.

2. Certain specialists, including heart surgeons, cardiologists, orthopedic surgeons, general surgeons, neurosurgeons, and oncologists – the economic lifeblood of most hospitals – are accustomed to acting decisively in clinical matters. This decisiveness carries over into business affairs.

3. Physicians are threatened by a hostile business climate and will move quickly to gain control of their economic and clinical destinies.

4. Physicians pride themselves on being independent professionals and are accustomed to acting with dispatch and with inadequate and uncertain information.

5. Physicians aren't impressed by business acumen. In their group opinion, physicians know hospitals, HMOs, management companies and large group practices have had their runs at owning, organizing and employing physicians, and for the most part, have failed to make a go of it.

6. Physicians understand the physician culture, and its underlying cohesion, even as critics dismiss it as 600,000 fragmented doctors with 2,000 charts each.

7. Physicians are skeptical that hospital executives understand the physician business. After all, few hospital CEOs have yet to spend a day in the trenches with real doctors and real patients.

8. Physicians know their market power. They have yet to hear a sick patient say, "I feel ill. I must go to my Integrated Delivery System." Patients still go to their responsible neighborhood physician or appropriate specialist.

9. Physicians are a self-organizing swarm. They move in unison to a professional beat bred into them by self-selection and training. Physicians are self-learning Darwinians who know how to act, react, adapt and survive as individuals and as members of groups.

10. Physicians do not like to be told how they should be compensated. They prefer not to be paid salaries. They wish to be rewarded on a basis of individual productivity. Physicians make bad employees. Ask HMOs, hospitals, IDSs, PPMCs or other healthcare corporations. They have tried and failed to rein in that individualism or to put physicians on salary.

11. Physicians are a brotherhood and sisterhood. They come out of a common professional incubator, and know how each other thinks and acts without asking.

12. Physicians ask to be trusted to do the right thing, to be considered professionals, to be paid for productivity, and seek information systems that provide relevant information and speed patient flow.

13. Physicians prefer to run their businesses from the bottom-up, rather than having it imposed on them from the top-down by outsiders.

So, given the nature of the physician culture, what are hospital CEOs, whose job may be at risk, to do?

Here is Zismer's advice:

1. Don't delegate physician relations to lower management. Approach leaders of key physician groups yourself and say something to the effect of: "The hospital and I are interested in ensuring that we understand your needs and are innovative in our methods to the success of our collective futures over the long term."

2. Remember, your hospital's future depends on specialists in multispecialty or single specialty groups, not with "medical staff." Explain to your board the fundamental difference between specialty groups and the "medical staff." The medical staff is not a business entity. A specialty group is.

3. Give an honest report to the board about the state of the physician business climate – the good and the bad. Board members don't like surprises.

4. Understand market risks and financial consequences of a specialty group pulling out of the hospital and building its own facility. Report these risks and consequences to the board.

5. Engage in organized and deliberate business planning with key groups.

6. Be willing to execute on business models that make sense for both the hospital and physician groups, even if these models aren't an exact fit for the hospital culture, even if it entails business partnerships with physicians, even if they dilute the hospital bottom line in the short term. In the longer term, the new arrangement will most likely extend market share.

7. Be always mindful of the legal considerations in designing hospital/physician collaborations, including, but not limited to, Stark self-referral statutes, anti-statutes, tax-exemption standards, and reimbursement issues.
Always keep in mind that physicians resist change that subjugates them to hospitals. Remember, physicians will accept change if it gives them more influence and control over clinical affairs, and if it helps them retain their autonomy.