Tuesday, October 30, 2007

Hospital-Physician Relationships Revisited

Hospital-physician relationships deeply interest me. With the help of a former hospital CEO, Jim Hawkins, I even wrote a book on the subject “The Sailing the Seven “Cs” of Hospital-Physician Relationships: Competence, Convenience, Clarity, Continuity, Competition, Control; and Cash (Practice Support Resources, 2005.

These relationships have always been testy, tense, even tumultuous. Today, they are even more so because of tightening economic conditions. Hospitals and physicians, after all, must cooperate and compete at the same time.. This paradox has spawned the term “co-opetition” – a term yet to make into most dictionaries.

Recently, despite market forces of decentralization, convenience, and outpatient-based care, the power balance may be shifting to hospitals. The reasons are many:

Hospitals have more,

• access to capital,

• unified organizational structures,

• political influence as large employers,

• visibility in the community.

But the reasons may be even deeper. Because of the physician shortage, social obligations to treat all in the ER, and increasing tendencies of specialists to bolt from the hospital to form and own their facilitates, including hospitals, hospital CEOs are spending most of their waking hours these days on physician relationships.

From the perspective of hospital CEOs , the top three physician issues of the day may be,

• Emergency call coverage

• Physician employment

• EMR technology that tethers physicians and hospitals

Of these, paying physicians for ER coverage may be the most pressing because caring for patients at their sickest is the hospitals’ reason for being. It is clear specialists will no longer cover for free, given the physician shortage, declining physician reimbursement, and the malpractice climate.

Physician employment is growing fast because doctors don’t want to put up with business concerns, hassles, malpractice fears, and long hours. Doctors, especially the young but the older too, seek security and more balanced life styles.

EMR technologies binding hospitals and physicians together are much talked about, but slow to evolve because lack of return on investment on both sides of the aisle, physician resistance to information technologies, and the variety and instability of HER vendors.

What is your template for better hospital-physician relationships and ties that bind?

For publications related to this topic, see Sailing the Seven “Cs” of Hospital Physician Relationships, The Voices of Health Reform, Innovation-Driven Health Care, And Who Shall Care for the Sick?

Medical Trends - YouTube as a Dress Rehearsal for Medical Procedures

YouTube to instruct patients about medical procedures? It was bound to come. YouTube burst onto the Internet scene several years back and quickly sold to Google.com by two young men for $1.6 billion.

Now medical and dental practices have adopted it to show educational videos for what they do. The Oct. 28 NYT carries a piece “You’ve Had the Root Canal. Now See the Movie.”

The article tells the story of Dr. Jerry Gordon, a dentist in Benslem, PA (www.dentalcomfortzone.com). A local videographer shot the 10 minute video for $2000. More than 11,000 people have viewed it in the two months it has been on YouTube. In 2006, 11 patients found Dr. Gordon through the video on his website. Since he posted the video on YouTube 68 patients have come to him via YouTube for a root canal.

YouTube now has hundreds of “clinical tutorials” or
”instructional videos, “the euphemistic names for video clips of clinical procedures, for everything from cardiac bypasses to joint replacements. The appeal of videos is universal. Some postings draw more than 1 million visitors. YouTube draws in viewers with this message. “Watch millions of videos. Share favorites with friends and family. Connect with others who share your interests. Upload your video worldwide.”

In posting this blog, I’m observing, not advocating , the clinical use of YouTube. I can see where these videos might be abused. But I also knowYouTube represents a profound innovation in the Internet world.

This should come as no surprise. As John Naisbitt, the author of Megatrends and now of Mind Set!, has observed, “There is unprecedented visual assertiveness in the world today, from art to architecture to high-end fashion, and the design of common goods. It is an MTV world, a world where visual narrative is overwhelming literary narrative.”

The world of medicine is now part of that visual world, whether we like or approve of it or not.

For publications related to this topic, see Sailing the Seven “Cs” of Hospital Physician Relationships, The Voices of Health Reform, Innovation-Driven Health Care, And Who Shall Care for the Sick?

Monday, October 29, 2007

Sermo, The Physicians Foundatiom the AMA -Practicing Doctors: The Missing Voice in Health Reform

Ask your patients or your local newspaper or TV station where doctors stand on health reform.

I’ll wager they don’t know.

Why not?

The AMA’s voice is curiously muted, perhaps because it is thought to represent a union for doctors, or simply a lobbying organization in Washington. This may be unfair. Besides, its message of expanding coverage through market mechanisms, leveling of tax deductions, extension of tax credits, reforming physician’s payments and the medical liability system, important as they are, are abstract issues to the public and the media world at large...

A more personal and pointed approach is needed. The Connecticut State Medical Society in the 1980s had the right idea when it launched its MD Health Plan with the theme “Nothing should stand between you and your doctor.” Later, in 1999, the Medical Society brought Aetna to the bargaining table with full-page ads in newspapers and on billboards with this slogan, ”Aetna is Playing Doctor with Our Patients.”

Then in 2004, 19 state medical societies, led by Connecticut and Texas and others, reached a settlement in federal court with Aetna and Cigna. This culminated with Aetna and Cigna contributing over $150 million, leading to the formation of the Physicians’ Foundation for Health System Excellence and the Physicians Advocacy Institute. These organizations issue grants to physician organizations and promote efficiency and quality improvement and negotiate with HMOs over contentious physician issues.

What’s now needed is a national megaphone, a data gathering and news outlet, such as Sermo.com, for these or similar organizations to make clear why and where practicing doctors stand on vital issues of physician practice viability and health reform. In some cases, such a primary care, the issue might be why some primary care physicians are an endangered economic species, or on the reform front, why third parties are in essence practicing medicine, standing between doctors and their patients.

Sunday, October 28, 2007

Clinical Innovation - A Story of Innovation from My Home Town

While roaming through the media countryside, gunning for a bird of thought to flash by for my blog, I came across a full-page ad in the October 25 USA Today. It bore the headline “Recognizing Talent Today Inspires the Innovation of Tomorrow. Congratulations to the 2007-2009 Siemens Competitions in Math, Science, and Technology.” The ad announced regional finalists and semifinalists of Siemens national innovation and entrepreneurial competition.

I noticed five regional finalists hailed from Oak Ridge High School, Oak Ridge, Tennessee, my alma mater. It was there I became a Bausch and Lomb national science search finalist. That honor lit the spark of innovation. It persists to this day in the form of this blog on medical innovation.

Last year a team of Oak Ridge High School seniors took Siemens $100,000 grand prize in the nation's science competition for research-minded high school students. That team’s project involved creating energy from biofuels. This year the high school and their inspirational teacher Benita Albert will field two teams again vying for Siemens top prize.

Oak Ridge is one of three high schools in the country to have two squads in regional finals in the Siemens Competition in Math, Science, and Technology. They'll compete for the nationals on Nov. 2, when they’ll present their studies to experts gathered at Georgia Tech.

The five Oak Ridge senior work with scientists at Oak Ridge National Laboratory. Students Byron Jaeger and Minghui Ren have worked with John Drake, the program manager for the lab's computational earth sciences group. They've studied climate-related computational and climate modeling. They seek to understand global warming by arriving at a more precise global average temperature.

Seniors Woody Austin, John Banks and Xinzhu Wang have been doing research with Vincent Meunier with the lab's Computational Chemical Sciences Group. The team's nanotechnology project can potentially be used in detecting chemical warfare agents. The research aims to develop software for creating nanosensors, tiny electronic devices used in solar cells and chemotherapy, among other applications.
If either Oak Ridge team wins the regional, it will advance to the national competition held Nov. 30-Dec. 3 in New York City.

The Oak Ridge High School team’s work reminds me America is an entrepreneurial bottom up society. Innovation thrives on big ideas like climate change, biofuels, chemical warfare, and health reform. This innovation requires support, collaboration, incubator environments, and prizes and recognition for work well.

This holds true in spades for health care, where innovations are badly needed to reform a $2 trillion system with runaway costs, which by the way, dwarf Iraq War costs by a factor of about 10. Many health care innovations, I believe, will start with medical students, medical residents, and doctors in the trenches. I have argued this point in my blogs and in my book Innovation-Driven Health Care, and I will stress it again in a talk I’m giving at the University of Pittsburgh Medical Center in two weeks.

For health care innovation to succeed, the U.S. needs supportive environments, business and scientific advisors, and capital, but more than anything else, we need inspirational mentors and supporters and the belief that innovation sets us apart as an achieving nation with solutions to big problems.

Maybe our medical schools will take a cue from Oak Ridge High School and create teams of doctors, scientists, and biomedical engineers that address innovations to solve the problems that beset our health care system.

Reforming the Primary Care Physician Payment System- Eliminating E&M Codes and Creating the Financial Incentives for an “Advanced Medical Home

Prelude: Norbert Goldfield, M.D., who heads up the 3M Informatics Group, and who practices primary care in Springfield, Massachusetts, and six associates affiliated with 3M have come up a report that says, in essence:

• Let’s pay primary care physicians for what they do – providing comprehensive and coordinated care for patients – rather than by fee-for-service for individual acts.

• Let’s tie this payment into the severity and complexity of the illness.

• Let’s encourage the primary care specialists to become involved in coordinating care with the specialists to whom they refer.

This report is in response to the growing crisis and potential collapse of primary care. The payment gap for primary care physicians and specialists, now approaching 1:2 to 1:4, is a problem gnawing at the underside of American medicine. No amount of primary care “efficiency” can overcome this gap. Only patient volume - seeing more and more patients with less and less time devoted to each – can solve the income problem for most practitioners. Various piecemeal innovations – more procedures by primary care doctors, better coding, computer interviewing of patients, payments for email communication with patients, EHRs, and office dispensing by doctors have been tried, but nothing seems to overcome the gap.

Some sort of more systematic approach may be needed, and that is what Norbert Goldfield and his associates have come up with. Here, in brief, are elements of their overall plan, along with their definition of the problem

Excerpts from Report

“The problem facing primary care physicians (PCPs) is that they can only maintain or increase their (inflation adjusted) incomes by increasing the volume of visits and associated services. The fundamental flaw in a fee-for-service system is that if you only pay for individual services, you get more services. “

“In addition, to the financial incentive to generate more visits and services, there is no financial benefit to a PCP, should they reduce their use of ancillary services, control the number of referrals to specialists, refer to less expensive specialists, or invest in better coordinating care so as to reduce hospital admissions and readmissions. Thus, PCPs have the financial incentive to increase the services and volume of visits they provide and no financial incentive to decrease the services they order.”

“This problem is clearly due to the unit of payment for PCPs (i.e., individual visits and services). Fee-for-service payment creates a situation where physician and payer incentives are completely misaligned. Payers want PCPs to use resources efficiently while rewarding inefficiency by paying for every additional service utilized on the RBRVS fee schedule.’

“PCPs who attempt to become more efficient can only do so by reducing their already none-too-high incomes. There currently does not exist an effective financial mechanism to foster the goals of both consumers and PCPs – an “advanced medical home” for patients which provide physicians with the incentive to increase coordination of care for their entire panel of patients. “

“The American College of Physicians (ACP) has introduced the term “advanced medical home” to describe physician groups that practice patient-centered care promoting improved outcomes in terms of quality and resource use (value). “

“The following details a series of payment reforms that adhere to these goals while heeding the call for fundamental payment redesign to achieve them.”

“Reform of the payment system for PCPs with the ultimate objective of facilitating the “advanced medical home” concept is centered on four principal objectives:

1. Financially reward PCPs for providing coordinated care to their patients by having PCP payment be, in part, based on the overall health care resource use of their patients.

2. Reform the current visit based PCP payment system that pays for reported physician effort using the CPT E&M codes to a transparent system that is based on the patient’s condition.

3. Do not increase the administrative burden on PCPs.

4. Provide a continuum of options in terms of the level of financial risk a PCP accepts for the coordination of care of their patients.”

What is your response to such a plan? Is it too radical? Does abandoning FFS for a quasi-capitated payment for comprehensive and coordinated care based on severity and complexity of illness make sense? Is it workable?

For publications related to this topic, see Sailing the Seven “Cs” of Hospital Physician Relationships, The Voices of Health Reform, Innovation-Driven Health Care, And Who Shall Care for the Sick?

Saturday, October 27, 2007

Physician Business Ideas - Why Not More Office Procedures? An Analysis of the Obvious

“It takes an unusual mind to undertake the analysis of the obvious.”’

Alfred North Whitehead (1861-1947), Science and the Modern World

John L. Pfenninger, MD, a Michigan family physician, passionately believes his compatriots in their offices can do more procedures and do them well with more convenience for patients with less cost to the health care system.

That’s why he founded the National Procedures Institute (NPI) in 1989 to teach procedural and surgical skills to primary care physicians. NPI has trained over 15.000 clinicians to perform appropriate procedures in their offices.

Saith John:

Doing procedures makes so much sense. Many things can be performed in office as opposed to the hospital. Surgeons are trained to do everything in the operating room but this markedly increases costs. Sebaceous cysts, lipomas, hemorrhoids, and many other conditions can be treated in the office setting. Patients appreciate this, as do the insurers, because costs are kept to the minimum.”

“Other advantages of doing procedures include a reduction in the delay of diagnosis. In other words, if a skin lesion looks atypical and the clinician is comfortable doing a skin biopsy, it is biopsied on the spot. The alterative is sending the patient away. This may take 6 to 8 weeks before another evaluation. In the case of melanoma, this puts the patient at increased risk.”

“If the clinician becomes more involved with seeing, feeling, and exploring the innuendos of a disease process, the diagnostic acumen become more accurate. Doing procedures can break up the monotony of the day-to-day practice.”

“In addition, reimbursements still are greater for surgeries and procedures, versus nonsurgical areas. Numerous studies are available showing that those who perform procedures have a significantly higher net income. For most family physicians, they chose the specialty not to be case managers or paper pushers, but rather, to provide comprehensive care. Doing procedures makes this more likely.”
To back up his argument and to give it obvious educational validity, NPI offers CME credits and has produced a mammoth 2080 page textbook Pfenningers &Fowler’s Procedures for Primary Care, Second Edition (Mosby, 2004) and code books for procedures. NPI can be accessed at www.npinstitute.com

For publications related to this topic, see Sailing the Seven “Cs” of Hospital Physician Relationships, The Voices of Health Reform, Innovation-Driven Health Care, And Who Shall Care for the Sick?

Thursday, October 25, 2007

Government reform - Goring Someone Else's Ox: Why Reform is Hard

“Over the long term, reform is only likely to come in response to a major war, depression, or large scale unrest”.

Victor Fuchs and Ezekial Emanuel, “Health Reform: Why? What? When?, Health Affairs, 2005

In Voices of Health Reform (2005), I argued comprehensive health reform is unlikely because it always gores someone’s economic ox.

In the Oct.25 NEJM, ”Learning from Failure in Health Reform, “ Jonathon Oberlander, PhD, an academic at UNC in Chapel Hill describes the strength of the ox and why it’s still alive and kicking.

First, “The status quo is deeply entrenched and despite its failings, the system is remarkably resistant to change, in part because man constituencies profit from it.”

Second, “Many Americans are satisfied with their own health care arrangements, so reforms that threaten those arrangements risk running afoul of the voting public.”

Third, “Expanding government authority over a health care system that accounts for more than $2 trillion and one sixth of the economy in a country that is ambivalent about public power is an inherently controversial exercise.”

Fourth, “Paying for health care remains a formidable challenge.”

Fifth, “U.S. political institutions limit presidential power, foster divisions in Congress, create opportunities for those with vested interests to block change, and generally complicate the adoption of health care reform.”

Sixth, “The window for enacting a comprehensive plan for health care reform never stays open for long, so failure comes at a high price – namely, the loss of political will to do anything about the uninsured for some time to come.”

Which leads to this perverse verse,

The Ox, The Pox, and The Fox

There once was a hurly burly health care ox,
Wonks and liberals placed on this ox a pox,
Which declared greed and profit aren’t fair,
And should be removed from health care,
But the ox turned out to be a ferocious fox.

For publications related to this topic, see Sailing the Seven “Cs” of Hospital Physician Relationships, The Voices of Health Reform, Innovation-Driven Health Care, And Who Shall Care for the Sick?

Physician Business Ideas - Physician Demoralization - Older Doctors Want Out.

Prologue: I reproduce the following press release without editing as evidence of the state of declining physician morale. As you read it, keep in the mind physicians are needed to meet the ever increasing demand for more care.


IRVING, TEXAS – In the next one to three years, 48 percent of physicians between the ages of 50 and 65 are planning to retire, seek non-clinical jobs, work part-time, close their practices to new patients, and/or significantly reduce the number of patients they see, a new survey indicates. The survey, conducted by Merritt Hawkins & Associates, a national physician search and consulting firm based in Irving, Texas, suggests that many experienced physicians are seeking a way out of traditional patient care roles.

“When Baby Boom doctors entered medicine they had control over how they practiced and the fees they charged,” notes Mark Smith, executive vice president of Merritt Hawkins & Associates. “But the rules changed on them in mid-stream and now many are looking for a ticket out.”

The survey indicates that 24 percent of older physicians plan to opt out of patient care in the next one to three years. Fourteen percent of these physicians said they plan to retire in the next one to three years, seven percent said they plan to seek a medical job in a non-patient care setting, and three percent said they plan to pursue a business or job in a non-medical field.

The survey also indicates that many older doctors, while staying in patient care roles, plan to reduce the number of patients they see in the next one to three years. Twelve percent of physicians surveyed said they would start working part-time in the next one to three years, eight percent said they would either close their practices to new patients or significantly reduce their patient load, and four percent indicated that they plan to work on a temporary basis.

Should older physicians elect to remove themselves from patient care or significantly reduce the number of patients they see, access to physicians would be greatly reduced, according to Smith.

“Almost half the physicians in the United States are 50 years old or older,” Smith observes. “An exodus of older doctors from medicine would be a disaster for patient care in this country.”

Younger Doctors Not as Hard Working?

The survey further indicates that many older physicians are underwhelmed by the work ethic of today’s younger physicians. Sixty-eight percent of older physicians surveyed indicated that physicians coming out of training today are less dedicated and hard working than physicians who came out of training 20 to 30 years ago.

“Whether valid or not, many older physicians see themselves as more wedded to medicine than are younger doctors,” Smith notes.

The survey suggests that disillusionment among experienced physicians runs deep. Forty-four percent of physicians surveyed indicated that they would not choose medicine as a career if they were starting out today. The majority (57 percent) indicated that they would not recommend medicine as a career to their children or to young people.

Over 1,170 physicians between the ages of 50 and 65 participated in the survey. Results of the survey are available on Merritt Hawkins & Associates’ web site at www.merritthawkins.com.

Wednesday, October 24, 2007

Hospitals and Doctors - “You Might Say We Own The Joint”

On ABC news radio, Hartford Hospital ran an ad extolling the fact that it had done more joint replacements than any other Connecticut hospital. The Hartford Hospital ad punch line was “You might say we own the joint.” That’s a clever play on words. I congratulate the Hartford Hospital marketing department or its ad agency.

Then I picked up the New York Times, only to be confronted by two full page ads. I would guess these ads costs $75,000 to $100,000 to run. The Baylor College of Medicine and the University of Pittsburgh Medical Center ran them.

• The Baylor ad contains nearly a full page picture of the legendary Michael DeBakey, MD, 90 year old + heart and vascular surgeon who made heart and vascular surgery what it is today – one of the most life saving and profitable service lines offered by major medical centers.

• The UPMC ad features its technologic achievements – national leader in health research, heart valve replacement and repair, organ transplantation, and advances in gene therapy and tissue engineering.

We need our volume-based centers, our doctor heroes, and our top-notch research institutions. It helps hospital businesses to publicize them. The ads are further evidence of the technological-based medical arms race between major hospital systems.

America hospitals derive 80% to 90% of profit-margins from orthopedic surgery, cardiovascular procedures, and a few other procedurally-based specialties. These specialty procedures are an intrinsic part of America’s medical industrial complex, which some claim make us the “best medical system in the world.”

I don’t necessarily buy into that claim, but I know we’re terribly good at high tech. The quality of the less-profitable high touch component, covering other patients in the population, is open to dispute and resides at the center of health reform debate on universal coverage.

What is your take on hospital marketing? Does it help marketing of your services?

U.S. health care system - Book Review - Fixing American Healthcare

Fixing American Healthcare: Wonkonians, Gekkonians, and the Grand Unification Theory of Healthcare, Publish or Perish, DBS, Pittsburgh, 2007) This 326 page paperback with its off-beat subtitle is a damn fine book. Richard N. Fogoros, MD, cardiologist, professor of medicine, consultant, blogger, and writer par excellence sent the book to me in response to my recent blog on the health system.

Professor Fogoros divides the health care into two camps: the Wonkonians and the Gekkonians.

Wonkonians (wonks) are government regulators, politicians, public health officials, and political liberals who believe too many greedy doctors are using too much expensive technologies.

Gekkonians, after Gordon Gekko, who proclaimed "Greed is good," in the movie Wall Street, include the insurance industry, health care executives, many physicians, free enterprise proponents, and political conservatives.

Fogoros further separates Wonkonians and Gekkonians into four shifting interrelated quadrants, which together make up the GUT (Grand Unification Theory) of health care.

Quadrant I - Here government centrally controls health care. Wonks insist this ensures quality because decisions rest on scientific and economic information, appropriately and equitably applied, using processes open to, vetted, and monitored by the public. The bad news? This system requires overt "rationing," a word most politicians and most Americans abhor.

Quadrant II - Patients and doctors make decisions on the ground. Patients spend their own money. "Because the individuals receiving the medical services will be paying for them, healthcare economics will begin to look like other, more typical economic spheres, and the quality or purchasing decisions will be begin to increase." Rationing is transparent and automatic, like all marketplace decisions.
Quadrant III -- Here "covert" rationing by health plans and government forces.
bedside rationing by doctors. "Covert rationing requires that patients remain passive and compliant, trusting that their doctors, the insurers, and the federal authorities - but especially their doctors - have their individual welfare at heart, will do right for them, and will tell them what they need to know." This, says Fogoros, destroys patient-doctor relationships and corrupts everything it touches.

Quadrant IV- This, the Tooth Fairy Quadrant, is where we are today. Patients and doctors are free to make their own decisions, as long as somebody else is paying the bills. It has a no limits mentality, i.e., everybody should receive the best possible care without limits. The Tooth Fairy creates expectations that can't be met, and fosters the medical-industrial complex because it is assummed all new technologies will be paid for. It costs too much, and it can't be sustained.

Fogoros sums up his book with a model solution, straddling Quadant I and II, and featuring open competition for services, and thee teirs - HSA s, Universal Basic Coverage, and Optional Insurance Plans, and a series of six principles which you can read by buying the book (hint: the principles include transparency, rationing decisions by patients, and clear rationing rules).

That's my GUT check on this fine book.

Tuesday, October 23, 2007

Physician Demoralization - Enough is Enough is Enough

This is about physicians rebelling against their loss of autonomy.

Gertrude Stein (1878-1946), American poet and writer, once famously said, “A rose is a rose is a rose.” By this she meant when all is said and done, a thing is what it is. In less poetic terms, she also might also have said, “A fact is a fact is a fact.” In other words, you can’t change reality.

There are two realities:

1) In this age of “accountability,” loss of autonomy – the freedom to treat patients according to their best clinical judgment – galls physicians because autonomy defines them\r role as medical doctors.

2) American physicians have had enough, which is why a broad and growing physician shortage exists, why ambitious and bright young people are choosing fields other than medicine, medical students aren’t choosing primary care residences, physicians are demoralized. A survey by the College of Physician Executives indicates lost autonomy, low reimbursements, bureaucratic red tape, patient overload, loss of respect, and an adverse malpractice climate discourages more than 60% of American physicians.

The reality is that American physicians have had enough.

• Enough unsubstantiated talk about killing 100,000 hospital patients annually.

• Enough chiding about failure to adopt electronic health records from vendors who may or may not remain in business.

• Enough general hospital and Congressional criticism about referring to facilities in which physicians have partial ownership and where care tends to be better and where they can be more productive and in clinical control.

• Enough impugning of their motives for investing in ancillary office-based services from which they derive revenues to meet rising overheads and shrinking bottomlines..

• Enough gratuitous advice about physicians teaching prevention as key to improve outcomes when the basic problem in improved outcomes is often lack of patient compliance – filling prescriptions, taking medicines as prescribed, eating properly, and being physically active.

• Enough mindless moralizing about their lack of compassion as they try to cope with increasing patient loads and demands.

• Enough lecturing from “experts” who have never been inside a medical office for any length of time about how to run their office.

• Enough assertions from Washington. D.C., pundits and Medicare officials about why fee-for-service should be abandoned and replaced by salaried positions where no “perverse” incentives exist to provide “unnecessary” and “unsafe” care.

• Enough cries for physicians to provide less care for patients face-to-face personal care in favor of impersonal, faceless, electronic communication.

• Enough Stark and other federal laws forbidding them to collaborate with each other and hospitals to establish such innovations such as bundled bills for hospital procedures, integrated care units for specific diseases, and convenient off –campus ambulatory care units..

• Enough stifling federal and state regulations that hamper clinical and technology innovation.

• Enough commentary about integrated computer systems, pay-for-performance, and electronic surveillance and compliance to quality guidelines are the final answers to improving the health system but with no mention of time, money, and training required..

• Enough blind beliefs that data mining of post hoc claims will yield sufficient information to separate and identify the “good”, i.e economical doctors quality performing physician following “the rules”, from the “bad” doctors, i.e. those who act independently following their own judgment based on face-to-face encounters with individual patients.

• Enough unproven investment in that concept that somehow “process metrics,” measuring what doctors do in their office or hospital settings, will automatically translate into better outcomes once patients leave the medical environment and return home to former lifestyles

• Enough third parties micromanaging care, setting fees capriciously and arbitrarily, dictating procedures to be done, and the process creating unneeded demand because patients develop an “entitlement syndrome” and have no sense of true costs.

As a conequence of these attitudes, a physician counter-revolution is brewing out there. This is taking various forms – organizing of more structured and larger physician organizations with the power and data to negotiate with payers, legal actions by physicians against HMOs to guarantee more equitable payment arrangements, establishing of “social networking” and “end-user” websites allowing physicians to talk to each other and to articulate why some “improvement” strategies don’t work and simply add more bureaucratic burdens, and a growing belief that physicians must establish some sort of national forum to air their grievances, present what is needed for health reform, and establish their own set of best practice guidelines. In the end, most physicians would prefer to deal with patients directly with full knowledge of costs, with patients paying at least a portion of the costs, and with both patients and physicians retaining their individual autonomy.

Monday, October 22, 2007

U.S health care system -The Cottage Industry Crumbles, Or Does It?

This is for your information, and is not intended to be inflammatory.

In Prescriptions for Excellence in Health Care, a collaboration between Jefferson Medical College and Eli Lilly, and Co, Michael Millenson – a respected physician critic and widely-read author – argues our current health system is ” inefficient” and may even threaten our economic and national security. He says further IT adoption by doctors is a “high-visibility failure”, and the public is increasingly “intolerant of unsafe and unnecessary care.” Powerful economic, technological, and cultural forces. he believes, will inevitably cause the physician cottage industry, i.e, doctors practicing in small isolated, independent groups, without adequate oversight, to crumble.

In a new publication, Prescriptions for Excellence in Health Care, a collaboration between Jefferson Medical College and Eli Lilly, and Co, Michael Millenson – journalist, author, consultant, and scholar at the Kellogg School of Management at Northwestern – argues the “cottage industry,” i.e., physicians practicing in small groups with limited oversight, may be crumbling.

In “The Cottage Industry Crumbles: QI and the Foundation of Health Care,” Millenson says,

1) The current system is “inefficient” and may constitute a problem “affecting both our economic and national security.”

2) “The slow adoption of information (IT) by health providers” is “a high-visibility failing; is being tracked by employers, health plans, and government agencies.”

3) Zeitgeist, “ ‘the spirit of the times,’ is exemplified by increasing public intolerance for unsafe and unnecessary care.”

Millenson concludes,

“The evidence that the cottage industry model of medicine wastes money and kills and injures patients needlessly is decades old. But it is only because of powerful economic, technological, and cultural pressures that the traumatic process of change, uncomfortable yet irreversible, if finally under way.”

Millenson may be right, but his view may also represent idealistic wishful thinking for a better health system. It may be he hopes for what should be, rather than what will be. His views may represent a “paradigm shift” among critics in search for a more perfect world, but I doubt it represents a fundamental shift among patients and doctors.

• Scant evidence exists government, health plans, or big groups, deliver more efficient or safer care. Medicare in on track for bankruptcy by 2017, health plans siphon 20% to 30% of money out of the system, and large groups, supposedly the cottage industry’s antidote, have 5% fewer physicians than 10 years ago (source: Center for Studying Health System Change). No stampede for “efficiency” and “safety” is occurring, though some hospitals are installing patient safety systems. One thing is certain – a 50,000 physician shortage. As for health reform, his scenario may exaggerate efficiency problems in the form of overcrowded offices and ERs and long waiting times. As the governor of Massachusetts, Deval Patrick, has observed, “Universal coverage without access is meaningless.”

• I’m aware of the advocacy of pay-for-performance systems to reward “good” doctors, interoperable computer systems to foster “necessary” and control “unnecessary” care, and widespread electronic medical records to solve efficiency and safety problems. But these systems are in their infancy, underfinanced, and expensive for physicians to install and maintain. Evidence for their efficiency for the most part remains unproven. Physicians in their cottages, already overworked, in severe shortage, many struggling to make a living and pay back educational debts, are skeptical these systems are workable, desirable, or efficient. Many doctors find paper template systems more efficient in meeting quality indicators, and less disruptive and less costly in their practices. I know of one well-known physician who spends most of his time taking down and dismantling EHR systems that have failed to measure up to expectations. As for being a “threat to economic and national security,” applying that language to current physician activities is an overstatement.

• The “spirit of the times” – concern over safety and efficiency –isn’t common among physicians and the public, though it may prevail among critics. Public concern for their lives and safety may exist but not on a large scale. Physicians worry about limited autonomy, and rules that discourage physician-hospital collaboration and innovation, and constant criticism that casts a pall on their clinical judgments.

In ivory towers, bureaucratic or business and congressional office suites. it may seem government, health plans, employers, and the public at large are actively, purposefully, inevitably taking steps causing our current system’ foundation - independent small group practices – to crumble to assure quality and safety, and, it may be, these “powerful economic, technologic, and cultural” forces will dictate and restrict how doctors should practice, according to dictums from on high.

In the near future, however, I believe patients will continue to visit physicians in their cottages and will trust their independent clinical judgments over outside mandates. If government is serious about universal electronic documenting, engaging in surveillance, and coordinating care, it should pass a Hill-Burton like act to provide funds activating systems it believes assures efficiency and safety.

I agree with Millenson shifts in behavior and employment patterns are occurring among physicians – and economic, technological, cultural forces are at work. I am simply saying the forces are evolutionary, not revolutionary, and the cottage walls are likely to remain intact for some time.

Sunday, October 21, 2007

Global Medicine - Globalization, Medical Tourism, American Doctors

You're aware of outsourcing of jobs, people, and products to India and China and other countries. But what about outsourcing American patients to countries for care costing as much as 90% less than in America?

An article in Healthleaders Magazine(“Predicting the Impact of Medical Tourism,” Oct. 12), says medical outsourcing may be the next big thing. The author says small businesses, health plans, and even state governments are promoting medical tourismm, i.e., patients going abroad for less expensive care.

David E. Williams, a consultant, predicts:

Prediction 1: Medical tourism will cross over to the insured population in 2008.

Prediction 2: Mini-med plans and small employers--not big health plans and blue chip companies--will be the early adopters.

Prediction 3: Opposition to medical tourism by U.S. physicians will be modest.

Prediction 4: State governments will begin to embrace medical tourism by 2010.
Prediction 5: The emergence of medical tourism won't have a major, direct impact on U.S. healthcare costs, but the secondary impact will be substantial

His rationale for prediction #3, viz, that American physicians won’t oppose patient outsourcing, is:

Medicine is already a global profession. Physicians from academic medical centers attend global conferences where American physicians from leading institutions treat their colleagues from other countries as peers. They have often trained together and they publish in the same journals. Leading physicians from overseas speak and read English.

At the community level, over 25 percent of physicians in the United States are foreign-born, according to the U.S. Census Bureau. They are familiar with the level of professionalism and training in other countries. Many of these foreign-born physicians are in secondary cities and rural areas, which also means that U.S. patients are already accustomed to getting their care from foreign physicians.

Do you agree with Mr. Williams, author of Health Business Blog and MedTripInfo? How do you react to his predictions and comments? Do you feel businesses, health plans, and state governments encouraging patients to go overseas for care is a good thing? Is it potentially dangerous?

Saturday, October 20, 2007

Consumer Driven Care - Bill Gates and the Physician Disconnect

On Oct. 6, I posted a blog “Microsoft Vaults into Personal Health Records Arena with Health Vault.com.” It was based on a Oct. 5 Wall Street Journal Op-Ed article “Health Care Needs an Internet Revolution” by Bill Gates, chairman of Microsoft, in which he said:

"What we need is to place people at the center of the health-care system and put them in control of their health information. We envision a comprehensive Internet-based system that enables health-care providers to automatically deliver health data to each person in a form they can understand and use. We also believe that people should have control over who they share the information with. Technology is not a cure-all for all the issues that plague the health-care system. But it can be powerful catalyst for change.”

On October 17, the WSJ published three doctor rejoinders to Gates’ in three letters to the editor.

1) Mr. Gates alludes to a never replicated study claiming that 98,000 patients die yearly from medical errors. Like others, he accepts this figure uncritically, despite the fact that the study contained enormous biases and conclusions are not supported by what is known to be true about medical errors from ongoing reporting to health departments in many states. He has an unreal expectation that computer-based advice to patients will motivate them to alter their lifestyles to lower their risk of acquiring chronic disease. I ca and do counsel lifestyle change to my patients. Most of them nod, smile and continue to do the opposite. Does Mr. Gates really believe an integrated network of computers can improve that reality?

Daniel C. Smith, M.D., Burnsville, Minnesota

2) Mr. Gates proposes an Internet-based health-care network to enable sharing of health-care information to prevent errors. Clearly, having numerous systems that don’t talk within and among institutions presents a challenge to creating on “source of truth.” Patients are unaware of their own health data and to some degree don’t even feel it’s their responsibility to know what procedures they’ve had, what medications they’re on.
, etc. Yet this solution at this time appears far worse than the disease. How will a system guard everyone’s privacy against hackers? Now, instead of only receiving 30credit care offers, and 200 spams per day, we can receive personalized junk manil addressed to “Dear Prozak User.”

Marci M. Lesperance, MD, Ann Arbor, Michigan

3) Bill” Gates prescribes a higher dose of computers and digital technology to help cure what ails our health system. However, most patients already have access to a computer and often tell their doctors they have done their “research” on the Internet. But most people do not have the knowledge and training to effectively use the mountain of medical data currently available to them. Why is it that man who is onw lawyer has a fool for a client, but in health care patients are encouraged to “take ownership” amd rely less on physicians?

Brian D. Kent, MD, Orange, California

Mr.Gates may have a IT dental problem, namely, overbyte. In any case, it seems physicians don’t buy the message that data and information at the patient-physician interface will solve the health care crisis.Not all patients are enthusiastic about comprehensive integrated computer-driven information either. I was speaking to a knowledgeable physician the other day, and he observed, “The last thing my patients want to see in the room is a computer between me and them. They want to see me, not watch me key in information in the computer.”

Friday, October 19, 2007

Interview, Satire - A Tongue-in-Cheek Interview with an Information Technology Expert

This lighthearted parody is a play on words and is not intended to downplay the significance of the Health 2.0 movement which is upon us and is growing stronger each day.

Q: Doctor Algorithm, you’re an acknowledged information technology expert. We’re privileged to have you here. I understand you speak the information technology language fluently. In other words, you’ve mastered the IT lingo. Is that correct?

A: That’s basically correct, I must say, in all immodesty and with an enormous lack of humility

Hopefully my expertise has a meaningful relevance to the exacerbating and escalating misunderstandings and incompatibilities encountered by physician end-users who find our flawless and facilitating flow of uninterrupted throughput and prodigious output to be dysfunctional and disruptive in their inefficient and unsafe practices, which need all our online and in-office digital assistance they can comprehend , which isn’t much.. Surely they can set aside time away from their revenue-producing practices to go linearly, longitudinally, and lickety-split and clickety-click through our vast menus.

Q: What’s your complaint about doctors?

A: Simply the fact that practicing doctors are consistently shunning, snubbing, and sniveling at our clarifying, crystallizing, and clairvoyant products. That boggles my mind, and it isn’t rational. We’re the epitome of reductionism and rationality.

Physicians’ computers, you see, ought to be packed, even overloaded, with quadrangulating data from patient health records, electronic medical records, health management sources, and vendor sources - all immediately accessible in inter-interpretative, inter-operative, inter-standardized, inter-changeable, and inter-understandable formats - designed for every other operative and participant in every medical office and in every other health care settings, both in-house and out-house, just like there ought to be a sink in every kitchen, indoor plumbing in every house, a car in every garage, and a computer in every car, bathroom, bedroom, home office, and every personal portable assistant device.

Q: I must say. That’s flawless use of information verbiage. Beautifully articulated, and spoken without a trace of an accent, I might add. I especially like those homey clich├ęs at the end. I appreciate your descending to my level.

Tell me, why don’t doctors like me understand your language? After all, in your mind, every conceptual byte in your cyber universe is perfectly clear, isn’t it?

A: Of course, it is. It’s hard data. In technological cyber heaven , our motto is: “In God we trust. All others use data.” To that great, inviolable, and unquestioned universal truth, I might add, “If it’s digitized, standardized, and descenditized from on high from cyberspace, it’s got to be good.” There’s nothing soft and subjective about it.

Q: Descenditized? That’s another neologism, isn’t it? You’re full of them. I like your use of the word “interoperability” – that’s an 8 syllable, 16 letter jargon jawbreaker. By the way, the term inoperative can also mean beyond surgical intervention, not practical, and not functioning properly. That doesn’t apply to your whole IT scheme, does it?

A: Of course not. Interoperability simply means the entire world is interconnected. Every twain shall meet, every human end shall abut against every other human abutment, and every hand and every mind shall meet, touch, and intertwine.

Q: I assume interoperability systems will include all health care consumers, which includes everyone. After all, we’re all destined to become patients at one time or another.

A: God Bless You. In your divine wisdom, you have grasped the intellectual nettle –ubiquitous transparent information for all -- anywhere, anytime, every time, everywhere, wirelessly, wonderfully, without wavering, waffling, or waiting.

Aggregate! Consolidate! Interdigitate! Those are our rallying cries! Leave no dot unconnected! Connect all the dots! That’s our goal. We don’t call our universe the dot.com world for nothing, you know.

Q: You’re certainly big on exclamation points. But to tell you the truth, you sound a little dotty to me! Perhaps I’m too dotful.

A: Right again! You catch on quickly, don’t you? If you want to be all inclusive, as opposed to all inconclusive, you instinctively know the terms dot.com, dot.org and dot.edu embrace all data dots and all numeric knowledge.

But make no mistake about it. Dot.coms, dot. orgs, and dot.edus will have impenetrable privacy firewalls between them. We, the conquerors and masters of cyber space, will mine data and intervene in care using impeccable data from predictive models and specialty experts, based on 20/20 hindsight and 20/30 foresight, with impunity. Privateers say hackers will tear down our firewalls, but they’re nearsighted, not farsighted like us. We’re not in our dotage.

Q: Doctor Algorithm, forgive me for my abysmal ignorance. But what’s this really all about?

A: I’m glad you asked. It’s about total quality leadership, continuous process improvement, data processing reengineering, protocol redesign and redeployment, clinical data intervention, artificial and virtual medical practice models, interoperable data redistribution, bioinformatics knowledge transfer, analytic algorithmic transparency, reformulating and interconnecting databases, and six sigma organizational transformation. It’s about Health 2.0, Health 3.0, and beyond.

Q; Is that all?

A: That’s enough for now. That ought to hold you. I’ve made myself perfectly transparent, haven’t I

Thursday, October 18, 2007

The Doctor Shortage Revisited

Just a note to observe my piece on the physician shortage is drawing a lot of comment (and fire) from sermo.com readers and other bloggers. Here is an example of a comment from a blogger, D.B.Medical Rants.

To colleagues at the University of Alabama in Huntsville and Birmingham, Robert M. Centor, MD, is a respected academician and administrator, serving as associate dean of the Huntsville regional medical campus, director of general internal medicine in Birmingham and attending at the Birmingham VA Hospital.

But to hundreds of Web surfers, Dr. Centor is the ”DB" of “D.B’s Medical Rants, "a Web log—or blog—he created in 2002 to broadcast his views on health care and medicine far beyond traditional academia. (“DB”, the site explains, stands for both "da boss," a nickname bestowed by colleagues, and "Dr. Bob," a moniker given him by golfing buddies.)

Dr. Reece Discusses The Elephant in The Room

October 12th, 2007

The Physician Shortage - The Achilles Heel of Health Reform

Dr. Reece nails this discussion. I hesitate to quote any part of his discussion, because the entire piece is so important. I will stress this one issue which is my pet peeve.

Physicians feel most secure in telling stories of difficult diagnoses, obscure cases, and unknown clinical causes. Reformers constantly forget that doctors entered medicine because of the intellectual challenges posed by the differential diagnosis process.

Reformers do not understand the appeal of medicine, nor the desires of patients. They try bureaucratic solutions without understanding the major issues.
To these suggestions I would add this one: have every pundit, every management consultant, every politician, and every health care reform, spend a month in busy doctors’ offices, walking in their moccasins, observing the patients they encounter, experiencing first hand their hassles, judging whether information technologies facilitate or hinder practice, and seeing why fewer ambitious young Americans are choosing to be practitioners.

To which I can only stand, clap and shout “Bravo!!”

Addendum: For those who doubt a doctor shortfall exists, or has any import in the scheme of things, I invite you to read, “October Cover Story: Will There Be Enough Doctors?” (www. healthleadersmedia.com). The piece describes how hospitals are scrambling to recruit doctors to fill the holes in their specialty ranks.

Wednesday, October 17, 2007

Clinical Innovation - Physician Advice on Innovation and Reform, #2

My second piece of advice on a speech I'm writing for an academic audience comes from Howard J. Luks, MD, a board certified orthopedic surgeon who specializes in orthopedic sports medicine, arthroscopy, and knee and shoulder replacement. He is Chief of Sports Medicine and Arthroscopy at University Orthopedics, PC, and Westchester Medical Center. He is an academic and practices in Hawthorne and Fishkill, New York. He blogs at howardluksmd.com

I must say that I clearly fall into your market oriented group.

I believe a multi-tiered system will arise from the rubble. The highest level will be for those who can afford and more importantly, those who want to afford it. They will have access to the most expensive (and potentially unproven) medications, technology and services. There will be a level below that which most employers will offer, but it will limit expenses on meds (Walmart's $4 list) and potentially limit access to "experimental" technologies and services. Somehow the patient will need to share the financial burden of some of their choices eg. MRI for knee pain, etc. But I do not beleive that chronic disease care, or emergency care should be tied to their deductible. You shouldn't be afraid to go to the ER with chest pain because of a deductible.

Ultimately there has to be a safety net program in place. This will assure that the 50 or so million americans who worry about their next illness and the "theft of a brighter financial future" has access to medically necessary care. Unlike Mcaid, even the safety net system will need to be a co-pay based system (even if it is only $5) to prevent some of the abuses that occur with Mcaid.

I strongly believe that the market should be allowed to drive the system. Meaningful, transparent and independent quality and outcome measures must be available to everyone.

Medical errors must be addressed by having a nationwide EMR/PHR system that will monitor for drug interactions, allergies and perhaps disease management too.

Not sure I helped...just my thoughts

Tuesday, October 16, 2007

Future - The View of the Future from Aspen and San Francisco

I have doubts about new technologies’ impacts at the point of care. I’m particularly skeptical about computational advances defining and limiting what doctors can and cannot do in their offices. But I recognize new computer technologies may remake medical practice, and Health 2.0 may forecast the future.

But will rosy computer-guided scenarios empower doctors and patients in office, clinics, and hospital settings? Will computational advances pan out in the present and near future clinical world? I’m dubious.

On the hand, I’m optimistic about new imaging, new less-invasive procedures, and new genomic advances .I have listed 28 of these innovations in a paper I’m now writing, and which I shall publish in this blog.

As practicing physicians, you deserve an update and rundown of what might be. Below Brian Klepper, PhD, a widely known futurist, fresh from meetings of great minds, at a recent Aspen Health Forum and a Health 2.0 conference in San Francisco, offers his views as expressed in The Health Care Blog. on October 12, 14, and 15. Because this current blog combines three blogs from another blogger, it is longer than usual. For busy clinicians with too little time to read this sort of thing, I apologize for this length.

Healing Unbound: The Promise of Advancing Computational Power

By Brian Klepper, PhD

• Laptop-attached ultrasound units that produce startlingly clear internal images for five dollars in the field.

• Organs that re-generate inside scaffolds.

• Drugs tailored to an individual’s biology.

• Micro-images of cancerous cells lit up by bio-chemical markers.

• Decision support tools that scan the physiological values in electronic health records for patterns too complex to be detected by an unaided clinician.

The advances available from dramatic improvements in computational capabilities were a recurring theme at the Aspen Health Forum, with experts from each discipline describing where the technology was leading us.

I attended two sessions featuring Star Trek clips that predicted realities now within at least theoretical reach. (Prescient and corny, audiences nodded nostalgically.) Sessions on biotechnology, imaging, electronic health records (EHRs), and the hospital of the future highlighted the power that is being leveraged to improve care.

The deeper point is that biological mechanisms are built on incredibly complex metabolic webs. The information we depend on has also become overwhelming in scope but fragmented.

We’re only now beginning to have the computational power required to model, integrate and manage the many processes contained in each of these arenas. The power we access through digital analytics allows us to extend and broaden our reach.
A simple example was the argument, made long ago by David Eddy, a pioneering giant in the application of information technology to care, that the explosion of new knowledge has outrun the capacity of even the best human minds to appreciate and incorporate it. Tens of thousands of new articles are added to the medical literature every month, far more than any professional can evaluate and absorb. But information technology can store all that updated knowledge in formats available at moments of decisions, when we need it most.

Dr. Eddy described the promise of cognitive processing, in which software routines would scan and compare dozens or hundreds of physiologic measures within a patient’s health record for patterns a clinician could never identify.

A quick analysis might show, for instance, that when 19 of the variables present appear in combination with the values detected, there’s a 62 percent probability of a particular condition. The tool would then describe possible next steps in the care pathway.

The horizon is receding across technologies. In a session on the future of diagnostic imaging, GE Healthcare’s Medical Director Robert Honigberg thrilled the audience by showing decade-old and new ultrasound images. He then ticked off ways that, combined with broader advances in information technology, greater macro- and micro-imaging clarity would improve our abilities to effectively address issues: screening for stroke, Alzheimers and cancer; strengthening the power of primary care physicians in rural settings; virtual identification of pathologies; global disease registries; image-guided radiation treatments; and on and on.

Finding ways to help patients, clinicians and purchasers leverage the vastness of health information for their own purposes falls into the larger realm of Health 2.0. Still in its formative stages but gathering steam quickly, this sector of health informatics could create the pricing/performance transparencies and decision support that can positively improve clinical quality and finally make health care markets work, lowering cost.

But one of Health 2.0’s real appeals is its business model which, as Google has learned, leverages the utility of information to create communities and markets that have commercial value. That, in turn, makes it low cost to the end user, and therefore highly accessible.

Some developments offer more accessible (i.e., lower cost) value propositions than others. In an everyday context, those, like Health 2.0, that depend almost strictly on data analysis and reformulation into decision-support will likely be far less costly, with far greater potential for population-level impact than, say, those that involve biologics. That relationship might be reversed, though, in situations like pandemics, when the biologics are the only recourse for populations. How does one work through these dilemmas?

It is difficult to not be dazzled by these possibilities. Who wouldn’t long for progress that can replace a child’s defective heart or kidney or eye, and make a compromised life whole again?

But as with virtually all progress, developments raise profound conflicts between what we want and what we can afford. In a system being crushed by cost – while the average American family’s health care costs $14,500 in 2007, one third of households make less than $35,000 – where do we invest and how should investors be rewarded? Is there a reasonable limit to the price of even great progress?

One thing was clear. The advances that have made these miracles possible will continue to accelerate and become less expensive, making the technologies that are now available but out of reach accessible as well.

A Rage To Know: A Few Days At The Aspen Health Forum

At one of the opening sessions of the Aspen Health Forum, Peter Agre and Michael Bishop, both physician researchers and Nobel laureates, recounted their childhoods, their families, their likes and dislikes, their school experiences, and the barriers, successes and lucky breaks that led them into lives of discovery. Dr. Agre won the award for identifying the mechanisms that allow water to cross the cell membrane. Dr. Bishop won for discovering how certain defects in genes can lead to cancer.

Those of us in the audience were struck by the commonness and good humor of their stories, but also by these individuals’ profound humility and, most of all, their passion. What Neen Hunt, Director of the Lasker Foundation, the third speaker on that panel, in her description of Dr. Charles Kelman, an ophthalmologist who revolutionized the way cataract surgeries are performed (more on that in another post), called “a rage to know.”

You could hear the same dedicated, focused passion in many of the senior attendees. There was Sir Roy Calne, Professor of Surgery Emeritus at Cambridge, a pioneering giant of organ transplantation, who at the end of his presentation gave special thanks to the organ donors. An exhibition of Dr. Calne’s paintings overwhelmingly conveyed the gravity and humanity of surgery.

The tone was in Tony Fauci’s presentation as well. Dr. Fauci is Director of the National Institutes of Health’s Institute of Allergy and Infectious Diseases, the leader of the US’ Global HIV/AIDS program, and was just awarded the Lasker Foundation’s 2007 Public Service Award for his contributions as architect of two major governmental programs, one on HIV/AIDS and the other on bio-defense.
He explained why AIDS explosive growth now demands greater attention to and resources for prevention. More than 20 million have died worldwide so far, and 60 million more now have HIV/AIDS. For every patient who receives anti-retroviral therapy, six more become infected.

Dr. Fauci was joined on that panel by Mary Robinson, President of Realizing Rights: The Ethical Globalization Initiative (the Aspen Institute is an institutional partner on that effort). Ms. Robinson was Ireland’s first woman President (1990-1997), and then UN High Commissioner of Human Rights (1997-2002). Ms. Robinson's compelling, articulate voice called for helping women gain control of their own sexual and life choices, which play enormous roles in the complex of this monstrous disease.

You arrive at the Aspen Institute not knowing quite what to expect. You know it is special, an international force in bringing together thought leaders from every area of human endeavor. And it is certainly beautiful, with the mountains rising around the campus, punctuated in autumn by yellow and orange.

But the true pleasure of the Health Forum was listening to and talking with this collection of extraordinary scientists, physicians, philanthropists, economists, business leaders, venture capitalists and policy experts, who have come together for no other purpose than to share and to learn. There are 28 and 78 year olds, people at the end and beginning of their careers, but no sense of caste or clannishness.
You walk into every meeting aware that everyone has something interesting to say, that they are informed, thoughtful, deliberate and focused on translating idea to action. There is a tacit understanding that, in their rage to know and do, they are most passionate about achieving something larger than themselves.

The Aspen Institute is a critical mass of extraordinary exchange. A few days of that make it an honor and an indelible experience, with the capacity to energize and facilitate meaningful change once we have returned home and to our daily work

A Broad Vision of Health 2.0: Reformulating Data for Transparency, Decision Support & Revitalized Health Care Markets

By Brian Klepper and Jane Sarashon-Kahn

What follows is a verbal rendering of a powerpoint presentation Health2.0-1011.ppt which contains graphics necessary for full understanding of Health 2.0’s complexities. Basically the graphics show PHR, EHR, health management, and vendor management data being dumped into a data repository were the combined is analyzed by sophisticated algorithms and analytic techniques.

The term Health 2.0 refers to the concept, described by O’Reilly in September of 2005, of Web-based platforms that allow users to reformulate data for their own purposes. The Health 2.0 movement is rapidly gaining steam and traction, propelled by established and startup firms. The efforts displayed at the recent Health 2.0 meeting in San Francisco, convened by Matthew Holt and Indu Sabaiya, were both wide-ranging and narrowly focused. Even so, several end-of-day panelists noted that, at this early stage, Health 2.0’s definitions and translations into practice remain murky and fragmented.

We thought it might be useful to try to develop an image of how Health 2.0 MIGHT develop: what its working parts were, what kinds of information it would receive and generate, who its users would be and what its impacts might be. The image that has resulted is simplistic; it doesn't try to explore any of the underlying mechanisms necessary to pull this off. But it does try to convey a vision of how innovators might come together to aggregate and reformulate large data sets from disparate sources to create tremendous new utility in the marketplace for patients, clinicians and purchasers of all types.

We are posting this image on the various sites where we write – others are welcome to post it as well – as an exercise. Where is the structure wrong? What are we missing? How can this be made clearer, stronger, more faithful to our best hopes for where health information management might take us? Let us hear from you, and we'll update the image as we collectively think through the issues involved.

One caveat. Please note that we have not included back-office operational functions. While it is entirely possible that these too will ultimately be managed through Web-based processes, they are by definition the most proprietary business management tools and therefore the least susceptible to sharing.

The Electronic Health Record (EHR) is the hub of patient management within the clinical setting, and should be understood here to be not only an expansive repository of patient information (ultimately with room for gene maps, family histories and information about alternative care maps), but a complex of tools that includes clinical decision support, health plan rules, product/service pricing, and so on.

The Patient Health Record (PHR) is a lay reflection of the more robust EHR, with linkage to tools that are aimed at the consumer’s self-management, including guidance on when to seek professional expertise.
Analytics are applied to the data in the data repository to reveal patterns, to evaluate patients’ health status, and to identify the desirability of different clinical and vendor choices. For example, the:

• Relative pricing and performance within and across regions of physicians by specialty, and hospitals by services,

• Relative pricing and performance of drugs and devices within class and by vendor.

• Identification of patients with specific risks.

• Identification of more or less effective diagnostic and treatment pathways.

There are several well-accepted, widely-used analytical classification and risk adjustment tools in the market, e.g.: ETGs, CRGs and DxCGs. These algorithms permit unbiased comparisons among providers, patients and treatments and facilitate identification of patients at risk, as well continuous updating of clinical and administrative best practice.

These tools allow decision-makers of all types to evaluate professionals, organizations, products and services in the marketplace. So it is critical that all health care stakeholders find the analytical processes trustworthy, credible and open to scrutiny. This is why it is so important that the methods used to achieve transparency be transparent as well.

Now comes the first result of the analyses, Identifying Patients At Risk. These might be patients identified with chronic conditions; they could also be patients with signs or symptoms predicting genetic anomalies or acute conditions. Information about the patients identified during this process would be forwarded to their EHRs and PHRs, as well as to the Health Management tools, so they can be contacted and, possibly, receive health interventions.

By receiving a continuous flow of data, by constantly watching for best clinical and financial outcomes for specific conditions and purchasing processes, and by working “backwards” to identify the common pathways that led to those outcomes, the analytical tools could presumably identify Best Practice Guidelines. These, in turn, could be passed along to and embedded in the EHRs, Health Management and Vendor Management tools, each in formats that make sense to the tools' different users. This becomes a continuous improvement process.

The third major result of the analytics, Pricing/Performance Transparency compares the relative pricing and performance of four major health care product/service classes: Providers, Payers, Products (Drugs, Devices, Equipment and Supplies), and Interventions/Treatments.

The information produced by the Pricing/Performance Transparency functions are distributed into two ways. First, they become readily available to stakeholders of all types through Public Reports, distributed by the host or by any other public or private group, and made available through the tools to purchasers, health managers, clinicians and patients. Again, to be credible, public reporters must be scrupulous and transparent in their evaluation methodologies.

The findings of the various Pricing/Performance analytics can also flow into constantly updated Decision-Support Tools, which are adapted to the needs of purchasers, health managers, clinicians and patients.

Decision Support is also informed by input from Expert Content – e.g., current knowledge on efficacy and value from the health care literature, medical encyclopedias, and best practice guidelines.

Finally, the PHR and patient decision-making are enhanced by User-Generated Content, guidance from patients and caregivers who have dealt with the condition in question, information about health or treatments that might not be contained in the current record, individualized search results, and other relevant information.

It is not difficult to imagine that, as these various functions come together and are integrated into continuously refined applications, the impacts on the health care marketplace could be profound. The inability to see and know the results of health care processes has created an opportunistic culture that pervades every part of the continuum. The unprecedented transparency that will result from these, as well as the decision-support capabilities for patients, clinicians, health managers and purchasers, should go far in finally helping health care begin to adhere to the same rules that govern other markets. When stakeholders can make informed decisions, based on solid data, the impacts on cost and quality could be transformational.
Some key questions remain. Does this model represent what is possible and likely to occur? Can the organizations working to integrate these functionalities access the data required, and will they be capable of developing or acquiring the various processing elements incrementally? Will certain stakeholders, knowingly or tacitly, work against the ultimate objectives of this model?

We’re optimistic, but time will tell.

Monday, October 15, 2007

Physician Advice on Reform and Innovation, #1

My first piece of advice on reform and innovation comes from Rich Fogoros, MD – cardiologist, consultant, writer, blogger (www.tdisease.about.com, a New York Times company, and www.covertrationingblog.com), and author of Fixing American Health Care – Wonkonians, Gekkonians, and the Grand Unification of Healthcare, October, 2007 ((Publish or Perish DBS, Pittsburgh, PA, October, 2007

Here’s his advice.

1) Health care rationing is an economic imperative we can’t avoid.

2) We’ve deputized government and health plans to covertly ration for us.

3) Covert rationing destroys the patient-doctor relationship because it must be done at the bedside, and because it requires obfuscation, opacity, and complexity to implement.

4) All proposed reforms to date fail to confront the necessity for rationing, and ingenious American doctor innovators are best positioned to make rationing equitable, fair, and at a bare minimum through a combination of technology, information technology systems, and reforms.

Sunday, October 14, 2007

A Talk on Reform and Innovation: Your Advice Please

I need your advice. I seek your take on what basic things you think it will take to transform the American health system to make it more patient and doctor friendly.

Why do I ask? Well, I’ve spent the last two days preparing a talk before an audience of entrepreneurs, information technologists, venture capitalists, hospital executives, business leaders, movers, shakers, and physician innovators at a leading eastern academic center.

My title is “The Rise of Innovation: Socioeconomic Schisms, Sophisticated Algorithms, and Marketing Rhythms.” Those who invited me to speak asked I address the doctor’s point of view on the role of innovation in health reform.

What can I say that hasn’t been said? On reform, some physicians believe in a political utopia – generous government programs covering the uninsured. Other more market-oriented doctors believe the uninsured problem has its roots in government overregulation, managed care micromanagement, and high premium costs. Many of the uninsured are young and healthy don’t think non-deductible premiums are worth it; other lower income folks simply can’t afford it.

I think the final reform measures will be a mixed bag, with equal elements of government and innovative market reform. What’s your belief?

Saturday, October 13, 2007

Ranking Doctors Using Claims Data Legal

I’ve never liked the idea of health plans using claims data to steer members to doctors. I don't think you can use data to judge human interaction in the patient-physician setting, what actions followed, or the quality of the physician.

But the use of claims data by health plans to steer patients to "quality" doctors is happening more and more , and you ought to be aware of what’s going on out there. Health plans are mining claims data with sophisticated algorithms to rank doctors for quality and economic performance. Doctors in New York State, Washington State, and Connecticut have objected, and have filed law suits, saying rankings focus primarily on cost, not quality.

To address the doctor backlash, George Washington University School of Public Health and the Robert Wood Johnson Foundation did a legal analysis. The analysis indicated rankings are legal under state laws. Their experts maintain physician rankings are critical to a broader movement to measure and publicly report on physician and hospital performance and to help improve the quality and value of health care (Source: Study Underscores Legality of Physician Ranking and Public Reporting Systems When Used to Improve Care Quality, Oct 9, 2007 - Washington, D.C.)

More health plans are rating physicians on quality and efficiency measures and are designing insurance products classifying physicians in tiers. Plans are given incentives to members to select certain high performing physicians. The GW legal analysis concludes transparency is critical when designing a tiering process.

The process should include physicians in the rating process and should be open and visible to physicians and allow their input. Classifying doctors based on the quality and efficiency of services is legal, and so is publishing information regarding health care quality. But undertaking these efforts in the dark could and should lead to physician backlash. Proprietary software should be open to inspection.

Standards should be developed by state insurance regulators in the case of insured plans, the Centers for Medicare and Medicaid Services in the case of Medicare and Medicaid plans, and by the U.S. Department of Labor in the case of ERISA-governed plans.

To me, much of this comes down to who do you trust – hard data from health plans, state and federal government, or subjective opinions of physicians. We shall see if these quality-directed efforts result in better or less costly care – or if they simply justify the economic existence of health plans and add to the bureaucratic red tape already strangling medical practices, or if published data alters the physician-patient relationship.

For doctors, avoiding judgments on quality based on data mining is likely a losing proposition To health plan executives and federal bureaucrats, this aphorism still holds, “In God we trust. All others use data.”
This is for your information. Your comments are invited.
The George Washington School of Public Health and the Robert Wood foundation have released an analysis saying that health plans can legally use sophisticated algorithms to mine claims data to steer health plan members to physicians whom the data indicates practice quality and economic medicine. The GW and RWJ experts maintain physician rankings are critical to a broader movement to measure and publicly report on physician and hospital performance and to help improve the quality and value of health care. The process, the analysis adds, should be transparent and should invite physician input.
For full story, see www.medinnovationblog.blogspot.com

Thursday, October 11, 2007

Health 2.0. Potentially Clinical Useful?

Alright, you gals and guys of the physician sisterhood and brotherhood. Gird your intellectual loins and open your minds to the concept of Health 2.0, which will supposedly make all health care data more transparent, standardized, more accessible, and more valuable and will deliver greater value to you and your patients. My friend, Brian Klepper, founder of the Center of Practical Health Reform, tells me Health 2.0 may transform the health care industry.

I want to know what you, as practicing physicians, think about prospects for Health 2.0. Basically Health 2.0 is the next generation Internet with increasingly simple health care applications and simultaneously more sophisticated software allowing ever widening access and uses of information at the site of care.

Got that? Good. Now here are a few quick definitions.

Health 2.0 --A new health care concept wherein all players (patients, doctors, payers) focus on value and use competition to improve the safety, efficiency, and quality of health care.

Health 2.0 --Next generation companies leveraging openness, standards, and transparency, and using collaboration, information exchange, and knowledge transfer to deliver value-added services empowering all health participants with freedom, choice, and accountability.

If you have not yet grasped “Health 2.0,” here a little table I’ve cooked up for a talk I’m giving soon on the “Rise of Health-Care Innovation.” On the left are the data sources (personal health records, electronic medical records, and health management and vendor management data), on the right it is being channeled into a data repository available to users at the point of care.

PHR Data All spilling into a centralized transparent
EMR Data data repository containing sophisticated
Health Management Data algorithms rendering the data useful
Vendor Management Data

Health 2.0 is more complicated than I’m letting on. I’m reminded of Alfred North Whitehead’s saying, “Seek simplicity and distrust it. “ In any event, Health 2.0 reformulates data for decision-support, transparency, and revitalized health care markets.

Health 2.0 contains expert content, data-based evidence, and artificial intelligence algorithms for better decision-making for patients, clinicians, health managers, and purchasers.

Health 2.0 is still conceptual. It’s a big idea being pursued by Goggle, Microsoft Webbed, and other big IT firms. Do you, as a physician, think of this approach, still several years off, as promising for your practice?

Goverment vs. Market Reform - Two Reform Schools

There are two schools of thought out there on how best to reform American health care.

• The government school says patients are basically helpless, composed mostly of the old, the poor, the children, and the sick. Most people, say its teachers, are not very bright, depend on government, tend to be passive, and, through no fault of their own, remain uninformed about doctors and hospitals who may take advantage of them at every turn. Therefore, a paternalistic and a caring government is necessary to protect most of the people most of the time against health care providers who charge patients for services rendered, even those without government subsidies. . Government must guarantee the populace universal access to care whatever it costs the government and its taxpayers.

The free enterprise, or market school says patients are resilient, intelligent, and are made up of a mixed population of the healthy, wealthy, the youth-preserving, the health seeking, the poor, and the sick. For the most part, most of the time, most citizens are perfectly capable of fending for themselves, spending a certain amount of their own money, judging whether what doctors and hospitals offer is of true value, and if they are helpless or poor, having government subsidize their care with taxpayer dollars. The poor and the sick, after all, will always be with us and must be provided for the more fortunate among us.

The government school has multiple articulate spokespersons among the mainstream media, among most major TV networks and national newspapers, among talk show TV hosts on major Sunday shows, among prominent politicians, among members of the elite and the academy. There’s an excellent chance their persuasive views will prevail in the next election, at least until costs to taxpayers of their well-intentioned and munificent efforts are tallied and subjected to open-debate to their true costs.

The free enterprise school has few spokespersons among the media, who tend to see their views as protecting the rich, health care special interests such as the drug and health plan industries, and affluent hospitals and physicians. Those who speak for this school tend to be Republicans, conservative think tank types, owners of certain media outlets such as Fox News and the Wall Street Journal, radio talk show hosts, and advocates of capitalism, who claim innovation and self-reliance lies at the heart and abides in the soul of the robust American economy. Some of their spokespersons, such as John Stossel of ABC News and its 20/20 program, have the audacity to say, “ Private competition, not government control, works best.

October 10, 2007. RealClearPolitics.com

Medical Competition Works for Patients

Health-care costs overall have been rising faster than inflation, but not all medical costs are skyrocketing. In a few pockets of medicine, costs are down while quality is up.

Dr. Brian Bonanni has an unusual medical practice. His office is open Saturdays. He e-mails his patients and gives them his cell-phone number.

"I need to be available 24 hours a day," he says. "I want to be there when a patient has questions, and I want to be reachable."

I'll bet your doctor doesn't say that. Bonanni knows he has to please his patients, not some insurance company or the government, because he's paid by his patients. He's a laser eye surgeon. Insurance rarely covers what he does: reshaping eyes so people can see without glasses.

His patients shop around before coming to him. They ask a question that people relying on insurance don't ask: "How much will that cost?"

"I can't get away with not telling the patient how much exactly it's going to cost," Bonanni says. "No one would put up with it. And the difference of a hundred dollars sometimes makes their decision for them."

He has to compete for his patients' business. One result of that is lower prices. And while the procedure got cheaper, it also got better. Today's lasers are faster and more precise.

Prices have fallen and quality has risen in other medical fields where most people pay for care themselves, like cosmetic surgery. Consumer power works -- even in medicine.

When government and insurance companies are kept away from the transaction, good new things happen.

A doctor in Tennessee I talked to publishes his low prices, such as $40 for an office visit.

Most doctors would say you can't make money this way. But Dr. Robert Berry told me you can. "Last year, I made about the average of what a primary-care physician makes in this country," he said.

Berry doesn't accept insurance. That saves him money because he doesn't have to hire a staff to process insurance claims, and he never has to fight with companies to get paid.

His mostly uninsured patients save money, too. Unlike doctors trapped in the insurance maze, Berry works with his patients to find ways to save them money.
"It's coming out of their pockets. And they're afraid. They don't know how much it's going to cost. So I can tell them, 'OK, you have heartburn. Let's start out with generic Zantac, which costs around five dollars a month.'" When his patients ask about expensive prescription medicines they see advertised on television, he tells them, "They're great medicines, but why don't you try this one first and see if it works?"

Sometimes the $4 pills from Wal-Mart are just as good as the $100 ones.

Speaking of Wal-Mart, medical clinics are popping up in Wal-Mart stores and in other similar markets. The clinics offer people with simple problems like sore throats and ear infections relatively hassle-free care ... cheap. Almost everything costs $59 or less. And the clinics are typically open seven days a week.

Grace-Marie Turner, president of the Galen Institute, a health-policy research organization, explains how these clinics thrive: "They're figuring how to do something faster, better, cheaper! They're responding to consumer demand because they see that they might make some money on this."

When consumers pay for medicine themselves, saving insurance for the big things, and doctors deal directly with consumers, doctors begin to compete. They start posting prices and work to keep them low.

And consumers gain more control of their health care. Instead of governments and insurance companies deciding for patients, patients decide.

Competition gives consumers more choices. And choice gives them power. Remember that when you hear a politician promise to make health case accessible and affordable through the force of government.


Two schools of thought exist out there on how to reform American health care –the government reform school and the free-enterprise reform school. In this presidential election year, each school will be vying for a piece of your mind and your vote. Think about the consequences of the lessons they are teaching – in tax dollars, in guaranteed coverage, in access to affordable care, and in the health care freedoms and choices 85% if Americans now enjoy and take for granted. And while you’re at it, consider a seldom mentioned third school combining elements of both with a heavy dose of prevention and responsible life styles.

Wednesday, October 10, 2007

Doctor Shortage - The Physician Shortage - The Achilles Heel of Health Reform

In 1988 I wrote And Who Shall Care for the Sick? The Corporate Transformation of Medicine in Minnesota (Media Medicus, Minneapolis). At the time, I had been present at a center of creation of HMOs for 15 years.

My thesis was straightforward. Managed care would ultimately alienate doctors and make medicine so impersonal and unattractive fewer doctors would enter the profession and few would be left to care for the sick. It’s a thesis worth revisiting in view of the mounting physician shortage.

Frustrated Doctors and Busy Doctors

For almost 100 years, starting with President Teddy Roosevelt’s 1912 call for universal health reform, a progression of politicians, poets, historians, and critics have struggled to explain what’s wrong about American health care. Success has eluded them. American doctors have stubbornly refused to sit still long enough to be analyzed. They’ve been too busy.

Chances are, they’ll become even busier. Richard Cooper, MD, in a February, 2001 Health Affairs piece, projected the U.S. will be short 50,000 physicians by 2010 and 200,000 by 2020.

Phillip Miller, a principal in physician recruiting firm of Merritt, Hawkins, & Associates, captured the gravity of the doctor shortage in the title of his recent book Will The Last Physician in America Please Turn Off the Lights (Physician Support Resources, Inc, 2005). In an interview with me, Miller observed,” People need to understand the seriousness of the shortage. Believe us, based on 3000 physician researches we did last year, there’s a tremendous shortage, and it’s growing.”

Miller’s comments are germane to health reform. After all, what good is universal coverage if no physicians exist to provide the care? If universal coverage is achieved, the physician shortage will intensify. This is already happening in Massachusetts, the state farthest down the path of coverage-for-all.

A July 25 Wall Street Journal piece (“Doctor Shortage Hurts a Coverage-for-All Plan”) tells the story of Tamar Lewis, who was told by two dozen primary care groups they no longer were accepting new patients. In Massachusetts, 49% of internists aren’t seeing new patients. Boston teaching hospitals employ 270 primary care physicians, and 95% of these hospital doctor groups don’t take new patients,

The reasons practitioners are hard to find are three fold:

1) A steady fall in medical students entering primary care (the percentage fell from 55% in 1998 to 20% in 2005);

2) “too little money for too much work” (mean income for primary care was $162,000 in 2005, which may not be enough in high cost urban environments to sustain a sensible life style and family life and pay off educational debts that may exceed $200,000);

3) an increase in demand with more elderly with multiple chronic diseases or aging baby boomers seeking perpetual youth and active life maintenance seeing fewer doctors.

Physician Demoralization Factor

In addition to these factors, reformers forget the physician demoralization factor. The College of Physician Executives surveyed 1,205 MDs in 2006. They found nearly 60% had considered leaving medicine. The top five complaints of clinical practitioners were:

1. Low reimbursement

2. Loss of autonomy

3. Bureaucratic red tape

4. Patient overload

5. Loss of respect

“Sea Change” in Gender and Plans of Young Doctors

There’s another factor as well. A “sea change” in career and life plans of young physicians. I lunched the other day with Robert Gifford, MD, who serves on the admissions committee of the Yale Medical School. He observed, among other things, more than half of accepted students are now women, none of the applicants, men or women, expressed any interest in primary care, and most said they were interested in careers offering decent incomes with regular hours, such as dermatology, anesthesiology, and radiology.

The physician shortage is likely to grow even worse, especially for physicians on the frontlines of medicine. . According to Merritt, Hawkins, and Associate Guide to Physician Recruiting, searches for primary care physicians in 2005/2006 picked up most dramatically for internists ( 46%), family practice ( 55%), but were also up for certain specialists serving patients in hospital settings: general surgeons 42%, hospitalists 81%, and emergency medicine 94%.

Fundamental Questions about Physician Attitudes

Another problem with health reform is that people looking for what’s wrong and how to correct it, are so preoccupied with their pet managerial and political solutions, they never stop to ask these fundamental questions:

• What do doctors really think about what needs to be done?

• How will they react?

• And who, after the management consultants, politicians, and critics have done their work, will care for the sick?

Doctors’ attitudes are important if we are to have health reform that works. Doctors’ orders, after all, account, in one way or another, for 80% of health care costs. Also no matter what rules are set in place, doctors can choose to support, finesse, and even undermine any reform system depending on whether the system treats them with respect as professionals or as mere technicians carrying out orders from on high.


What do doctors really think? To define physician trends, a company called Sermo.com in Cambridge, Massachusetts, has set up a web site, funded partly by Wall Street firms tracking doctor trends and partly by a contract with the American Medical Association. Only licensed physicians can visit the site, and Sermo encourages them to write “posts” and comment on posts of others. It’s a free-wheeling discussion forum. Responses to posts are instant, and give one a clear feel of the pulse of what America’s doctors are thinking.

Ten Conclusions

The results are a mixed bag, but here are 10 conclusions I have reached.

1. Physicians are intellectually restless, politically edgy, and full of angst about their future. They have little respect for the bureaucracy of managed care organizations, and they see little forthcoming from these organizations and government but more bureaucracy in the form of clinical protocols, restrictions based on evidence based medicine, and pay-for-performance rules and regulations.

2. Physicians prefer terse brevity to verbal longevity when discussing current practice conditions or reform measures. Doctors are weary of being lectured by consultants and long-winded directives from health plans and Medicare on how to practice medicine.

3. Physicians feel most secure in telling stories of difficult diagnoses, obscure cases, and unknown clinical causes. Reformers constantly forget that doctors entered medicine because of the intellectual challenges posed by the differential diagnosis process.

4. Physicians dislike being lecturing by others about how to conduct clinical and business practices. If there’s anything that turns off doctors, it’s being judged by “experts” who have never set a foot in a doctor’s office, or spent any time following doctors during office hours and hospital rounds.

5. Physicians often express skepticism about radical health reform, either from the left or the right. When told of the glories of guaranteed health care for all in other countries or the promise of a purely market-driven solutions, doctors tend to scoff. With patients flooding into their offices, they don’t foresee any magic solutions.

6. Physicians regard information technologies – either from data mining algorithms or electronic medical records – as overrated. An emergency room physician in California once told me, when seeing a patient, he often had to enter six different software programs, give his user name and password, and wait for the download – each entry and exist requiring several minutes of his precious time.

7. Physicians distrust large integrated systems that reduce them to protocol-following functionaries. For thirty years, the Kaisers, Mayos, Cleveland Clinics, and other large multispecialty groups have been saying health care solutions lie in teamwork, scale, and infrastructure, yet 60% of doctors stubbornly remain in groups of five or less.

8. Physicians question the value of retail clinics, off-site clinics, and disease management systems in which they do not directly participate. The realities and successes of the marketplace may alter this resistance, but don’t count on it.

9. Physicians remain wary, even hostile, towards managed care, often regarding it as unwelcome, intrusive, ill-informed, and obsessed with cost not quality. This is unlikely to change because most doctors, like most Americans, are anti-authoritative.

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

In the course of sorting through and selling some of my books, I came across an introduction to a book The American Character (George Braziller, Inc, publisher, 1983), written by William E. Bundell Staff Writer, Wall Street Journal, 1983.

The book consists of a series of Wall Street Journal stories describing energetic, sometime star-crossed, always individualistic Americans. To me it explains why the America health system is what it is and what it is likely to be.

“The manufacture of the future is the life and business of America. But it is increasingly a fragmented, specialized, and urbanized endeavor; we are becoming a nation of isolated individuals ever more dependent on each other, and at the same time ever more ignorant of how we are connected.”

“The characteristic of America that resists any attempt at a definition, lasting analysis of the nation is the constant upwelling of self-induced change in our society. We remake that society every few years, scrapping whatever isn’t working and trying something new.”

“But beneath the turmoil some things never change. We are now, as we always have been, the most individualistic of peoples. We insist on being treated as individuals and not as impersonal, faceless numbers.”

Coverage without Access is Meaningless

Governor Deval Patrick of Massachusetts noted, “Health care coverage without access is meaningless.” The shortage is likely to grow even worse as America’s 78 million babyboomers enter the Medicare in 2011.

Suggested solutions to ease the doctor shortage include:

• build more medical schools,

• change the criteria for medical school admissions, focusing on those likely to pursue careers in primary care,

• Send medical students out into the field to serve as preceptors for busy doctors,

• pay primary care physicians more,

• reduce the pay differentials between primary care physicians and specialists by placing doctor in salaried groups where pay can be controlled,

• employ more nurse practitioners and physician assistants,

• recruit more international medical graduates and make it easier for them to enter the country.

• Decrease patient demand -- shift more costs to patients, make them conscious of what health care costs, and let them spend more of their own money so they will become more prudent medical shoppers

To these suggestions I would add this one: have every pundit, every management consultant, every politician, and every health care reform, spend a month in busy doctors’ offices, walking in their moccasins, observing the patients they encounter, experiencing first hand their hassles, judging whether information technologies facilitate or hinder practice, and seeing why fewer ambitious young Americans are choosing to be practitioners.