Friday, November 30, 2007

Hospices: Delayed Death and Payment Consequences

“Doing this for 40-something years. Every time I think someone is going to die tomorrow, damned if they don’t live for a year and a half.”

Sumpter Blackmon, MD, Camden, Alabama
Medical Director, Hometown Hospice, a hospice Medicare is dunning because its patients live too long

On November 25 a New York Times front page article, “In Hospice Care, Longer Lives Mean Money Lost,” reported,

“Over the last eight years, the refusal of patients to die according to actuarial schedules has led the federal government to demand that hospices exceeding reimbursement limits repay hundreds of millions of dollars to Medicare.”

Sometimes, in its desperation to save money, Medicare does something silly. No one, not even the most esteemed among us, knows with certainty how long it will take patients to die. It depends on the underlying disease, on what organ will shut down first and the organ failure cascade that follows, on the will to live, on the desire to die, and maybe even on something or some one greater than one’s self.

The only thing we know with certainty is that Medicare hospice care, started in 1983, is growing more expensive. Medicare payments tripled from 2000 to 2005, to $8.2 billion, and 40% of Medicare recipients now use the service, often for routine care in the home, where Medicare pays $135 a day. Duke University researchers say hospice care saves money, if one takes into account alternative forms of care in other settings, such as hospitals, nursing homes, or Medicaid home care.

Hospice care was originally designed for cancer patients, who are assumed to run a predictable course at a certain point in their illness. But in recent years, patients with Alzeimer’s , amyotrophic lateral sclerosis, strokes, and Parkinson’s disease are being admitted to hospice. The average stays for these patients is 86 days versus 44 days for cancer. To be admitted, two doctors must certify that the patient has less than 6 months to live.

Medicare and others have determined that 1 of 13 hospices, some 220 to 250 of them, are somehow gaming the system – mismanaging the disease or misestimating the time to die – to the tune of $166 million to $200 million a year. According to Congress, a hospice’s total annual reimbursement can’t exceed the product of the number of patients it serves and the per patient allowance set by Congress ($21, 410 in 2007). If a hospice has exceeded its reimbursement limit over the last five years, it must structure a plan to pay back Medicare a high interest rate, 12.5% in the case of the Camden, Alabama hospice.

Somehow this all seems wrong. Has Medicare seriously considered the cost of alternative forms of care, which often involve continuing chemotherapy or other fruitless pursuits for cure? Has Medicare polled its constituents, whom they serve, to ask their level of satisfaction with hospice care? What will be the human consequences of putting out of business hospices in rural areas, where no alternative care for the dying is available? Has Medicare considered patients die individually, rather than statistically?

Thursday, November 29, 2007

Blogging Doggerel - Never Say Die

Old Internists never die, they just lose their differentials.

Old Family Physicians never die, they just keep it in the family.

Old Orthopedic Surgeons never die, they’re just get cast aside.

Old Cardiologists never die, they just lose heart.

Old Heart Surgeons never die, they just get bypassed.

Old Urologists never die, they just get stoned.

Old Pathologists never die, they just get disembodied.

Old Anatomists never die, they just become disorganized.

Old Endocrinologists never die, they just make their Last Gland Stand.

Old Hospitalists never die, they just walk down their last corridor.

Old Pulmonologists never die, they just breathe their last.

Old Fertility Experts never die, they just breed their last.

Old Obstetricians never die, they just can’t deliver anymore.

Old Surgeons never die, they just can’t cut it anymore.

Old Plastic Surgeons never die, they just do a final lifo-suction.

Old Gastroenterologists never die, they just disappear up their own fundamental aperture.

Old Neurologists never die, they just lose their nerve.

Old Psychiatrists never die, they just lose their minds.

Old Physiatrists never die, they just can’t rehab themselves anymore.

Old Radiologists never die, they just disappear into the shadows and lose their body image.

Old Dermatologists never die, they just shed their skins.

Old Ophthalmologists never die, they just make spectacles of themselves.

Old Allergists never die, their immune systems reject them.

Old Nephrologists never die, their machines fail and they lose their metabolic balance.

Old Physician Executives never die, they just cross the Great Divide to the Other Side.

Old Anesthesiologists never die, they just pass their final gas.

Old Critical Care physicians never die, they just reach critical mass.

Old Emergency Room Physicians never die, they just triage themselves.

Old Oncologists never die, they just lose their sense of tumor.

Old Otolaryngologists never die, they just close their ears, noses, and throats.

Old Osteopaths never die, they just get the credit they deserve.

Old Veterinarians never die, they just go to the dogs.

Wednesday, November 28, 2007

Clinical Innovation - Simplicity and Innovation: The Case (and the Multiple Cases) of Gatorade

Robert Cade, MD, the nephrologist who invented Gatorade in 1965, to rehydrate dehydrated University of Florida football players, died in Gainesville, Florida, on November 26 of end stage kidney disease.

He died a wealthy man because of a profoundly simple idea: that you could replace electrolytes lost through sweating by replacing lost electrolytes with electrolytes in a sweet drink. The drink, Gatorade, named after the Florida athletic team’s mascot and Cade's last name, was made up of water, sucrose, glucose, salt, lemon juice, and a cunning dash of whatever.

This year people drink 12 million bottles of Gatorade each day. Athletes drink it on the practice field and during games, dehydrated patients receive it, and the rest of us drink it because we’re thirsty. Gatorade commands 81% of the sports drink market, and it has generated more than $150 million of royalties for the University of Florida (and for the Cade family), which agreed to split the royalties after a 31 month legal battle in the 1960s.

Gatorade is a huge success because its concept is simple, it fills a need, and it’s name is memorable. Its genesis was simple. Cade created it after the University of Florida football coach, Dwayne Douglas, asked Cade<” Why don’t my players urinate after a game?” Even its taste is simple. Athletes rejected the first Gatorade because it was tasteless. Cade’s wife, Mary, said, “Why don’t you add a little lemon juice?”

In the end Gatorade works because it fills the late Peter F. Drucker’s first postulate for a successful innovation;

“Innovation has to be simple and focused. If it does morethan one thing, it confuses. If it isn’t simple, it won’t work. The greatest praise of Innovation is, ‘This is obvious. Why didn’t I think of it?”

Gatorade does one thing: It replaces what’s lost.

Monday, November 26, 2007

Government Reform - 365 Blogs, 365 Days; Still No Reform in Sight

A year ago, I struck out to write a blog a day over the course of a year. Today ends that trek. Here are the changes of import I am witnessing.

Fading hopes for single-payer (even in Massachusetts, it’s clear that will not happen).

Moves towards “convenience care, “ retail, worksite clinics, ambulatory and urgent care centers, as employers search for answers to cost problems (These developments collectively may be the innovation of the year)

Embrace by the public, doctors, CMS, and health plans of generics to take edge off brand name expense ( An example of this is the rush of seniors to fill the Medicare “donut hole” with generic equivalents).

Wary gains of consumer –driven care as more and more small and mid-sized employers replace HMOs and PPOs with high-deductible/HSA fueled plans and Medicare makes HSAs universally available for the first time).

Growing empowerment among physicians as they sense that they’re central to any reform and that 70% of health costs sluice through hospitals, other health institutions, health plans, and administration structures (doctors are expressing this empowerment through, the AMA, and the Physicians Foundation for Health Systems Excellence, an organization of state medical societies representing 500,000 physicians)

I see no prospects for sweeping reforms. I’m no fan of the New York Times editorial page, but it’s lead editorial in today’s Sunday Times gets it about right on many counts ( “ The High Cost of Health Care, November 25)

Here’s what the editorial had to say.

The Problems

High health costs causes vary and are rooted deep – our wealth and willingness to spend more, our reliance on specialists and technologies, our fragmented array of providers and insurers (one man's fragmentation is another man's personal doctor). The fundamental question is: what can be done to lower costs and rate of increases, and does it matter?

The Solutions

Cut 30% cost variance by regions (to me this is wishful thinking. Every region expense priorities and beliefs in what constitutes "quality care" differs and will never be the same). Identify what care works, inform consumers what works, reward doctors that make it work (what works, unfotunately, often falls into “gray” areas, and comparative effectiveness studies are in their infancy). Managed care is creeping back into health plans in the form of protocols and P4P (but there are signs a backlash is growing ). Implement information technologies on a grand scale ( I differ with the Times assessment that “There is little doubt” widespread computerization could greatly reduce the paperwork burden, head off drug errors, and reduce replication of diagnostic tests). Preventive measures – controlling weight, exercising, stopping smoking, checkups and screening and judicious use certain drugs – will slash costs (fat chance in individualist and misbehaving America). Carefully coordinating care and managing chronic disease ( I believe this is sound approach). Have the government negotiate Medicare drug prices and import drugs from abroad (I’m not optimistic beat the pharmaceutical and device manufacturer lobbies).

Who Picks Up the Tab?

Pay doctors less ( The Times doesn’t favor this, and neither do I). Stress Primary Care ( The Times says this will be a long term-project, requiring changes in reimbursement formulas and medical education reform. I agree). Give consumers skin in the game ( The Times cites 1972-1982 Rand studies showing consumers spending own money spent 30% less, but doubts consumers have competence to second guess doctors, and says consumer-driven care will apply to the poor and the sick. Single payer whereby government pays for all care and dictate prices (The Times says such a system might cut costs but has limited political support.

The Times conclusions? No silver bullet exists to slash costs; there is not enough information to cut costs without impairing quality, and maybe, just maybe, some hope for cost lwoering lies in “cascading knowledge’ flowing from human genome project, nanotechnologies, tailor-made personal treatments. I’m dubious about the latter, but hope springs eternal, and I may be wrong.

Sunday, November 25, 2007

Book Review - A Novel for Dialysis Patients

That Damn Dialysis – A Book Review

For patients undergoing dialysis and waiting for a possible kidney transplant, That Damn Dialysis, a dramatic, sometimes comical, account of the emotional gauntlet through which a dialysis patient passes, offers a shared experience for those suffering from the disease. . Nephrologists may want to recommend That Damn Dialysis for patients seeking information, empathy, and hope.

The author is Cindy Barclay. She is a RN and critical care nurse with 20 years in the dialysis field and 14 years as owner and CEO of Quality Dialysis, Inc, a Houston, Texas based company with 50 employees. She noted early on the nephrology industry tended to treat patients in a vacuum, leaving patients and families in a dark and confused state about their disease’s implications.

To clear up the confusion, she first wrote a manual for dialysis patients. The manual evolved into That Damn Dialysis (Claybar Publishing, Inc, 2007, $19.95, $10 for dialysis patients). It took two years to write. It’s a tale about the trials and tribulations of Cledus Washington, a 50 year cabinet maker after he learns he has chronic kidney disease and needs dialysis. Mrs. Barclay is now at work on a sequel to That Damn Dialysis about Cledus’ life once he receives a kidney transplant.

I asked Ms. Barclay, “Why a novel?” And she responded, “ Because people like drama, and it’s an effective way to explore relationships and tell a story.” In the story, Cletus loses his girl friend and fears he will lose his job because of the time required for three times a week dialysis treatment.

In writing the book, Ms. Barclay realized 20.6 million Americans diagnosed with chronic kidney disease had little access to understandable information about their disease. Most information on bookshelves is written for medical professionals, rather than patients. This leaves a void for patients trying to understand their own debilitating illness.
This novel describes one man’s struggle with kidney disease and dialysis. It carefully explains the medical terms, options, and what Medicare for dialysis patients is all about.

When the news is broken to Cledus that he will need a machine to keep him alive, his life turns upside down. Not only does he lose his kidney function, he loses his girl friend, too. He feels his job may be in jeopardy. He contemplates the possibility of a kidney transplant. Ultimately, Cledus reaches into his soul and survives.

In the book . patients will find new hope and understanding about this devastating disease. After reading it, dialysis patients will learn that can live with their disease and still enjoy life without letting dialysis completely control their destiny.

According to Charles Crumb, MD, a Houston nephologist with 35 years experience. “I look forward to finding out how Cledus deals with his kidney transplant. Excellent reading material; a great story, combined with easy to read medical knowledge.”

That Damn Dialysis
is available at:,

Saturday, November 24, 2007

Transparency - In a Clash All By Myself

Health Care Transparency and Returns on Social and Personal Investments

The test of a first-rate intelligence is the ability to hold two opposed ideas in the mind at the same time, and still retain the ability to function.

Francis Scott Fitzgerald, 1896-1940, The Crack-up, 1936

Let me be perfectly clear.

I am for transparency, clarity, openness, honesty, integrity, accountability, data measurement and management, sunshine laws, collaboration, joint ventures, the common good, adequate returns of social investments, public disclosure of outcomes and ties to pharmaceutical companies, and physician teamwork to improve care.

I am against rigid, arcane laws requiring armies of attorneys to interpret and which stifle physician-physician and physician-hospital collaboration and joint ownership.

I am for physician individualism, competition, economic freedom, adequate compensation, innovation, personal creativity, self-interest, wealth creation, inherent human nature tendencies, doing well by doing good and reasonable returns on personal investments.

I am against unbridled and unfettered greed, monopolies, and oligopathies.

I am, in short, in a clash all by myself. To be clear, and that’s what this discursive essay is all about, I believe more health care transparency is a good thing, and, at the same time, I believe total transparency has inherent limitations.


Revenue-producing ancillary services in doctors’ offices. In theory, physicians ought to make all their money for time spent with patients, not on side investments. . But as every doctor knows, given falling reimbursements for time spent, those who preach transparency delude themselves. Besides health consumers like one-stop shopping, even if a doctor’s business interests are involved. It’s about convenience, not conflict of interests.

Referral to services in which you have part-time ownership – such as joint ownership of MRI or CT scanners. Pete Stark not withstanding, to whom should you refer – to local hospitals, to competitors, to academic institutions, to others who profit from your referrals? Should you reward yourself – or others? To many, self-reward is more commonsensical.

Use of medical devices in which you have a financial interest, you believe in, have developed, have a patent on, or receive royalties from. Suppose you think your device is best thing on the market, which is why you conceived it. . Personally I believe doctors should tell your patients of financial interests, royalties, and self-interests. The proposal before Congress, the Physician Payment Sunshine Act of 2007, requiring companies to publicly disclose payments of $25 or more to physicians may be a good thing.

Wide deployment and diffusion of data of factual information, i.e., data, from multiple sources funneling into a common data tank so government, payers, and consumers can objectively judge for themselves the best value, the best providers, the best outcomes, and the best deal. In some circles, this is known as Health 2.0 – or management by data –reformulating algorithms in an open and transparent market. I applaud data diffusion, but doubt its practicality.

Universal communication through electronic medical records systems between hospitals and doctors so everybody can coordinate care and everybody can know what everybody else is doing with standards and controls to continuo sally improve quality, outcomes, and safety. Good idea, hard to do, given costs, privacy and security returns, and dubious returns on hospital and physician investments.

I trust I have been clear I’m for common social ends lofty goals can bring and against the realistic barriers human nature brings.

For doctors, transparency poses nettlesome problems – interference with improving the bottom line, keeping up a leg up on your competition, attracting patients, and concealing secrets of your success.

Then, on the part of doctors, there are other problems as well – expense of data input, loss of productivity during the transition to computers, use of your own data against you, lack of capital resources to install systems, the huge amount of work to get a system up and running, start-up costs of $25,000 to $50,000 per doctor to get EMRs off the ground, and maintenance costs of $5000 to $10,000 to maintain.

Good will, trust, and desire for the common good and better health care may overcome barriers to transparency – such as privacy, common terminologies, security, and cost. Maybe we’ll find a way to pay. But convincing doctors there’s a business and clinical case to be made for transparency will be formidable – with attractive but uncertain long term social gains but intractable and certain short term problems.

Friday, November 23, 2007

Stem Cells - Stem Cell Breakthrough More than Skin Deep

When the news broke in Cell and Science, two prestigious scientific journals, that research teams in Japan and Wisconsin had re-programmed skin cells to mimic embryonic stem cells, I thought of Lewis Thomas, MD, renowned pathologist, scientist, and writer (1913-1993).

Thomas was best known for a series of New England Journal of Medicine essays, “Notes of a Biology Watcher. “ The essays ran from 1974 to 1990 and became best-selling books, including The Lives of A Cell. In that book, he made this prophetic statement.

I have been trying to think of the earth as a kind of organism, but it is no go. I cannot think of it this way. It is too big, too complex, with too many working parts lacking visible connections. The other night, driving through a hilly, wooded part of southern New England, I wondered about this. If not like an organism, what is it like, what is it most like? Then, satisfactorily for that moment, it came to me: it is most like a single cell.

Indeed it is. And single cells may transform health care into a curative science.

Thomas said health care progress depended on basic research, such as the Salk polio vaccine. -- on understanding root causes of disease, not on “half-way technologies, “such as renal dialysis or coronary bypass.

Too many current innovations, though they may save lives and restore life style function, don’t root out pr explain basic causes, or reverse progression of underlying diseases.

Say what you will about skin cell re-programming into stem cells, that this re-programming.

defuses the political debate,

frees up funding for free-wheeling research,

eliminates need to destroy embryos

has the potential to cure cancer, heart disease, Alzheimers, paralysis, Parkinsons disease, amyotrophic lateral sclerosis, and diabetes.

But the true meaning of the skin-cell transformation is the triumph of basic science.

Here’s a Chicago Tribune described what has happened,”The potential here is staggering: A few flakes of skin could be turned into your own personal line of stem cells, coaxed to attack illnesses or even create replacement parts like a new organ, all without fear of an attack by the body's immune system. ‘It's just a spectacular, spectacular advance. was the way one prominent stem cell researcher described the findings.’ “

The research defuses political and ethical debate over destroying human embryos to harvest stem cells. This new technique promises an unlimited supply of stem cells without destroying embryos. Technical hurdles remain, but they're probably surmountable.Science and politics may finally get beyond distracting debates and embrace research unlocking potential of stem-cell therapies.

This latest technique won't replace human embryonic stem cells in medical research. Those stem cells are still the "gold standard" by which all other stem-cell lines are measured.

Researchers may soon develop an extensive array of stem cells derived in different ways because some stem cells may work against some kinds of illnesses but not others. It's also possible combinations of stem cells derived in different ways could be most potent against certain illnesses.If the ethical and political turmoil is resolved, and the federal spigot opens wide for research, stem-cell scientists may revolutionize medicine.

The triumph is more than skin-deep. It shows the importance of going back to basic academic research, past the half-way technologies ease symptoms but not cause or progression of disease. Transformed skin cells may not be ready for prime time, but they could be an example innovation becoming revelation.

Thursday, November 22, 2007

Physicians and Health Plans - The Physician-Health Plan Tango

“Tango – A highly stylized dance of Latin American origin in 2/4 time in which the steps are punctuated by glides and sudden pauses.”

Encarta World English Dictionary, 1999

In And Who Shall Care for the Sick? The Corporate Transformation of Medicine in Minnesota (Index Medicus, 1988), I described a tango between HMOs and doctors addressing who should control patient care.

I forecast physicians would rebel against HMO micromanagement. They did. But in the meantime HMOs have picked up the tango tempo by implementing pay-from-performance and physician ranking programs to control costs in the name of quality.

In recent weeks, the tango has reached a new level of intensity.

· In Minneapolis on November 19, The Star Tribune announced the Minnesota Medical Association, representing 11,000 doctors, 60% of the state’s practicing physicians, had issued a report complaining the state’s nine different insurers, using different criteria in their pay-for-performance (P4P) programs, had created unnecessary administrative and cost burdens for doctors. The title of the article was “Minnesota Doctors Turn Tables by Ranking Insurers.” The doctors ranked Minnesota’s nine insurers all of whom had implemented P4P programs. The programs give bonuses to doctors who met certain goals, such as ordering mammograms or checking eyes of diabetics. The doctors say bonuses flowing from P4P weren’t large or dependable enough to justify the expense of tracking compliance or effective in making system changes.

Across the U.S, 150 P4P programs exist with bonuses in the 3% to 20% range. Doctor David Sabin, a University of Minnesota family physician and an expert on P4P, commented, “ I worry about raising a generation of future doctors who do what they do because they follow guidelines. Why? Because they follow the money!” Why, some critics complain, should doctors be rewarded for what they should be doing already.

· In New York City on November 20, New York Attorney General Andrew Cuomo announced UnitedHealth Group Inc. (UNH), Group Health Inc. and HIP Health Plan of New York had agreed to adopt a model for physician-ranking programs.

UnitedHealth said it would apply the model nationwide and planned to launch a doctor-ranking program known as UnitedHealth Premium in New York. The agreement also covered Oxford Health Plans Inc.

"We are witnessing the insurance market correcting itself," Cuomo said, "The three largest insurers in the country have now all said they will apply the principles of our model for doctor rankings nationwide. Leaders in the insurance industry are setting the standard for rating doctors by using a model that was created with the input of physicians and consumers."

The model requires companies to ensure their rankings for doctors aren't based solely on cost, to use established national standards to measure quality of care, and to disclose to consumers how their programs are designed and how doctors are ranked.

Wellpoint Inc. (WLP), Cigna Inc. (CI) and Aetna Inc. (AET) recently have agreed to make similar changes to their physician-ranking programs nationwide.

Empire Blue Cross Blue Shield, a subsidiary of Wellpoint, will adopt Cuomo's model for any future program it adopts in New York state.

And so the tango continues across the health care dance floor– with moves and countermoves, rankings and counter-ranking, forward steps and sidesteps, glides and slides, pirouettes and pauses.

Where will the dance partners be when the music stops?

Wednesday, November 21, 2007

Effect of Culture - Thanksgiving - A Time to Say Thanks

Thank you, whoever and wherever you are, for the privilege of being a doctor.

Thank you for granting me the abilities, , the gifts, and the intelligence to help others.

Thank you for the good fortune to live in a free country, where I can choose the specialty I please, where I can practice where I please as I please, and where I can say what I please.

Thank you for the honor of serving patients – for being available to them, listening to them, comforting them, finding what’s wrong with them, treating them.

Thank you for allowing me to reside in a nation encouraging innovation and rewarding ingenuity for developing medical technologies, devices, and drugs.

Thank you for offering so many options and providing so many flexibilities to pursue what I want and to continue to learn.

Thank you for our political system – the longest standing democracy on the planet.

Thank you for the environment of freedom encouraging expression of honest differences of opinion.

Thank you for permitting to live in this vast nation with its abundant natural resources, stretching from sea to shining sea, from Alaska to Hawaii, and from Canada to Mexico.

Thank you for encouraging an open and diverse culture with a common language that attracts more immigrants than any other country and remains the magnet of opportunity for the rest of the world.

Thank you for allowing me to live under the system of capitalism and freedom, which despite its occasional inequities, generates the highest standard of living and best urgent medical care system known to man.

Thank you for the freedom to choose whatever doctor, alternative provider, hospital, or medical facility that suits my intelligence, fancy, convenience, or proximity to home.

Thank you for our medical teachers, now in 125, soon to be 131, medical schools, teaching hospitals, the VA system, and everywhere else teachers and mentors lend a hand up.

Thank you for my colleagues – for the medical sisterhood and brotherhood - who set examples for me, tolerate me, and support me in darkness and light.

Thank you for the ability to state my mind to my local, state, specialty, and national medical societies, to politicians at every level, to the local media, and to whomever else who will listen.

Thank you to wives, husbands, children, significant others, and whoever else listens to us, supports us, and loves us.

Thank you for the warmth and comforts of home and family and the ample food and drink.

Thank you for letting me say this on this Thanksgiving Day in this magnificent country of ours – the home of the Brave, the True, The Free, and the Grateful.

Tuesday, November 20, 2007

Kaiser - Systems Engineering and Individualism: Is There Room for Both in Health Care?

The question posed in the title isn’t trivial. It’s a very large question. To some, it’s about safety and quality; to others it’s simply unnecessary meddling; to still others, it’s the essence of health reform.

But systems, no matter how well designed, are limiting. Then the question becomes: how much slack, initiative, responsibility, and freedom to act are we going to give the individual? These too aren’t small questions.

Systems engineering promises a systematic, organized, and purposeful approach to minimizing variation, maximizing outcomes, and measuring results. Furthermore, it lends itself to deploying information technologies to guide doctors and inform patients.

The trouble is that system applications may impinge upon individualism – a characteristic that distinguishes America from other cultures. We believe, above all else, in individual autonomy – in the ability of individual patients and individual physicians having freedom to make health care choices.

Systems engineering is an interdisplinary field of engineering. It focuses on developing and organizing complex systems. It disciplines groups into a team effort Systems engineering considers the business and the technical needs of customers to provide a quality product meeting user needs.

Clinical protocols, paying only for care based on scientific evidence, paying -for-performance, measuring process and outcome metrics, and making electronic medical records mandatory are examples of systems engineering. Physicians in independent practice might prefer to the term “social engineering” to “systems engineering” and object to thinking of health care in systems terms because “systems” may violate the freedom-loving Americans.

Perhaps the most ardent proponent of systems engineering in health care is George Halvorson, CEO of Kaiser. Halvorson pushes the idea of electronic medical records to achieve consistency, standardization, quality tracking, and diagnostic support for following patients outside the exam room to see if they’re complying with instructions and improving outcomes. The key to this, says Halvorson is e-support – e-visits, e-scheduling, e-reminders, and e-care.

Halvorson feels we can overcome our system’s lapses and improve “systems” thinking. By systematically applying data, we can organize teams to provide answers, tamp down variables, strive for zero defects, coordinate everyone through e-systems and put all relevant data at physicians’ fingertips in the exam room.”

Halvorson maintains room exists for both systems engineering and individualism, and the final clinical judgment rests with the individual physician.

Does the health system need the discipline of systems engineering? Or is it simply an unnecessary clinical impediment? Let me know what you think.

Monday, November 19, 2007

Book Reviews - Reece's Pieces - Occasional Notes and Comments

I. Schools of Thought


Fixing American Healthcare: Wonkonians, Gekkonians, and the Grand Unification Theory of Health Care, Publisher or Perish Publishers, 2007

“Government regulators, politicians, public health officers, political liberals (wonks, in other words) espouse the Wonkonian school of thought.”

“The insurance industry, healthcare executives, many physicians, and most free market proponents espouse the Gekkonian school of thought, named for Gordon Gekko, the character in the movie Wall Street, who said greed is good. “


It’s hard to choose between those who make money at the expense of patients and those who exercise power by spending other people’s money.


Would you rather be an idealistic Wonk,
Or an realistic Gekko who’s not a Monk?
Would you rather rule from top-down,
Or wear a mercenary merchant’s crown?
Either way you’ll learn from the school of hard Knonks.

II. Faith in Doctors

Source Grooks, “My Faith in Doctors,” Piet Hein

“My faith in doctors is immense.
Just one thing spoils it;
their pretenceof authorized


An English, American, and Russian surgeon are boasting of their greatest deeds. The English says he performed a brain transplant on a mute who has never stop talking since. The American claims he performed a heart lung transplant without anesthesia. The Russian says, “I did a tonsillectomy.” “What’s so great about that,” chimed in the other two. “Well,” said the Russian, “in my country people are afraid to open their mouth, so I had to approach it in a different direction.” The moral is” no miracles among follow professionals, please.


Two cheers for my fellow physicians,
Why not three cheers for clinical magicians?
Because no matter how resolute.
Nothing is ever absolute,
Under all conditions.

III. Generalists and Specialists

Source: “Too Many Specialists, Not Enough Primary Care Doctors, Worry Health System Experts, ” Newspaper headline


Edward DeBono, MD, a world class expert on thinking based on London, once wrote that there are two kinds of thinkers - those who survey the landscape laterally and those that dig ever and ever deeper vertical holes. At the bottom of each hole, you will find a world-class expert. The problem is: the holes don’t connect.


There are those of us who are generalists.
More of us consider ourselves specialists.
Generalists think laterally,
Specialists think vertically,
As for me, I think bilaterally.

Sunday, November 18, 2007

Medicare Offers Savings Accounts for First Time

From Greg Scandlen, president of Consumers for Health Care Choice, an organization favoring consumer driven care fueled by HSAs, comes this November 15 message:

“With Open Enrollment starting yesterday (November 15) and going to December 31, Consumers for Health Care Choices has released a new paper alerting beneficiaries to a new option -- Medical Savings Accounts.”

“For the first time ever Medicare is making Medical Savings Accounts available to virtually all beneficiaries during the current open enrollment season. The program could be a huge boon for beneficiaries because it eliminates the need for MediGap coverage, provides a way of paying for non-Medicare covered services, limits out-of-pocket exposure, and offers the opportunity to save-up for future expenses. Beneficiaries should be sure to check it out.”

“This paper explains some of the advantages and lets readers know how to find information on the CMS web site.”

“Consumers for Health Care Choices is a national membership organization of citizens devoted to putting the consumer in the driver's seat of the health care system. It was organized two years ago and is growing quickly as more people realize the future of health care rests with empowered consumers. The Board Chair is Daniel (Stormy) Johnson, Jr., MD, a radiologist in Metairie, Louisiana, and former president of the American Medical Association.”

Comment: This message has enormous implications in that it might eliminate need for Medigap coverage, a huge source of revenue for the nation’s health plans. For more information, access or contact Website: , Greg Scanlen, Consumers for Health Care Choices,, 301-606-7364

Saturday, November 17, 2007

Hospitals and Doctors - New Twists in Specialty Hospital Development

In Innovation-Driven Health Care (Jones and Bartlett, 2007), I said total knee replacement was an innovator’s dream. It played perfectly into Americans’ penchant for quick technological fixes, desires of aging baby boomers for an active functional life style, into the booming business of treating athletic injuries, and in the dramatic shift to outpatient care.

These factors haven’t gone unnoticed by orthopedic surgeons, and by hospitals whose bottom lines depend heavily on orthopedic procedures. That’s why orthopedic surgeons own 50% of orthopedic specialty hospitals, and why general hospitals, fearful of being stripped of profitable procedures, succeeding in imposing a federal moratorium on specialty hospitals – made up mostly of doctor-owned hospitals devoted to short term stays for heart, orthopedic, other surgical, and women’s procedures.

The federal moratorium on physician-owned specialty hospital is ending, and there are signs the specialty hospital building boom will soon be underway.

There are two fundamentally new twists in specialty hospital development.

An antitrust suite against hospitals blocking doctor-owned facilities -- The U.S, District of Kansas has allowed Heartland Spine & Specialty Hospital, in Overland Park, Kansas to pursue an anti-trust lawsuit accusing two major insurers and three Kansas City acute care hospitals from conspiring to put the doctor-owned facility out of business. The question before the court is “ Can a doctor-owned specialty hospital sue hospitals and insurers for allegedly conspiring to block competition?” The hospital defendants control 90% of managed care enrollees in Kansas City. Cases like Heartland are popping up in States where Certificate of Needs laws are lax or non-existent.

The building of specialty hospitals in joint ventures with physicians -- Hospitals are moving rapidly to build specialty hospitals in joint ventures between the hospital and physicians or investor-owned chains. Physicians typically want 50% ownership. From the hospital point of view, the question seems to be: have the pie or none at all. .According to DGAPartners in Bala Cynwyd, Pennsylvania, a hospital consulting group, the criteria for entering into a joint venture should include:

1) Make sure market projections indicate at least 25% of caseload for the specialty hospital comes from increased demand or market growth;

2) consider the full impact of the specialty hospital on hospital revenues;

3) structure the deal to give flexibility for physician exit;

4) plan for a highly efficient high amenity facility. These facilities are usually 20 to 25 beds and serve a population 0f 150,000 to 200,000. Usually they provide care for routine orthopedic, neurosurgical, or cardiac procedures.

Ideally, if planned right, specialty hospitals should be profitable for hospitals and physicians alike.

Friday, November 16, 2007

Hospital and Doctor Relationships: Anything New Under the Sun?

I recently came across a 1986 book The Corporatization of Health Care Delivery, published by the American Hospital Publishing, Inc, a subsidiary of the American Hospital Association.

The book includes chapters on new models, hospital-physician competition, joint ventures, medical staff networks, how to pay doctors, and preventing malpractice losses. It contains diagrams of the independent corporate model, the traditional specialist divisional model, the parallel model, the joint venture model, and the malpractice pyramid.

Nothing new there.

The title of the book “The Corporatization of Health Care Delivery” says it all. In 1986, in AHA’s eyes, hospitals and their various corporate models were where the power, the glory, the center, the pivot, and the fulcrum of health care delivery. I suspect this remains so in most communities.

But there are new changes and new strains in the relationship – a few new things under the sun.

· One is the increasing business savvy of American physicians, fostered in part by business training in medical school, MD/MBA programs, and physician executive programs.

· Two is the realization that one man’s meat is another man’s poison. Hospitals have always had a power advantage over physicians because of their corporate structure and physicians’ “open democracies” But physicians are now developing more disciplined corporate structures of their own in centralized group practices, specialty hospitals, outpatient surgery and diagnostic facilities.

· Three is the accelerated migration of specialists outside of hospitals, thanks to advances in non-invasive or minimally invasive technologies in the realms of anesthesia and imaging and intravascular device placement. This is weakening traditional hospital-physician loyalties.

· Four is the rapid advance of “convenience care” – retail clinics, urgent clinic, multispecialty ambulatory care clinics – outside the central hospital campus. Whose patients are these new health consumers demanding convenience in nontraditional outpatient settings anyway?

· Five is the dawning of recognition that hospitals and physicians have different priorities. Hospitals and their boards tend to focus on protecting the corporate mission of the hospital, which includes the business function and caring for the sick; while physicians concentrate on serving patients within their practices and protecting their own bottom lines. What’s good for the goose may not be good for the gander.

· Six are the multiple effects of a new generation of doctors and economic pressures from the uninsured – more emphasis on 40 hour weeks, paid vacations, and malpractice coverage, forgiveness of training debts by physicians; more hospital employment; more hospitalists; more demands by physicians for payment for coverage of the emergency rooms.

· Seven are increased pressures on hospitals to create safe (e.g. the MRSA problem) and quality environments (e.g., P4P with measurable evidence of quality) with payments denied or tied to both.

· Eight is the relentless rhetoric about failures of hospital and physician electronic record systems that actually talk to each other and problems forming RHIOs (Regional Health Information Organizations) which require competing health systems and doctors sharing data with competitors.

Yes, there are new things glittering, glimmering, and glowing faintly under the hospital-physician sun, but they don’t brightly glisten or glare in the noonday sun because grinding evolutionary processes tend to occur at dawn or nightfall.

AARP Poll on Provider Favorability and Medicare Challenges

A recent AARP poll, published in the November issue of the AARP Bulletin shows patients like their doctors and their pharmacists, even as they dislike the system.

Here’s their poll of 1019 adults aged 18 and older. I have taken the liberty of arranging results in descending order of favorability.

Pharmacists, 82.0% overall favorability, 78% favorable under 50., 86% favorable over 50

Doctors, 81.5% overall favorability , 79% favorable under 50, 84% favorable over 50

Local Hospitals, 72.5%, overall favorability, 65% favorable under 50, 80% favorable over 50

Health Insurance Companies, 41.5% overall favorability, 40% under 50, 43% over 50

Drug Companies, 37.0%. overall favorability , 41% under 50, 33% over 50

HMOs, 35.5%, overall favorability, 37% under 50, 34% over 50

Meanwhile Medicare ”challenges” disturb AARP. Monthly Medicare premiums have risen from $43 to $96 over the last decade. Overall Medicare costs have gone from $2.7 billion in 1965 when President Lyndon Johnson signed Medicare into law to $372.3 billion this year. Medicare faces bankruptcy by 2019.

The answer to these cost problems, says AARP, is to curb waste, trim 12% overpayment to Medicare private plans, ensure doctors don’t pull out of the program, and extend coverage to all Americans.

Medicare will have to pay perhaps $15 to $20 billion more to keep doctors in the program, and coverage to the uninsured will cost $110 to $120 billion in the first year. Medicare costs have multiplied by 14 times since 1965, hardly a record that inspires confidence in Medicare’s ability to discipline itself.
In a 2005 interview I conducted with Joseph Antos, PhD, an economist for the American Enterprise Institute, for my book Voices of Health Reform, he called Medicare the “Sheriff of the U.S. Health System.” He observed 99.9% of hospitals, and 95% of doctors have to follow the Sheriff’s rules, and private plans follow in lockstep Medicare’s reimbursement patterns. Thus, Medicare profound influences health costs.

Antos concluded, “Medicare is the biggest actor in the system, with a badge to back it up. It’s unwise to buck the big boy. We’d be better off if we had a Medicare program that throttled back on rules and regulations and allowed providers and patients more opportunity to take the initiative.”

Thursday, November 15, 2007

Mandatory Electronic Medical Records: The Right Thing to Do?

Dave Hansen, an AMA Medical News reporter, called the other day to ask: Would, could, and should electronic medical records be mandatory? Health Partners, the big Boston Medical Group, he said. Had mandated EMR use.

Peter F. Drucker (1909-2006) was famous for saying, “Doing the right thing is more important than doing things right. Doing the right thing is effectiveness. Doing things right is efficiency. Focus first on effectiveness; then concentrate on efficiency.”

That only 20% of U.S. practitioners have installed electronic medical records may mean doctors are following Drucker’s advice. They’re focusing first on effectiveness, i.e., do EMRs make my practice more effective? rather than on efficiency, i.e., do EMRs make my practice more efficient? They’re watching and waiting for EMRs to mature.

That’s what I conclude from Medical Records Institute survey of 729 doctors in 2006 and 819 in 2007 cited in the November 12 issue of AMA Medical News. When asked, practitioners using EMRs responded:

Advantages, 2006, and 2007

Improved workflow efficiencies, 81.7%, 71.3%

Improved coding and charge capture, 80.0%, 64.2%

Value-based purchasing/P4P, 33.0%, 33.1%

Improved competitiveness, 44.4%, 30.4%

Pressure from government, insurers, 8.9%, 19.9%

Possibility of subsidized purchase, 15.8%, 19.5%

The Medical Record Institute survey also indicates barriers to EMR implementation – cost, return on investment, lack of partner support - are dropping by about 10%.

Surely EMRs’ time has come. But maybe not. Another survey of effectiveness among EMR and non-EMR users says non-EMR users have more effective performance, “EMRs don’t guarantee quality care, a review of 50,000 patient records shows; on 14 of 17 measures, physicians using paper records did equally well as those using EMRs. They even outperformed electronic record users in one area”, AMA Medical News, August 13, 2007).


Among Medicare officials, health plans, AARP, other medical societies, HIMSS (Health Information Management Systems Society), the Medical Records Institute, politicians, academic health centers, and members of large group practices, the need for EMRs to decrease waste, improve quality and safety, and enhance coordination, is a given.

That practitioners haven’t embraced EMRs frustrates electronic aficionados. Here, in a foreword to The Physician-Computer Conundrum: Get Over It!, M. Michael Shabot, MD, a medical director at Cedar-Sinai Medical Center, UCLA, expresses the frustration,

“What is this conundrum? Simply stated, it is the disconnect between the highly computerized and network world physicians live in and the grossly retarded state of computerization in most hospitals and health care settings where physicians live and work. Almost all physicians engage in technically complicated electronic transactions in their everyday life, like paying for gasoline at a pump or ordering goods over the Internet, but few enter medical records into a computer.”

And here’s Jonathon Cohn, writing in The New Republic, on November 12.

“ Several European countries are way ahead of us when it comes to establishing electronic medical records. It's the single easiest way to prevent medication errors--a true innovation. Thousands of Americans die because of such errors every year, yet the private sector has neither the will nor, really, the way to fix this problem.”

Should EMRs be mandatory? It’s a hot topic. In its November 12-14 meeting in Hawaii, one resolution before the House of Delegates is : “Do you agree the AMA should seek a full refundable federal tax credit or equivalent financial mechanism to indemnify physician practices for the cost of purchasing and implementing electronic medical records?”

If government wants a national EMR system so badly, perhaps it should pay for universal EMRs, maybe by subsidizing a program analogous to the Hill-Burton Act of 1946. That would be doing the right thing, even if it’s not yet determined to be the right thing to do.

Just because computer can do something doesn’t make it the right thing to do in all circumstances. Universal EMRs may be doing the right thing. They may even increase efficiency. Whether they are more effective in enhancing quality and safety remains moot.

Just because practitioners don’t embrace EMRs doesn’t mean doctors are antediluvian. It may mean doctors want to protect their autonomy and their patients’ privacy; don’t believe EMRs are ready for prime time; don’t feel EMRs are end user-friendly; feel computers in the room negatively impact chemistry of the doctor-patient relationship; regard pen and paper as more effective than mouse and screen. EMR adoption is in transition. It may take 10 years to get from here to there to find what’s the right thing to do.

Tuesday, November 13, 2007

Clinical Innovation, universal coverage - Can Innovation and Universal Coverage Co-Exist?

Innovation is the U.S. health system’s prime asset, and government-controlled universal coverage may threaten it.

That being the case, I was surprised to find unexpected support for my thesis from a Nov. 12 article in the The New Republic, a liberal publication that’s usually a staunch proponent of government controlled universal coverage.

The writer, Jonathon Cohn, in a Nov. 12 piece, “Creative Destruction: The Best Case against Universal Health Care,” cites the case of Michael Kingsley, former New Republic editor. Kingsley has Parkinson’s disease. It improved in 2006 after he received a new innovative treatment, Deep Brain Stimulation, at the Cleveland Clinic.

In his 4000 word essay, Cohn uses the word “innovation” 33 times. Here are a few things Cohn has to say.

“The United States is famously the world leader in medical innovation-- in part, it would seem, because we spend like a drunken sailor when it comes to medical care.”

“Maybe the trade-offs between covering everybody and fostering innovative health care is inevitable--and perhaps innovation has to come second.”

“Innovation ultimately benefits everybody by pushing the boundaries of the medically possible. Can we really count on a universal coverage system to weigh all of that? In other words, can we really be sure that universal health care won't come at the expense of innovative medicine?”

· “In a universal coverage system, the government would seek to limit spending by forcing down payments to doctors and pharmaceutical companies, while scrutinizing treatments for cost-effectiveness. This, in turn, would lead to both less innovation and less access to the innovation that already exists. And the public would end up losing out, because, as Tyler Cowen wrote last year in The New York Times, ‘the American health care system, high expenditures and all, is driving innovation for the entire world.’ "

· “Most economists would concede that it's possible a universal system could stifle innovation by pushing too hard on prices or applying the wrong kind of scrutiny to medical treatments.”

· “The forces that produce innovation in medicine turn out to be a great deal more complicated than critics of universal coverage seem to grasp. Ultimately, whether innovation would continue to thrive under universal health care depends entirely on what kind of system we create and how well we run it. In fact, it's quite possible that universal coverage could lead to better innovation.”

· “Computed Tomography (CT)--which a survey of internal medicine doctors recently ranked the top medical innovation in recent history--owes its existence to basic scientific discoveries about physics. But it's the steady involvement of companies like General Electric, which have poured untold sums into research and development of CT scanners that produced the technology we have today--and will produce even better technology tomorrow.”

Ultimately, of course, The New Republic being a liberal publication, Cohn comes down on the side of centralized systems controlling innovation.

· “The government, by contrast, has plenty of incentive to prioritize these sorts of investments. And, in more centralized systems, it can do just that. Several European countries are way ahead of us when it comes to establishing electronic medical records. It's the single easiest way to prevent medication errors--a true innovation. Thousands of Americans die because of such errors every year, yet the private sector has neither the will nor, really, the way to fix this problem.”

· “Another virtue of more centralized health care is its ability to generate savings by reducing administrative waste. A universal coverage system that significantly streamlined billing (either by creating one common form or simply replacing basic insurance with one, Medicare-like program) and cut down on the need for so many insurance middle-men would leave more resources for actual medical care--and real medical innovation.”

· “You don't have to choose between universal access and innovation. It's possible to have both-- as long as you do it right. “

That’s possible, but improbable. Centralized health care technological assessment and innovative development has never worked across the health care spectrum.

Clinical innovations - Rise of Innovation-Driven Care

Physician Innovations as Positive, Collaborative, and Achievable Engines for Reform

* Planned presentation before Innovators Conference, Heberman Center, Magee-Womans Hospital, University of Pittsburgh Medical Center, November 9, 2007. Not delivered because of death in author’s family.

Thank you for that generous introduction, which I so richly deserve but so seldom get. Thank you too – Doctor Anthony DeGoioia, the inspiration for this conference, AMD3 Education and Research Foundation, the Innovation Center of Magee-Womens Hospital of the University of Pittsburgh Medical Center, and Blue Belt Technologies, a technology development firm here in Pittsburgh.

My theme today is,

Nothing achievable, practical, or sustainable will occur in health reform unless physicians participate and actively collaborate.

My creed is,

innovations showing American physician ingenuity at its best are our best chance for positive health system reform – better, cheaper, more convenient care;

physicians can best initiate and carry out these innovations by collaborating with hospitals, other health care institutions, and the business community;

innovations most achievable are an extension of our present knowledge base using existing human and institutional resources.

Sophisticated Audience

You’re a sophisticated group. I will not fog any fastballs by you or bewilder you with softballs. The real world has hardened you. Your members include entrepreneurs, innovators, movers, shakers, venture capitalists, information technologists, biomedical engineers, hospital executives, business leaders, and physicians, all bent on innovating.

Keys to Innovation Success

What makes innovations tick?

The keys to successful innovation are:

• Experienced entrepreneurs, often physicians, armed with concepts that make a difference, and management teams that takes those concepts to market.

• Usually local, but increasingly national and even international venture capitalists, with the resources to convert concepts into achievable realities.

• Incubator cities with commercially successful business enterprises, financial resources, established medical institutions, and academic and business feeders of talent, all possessing the requisite skills in a critical enough mass to make innovations work.

• Markets to support innovation. No innovation is worth a damn, unless it advances care, .doesn’t burn cash too quickly, and supports the management team, the talent required , and mounts marketing effort needed.

Supportive Environments

We all know the legendary supportive urban and regional environments. These environments exist in every major U.S. city over a million inhabitants where critical talents and resources meet.

Nashville, HCA, heart of the for-profit hospital industry, which has spawned over 300 health care companies in Nashville and environs.

Boston, Route 128, to which innumerable health enterprises, many venture capital firms, a number of leading academic medical centers, the Massachusetts Institute of Technology, and the Harvard Business School contribute.

Minneapolis, Medical Alley, home of Mayo, the University of Minnesota Medical School, Medtronic, St. Judes, The United Health Group, and more than 800 licensed medical device dealers.

Pittsburgh, this Innovation Center, the University of Pittsburgh Medical Center, Carnegie Mellon, to mention a few, and others. You know what makes this great city tick as a an engine of medical innovation.

Other supportive innovation environments include: Seattle, Microsoft; Silicon Valley; Google, et al; Baltimore-Washington, D.C (Darkness and Confusion), Johns Hopkins, Revolution Health; The NYC medical industrial complex, Chicago, Austin, other Texas cities, and a host of other cities.

A Word about Orthopedic Surgeons

Just a word, if I may, about innovation and orthopedic surgeons. About fifteen years ago, I gave the keynote address before the American Academy of Orthopaedic Surgeons in San Francisco. Afterwards, the president of the association, a medical school classmate from Duke, toured me around the exhibit area. .I thought I was at a hardware convention – braces, splints, screws, nails, metallic inserts, hinges, rods, surgical saws – every imaginable device.

Ever since, I’ve said, “You can never tell what an orthopedic surgeon will do when left to his own devices.” And that preceded the boom in knee and hip implants, and other joint devices. I have a chapter in my book “Total Knee Replacement: An Innovator’s Dream,” which includes a bad pun, namely, that every orthopedic surgical innovator knows what Knees to be done. Now, of course, you’ve progressed to partial knees and robotic surgery. If, in this talk, I make any disjointed, displaced, fragmented, or miscast statements, I ‘m sure orthopedic surgeons in the audience will bring me into alignment. P.S. cardiovascular specialists are equally adept at device-development.

Hitting Nails on the Head

Speaking of hardware, I’m reminded of a phrase in The Golden Book of Writing, by a Dartmouth Professor, David Lambuth. He wrote, memorably, “If you have a nail to hit, hit it on the head.”

Today I shall hit these nails on the head., I shall speak,

• of what it takes for successful innovations;

• about the rise of innovation care as the salvation and heart of American health system;.

• of examples of what I consider major innovations;

• of 28 innovations heralded by Health Affairs, Wall Street Journal, and Cleveland Clinic.

• of what lies ahead.

Rise of Innovation

Innovation and entrepreneurship lie at the heart of the U.S. economy and of Western Capitalism. These twin concepts separate U.S. from other nations, and largely account for our robust economy, a theme articulated by Peter F. Drucker in Innovation and Entrepreneurship (Harper, 1986). Even today, even given the rise of globalization and the entrepreneurial Asian tigers,

• Most major innovations still come from U.S. This is changing with globalization and Internet, as evidenced by the sharp spike in collaborative innovation ventures with European and Asian companies

• innovation conferences, including this one, and Innovation Institutes, Innovation Congresses, and Innovation Summits are sprouting everywhere;

• emergence of CIOs (Chief Innovation Officers) as co-equal members of “C-suite, ” the new big thing in American hospitals.

• obsession with new ways to create a constant stream of new innovation ideas.. “Wild idea teams,” are blooming as keys to survival and thrival;

• explosive growth of alternative sites of care – retail clinics, urgent clinics, cash clinics, ambulatory centers of care, surgical hospitals, worksite clinics, and homes themselves – all falling until the rubric of “convenience care sites.”

• sudden entries into the health care technological arena of the IT Big Dogs, Microsoft, Google, WebMD, and countless other mid and large technological tigers with a Health 2.0 agenda. This agenda includes the aggregation and interdigitation of PHR, EMRs, Claims, Health Management, and Vendor Management Data – with data dumping into a common data repository guided by algorithms.

• movements towards more private and personal care settings –concierge and retainer practices, and home care is taking place.

Not All Innovations Are Technological

Not all innovations are technological. Health reform is not primarily technological, though all politicians are pushing information technologies as the underlying key to success. Many innovations are cultural, sociol, organizational, physician-developed, or market-driven products reflecting desire for reform, safety, quality, greater economic and clinical convenience, freedom, and choice.

• New practice sites, retail and workplace clinics, for privacy, convenience, and lower prices.

• New methods of payment, including an active credit industry, for elective, life style-enhancing and even life-saving procedures

• New organization models, Big MACCs (Multispecialty ambulatory care centers) removed from hospital campuses and situated in suburban, exurban, regional, and retirement communities

• New practice designs – concierge, cash, retail, urgency care, disease specific integrated ventures, group care

• New forms of marketing and patient engagement – kiosks, internet-based user groups, medical shopping complexes.

A Little Background as to My Qualifications

I’m a pathologist, I’ve watching these events for the last 35 years through conversations in hospital staff rooms, medical meetings, and front-row seat in operating rooms and differential diagnosis sessions. I founded the National Association of Physician Hospital Organizations, now defunct because PHOs became known to doctors as HPOs, i.e. run by hospitals for their benefit, not the benefit of physicians. For the last 11 years, I’ve been editor-in chief of Physician Practice Options, a monthly newsletter designed to promote efficient doctor practices. I’m author of Innovation-Driven Health Care, 34 Keys to Transformation (Jones and Bartlett, 2007), now used in many MHA and MD/MBA programs. I’m a blogger., My blog now has 340 daily entries. Lastly, I’m on the Medical Advisory Board, America’s Top Doctors, which, through a complicated process of peer approval and peer questions, picks the top specialists in America, most of whom practice in academic settings.

Lastly, and perhaps most important, I’ve had a personal interest in these innovation projects.

-- developing a differential diagnosis program based on 700 abnormal lab results in early days of Internet,

--creating 150 bundled bills combining hospital and specialty fees for hospital-based procedures,

-- following closely the launch of, and SHAPE Medical Systems.

Out of These Activities

Out of these activities has come,

This personal bias: Physicians often make best “early” medical entrepreneurs and innovators. They know physician and public mindsets and unfilled medical niches. “Innovation is easy. Find the niches – and reward the sons of niches, ”

And this huge caveat: To ensure the success of any innovative physician enterprise, physicians need help (and lots of it) in writing business plans, forming management teams, seeking venture capital, taking products to market, and knowing when to step down once innovation is launched

Examples of Innovations with Which I Have Personal Experience

Bundled Bills for Hospital-Medical Staff Procedures, Oklahoma City, while serving as a PHO chairman

Emmi Solutions online interactive “expectation” programs for patients about to undergo surgery – in current use at U. of Pittsburgh Medical System for free-wheeling dialogue between physicians

SHAPE (Superior Hospital and Pulmonary Evaluation, Mayo Clinic

Bundled Hospital-Physician Bills for Hospital Procedures, Oklahoma City

This is a powerful because consumer-driven health care will demand it or some variation in the future and because it requires close collaboration between physicians and hospitals.

Market demands will include:

• Transparency in advance

• Close collaboration between hospitals and doctors

• Predictability backed by reinsurance

• Efficiency, convenience, ease of access for consumers

• Inevitability because of ability of IT data mining and predictive modeling to predict costs of “episodes of care”

• Need for hospitals and doctors to co-exist in Medical Arms Races and to differentiate themselves from rivals.

Emmi Solutions, Chicago, Illinois

This is powerful because it brings together and entails practical collaboration between – hospitals, physicians, and patients – and benefits all of them by bringing greater safety, efficiency, understanding, and lower malpractice risks.

• Doctor inspired. Chicago-Based

• Online Patient Accessible, Internet Programs

• Verbal, Visual, and Interactive Features

• Hospital Financed

• Doctor “Prescribed”

• Addresses and overcomes cultural Illiteracy

• Engages patients on their own level

• Prepares patients and meets their expectations

• Reduces malpractice exposure, Cambridge, Massachusetts

This is powerful because its sets up an easily accessible discussion forum for practicing physicians, and in the process, shows their concerns, biases, thinking patterns, trends, inclinations, and disinclinations. Whether our critics like it or not, physicians are the driving engines of innovation and reform, and their input and collaboration will be required to achievable reforms.

• Physician founder and CEO

• For licensed doctors only

• Free-wheeling discussion site

• Backed by Wall Street firms and AMA

• Focuses on doctor trends. attitudes, and beahivors

• Doctors driving force for 80% of spending

• Revealing pros and dons of marketing innovations directed towards practicing doctors.

SHAPE Medical Systems, Inc, St. Paul, Minnesota

This is powerful because it used tested and proven methodologies, addresses two of the leading causes of death in America, detects them early through physiological tests, and is portable, affordable, and useable in multiple settings – inside and outside physician offices. It builds on the past and will be achievable in the future and rests on the solid collaboration with a major institution.

• Fifth generation – 50 years of heart and lung physiological testing

• Less expensive, smaller, and less risky than traditional coronary treadmill

• Tests heart and lung function simultaneously and early

• Predictive modeling – risks of hospitalization and death

• Lends itself to testing for multiple testing situations and in multiple settings

• Validated by Mayo Clinic

Lists of 28 Innovations

First, Health Affairs

1. MRI and CT

2. ACE and angiotensin inhibitors

3. Balloon angioplasty with stents

4. Statins



7. Proton Pump Inhibitors and H2 Blockers

8. SSRIs

9. Cataract extractions,. Lens implant

10.Hip and knee replacement.

Wall Street Journal List

1. Tekturna, anti-hypertensive drug, Novartis/Speedel

2. Technology for single test to identify infectious organisms, Genaco Biomedical products

3. Elaprase, Rx for Hunter’s syndrome

4. Humira, injectable Rx for Chrohn;s disease

5. Noxzfil, Rx for life-threatening fungal disease

6. Eclipse – Portable 17 pound unit carrying
concentrated O2 for victims of lung disease

7. Upright MRI, Fonar

8. Titanium device for Rxing lumbar stenosis symptoms

Cleveland Clinic List

1. Flexible intralumenal robotics

2. Percutaneous aortic valves

3. RNA therapeutics to reduce LDL and triglycerides

4. Genomic screening for health assessement

5. New drugs for clotting and bleeding control

6. Nasal administration of flu vaccine to infants

7. Image fusion for dxing and guiding minimally invasive procedures

8. Implanted devices to restore movement

9. Engineered cartilage for joint repair

10. Dual energy source for CT to reduce radiation exposure

General Spheres of Future Major Innovations

1. Consumer-driven health care

2. Chronic disease management

3. Health care IT (particularly tools for consumers to better manage and pay for health care)

4. Public-private partnerships to manage care for seniors

5. Customized care centers (chains to deliver high quality, cost effective services locally, regionally ,and nationally.

6. Health 2.0 -This Data-Mongering, Mother, and Granddaddy of All Innovations , reformulates data for decision-support, transparency, and revitalized health care markets. It consists of expert content, data-based, artificial intelligence and predictive-modeling algorithms for better decision-making for patients, clinicians, health managers, and purchasers.

Whether Health 2.0 represents hype or reality is not known at present.


I close with two thoughts on innovation.

1) The Internet is the greatest innovation ever to hit health care.

2) Data – no matter how innovatively manipulated or how artificial intelligence refines it or mines it – will ever define or dictate – the human experience with health care: it takes doctors, interacting intimately with patients – to do that.

Thank you.

Monday, November 12, 2007

Costs - In the Abstract Not The Concrete

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

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

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

So, constrain costs we must.

But how?

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

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

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

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

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

Sunday, November 11, 2007

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

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

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

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

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

Health Care Reporting

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

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

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

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

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

There reports are balanced straight reporting.


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

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

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

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

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

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

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

Saturday, November 10, 2007

Those Radical Republicans

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

Right? Wrong!

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

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

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

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

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

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

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

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

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

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

Friday, November 9, 2007

AMA: A Sleeping GIant Rouses

The AMA is becoming a more visibly activist organization.

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

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

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

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

The sleeping giant is now aroused.

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

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

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

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

2) Whether the AMA should amend HIPPA and similar regulations

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

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

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

Out into the Open

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

Thursday, November 8, 2007

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

What’s it all about, Alfie?

Is it just for the moment we live?

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

Are we meant to take more than we give?

Or are we meant to be kind?

And if only fools are kind, Alfie?

Then I guess it's wise to be cruel.

And if life belongs only to the strong, Alfie,

What will you lend on an old golden rule?

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

I know there's something much more.

Lyric to Alfie, 1960’s popular song

Suddenly people want to become doctors.

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

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

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

What’s it all about?

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

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

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

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

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

Tuesday, November 6, 2007

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

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

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

A: 21 years.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Q: What are your best selling publications?

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

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

Publication information on Physician Practice Management and Physician-Hospital Relations can be viewed on the Practice Support Resources, Inc. website 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?