I’ve been reading George Halvorson’s new book Health Care Reform Now! (Wiley, 2007). Halvorson is chairman and CEO of Kaiser Foundation and Hospitals, a $35 billion health plan in Oakland, California. Kaiser has invested heavily ($3 billion) in a system-wide EMR and in targeted improvement of 5 chronic diseases – diabetes, asthma, coronary artery disease, CHF, and depression - which consume 70% of U.S. health care dollars.
Halvorson thinks of U.S. health care as a disorganized colossus that needs to be reorganized under a national corporate umbrella with systematic gathering of data, process re-engineering, continuous improvement, and infrastructure vendors who put the delivery of care up for bids.
He envisions an ideal health care system patterned after General Electric’s Six Sigma improvement model. His view isn’t my cup of tea. It makes doctors functionaries of large health care organizations, threatens private practice, and restricts physician freedom. Still it’s a view that needs to be understood.
Halvorson says eight developments make reform imminent.
1. A Common Provider Number – All doctors will soon have a single number identifying each individual doctor for all payers and all care. The number can be used to track your performance nationally. Halvorson states “Health care reform becomes possible when we have real performance data about care.”
2. Computerized Databases – All payers have computerized data bases. All databases are standardized and electronic. This assures uniform data flow and can be used to track each patient’s incident of care.
3. Electronic Claims Data Portability – You can transfer data between health plans just as banks can transfer data. Halvorson says this is a “data bonanza for health care.” Data transfer creates databases for each individual patient and each doctor, Further, community databases can track patterns of care and caregiver performance.
4. Government Transparency about Payment Data - Halvorson says government’s willingness to share Medicare and Medicaid data is a huge transparency step forward because you can now compare physician performance.
5. Universal Awareness of Quality Issues – Halvorson says widespread awareness that the health care infrastructure is “badly flawed, perversely incented, inadequately coordinated, incredibly inconsistent, strategically unfocused, and too often dangerously dysfunctional” will facilitate reform.
6. Buyers Are Ready for Change - Halvorson believes primary buyers of care – government and employers – are ready for change. There are no “happy buyers,” he asserts, and employers are cutting benefits, and markets and industries are ready to try anything that works.
7. Internet Functionality Used for Care - In purchasing, banking, investing, and education, the Internet has made “massive inroads into how we do business.” Halvorson foresees e-scheduling, e-visits, e-follow-ups, e-reports, e-reminders, e-consults, and e-home visits. Halvorson says, “Paper can’t do the job. We need the web to reform care.” The Internet could make an e-normous difference if only we could weed out e-relevant misinformation.
8. Lawmakers are Ready for Reform - Halvorson cites 20 states - California, Colorado, Connecticut, Florida, Hawaii, Kansas, Illinois, Maine, Maryland, Massachusetts, Minnesota, Missouri, New Hampshire, New Yoke, Ohio, Oklahoma, Pennsylvania, Rhode Island, Vermont, and Wisconsin – that have introduced State Health and Universal Coverage Initiatives.
Fourteen states – Kansas, Kentucky, Massachusetts, Michigan, Minnesota, New Jersey, New York, Ohio, Oregon, Pennsylvania, Rhode Island, Tennessee, ashington, and West Virginia – have mandated employer health insurance coverage.
And one state. Massachusetts has imposed a “free rider surcharge” on employees who don’t provide coverage.
Wrap-up
It’s possible a single provider number, data from EMRs and PHRs and retrospective claims , data portability, and payers seeking change will make for real health reform soon. It’s possible data-based large virtually integrated groups, acting synchronously and strategically, focusing in continuous improvement, will bring about reform.
But it’s unlikely, given the reality that 90% of America’s doctors now practice independently, mostly in small groups. It would require a massive physician cultural shift. But likely or not, Halvorson insists the technological and management tools are there, and it is “doable.”
I find Halvorson’s vision Orwellian. He is saying in the future Big e-Brother will be watching you. What Halvorson says may be logical, but it frightens me because it compromises the freedom of American physicians and patients..
What do you, America’s independent practitioners, think of Halvorson’s vision? Is it doable? Is it desirable?
Sunday, December 30, 2007
Saturday, December 29, 2007
Health Plans - America’s Health Insurance Plans Move to Cover Political Black Eye
America’s Health Insurance Plans (AHIP) are proposing to cover more people with pre-existing conditions if individual states will help subsidize the cost.
Currently health plans have a political black eye for canceling or refusing to accept individuals with pre-existing conditions or who are otherwise at high risk. In a survey, AHIP found 11% of all people who apply for policies are not accepted. Nearly 30% of individuals in their 60s too young for Medicare are rejected.
In putting forth this proposal, AHIP is reacting to universal coverage initiatives in 11 states, which frequently contain a clause saying all individuals with pre-existing coverage must be accepted. Forcing acceptance of all with pre-existing conditions is also popular among presidential candidates.
The health plan industry is proposing everybody whose medical costs are twice the average, and to cap the premiums of other high risk individuals at 150% of the market rate..
The AHIP is the latest example of the shifting reform sands as the health plan industry attempts to adjust to demands for wider coverage and a broader safety net.
I believe broader coverage for individuals with pre-existing illness or who are at high risk is a good idea. I wonder how often physicians encounter these individuals and how you help resolve their problems.
Currently health plans have a political black eye for canceling or refusing to accept individuals with pre-existing conditions or who are otherwise at high risk. In a survey, AHIP found 11% of all people who apply for policies are not accepted. Nearly 30% of individuals in their 60s too young for Medicare are rejected.
In putting forth this proposal, AHIP is reacting to universal coverage initiatives in 11 states, which frequently contain a clause saying all individuals with pre-existing coverage must be accepted. Forcing acceptance of all with pre-existing conditions is also popular among presidential candidates.
The health plan industry is proposing everybody whose medical costs are twice the average, and to cap the premiums of other high risk individuals at 150% of the market rate..
The AHIP is the latest example of the shifting reform sands as the health plan industry attempts to adjust to demands for wider coverage and a broader safety net.
I believe broader coverage for individuals with pre-existing illness or who are at high risk is a good idea. I wonder how often physicians encounter these individuals and how you help resolve their problems.
Thursday, December 27, 2007
Medical Trends - Top 12 Trends of 2007 for Physicians
Judging importance of trends is a subjective exercise. Nevertheless, here goes.
1. Medicare Cutbacks - It’s finally dawned on government. Unless it cuts back on entitlements and federal largess, Medicare growth will eat the federal budget alive. Accordingly, Medicare is raising premiums, slashing physician and hospital pay, and no longer paying for preventable medical errors.
2. State Universal Reform Setbacks – Universal coverage plans in California, Massachusetts, Pennsylvania, and Illinois, are hitting roadblocks. Plans share these features – mandatory payments by individuals, paying for all pre-existing disease or high risk persons, and seeking answers to two questions: Who shall pay? How much will state government, business, and health providers be forced to cough up to make reform work?
3. Leveling Off of Malpractice Premiums – That 84% of premiums have leveled off or dropped is welcome news. These factors contribute: cyclic business changes, competition between liability companies, risk reduction programs, and legislative acts, such as those in Texas, capping rewards. Through the work of its Medical Society Insurance Company, Minnesota has achieved the lowest rates for all specialties of any state.
4. Physician Shortages - It’s now acknowledged physician shortages are with us and will grow worse through 2020. This shortage makes universal coverage difficult, handicaps rural hospitals’ efforts to provide comprehensive care, and makes it hard for new Medicare patients to find physicians. Laws of supply and demand will make physicians a more precious commodity.
5. Transparency Push (Ranking, P4P, Pricing) –If only, saith soothsayers, we could make medical pricing clear in advance, we could steer patients to the best, most effective, least costly providers, reward only high performing doctors, streamline and improve the system. But nagging questions remain. Should data trump provider choice? Will P4P programs requiring expensive IT tracking and training, save money and improve care?
6. Physician Empowerment - Doctors are re-awakening to the reality they hold the key to effective, efficient, and safe healthcare. They’re asserting themselves through legislative efforts to reduce malpractice costs, state medical societies curtailing health plan abuses, social online networking in sites like Sermo, and health care practices offering prompt same-day access and more efficient and friendly care.
7. RHIO Collapse - Regional Health Information Organizations are dying from lack of support from participating physicians, hospitals, and others. These groups simply don’t see anything to gain from aggregating strategic data, and sharing it with competitors in the same markets.
8. Pharma Repositioning – With dwindling drug pipelines; patents running out; patients switching to generics; cost gaps growing between America and other countries; and an impending Democratic take-over of Congress, Pharma faces an uncertain future. It’s repositioning itself by cutting back on drug reps, laying off employees, getting into generics, and offering value-added, non-drug related, practice-building products to physicians.
9. EMR Pressures - Michael Leavitt, CMS Secretary , says physician Medicare cuts should occur if doctors fail to install EMRs. The mandatory EMR threat mirrors attitudes of other physician controllers, and policy wonks in think-tanks, health plans, and government, who believe only a national linked computer system will save money and improve care. The problem? Hospitals and doctors are slow to buy into the IT Holy Grail message and are taking a wait-and-see attitude.
10. Out of Hospital and Out of Practice Business Models - Providing care outside of traditional hospital and office practice settings is a huge, fast-growing market-based movement. . It isn’t restricted to retail clinics. It includes worksite clinics, urgent care clinics, ambulatory surgery centers, specialty hospitals, and Big MACCs (multispecialty Ambulatory Care Centers)
11. Health Plan Readjustments – America’s Health Plans have proposed to offer coverage to chronically ill and high risk individuals under certain conditions (e.g. if they’re less than twice the cost risk). This is significant and is intended to reduce the number of uninsured and to mollify those who, in the name of reform, would make mandatory coverage of all who apply for coverage.
12. ER Coverage - 25% of hospital emergency directors say lack of specialist coverage threatens public health in their communities. The reasons for are many – specialty shortages, low or no payments for coverage, inadequate payment from those treated, high malpractice risks, disrupted life styles, time away and money lost from practices, and shift of physician focus away from hospitals.
1. Medicare Cutbacks - It’s finally dawned on government. Unless it cuts back on entitlements and federal largess, Medicare growth will eat the federal budget alive. Accordingly, Medicare is raising premiums, slashing physician and hospital pay, and no longer paying for preventable medical errors.
2. State Universal Reform Setbacks – Universal coverage plans in California, Massachusetts, Pennsylvania, and Illinois, are hitting roadblocks. Plans share these features – mandatory payments by individuals, paying for all pre-existing disease or high risk persons, and seeking answers to two questions: Who shall pay? How much will state government, business, and health providers be forced to cough up to make reform work?
3. Leveling Off of Malpractice Premiums – That 84% of premiums have leveled off or dropped is welcome news. These factors contribute: cyclic business changes, competition between liability companies, risk reduction programs, and legislative acts, such as those in Texas, capping rewards. Through the work of its Medical Society Insurance Company, Minnesota has achieved the lowest rates for all specialties of any state.
4. Physician Shortages - It’s now acknowledged physician shortages are with us and will grow worse through 2020. This shortage makes universal coverage difficult, handicaps rural hospitals’ efforts to provide comprehensive care, and makes it hard for new Medicare patients to find physicians. Laws of supply and demand will make physicians a more precious commodity.
5. Transparency Push (Ranking, P4P, Pricing) –If only, saith soothsayers, we could make medical pricing clear in advance, we could steer patients to the best, most effective, least costly providers, reward only high performing doctors, streamline and improve the system. But nagging questions remain. Should data trump provider choice? Will P4P programs requiring expensive IT tracking and training, save money and improve care?
6. Physician Empowerment - Doctors are re-awakening to the reality they hold the key to effective, efficient, and safe healthcare. They’re asserting themselves through legislative efforts to reduce malpractice costs, state medical societies curtailing health plan abuses, social online networking in sites like Sermo, and health care practices offering prompt same-day access and more efficient and friendly care.
7. RHIO Collapse - Regional Health Information Organizations are dying from lack of support from participating physicians, hospitals, and others. These groups simply don’t see anything to gain from aggregating strategic data, and sharing it with competitors in the same markets.
8. Pharma Repositioning – With dwindling drug pipelines; patents running out; patients switching to generics; cost gaps growing between America and other countries; and an impending Democratic take-over of Congress, Pharma faces an uncertain future. It’s repositioning itself by cutting back on drug reps, laying off employees, getting into generics, and offering value-added, non-drug related, practice-building products to physicians.
9. EMR Pressures - Michael Leavitt, CMS Secretary , says physician Medicare cuts should occur if doctors fail to install EMRs. The mandatory EMR threat mirrors attitudes of other physician controllers, and policy wonks in think-tanks, health plans, and government, who believe only a national linked computer system will save money and improve care. The problem? Hospitals and doctors are slow to buy into the IT Holy Grail message and are taking a wait-and-see attitude.
10. Out of Hospital and Out of Practice Business Models - Providing care outside of traditional hospital and office practice settings is a huge, fast-growing market-based movement. . It isn’t restricted to retail clinics. It includes worksite clinics, urgent care clinics, ambulatory surgery centers, specialty hospitals, and Big MACCs (multispecialty Ambulatory Care Centers)
11. Health Plan Readjustments – America’s Health Plans have proposed to offer coverage to chronically ill and high risk individuals under certain conditions (e.g. if they’re less than twice the cost risk). This is significant and is intended to reduce the number of uninsured and to mollify those who, in the name of reform, would make mandatory coverage of all who apply for coverage.
12. ER Coverage - 25% of hospital emergency directors say lack of specialist coverage threatens public health in their communities. The reasons for are many – specialty shortages, low or no payments for coverage, inadequate payment from those treated, high malpractice risks, disrupted life styles, time away and money lost from practices, and shift of physician focus away from hospitals.
Wednesday, December 26, 2007
Physician Payment - Paying Doctors for ER Coverage
Doctors, as rational professionals, at times protect their time with family, life style. Incomes, and avoid malpractice risks by asking to be paid for emergency room coverage.
Many think doctors should provide such coverage as an act of charity, as a professional duty, and as a way of showing fealty to hospitals. And more often than not, probably 75% of the time, doctors do.
Yet, lack of specialty ER coverage has become a critically important issue. In a survey by the Schumacher Group, a Lafayette, Louisiana ER management firm, 34% of hospitals say coverage lack poses a public safety threat. Still, doctors are more and more unwilling to cover without compensation because of malpractice risks, lifestyle burdens, and economic factors.
Here are % of hospitals paying extra for the following specialists (2005 survey of 1328 ER directors)
• General surgeons, 25%
• Orthopedists, 20%
• Neurosurgeons, 16%
• Ob/Gyn, 12%
• ENT, 7%
• Ophthalmology, 6%
• Plastic surgery, 6%
• Psychiatry, 6%
• Hand surgery, 5%
• Vascular surgery, 4%
• Gastroenterology, 4%
Below are hourly rates for specialties, on-house and off-site (Source: Sullivan, Cotter, and Associates On-Call Pay Survey)
• Anesthesiology, $80. $32
• ER, $72, N.A.
• OB/GYN, $85, N.A,
• Primary Care, $45, N.A.
• Psychiatry, $75, $18
• Surgery, $48, N.A.
• Surgical specialties, $81. $31
• Trauma, $95, N.A.
Are these rates too much to ask? After all, doctors covering ERs,
• stand a low chance of being paid a high chance of being sued,
• don’t know the patients and may never see them again,
• may compete with the hospitals who are asking them to cover,.
• are distracted from their home and personal lives while being on call,
• must take time away from their practice, thus losing income, while traveling to and from the hospital or doing required procedures.
There may be other factors as well. A November study by the Center for Studying Health System Change, says doctors are shifting focus from hospitals to their practices and outpatient facilities. Treating ER patients takes time and money from their practices. When treating patients in their own centers, doctors can also collect facility fees – just as hospitals do in their ERs.
Lack of specialty coverage in hospital is a problem, because treatment delays can cause deaths or permanent injuries. But it’s a problem hospitals are correcting by contracting with physician groups for ER coverage, paying stipends to covering doctors, and paying doctors for treating uninsured patients while on call
Many think doctors should provide such coverage as an act of charity, as a professional duty, and as a way of showing fealty to hospitals. And more often than not, probably 75% of the time, doctors do.
Yet, lack of specialty ER coverage has become a critically important issue. In a survey by the Schumacher Group, a Lafayette, Louisiana ER management firm, 34% of hospitals say coverage lack poses a public safety threat. Still, doctors are more and more unwilling to cover without compensation because of malpractice risks, lifestyle burdens, and economic factors.
Here are % of hospitals paying extra for the following specialists (2005 survey of 1328 ER directors)
• General surgeons, 25%
• Orthopedists, 20%
• Neurosurgeons, 16%
• Ob/Gyn, 12%
• ENT, 7%
• Ophthalmology, 6%
• Plastic surgery, 6%
• Psychiatry, 6%
• Hand surgery, 5%
• Vascular surgery, 4%
• Gastroenterology, 4%
Below are hourly rates for specialties, on-house and off-site (Source: Sullivan, Cotter, and Associates On-Call Pay Survey)
• Anesthesiology, $80. $32
• ER, $72, N.A.
• OB/GYN, $85, N.A,
• Primary Care, $45, N.A.
• Psychiatry, $75, $18
• Surgery, $48, N.A.
• Surgical specialties, $81. $31
• Trauma, $95, N.A.
Are these rates too much to ask? After all, doctors covering ERs,
• stand a low chance of being paid a high chance of being sued,
• don’t know the patients and may never see them again,
• may compete with the hospitals who are asking them to cover,.
• are distracted from their home and personal lives while being on call,
• must take time away from their practice, thus losing income, while traveling to and from the hospital or doing required procedures.
There may be other factors as well. A November study by the Center for Studying Health System Change, says doctors are shifting focus from hospitals to their practices and outpatient facilities. Treating ER patients takes time and money from their practices. When treating patients in their own centers, doctors can also collect facility fees – just as hospitals do in their ERs.
Lack of specialty coverage in hospital is a problem, because treatment delays can cause deaths or permanent injuries. But it’s a problem hospitals are correcting by contracting with physician groups for ER coverage, paying stipends to covering doctors, and paying doctors for treating uninsured patients while on call
Monday, December 24, 2007
Blogging, Doggerel - Christmas Is Green
All right, fellow physicians out there.
Put this in your Christmas stocking,
And in your Santa Claus hat,
Take the day off from doctor thoughts,
And think like a child.
After all, it is their day.
Christmas is green.
And not for the reason you think
It is Green because it is Green.
This is simply a matter of fact.
It is ridiculous to ask why.
Oh, I know some say it is White.
Some even say it is Blue.
While others claim it is Red.
These people are wrong.
White is New Year’s Day.
Blue is reserved for Columbus Day
Because he sailed the Ocean Blue.
And the Fourth of July is Red,
A Hot Red, a Glorious Red.
A Swinging, Beautiful, Sunset Red.
What about Brown?
Could Christmas be Brown?
No, Brown is Thanksgiving.
Thanksgiving looks, smells, and sounds Brown,
A Glowing, Lush, Golden Brown.
Of course, Labor Day is Gray.
What other color could it be?
It sounds correct, and it is correct.
Besides there is no other Holiday
That is remotely Gray.
Not Washington’s or Lincoln’s birthdays,
Which are respectively Purple and Black.
And so all most Holidays are accounted for,
Except Easter, Memorial Day,
And Martin Luther King Day..
Easter as everybody knows is Yellow,
A Kight Yellow, almost a White Yellow.
Some uniformed people say Easter is Pink,
But these people are uniformed.
And what about Memorial Day?
Undoubtedly that day is Orchid,
A mixture of sadness and gladness
And Red and White and Blue
So Orchid Memorial Day is,
Martin Luther King Day?
Blue Black overcast with Gray.
And so by logical exclusion
In your differential diagnosis,
That leaves Green for Christmas.
What does all of this have to do with doctoring?
Nothing at all.
But it has everything to do
With faith and hope
And colors and celebrations
And imagination.
After all, that is what
Christmas is all about.
Put this in your Christmas stocking,
And in your Santa Claus hat,
Take the day off from doctor thoughts,
And think like a child.
After all, it is their day.
Christmas is green.
And not for the reason you think
It is Green because it is Green.
This is simply a matter of fact.
It is ridiculous to ask why.
Oh, I know some say it is White.
Some even say it is Blue.
While others claim it is Red.
These people are wrong.
White is New Year’s Day.
Blue is reserved for Columbus Day
Because he sailed the Ocean Blue.
And the Fourth of July is Red,
A Hot Red, a Glorious Red.
A Swinging, Beautiful, Sunset Red.
What about Brown?
Could Christmas be Brown?
No, Brown is Thanksgiving.
Thanksgiving looks, smells, and sounds Brown,
A Glowing, Lush, Golden Brown.
Of course, Labor Day is Gray.
What other color could it be?
It sounds correct, and it is correct.
Besides there is no other Holiday
That is remotely Gray.
Not Washington’s or Lincoln’s birthdays,
Which are respectively Purple and Black.
And so all most Holidays are accounted for,
Except Easter, Memorial Day,
And Martin Luther King Day..
Easter as everybody knows is Yellow,
A Kight Yellow, almost a White Yellow.
Some uniformed people say Easter is Pink,
But these people are uniformed.
And what about Memorial Day?
Undoubtedly that day is Orchid,
A mixture of sadness and gladness
And Red and White and Blue
So Orchid Memorial Day is,
Martin Luther King Day?
Blue Black overcast with Gray.
And so by logical exclusion
In your differential diagnosis,
That leaves Green for Christmas.
What does all of this have to do with doctoring?
Nothing at all.
But it has everything to do
With faith and hope
And colors and celebrations
And imagination.
After all, that is what
Christmas is all about.
Sunday, December 23, 2007
U.S. Health Care System - Reflections on Commonwealth Fund Report
I’m leery of think-tank pronouncements. The latest report of the Commonwealth Fund, a New York City think tank, Bending the Curve: Options for Achieving and Improving Value in Health Spending, is such a pronouncement.
Here are the words expressing four highlights of the report in bold print of the Commonwealth Fund press release with my reflections in italics.
1. Information Technology: With an initial increase in investment, $88 billion could be saved by accelerating health care providers' adoption of health information technology that would allow them to share all patient health information with the other health care providers involved in the patient's care.
The operative words here are “could” and “accelerate.” Health IT could save $88 billion and could improve care. But will it? Present evidence indicates EMRs don’t ensure quality and are no better than paper-based systems (Linder, J.A., Electronic Health Records Use and the Quality of Ambulatory Care in the United States, Arch Int Med, 2007: volume 167, pages 1400- 1405). After 5 years of electronic records being promoted as the Holy Grail, only 5% of hospitals, 10-15% of practitioners have EMRs, and less than 5% of patients own patient health records (PHRs). Why the hold up? Well, for clinicians, it’s a combination of excessive expense, practice disruption, lack of return on investment, suspicion data will be used against them, clinical clumsiness trying to use EMRS during patient exams. Besides, where’s the money coming from, roughly $100 billion, it would take to install system integrating IT systems for the nation’s 5000 hospitals, 750.000 doctors, and 300 million patients?
2. Center for Medical Effectiveness and Health Care Decision-Making: Investing in the knowledge needed to improve health care decision-making; incorporating information about relative clinical and cost effectiveness into insurance benefit design; and including incentives for providers, payers and consumers to use this information. An estimated $368 billion could be saved by all payers over ten years.
Among policy wonks, the view persists computer-guided artificial intelligence can mimic clinical care, interpret nuances of patient-doctor interaction, dictate tests or procedures to perform, predict their relative effectiveness, and substitute and augment clinical judgment. That these functions can save money is unproven. In Minnesota, a state dedicated to creating a statewide record system by 2015, health costs are out of control- in a state of 3.8 million, 1.1 million Minnesotans expect to pay 10% of their pre-tax income for health benefits next year, and for a quarter of residents, the cost will be 25% of pretax income
(“Healthcare Takes a Hefty Bite out of Minnesotan’s Income,” Star Tribune, December 20, 2007)
3. Public Health - Reducing Tobacco Use: Increasing federal taxes on tobacco products by $2 per pack of cigarettes, with revenues to support national and state tobacco programs, could yield an estimated $191 billion savings over 10 years, shared by all payers.
Over the last 50 years, cigarette use has dropped from 50% to 20% thanks to public awareness of tobacco hazards. Further strategies such as a $2 a pack tax, raising premiums on tobacco users, outlawing use in public and private places, not employing smokers, and making smokers persona non grata in the media, may further reduce smoking use. These may be good things to do. But keep in mind that America is a democracy, not a nanny or a police state, where freedom and choice and even bad behavior reign. Behavioral intervention by government has limits in a democracy.
3. Strengthen Primary Care and Care Coordination: Improving Medicare reimbursements to primary care physician practices to support enhanced primary care services, such as care coordination, care management, and easy access to care. Such a "medical home" approach could result in net health system savings of $194 billion over 10 years if all Medicare fee-for-service beneficiaries were enrolled. Estimated national savings would be larger if this approach were adopted by all payers.
This will be hard to do. Barriers are significant and hidden in plain sight. Medical students are no fools, and they can plainly see primary care departments have a second rate status in academic medical centers and specialists have twice to the income of primary care physicians, Besides, the present RBRVS payment system favors sub-specialists, managed care gatekeeper systems have failed, and Medicare data indicates chronically ill Americans see 6 to 8 specialists each year in addition to primary care doctors. Because of lack of incentives embedded in the American medical education system and the preference of our culture or specialists, the primary care supply is likely to continue to dwindle.
Here are the words expressing four highlights of the report in bold print of the Commonwealth Fund press release with my reflections in italics.
1. Information Technology: With an initial increase in investment, $88 billion could be saved by accelerating health care providers' adoption of health information technology that would allow them to share all patient health information with the other health care providers involved in the patient's care.
The operative words here are “could” and “accelerate.” Health IT could save $88 billion and could improve care. But will it? Present evidence indicates EMRs don’t ensure quality and are no better than paper-based systems (Linder, J.A., Electronic Health Records Use and the Quality of Ambulatory Care in the United States, Arch Int Med, 2007: volume 167, pages 1400- 1405). After 5 years of electronic records being promoted as the Holy Grail, only 5% of hospitals, 10-15% of practitioners have EMRs, and less than 5% of patients own patient health records (PHRs). Why the hold up? Well, for clinicians, it’s a combination of excessive expense, practice disruption, lack of return on investment, suspicion data will be used against them, clinical clumsiness trying to use EMRS during patient exams. Besides, where’s the money coming from, roughly $100 billion, it would take to install system integrating IT systems for the nation’s 5000 hospitals, 750.000 doctors, and 300 million patients?
2. Center for Medical Effectiveness and Health Care Decision-Making: Investing in the knowledge needed to improve health care decision-making; incorporating information about relative clinical and cost effectiveness into insurance benefit design; and including incentives for providers, payers and consumers to use this information. An estimated $368 billion could be saved by all payers over ten years.
Among policy wonks, the view persists computer-guided artificial intelligence can mimic clinical care, interpret nuances of patient-doctor interaction, dictate tests or procedures to perform, predict their relative effectiveness, and substitute and augment clinical judgment. That these functions can save money is unproven. In Minnesota, a state dedicated to creating a statewide record system by 2015, health costs are out of control- in a state of 3.8 million, 1.1 million Minnesotans expect to pay 10% of their pre-tax income for health benefits next year, and for a quarter of residents, the cost will be 25% of pretax income
(“Healthcare Takes a Hefty Bite out of Minnesotan’s Income,” Star Tribune, December 20, 2007)
3. Public Health - Reducing Tobacco Use: Increasing federal taxes on tobacco products by $2 per pack of cigarettes, with revenues to support national and state tobacco programs, could yield an estimated $191 billion savings over 10 years, shared by all payers.
Over the last 50 years, cigarette use has dropped from 50% to 20% thanks to public awareness of tobacco hazards. Further strategies such as a $2 a pack tax, raising premiums on tobacco users, outlawing use in public and private places, not employing smokers, and making smokers persona non grata in the media, may further reduce smoking use. These may be good things to do. But keep in mind that America is a democracy, not a nanny or a police state, where freedom and choice and even bad behavior reign. Behavioral intervention by government has limits in a democracy.
3. Strengthen Primary Care and Care Coordination: Improving Medicare reimbursements to primary care physician practices to support enhanced primary care services, such as care coordination, care management, and easy access to care. Such a "medical home" approach could result in net health system savings of $194 billion over 10 years if all Medicare fee-for-service beneficiaries were enrolled. Estimated national savings would be larger if this approach were adopted by all payers.
This will be hard to do. Barriers are significant and hidden in plain sight. Medical students are no fools, and they can plainly see primary care departments have a second rate status in academic medical centers and specialists have twice to the income of primary care physicians, Besides, the present RBRVS payment system favors sub-specialists, managed care gatekeeper systems have failed, and Medicare data indicates chronically ill Americans see 6 to 8 specialists each year in addition to primary care doctors. Because of lack of incentives embedded in the American medical education system and the preference of our culture or specialists, the primary care supply is likely to continue to dwindle.
Friday, December 21, 2007
Reduce Malpractice Premiums: Show Plaintiff’s Bar You Mean Business
Everything must degenerate into work if anything is going to happen.
Peter F, Drucker, 1900-2006
In my last blog, I brought attention to the fact that the lowest malpractice premiums are in a tier of Northern Midwestern states – Minnesota, Wisconsin, Iowa, and the Dakotas.
As I looked at this 2007 data from the Medical Liability Monitor, I asked myself – Why does this swath of states have such low premiums?
Having spent 1975 to 1990 as editor of Minnesota Medicine, I decided to find out. I called Chuck Meyer, an internist who now serves as editor-in-chief of Minnesota Medicine. He referred me to Mark Odland, a surgeon at Hennepin County Medical Center who has assumed the role of Group Chairman of the Minnesota Medical Insurance Company (MMIC), which directs malpractice traffic for the Minnesota Medical Association.
Here's what Dr Odland said .
• One, malpractice premiums are low in Minnesota because MMIC, which has 101 employees, has very worked very hard for a number of years on programs to keep them low.
• Two, MMIC also manages the physician-directed malpractice businesses of Iowa, parts of Wisconsin, and the Dakotas.
• Three, MMIC defends all malpractice suits, no matter how small or how frivolous, for Minnesota and its sister states.
• Four, MMIC conducts “in-house” investigations of groups having malpractice problems and offers consulting services to practices belonging to the Minnesota Medical Association or sister state associations.
• Five, only 4 to 100 Minnesota physicians is currently being sued, down from 6 or 7 a decade ago.
• Six, lawyers win only 1 of 100 cases brought to trail, and MMIC wins 86 to 90% of cases reaching the courtroom.
• Seven, the rate of “outrageous : million dollar settlements for attorneys like Scruggs of Mississippi or Edwards of North Carolina is extremely low.
• Eight , the Minnesota Medical Association and MMIC conducts aggressive programs, often featuring EMRs and atlity, safety, and patient communication.
• Nine, the purpose of all of the above is to send a powerful message to the plaintiff’s bar that physicians mean business and are taking every measure to document what goes on between doctors and patient, to assure safety and quality, to investigate and defend every case (usually with internal personnel rather than hiring lawyers), and to always take a proactive role in bringing down malpractice claims and settlements.
• Ten , MMIC is working because MMIC works hard at challenging lawyers. The attitude seems to be, “We dare you to make a claim and make it stick.”
What Dr. Odland is saying it this: to lower malpractice premiums, raise the bar to the bar, i.e. raise the price of failure to execute a successful malpractice claim.
Peter F, Drucker, 1900-2006
In my last blog, I brought attention to the fact that the lowest malpractice premiums are in a tier of Northern Midwestern states – Minnesota, Wisconsin, Iowa, and the Dakotas.
As I looked at this 2007 data from the Medical Liability Monitor, I asked myself – Why does this swath of states have such low premiums?
Having spent 1975 to 1990 as editor of Minnesota Medicine, I decided to find out. I called Chuck Meyer, an internist who now serves as editor-in-chief of Minnesota Medicine. He referred me to Mark Odland, a surgeon at Hennepin County Medical Center who has assumed the role of Group Chairman of the Minnesota Medical Insurance Company (MMIC), which directs malpractice traffic for the Minnesota Medical Association.
Here's what Dr Odland said .
• One, malpractice premiums are low in Minnesota because MMIC, which has 101 employees, has very worked very hard for a number of years on programs to keep them low.
• Two, MMIC also manages the physician-directed malpractice businesses of Iowa, parts of Wisconsin, and the Dakotas.
• Three, MMIC defends all malpractice suits, no matter how small or how frivolous, for Minnesota and its sister states.
• Four, MMIC conducts “in-house” investigations of groups having malpractice problems and offers consulting services to practices belonging to the Minnesota Medical Association or sister state associations.
• Five, only 4 to 100 Minnesota physicians is currently being sued, down from 6 or 7 a decade ago.
• Six, lawyers win only 1 of 100 cases brought to trail, and MMIC wins 86 to 90% of cases reaching the courtroom.
• Seven, the rate of “outrageous : million dollar settlements for attorneys like Scruggs of Mississippi or Edwards of North Carolina is extremely low.
• Eight , the Minnesota Medical Association and MMIC conducts aggressive programs, often featuring EMRs and atlity, safety, and patient communication.
• Nine, the purpose of all of the above is to send a powerful message to the plaintiff’s bar that physicians mean business and are taking every measure to document what goes on between doctors and patient, to assure safety and quality, to investigate and defend every case (usually with internal personnel rather than hiring lawyers), and to always take a proactive role in bringing down malpractice claims and settlements.
• Ten , MMIC is working because MMIC works hard at challenging lawyers. The attitude seems to be, “We dare you to make a claim and make it stick.”
What Dr. Odland is saying it this: to lower malpractice premiums, raise the bar to the bar, i.e. raise the price of failure to execute a successful malpractice claim.
Thursday, December 20, 2007
Malpractice Picture Brightens
Physicians’ greatest fear, dread, and anger focuses on frivolous malpractice suits and high malpractice premiums that ensue.
Things may getting better. According to The American Medical News, there’s room for optimism as 84% of liability companies reported in 2007 rates held steady or dropped,
But rates remain sky-high in certain markets. Furthermore, national tort reform is unlikely. So are reduced rates in high risk cities.
The 2007 Medical Liability Monitor Rate Survey indicates wide regional variations among states.
• Highest rates for internists ($68,867), general surgeons ($275, 466), and Ob-Gyns ($275,466), are all in Dade Country, Florida.
• Lowest rates for internists ($3,375), general surgeons ($11,306), and Ob-Gyns ($20.626), are all in Minnesota.
• Besides Florida, states ranking in the top tier rates are Michigan (Wayne) , Illinois (Cook, Madison, St. Clair) and Ohio (Cuyahoga, Loraine)
• Besides Minnesota, states ranking in low tier are South Dakota, Wisconsin, and Iowa.
What’s going on here?
I suspect factors at work are, :
• Cultural. High rate states are crowded metropolitan regions with a mixed citizenry, while low rate states are more thinly populated, have more homogeneous populations, have higher society trust levels, and have citizens who are less inclined to litigate
• Reform based. This is noteworthy in Texas, where voters in 2003 passed a $250,000 non-economic damage cap as a constitutional amendment. Ob-Gyns in Texas now have rates $26,516, a drop of 5.7% from 2006.
• Competition among medical liability companies increasingly offering credits and rebates to physician policy holders.
• A series of favorable court rulings in Ohio and Louisiana holding lawyers accountable for filing liability suits without merit. .
There may other factors as well. These vary from state to state and include:
• Risk-resource organizations in hospitals where doctors and the hospital partner in systematic programs to reduce risk.
• Formation of alternative risk reduction groups among doctor-led state medical society liability organizations.
• On-line services that make informed consent documentation routine and engage patients in the process.
• A general awareness among physicians of what it takes to reduce liability risks:
1) carefully documenting each patient encounter and doing it electronically;
2) providing patients with details of their visit before they leave the office:
3) communicating thoroughly through conversation and paper documentation;
4) having patients repeat what they have been told;
5) having patient sign informed consent waivers saying they won’t sue for frivolous reasons;
6) informing patients of risk through patient education materials;
7) systematically spotting potentially litiginous patients and handling them cautiously.
I spoke to Dr. Mark Odland, a surgeon at Hennepin County Medical Society and Group Chairman of the Minnesota Medical Insurance Company (MMIC), to ask why Minnesota has the lowest malpractice rates in the nation. He said it’s a combination of things – a culture of collegiality among doctors and society as a whole, more doctors practicing in large groups or in large organizations, and MMIC-sponsored aggressive programs focusing on reducing malpractice risks, patient safety, communication, and quality. In my next post, I will sum up my conversation with Dr. Odland.
Things may getting better. According to The American Medical News, there’s room for optimism as 84% of liability companies reported in 2007 rates held steady or dropped,
But rates remain sky-high in certain markets. Furthermore, national tort reform is unlikely. So are reduced rates in high risk cities.
The 2007 Medical Liability Monitor Rate Survey indicates wide regional variations among states.
• Highest rates for internists ($68,867), general surgeons ($275, 466), and Ob-Gyns ($275,466), are all in Dade Country, Florida.
• Lowest rates for internists ($3,375), general surgeons ($11,306), and Ob-Gyns ($20.626), are all in Minnesota.
• Besides Florida, states ranking in the top tier rates are Michigan (Wayne) , Illinois (Cook, Madison, St. Clair) and Ohio (Cuyahoga, Loraine)
• Besides Minnesota, states ranking in low tier are South Dakota, Wisconsin, and Iowa.
What’s going on here?
I suspect factors at work are, :
• Cultural. High rate states are crowded metropolitan regions with a mixed citizenry, while low rate states are more thinly populated, have more homogeneous populations, have higher society trust levels, and have citizens who are less inclined to litigate
• Reform based. This is noteworthy in Texas, where voters in 2003 passed a $250,000 non-economic damage cap as a constitutional amendment. Ob-Gyns in Texas now have rates $26,516, a drop of 5.7% from 2006.
• Competition among medical liability companies increasingly offering credits and rebates to physician policy holders.
• A series of favorable court rulings in Ohio and Louisiana holding lawyers accountable for filing liability suits without merit. .
There may other factors as well. These vary from state to state and include:
• Risk-resource organizations in hospitals where doctors and the hospital partner in systematic programs to reduce risk.
• Formation of alternative risk reduction groups among doctor-led state medical society liability organizations.
• On-line services that make informed consent documentation routine and engage patients in the process.
• A general awareness among physicians of what it takes to reduce liability risks:
1) carefully documenting each patient encounter and doing it electronically;
2) providing patients with details of their visit before they leave the office:
3) communicating thoroughly through conversation and paper documentation;
4) having patients repeat what they have been told;
5) having patient sign informed consent waivers saying they won’t sue for frivolous reasons;
6) informing patients of risk through patient education materials;
7) systematically spotting potentially litiginous patients and handling them cautiously.
I spoke to Dr. Mark Odland, a surgeon at Hennepin County Medical Society and Group Chairman of the Minnesota Medical Insurance Company (MMIC), to ask why Minnesota has the lowest malpractice rates in the nation. He said it’s a combination of things – a culture of collegiality among doctors and society as a whole, more doctors practicing in large groups or in large organizations, and MMIC-sponsored aggressive programs focusing on reducing malpractice risks, patient safety, communication, and quality. In my next post, I will sum up my conversation with Dr. Odland.
Saturday, December 15, 2007
Sermo - Ten Things I’ve Learned from Sermo Doctors
A Sermo loyalist recently said Google, Sermo, and Wikipedia were three websites he consulted most.
Based on six months of contributing to Sermo posts and reading the feedback and blowback, I agree with the reader on Sermo. I also like the other two, and would throw in Healthleadersmedia.com as a fourth choice.
The learning has come from the heat – criticisms with what I had to say, and the humility – finding what I had to say didn’t make much sense. For me, it’s the heat, not the humility.
My interest is medical innovation, what doctors can do to survive and thrive and improve care and outcomes.
Here are ten things I’ve learned from Sermo.
Doctors prefer,
One, the technological to the ideological. I should have known this. In 2001, 225 internists were asked what the ten most important innovations during the last 20 years.
The top ten choices were:
1) MRI and CT scanning
2) ACE inhibitors and angiotensin antagonists
3) Coronary stents
4) Statins
5) Mammography
6) CABG
7) Proton pump inhibitors
8) SSRIs
9) Cataract extraction and lens implant
10) Hip and knee replacements.
Two, the democratic to the autocratic. Doctors obsess on
what they can do on the ground not on how to react to what flows down from government or health plans.
Three. the clinical to the managerial. In sheer numbers, clinical posts and comments dominate Sermo. Doctors prefer to talk of what they do, not what government agencies, health plan medical directors, or practice managers tell them to do. The lesson for me: don’t wander too far off the clinical reservation.
Four, teaching to preaching. Doctors love to teach each other, to share experiences rather than being preached to. When I get preachy about reform or some other matter from on high, my Sermo ranking plummets.
Five, performing to reforming. Doctors have solid and specific ideas on how to reform the system, but they prefer to talk about how best to perform in the clinical trenches.
Six, the pragmatic to the axiomatic. When outsiders proclaim doctors must do things according to protocol, :doctors respond by saying I will do it the best way that fits my patient’s circumstances.
Seven, patient chronologies to informational technologies. Doctors remain skeptical of IT, diagnostic support systems, or electronic and personal records, as practical or universal substitutes for their personal knowledge of patients.
Eight, pen on paper to finger on keyboard. Many doctors say they think better through the head of a pen than the tap of a key. It’s more human, and patients consider it more personal. Patients detest having a computer between them and their doctor.
Nine, patients rather than health plans. For years, doctors have been tangoing with health plans on who should control care. Doctors prefer dealing directly with paying patients rather than being paid indirectly on not at all through third parties.
Ten, clarity, verity, and parity between market and government driven care to ideological purity. Doctors recognize Medicare and Medicaid have been a God-send to many Americans, but we also know the market brings innovation, choice, and freedom. We’re healers, not conservatives or liberals.
Based on six months of contributing to Sermo posts and reading the feedback and blowback, I agree with the reader on Sermo. I also like the other two, and would throw in Healthleadersmedia.com as a fourth choice.
The learning has come from the heat – criticisms with what I had to say, and the humility – finding what I had to say didn’t make much sense. For me, it’s the heat, not the humility.
My interest is medical innovation, what doctors can do to survive and thrive and improve care and outcomes.
Here are ten things I’ve learned from Sermo.
Doctors prefer,
One, the technological to the ideological. I should have known this. In 2001, 225 internists were asked what the ten most important innovations during the last 20 years.
The top ten choices were:
1) MRI and CT scanning
2) ACE inhibitors and angiotensin antagonists
3) Coronary stents
4) Statins
5) Mammography
6) CABG
7) Proton pump inhibitors
8) SSRIs
9) Cataract extraction and lens implant
10) Hip and knee replacements.
Two, the democratic to the autocratic. Doctors obsess on
what they can do on the ground not on how to react to what flows down from government or health plans.
Three. the clinical to the managerial. In sheer numbers, clinical posts and comments dominate Sermo. Doctors prefer to talk of what they do, not what government agencies, health plan medical directors, or practice managers tell them to do. The lesson for me: don’t wander too far off the clinical reservation.
Four, teaching to preaching. Doctors love to teach each other, to share experiences rather than being preached to. When I get preachy about reform or some other matter from on high, my Sermo ranking plummets.
Five, performing to reforming. Doctors have solid and specific ideas on how to reform the system, but they prefer to talk about how best to perform in the clinical trenches.
Six, the pragmatic to the axiomatic. When outsiders proclaim doctors must do things according to protocol, :doctors respond by saying I will do it the best way that fits my patient’s circumstances.
Seven, patient chronologies to informational technologies. Doctors remain skeptical of IT, diagnostic support systems, or electronic and personal records, as practical or universal substitutes for their personal knowledge of patients.
Eight, pen on paper to finger on keyboard. Many doctors say they think better through the head of a pen than the tap of a key. It’s more human, and patients consider it more personal. Patients detest having a computer between them and their doctor.
Nine, patients rather than health plans. For years, doctors have been tangoing with health plans on who should control care. Doctors prefer dealing directly with paying patients rather than being paid indirectly on not at all through third parties.
Ten, clarity, verity, and parity between market and government driven care to ideological purity. Doctors recognize Medicare and Medicaid have been a God-send to many Americans, but we also know the market brings innovation, choice, and freedom. We’re healers, not conservatives or liberals.
Friday, December 14, 2007
Limits of Technology - Limits of Medical Intervention
Cholesterol Lowering and Obesity Control
The U.S. government estimates the mean cholesterol of the typical adult American has dropped to 199 from about 210 a decade ago. This drop is attributed to increased public awareness of dangers of high cholesterol levels, to 60% of 70% Americans knowing their cholesterol levels, and to millions of Americans being on statins such as Lipitor, the all-time best selling drug, with $80 billion of prescriptions sold in the last 20 years.
But while we may be winning the fight to lower cholesterol, we’re losing the battle against obesity. According to the Center of Disease Control and Prevention, the average weight for men in the U.S. increased by 24 pounds from 1960 to 2002, with similar increases in women. We’re fast becoming a nation of fatties.
In a book review of Obesity : Epidemiology, Pathophysiology, and Prevention, CRC Press, 2007), Margo Denke, MD, of the University of Texas in San Antonio, remarks,
Obesity is an appropriate target for intervention, and one would have thought that almost any weapon would help to make us a worthy opponent of the enemy. But clinicians have been humbled by obesity. Each new inroad researchers have made into understanding the mechanism of obesity appears to been met with yet another battalion in the enemy’s army. Our efforts to manage obesity have been soundly defeated.
Today men are consuming 7% more calories, and women 24% more calories than in yesteryear. Food is often downed as an afterthought, as an escape from the pell-mell rush of American life. Labor saving devices, fast food consumption, large restaurant portions, sedentary time before TV and computer screens, lack of exercise, and door to door car transit – all beyond physician control – make for formidable obstacles to overcome.
The answer to obesity comes down to social and personal responsibility, often among parents. Adolescent obesity is on a rampage and will almost certainly overcome the benefits of lowering cholesterol in reducing coronary artery disease (“Adolescent Overweight and Future Adult Coronary Disease,” NEJM, December 6, 2007).
Maybe the pharmaceutical industry will come up with a blockbuster drug to defeat obesity, as Merck and others are striving to do, but chances of developing such a drug based on new chemical manipulation seem remote, as the industry lays off chemists (“As Drug Industry Struggles, Chemists Face Layoffs,” Dec. 11, WSJ, “Big Pharma Faces Grim Prognosis, Dec, 6, WSJ), as the industry fails in its quest to find new wonder drugs like Lipitor based on reshuffling of existing chemical compounds.
Perhaps doctors will find a way to quell the epidemic through patient education and counseling, but I doubt it. As we all know, the problem is cultural and societal, not medical. The question is; How can doctors help persuade people from digging their graves with their own teeth? I don’t have an answer, or a set of answers, do you?
The U.S. government estimates the mean cholesterol of the typical adult American has dropped to 199 from about 210 a decade ago. This drop is attributed to increased public awareness of dangers of high cholesterol levels, to 60% of 70% Americans knowing their cholesterol levels, and to millions of Americans being on statins such as Lipitor, the all-time best selling drug, with $80 billion of prescriptions sold in the last 20 years.
But while we may be winning the fight to lower cholesterol, we’re losing the battle against obesity. According to the Center of Disease Control and Prevention, the average weight for men in the U.S. increased by 24 pounds from 1960 to 2002, with similar increases in women. We’re fast becoming a nation of fatties.
In a book review of Obesity : Epidemiology, Pathophysiology, and Prevention, CRC Press, 2007), Margo Denke, MD, of the University of Texas in San Antonio, remarks,
Obesity is an appropriate target for intervention, and one would have thought that almost any weapon would help to make us a worthy opponent of the enemy. But clinicians have been humbled by obesity. Each new inroad researchers have made into understanding the mechanism of obesity appears to been met with yet another battalion in the enemy’s army. Our efforts to manage obesity have been soundly defeated.
Today men are consuming 7% more calories, and women 24% more calories than in yesteryear. Food is often downed as an afterthought, as an escape from the pell-mell rush of American life. Labor saving devices, fast food consumption, large restaurant portions, sedentary time before TV and computer screens, lack of exercise, and door to door car transit – all beyond physician control – make for formidable obstacles to overcome.
The answer to obesity comes down to social and personal responsibility, often among parents. Adolescent obesity is on a rampage and will almost certainly overcome the benefits of lowering cholesterol in reducing coronary artery disease (“Adolescent Overweight and Future Adult Coronary Disease,” NEJM, December 6, 2007).
Maybe the pharmaceutical industry will come up with a blockbuster drug to defeat obesity, as Merck and others are striving to do, but chances of developing such a drug based on new chemical manipulation seem remote, as the industry lays off chemists (“As Drug Industry Struggles, Chemists Face Layoffs,” Dec. 11, WSJ, “Big Pharma Faces Grim Prognosis, Dec, 6, WSJ), as the industry fails in its quest to find new wonder drugs like Lipitor based on reshuffling of existing chemical compounds.
Perhaps doctors will find a way to quell the epidemic through patient education and counseling, but I doubt it. As we all know, the problem is cultural and societal, not medical. The question is; How can doctors help persuade people from digging their graves with their own teeth? I don’t have an answer, or a set of answers, do you?
Thursday, December 13, 2007
U.S. Health Care System - Is American Health Care Manageable?
I see in the December 13th New England Journal of Medicine that Alain Enthoven, the Stanford economist who inspired Hillary Clinton’s failed managed-competition plan in 1993-1994 is at it again. This time he’s proposing America emulate the Dutch plan (“Going Dutch—Managed-Competition Health Insurance in the Netherlands”).
Enthoven’s thoughts brought to mind something I wrote back in 2005 in Voices of Health Reform after interviewing 42 “experts” on health reform.
Americans, I said, are individualistic, pro-opportunity, pro-democracy, and anti-government. These attitudes, I added may explain why Americans:
• prefer local health solutions,
• reject federally-mandated coverage with inevitable rationing,
• feel capable of making their own health care decisions,
• seek equal opportunity access to high technologies,
• prefer pluralistic payment systems,
• allow market-based and public-based institutions to co-exist and compete,
• let doctors, hospitals, and health plans act independently from government..
Elites run our dominant institutions. Their opinions don’t necessarily coincide with those of the general public. Liberal elites think we ought to have universal mandatory coverage with government making basic decisions; conservative elites think we ought to have a market-driven care with patients and doctors making decisions.. Elites on both sides control media information supplied to citizens.
Personally I wonder if this mix is manageable and if it can possibly end with a “unitary” health system. Meanwhile the rest of the civilized world wonders why affluent America doesn’t have a system that covers everyone.
Recently I ran across a book The Eagle’s Shadow: Why America Fascinates and Infuriates The World (Farrar, Straus and Giroux, 2002). The author, Mark Hertsgaard, a well-traveled journalist who has interviewed countless foreigners what they think about America, says the following reflects what others think of us.
1. America is parochial and self-centered – In health care, for example, we don’t necessarily care what others think of us.
2. America is rich and exciting – Our health system interests them because it generates most of the world’s new innovations in the realm of acute care and “medical miracles.”
3. America is the land of freedom – That’s why so many foreign physicians come to America to train and to practice, and once here, often stoutly defend America’s approach to health care.
4. America is an empire—We are hypocritical, dominant, and domineering, not our most endearing traits.
5. America is naïve about the rest of the world – Two oceans insulate us, we listen, only to our own media, and we don’t speak other people’s languages.
6. American is philistine – We;e materialistic to a fault and indifferent to the rest of the world.
7. America is the land of opportunity – We attract 85% of the world’s immigrants and generate much of the world’s wealth (and its pollution).
8. America is self-righteous about its democracy - We think we have all the answers despite our many faults.
9. America is the future - America’s arts, movies, news, Internet, and technologies set the pace for the rest of the world.
10. America is out for itself – We may proclaim ourselves as generous but down deep we’re greedy.
A national health policy might settle a couple of things. There might finally be unity in health care in the American Republic, and the old theory of states having the right to impose mandates (There are more than 1000 in individual states, including 83 in Minnesota alone) might wither away. Also people ought to able to shop across state lines for health policies anywhere in the union as advocated by the Council for Affordable Health Care (“A Health-Care Solution,” WSJ, December 12, 2007). This would do away with such abominations as the cheapest family health plan costing $20,000 in New Jersey while being available at 1/3 that cost in neighboring Pennsylvania).
My own view is we’ll muddle along. We’ll manage. In the end, we’ll do the right thing –having choice and affordability for all.
Is American Health Care Manageable?
I see in the December 13th New England Journal of Medicine that Alain Enthoven, the Stanford economist who inspired Hillary Clinton’s failed managed-competition plan in 1993-1994 is at it again. This time he’s proposing America emulate the Dutch plan (“Going Dutch—Managed-Competition Health Insurance in the Netherlands”).
Enthoven’s thoughts brought to mind something I wrote back in 2005 in Voices of Health Reform after interviewing 42 “experts” on health reform.
Americans, I said, are individualistic, pro-opportunity, pro-democracy, and anti-government. These attitudes, I added may explain why Americans:
• prefer local health solutions,
• reject federally-mandated coverage with inevitable rationing,
• feel capable of making their own health care decisions,
• seek equal opportunity access to high technologies,
• prefer pluralistic payment systems,
• allow market-based and public-based institutions to co-exist and compete,
• let doctors, hospitals, and health plans act independently from government..
Elites run our dominant institutions. Their opinions don’t necessarily coincide with those of the general public. Liberal elites think we ought to have universal mandatory coverage with government making basic decisions; conservative elites think we ought to have a market-driven care with patients and doctors making decisions.. Elites on both sides control media information supplied to citizens.
Personally I wonder if this mix is manageable and if it can possibly end with a “unitary” health system. Meanwhile the rest of the civilized world wonders why affluent America doesn’t have a system that covers everyone.
Recently I ran across a book The Eagle’s Shadow: Why America Fascinates and Infuriates The World (Farrar, Straus and Giroux, 2002). The author, Mark Hertsgaard, a well-traveled journalist who has interviewed countless foreigners what they think about America, says the following reflects what others think of us.
1. America is parochial and self-centered – In health care, for example, we don’t necessarily care what others think of us.
2. America is rich and exciting – Our health system interests them because it generates most of the world’s new innovations in the realm of acute care and “medical miracles.”
3. America is the land of freedom – That’s why so many foreign physicians come to America to train and to practice, and once here, often stoutly defend America’s approach to health care.
4. America is an empire—We are hypocritical, dominant, and domineering, not our most endearing traits.
5. America is naïve about the rest of the world – Two oceans insulate us, we listen, only to our own media, and we don’t speak other people’s languages.
6. American is philistine – We;e materialistic to a fault and indifferent to the rest of the world.
7. America is the land of opportunity – We attract 85% of the world’s immigrants and generate much of the world’s wealth (and its pollution).
8. America is self-righteous about its democracy - We think we have all the answers despite our many faults.
9. America is the future - America’s arts, movies, news, Internet, and technologies set the pace for the rest of the world.
10. America is out for itself – We may proclaim ourselves as generous but down deep we’re greedy.
A national health policy might settle a couple of things. There might finally be unity in health care in the American Republic, and the old theory of states having the right to impose mandates (There are more than 1000 in individual states, including 83 in Minnesota alone) might wither away. Also people ought to able to shop across state lines for health policies anywhere in the union as advocated by the Council for Affordable Health Care (“A Health-Care Solution,” WSJ, December 12, 2007). This would do away with such abominations as the cheapest family health plan costing $20,000 in New Jersey while being available at 1/3 that cost in neighboring Pennsylvania).
My own view is we’ll muddle along. We’ll manage. In the end, we’ll do the right thing –having choice and affordability for all.
I see in the December 13th New England Journal of Medicine that Alain Enthoven, the Stanford economist who inspired Hillary Clinton’s failed managed-competition plan in 1993-1994 is at it again. This time he’s proposing America emulate the Dutch plan (“Going Dutch—Managed-Competition Health Insurance in the Netherlands”).
Enthoven’s thoughts brought to mind something I wrote back in 2005 in Voices of Health Reform after interviewing 42 “experts” on health reform.
Americans, I said, are individualistic, pro-opportunity, pro-democracy, and anti-government. These attitudes, I added may explain why Americans:
• prefer local health solutions,
• reject federally-mandated coverage with inevitable rationing,
• feel capable of making their own health care decisions,
• seek equal opportunity access to high technologies,
• prefer pluralistic payment systems,
• allow market-based and public-based institutions to co-exist and compete,
• let doctors, hospitals, and health plans act independently from government..
Elites run our dominant institutions. Their opinions don’t necessarily coincide with those of the general public. Liberal elites think we ought to have universal mandatory coverage with government making basic decisions; conservative elites think we ought to have a market-driven care with patients and doctors making decisions.. Elites on both sides control media information supplied to citizens.
Personally I wonder if this mix is manageable and if it can possibly end with a “unitary” health system. Meanwhile the rest of the civilized world wonders why affluent America doesn’t have a system that covers everyone.
Recently I ran across a book The Eagle’s Shadow: Why America Fascinates and Infuriates The World (Farrar, Straus and Giroux, 2002). The author, Mark Hertsgaard, a well-traveled journalist who has interviewed countless foreigners what they think about America, says the following reflects what others think of us.
1. America is parochial and self-centered – In health care, for example, we don’t necessarily care what others think of us.
2. America is rich and exciting – Our health system interests them because it generates most of the world’s new innovations in the realm of acute care and “medical miracles.”
3. America is the land of freedom – That’s why so many foreign physicians come to America to train and to practice, and once here, often stoutly defend America’s approach to health care.
4. America is an empire—We are hypocritical, dominant, and domineering, not our most endearing traits.
5. America is naïve about the rest of the world – Two oceans insulate us, we listen, only to our own media, and we don’t speak other people’s languages.
6. American is philistine – We;e materialistic to a fault and indifferent to the rest of the world.
7. America is the land of opportunity – We attract 85% of the world’s immigrants and generate much of the world’s wealth (and its pollution).
8. America is self-righteous about its democracy - We think we have all the answers despite our many faults.
9. America is the future - America’s arts, movies, news, Internet, and technologies set the pace for the rest of the world.
10. America is out for itself – We may proclaim ourselves as generous but down deep we’re greedy.
A national health policy might settle a couple of things. There might finally be unity in health care in the American Republic, and the old theory of states having the right to impose mandates (There are more than 1000 in individual states, including 83 in Minnesota alone) might wither away. Also people ought to able to shop across state lines for health policies anywhere in the union as advocated by the Council for Affordable Health Care (“A Health-Care Solution,” WSJ, December 12, 2007). This would do away with such abominations as the cheapest family health plan costing $20,000 in New Jersey while being available at 1/3 that cost in neighboring Pennsylvania).
My own view is we’ll muddle along. We’ll manage. In the end, we’ll do the right thing –having choice and affordability for all.
Enthoven’s thoughts brought to mind something I wrote back in 2005 in Voices of Health Reform after interviewing 42 “experts” on health reform.
Americans, I said, are individualistic, pro-opportunity, pro-democracy, and anti-government. These attitudes, I added may explain why Americans:
• prefer local health solutions,
• reject federally-mandated coverage with inevitable rationing,
• feel capable of making their own health care decisions,
• seek equal opportunity access to high technologies,
• prefer pluralistic payment systems,
• allow market-based and public-based institutions to co-exist and compete,
• let doctors, hospitals, and health plans act independently from government..
Elites run our dominant institutions. Their opinions don’t necessarily coincide with those of the general public. Liberal elites think we ought to have universal mandatory coverage with government making basic decisions; conservative elites think we ought to have a market-driven care with patients and doctors making decisions.. Elites on both sides control media information supplied to citizens.
Personally I wonder if this mix is manageable and if it can possibly end with a “unitary” health system. Meanwhile the rest of the civilized world wonders why affluent America doesn’t have a system that covers everyone.
Recently I ran across a book The Eagle’s Shadow: Why America Fascinates and Infuriates The World (Farrar, Straus and Giroux, 2002). The author, Mark Hertsgaard, a well-traveled journalist who has interviewed countless foreigners what they think about America, says the following reflects what others think of us.
1. America is parochial and self-centered – In health care, for example, we don’t necessarily care what others think of us.
2. America is rich and exciting – Our health system interests them because it generates most of the world’s new innovations in the realm of acute care and “medical miracles.”
3. America is the land of freedom – That’s why so many foreign physicians come to America to train and to practice, and once here, often stoutly defend America’s approach to health care.
4. America is an empire—We are hypocritical, dominant, and domineering, not our most endearing traits.
5. America is naïve about the rest of the world – Two oceans insulate us, we listen, only to our own media, and we don’t speak other people’s languages.
6. American is philistine – We;e materialistic to a fault and indifferent to the rest of the world.
7. America is the land of opportunity – We attract 85% of the world’s immigrants and generate much of the world’s wealth (and its pollution).
8. America is self-righteous about its democracy - We think we have all the answers despite our many faults.
9. America is the future - America’s arts, movies, news, Internet, and technologies set the pace for the rest of the world.
10. America is out for itself – We may proclaim ourselves as generous but down deep we’re greedy.
A national health policy might settle a couple of things. There might finally be unity in health care in the American Republic, and the old theory of states having the right to impose mandates (There are more than 1000 in individual states, including 83 in Minnesota alone) might wither away. Also people ought to able to shop across state lines for health policies anywhere in the union as advocated by the Council for Affordable Health Care (“A Health-Care Solution,” WSJ, December 12, 2007). This would do away with such abominations as the cheapest family health plan costing $20,000 in New Jersey while being available at 1/3 that cost in neighboring Pennsylvania).
My own view is we’ll muddle along. We’ll manage. In the end, we’ll do the right thing –having choice and affordability for all.
Is American Health Care Manageable?
I see in the December 13th New England Journal of Medicine that Alain Enthoven, the Stanford economist who inspired Hillary Clinton’s failed managed-competition plan in 1993-1994 is at it again. This time he’s proposing America emulate the Dutch plan (“Going Dutch—Managed-Competition Health Insurance in the Netherlands”).
Enthoven’s thoughts brought to mind something I wrote back in 2005 in Voices of Health Reform after interviewing 42 “experts” on health reform.
Americans, I said, are individualistic, pro-opportunity, pro-democracy, and anti-government. These attitudes, I added may explain why Americans:
• prefer local health solutions,
• reject federally-mandated coverage with inevitable rationing,
• feel capable of making their own health care decisions,
• seek equal opportunity access to high technologies,
• prefer pluralistic payment systems,
• allow market-based and public-based institutions to co-exist and compete,
• let doctors, hospitals, and health plans act independently from government..
Elites run our dominant institutions. Their opinions don’t necessarily coincide with those of the general public. Liberal elites think we ought to have universal mandatory coverage with government making basic decisions; conservative elites think we ought to have a market-driven care with patients and doctors making decisions.. Elites on both sides control media information supplied to citizens.
Personally I wonder if this mix is manageable and if it can possibly end with a “unitary” health system. Meanwhile the rest of the civilized world wonders why affluent America doesn’t have a system that covers everyone.
Recently I ran across a book The Eagle’s Shadow: Why America Fascinates and Infuriates The World (Farrar, Straus and Giroux, 2002). The author, Mark Hertsgaard, a well-traveled journalist who has interviewed countless foreigners what they think about America, says the following reflects what others think of us.
1. America is parochial and self-centered – In health care, for example, we don’t necessarily care what others think of us.
2. America is rich and exciting – Our health system interests them because it generates most of the world’s new innovations in the realm of acute care and “medical miracles.”
3. America is the land of freedom – That’s why so many foreign physicians come to America to train and to practice, and once here, often stoutly defend America’s approach to health care.
4. America is an empire—We are hypocritical, dominant, and domineering, not our most endearing traits.
5. America is naïve about the rest of the world – Two oceans insulate us, we listen, only to our own media, and we don’t speak other people’s languages.
6. American is philistine – We;e materialistic to a fault and indifferent to the rest of the world.
7. America is the land of opportunity – We attract 85% of the world’s immigrants and generate much of the world’s wealth (and its pollution).
8. America is self-righteous about its democracy - We think we have all the answers despite our many faults.
9. America is the future - America’s arts, movies, news, Internet, and technologies set the pace for the rest of the world.
10. America is out for itself – We may proclaim ourselves as generous but down deep we’re greedy.
A national health policy might settle a couple of things. There might finally be unity in health care in the American Republic, and the old theory of states having the right to impose mandates (There are more than 1000 in individual states, including 83 in Minnesota alone) might wither away. Also people ought to able to shop across state lines for health policies anywhere in the union as advocated by the Council for Affordable Health Care (“A Health-Care Solution,” WSJ, December 12, 2007). This would do away with such abominations as the cheapest family health plan costing $20,000 in New Jersey while being available at 1/3 that cost in neighboring Pennsylvania).
My own view is we’ll muddle along. We’ll manage. In the end, we’ll do the right thing –having choice and affordability for all.
I see in the December 13th New England Journal of Medicine that Alain Enthoven, the Stanford economist who inspired Hillary Clinton’s failed managed-competition plan in 1993-1994 is at it again. This time he’s proposing America emulate the Dutch plan (“Going Dutch—Managed-Competition Health Insurance in the Netherlands”).
Enthoven’s thoughts brought to mind something I wrote back in 2005 in Voices of Health Reform after interviewing 42 “experts” on health reform.
Americans, I said, are individualistic, pro-opportunity, pro-democracy, and anti-government. These attitudes, I added may explain why Americans:
• prefer local health solutions,
• reject federally-mandated coverage with inevitable rationing,
• feel capable of making their own health care decisions,
• seek equal opportunity access to high technologies,
• prefer pluralistic payment systems,
• allow market-based and public-based institutions to co-exist and compete,
• let doctors, hospitals, and health plans act independently from government..
Elites run our dominant institutions. Their opinions don’t necessarily coincide with those of the general public. Liberal elites think we ought to have universal mandatory coverage with government making basic decisions; conservative elites think we ought to have a market-driven care with patients and doctors making decisions.. Elites on both sides control media information supplied to citizens.
Personally I wonder if this mix is manageable and if it can possibly end with a “unitary” health system. Meanwhile the rest of the civilized world wonders why affluent America doesn’t have a system that covers everyone.
Recently I ran across a book The Eagle’s Shadow: Why America Fascinates and Infuriates The World (Farrar, Straus and Giroux, 2002). The author, Mark Hertsgaard, a well-traveled journalist who has interviewed countless foreigners what they think about America, says the following reflects what others think of us.
1. America is parochial and self-centered – In health care, for example, we don’t necessarily care what others think of us.
2. America is rich and exciting – Our health system interests them because it generates most of the world’s new innovations in the realm of acute care and “medical miracles.”
3. America is the land of freedom – That’s why so many foreign physicians come to America to train and to practice, and once here, often stoutly defend America’s approach to health care.
4. America is an empire—We are hypocritical, dominant, and domineering, not our most endearing traits.
5. America is naïve about the rest of the world – Two oceans insulate us, we listen, only to our own media, and we don’t speak other people’s languages.
6. American is philistine – We;e materialistic to a fault and indifferent to the rest of the world.
7. America is the land of opportunity – We attract 85% of the world’s immigrants and generate much of the world’s wealth (and its pollution).
8. America is self-righteous about its democracy - We think we have all the answers despite our many faults.
9. America is the future - America’s arts, movies, news, Internet, and technologies set the pace for the rest of the world.
10. America is out for itself – We may proclaim ourselves as generous but down deep we’re greedy.
A national health policy might settle a couple of things. There might finally be unity in health care in the American Republic, and the old theory of states having the right to impose mandates (There are more than 1000 in individual states, including 83 in Minnesota alone) might wither away. Also people ought to able to shop across state lines for health policies anywhere in the union as advocated by the Council for Affordable Health Care (“A Health-Care Solution,” WSJ, December 12, 2007). This would do away with such abominations as the cheapest family health plan costing $20,000 in New Jersey while being available at 1/3 that cost in neighboring Pennsylvania).
My own view is we’ll muddle along. We’ll manage. In the end, we’ll do the right thing –having choice and affordability for all.
Tuesday, December 11, 2007
Coding, Physician Payment - The RUC (RVS Update Committee) Ruckus
RUC is short for RBVS Update Committee. Aticles have surfaced recently questioning whether the AMA has overloaded the RUC (whose members are not known) with subspecialists. Consequently, say critics, subspecialists may be rewarded at the expense of generalists.1-4
Here is what Dr. John Goodson, a Mass General Internist, says about the matter.
I am starting to believe that the distortions of physician reimbursement orchestrated behind the scenes by the shadowy RUC are one of the main reasons US health care is in such a mess. We had posted about the RUC, based on some important articles published this year that first brought its machinations to light (1, 2,3) 4
The story of the RUC often reminds me of conspiracy theories. They (we never really know who they are) determine the fate of the world (or at least the economy). The RUC has disproportionate power and has apparently taken a reasonable idea (RBRVS) and may have corrupted it.
I don’t have the knowledge to judge the merits of Goodson’s argument.
Here’s t the AMA says about the RUC’s composition:
Composition of the RVS Update Committee (RUC)
The RUC represents the entire medical profession, with 23 of its 29 members appointed by major national medical specialty societies including those recognized by the American Board of Medical Specialties, those with a large percentage of physicians in patient care, and those that account for high percentages of Medicare expenditures. Three seats rotate on a two-year basis, with two reserved for an internal medicine subspecialty and one for any other specialty. The RUC Chair, the Co-Chair of the RUC Health Care Professionals Advisory Committee Review Board, and representatives of the AMA, American Osteopathic Association, the Chair of the Practice Expense Review Committee and CPT Editorial Panel hold the remaining six seats. The AMA Board of Trustees selects the RUC chair and also the AMA representative to the RUC. The individual RUC members are nominated by the specialty societies and are approved by the AMA.
I do know this. Primary care is on the verge of collapse, and its practitioners are taking a series of steps to reinvent themselves - same day access, no phone trees when calls are made to the office, email consults, EMRs, and group visits. In high volume, low margin practices, these steps may not be enough if (and this is a very big if ) if reimbursement is skewed against primary care.
1. Bodenheimer T, Berenson RA, Rudolf P. The primary care-specialty income gap: why it matters. Ann Intern Med 2007; 146: 301-306..
2. Maxwell S, Zukcerman S, Berenson RA. Use of physicians' services under Medicare's resource-based payment system. N Engl J Med 2007; 356: 1853-1861.
3. Newhouse JP. Medicare spending on physicians - no easy fix in sight. N Engl J Med 2007; 356: 1883-1884.
4. Goodson JD. Unintended consequences of Resource-Based Relative Value Scale reimbursement. JAMA 2007; 298(19):2308-2310.
Here is what Dr. John Goodson, a Mass General Internist, says about the matter.
I am starting to believe that the distortions of physician reimbursement orchestrated behind the scenes by the shadowy RUC are one of the main reasons US health care is in such a mess. We had posted about the RUC, based on some important articles published this year that first brought its machinations to light (1, 2,3) 4
The story of the RUC often reminds me of conspiracy theories. They (we never really know who they are) determine the fate of the world (or at least the economy). The RUC has disproportionate power and has apparently taken a reasonable idea (RBRVS) and may have corrupted it.
I don’t have the knowledge to judge the merits of Goodson’s argument.
Here’s t the AMA says about the RUC’s composition:
Composition of the RVS Update Committee (RUC)
The RUC represents the entire medical profession, with 23 of its 29 members appointed by major national medical specialty societies including those recognized by the American Board of Medical Specialties, those with a large percentage of physicians in patient care, and those that account for high percentages of Medicare expenditures. Three seats rotate on a two-year basis, with two reserved for an internal medicine subspecialty and one for any other specialty. The RUC Chair, the Co-Chair of the RUC Health Care Professionals Advisory Committee Review Board, and representatives of the AMA, American Osteopathic Association, the Chair of the Practice Expense Review Committee and CPT Editorial Panel hold the remaining six seats. The AMA Board of Trustees selects the RUC chair and also the AMA representative to the RUC. The individual RUC members are nominated by the specialty societies and are approved by the AMA.
I do know this. Primary care is on the verge of collapse, and its practitioners are taking a series of steps to reinvent themselves - same day access, no phone trees when calls are made to the office, email consults, EMRs, and group visits. In high volume, low margin practices, these steps may not be enough if (and this is a very big if ) if reimbursement is skewed against primary care.
1. Bodenheimer T, Berenson RA, Rudolf P. The primary care-specialty income gap: why it matters. Ann Intern Med 2007; 146: 301-306..
2. Maxwell S, Zukcerman S, Berenson RA. Use of physicians' services under Medicare's resource-based payment system. N Engl J Med 2007; 356: 1853-1861.
3. Newhouse JP. Medicare spending on physicians - no easy fix in sight. N Engl J Med 2007; 356: 1883-1884.
4. Goodson JD. Unintended consequences of Resource-Based Relative Value Scale reimbursement. JAMA 2007; 298(19):2308-2310.
Monday, December 10, 2007
Medicare, Specialty Hospitals, Doctors and Hospitals - Congress Tries to Tie Medicare Cuts and Specialty Hospital Ownership
A December 9 article in the Washington Post, “Limits Weighted on Physician-Owned Hospitals: Lawmakers Seeing, Curbs on Specialty Facilities to Attach Provision to Medicare Bill,” indicates Congress are trying to tie together a 10.1% cut in Medicare fees, due to be voted on January 1, 2008, with the moratorium on physician owned specialty hospitals.
Congress is playing with market dynamite.
If Medicare cuts go through, AMA surveys indicate 30% of physicians may either close their practices to new Medicare patients or cut back on services. This is the market at work. If physicians can no longer afford to accept Medicare patients, they will simply stop accepting new patients. The cut may have political consequences as well as the rising gorge of aging baby boomers are unable to find a physician who will see them.
If the specialty hospital moratorium is renewed, the market consequences are less clear. The community hospital lobby argues specialists are ‘cherry picking’ profitable heart and orthopedic patients, thereby depriving hospitals of much needed revenue to treat less profitable patients. Specialists, who now “own” some 180 hospitals across the land, argue specialty hospitals provide better care of higher quality with better outcomes, and represent the market at work.
Senator Grassley, R-Iowa, who opposes doctor-owned hospitals, argues:
"My motivation for seeking reforms over a long period of time is the effect that specialty hospitals have on community hospitals when specialty hospitals pass the buck on emergency care and cherry-pick based on profits rather than patient needs."
Pete Stark, Democrat Representative from California, no friend of doctors, weighs in “The major hospitals are more or less being cannibalized.”
On the other side of debate are these statements:
"To say that competition in the hospital business is bad goes against all the factual information that we have," saya William G. Plested III, immediate past president of the AMA, which opposes ownership restrictions. "We have all kinds of data that show that if you have a specialty hospital open up, the first thing that the general hospital will do is to try to improve their quality to compete."
Badr Idbeis, co-founder of Kansas Heart Hospital and president of Cardiovascular Hospitals of America, complains traditional hospitals use their muscle to lure patients, negotiate exclusive agreements with insurers, and pressure doctors not to send patients elsewhere.
Idbeis says physician ownership will lure the best minds to medicine and ensure patient care trumps bureaucracy. Kansas Medical Center has at least one nurse for every four patients, he says, and the hospital has little administrative overhead.
"America made its greatness allowing the market to decide what works and what does not work," he said. "Obviously patients are getting very good care in our hospitals. We should let the market decide what's good and what's bad."
What do doctors outside the specialties involved in owning these facilities think about this issue? My take is that Medicare cuts, which involve all physicians, should not be tied to specialty hospital ownership, which involve only a few specialists.
Congress is playing with market dynamite.
If Medicare cuts go through, AMA surveys indicate 30% of physicians may either close their practices to new Medicare patients or cut back on services. This is the market at work. If physicians can no longer afford to accept Medicare patients, they will simply stop accepting new patients. The cut may have political consequences as well as the rising gorge of aging baby boomers are unable to find a physician who will see them.
If the specialty hospital moratorium is renewed, the market consequences are less clear. The community hospital lobby argues specialists are ‘cherry picking’ profitable heart and orthopedic patients, thereby depriving hospitals of much needed revenue to treat less profitable patients. Specialists, who now “own” some 180 hospitals across the land, argue specialty hospitals provide better care of higher quality with better outcomes, and represent the market at work.
Senator Grassley, R-Iowa, who opposes doctor-owned hospitals, argues:
"My motivation for seeking reforms over a long period of time is the effect that specialty hospitals have on community hospitals when specialty hospitals pass the buck on emergency care and cherry-pick based on profits rather than patient needs."
Pete Stark, Democrat Representative from California, no friend of doctors, weighs in “The major hospitals are more or less being cannibalized.”
On the other side of debate are these statements:
"To say that competition in the hospital business is bad goes against all the factual information that we have," saya William G. Plested III, immediate past president of the AMA, which opposes ownership restrictions. "We have all kinds of data that show that if you have a specialty hospital open up, the first thing that the general hospital will do is to try to improve their quality to compete."
Badr Idbeis, co-founder of Kansas Heart Hospital and president of Cardiovascular Hospitals of America, complains traditional hospitals use their muscle to lure patients, negotiate exclusive agreements with insurers, and pressure doctors not to send patients elsewhere.
Idbeis says physician ownership will lure the best minds to medicine and ensure patient care trumps bureaucracy. Kansas Medical Center has at least one nurse for every four patients, he says, and the hospital has little administrative overhead.
"America made its greatness allowing the market to decide what works and what does not work," he said. "Obviously patients are getting very good care in our hospitals. We should let the market decide what's good and what's bad."
What do doctors outside the specialties involved in owning these facilities think about this issue? My take is that Medicare cuts, which involve all physicians, should not be tied to specialty hospital ownership, which involve only a few specialists.
Sunday, December 9, 2007
Limits of Technology, Internet - Medicine Doesn't Run on Internet Time
The world now runs on Internet time.
Andy Grove, founder of Intel
Clinical medicine doesn’t run on Internet time. Health care needs are so intimate, strong, varied, and diverse with so many permutations and combinations that personal care has yet and may never yield completely to the Internet or to be dramatically improved by it.
My skepticism makes me one of a diminishing few. Others think the Internet will transform medicine. To explain how this might happen , IT professionals use the term “Killer Apps.” A Killer App, short for Killer Application, refers to any computer application of power, originality, or market reach that turns the world upside down.
Prime examples of killer apps include the Internet and Google. The latest example may be the laptop itself. If you’ve been following the news lately, you’ve no doubt heard of Nicholas Negroponte. He’s founder and chairman of the One Laptop per Child non-profit association.
Negropante believes dirt-cheap laptop computers, distributed to illiterate children in the developing world, will be a world-wide boon to education and a blessing to mankind. In the health care realm, some believe universal laptops, in the hands of Internet savvy clinicians, may revolutionize medicine But, in a foreword to Unleashing the Killer App, Negroponte cautions Internet applications are often simultaneously understated and over-hyped..
You can appreciate his comment about understatement when you consider the hoopla about electronic medicine. Consider EMRs, EHRs, e-prescribing, telemedicine, and clinical monitoring of patients with chronic disease. Yet, for most doctors not much as changed in the clinical trenches. The most evident change in clinical medicine has been CT and MRI scanning. Internists have voted these computer-guided imaging devices as the number #1 clinical innovation over the last 20 years.
As far as hype goes, we have yet to see the clinical fruits of the computer-assisted stem cell revolution, individualized treatment of disease based on genomic analysis, diagnostic support systems, applications of predictive modeling on clinical practice, or even the much touted consumer health care sites such as WebMD or Revolution Health, Most so called killer apps, in the form of sophisticated algorithms, has been applied to streamlining managerial monitoring and “tiering” of clinicians. Until the killer apps have a more direct application to clinical medicine itself, I shall remain skeptical.
Andy Grove, founder of Intel
Clinical medicine doesn’t run on Internet time. Health care needs are so intimate, strong, varied, and diverse with so many permutations and combinations that personal care has yet and may never yield completely to the Internet or to be dramatically improved by it.
My skepticism makes me one of a diminishing few. Others think the Internet will transform medicine. To explain how this might happen , IT professionals use the term “Killer Apps.” A Killer App, short for Killer Application, refers to any computer application of power, originality, or market reach that turns the world upside down.
Prime examples of killer apps include the Internet and Google. The latest example may be the laptop itself. If you’ve been following the news lately, you’ve no doubt heard of Nicholas Negroponte. He’s founder and chairman of the One Laptop per Child non-profit association.
Negropante believes dirt-cheap laptop computers, distributed to illiterate children in the developing world, will be a world-wide boon to education and a blessing to mankind. In the health care realm, some believe universal laptops, in the hands of Internet savvy clinicians, may revolutionize medicine But, in a foreword to Unleashing the Killer App, Negroponte cautions Internet applications are often simultaneously understated and over-hyped..
You can appreciate his comment about understatement when you consider the hoopla about electronic medicine. Consider EMRs, EHRs, e-prescribing, telemedicine, and clinical monitoring of patients with chronic disease. Yet, for most doctors not much as changed in the clinical trenches. The most evident change in clinical medicine has been CT and MRI scanning. Internists have voted these computer-guided imaging devices as the number #1 clinical innovation over the last 20 years.
As far as hype goes, we have yet to see the clinical fruits of the computer-assisted stem cell revolution, individualized treatment of disease based on genomic analysis, diagnostic support systems, applications of predictive modeling on clinical practice, or even the much touted consumer health care sites such as WebMD or Revolution Health, Most so called killer apps, in the form of sophisticated algorithms, has been applied to streamlining managerial monitoring and “tiering” of clinicians. Until the killer apps have a more direct application to clinical medicine itself, I shall remain skeptical.
Friday, December 7, 2007
Physician Leadership, The Physicians Foundation - Who Speaks for Doctors?
You’re a physician. Who, in your opinion, speaks for you?
The AMA? Theoretically, that’s the way it supposed to be. But AMA membership is slipping, and its cumbersome bureaucracy is slow to respond and hard to penetrate. Two-thirds of American doctors don’t belong, perhaps because the AMA has been relatively ineffective in matters of inadequate Medicare reimbursement, national tort reform, and rules and regulation battles with CMS and health plans.
State and local medical societies? These societies are closer to members than the AMA and are more focused on local and state issues. It was 19 state medical societies who succeeded in legal actions in 2003 against national health plans , which culminated in Aetna and Cigna providing over $150 million to form the Physician Foundation of Health System Excellence, dedicated to improving the overall health system and settling fee disputes between health plans and physicians.
Specialty medical societies? These societies represent the clinical, business, and political interests of their specialty members and hire lobbyists to work for them. But because there are some specialties (190 at last count), their overall impact tends to be diluted and drowned out in the cacophony of voices, each representing their own view of what’s best for their specialty and the nation as a whole. Probably the MGMA, a practice management organization said to represent 300,000 doctors should be included in this category.
Organizations employing physicians – large group practices, academic medical centers, and hospitals – These organizations are powerful and employ somewhere between 10 – 20 percent of physicians, but they do not, for the most part, speak for independent physicians, 70% of 80% of whom practice in groups of 10 or less. In the case of hospitals, they may be real or quasi-competitors of doctors.
Pharmaceutical companies - Relationships between Big Pharma and physicians have soured over the last ten years, because of direct consumer advertising, overly-aggressive sales reps, under the table payments to doctor consultants for drug or device promotion, rising drug costs, and a generally negative image in the media and among politicians. Physician-Pharma relationships may change as the fortunes of the Big Pharma decline politically and as the result of failing to produce new block-buster drugs (“Big Pharma Faces Grim Prognosis: Industry Fails to Find New Drugs to Replace Wonders Like Lipitor, “ WSJ, December 6. 2007).
I believe physicians will increasingly speak more for themselves through social networking websites such as Sermo.com, which will categorize and organize their points of view in such a way as to make them known to the wider public and to those who rely on physicians for their livelihoods. It’s becoming increasingly clear that for any practical reform to be achieved physicians will have to be at the bargaining table.
You physicians out there. Please let us know who you think speaks for you
The AMA? Theoretically, that’s the way it supposed to be. But AMA membership is slipping, and its cumbersome bureaucracy is slow to respond and hard to penetrate. Two-thirds of American doctors don’t belong, perhaps because the AMA has been relatively ineffective in matters of inadequate Medicare reimbursement, national tort reform, and rules and regulation battles with CMS and health plans.
State and local medical societies? These societies are closer to members than the AMA and are more focused on local and state issues. It was 19 state medical societies who succeeded in legal actions in 2003 against national health plans , which culminated in Aetna and Cigna providing over $150 million to form the Physician Foundation of Health System Excellence, dedicated to improving the overall health system and settling fee disputes between health plans and physicians.
Specialty medical societies? These societies represent the clinical, business, and political interests of their specialty members and hire lobbyists to work for them. But because there are some specialties (190 at last count), their overall impact tends to be diluted and drowned out in the cacophony of voices, each representing their own view of what’s best for their specialty and the nation as a whole. Probably the MGMA, a practice management organization said to represent 300,000 doctors should be included in this category.
Organizations employing physicians – large group practices, academic medical centers, and hospitals – These organizations are powerful and employ somewhere between 10 – 20 percent of physicians, but they do not, for the most part, speak for independent physicians, 70% of 80% of whom practice in groups of 10 or less. In the case of hospitals, they may be real or quasi-competitors of doctors.
Pharmaceutical companies - Relationships between Big Pharma and physicians have soured over the last ten years, because of direct consumer advertising, overly-aggressive sales reps, under the table payments to doctor consultants for drug or device promotion, rising drug costs, and a generally negative image in the media and among politicians. Physician-Pharma relationships may change as the fortunes of the Big Pharma decline politically and as the result of failing to produce new block-buster drugs (“Big Pharma Faces Grim Prognosis: Industry Fails to Find New Drugs to Replace Wonders Like Lipitor, “ WSJ, December 6. 2007).
I believe physicians will increasingly speak more for themselves through social networking websites such as Sermo.com, which will categorize and organize their points of view in such a way as to make them known to the wider public and to those who rely on physicians for their livelihoods. It’s becoming increasingly clear that for any practical reform to be achieved physicians will have to be at the bargaining table.
You physicians out there. Please let us know who you think speaks for you
Thursday, December 6, 2007
Primary Care, Physician Payment - Nonintendo and Hardening of the Categories.
Nonintendo and Hardening of the Categories
An article in the December 5 JAMA, “Unintended Consequences of Resource-Based Relative Value Scale,” from the department of medicine at Massachusetts General Hospital, prompts this blog.
Its author, Dr. John Goodson, argues RBRVS is responsible for the impending collapse of primary care in America.
Here is how Dr. Goodson puts it:
Medicine's generalist base is disappearing as a consequence of the reimbursement system crafted to save it—the resource-based relative value scale. The US physician workforce is unique among developed economies of the world. Virtually all European countries have a broad generalist foundation comprising 70% to 80% of practicing physicians. The United States is the opposite. Starfield has summarized the benefits of a generalist workforce as access to health service for relatively deprived populations; care equal to specialists in most situations (recognizing the invaluable contribution of the specialist physicians but acknowledging that the diffusion of knowledge increases the ability of the non-specialist to provide up-to-date care); improved preventive service delivery; efficient management of multiple simultaneous medical, surgical, and mental health problems in active and fully functional patients; provision of continuity in the health care experience, advice, and counsel where appropriate and access to appropriate diagnostic, consultative, and specialty.
And here is what Goodson sees as a solution:
The medical profession needs to reformulate the way the value of clinical services and the infrastructure expenses of practice are determined, needs to make the process open and accountable, and needs to solicit input and oversight from those who have the health of individuals, the nation, and the economy as their highest priorities. The resource-based relative value scale system originally developed to achieve full value for cognitive services currently threatens the sustainability of the generalist base. As a result, a large portion of the population will lose access to the continuous and personalized care provided by generalist physicians whose repertoire of clinical skills and interventions coupled with access to specialty and diagnostic services are essential for ensuring efficient and effective health care delivery.
I agree with Dr. Goodson, and I’m reminded of the law of unintended consequences. It refers to situations where an action results in an outcome not intended. The unintended consequences may be foreseen or unforeseen, and may fall into three categories.
1. A positive unexpected benefit, usually referred to as serendipity or a windfall.
2, A potential source of problems, according to Murphy’s Law ro system engineering
3. A negative or a perverse effect, which is the opposite result of what is intended
RBRVS falls into the third category, and to me it indicates the government and other creators and enforcers of RBRVS are suffering from a dire disorder known as “hardening of the categories, “ which, in the case of Medicare, may be irreversible.
An article in the December 5 JAMA, “Unintended Consequences of Resource-Based Relative Value Scale,” from the department of medicine at Massachusetts General Hospital, prompts this blog.
Its author, Dr. John Goodson, argues RBRVS is responsible for the impending collapse of primary care in America.
Here is how Dr. Goodson puts it:
Medicine's generalist base is disappearing as a consequence of the reimbursement system crafted to save it—the resource-based relative value scale. The US physician workforce is unique among developed economies of the world. Virtually all European countries have a broad generalist foundation comprising 70% to 80% of practicing physicians. The United States is the opposite. Starfield has summarized the benefits of a generalist workforce as access to health service for relatively deprived populations; care equal to specialists in most situations (recognizing the invaluable contribution of the specialist physicians but acknowledging that the diffusion of knowledge increases the ability of the non-specialist to provide up-to-date care); improved preventive service delivery; efficient management of multiple simultaneous medical, surgical, and mental health problems in active and fully functional patients; provision of continuity in the health care experience, advice, and counsel where appropriate and access to appropriate diagnostic, consultative, and specialty.
And here is what Goodson sees as a solution:
The medical profession needs to reformulate the way the value of clinical services and the infrastructure expenses of practice are determined, needs to make the process open and accountable, and needs to solicit input and oversight from those who have the health of individuals, the nation, and the economy as their highest priorities. The resource-based relative value scale system originally developed to achieve full value for cognitive services currently threatens the sustainability of the generalist base. As a result, a large portion of the population will lose access to the continuous and personalized care provided by generalist physicians whose repertoire of clinical skills and interventions coupled with access to specialty and diagnostic services are essential for ensuring efficient and effective health care delivery.
I agree with Dr. Goodson, and I’m reminded of the law of unintended consequences. It refers to situations where an action results in an outcome not intended. The unintended consequences may be foreseen or unforeseen, and may fall into three categories.
1. A positive unexpected benefit, usually referred to as serendipity or a windfall.
2, A potential source of problems, according to Murphy’s Law ro system engineering
3. A negative or a perverse effect, which is the opposite result of what is intended
RBRVS falls into the third category, and to me it indicates the government and other creators and enforcers of RBRVS are suffering from a dire disorder known as “hardening of the categories, “ which, in the case of Medicare, may be irreversible.
Wednesday, December 5, 2007
Quality - “Quality:” It Depends on What “Is” Is
President Bill Clinton will be remembered for saying, “It depends on what ‘is’ is.”
Similarly quality of care will be judged for what “is” is in the eyes of beholders.
For years, a debate has waged as to what makes for the best “quality” – solo, small, or large practices. As pointed out in the November 26 AMA Medical News, “Bigger Practice, Better Quality?” it depends on what you think quality is.
If you think quality is a more intimate, responsive, and closer relationship with your patients, solo or small practices may be your gig. Solo doctors, such at L. Gordon Morre or Rochester, New York , or John Brady, of Newport News, Virginia, family physicians both, feel they are delivering higher quality care than they did as members of larger groups.
They do so be cutting overhead, using EMRs, taking a proactive approach to caring for patients with chronic disease, being available 24 hours a day, answering their own phone, and seeing patients on the day they call. There are now about 100 similar solo groups operating in the U.S, along with roughly 500 concierge or retainer practices.
But if you think quality is defined and measured by more acceptable and concrete measurements, the big groups win hands down. A cross-sectional study of 119 California groups pitted against small groups found the following.
Quality measures, large groups vs. small groups
1. Mammography, 73%, 58%
2. Pap smear screening, 53%, 30%
3. Chlamydia screening, 235, 9%
4. Diabetic eye screeing, 42%, 29%
5. Asthma-control, medication,77%, 76%\
6. Beta blocker after acute MI, 80%, 69%
Quality improvement strategies, large groups vs. small groups
1. have an EMR, 37%, 2%
2. Offer quality bonuses to physicians, 32%, 13%
3. Provide reminders about missed:
--Mammography appointments, 74%, 28%
--Diabetic eye screening, 53%, 18%
--Well-child immunizations or visits, 47%, 10%
-- Influenza vaccine, 54%, 25%.
Like I said, the perception of quality depends on what “is” is – on what you perceive quality to be. Whoever is “right,” more doctors are switching from smaller to larger groups as indicated.
% of doctors in small vs. larger groups, 1996-1997 vs 2004-2005
1. 1-2 physicians, 42% to 33%
2. 3-5 physicians, 12% to 10%
3. 6-50, 13%, to 17%
4. 50+. 3% to 4%
5. Medical schools, 7 to 9%
6. Hospitals, 11% to 13%.
One piece of information missing is what patients consider to be quality. This is essential. After all, first visits of some 50% of patients are with primary care physicians in small groups (National Center of Health Statistics, 2005).
John Guaspari, a management guru, has written in his book I Know It When I See It: A Modern Fable about Quality (1991) that anyone who thinks they know quality when they see it is living a myth.
Can the same thing be said of patients? And if not, how can this lack of knowledge of quality by patients be overcome? By health plan steerage of patients to doctors with documented quality? By public disclosure of quality data? By marketing of their quality data by large groups?
I am dubious about the effectiveness and propriety of any of these approaches. There are intangibles of doctor-patient relationships that transcend data. Still I have no doubt large practices, given their resources, can take a more systematic, organized, and purposeful approach towards quality.
Similarly quality of care will be judged for what “is” is in the eyes of beholders.
For years, a debate has waged as to what makes for the best “quality” – solo, small, or large practices. As pointed out in the November 26 AMA Medical News, “Bigger Practice, Better Quality?” it depends on what you think quality is.
If you think quality is a more intimate, responsive, and closer relationship with your patients, solo or small practices may be your gig. Solo doctors, such at L. Gordon Morre or Rochester, New York , or John Brady, of Newport News, Virginia, family physicians both, feel they are delivering higher quality care than they did as members of larger groups.
They do so be cutting overhead, using EMRs, taking a proactive approach to caring for patients with chronic disease, being available 24 hours a day, answering their own phone, and seeing patients on the day they call. There are now about 100 similar solo groups operating in the U.S, along with roughly 500 concierge or retainer practices.
But if you think quality is defined and measured by more acceptable and concrete measurements, the big groups win hands down. A cross-sectional study of 119 California groups pitted against small groups found the following.
Quality measures, large groups vs. small groups
1. Mammography, 73%, 58%
2. Pap smear screening, 53%, 30%
3. Chlamydia screening, 235, 9%
4. Diabetic eye screeing, 42%, 29%
5. Asthma-control, medication,77%, 76%\
6. Beta blocker after acute MI, 80%, 69%
Quality improvement strategies, large groups vs. small groups
1. have an EMR, 37%, 2%
2. Offer quality bonuses to physicians, 32%, 13%
3. Provide reminders about missed:
--Mammography appointments, 74%, 28%
--Diabetic eye screening, 53%, 18%
--Well-child immunizations or visits, 47%, 10%
-- Influenza vaccine, 54%, 25%.
Like I said, the perception of quality depends on what “is” is – on what you perceive quality to be. Whoever is “right,” more doctors are switching from smaller to larger groups as indicated.
% of doctors in small vs. larger groups, 1996-1997 vs 2004-2005
1. 1-2 physicians, 42% to 33%
2. 3-5 physicians, 12% to 10%
3. 6-50, 13%, to 17%
4. 50+. 3% to 4%
5. Medical schools, 7 to 9%
6. Hospitals, 11% to 13%.
One piece of information missing is what patients consider to be quality. This is essential. After all, first visits of some 50% of patients are with primary care physicians in small groups (National Center of Health Statistics, 2005).
John Guaspari, a management guru, has written in his book I Know It When I See It: A Modern Fable about Quality (1991) that anyone who thinks they know quality when they see it is living a myth.
Can the same thing be said of patients? And if not, how can this lack of knowledge of quality by patients be overcome? By health plan steerage of patients to doctors with documented quality? By public disclosure of quality data? By marketing of their quality data by large groups?
I am dubious about the effectiveness and propriety of any of these approaches. There are intangibles of doctor-patient relationships that transcend data. Still I have no doubt large practices, given their resources, can take a more systematic, organized, and purposeful approach towards quality.
Tuesday, December 4, 2007
Electronic Medical Records, Limits of Technology -EMRs and PHRs Don't Impress Doctors and Patients
Something’s going on out there in the electronic medical world, and the “experts,” government and commercial cyber pushers, don’t know what to make of it or what do about it.
Doctors and patients aren’t flocking to EMRs (electronic medical records) and PHRs (patient health records) as the be-all, do-all, and end-all to eliminate medical errors, coordinate care, and streamline care.
It’s not for lack of trying. There are as least 300 EMR vendors are there, and more than PHR systems are available. And yet only 10% of solo physicians, and 20% of all doctors have installed EMRs, and only 5% of doctors and patients are using PHRs. This is even in face of the fact that the Veterans Administration has a system-wide EMR, and Kaiser has both an EMR, available to its 12,000 doctors, and a PHR, My Health Record, available to 8.7 million Kaiser members.
What’s the hang up? Personally, I don’t hanker to go to a doctor to have my problems documented. There are certain personal things I want to keep personal. I want the doctor to pay attention to me, not to the computer. To me documenting isn’t the same as doctoring. As David Pallestrant, MD, founder of Sermo, commented to me, “Having a computer in the room changes the chemistry of the doctor-patient relationship.” And as one VA patient said to me, “ I hate to go the VA. The doctor is always sitting behind that damn computer.” To have a personal record of the encounter is not sufficient incentive to me. Even Gary Baldwin, the technological advisor of Healthleadersmedia and an ardent EHR supporter, admits that his doctor having an EMR is not a sufficient reason to switch doctors.
So what are the experts to do? Michael Leavitt, secretary of HHS, is resorting to veiled threats. In a recent statement, he said he was inclined to proceed with the 10.1% Medicare payment cut unless doctors installed EMRs. This “or else” comment has the sound of childish playground threat and certainly doesn’t speak to the maturity of Mr. Leavitt.
Doesn’t Mr. Leavitt know,
Only 1/10 to 1/5 of doctors have installed EMRs despite 5 years of government and health plan pressure.
EMRs costs $20,000 to $40,000 per doctor to install, and primary care physicians are already trying to make ends meet.
Current evidence indicate EMR users are not less error prone, quality-enhanced, or productive than non-EMR users.
Most doctors see no tangible return on investment form EMR-use.
Meanwhile on the PHR front, vendors are reaching out to health plans and employers to make PHRs more attractive. They’re expanding the data base to make PHRs more useful to doctors.
But privacy, security, and personal obstacles remain. PHRs have advantages for patients with active conditions requiring transfer from one doctor to another, but they have yet to catch on among doctors because of their costs, negative impact on work flow, and expense to maintain, and among patient, who remain concerned about privacy issues. Going to a doctor is not the same as a routine retail transaction, either for the doctor or the patient.
1. Kevin Freking,"Leavitt: Doctors Need Electronic Records, Associated Press, December 3, 2007.
2. Pamela Lewis Dolan, "Pretty Half-Hearted Reception, " American Medical News, December 3, 2007
Doctors and patients aren’t flocking to EMRs (electronic medical records) and PHRs (patient health records) as the be-all, do-all, and end-all to eliminate medical errors, coordinate care, and streamline care.
It’s not for lack of trying. There are as least 300 EMR vendors are there, and more than PHR systems are available. And yet only 10% of solo physicians, and 20% of all doctors have installed EMRs, and only 5% of doctors and patients are using PHRs. This is even in face of the fact that the Veterans Administration has a system-wide EMR, and Kaiser has both an EMR, available to its 12,000 doctors, and a PHR, My Health Record, available to 8.7 million Kaiser members.
What’s the hang up? Personally, I don’t hanker to go to a doctor to have my problems documented. There are certain personal things I want to keep personal. I want the doctor to pay attention to me, not to the computer. To me documenting isn’t the same as doctoring. As David Pallestrant, MD, founder of Sermo, commented to me, “Having a computer in the room changes the chemistry of the doctor-patient relationship.” And as one VA patient said to me, “ I hate to go the VA. The doctor is always sitting behind that damn computer.” To have a personal record of the encounter is not sufficient incentive to me. Even Gary Baldwin, the technological advisor of Healthleadersmedia and an ardent EHR supporter, admits that his doctor having an EMR is not a sufficient reason to switch doctors.
So what are the experts to do? Michael Leavitt, secretary of HHS, is resorting to veiled threats. In a recent statement, he said he was inclined to proceed with the 10.1% Medicare payment cut unless doctors installed EMRs. This “or else” comment has the sound of childish playground threat and certainly doesn’t speak to the maturity of Mr. Leavitt.
Doesn’t Mr. Leavitt know,
Only 1/10 to 1/5 of doctors have installed EMRs despite 5 years of government and health plan pressure.
EMRs costs $20,000 to $40,000 per doctor to install, and primary care physicians are already trying to make ends meet.
Current evidence indicate EMR users are not less error prone, quality-enhanced, or productive than non-EMR users.
Most doctors see no tangible return on investment form EMR-use.
Meanwhile on the PHR front, vendors are reaching out to health plans and employers to make PHRs more attractive. They’re expanding the data base to make PHRs more useful to doctors.
But privacy, security, and personal obstacles remain. PHRs have advantages for patients with active conditions requiring transfer from one doctor to another, but they have yet to catch on among doctors because of their costs, negative impact on work flow, and expense to maintain, and among patient, who remain concerned about privacy issues. Going to a doctor is not the same as a routine retail transaction, either for the doctor or the patient.
1. Kevin Freking,"Leavitt: Doctors Need Electronic Records, Associated Press, December 3, 2007.
2. Pamela Lewis Dolan, "Pretty Half-Hearted Reception, " American Medical News, December 3, 2007
Monday, December 3, 2007
Limits of Technology - Why Not Regional Health Information Organizations?
“RHIOs Hit Financial Stumbling Block on Path to National Network ”
AMA Medical News headline
Everybody is looking for the telling phrase that clears the underbrush to assure health reform.
For liberals, it’s the long-held and cherished “universal coverage.” Who could be against protecting everybody against every health eventuality and bankruptcy from disease?
For conservatives, it’s the new kid on the block, “consumer-driven care.” Who could be against informed consumers making their own decisions?
For liberals and conservatives alike, it’s “patient-centered care.” Who could challenge the notion the nation should focus on patients?
For the managerial and political classes, it’s “transparency.’ Who could oppose open and honest dealings above the table?
For lawyers and technocrats and paymasters, it’s “accountability.” Who could anyone be against holding everybody else for being “responsible” and “accountable” for their actions?
For everybody, it’s “information” and “data”, or “infodata.” If we only all had all that factual and revealing information – on who is good, who is bad, who is naughty and nice, and who get the best results for the least cost, everything would be OK.
With respect to “infodata,” it’s a dream among many that “RHIOs “(Regional Health Information Organizations) will be the backbone or the central data bank for a national health information exchange. This open exchange will serve as the foundation for a national interoperative computer system linking all major health care entities.
When it comes to RHIOs, I’m reminded to the phrase, “when they say it’s the principle and not the money, it’s the money.” In principle, RHIOs are unassailable. Who could be against sharing infodata for the common good? Though data sharing may be good for society, those sharing the data don’t seem to understand what’s in it for the good of their organization or for the good of themselves. The principle of enlightened self-interest seems to be at work here.
Therefore, human nature being what it is, RHIO participants have a hard time raising money. The financial underpinning of RHIOs in the startup and transitional phases depends on gifts, grants, and members fees.
The dreamers seem not to have stopped and asked: why should regional organizations share their data and operating secrets with competitors when there is no tangible financial return? America is, after all, a competitive society, the pillar of Western capitalism. It may take a while for the concept of cooperation and collaboration for the common good to catch on among close rivals.
Americans’ obsession with competition can be destructive. Alfie Kohn. an academic then living in a cooperative household in Cambridge, Massachusetts (where else?), described this destructiveness in No Contests. The Case Against Competition, Houghton-Mifflin, 1986), in this way,
“Unfortunately the case competition does not stand up under close scrutiny .It has been constructed on four myths. The first myth is that competition is an unavoidable fact of life, part of human nature. The second myth is that competition motivates us to do our best. Third, it is asserted contests provide the best, if not the only, way to have a good time. The last myth is that competition builds character, that it is good for self-confidence.”
Well, maybe, but Americans, including health care players, have been trained not only to compete but to believe in competition. That training and belief isn’t going to go away soon, perhaps too late for RHIOs.
To conclude:
Why not regional networks loaded with transparent data? Doesn’t everybody know infodata will end health care errata? Surely everybody will fork up cash to share their numbers, and willingly stop competing and reveal their blunders. When, oh when, will competitors join the infodata intifada?
You can array against evils of our present culture. You can inveigh against the competitive vulture. You can lead people to the very edge of the stream. But you won’t drink if they believe it to be extreme. Or if it goes against their fundamental nurture.
AMA Medical News headline
Everybody is looking for the telling phrase that clears the underbrush to assure health reform.
For liberals, it’s the long-held and cherished “universal coverage.” Who could be against protecting everybody against every health eventuality and bankruptcy from disease?
For conservatives, it’s the new kid on the block, “consumer-driven care.” Who could be against informed consumers making their own decisions?
For liberals and conservatives alike, it’s “patient-centered care.” Who could challenge the notion the nation should focus on patients?
For the managerial and political classes, it’s “transparency.’ Who could oppose open and honest dealings above the table?
For lawyers and technocrats and paymasters, it’s “accountability.” Who could anyone be against holding everybody else for being “responsible” and “accountable” for their actions?
For everybody, it’s “information” and “data”, or “infodata.” If we only all had all that factual and revealing information – on who is good, who is bad, who is naughty and nice, and who get the best results for the least cost, everything would be OK.
With respect to “infodata,” it’s a dream among many that “RHIOs “(Regional Health Information Organizations) will be the backbone or the central data bank for a national health information exchange. This open exchange will serve as the foundation for a national interoperative computer system linking all major health care entities.
When it comes to RHIOs, I’m reminded to the phrase, “when they say it’s the principle and not the money, it’s the money.” In principle, RHIOs are unassailable. Who could be against sharing infodata for the common good? Though data sharing may be good for society, those sharing the data don’t seem to understand what’s in it for the good of their organization or for the good of themselves. The principle of enlightened self-interest seems to be at work here.
Therefore, human nature being what it is, RHIO participants have a hard time raising money. The financial underpinning of RHIOs in the startup and transitional phases depends on gifts, grants, and members fees.
The dreamers seem not to have stopped and asked: why should regional organizations share their data and operating secrets with competitors when there is no tangible financial return? America is, after all, a competitive society, the pillar of Western capitalism. It may take a while for the concept of cooperation and collaboration for the common good to catch on among close rivals.
Americans’ obsession with competition can be destructive. Alfie Kohn. an academic then living in a cooperative household in Cambridge, Massachusetts (where else?), described this destructiveness in No Contests. The Case Against Competition, Houghton-Mifflin, 1986), in this way,
“Unfortunately the case competition does not stand up under close scrutiny .It has been constructed on four myths. The first myth is that competition is an unavoidable fact of life, part of human nature. The second myth is that competition motivates us to do our best. Third, it is asserted contests provide the best, if not the only, way to have a good time. The last myth is that competition builds character, that it is good for self-confidence.”
Well, maybe, but Americans, including health care players, have been trained not only to compete but to believe in competition. That training and belief isn’t going to go away soon, perhaps too late for RHIOs.
To conclude:
Why not regional networks loaded with transparent data? Doesn’t everybody know infodata will end health care errata? Surely everybody will fork up cash to share their numbers, and willingly stop competing and reveal their blunders. When, oh when, will competitors join the infodata intifada?
You can array against evils of our present culture. You can inveigh against the competitive vulture. You can lead people to the very edge of the stream. But you won’t drink if they believe it to be extreme. Or if it goes against their fundamental nurture.
Sunday, December 2, 2007
Wellness - The Katz Meow
Critics claim doctors know nothing about nutrition. Our distracters say nutrition’s not in medical school curricula; doctors eschew vitamins, supplements, essential minerals, herbs; home remedies, and oriental concoctions; and have no clue about carbohydrates, fats, and proteins . Furthermore, critics assert doctors’ general advice to eat fresh fruit and vegetables and to go easy on the fat, sugar, and salt simply won’t do anymore.
Meanwhile health food stores, “healthy” diets, farmers markets, food labels, and cooking shows are flourishing. Every chef, retailer, and marketer worth their salt claims their food is “healthier” than the competitors.
David Katz, MD, director of the Yale-Griffin Prevention Center in New Haven, must be purring these days. He has taken a giant step towards silencing critics of doctors’ lack of nutritional knowledge. He and an academic team have created a rating system called the Overall Nutritional Quality Index, or ONQI. The Katz system will ultimately rate all foods in grocery stores on a 1-to-100 basis, with 100 being the healthiest.
Ric Jurgens, president and CEO of Hy-Vee Grocery Stores, a consolidated grocery store chain, has endorsed the Katz system and bought a stake in the Katz algorithm. His stores will start using it on their shelves next summer.
Doctor Katz came up with the idea for his rating system because he was frustrated. He could not explain to his family and his patients how to interpret food labels and eat the right foods. The food labels in grocery stores befuddled, bewildered, and baffled his family and patients.
What to do? Katz assembled a panel of academics to weigh and rate the nutritional value of vitamins, bioflavonoids, anti-oxidants, sodium, minerals, carbohydrates, proteins, and everything else naughty or nice. So far they have rated 20,000 foods and will have 50,000 more done by next summer.
This is a classic example of creating an innovation to fill needs – patients’ needs for better and more specific information on what constitutes healthy foods, doctors’ needs to provide them with that information, and society’s need for better nutrition.
Meanwhile health food stores, “healthy” diets, farmers markets, food labels, and cooking shows are flourishing. Every chef, retailer, and marketer worth their salt claims their food is “healthier” than the competitors.
David Katz, MD, director of the Yale-Griffin Prevention Center in New Haven, must be purring these days. He has taken a giant step towards silencing critics of doctors’ lack of nutritional knowledge. He and an academic team have created a rating system called the Overall Nutritional Quality Index, or ONQI. The Katz system will ultimately rate all foods in grocery stores on a 1-to-100 basis, with 100 being the healthiest.
Ric Jurgens, president and CEO of Hy-Vee Grocery Stores, a consolidated grocery store chain, has endorsed the Katz system and bought a stake in the Katz algorithm. His stores will start using it on their shelves next summer.
Doctor Katz came up with the idea for his rating system because he was frustrated. He could not explain to his family and his patients how to interpret food labels and eat the right foods. The food labels in grocery stores befuddled, bewildered, and baffled his family and patients.
What to do? Katz assembled a panel of academics to weigh and rate the nutritional value of vitamins, bioflavonoids, anti-oxidants, sodium, minerals, carbohydrates, proteins, and everything else naughty or nice. So far they have rated 20,000 foods and will have 50,000 more done by next summer.
This is a classic example of creating an innovation to fill needs – patients’ needs for better and more specific information on what constitutes healthy foods, doctors’ needs to provide them with that information, and society’s need for better nutrition.
Saturday, December 1, 2007
Universal Coverage – Massachusetts, Canada, and the U.S,
The November 25 New York Times, carried this article “Massachusetts Faces a Test on Health Care.” A year after its Universal Coverage bill was enacted, Massachusetts officials say between 200,000 and 400,000 residents haven’t signed up. Meanwhile, health insurers in Massachusetts may raise rates 10% to 12%, twice the national average; and there may be a budget overrun of $150 million. Universal coverage in the Bay State is in trouble.
Two years ago, I published a book Voices of Health Reform, based on 42 interviews with national reform authorities. One interviewee was Dr. David Himmelstein, a Harvard faculty member, who, with his wife, Dr. Stephanie Woolhandler, back a Canadian-type system for the U.S. Himmelstein and Woolhandler claim Canada has lower administrative costs, higher quality care, and better access at every income level.
John Goodman, PhD, a conservative economist, says these claims are myths. These are his words.
The Myth of Low Administrative Costs. Himmelstein and Woolhandler claim administrative costs of the Canadian system are much lower than our own - so much so that we could insure the uninsured through administrative savings alone. However, they aren’t economists. They count the cost of private insurance premium collection (e.g. advertising, agents' fees, etc.) but they ignore tax collection costs to pay for public insurance. Economic studies show cost of collecting taxes is very high. The excess burden of a universal Medicare program would be twice as high as the administrative costs of universal private coverage.
The Myth of High Quality. H&W say that Canadian life expectancy is two years longer than ours, implying the health care systems of the two countries have something to do with that result. Doctors don't control our overeating, overdrinking, etc. Where doctors make a difference, the comparison doesn’t favor Canada. In an NBER study, David and June O'Neill draw on a large US/Canadian patient survey to show that:
o The percent of middle-aged Canadian women who have never had a mammogram is double the US rate. o The percent of Canadian women who have never had a pap smear is triple the US rate.
o More than 8 in 10 Canadian males have never had a PSA test, compared with less than half of US males.
o More than 9 in 10 Canadians have never had a colonoscopy, compared with 7 in 10 in the US.These differences in screening may explain why US cancer patients do better than their Canadian counterparts. For example:
o The mortality rate for breast cancer is 25% higher in Canada.
o The mortality rate for prostate cancer is 18% higher in Canada.
o The mortality rate for colorectal cancer among Canadian men and women is about 13% higher than in the US.
o Among senior citizens, the fraction of Canadians with asthma, hypertension, and diabetes who are not getting care is twice the rate in the US.
o The fraction of Canadian seniors with coronary heart disease who are not being treated is nearly three times the US rate.
Apparently, putting everyone in (Canadian) Medicare leads to worse results than having only some people in (US) Medicare - ensconced in an otherwise private system.
The Myth of Equal Access. The most common argument for national health insurance is that it gives rich and poor the same access to health care. Surprisingly, there is no evidence of that outcome. Indeed, national health insurance in Canada may have created more inequality than otherwise would have existed. (Similar results have been reported for Britain.) The O'Neill's study shows that:
o Both in Canada and in the US health outcomes correlate with income; low-income people are more likely to be in poor health and less likely to be in good health than those with higher incomes.
o However, there is apparently more inequality in Canada; among the non-elderly white population of both countries, low-income Canadians are 22% more likely to be in poor health than American counterparts.
The Nub-of-It-All
Himmelstein and Woolhandler say Canadian medicine surpasses the U.S for three reasons --lower administrative costs, higher quality, and equal access. Not so, retorts John Goodman, of the National Policy Institute in Dallas, an American think tank. He rebukes Himmelstein and Woolhandler with data showing:
Canadians:
· undergo preventive tests and procedures (pap smears, mammograms, PSAs, and colonoscopies) much less often;
· have higher cancer rates with poorer results,
· get less care for diabetes, asthma, and coronary artery disease than U.S. counterparts;
· low-income Canadians are more likely to be in poor health.
Apparently the idea of having universal coverage, appealing as it may be, doesn’t translate into superior performance or healthier citizens.
Two years ago, I published a book Voices of Health Reform, based on 42 interviews with national reform authorities. One interviewee was Dr. David Himmelstein, a Harvard faculty member, who, with his wife, Dr. Stephanie Woolhandler, back a Canadian-type system for the U.S. Himmelstein and Woolhandler claim Canada has lower administrative costs, higher quality care, and better access at every income level.
John Goodman, PhD, a conservative economist, says these claims are myths. These are his words.
The Myth of Low Administrative Costs. Himmelstein and Woolhandler claim administrative costs of the Canadian system are much lower than our own - so much so that we could insure the uninsured through administrative savings alone. However, they aren’t economists. They count the cost of private insurance premium collection (e.g. advertising, agents' fees, etc.) but they ignore tax collection costs to pay for public insurance. Economic studies show cost of collecting taxes is very high. The excess burden of a universal Medicare program would be twice as high as the administrative costs of universal private coverage.
The Myth of High Quality. H&W say that Canadian life expectancy is two years longer than ours, implying the health care systems of the two countries have something to do with that result. Doctors don't control our overeating, overdrinking, etc. Where doctors make a difference, the comparison doesn’t favor Canada. In an NBER study, David and June O'Neill draw on a large US/Canadian patient survey to show that:
o The percent of middle-aged Canadian women who have never had a mammogram is double the US rate. o The percent of Canadian women who have never had a pap smear is triple the US rate.
o More than 8 in 10 Canadian males have never had a PSA test, compared with less than half of US males.
o More than 9 in 10 Canadians have never had a colonoscopy, compared with 7 in 10 in the US.These differences in screening may explain why US cancer patients do better than their Canadian counterparts. For example:
o The mortality rate for breast cancer is 25% higher in Canada.
o The mortality rate for prostate cancer is 18% higher in Canada.
o The mortality rate for colorectal cancer among Canadian men and women is about 13% higher than in the US.
o Among senior citizens, the fraction of Canadians with asthma, hypertension, and diabetes who are not getting care is twice the rate in the US.
o The fraction of Canadian seniors with coronary heart disease who are not being treated is nearly three times the US rate.
Apparently, putting everyone in (Canadian) Medicare leads to worse results than having only some people in (US) Medicare - ensconced in an otherwise private system.
The Myth of Equal Access. The most common argument for national health insurance is that it gives rich and poor the same access to health care. Surprisingly, there is no evidence of that outcome. Indeed, national health insurance in Canada may have created more inequality than otherwise would have existed. (Similar results have been reported for Britain.) The O'Neill's study shows that:
o Both in Canada and in the US health outcomes correlate with income; low-income people are more likely to be in poor health and less likely to be in good health than those with higher incomes.
o However, there is apparently more inequality in Canada; among the non-elderly white population of both countries, low-income Canadians are 22% more likely to be in poor health than American counterparts.
The Nub-of-It-All
Himmelstein and Woolhandler say Canadian medicine surpasses the U.S for three reasons --lower administrative costs, higher quality, and equal access. Not so, retorts John Goodman, of the National Policy Institute in Dallas, an American think tank. He rebukes Himmelstein and Woolhandler with data showing:
Canadians:
· undergo preventive tests and procedures (pap smears, mammograms, PSAs, and colonoscopies) much less often;
· have higher cancer rates with poorer results,
· get less care for diabetes, asthma, and coronary artery disease than U.S. counterparts;
· low-income Canadians are more likely to be in poor health.
Apparently the idea of having universal coverage, appealing as it may be, doesn’t translate into superior performance or healthier citizens.
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