Wednesday, April 30, 2008

Government vs market reforms - What’s The Right Mix of Private and Government Health Care?

This is April 30, the very last day of national poetry month,

A fitting time, I would say, for a poem about the trillioneth,

$2.2 trillion, to be precise, on health care the U.S spends

A number that an annual rate of 8%-10% always ascends.

It’s said by some only in God can we trust,

But other say it’s realistic data or go bust.

It’s either data,

Or costly errata.

With these thoughts firmly in mind I came across this table,

the numbers of which the rest of this poem will enable.

Health Care Insurance

Private Insurance 67.9%

Employer-Based 59.7%

Direct Purchase 9.1%

Government Insurance

Medicare 13.6%

Medicaid 12.9%

Military 3.6%

Uninsured 15.8%

For me that puts the whole matter in context

Whether your politics are concave or convex.

Some say these numbers call for more federal mandates,

Or, at the very least, for extensive marketplace rebates.

I’m not so cocksure,

We can for all insure.

My reasoning may be a bit light,

But the numbers seem about right.

A two-thirds burden for the private sector,

Just over one-fourth to the government specter.

What worries me is the final one-sixth of the mix

The feds and business together have that to fix.

Physician Business Ideas - Straight Talk about Physician Practices

John McDaniel, 57 year old president of a physician practice management company, called the other day from New Orleans to talk about the lay of the health care landscape.

John’s company, Peak Performance Physicians, manages physician groups throughout the country. He is a former hospital CEO and has been in the physician practice management business for about two decades.

John talks straight. Indeed, I would call him a pragmatic fundamentalist who does not sugarcoat issues facing physicians, such as flat or dropping incomes weak cash flow, physician shortages, overcrowded schedules, and pay cuts from the 3Ms – Medicare, Medicaid, and Managed Care.

Among other things, John says,

• Many physicians are dropping out of HMOs and PPOs that offer low rates of reimbursement. One of the most commonly dropped plans is UnitedHealth, though this is tough where United has dominant market share. John cited one physician, a neurologist, who has withdrawn from 16 plans.

• To bolster cash flow and decrease accounts receivable, more and more physicians are asking for payment before the patient leaves the office. This may account for as much as 20% to 25% of revenues.

• Only 25% of the groups he manages or consults with have installed EMRs. These groups await better and less expensive systems with a tangible return on investment.

• Young doctors are increasingly turning to hospitals to help them get started in practice. Given their educational debts and costs of starting a practice, there is simply no other way to establish themselves.

• The influx of women doctors into medical practice is altering traditional thinking about how many doctors we need. He cited the case of a 12 woman obstetrical practice in which each partner worked a three day week. He pointed out that was the equivalent of a full-time four person group.

• As many as 75% to 80% of doctors undercode because they fear a federal audit. John says this is too bad because an annual audit would quickly reveal undercoding, and corrective coding would greatly increase revenue for most practices.

• John says the American public will never be sympathetic with doctors who complain of low reimbursement from Medicare, Medicaid, and managed care. To the public, most doctors are wealthy, and no amount of moaning, groaning, or whimpering will correct that misperception. What people understands is lack of access. If enough doctors restrict access and can justify that restriction, the public and the politicians will come around.

Tuesday, April 29, 2008

Reece, personal musings - Life's Little Instruction Books

If you seek moments of truth and instructions to pursue it, read Life’s Little Instruction Book (Rutledge Hill Press, Nashville, Tennessee) It comes in two small volumes and contains 1028 pieces of distilled wisdom from a father to his son, who was departing for college.

Here are 35 of my favorites, followed by 12 of my own making.

1. Never give up on anybody. Miracles happen every day.

2. Think big thoughts, but relish small pleasures.

3. Never deprive someone of hope; it might be all they have.

4. Never resist a generous impulse.

5. Leave everything a little better than you found it.

6. Give people more then the expect

7. Don’t think expensive equipment will make for lack of talent or practice.

8. When you make a mistake, take immediate steps to correct it.

9. Listen to your critics. They will keep you on your toes.

10. Accept the fact that regardless of how many times you're right, you will sometimes be wrong.

11. Remember the 3 Rs: Respect for self; Respect for others; Responsibility for all your actions.

12. Take off the convention badge as soon as you leave the convention hall.

19. Share your knowledge. It's a way to achieve immortality.

20. Love someone who doesn't deserve it.

21, Have a firm handshake.

22. Look people in the eye.

23. Sing in the shower.

24. Keep secrets.

25. Always accept an outstretched hand.

26. Make it a habit to do nice things for people.

27. Don't allow the phone to interrupt important moments. It's there for your convenience, not the caller's.

28. Keep it simple. Be modest. A lot was accomplished before you were born.

29. Remember no one makes it alone. Have a grateful heart and be quick to acknowledge those who helped you.

30. Visit friends and relatives when they are in hospital; you need only stay a few minutes.

31.Answer the phone with enthusiasm and energy in your voice.

32. Keep a note pad and pencil on your bed-side table.

33. Million-dollar ideas sometimes strike at 3 a.m.

34. Remember that 80 per cent of the success in any job is based on our ability to deal with people.

35. Don't expect life to be fair.

And here are a dozen of my own.

1. Health care costs will not grow to the sky.

2. Listen to your spouse and your nurse. They are giving you honest opinions
you won't get elsewhere.

3. Not everything in health care computes.

4. Buy a huge wastebasket. Keep it full of material you’ll never read again.

5. It’s never too late to innovate.

6. For the health care entrepreneur, there are always niches and sons of niches.

7. Click often on Sermo, Google, and Wikipedia. They will tell you most of what you want to know – early, soon, and quickly.

8. He who constantly throws dirt loses ground but gains a sense of humus.

9. Be skeptical of information technologists doctors don’t use. If doctors don’t use it, patients will not benefit.

10. Your patient’s time is just as important as yours.

11. Universal coverage without access to primary care doctors is meaningless..

12. To patients, convenience means not waiting to receive care.

Monday, April 28, 2008

Book Review - A Little Book

I wish to acquaint you with my little 38 page book Navigating the Maze of the Health Coverage & Access: A Quick Guide for Physicians (, 800-067-7790).What follows are the book’s introduction and table of contents.


“The pernicious aspect of this cry for universal coverage is that it is too easy for politicians. The hard work is getting at the underlying inefficiencies in the health system, the perverse incentives that have everybody in the dark.”

Joseph Antos, PhD, Health Policy Expert, The American Enterprise Institute, “Coming Soon: Health Care Debate, Part 2,” New York Times, March 2, 2008

This little book contains 20 quick takes on health reform for doctors and patients. I present it as questions and answers on leading reform issues of today. This small manual is not intended to be exhaustive or inclusive, but rather to be instructive. Despite the 20 topics covered herein, the book lacks 20/20 vision.

The health system is complex. This book is simple. It follows Kipling’s instructions. Write on the Whats, Whys, Whens, Hows, Wheres, and Whos.

I keep six honest serving men
(They taught me all I knew)
Their names are What and Why and When
And How and Where and Who

Rudyard Kipling, 1865 - 1936
The Just-So Stories (1902), The Elephant’s Child

I do not pretend to be an expert on all reform issues, but I have learned a thing or two while writing three books over the last three years – Sailing the Seven C’s of Hospital-Physician Relationships, Voices of Health Reform, and Innovation-Driven Health Care.

The health system is more complex than it need be. The system, which critics insist on calling a “non-system,” is, in many ways, the worst of all possible worlds - a bewildering mix of arcane government rules, Byzantine private red tape, obstructive legal entanglements – and, for patients, waiting, waiting, waiting, not knowing what to expect.

An April 5, 2008, New York Times story, “In Massachusetts, Universal Coverage Strains Care”, reports that some patients must wait over a year for a physician in a primary care doctor’s office. And this in a state with more doctors per capita than any other state. Project this picture to states with far fewer doctors, and you begin to appreciate the magnitude of the universal coverage problem.

I believe in intelligent informed consumers and commonsensical doctors, acting together and deploying user-friendly Internet engines – Sermo, Google, Wikipedia. The three have exploded in growth over the last two to ten years and will galvanize reform. Information technologies will help lead the way out of the health reform wilderness.

Nobody is closer to patients than doctors. Together, with the help of electronic communication, redesigned practices, and more and better paid primary care doctors, patients and doctors will prevail.

Although I look at computer-generated information as a powerful transformative force, I do not believe in the Internet as the do-all and be-all. Doctors’ offices need broad band access, but they do not need electronic medical record systems with all the bells and whistles and the $50,000 per doctor investment required to install and maintain them.

Nor should every doctor aim for a “paperless” office. Canadian pulp manufacturers are doing more business than ever, thanks to paper downloading of Internet files. Much talk about health 2.0, and health 3.0, is sheer balderdash, geekspeak and cyber-chutzpah.

Paper has its place in the form of small manuals, check-off lists, and management modules. Besides, as Dr. Daniel Pallestrant , founder of Sermo, has observed, a computer in the same room situated between a doctor and a patient changes the human chemistry between the two. Some things are best expressed through the head of a pen rather than the click of a mouse. Computers are not magical machines. They are human tools.


Chapter One HEALTH 2.0 1

Chapter Two SERMO 2

Chapter Three GOOGLE 4

Chapter Four WIKIPEDIA 5




Chapter Eight TRANSPARENCY 13

Chapter Nine PATIENT SAFETY 15



Chapter Twelve THE UNINSURED 21

Chapter Thirteen EMRS AND PHRS 23

Chapter Fourtee RETAIL CLINICS 25

Chapter Fifteen ACCESS 27

Chapter Sixteen HARD TRUTHS 29

Chapter Seventeen HEALTH PLANS 31

Chapter Eighteen BIG PHARMA 33

Chapter Nineteen ENGAGING PATIENTS 35

Chapter Twenty MEDICAL TOURISM 37

Sunday, April 27, 2008

Medical trends - The American Doctor Story: Reflections on Ten Trends

I’ve been reading The American Story: The Age of Exploration and the Age of the Atom (Channel Press, 1956) – a series of essays by historians on transforming events and individuals. The common theme is American exceptionalism - molded by our frontier mentality, individualism, distrust of authority, the U.S. Constitution, dissatisfaction with the status quo, and determination to better things. These same traits apply to American doctors today.

1) American Doctors Seek Reform

A survey of 2193 doctors published in the April 1 Archives of Internal Medicine indicates 59% of doctors favor universal coverage. This survey is misleading for 2 reasons. It polls only a small number of doctors polled. And it doesn’t distinguish between single payer and incremental reform. It’s no secret American doctors are dissatisfied with the status quo, and it’s known most favor “incremental reform.” Doctors have a bad taste in their mouth over Medicare, and an even greater distaste for managed care... A truly national survey, such as the one now being conducted by Physicians Foundation for Health System Excellence, an organization representing doctors in state medical societies, will likely show what sort of reform doctors have in mind.

2) Convenience Care Will Be Wave of Future

Craving for convenience is driving health care reform. There is even a Convenient Care Association ( Thirst for convenience takes multiple forms - nurse-run retail clinics, doctor-managed retail clinics, worksite clinics, urgicenters, free-standing emergency rooms, surgicenters, and multispecialty ambulatory centers. Cash-only clinics, retainer practices, doctors making house calls, work calls, and hotel calls, and non-office based doctors bearing laptops and making e-visits are variations. All sorts of facilities are springing up in suburbs. A central theme is: go to where the patients are rather than waiting for them to come to you. Patients want convenience – nearby locations, longer hours, shorter waiting times, easy payments, and doctor’s practice who delivers convenience will grow.

3) High Tech, High Touch Will Prevail

In his 1982 book, Megatrends, John Naisbitt, after studying American newspapers for 10 years, concluded for every high tech health care development, Americans sought a high touch counterpart. For every coldly scientific specialist, Americans seek a warm generalist. For every major cancer center, there is a holistic component. Americans frequent the offices of alternative practitioners twice as often as they visit regular doctors. The trick for doctors is to find the right balance between alternative medicine and traditional medicine. Dr. Neil Baum, a medical marketing expert, says the best way to strike a balance is to ask patients about alternative therapies, show neutrality and understanding, and form and develop referral relations with legitimate alternative practitioners. Health plans cover 40% of acupuncture procedures and 80% of chiropractic care. American doctors will learn to live with alternative medicine. It’s here to stay.

4) Achieving Quality and Performance Goals Unlikely

Today the rage is to measure quality and performance of doctors through use of data. Indeed, these measurements and data accumulations have become the raison d’etre for health plans and regulatory agencies. Yet data documentation and analysis has yet to make much of a difference in efficiency and costs. Indeed, over the last 14 years studies by the Agency of Healthcare Research and Quality have shown little linkage between costs and quality. The reasons may be simple: it’s easy to measure costs, but quality resides in the eyes of beholders. Health quality doesn’t yield itself to metrics; it’s based on human relationships, expectations, and outcomes. And it’s difficult to judge physicians’ impacts on outcomes because most outcomes depend on what patients do outside of hospitals and doctors’ offices and on their socioeconomic status. Doctors have no control over how income interacts with race, gender, and education, yet these principle factors that influence health and longevity.

5) Ideas That Lower Costs Are Scarce

Experts say 70% of high health costs are due to new technologies. This may be, so the search is on for technologies that lower costs. These technologies are rare, and most focus on IT technologies – aggregating costs to identify costs of total system encounters of a given disease, data channeling patients to low cost providers; predictive modeling to show most effective intervention strategies, instant nanotechnology testing at the site of care, use of e-visits to avoid office visits, and websites, such as, showing patients what providers offer the best value for the buck. Other ideas include: doctors dropping all health plans and dealing with patients directly, cash-only practices with low overheads, preventive wellness programs cutting high cost chronic diseases in the bud, and high-deductible plans making patients more conscious and responsible for spending their own money

6) Doctors Need New Capital Partners

In the health care marketplace, the hard truths are it takes money to compete, to market, to save money and to make money. Every doctor’s health care bright new idea requires start-up capital to test its validity and marketability; every doctor organization needs capital to recruit doctor believers, to integrate, and to lay down infrastructure to establish its creditability; and every physician and every physician group must interdigitate in some way with other health care players. These are some of the reasons why doctors are partnering or being acquired by hospitals; why physician entrepreneurs are seeking out venture capitalists; why corporations are turning to doctors to help them cut down on health costs; why health plans have decided that low pay for less care doesn’t work, and more pay for coordinated care or bonuses for measurable outcomes for certain diseases might be the answer. The search for capital will create new bedfellows.

7) “Cottage Industry” to Transform

The one-on-one relationship of patients with doctors is a tested, time honored, and honorable tradition and it will continue. But it will surely change in the face of cost pressures and search for more productivity, greater convenience, and lower costs. Decentralization outside of hospitals and traditional doctors’ office is already well underway. The idea of hanging out a shingle and waiting for patients to come to you is under stress. In the future, it is likely doctors in “medical homes” and other settings will oversee teams of nurses so more patient care can be supervised; patients with chronic conditions will be handled routinely in their homes or at work through telemedicine and home visits; many patients known to the doctors will be treated through telemonitoring and audiovisual communication; and those patients who do come in for evaluation will come bearing their personal health records or computer-generate histories based on their complaints, symptoms, age, and gender.

8) More Minimal Invasiveness and Robotic Surgeries

In the quest to minimize pain, avoid complications, shorten recovery time, achieve standardization, and lower costs, minimally invasive techniques are currently in vogue and will grow in use. The most common gateway to most of these techniques is clearly either through either the vascular system – stents, catheters, ablation procedures, and implanted devices – or through laparoscopic approaches featuring small incisions, remote manipulation, visual manipulation, and things like gastric bands. Other examples are “virtual” examinations of the bronchial tree, GI tract, biliary tract, or genitourinary system. . Finally, there is robotic surgery, most commonly performed in major academic centers and large hospitals using the De Vinci system, performed on over 40,000 patients last year..

9) Problems of Managed Care

It is not an overstatement to say doctors consider themselves at war with managed care organizations that have appointed themselves as remote guardians and overseers of care. More and more doctors and their organizations are suing health plans for underpayment, delaying and rejecting claims, unwarranted bundling and lowering of fees, eliminating patients for pre-existing illnesses, canceling policies for costly patients, underpaying for out-of-network care, or so simply steering patients to lowest-cost providers, and in general, basing physician performance on a cost-basis. To doctors, the problems of dealing with health plans go even deeper and raise these questions: Who is health plans to judge what went on at the patient encounter when the plans were not there? Doesn’t what health plans do constitute the practice of medicine? Isn’t doctor time devoted to paperwork a sheer waste of training and talent? And isn’t the physician skyrocketing overhead, due largely to hiring staff to handle claims, an unreasonable health care cost?

10) IT Will Fall Short of Promises

Finally for physicians, there are the over-hyped promises of IT as the panacea for better care, lower costs, higher quality, and greater safety. So far studies have shown only marginal or no benefits of “paperless” practices. The siren songs of EMRs, PHRs, clinical protocols, evidence-based care sound too good to be true, and they ignore expenses of installation and management, lost productivity, low returns on investment, and difficulties of convincing partners and staff of value. What is needed are lower cost systems that talk to each other, portable easy-to-use entry devices, user-friendly systems adapted to practical clinical use, studies showing a positive return on investment, less harassment and pressure from those who have never been in practice, financial incentives to use the systems, systems that address the true needs of patients and doctors at the point of care.

Saturday, April 26, 2008

Emergency Rooms – Troubles and Transformations

Scarcely a day passes that you don’t read something about. ERs. Today, April 25, the Los Angeles Times and USA Today have the honors.

• The L.A. Times report “ Exodus of specialists from ERs raises concerns,” says California specialists are staying away “in droves” from ERs for various reasons – more uninsured patients, language barriers, high malpractice risks, and disruption of family and private time. Lack of specialty coverage is particularly acute in community hospitals, which have no house staff to cover. And in California, specialty shortabes are mounting, as the state cuts back on Medi-Cal because of budget overruns.

• The USA Today report “More ERs move away from hospitals “ is more upbeat. It simply says hospitals and entrepreneurial doctor groups are building more free-standing ERs, often miles away from hospitals. These new facilities have more amenities but still have life saving equipment. They have no medical ward to transfer to

The new disconnected ERs offer convenience to patients and can ease overcrowding in nearby hospital ERs. Freestanding ER grew 23% from 2005 to 2006, jumping from 146 to 179, according to an American Hospital Association survey. About a dozen more are opening or are planning detached ERs in Florida, Minnesota and Texas. In Connecticut, Middlesex Hospital has two freestanding ERs miles away from its main campus, with ambulance and helicopter services for critical patients.

Answers are evolving to relieve the ER crisis, manifest by overcrowding, ambulance diversions, lengthy waiting times, delays in transfer to medical or surgical wards, and lack of specialty coverage. Some hospitals are hiring full-time specialists and more critical care and hospitalists to meet the crisis.

I interviewed the physician who headed the California Emergency Physician organization. He had a few suggestions for helping to make ER physicians more productive: have a physician at the front door doing the triage, hire a scribe to follow the ER doctor around to document the encounter, do away with some of the software programs the doctor must open and close, minimize the bureaucratic demands of the various hospital department, pay specialists to cover.

Meanwhile numbers of free-standing ERs are growing. They’re open around the clock, offer shorter wait times than hospital-based departments, and reat a variety of illnesses and problems, such as fevers, broken bones and serious cuts. The growth of stand-alone emergency departments helps “decongest” overcrowded hospital ERs. Competition among hospitals stimulates expansion in fast-owing suburbs. Among other reasons for building free-standing emergency departments are: shortening travel times for suburban or rural residents; gaining a foothold in a growing suburb; and competing with a rival hospital.

Free-standing ERs have troubles and critics. Perhaps 10% of patients need to be transferred to hospitals. A stop in a freestanding ER may delay treatment for critically ill patients. Care in free-standing facilities costs more than urgent care centers. Ambulance services are refusing to take heart attack or stroke patients to free-standing centers . Legislators are concerned freestanding centers may not have the standards of hospital ERs.

Stand-alone emergency centers are part of convenience driven care movement featuring in-store clinics, work site clinics, and doctor-owned urgent care centers. Some of the questions being asked are: Are quality, safety, and continuity of care being sacrificed on the altar of convenience? What is the role of entrepreneurial physicians in building and owning free-standing ERs? Who sets the standards for these new centers?

Friday, April 25, 2008

Limits of health care, limits of technology - History Lessons and Health Care Arguments

In his new book, The Thirteen American Arguments: Enduring Debates That Define and Inspire Our Country, Newsweek columnist Howard Fineman says the American penchant for arguments is all for the best.

"We are an Arguing Country," he writes, "born in, and born to, debate. The habit of doing so--the urgent, almost neurotic need to do so--makes us unique and gives us our freedom, creativity, and strength." Rather than arguing too much, which is "the conventional wisdom's critique," he notes, "we in fact do not argue enough about the fundamentals." Our never-ending, evolving disputes shape the very essence of America, he maintains, serving as a blessing rather than a burden.

In health care, current arguments boil down to Big Government vs. Individual Choice, and Health 2.0 vs. Human 2.0.

Government and Choice - Proponents of government care argue only government has the wherewithal and wisdom to cover all the people for the common good. We’re doing it in Social Security, Medicare, and National Defense, why not for Health Security for all? But, ah, say historians, America is built on the Constitutional foundation of checks and balances – on a bottom-up system of governance giving individuals the right to check the power of government to intervene in individual lives.

So who will win this argument? When will reform occur? Not this year or next, maybe not even in the next decade. After all, Americans have been arguing about national health insurance since 1912. Health reform in America is an evolutionary and incremental phenomenon. What will it take? Probably a charismatic, bullet-proof President with a veto-proof, lobby-proof Congress, a promise of no tax raises, no goring of special interest oxen, and cooperation of physicians to deliver the goods.

Health 2.0 vs. Human 2.0 - Health 2.0 is the next generation Internet with increasing simple applications and simultaneously more sophisticated software allowing ever widening access and uses of information at the site of care by end-users, namely patients and doctors. Proponents of Health 2.0 argue that the health care world already runs on Internet time, that friendly end-user search and social networking programs empower and enlighten everyone; that we can now aggregate data, spend money rationally, predict outcomes, and intervene wisely; and that we can make real-time, informed decisions everywhere, anytime, every time.

Wait a minute, argue skeptics. Health 2.0 creates electronic straitjackets constraining individual choice, imposes artificial, often irrelevant decisions on doctors and patients that don’t fit real-world conditions; invades and threatens privacy and security of patients and doctors; gives payers unwarranted power to monitor and police those seeking and giving care; and, in many ways, overcomplicates, in many cases, simple clinical situations. Besides, say opponents, a computer in the same room situated between a doctor and a patient changes the human chemistry between the two. Some things are best expressed through the head of a pen rather than the click of mouse. Computers are not magical machines. Computers are human tools.
And so the arguments continue.

Thursday, April 24, 2008

Prevention - Distilling the Essence of Red Wine

“Glaxo to Buy Sitris in Bet on Anti-aging Research”, Wall Street Journal headline

Sitris, of Cambridge, Mass., is working on commercializing resveratol, a chemical in red wine, and a follow-on drug to fight diabetes and other conditions. Advocates suspect that resveratol may also increase lifespan, though that has yet to be shown.

Keith J. Winstein, Wall Street Journal, April 23, 2008

I’ve heard it said, and I’m sure it’s true
That drinking red wine is good for you.

That’s why Glaxo, Inc., is buying Sitris, Inc
Another Pharma which, acting on inc-tinct,

Sitris is hastily commercializing Reseveratol,
That stuff in red wine that’s better than Geritol,

After all, people surrounding the Mediterranean basin,
Live longer than Americans who towards death do hasten.

You may say it’s not the wine but the siestas,
But red wine adds something to life’s fiestas.

And you may say it’s all that olive oil,
That adds more time in this earthly coil.

Say what you may,
Red wine is OK.

Resveratol may make you feel more exhilarated,
It may help you liinger longer than anticipated.

Resveratol given in large doses to diabetics,
Greatly enhances glucose lowering kinetics.

And when Resveratol is fed to morbidly fat rats,
It’s been shown to gives them more times-at-bats.

When it comes to longer and better living,
Some say more red wine keeps on giving.

Whether the essence of red wine,
Prolongs life of the human line.

Remains yet to be seen,
But people will be keen,

To volunteering as subjects in clinical trials,
My bet is they’ll be lining up in the aisles.

Caveat: Too much red wine can be dangerous thing,
If it propels you to go on a derangerous fling.

Costs - Lifestyle Maintainance Costs

Each morning, I have coffee with a small group of a dozen or so older gentlemen in our town. We discuss domestic, foreign, and health affairs.

I’m the only doctor in the group. The others come from other layers of society – politics, law enforcement, small business, corporate America, insurance, and skilled workers.

Most are on Medicare, have company health benefits, or supplemental plans. Most trust their doctors. All expect prompt and immediate attention should they come down with health problems. Their ages range from 60 to 91. All function at high levels - at home, socially, and on golf and tennis playing fields.

They share with me and each other their medical problems. They’re grateful to be so active, able, and willing at their ages. Almost to the man, they have active lifestyles because of medication support, CT and MRI scans to diagnose their conditions and medical “repairs” of their aging joints or organs.

• Three cataract procedures

• Five removals of skin cancers or suspicious lesions

• Ten on various drug regimens for lipid control, hypertension, cardiac problems, pain, gout, or GERD.

• A unilateral partial knee replacement

• Bilateral total knee replacements.

• Two total hip replacements.

• A lumbar disc fusion.

• A cervical disc fusion

• Metal rods in the sternum and vertebra

• A coronary bypass

• A coronary stent

• A common iliac prosthesis

• A rotator cuff repair

• A shoulder replacement

• A periodic bladder “wash” to treat in-situ bladder cancer.

As I have talked to these gentlemen over the years, I have come to grips with three realizations.

1. They think of these drugs, scans and repairs, and prompt access to them, as the expected standard of care in America.

2. They’re grateful to be alive, kicking, pain-free, and productive at their ages.

3. They’re only dimly aware, nor do they care, that much of the cost of medicine in America goes to keeping folks like themselves functional.

How can Medicare rein in these types of costs? Should it? I have no idea. I know these gentlemen well, and in my opinion, the procedures done upon them were indicated.

They have paid their dues during their working lives, and they expect returns on investment for their blood, sweat, and tears.

Wednesday, April 23, 2008

Employers - Health Care: The U.S. Employers Perspective

U.S. health care differs from other countries largely because in the U,S. employers foot much of the bill while abroad government take most of the hit. This has its good – universal coverage, protecting individuals against insolvency, less of the GDP devoted to health care - and bad points – high taxes, stringent financial controls, and less access to high technologies.

I shall not dwell on these differences here.

Instead I shall do two things;

1) Point out the global economy, which will not go away no matter how much we legislate, is changing everything. As an American CEO has said, “We no longer view ourselves as an American company; we act as a global company in all our decision making.” And as another CEO noted, “Less than half of our workforce is in the United States – but 95 percent of our costs are.”

2) Bring your attention to a remarkable 7 page advertising section in the April 22 WSJ, “Benefit Trend: Change Is Now Constant,” produced by the Employee Benefits Institute in collaboration with Employer Benefits, Inc., laying out in detail and with frankness the U.S, employers’ position on health care..

The ad section says, among other things, that

• employers plan to continue to offer health benefits because benefits are an effective tool for recruiting and retaining valuable employees;

• employers and employees alike want employers to continue to offer benefits and prefer the employer model over a government takeover model;

• investing in programs to keep employees healthy and working beats paying them when they’re out and sick;

• employers will continue to shrink benefits for active employees and retirees and to shift cost risk to current and past employees to defray relentlessly rising health costs;.

• cost differences between U.S. health care and other countries stem largely from the desire of Americans for access to high technologies and for individual freedom and choice over community benefits;

• national health systems reduce the health cost obligations of businesses;

• the jury is still out on consumer driven care, now used by 7.5 million Americans, 7% of the market Whether this type of care will reduce costs and satisfy employees, remains in doubt, but employers are willing to give it a try, hope it will grow, and predict it will not go away.

• employers are still not at the “tipping point, “ that point at which they will decide to jettison employer-based care for a government system; not yet, but they are beginning to think seriously about it;

• employers still want government as a partner to set quality standards, to help cover the uninsured, and to continue to serve as a safety nte.

Tuesday, April 22, 2008

Future - Dream of a Perfect Health System

Last night I dreamt of a perfect health system.

It would be integrated with health plans, hospitals, doctors, and consumers having seamless equal say, pay, and power.

It would feature empowered consumers, each with personally controlled personal health records and instant access to records of doctors and hospitals they might want to visit or consult.

It would offer consumers unlimited choice and freedom to choose their doctors and treatment modalities and facilities.

It would have consumers following all of the rules of prevention and behavior – getting their tests, fleecing, eating right, exercising, and avoiding drugs, booze, and nicotine.

It would have doctors with practice websites, e-mail access, personal videos, and cell phones showing their picture as they spoke and sophisticated electronic record systems telling patients and doctors everything they wanted to know about each other.

It would have all the bells and whistles of health 3.0, including firewalls and other fail-safe systems that would prevent any breeches of patient or physician security.

It would ensure complete documentation of everything that occurred in the doctor-patient encounter, including audio and video recordings of what transpired.

It would treat all doctors fairly and equally with no financial differences between primary care physicians and specialists and with their educational and practice debts taken fully into account.

It would have instantaneous universal access at the point of care on genetic, environmental, historical, diagnostic support, and the latest research information from anywhere on the planet..

It would have protocols, algorithms, and evidence-based guidelines that would take the guesswork out of medical practice.

It would have lists of top local, regional, national, and international doctors for procedures, diseases, and life style conditions.

It would be absolutely safe – no drug interactions, no hospital hazards, no iatrogenic infections, no complications such as bed sores or venous occlusions.

It would offer financial support for patients and doctors alike – with all things covered, no fears of patient bankruptcy, and no trepidations about underpayment or exclusion of doctors.

It would cover and protect absolutely everybody for everything under the sun.

Then I awoke, pulled the covers all, and faced an imperfect but more plausible day.

I’ve got to go now. I have an appointment with a doctor my neighbor recommended

Monday, April 21, 2008

Electronic medical records, limits of technology - Bad Rap on Physician IT Use Not Deserved

Many physicians are actually very savvy, particularly when it comes to online interactions—99% of all physicians now use the Internet, according to a recent poll. In fact, I would say physicians are ahead of the curve when it comes to finding practical, professional uses for Web 2.0 technology.

Elyas Bakhtiari, “Physician 2.0,” HealthLeaders Media, April 17, 2008

I was pleased when I ran across the above quote. Generally,among pundits, government officials, and IT aficionados, physicians get a bad rap when it comes to adopting EMRs, e-prescribing, diagnostic support systems, and other IT paraphenalia.

The attitude seems to be, if information is computerized, it’s got to be good.

Wrong. It can be bad, too, when it’s too much, too soon – poorly designed, user-unfriendly, and unhelpful. What physicians want is simple, useful information when it’s needed – when sending a patient to the emergency room, or helping a patient with a newly diagnosed cancer navigate the system.

Most physicians know exactly what they’re doing. Many of the systems aren’t yet ready. And doctors aren’t ready for systems that cost too much, take too much time, require excessive documentation, slow them down, don’t meet their needs, threaten patient privacy, reward health plans and government, harass them, unnecessarily complicate their practices, and are clearly not yet up to speed for clinical prime time.

The time for practical, simple systems that improve care and make it safer will no doubt come, but for most doctors, we’re not there yet.

But physicians are ready for being paid for email communication for patients, for installing practice websites to speed scheduling, educating patients, refilling prescriptions, for reading pertinent helpful blogs from colleagues, for seeking information on google and other sites, , for educational wikis (, for sharing videos (Doctor Channel, Inc), for hanging out with colleagues (, and exchanging views on such powerful and easy-to-use online social networking sites such as

Friday, April 18, 2008

Health care, unpredictability - Health Care and the Butterfly Effect

Dr. Edward N. Lorenz, a meteorologist who tried to predict the weather with computers butinstead ended up fathering chaos theory, died at 90 on April 17 at his home in Cambridge, Massachusetts.

Lorenz was best known for describing the “butterfly effect,” the idea that a small disturbance like a butterfly flapping its wings in Brazil could cause a tornado in Texas. The flapping wings represents a small change in the initial condition of a system. This causes a chain of events leading to large-scale phenomena. Had the butterfly not flapped its wings, the final system migh have vastly differed.

Dr. Lorenz realized perfect weather forecasting was a fantasy. Perfect forecasting required perfect knowledge of wind, temperature, humidity, and other conditions everywhere around the world at one moment of time. Even a small descrepancy could lead to completely different weather.

The butterfly effect applies to all matters initiated by mankind – stock markets, epidemics, wars, global warming, forest management, mortgage crises, physician shortages, and health system costs and outcomes.

Itis also a fantasy that one can predict social consequences with computers. The variables are simply too many. As chaos theorists say, “Small variations of the initial condition of a nonlinear dynamical system may produce large variations in the long term behavior of the system.”

Health care examples are:

• Introduction of Medicare in 1965, originally estimated to cost no more than $9 billion, now consumes $400 billion, 25% of federal budget. The butterfly effects here were, given unfettered access to “free” health care, people would flock to it, and doctors would provide more of it than ever anticipated.

• Estimates of a physician glut in early 1980s by various authorative bodies, but now with a widely acknowledged physician shortfall of 30%. The butterfly effects here were unpredicted population surges, massive immigration influxes, unprecedented prosperity with more discrtionary spending,, demands for technogical access, and changes in physician behavior and health care workforce makeup.

• Technologic innovations, CTs scans and MRIs, leading to the fastest growing cost of U.S. health care segment, 15%- 20% a year. The butterfly effect here was an unparalled technological advance, allowing doctors to look inside the brain, body cavities, and joints, and becoming thought as a routine standard of care by patients and doctors alike.

• The dread of malpractice suits and defensive medicine behavior by physicians, leading to chains of tests, procedures, and referrals. These chains may cost $200,000 or more for routine workups of chest pain and severe headache. The butterfly effects here, which is immeasurable by computers, are how patients, doctors, and lawyers react to thoughts of winning or losing the lawsuit lottery and how everyone along the chain profits.

• The endgame of information technologies, which promises perfect knowledge of all the variables – financial incentives, documented actions, disease outcomes, system costs, provider behaviors – with unknown butterfly effects at present.

There is no perfect model for predicting health care costs, human behavior, and market responses. In 1964 Dr. Lorenz published described “ how a small twiddling of various paramenters in a model could produce vastly different beahvior, transforming regular, periodic events into a seemingly random chaotic pattern.’

When I contemplate health care, I think first of Mark Twain’s remark, “Everybody talks about the weather, but nobody does anything about it.” Health care is different. When I ponder health care and the “butterfly effect,” I realize everybody talks about it, everybody does something about it, everybody thinks they can use computers to measure it, but nobody knows where the next tornado will land.

Thursday, April 17, 2008

Health care and the economy -Best Kept Secret: Health Care is Good for the Economy

For many residents of Bangor, the hospital is replacing the mill as the passport to the middle class. This trend extends nationally, and it could help blunt the faltering U.S. economy. Demand for health care tends to stay strong during recession. Cash-strapped consumes are more likely to cut back on new appliances or cars than visits to the emergency room.

Conor Doughtery, “Factories Fading, Hospitals Step In,” Wall Street Journal, April 15, 2008

To hear politicians tell it, health care in the U.S is in a doleful state – unfair, unaffordable, inaccessible, uncoordinated, and uncommonly and unnecessarily complicated.

Yet if you speak to the local chambers of commerce, business groups, employer recruiters, or economists-in-the-know, they’ll tell you health care is the biggest employer in town – bigger than oil in Houston, bigger than the Street in New York City, bigger than education in Boston, bigger than insurance in Hartford, bigger than the furniture industry in North Carolina, bigger in Nashville than state government, bigger in Arkansas than chicken , bigger than Hollywood in L.A., bigger than manufacturing almost everywhere you care to look.

In the U.S. from 1998 to 2007, manufacturing fell from 14% to 10% of those employed, while health care rose from 9.5% to 11.5%. Last year, manufacturing lost 310,000 jobs. Health care gained 363.000. In places like Duluth, health care now employs 20% of all workers, up from 14% five years ago. In Minnesota as a whole – thanks to United Healthcare, Medtronic, the Mayo Clinic, and countless other health related firms in Medical Alley – health care is by far the dominant employer. In Bangor, Maine, from 1990 to 2007, manufacturing jobs fell from 16% to 6%, while health care positions rose from 12% to 20%. And so it goes in almost every city and region in the US.

Health care differs in some ways from manufacturing. Entry level jobs pay less, and wage differentials from workers and top doctors and hospital administrators tend to be greater. Health care requires more education. You can’t just step off the street into a job.

And if Democratic politicians have their way, health care may grow even faster, as more federal monies are pumped into the system. It’s going to happen with Republicans, too, as market-based health care grows. There’s no getting around it. As Americans age, they require and demand more health care. So relax, you doctors out there. You’re in a growth industry

Wednesday, April 16, 2008

Government vs Market Reform - Summary of Six NEJM Reform Articles in April 17 Issue

1. R. Steinbrook, MD “Personally Controlled Health Data – The Next Big Thing in Medical Care?” Dr. Steinbrook is national Correspondent for the Journal - Reports 26% of patients use EMR and 60% to 91% desire to use some aspect of EME. Notes that Dossia(AT&T, Intel, Wal-Mart, and 5other large employers), Google Health, and Microsoft HealthVault have entered personal health record market.

2. Pamela; HrtzbandMD and Jerome Groopman, MD, “Off the Record – Avoiding the Pitfalls of Going Electronic, ”Drs. Hartzman and Groopman are Harvard Medical School faculty members. Express cautionary warning that electronic templates may constrain critical creative clinical thinking.

3. David Goodman, MD, and Eliot Fisher, MD, “Physician Workforce Crisis – Wrong Diagnosis, Wrong Prescription. Authors are with Center for Health Policy Research at Dartmouth. Believe problem with U.S. system is not shortage of doctors, but tremendous variations in practice. Cite variations between 5 leading academic centers – Johns Hopkins, Mayo Clinic, UCLAS, Cleveland Clinic, and Mass General.

4. Kenneth Mandl, MD, and Isaac Kohane, MD, “Tectonic Shifts in the Health Information Economy. Authors are academic medical information expects from Harvard. Talk of PCHRs (Personally Controlled Health Records0 and 5 hurdles blocking adoption – agreement on standard formants, lack of commitment from medical providers. Clinical laboratory rules that do not permit release of data to patients; too much data still store don paper, no patient identifier in U.S.

5. Rebecca Kush, PhD, and three PHD colleagues, “Electronic Health Recurs, Medical Research, and the Tower of Babel, Clinical Data Consortium, Authors assert uniform standards would result in innovative research that would enhance quality and safety of daily care.

6. John Iglehart ,”Grassroots Activism and the Pursuit of an Expanded Physician Supply, “Iglehart is national correspondent for Journal. Tracks downs and ups of various prestigious medical organizations on predicting physician workforce. Despite record numbers of physicians, physician shortage said to exist. American Academy of Medical Colleges now recommends 30% increase in medical student numbers and removal of cap on graduate medical education positions. Increase in physician supply will clash with desire to reduce growth of Medicare spending

Tuesday, April 15, 2008

Costs, Health Plans - Two Pretty Kettles of Fish

The phrase :pretty kettles of fish" comes from a custom along the Scottish border during the salmon run – eating hot, boiled salmon with your fingers from a huge pot in a catch-as-catch can fashion. A pretty kettle of fish has long been synonymous with confusion, muddle, and mess.

The April 14 New York Times and Wall Street Journal contains two pretty kettles of fish boiling health plans.

• The NYT’s three lead titles say it plainly 1) “Co-Payments Go Way Up for Drugs with High Costs; 2) Insurers Shift Burden; 3) Fees for Most Expensive Class of Drugs Soar Ten Fold or More.” Not a pretty kettle of fish if you have cancer, rheumatoid arthritis, multiple sclerosis, or some other dread disease requiring drugs costing $100, 000 or more a year. Insurers, including Medicare., are abandoning the traditional practice of paying $10, $20, or $30 for a co-pay for a prescription and going to 20% to 30% of the total cost. Patients are forced to pay the price or go without. When patients go to the pharmacy, they may suddenly be surprised with a bill of $5, 000 to $10,000 or more, something they overlooked in the fine print of their health plan contract or missed in a letter from the their health plan. As one might expect, the Times editorial page followed with “When Drug Costs Soar Beyond Reach.” Its writer blamed drug companies, employers, government, and health plans for cruelty to patients.

• The WSJ op-ed column, by Dr. Jonathon Kellerman, novelist and clinical professor of psychology and pediatrics at USC’s Keck School of Medicine, paints an even less pretty picture in “The Health Insurance Mafia.”

“Most discussion about the rising cost of health care emphasizes the need to get more people insured. The assumption seems to that insurance – rather thanthe service delivered by doctor to patient is the important commodity.”

“But perhaps the solution to much of what currently plagues us in health care – rising costs and bureaucracy, diminishing levels of service – rests on a radically different approach: fewer people insured.”

“Physicians and other providers need to liberate themselves from the Faustian bargain they’ve cut with the Mephistophelian suits who now run their professional lives.”

“If substantial number of health-care providers shook off the insurance monkey off their back, en masse, and the supply of providers was substantially increased by opening more medical schools, the result would be more honest, cost-effective system benefiting everybody. Except the insurance companies.

How’s that for two pretty kettles of health plan fish?

Monday, April 14, 2008

Doctors and Nurses - Doctor Nurses

The U.S. is now 30% short of primary care doctors and nurses. As the shortage intensifies, two schools of thought about doctor nurse relationships are becoming evident, as expressed in a series of letters to the editor in the Wall Street Journal onApril 6, 2008.

1. Doctors and nurses complement and should work together as a team. Sherri Osborne, a nurse practitioner in Kernersville, North Carolina, expressed this view in a recent WSJ letter to the editor, “Each profession has a lot to learn from the other, and the problem of access to health care needs to be addressed by the physician and nursing professions working together as a team.”

3. Doctors and nurses can co-exist competing, independent professions with equal treating and admitting privileges. Carla Millis, Nurse Practitioner and president of Maverick Health in Naples, Florida, says it this way, “I fully respect the skills doctors posses, as well as their education and training. However, as a nurse practitioner, I, too, have skills, experiences, and expertise doctors don’t possess. Within my scope of practice, studies have shown my care is equal to or superior to physician care.”

4. Doctors and nurses have different backgrounds and their roles as “doctors” should not be confused. Says Edward Langston, MD, Chair of the AMA Board of Trustees. “I have the deepest respect for nurses. However, it’s an undeniable fact that a nurse with a graduate degree doesn’t have the same education as a doctor who has completed medical school and residency.”

What set off this debate? An article in the April 2 WSJ “Making Room for ‘Dr.Nurse’” The article, by Laura Landro, reports that 200 nursing schools have launched doctorates in nursing programs to produce nurse with skills “equivalent to primary care physicians.” These new doctor nurses will have two years of additional training and a year of residency beyond their nurse practitioner training.

Mary Mundinger, PhD, dean of the Columbia School of Nursing and a not-for-profit organization, the Advancement of Comprehensive Care, staunchly back the doctor nurse concept. Furthermore, the National Board of Medical Examiners is developing a voluntary Doctor of Nurse Practitioner (DNP) certificate test, similar to that given to primary care physicians, to quality, doctor nurses to practice.

It is proposed that these new nurse doctors will.

1. Have RN and NP licenses with DNP certification.

2. Be capable of managing complex diseases in hospital, ER, and office settings.

3. Concentrate on preventive and coordinating care.

4. Prescribe medications.

5. Refer to other doctors

6. Qualify for admission to medical staffs.

Whether “doctor nurses” should be considered the “equivalent of primary care physicians” is an issue that should be met head on It represents a sea change in doctor nurse relationships. There are now 125,000 nurse practitioners. Many of these could soon qualify as “doctor nurses,” as will as thousands more as nursing schools ramp up to produce more of nurses functioning as doctors.

As physicians, what are your attitudes towards this development? A good or bad thing? A potential solution to the primary care shortage? A threat to the medical professional? Please comment.

Sunday, April 13, 2008

Primary Care Educational Debt

Like most doctors, I’m easily impressed by facts. Lately, I’ve been asking myself. Why don’t we have more primary care physicians? I know the usual suspects – little prestige, lack or respect in academic medical centers, low incomes, overwork, too much hassle a plot by the A.M.A’s Relative Value Update Committee (RUC) to keep code values down.

But sometimes I don’t think we pay enough attention to the facts of educational debts of family physicians.

In a spate of letters to the editor in the NYT on April 13, 2008, about why Massachusetts lacks primary care physicians (“Universal Health Care, but by Whom?”), one letter writer, Lee Shapley from Philadelphia, who has been accepted to medical school, writes he received an acceptance package from the Boston University School of Medicne containing this financial information about the current academic year, Tuition, he adds, is expected to go up by 4.5% next year.

Tuition: $42,734
Fees: $2,914
Room and Board: $11,923
Books and supplies: $2,845

This totals $60,416.

Now let’s do a little more math, assuming a 4.5% tuitions increase each year.

Cost of year #1 - $62, 735

Cost of year #2 - $65,558

Cost of year #3 - $68,307

Cost of year #4 - $71,381

Total $267,981

Paying off the principle of debt over the course of five years would require monthly payments of $4450, with more added for interest of course.

Assume no more debts are acquired during residency and the entry income of a family physician at $150,000, or $12,500 a month before taxes, and you get the picture.

Given these facts, it is hard to argue with Mr. Shapley’s concluding paragraph.

With a debt load that size, a family practice doctor would probably take home less money than a registered nurse/. Until the reimbursement system is fixed and the debt load addressed there will be shortage in primary care. The numbers don’t lie.

Limits of Technology - The Limits of Digital Technology

Comparing past and present to look for changes is an essential part of reading mammograms. But the digital and film versions can sometimes be hard to reconcile, and radiologists who are retraining their eyes and minds may be more likely to play it safe by requesting additional X-rays — and sometimes ultrasound exams and even biopsies — in women who turn out not to have breast cancer.

Denise Grady, “In Shift to Digital, More Repeat Mammograms,” New York Times, Aparil 10, 2008

Technology was going to solve all of our problems. Life was about to become easier and a lot more fun. Well, here we are. It didn't quite pan out, did it? As we spend a larger and larger portion of each day staring at screens, we are effectively redefining our priorities and thus our lives. And the question remains: Will it make us happy? This answer is hugely important. If we knew it, we would be able to figure out the best ways to deploy and live with these fantastic technologies.

William Powers: Off Measure: Measure for Pleasure. National Journal, April 11, 2008

As a pathologist, I’ve always admired and envied radiologists. Radiologists have been riding a technology wave for 20 years – CT, MRI, and now PET scans – all powered by digital technologies, all giving them the story.of what’s going on inside the body and the joints.

Pathologists, it is said, know everything, but it’s too late. Not so for radiologists. They know everything, and it’s early. Pathologists have to have the tissue in hand. Radiologists can see it clearly from afar. We influence care from the backlines; radiologists are on the frontlines. Indeed, the current breed of medical students and residents may order radiographic images even before they do the physical.

For radiologists, digitally-powered images have become the magic wand. There’s only one problem, of course. What images mean reside in the eyes of the beholder. Image subtleties must be interpreted. It’s a high art form, based on years on experience, a discerning eye, the quality of the image, comparison to past images, even the mood, time of day, number of images required to be interpreted, and in the case of mammography, the density of the breast tissue.

Just because mammograms are now digital doesn’t remove the subjective element in interpreting them. Radiologists know this. That’s why they ask for repeat films. That’s why they compare present images to past images. That’s why mammogram interpretation is such a frequent source of worry about malpractice suits. Interpreting images is not an easy business, even to those of us who envy radiologists.

Yet, to some left brain linear thinkers of the world, if it’s digital, it must be better than the old ways of looking at things. But we right brain image-oriented thinkers know new technologies don’t remove the subjectivity of reading images, particularly when comparing the new to the old.

As a radiology friend of mine once told me, “The technology is always ahead of the interpretation.”

Thursday, April 10, 2008

Physician Business Ideas - New Parkinson’ Law: No Office, No Staff, No Waiting Room, No Overhead, No Bureaucracy, No Problem

Work expands so as to fill the time available for its completion

Parkinson’s Law, 1955

I keep running across MD innovators in their thirties. They want nothing to do with old ways of doing things. Today I spoke to Jay Parkinson, MD, 32 year old founder of a new web program, It debuts in June, 2008. will be an online site allowing doctors and patients to talk to each other. There will be no third party, no doctor’s office, no office staff, no health plan. All patients will need to talk to their doctor will be a personal phone call. Parkinson envisions a mobile neighborhood service. Doctors will make house alls and work calls, whatever is most convenient to patients.

Parkinson is a 32 year old year old who cut his teeth on computers at age 5. He graduated from Washington University Medical School, did a residency in pediatrics, and restricts his practice to the under 40 crowd (average age, 27). His patients come from Gen Y, those under 30. His patients are largely artists, writers, artisans, freelancers, digital media folk and other young professionals in his Williamsburg, Brooklyn neighborhood.

Parkinson regards patients as online pals. They trust him and each other, but tend to distrust those in the medical establishment over 40. Parkinson is big news these days. He’s the cover boy in the most recent issue of Hospital and Health Networks, HH&N, the American Hospital Association’s main publication, “America’s most wired healthcare magazine.” HH&N dubbed him “Dr. IM” (IM is Instant Messaging) on its cover and ran a 2300 word article “Your Future Chief of Staff?” Among the young MD entrepreneurial crowd, that’s an impressive and memorable debut.

Dr. Parkinson is six months into his practice, has 3000 active patients, and makes 8 visits a day to his clients, Half of patients are uninsured and willingly pay his $150 to $200 fee. Parkinson never leaves ZIP code. You communicate with him by email, text messaging, or by cell phone video, not by snail mail.

Dr. Parkinson answers phone calls in person. He says his clients are responsive and comfortable with the convenience of online neighborhood care, and often refer their friends to him.

Gen Y, he asserts, want understandable, transparent, and, above all, convenient care. They seek the same level of service they get from banks and other commercial firms. They don’t balk at online care. They expect it.

When patients need a specialist or a surgeon, or a hospital or free standing clinic, Dr. Parkinson is ready. He has done his homework and knows prices and quality. Of his approach, he says, “Keeping in touch with clients is cool. I think it is quite revolutionary.” is venture backed. This online service will guide patients to a pleasant consumer experience, provide free generic drugs when needed, negotiate discounts from neighborhood merchants, provide personal access to physicians. For doctors, Hello Health will allow provide more freedom, more money, closer patient relationships, and more personal care.

Personally, as someone well beyond 40, of an age where I
may come down at any moment with a chronic disease requiring coordinated comprehensive care, I’m dubious about, perhaps because I may be moving soon towards, or even

Besides, as time passes by, I may have to trust somebody over 30, even over 40. Sir William Osler once said, tongue-in-cheek, that we ought to eliminate everybody over 40 to make health care more efficient. Fortunately, we’re not there yet.

The HH & N article doesn’t restrict its comments on online medicine to Parkinson. It also cites the work of Dr. Allen Wenner, a South Carolina primary care doctor. He developed the Instant Medical History where patients can tell their story using structured clinical algorithms

Dr. Parkinson’s online concept reminds me of the young lad who, after mastering hands-on bicycle riding, lets loose of the handlebars, looks at mother, and yells, “Look, Maw, no hands!” In Parkinson’s case, it’s no office, no staff, no paperwork, and presumably no problems, provided he doesn’t fall off hi bike and his patients don’t need to go off-line.

I wish Dr. Parkinson luck. He is a great geek and a fine doctor, and extremely innovative. All cash may be a bit rash, but it might just work, for the young and healthy at least.

In any event, the new Parkinson Law bids well to replace the Old Parkinson’s Law -
Expanding bureaucracy to fill the time and space provided for it. The New Parkinson’s Law cuts bureaucracy, and fills the time left to care for patients. It’s a noble idea, and I applaud it.

Prevention - Apples and The Metabolic Syndrome

Remember Johnny Appleseed
All ye who love the apple
He served his kind by word and deed.


Ordinarily, as a pathologist, I don’t speak of clinical matters. Clinical medicine is not my core competence But apples are in exception.

A recent study indicates a daily diet of apples or its byproducts – apple sauce and apple juice - may prevent or ease the metabolic syndrome.

Metabolic syndrome affects as many as 25% of adult Americans. It is defined as having three or more of these signs,

• Fasting hyperglycemia — diabetes mellitus type 2 or impaired fasting glucose, impaired glucose tolerance, or insulin resistance;
• Hypertension;
• Central obesity(also known as pot or beer belly), with fat deposits around the waist;
• Decreased HDL cholesterol;
• Elevated triglycerides

The study, presented at the Experimental Biology 2008 meeting this week, analyzed adult food consumption data collected in the 1999-2004 National Health and Nutrition Examination Survey (NHANES), the government’s largest food consumption and health database.

Dr. Victor Fulgoni, PhD, a nutrition expert and senior Vice President of Nutrition Impact, LLC,. studied consumption of apples and apple products, nutrient intake, and various measures related to metabolic syndrome. When compared to non-apple eaters, adult apple product consumers had 27% less odds of being diagnosed with metabolic syndrome.

Adults who eat apples and apple products have smaller waistlines , less abdominal fat, lower blood pressure, and a reduced risk of metabolic syndrome. They have 30% less elevated diastolic blood pressures, 36% decreased elevated systolic blood pressure, and a 21% smaller waist circumferences – all precursors of cardiovascular disease and metabolic syndrome.

Furthermore, apple eaters’ diets are healthier than apple eaters – they take in more fruit and key nutrients, including dietary fiber, vitamins A and C, calcium and potassium. Apple aficionados also eat less total fat, saturated fat, discretionary fat and sugars.

To talk of the metabolic syndrome and the role of apples in preventing or easing it is a handy way of expressing alarm about that precursor triad – high blood sugar, hypertension, and obesity – occurring alone or in clusters to produce the three most devastating killer diseases in America - diabetes, heart disease, and chronic heart failure. Together these killer diseases are America’s leading cause of death and disability and account for more than 50% of health costs. If something as simple as an apple, or two or three a day, can slow the death toll, apples are worth talking about.



Wednesday, April 9, 2008

Clinical innovation - 12 Things I've Learned from Blogging about Innovation

12 Things I’ve Learned from Blogging about Innovation

“Imagination is more important than knowledge”

Albert Einstein

“Let computers compute. It’s the age of the right brain.”

“Bright Ideas” headline, New York Times, April 6, 2008

In November 2006, I started a blog, I was in the midst of writing a book Innovation-Driven Health Care: 34 Key Concepts for Transformation (Jones and Bartlett, 2007). I wanted to get my arms around the Innovation Universe. Little did I know that I had embarked on writing a daily blog , talking to hundreds of like-minded people, and culling what I could from the health care innovation literature.

Here are 12 things I’ve learned.

One: We’re all in this together. People from every health care sector – 636, 000 doctors, 39 million people with health care conditions, 3.4 million nurses, 64,000 in hospital administration, 1167 HMOs and PPOs, 182,000 dentists, 21,000 pharmacy chains, 59,000 pharmacies, 45,000 pharmacists, 135 million households, and 12 million healthcare workers – have innovative ideas on how to make things better.

Two: Think small. Chunk. Chunking is defined as “Allowing complex systems to emerge out of links among simple systems that work well and are capable of operating independently (Edgeware, VHA. Inc, 1998).

Three: Invite wild and crazy ideas. Gather your people from the front lines of your organization and ask for wild and crazy ideas. Enforce only one rule: no snickering.

Four: Appoint a chief innovation officer for your practice – no matter how small and no matter what level of authority. In medical practices, the best CIO is often a nurse. If you’re a doctor, have her follow you around and ask, “How could I do this better?”

Five: Respect health consumer intelligence. Theywill make a few mistakes, but they will learn quickly, particularly if they’re spending their own HSA in high deductible plans.

Six: Let patients do their own electronic history. Permit patients, guided by clinical algorithms, enter their own history based on their gender, age, and chief complaint. The result is a thorough, accurate, documented, record with minimal data entry costs.

Seven: Engage patients at their communication and convenience level. Emmi Solutions, Inc, in Chicago, allows doctors to “prescribe” interactive online programs, downloadable at home, for patients – led by pleasant voice, anatomic illustrations, and plain language – telling them exactly what to expect from upcoming surgery.

Eight: Make it simple for patients to “talk to each other” and share information online: For patients there’s a website called and for doctors there’s a professional networking site named, (“sermo” is Latin, for “conversation”, which now has over 60,000 doctor members, and for medical students and residents there’s

Nine: Get a dialogue going between innovators everywhere. Perhaps the best site now going in this venue is www., sponsored by Humana, Inc.

Ten: Don’t fear borrowing ideas from retail or engaging retailers in the innovation process. Examples are retail clinics, worksite clinics, posting prices, or in being transparent in what you’re doing or how good you are compared to the competition.

Eleven: Remember this: If it doesn’t work for physicians, it isn’t like to help patients. A glaring current example, is the miserably low physician adoption rate of electronic medical records (EMRs), which sound good in theory but fail in execution. There are simpler ways for patients to communicate – email.

Twelve: Learn from leading innovative organizations. Visit their sites and watch their smoke. Here’s a list for starters. See, April 3, #477 in a series.

Tuesday, April 8, 2008

Physician incomes - Income Comparisons

Whenever one talks to physicians about comparitive incomes and their standing in the economic scheme of things, sooner or later they come around to comparing themselves to professionals in other fields. These fields most commonly include sports figures, corporate executives, and hospital CEOs – fields where formal educational requirements are far shorter and less stringent than in medicine. Sometimes stock brokers and other financial types are mentioned. For good reason. According to Bloomberg News, the average Wall Street bonuses for 2007 exceeded $200,000 pr person.

Never mind that these other professionals function in different environments. Or that comparing physicians to these high-earners, matches apples against oranges.
The market judges sports figures by the television revenues and crowds they attract; corporate executives by the magnitude of enterprises and revenue they oversee; and hospital CEOs by what their boards, stacked with local businessmen, deem they deserve.

Physicians, on the other hand, generally practice on a one-on-one basis, making life and death and health decisions, in what critics often deride as a “cottage industry,” as indeed it most often is. You don’t attract hordes of fans, employ or oversee thousands of workers, or supervise sprawling health care enterprises.

Third parties, interested in containing costs, decide what physicians should be paid. Doctors generally enter medicine not for the money, but for the mission. A large element of altruism and idealism remains. Still, educational debts, malpractice premiums, staff, and college tuitions must be paid. Doctors are human. They want to enjoy the simple luxuries as much as other folk, and they want to do well while doing good.

This week newspapers published average salaries in other fields.

• Major league baseball players. $5.1 million, up 7.1%

Source: USA Today, April 2

• Corporate executives of 200 large companies, $11.7 million, up 5.0%

Source: New York Times, April 6

• CEOs of top ten hospital systems, $5.9 million, no comparison to
previous years

Source: Wall Street Journal, April 4.

I unearthed comparable figures for doctors and found these numbers,

• Average primary care incomes, 1995 to 2003, $121,000, -10%\

• Average specialty incomes, 1995-2003, $175,000 -2%

Source: American Medical News, July 24/31, 2006

These income figures seemed low to me, so I sought later figures being offered to physicians being recruited.

Income offered to top 15 recruited specialties in 2006.

1l Internal Medicine, $162,000
2) Family Medicine, $145,000
3) Radiology, $351,000
4) Orthopedic Surgery, $370,000
5) Cardiology, $342,000
6) General Surgery, $272,000
7) Hospitalist, $175,000
8) OB/GYN, $234,000
9) Gastroenterology, $315,000
10) Emergency Medicine, $230,000
11) Urology, $320,000
12) Anesthesiology306,000
13) Psychiatry, $174,000
14) Neurology, $210,000
15) Otolaryngology, $272,000
Average, $258,000, -1.1%

Source: Merritt, Hawkins, & Associates, Guide to Physician Recruiting (Practice Support Resources, Inc,, 2007)

On the whole, physicians have nothing to complain about except their incomes remain flat and don’t keep pace with inflation. Except for some doctors on the lower rungs of primary care, doctors are still among society’s top earners Also we’re comparing here average incomes of physicians to top incomes of people in their respective fields. Markets drive incomes in other fields. In medicine, third parties like Medicare and health plans call the tune. Finally, it is unclear what top earners in medicine make, although I doubt their average top income exceed $1 million on average, at least I have never seen figures to that effect.

After all is said and done, this little comparative exercise , flawed as it certainl is, has some utility. It puts matters in context. Also note that ambitious young Americans are sharply aware of these differences in earning potentials. This may be why our best and brightest often select entrepreneurial, financial, technological, and managerial fields over medicine.

Monday, April 7, 2008

Hospitals and Doctors - Nonprofit Hospital Revenues Soar: CEOs Profit

The April 4 WSJ contains a front-center page article entitled “Nonprofit Hospitals, Once for the Poor, Strike It Rich.”

And so they have. Revenues of the top 50 non-for-profits increased 8-fold, from $544.7 million in 2001 to $4.27 billion in 2006. Twenty five of the nonprofits earned more than $250 million.

The CEOs of major nonprofit hospitals did well too.

Best Paid CEOs

1. Gary Mecklenburg, Northwestern Memorial Hospital , $16.4 million, 2006

2. Floyd Loop, Cleveland Clinic, $7.5 million, 2006

3. Mark Neaman, Evanston Northwestern, $5.4 million, 2006

4. Lloyd, Dean, Catholic Healthcare West, $5.3 million, 2006

5. Phillip Incarnati, McLaren Healthcare, $5.2 million, 2006

6. Joseph Trunflo, AHS Hospital, $5.0 million, 2005

7. Alan Bransi, Promedica, $4.3 million, 2005

8. Herbert Pardes, New York Presbyterian, $3.5 million, 2006

9. Jeffrey Romoff, University of Pittsburgh Medical Center, $3.3 million, 2006

10. Douglas French, Ascension Health, $3.3 million, 2004

Reasons given for the hospital profit boom and high CEO pay are:

• Gradual increase in Medicare reimbursements

• Mergers with minimization of competition

• Demanding upfront payments from patients

• Hiking costs for procedures and services several times their actual cost

• Focusing on high-end procedures

• Selling patient debts to collection agencies

• Issuing tax-free bonds and investing proceeds in high yield securities

The questions raised in article are:

Do these nonprofit hospitals’ profits make sense when costs are perceived to be out of control?

Are nonprofits giving enough back to communities in charities and other programs to justify their tax-exempt status?

Is the term “nonprofit” a misnomer?

Should it be replaced by “nontaxable”?

Should nonprofits be taxed?

I await your opinion.

Sunday, April 6, 2008

Rural Practice, Physician Business Ideas - Rural Vs Urban Practice: The Lure of the Country, The Pull of the City

Fly the rank city, shun its turbid air:
Breathe not the chaos of eternal
And volatile corruption.
…and tho’ the lungs abhor
Those tender cells that draw the vital
While yet your breathe away! The ru-
ral wilds

John Armstrong, M.D. The Art of Preserving Health, 1744

When it comes to luring doctors to practice, the city wins hands down over the country. Cities attract 134 vs. 54 specialists and 77 vs. 53 primary care doctors per 100,000 populations.

But it doesn’t not always need to be so. David Rousch, president and COO of which does 60% of its business in rural America, writes in the April 2 that three myths exist concerning rural practice.

Myth #1: You won’t make much money. He says rural physicians have 13% more purchasing power than their urban counterparts and average $242,000 per year compared to $235,000 for urban physicians.

Myth #2: You’ll be on call 24 hours a day, 7 days a week. Rousch says rural doctors have more time with family and non-professional pursuits. Among other reasons, they’re not spending 1 to 3 hours a day commuting to work

Myth #3: You can’t possibly know enough (you’ll be isolated and “over your head.) Not true according to a survey. Rural doctors feel more closely connected to colleagues and have closer relationships to specialists to whom they refer.

Rousch concludes with these advantages of rural practice.

• Slower pace of life
• Greater feelings of safety for self and family
• Less traffic and pollution
• Shorter commuting times
• Higher net income
• Lower housing costs
• Less competition
• Closer proximity to outdoors
• Increased status in community

Rousch has his own business ax to grind, but what it has to say has the germ of truth. Still the ratio of urban/rural doctors in primary care is 1:5 and among specialists, it is 2.5: 1. Clearly most of the profession continues to prefer urban to rural practice.

Saturday, April 5, 2008

Spencer - Poet-at.Large and Priest-To-Be

Prelude: One of the joys of writing a blog is you can express your personal feelings. Here a proud father writes about his son. Most of my blogs concern innovation. A key to innovation is keeping an open mind to developments like spirituality in medicine.

Usually fathers teach sons. For me, the reverse is true. My son taught me what I thought I knew.

My son, Spencer, a well-known poet, will enter Yale Divinity School this fall. Three years later, he will emerge an Episcopalian priest. He wants to serve hospice patients. He now performs this work in a West Palm Beach hospice.

Spencer was born in 1964 at Hartford Hospital, where I was a resident in pathology, and my wife was a nurse. He weighed in at 10 pounds, the biggest kid, in the nursery. OB Nurses called him The Prince.

He attended Bowdoin for two years, graduated from Wesleyan, and earned Masters from York University in England and Harvard Divinity School. Unfortunately, he had no practical career plans.

He toiled for 12 years at Brooks Brothers, first in Minneapolis, then in West Palm Beach and Palm Gardens. During the day he plied the retail trade. In off-hours he composed poetry.

Publishers rejected 300 poems. Spencer persisted. Then, Louise Gluck, America’s poet laureate, spotted his work. She put in his name for the Bakeless Prize at the Bread Loaf Writers Conference. He won. A book of poetry, The Clerk’s Tale (Houghlin-Mifflin, 2004) resulted.

Gates opened. Fame followed. He read before the Library of Congress, won a Guggenheim and other prizes, and recited at leading universities and book fairs. The New York Times, the Washington Post, and major Florida papers interviewed him. The American Poetry Review adorned him with a full page picture on its cover, and his essay “A Man of the Cloth” appeared in the New York Times Magazine. He became known as the Bard of Brooks Brothers.

My wife and I attended two of his poetry readings. We came away with these impressions.

1) Poetry is big.

2) Spirituality is back.

3) Materialism is out.

4) People seek hope.

5) Rejection inspires.

A Father’s Learning Curve.

What I have learned?

Importance of humility. At York, Spencer studied humility in works of Renaissance poets, George Herbert (1593-1633) and John Donne (1572-1631). Humility shines through in Spencer’s readings. People like humility in this age of celebrity self-centeredness and quests for instant fame.

Power of language. You see this in Barack Obama’s speeches. In Spencer’s case you sense it in his poetic
imagery. Here he describes how a mother reacted to her baby’s death in hospice, “The mother walked out of the room, her arms slackening at her side like old latches on the door of an abandoned house.”

Dignity of death. As Spencer explained to me, “Dad, all people want as they lay dying is the sense their lives meant something – even if only to themselves.”

Perhaps that’s what John Donne meant,

” Death be not proud, though some have called
Mighty and dreadful, for thou art not so,
For those whom thou think’st thou dost
Die not, poor death, nor yet canst though kill me.”

Spirituality to medicine. People thirst for spirituality. One hundred of America’s 150 medical schools now have spirituality as part of required courses. People are recognizing science and technology have limits, end-of-life care has a spiritual side, hospice care is relevant, managed care offers little solace, holistic medicine is here to stay. Americans and doctors are maturing in their attitudes towards aging, disease, and death. Machines will not get us out of this alive once the end nears.

When my time comes, I will rejoice. People like my son.
Spencer, will be there to comfort me, tell me I meant something, and guide me to what beckons beyond.

Thursday, April 3, 2008

Innovation Centers - List of Health Care Innovation Centers

I recently interviewed Lyle Berkowitz, MD, a 42 year old internist who is program director of the Szollosi Healthcare Innovation Program at the Feinberg School of Medicine of Northwestern University in Chicago.

Dr. Berkowitz believes innovation offers America the surest and best chance of offering better health care for patients and physicians alike. He is now touring America, visiting various innovation centers. As part of our interview, he supplied me with the following list of major centers of healthcare innovation in the U.S. with some of their contact information.

Innovation Centers

• Kaiser Garfield Innovation Center:

• Group Health’s MacColl Institute for Healthcare Innovation:

• Johns Hopkins Center for Innovation (Peter Provonost) –

• MGM Innovation in Primary Care –

• Vanderbilt Innovation team:

• Ascension Health:

• Geisinger Ventures:

• The Innovation Program at Partners HealthCare

• Innovation Center at University of Pittsburgh Medical Center

• Northwestern’s Szollosi Healthcare Innovation Program (SHIP): (coming soon)

Other relevant innovation organizations

• IHI Institute for Healthcare Improvement:

• California Healthcare Foundation:

Reece, personal musings - On Being Dyslexic

I have a confession to make

I am dyslexic

It’s not asey being dsylexic

I titled my last medinnovation blog

“Slwoing” the growth of health costs

You’d think I’d spellcheck

I will the time next

Being dyslexic

Can be downright em-bareassing

If you know what I mean

I don’t google

I go ogle

I don’t walk into a bar

I walk into a bra

In church I don’t say

Word of God

I say Gord of Wod

I reverse telephone numbers

And my social security number

People don’t understand

Dyslexia is verbal contraband

I misspell words

I mix up my “c’s” and “s’s”

and my “b’s” and “d’s”

and my bvds and my dvds

I misread the clock

And the time of day

Instead of 2:10 it is 1:20

I’m always early – or late

No, it’s not esay being dyslexic

Especially in something

As delirious as health.

Dyslexia is not sexia

Please forgive me

I know not always

What I did.

Wednesday, April 2, 2008

Massachusetts - Slowing Health Costs - The View from Boston

Three doctors from Partners HealthCare System – Drs. James Morgan, Timothy Ferris, and Thomas Lee – outline options for slowing health cost growth in the April 3 New England Journal of Medicine.
Brigham and Women's Hospital and Massachusetts General Hospital founded Partners HealthCare in 1994. Partners is a vast integrated health care system. The system includes hundreds of primary care and specialty doctors, five community hospitals, a psychiatric hospital, the two founding academic medical centers, specialty facilities, community health centers, and related health entities. In many ways, Partners dominates Boston’s health scene..


Here’s what the three doctors see as options to reduce cost growth.

1. Allow current situation to persist, an unthinkable solution.

2. Invest in effectiveness review bodies to maximize cost effectiveness.

3. Promote EMRs to yield to maximize computerized diagnostic support.

4. Standardize transactions to drive down administrative costs.

5. Back regional efforts to improve care at end of life.

6. Support prevention programs to enhance quality of life and worker productivity.

Potential of Options

And here’s what options the three doctors thought had the greatest and least potential.

Highest Potential

• Payment reform through capitation, case rates, or P4P –Capitation is limited by patient preference; case rates apply to only small numbers of patients; and P4P remains unproven value but is evolving.

• Effectiveness review of new drugs and technologies - May limit innovation and delay new products.

• EMRs - May reduce variation but will require time, resources, and cultural change.

• Improved care for chronic disease - Most promising but requires organized providers and payment reform

Intermediate Potential

• Restructured end-of-live care – Requires profound cultural change.

• Consumerism – Limited because it helps relatively well and not the chronically ill.

• Reduced administrative costs – May result in some savings, but reduces choice and innovation, and may lead to government intervention, delays, and reduced benefits.

Lowest Potential

• Malpractice reform – Needs improvement but will have limited effect on costs.

• Drug pricing reform – Will have modest cost effect, and will restrict innovation.

• Prevention – Not shown to reduce overall costs; may shift costs to Medicare

Rationing Options

• Indirect through fixed budget for all payers – Doesn’t fit American culture; requires large government role; and hasn’t succeeded in other countries

• Indirect through expanded consumer choice, restricted Medicare and Medicaid - Will present dramatic visible evidence of two class culture; and is not compatible with U.S. core values.


Boston’s three leading Partners doctors conclude: Move away from clich├ęs fitting political beliefs and grapple with true effectiveness and political realities. Have true dialogue during election year.

That’s the view from good old Boston,
The home of the Bean and the Cod,
Where the Lowells talk only to the Cabots,
And the Cabots only to God.
Where physicians from a leading academic center,
Pride themselves on being our economic mentor.
But where costs are highest in the land,
At least that’s where things now stand.


1. Morgan, J.J. et al, “Options for Slowing the Growth of Health Costs, “ NEJM, 358:1509-1513, April 3, 2008

2. City vs. City: When It Comes to Health Insurance Costs, Geography Matters. Press Release, December 21, 2006. Agency for Healthcare Research and Quality, Article says individual coverage for Boston worker, $867, is highest among U.S. cities.

3. “Health Plans Say Transparency is Two-Way Street, “ Boston Business Journal, March 28, 2008, contains this quote, ‘Massachusetts health care is the most expensive in the world and the premiums of the health plans reflect the cost of the care given,’ said Dr. MaryLou Buyse, a primary care physician, who is president of Massachusetts Association of Health Plans. “
“Health care spending per person in Massachusetts in 2006 was $9,662, compared with the national average of $7,256. MAHP statistics show health care spending here grew from $46.5 billion a year in 2002 to $62.1 billion in 2006 -- an increase of 33 percent. Overall premiums in the state have been rising between 8 percent and 12 percent each year for the last several years. “

Tuesday, April 1, 2008

Minnesota - The Minnesota Health Reform Dream

Minnesota considers itself a state that works. I know. I lived and practiced there for 25 years. The mix and success of its liberal politics and conservative business practices always astonished me.

Minnesota believes you can do good and do well at the same time with the right top-down, bottom-up alignments. In the current health care scene, with public-private sectors cooperating, Minnesota legislators believe you can cover the state’s 374,000 uninsured, shave 20% off the state’s health bill, improve health, ease disease burdens , and small and big businesses will still do well, all in a state that consistently ranks number one among the 50 states in its citizens’ health status.

A pipe dream? An An April Fool Joke? Perhaps, if no financial mishaps or budget overruns occur. In Minnesota with its highly educated, mostly white but shrinking populace, and its relatively small but growing underclass, it could work.

It probably won’t. But it might. Minnesota, after all a state of 5.2 million people, has the lowest rate of uninsured, 7.2 %, in the nation, and that will help cut the state’s looming budgetary shortfall. As one cynic remarked, “There’s always gloom for improvement.”

The Minnesota Senate is considering passing health reform bill, which has yet to pass the House and withstand a possible Governor’s veto. The bill contains some of these elements.

• Hospitals and doctors fees will be made public ( lack of transparency is considered errancy).

• Primary care doctors will be paid more for creating 24/7 medical homes where care will be coordinated( the compulsion to coordinate may be inordinate)

• Standard benefit sets for common care will permit consumers to compare care and prices ( standardization trumps individualization)

• The state will mandate tracking of childhood obesity levels (The body mass index is more important than exercise during gym class or recess)

• Chronic disease will be managed through nurse phone calls, not through doctor office visits ( home visits will supplement frequent doctor re-visits)

• Small businesses and individuals will be able to purchase private health plans with tax-free dollars ( the desire is to level the health care playing fields , i.e. require big and small employers to act the same).

Some of these things sound sensible – transparency of fees, chronic disease management by nurses, tax credits for all – but others – tracking childhood obesity – do not. The latter smacks of government invading private lives. What will be next – monitoring diets, randomly checking blood alcohol and nicotine levels, surveillance of smoking in the home?

Can government cut health costs? The failed Medicare precedent is evident. Nevertheless, that’s the central strut of Minnesota’s health bill and Democratic presidential candidates’ health proposals. The proof will be in the pudding (fittingly, a sweet dessert with a creamy texture), but the pudding will take a long time to cook.

Can government save money by forcing all to buy health insurance? Individual mandates, liberals claim, will lower premiums for all. It will compel young “invincibles,” who deem themselves immortal and who prefer to spend money on other life style choices, to buy insurance and help carry the load for the old. Unfortunately, here the Law of Unintended Consequences kicks in. In mandate-enforced Boston, health premiums for the young cost five times more than in mandate-free Tucson. It may also be why health costs are so high in Minnesota. It has a nation-leading number of 64 mandates premiums must cover.

But I’m off track. The Minnesota legislature doesn’t propose individual mandates. Instead, it’s saying , among other things, that making fees public and allowing consumers to compare care and prices will allow private competition to thrive. To the governor, it’s a market based bill.

On a national level, there are sensible basic steps that could be taken to lower prices and improve care.

• Allow national health plans to compete across state lines, another way of saying, make health plans portable.
• Reduce mandates in states, the main reason state premiums vary so much.

• Post prices for insured – and uninsured.

• Reform malpractice.

• Repeal state laws limiting retail clinics

• Scrap employer health plan deductibility and introduce health care tax credits for every individual.

These steps may never be taken. They are too sensible for the Wise Wizards, dubbed the Bungling Bureaucrats by some, of Washington and state capitols. These technocrats believe they and only they, not consumers, have the wisdom to bring about affordable health care.