Thursday, July 31, 2008

"Ask Your Doctor," "See Your Doctor"

So run taglines on ubiquitous pharmaceutical commercials. One ad even goes so far as to say, “If you have an erection lasting more than four hours, see your doctor.” Chances are your doctor will see you because he/she has never seen a four hour erection.

If I were the doctor, I wonder how I would handle the problem. Is there a known antidote? Would a bucket of ice water do? Do I refer this rare rigidity problem to an urologist who knows about priapism? Do I go to the Internet? I just googled for an answer and didn’t find any in medical texts.

According to Slate Magazine, a non-medical publication that usually only talks of political resurrections, says of a four hour erection,

”At least 38 men who have taken Viagra have gone blind, and the drug's manufacturers said it would consider adding a warning to the label. Drug companies already warn consumers that Viagra and competitors like Levitra and Cialis have several other side effects, like blurred vision, headaches, indigestion, and painful erections that last four hours or more. What do you do with an erection that won't quit?”
“Call your doctor—and be very, very afraid. Though the makers of erectile dysfunction drugs list prolonged, unwanted erections as a potential side effect, urologists have their doubts.
Priapism, a rare condition defined by prolonged erections in the absence of sexual arousal, is associated with certain blood diseases, hypertension, and recreational drug use. No matter what its cause, priapism can be dangerous if left untreated. A man who has a painful erection for more than 12 hours is at high risk for permanent damage.”
I don’t want to make too much fun of this. It is no laughing matter when blood for your brain and other vital structures pools in another organ..

Besides, the idea of asking or seeing your doctor for every possible side-effect is a serious business.

I don’t blame the pharmaceutical industry. What they advise is a safe and easy thing to do, and it’s good malpractice cover. Moreover, it may flatter some doctors to be asked. But, sad to say, doctors don’t know everything. And doctors may be a bit irritated spending time answering questions posed by the pharmaceutical industry, or feeling pressured to prescribe every pill that alluring Pharma ads recommend.

I suppose it all comes down to a matter of patient-doctor trust, which, according to a recent NYT article, is slipping with ¼ of patients saying they distrust their doctors. This may be because, given declining reimbursements, doctors can’t afford to spend more than 8 minutes or so per patient. One suggested solution is to have patients show up with a list of questions – no more than three please. Most doctors don’t have the time to go through the complete list of side-effects or contraindications rolled out on those ads or on medical websites.

I suppose the doctor could say, ask your drug manufacturer or their lawyers, or I can’t protect against all eventualities listed by the drug manufacturer, but that would be tacky and might destroy the image of the all-knowing, all-seeing, and all-answering doctor.


Tara Parker-Pope, “Doctor and Patient, Now at Odds, “ New York Times, July 29, 2008.

Wednesday, July 30, 2008

Interview with Health Care Buzz Word Expert

Medinnovation: Are you a health care buzz expert?

Buzz Word Expert: Indeed, I am. My remarks will reek of transparency, interoperability, transferability, the scholarship of quality and will be evidence-based and digitally-supportable.

Medinnovation: Well said. Can’t ask for anything more than that. But what exactly is a health care buzz word?

Buzz Word Expert: It is a fashionable word or concept associated with health care not understood by outsiders. It’s an inside game only buzz word experts can play.

Medinnovation: Could you be more specific?

Buzz Word Expert: Specificity is not the name of our game. The word or concept must be nebulous, noble, notable and express a common good for mankind. It must represent a quest for the Holy Grail. It must be unanswerable, unchallengeable, and smack of apple pie, motherhood, and fatherhood – all expressed in high-order language and words.

Medinnovation: Anything else?

Buzz Word Expert: Yes, the buzz words must be polysyllabic, and it helps if they come in bursts of three that can be used in any combination: quality information infrastructure, interoperable transparent organizations, performance improvement methodologies, evidence-documented medicine, comprehensive coordinated delivery, actionable support systems, implementable interventions, systematic re-engineering, measurable output parameters, and documentable quality indicators. These are admirable examples. The concepts have to be big, and the words have to be big too.

Medinnovation: It there any room for verbs?

Buzz Word Expert: Of course, Everything must be integrated, coordinated, digitally organized, universally applied. There is no space here for individualism.

Medinnovation: Why can’t you just use simple concepts and simple words for doctors. You might say, for instance: This is the right thing to do. Here are end points to aim for. Here is how to make patients healthy and well. Here is a check list to follow in your practice?

Buzz Word Expert: That is much too transparent and too easily understood by doctors, who we try to keep as “outsiders” in the quality game.

Medinnovation: Who are the “insiders?’

Buzz Word Expert: The “insiders” are outside experts, middlemen, and managers who must come up with a framework, the profits, the transferable information databases, all of which they can use to intervene to institute improvement in the multiple dimensions of quality to justify their continuing existence.

Medinnovation: Like health plans?

Buzz Word Expert: That’s a good example. Health plans can no longer justify their 10 to 20% administrative load by simply paying bills promptly, easing doctor transactions, partnering with physicians, or paying for people with pre-existing illness. Health plans must do something else to oversee the quality and outcomes processes and metrics to keep patients and their bottom lines well.

The insurers must demonstrate they can cut costs, improve health of members, or enhance quality of care and its various and multidimensional measurements at costs employers, doctors, and consumers will swallow. To care out these noble and irrefutable goals, health plans must manage care by data-mining and preventive and predictive model algorithms in order to splice, slice, dice, parse, and predict what might go wrong and how to make it right.

Medinnovation: But how do health plans justify costs of doing all these things? How do they convince skeptical doctors who have yet to see benefits for themselves or their patients on the ground? How do they overcome doctors’ deeply embedded suspicions that health plans rarely do anything constructive that is tangible in the trenches?

Buzz Word Expert: Health plans combine evidence-based medicine with evidence-based management to implement and intervene to impose quality improvement strategies of the highest order and the greatest magnitude and greatest good for all.

Medinnovation:: In other words, talk big, aim high, and let others walk the talk and absorb the cost.

Buzz Word Expert: Something like that.

Monday, July 28, 2008

Saving Money by Paying Primary Care More

Here are five notable and quotable responses to “Trying to Save by Increasing Physicians’ Fees” (NYT front page, July 21, 2008).

“Early intervention is medically effective, but there’s no good reason it cannot be financially effective in our current system of using commercial insurance companies. ” Bert Hansen, Teacher, History of Medicine, Baruch College

“Medicare now pays doctors only to specific medical procedures. Medicare does not pay doctors to listen to patients and to communicate.” Newton Minow, Chicago

“While it is sound to pay primary-care doctors enough so that they spend more than eight minutes with a patient, it is also important for doctors to really know their over time – for many years.” Sara Hartley, MD, University of California, Berkley, School Public Health

“An aspect that should be addressed is whether physician’s skills in obtaining clinical information’s have atrophied. If so, that would impede the desired result.”
Roy T. Steigbigel, MD, Professor of Medicine, SUNY

“Most doctors know how and want to provide good care for their patient’s the current health care payment system insidiously interferes. It is refreshing to see that thdse pilot project variants of the concierge practice have recognized this.” Dean E. Kross, MD, cardiologist, Pittsburgh

The American public doesn’t yet recognize primary care verges on obsolescence because of practitioner dispair over lack of money and other issues. A national physician organization is nearing the end of a massive survey of all primary care physicians to bring this truth home. Once the truth is known, perhaps health policies will change.

Friday, July 25, 2008

Boxed In, but Not Out: Eight Evolving Physician Business Models

Converging events – health reform, Medicare cuts, electronic monitoring, pay or punishment for performance, government oversight as far as the eye can see – have boxed physicians into the corner.

Doctors are being told they must generate, share, and compare data; acquire and use IT tools, adhere to guidelines, join larger groups, and work with themselves and others to achieve scale and infrastructure.

How to get out of the box? This may not be possible or desirable. But the answer may to build your own box. Two ways, for physicians to take control of their clinical and economic destinies by one, creating their own organization; or two, incorporating themselves into new organizations that have elements critics lambaste them for not having or not deploying.

Here, in no particular order, are eight evolving physician business models.

1. Specialty Walk-in Clinics - The Jewett Orthopedic Group in Orlando and Winter Park, Florida, has set up a series of orthopedic walk-in clinics where those with minor injuries can be seen by an orthopedic surgeon, have x-rays taken and interpreted, and have casts applied. This is convenient and accessible access to specialty care at work.

2. New Locations in Abandoned Retail Spaces – A number of physicians and health care enterprises are moving into medical malls and commercial building to set up practices. The lease is cheap, reconstruction is affordable, parking is ample, foot and car traffic is heavy, and access is easy.

3. Big MACCs (Multispecialty Ambulatory Care Centers )- A cardinal rule of innovation is: “Hit ‘em where they ain’t.” Following this dictum, medical entrepreneurs have organized Big MACCs in underserved medical areas where retirees and urban expatriates are moving, where major highways intersect, and where the “new-old” are seeking specialty care, pharmacy and physical therapy services. Big MACCs sometimes constructed with help of hospitals. Most often they are not placed on hospital grounds, but more often in non-urban settings.

4. Free-Standing Procedural Centers - Americans prefer to have certain procedures – cosmetic, ophthalmologic, bariatric, hernias, gallbladders, minor orthopedic surgeries, biopsies and, even births and vaginal hysterectomies, and other unmentionables – performed during the day, where they can enter in the morning and are home at night.

5. Medical Homes, Office and Institutional Based – “Medical Homes” are on everybody’s lips, Medicare, the United Healthcare Group, the American Association of Medical Colleges – as well the national primary care organizations – endorse medical homes. The Duke medical home team has dropped hospitalizations 68%, ambulance transport 49%, ER visits 41%, and asthma-related admissions 40%. But my sense is: physicians have yet to find the model that avoids burdensome paperwork, pays adequately, and helps retain some semblance of control and independence.

6. Retail Clinics and Worksite Clinics - Some tout these as the next retail wave, either alone or in tandem. Walgreen will soon have 500 retail and worksite clinics operating, CVS and Walmart are in the game, and Pitney Bowes has a number of worksite clinics. For primary care doctors, the attractions of worksite clinics are 30-40% more pay, owner-installed EMRs, online access to best practice guidelines, a ready audience of patients, and the ability to control specialty referrals.

7. Hospitals are Physician Partners and Employers – This is a movement that has been accelerating for the last five years, especially among young doctors seeking a balanced life style, free time, fringe benefits, payment of educational and malpractice debts, and opportunities for executive advancement. Hospitals are now busy hiring consultants to build medical staff development plans. One problem here is that the “medical staff” is not a business entity; others are control, capital, and cash distribution issues. In the upper Midwest, hospitals, who have capital and brand name recognition, are acquiring multispecialty groups, who may have neither. Across the U.S. Walmart is opening 400 more retail clinics, to be owned, staffed and run by hospitals with the help of hired physicians.

These models share certain things in common, need for enlightened physician business leadership, necessary capital, adequate information infrastructure, compliance
Regulations, affordable and suitable real estate, and physician supply demand analysis. It is apparent surgical and procedural based specialists have the where-with-all and like-mindedness to put together business entities quicker than primary care doctors with less resources and more diffuse interests.

Thursday, July 24, 2008

Physicians: Health Cost Elephants in the Room?

Call it what you will - gaming, flat of the curve medicine, perverse fee-for-service incentives, doing more to make more, inappropriate testing or treatment to maximize income, defensive medicine, self-referral, or, on the flip side, enlightened self-interest.

Whatever you call it, a bevy of critics are saying the elephant in the room causing excessive health costs are “ungoverned” doctors in small practices, large practices, and academic medical centers are ordering tests, doing operations, mindlessly over-using technology, referring to themselves, buying unneeded technologies, cutting deals -- all to maximize income rather than practicing “quality” medicine to make patients better or to enhance outcomes. These critics tend to inhabit office suites of payers far removed from action on the ground and from what drives doctors and their patients.

I run across these critics often when I write of health reform. Their comments, generally nonspecific or sotto voce so as not to be overhead, run along these lines,” We’r to blame for these high costs.” “We’re the villains.” “What else can you do in a system like this when Medicare and health plans keep ratcheting down your reimbursements.?” Or, “It’s just plain greed.”

Now I am not one to sit in judgment of my fellow physicians. We all do things for a reason, and all of us take steps to stabilize our revenues. There are a lot of factors at work here, including high education debts and escalating, escalating overhead, and whole new set of suggested (expesnive) solutions – protocols, evidence-based medicine, P4P, and, of course, that ceaseless pressure to install EMRs at your own expense in the name of quality.

And the solutions are myriad as well;

• Place doctors on salary to remove financial incentives.
• Slash pay gaps between specialists and primary care doctors and produce more of the latter, who cost less.
• Make all pricing and costs transparent and public.
• Bundle hospital and doctor bills so consumers can know in advance what to expect.
• Place computers at doctors’ fingertips so they can compare, share, and judge what works.
• Use “systems engineering” to redesign the whole system to ensure the best care at the best time for the right reason.
• Encourage doctors to join large groups with enough data infrastructure so outside payers and inside physicians can oversee each other.

There are, of course, two main schools of thought:

• One, let government take care of everything – pricing, regulations, monitoring of quality, and auditing, punishment, and rewards for physicians who play the government game.
• Two, wait for the storm of changes now moving through the marketplace - retail clinics (now numbering about 1000), worksite clinics (perhaps 500), and high deductible health plans (15% of employees now belong), and outrage over high costs to induce competition and bring costs down.

I happen to think “the system” and “American culture” dictates how physicians and patients behave. Each rests on believes in individualism, choice, and freedom to chose what technology and treatment options to pursue. In short, free enterprise.

\It may be that pay-for-performance programs, initiated and monitored by government, as in England, where 25% of physician income, is tied to quality, is a partial answer, but that approach is easier said than done, and doctors may exclude patients from P4P targets to increase income, a practice know as “gaming.”

In the long run, savvy informed patients spending their own premium monies, may the best safeguard against excess care.

Wednesday, July 23, 2008

Obama Plan

What: Obama health reform plan

Why: Because at this point (July 22, 2008), Obama leads McCain 4.4% in aggregate polls, is a 2:1 favorite among Intrade oddsmakers, and is favored to win presidency.

When: His plan proposes to cut health costs by $214 billion and to cover all Americans by end of first term

How: By saving $77 billion with computerized health records, $46 billion by reducing administrative costs, and $81 billion by preventive and chronic disease management programs, and an unspecified amount by eliminating “unneeded procedures ”in plan largely devised by unpaid advisors from Harvard.

Where: Everywhere as directed by government.

Who: Obama wants government do job by spending more than $100 billion - $50 billion on EMRs and another $50 billion or so on tax subsidies for the “poor” and “middle-class” so they can join such plans as Federal Employee Health Benefit Program (FEHBP). Presumably money to pay for this would come from taxing the “rich”, i.e. ending Bush tax cuts for this group and by internal savings, such as having government negotiate lower Medicare drug prices.

Conclusion: Noble, but perhaps undoable in 4 years, maybe even in 10. It is true system is “bloated’ with waste, but government has poor record for containing costs: the “rich,” historically and paradoxically, pay less taxes when taxed more; health plans and drug companies and lobbyists will resist Obama’s plans to make them take all comers regardless of health status, and to negotiate drug prices; Medicare’s pilot project to coordinate care was cancelled because it failed to save money; and who is to say when a procedure is “unneeded “ – A Medicare official, a physician, or a patient.

Tuesday, July 22, 2008

What Can Physicians Do?

This week a Philadelphia psychiatrist, a backer, called. She waxed enthusiastically about Sermo’s open letter to the American public, which now has now 5800 signatures with a goal of 10,000 signers. The letter expresses displeasure with American health care and with physician relationships with HMOs and other health plans.

She said she had spotted me a “pragmatic futurist,” meaning, I gathered, I know what needs to done to right the physician ship and keep it afloat.

After 43 years of Medicare and roughly 25 years of intensive managed care, turning around the ship quickly will be like turning around the Queen Mary on the dime.
Nevertheless, here are a few ideas.

• Publish the Sermo letter and give it wide publicity to show all is not right and doctors are unhappy (As an aside, I don’t think complaining, bitching, and moaning is particularly helpful).

• Conduct a national survey of all primary care physicians to show their stark plight and the threat to their very existence (This is being done as I speak).

• Hold a physician-led national conference featuring leaders of state medical societies interacting with major stakeholders – health plans, drug firms, Medicare, AMA, AHA, device firm, supply chain companies – with the purpose of seeking innovative and systematic compromises. (in other words, quit kibitzing and take the lead).

• Push the hell out of a practical solutions that doctors think will restore sanity to the system, cut costs, put patients in the center, and reduce paper overload (This will inevitably involve streamlined IT systems, and new workable practice models).

• Acknowledge the marketplace, specifically consumers, business leaders, and an increasingly shaky Medicare system, is poised for change and is looking for leadership (Why not from physicians)

It may be a long way from here to there – from Disarray to Tipperary – but perhaps not. In a talk before the American Society of Medical Executives in Minneapolis on July 25, my fellow pragmatic reformer, Brian Klepper, says doctors and their medical societies, ought to face these “market inevitabilities.

1. Data-driven decision support systems
2. More public performance reporting
3. Reduced reimbursements
4. Larger practices
5. More pay for primary care
6. Big box retailing by corporations.

Brian may be right, but these things are just over the horizon. Doctors are at best lukewarm about points 1-4 and show little signs of moving decisively in those directions. There is general agreement primary care doctors should be paid more, but specialists are resisting if it comes out of their pockets. As far as doctors practicing in Big Boxes, retail malls, retail or worksite clinics, this remains a dream of the business community - the CVSs, Walmarts, and Walgreens of the world.

Brian sees Health 2.0 – web-based information platforms to support, aggregate, and reformulate care and to respond to market vacuums – and medical homes in various settings – corporate, retail, and offices – as the next two big waves.

He concludes, doctors and medical societies ought to;

1. Acquire the use IT
2. Understand others are watching and comparing
3. Adhere to best practices
4. Share data
5. Gain scale to enhance infrastructure.

Whatever we do, for physicians, it’s time to take the lead.

Monday, July 21, 2008

It Takes All Kinds

It takes all kinds,
those of all minds,
to make the system work,
to make it really perk.

It takes those who follow the federal Piper.*
Great rats, small rats, lean rats, brawny rats,
Brown rats, black rats, gray rats, tawny rats,
Grave old plodders, gay young friskers,
Fathers, mothers, uncles, cousins,
Cocking tails and pricking whiskers,
Families, tens and dozens,
Brothers, sisters, husbands, wives,
Those who rely on the Piper for their lives.
We must all pay the Piper
For the Piper calls the tune.

But it takes all kinds,
Some have other minds.
Great innovators, small innovators, lean innovators, brawny innovators,
Innovators who move in different directions,
Innovators who take different mental elevators,
Entrepreneurs who see new and better ways of doing things,
Entrepreneurs who believe the future belongs to those who take flings,
Entrepreneurs who see forward opportunities,
Where others see only wayward communities
Innovators and entrepreneurs who are digitally prepared,
Innovators and entrepreneurs who are digitally impaired.

It takes all kinds,
To draw the lines.
Idealistic missionaries, realistic visionaries,
Bankbenchers, doctors in the trenches,
Primary care doctors of every type,
Specialists of every kind of stripe.
There is no single answer,
To the health cost cancer.
It takes all kinds,
No size fits all minds.

*Apologies to Robert Browning, 1812-1889, Pied Piper of Hamelin, 1845

Sunday, July 20, 2008

Diet - Atkins Diet: Weight Loss and Better Lipids Don’t Lie

The low carbohydrate Atkin’s diet invites controversy and skepticism.

After all, how could a diet laden with fats, cheese, and red meat be good for you? How could it help you lose weight? How could it lower your blood cholesterol or your blood fats leading to those fatty cholesterol plaques?

It doesn’t make sense. It’s just plain counterintuitive. Besides, its creator, the late Doctor Robert Atkins, was an unabashed self-promoter, writing best selling diet books and building a company to make Atkins diet products. No self-respecting doctor toots his own horn. He relies on scientific evidence.

The evidence has just arrived. A July 17 New England Journal Report, in a “tightly controlled” 2 year, 23 author study of 322 overweight Israelis, compares low-carbohydrate, Mediterranean, and low-fat diets It finds Atkins dieters lost more weight, lowered their “bad” cholesterol (LDL cholesterol) more, boosted their “good” cholesterol (HDL cholesterol) more, reduced their triglycerides more, and dropped their ratio of total cholesterol to HDL cholesterol more.

How could this be? Well, figures don’t lie.

Controversy persists. The numbers show something the low-fat crowd doesn’t want to hear, so again it fuels controversy. It contradicts advice set forth in www., itself controversial because it doesn’t always rely on world-class experts. That advice reads:“Do not follow the low-carbohydrate diet for purposes of weight loss. These diets tend to be high in saturated and transfats.” It distracts from the work of health officials who are cracking down on transfats and saturated fats in public eating places. Besides, a Jenkinstown, Pennsylvania, Nutritional Research Foundation, established by none other than Dr. Robert Atkins, supported the study. Surely there must be bias.

Still, if you can’t trust a well-controlled study conducted by a highly regarded team from Israel and Harvard, who deny bias, who can you trust? It’s hard to fudge weight loss and lipid figures in a double-blind study.

The Atkins diet works for a lot of people because of its simplicity. I have heard this simplicity explanation expressed from those in whom the diet has resulted in permanent weight loss.

• “I just don’t eat anything white, like bread or pasta.”
• “I just shop at the periphery of the store, in the fruit, vegetable, and meat sections, and stay out of the central aisles.”
• “ I never eat processed foods sitting on shelves.”
• “ I no longer believe the myth if it tastes good, it’s bad for you.”
• “You can lose weight and eat well, and you don’t have to sweat the details.”

These people also tell me they enjoy the freedom to enjoy the good tastes and pleasant satiation of diary products, cheese, proteins, and beef containing fat. Let’s face it. Fat makes food taste better.

For the Atkins’s disbelievers, there’s the Mediterranean diet, which came in a very close second to the Atkins diet in weight loss and lipid benefits and was better in glucose control. The Mediterranean diet replaces beef and lamb with poultry and fish, but has plenty of olive oil, nuts and red wine.

Low-fat fans need to face facts. But they don’t have to give up their quests for low fat foods. They can always go to New York City, which has forbidden restaurants from using saturated fats and transfats in preparing foods, or, if all else fails, they break out the olive oil.


1. Iris, Shai, with 22 co-authors, “Weight Loss with a Low-Carbohydrate, Mediterranean, or Low-Fat Diet.” New England Journal of Medicine, July 17, 2008.

2. William Bulkley, “Study Feuls Fat Vs. Low Carb Debate, “Wall Street Journal, July 17, 2008.

Friday, July 18, 2008

Limits of Intervention -Getting Real About Reform

Given the health reform buzz, it’s easy to forget intervening into existing health markets has realistic limits.

First, among those pushing universal care with rules to make it work, we forget government simply doesn’t have resources or personnel, or for that matter rules, regulation, and databases, to track and enforce the 2 billion health care transactions that occur at the point of care each year. Nor are officials capable of measuring performance or outcomes. Nor can they second-guess every patient-doctor transaction, many of which have little “scientific basis, “but rest rather on clinical experience, doctors’ search for more revenue, and individual patient desires or demands.

Second, the U.S. has a deeply embedded for-profit capitalistic health system that feeds American doctors and patients appetites for new technologies and other medical advances. To sustain profit growth and innovations, these enterprises hire thousands of lobbyists who pump money into political coffers of both parties.

Health Care Lobbying Contributions

Health Care Contributors

Pharmaceutical/medical products $227 million
Health insurance companies $138 million
Hospitals/nursing homes $91 million
Health Professionals $70 million
HMOs/health services $52 million

Other Big Health-Related Spenders

U.S. Chamber $53 million
GE $23.6 million
PhRMA $22.1 million
AMA $22.1 million
AHA $19.7 million

Consider the last list. U.S. Chambers know in many communities health care is their meal ticket. GE is heavy into health care, particularly scanning technologies. And Big Pharma, the AMA, and the AHA are the bedrock of our health system.

Third, there is simply the tyranny of the status quo. My friend, Brian Klepper, beautifully explained this tyranny in a recent blog.

There is broad expert consensus that one-third to one-half of all health care expenditure is waste. Talk privately with most health care professionals - physicians, hospital execs, health plan administrators, benefits managers, supply chain execs - and there is reasonable agreement on critical principles that are necessary to re-establish the system's stability and sustainability: some form of universal coverage for at least basic health services; a comprehensive and compatible IT infrastructure; a transition from fee-for-service to some form of performance-based reimbursement; pricing and performance transparency; and much more.
Such changes could drive tremendous savings for individual, corporate and governmental purchasers, but at significant cost to health care firms and professionals. Revenues and profitability would plummet. As the struggles over health care resources intensify, the efforts to protect and enhance each interest's position through policy will intensify as well.

It’s easy to glibly say America ought to have universal coverage, universal IT, total transparency, evidence-based performance bonuses, and transitioning from fee-for-service to packaged pricing, but embedded interests have a lot to lose, and they will not yield quickly until they understand the profit-tradeoffs.

Wednesday, July 16, 2008

Goverment ss. Market reforms, Republicans, The McCain-Obama Health Care Gulf

I recently interviewed Grace Marie Turner, president of the Galen Institute, a market-based think tank, and a McCain sympathizer, and David Cutler, PhD, Harvard economist who is Senator Obama’s chief health care advisor.

The gulf between the Obama-McCain beliefs black and white (no pun intended), between government dominated and guaranteed care and market-based care with incentives to expand coverage, between government officials who think they know best and doctors and patients who believe
they know best.

Talking to their advisors was like watching two battleships
passing in the dark, with their captains dismissive, even condescending, of the other’s point of view. Grace-Marie

• Turner warns of a “government-organized, government-dominated, government-run system”.

• Dr. Cutler says consumer-driven care with HSAs and high deductible plans is simply a “fad.”

The truth, as everybody knows, lies somewhere in between.

The McCain camp believes in health care markets, with patients deciding what to do at the point of care. He thinks market competition, supplemented by tax credits for all and risk pools in states, will cut costs, allow freedom of choice, and provide affordable accessible care for most citizens. McCain, in short, espouses bottom-up innovative market solutions.

Senator Obama, on the other hand, would pour a $100 billion government money (for starters) into the system to enable doctors “to do the right thing.” To help doctors, he would create $50 billion in government subsidies and incentives to install EMRs in every physician’s office, pay bonuses to doctors who practice prevention, coordinate chronic care through medical homes, and assiduously follow pay-for-performance and “evidence-based” protocol – all in name of “quality.”

Obama would also organize consumers into government-run risk pools and plans, such as the Federal Employee Health Benefit Plan (FEHBP). In the process, he would expand Medicare and Medicaid programs, tighten their rules and regulations, and end paying for unneeded procedures. Obama, in other words, believes in stronger government programs to guide, protect, and guarantee universal coverage.

No one knows the end game.

I doubt government officials can consistently dictate the “right thing to do,” no matter how large the information database or how tight the computer guidelines. Officials
are just too far removed from the site of care and subtleties and nuances that shape physician-doctor decision-making.

Nor do I believe the American public will accept a free-wheeling market system, without protections for the poor, the sick, the frail, and the elderly.

Since the founding of the Republic, Americans have been individualistic, basically conservative and leery of big government and sweeping changes. I am counting on Americans’good sense to “do the right thing,” even if more targeted government policies are needed to do it, without sacrificing choice and freedom and quick access to the best acute care in the world.

Monday, July 14, 2008

Obituaries - Michael DeBakey, MD, 1908-2007

Michael DeBakey. M.D. – trailblazing surgeon, innovator, educator, and medical statesman – died at age 99 at Methodist Hospital in Houston on Friday, July 9. He practiced surgery for 70 years and put down his scalpel at age 90.

I knew DeBakey only indirectly, having met in New Orleans with his two charming and loyal sisters, who aided him in writing and publishing his contributions to medicine. They were a close-knit family, and they survive him.

During his career, DeBakey performed 60,000 surgeries, trained hundreds of surgeons, operated on the high and mighty, including Boris Yeltsin, the Duke of Windsor, the Shah of Iran, and Marlene Dietrich, conducted a famous feud with his protégé, Dr. Denton Cooley, vaulted Baylor into a leading heart and vascular center, and left an unparallel string of innovations in his wake.

His innovations included.

• As a medical student at Tulane in the 1930s, he developed the roller pump, first used in transfusions and later at the central component of the heart lung machine.

• In 1939, he and Dr. Alton Oschner brought the medical world’s attention to smoking as a leading cause of o lung cancer.

• In 1952, he was the first to successfully repair an abdominal aneurysm.

• In 1958, he inserted a Dacron graft, and showed Dacron could substitute for damaged arteries.

• In 1966, he and his team perfected a left ventricular assist device to help patients with failing hearts.

• He worked constantly with an engineer at the site of his surgeries to create new sutures, new instruments, and new devices to improve surgical techniques.

• He modernized military surgery by pushing for MASH (Mobile Ambulatory Surgical Hospitals) so surgeons could operate near the front lines and later developed medical programs for returning veterans.
• Helped rejuvenate the National Library of Medicine in Bethesda.

For these and other achievements, he received many national and international awards. I will not list these now. Suffice it to say, he was the world’s best known surgeon.

DeBakey was not a modest man, for he had little to be modest about. He was a harsh taskmaster, sometimes openly criticizing residents during surgery even summarily discharging them from the program for minor errors, but he was always kind and gentle to patients and medical students.

Stories about DeBakey number in the hundreds. I recall chatting with his hospital administrator 35 years ago, who said DeBakey brought more than 50 million dollars into Methodist Hospital, and gratefully commenting as an afterthought, “You know, he only kept $8 million for himself.” As a leader of surgical teams, he circulated between operating rooms, snacking between cases. He sometimes did an entire case, sometime played only
a minor role, depending his mood and the
circumstances. Once in the midst of half dozen or so surgeries, he poked his head out outside the door and said, “Anybody out there needs surgery. We’re just getting warmed up.”

He was no stranger to controversy. There was the widely publicized feud with Cooley, who he blamed for conducting an unauthorized surgery using a mechanical heart without notifying DeBakey. After 40 years, they reconciled and presented each other with awards. When the AMA opposed Medicare, DeBakey supported it and teamed with President Johnson to make it happen. On the scientific front, he
never accepted cholesterol as the dominant cause of atherosclerosis, a disease whose ravages he spent a life time correcting.

DeBakey was tireless. He awoke at 5AM, wrote for two hours, drove to the hospital in a sports car, and ended his rounding and operating day at 6PM, He attributed his longevity and productivity to good salads, constant intellectual challenges, and 4 to 5 hours sleep each night. His health and resilience amazed to the end of his life. At age 97 he suffered an aortic dissection, but recovered nicely after surgeons using the “DeBakey procedure” corrected the dissection. He was the oldest patient ever to undergo that procedure.

DeBakey was larger than life. If life were considered a word game, he was a verb – a man of constant action. He believed what one could conceive and believe in, one could achieve. Let us now praise this remarkable man.

Saturday, July 12, 2008

Medicare Realities

Medicare Realities

This week’s U.S. Senate rejection of 10.6% physician Medicare cuts brings to mind certain realities.

• Medicare costs remain out of control and are still unsustainable

• The central issues in the Senate debate were: One, the $20 billion the cuts would have saved Medicare; Two, Medicare Advantage outlays through the lack of cuts would have required trimming of outlays for managed care giants as Humana, Wellpoint, and UnitedHealthGroup.

• In the current political climate, physicians are more popular than health plans – an industry many have come to hate. Restoring the cuts was an opportunity for Democrats to make political hay.

• The AMA’s strategy of attacking 10 Republican Senators in their home states who would have made the cuts possible through negative ads worked.

• The “fury” of doctors over the unfairness of the cuts was palpable and effective. In a survey of 1100 doctors, 70% said they would consider “cash only’ practices, and another 60% said they consider careers outside of medicine.

• The looming physician shortage is the Achilles Heel of proposed expansions of care: universal coverage is not the same as universal access, and indeed, may bear little relationship with it. If you can’t find a doctor to care for you, universal coverage is meaningless.

• CMS’s huge bureaucracy (its budget is the 5th largest in the world) and its 150.000+ pages of rules, regulations, and compliance measures and fines sometimes impedes or blocks marketplace innovations.

• Medicare and Medicaid still cover only about 1/3 of the U.S. population, and more and more, higher copays and deductibles and Medicare supplementplans are required to pay for the costs. The Achilles Heel of federal and state programs to cover the uninsured and underinsured is increasingly the looming and escalating doctor shortage, particularly of primary care physicians. Again, expanded coverage doesn’t equate with expanded access, if physicians are in short supply or refuse to accept new patients covered by federal programs.

• Medicare, now 43 years old, will face an onslaught of older baby boomers by its 50th birthday. If physicians, confronted by lower reimbursements, arcane rules that increase cost of doing business , Medicare refusal to pay for common complications such a venous thromboses, and widespread impositions of protocols, pay for performances measures, and exclusion of physicians based on “quality, “ access to care may be threatened. Doctors may simply to choose cash only practices, concierge arrangements, refusal to see Medicare and Medicaid patients, or withdrawing from practice. Medicare is here to stay. It has public, bipartisan, and physician support, but it needs to adjust to physician practice realities.

Monday, July 7, 2008

Bundled Payments, Physician payments, Medicare, Doctors and Hospitals - DRGs in Drag? Bundled Medicare Hospital-Physicians Bills

You can look at the Medicare Payment Advisory Commission report1 recommending bundled hospital-physician bills in diverse ways, depending on your point of views.

• One, as a means of saving Medicare from bankruptcy by dumping costs into diagnostic bins, just as Congress did with DRGs in the mid-1980s, only this time dragging physicians into the mix.

• Two, as an attack on fee-for-service’s perverse financial incentives, as the primary cause of runaway Medicare costs by inviting uncoordinated physician greed by providing more services than needed.

• Three, as a way reducing variation in costs by “capitating” hospital care, long a goal to managerially-minded policy wonks, and to coordinate care by forcing hospitals and doctors to act in tandem.

• Four, as a mechanism to achieve transparency and predictable costs in advance, thriving forces behind the consumer-driven care movement which says consumers and payers may change their spending behavior on the basis of value and costs known in advance...

I lean towards the fourth interpretation because as chairman of a Physician Hospital Organization (PHO) nearly 20 years ago, I helped develop a series of over 50 bundled bills for an Oklahoma hospital.2

The through behind our PHO’s bundled bills was straightforward: estimate the hospital costs for a given episode of care or a given diagnosis or procedure, average the fee-for-service costs for physicians delivering these services, add hospital costs to physician costs, and back the total bundled bill with re-insurance if costs exceeded our estimates.

The motivation of our PHO was to attract consumers and payers to the hospital. If you give the matter any thought at all, you will realize consumers, health plans, government payers, and employers would be attracted to predictable costs they could budget for.

This approach doesn’t punish fee-for-service physicians. It potentially disciplines and rewards fee-for-service practitioners with more business. Unfortunately at the time we introduced bundled bill, health plans weren’t ready. They preferred to deal with hospitals and doctors separately with a divide and conquer strategy.

But, if I may use three time-honored clichés, when costs spin out of control. timing is everything what goes around comes around, necessity is the mother of innovation.

The principals who direct or advise the Medicare Payment Advisor Commission (MedPAC) have a fundamentally different philosophical take, which they dub “collective accountability,” on the necessity for bundled bills.

I will let them speak for themselves,

“Medicare’s projected spending growth is unsustainable. The incentives inherent in the dominant fee-for-service payment system are the root cause. Fee-for-service spurs spending growth, support a fragmented and compartmentalized delivery system, and does nothing to reward quality or value… Under a bundled payment approach, Medical would pay a single provider entity (comprising a hospitals its affiliated physicians) a fixed amount intended to cover the costs of providing a full range of services during an episode, which might be defined as the hospital stay plus 30 days per disease. Bundling payments should provide incentives to increase efficiency, coordinate in-hospital and post-hospital care, and, if combined with pay-for-performance initiatives, improve the quality of care.”

Well. maybe. I’ve always been dubious about the effectiveness bureaucratic bullying cost-reducing billing clubs to reduce costs, especially when you factor in administrative overhead.

In any event, MedPAC proposes a two year pilot study focusing on episodes of congestive failure, chronic lung disease, and coronary-bypass grafting with cardiac catheterization. It adds a cautionary note, “MedPAC is under no illusion that the policy of policy change outlined here is eas .Unforeseen consequences are likely and mid-course corrections will be needed. But a continuation of the status quo is unacceptable.”

I would add, once fee-for-service is out of the barn, herding it back won’t be easy, DRGs have been of limited effectiveness in reducing costs, and hospitals and physicians are likely to act at the edges of care outside of hospitals to compensate for government policy changes. .


1. Glenn Hackbarth, J.D., Robert Reischauer, PhD, and Ann Mutti, M.P.A, “Collective Accountability for Medical Care – Towards Bundled Medicare Payments, “ New England Journal of Medicine, July 3, 2008.

2. Richard Reece, MD, Innovation-Driven Health Care: 34 Concepts for Transformation, Jones and Bartlett, 2007

Saturday, July 5, 2008

Health plans - Survey of Pay for Publicly Traded Health Plan CEOs

What: Survey by Equilar, a Redwood Shores, California-based executive compensation research firm.

Why: Among critics of U.S. health care system and physicians, feelings persist that Health Plan CEOs are overpaid and symbolize high administrative costs of U.S. health care, which may run as high as 30%.

When: 2007

How: Based on analysis of compensation of top executives of S&P 500 companies. Median total compensation was $8.8 million for executives overall, and $9.1 for CEOs of six publicly traded health plan CEOs.

Where: Everywhere there is concern among stockholders that compensation may have no relationship to performance. So far in 2007, publicly traded HMO stocks are up about 15%, from a mean of 53 to a mean of 61.

Who: Total compensation is said “not to be out of line by Wall Street standards,” and included the following health plan CEOs.

• H. Edward Hanway, Chair and CEO, Cigna, $25,839,777

• Ron Williams, Chair and CEO, Aetna, $23,045,834

• Dale B. Wolf, CEO, Coventry Health Care, $14,889,823

• Stephen Hemsley, $13,164,529

• Mike B. McCallister, President and CEO, Humana, $10,312,557

• Angela F. Braly, President and CEO, Wellpoint, $9,094,771

• Jay M. Gellert, PRESIDENT AND ceo, Health Net, $3,686,230

Where to: With sluggish economy, CEO pay is expected to decline. With this decline, physician compensation may decline too, as CEOs “try to do what they’re paid to do – make the biggest profit possible.” This reality and the fact that the ratio of top health plan median CEO pay, $9.1 million, to median physician pay, $200,000, is 45.5/l makes some physicians wince. Pay standards for Wall Street and Main Street differ dramatically.

Source: Emily Berry, Health Plan Executives: What’s in Their Wallets, American Medical News, June 23/30, 2008

Electronic medical records - Frequency of EMR Installations

What: National survey of 2758 physicians and why and why not they installed EMRs. Frequency of fully functioning EMR installations was 4% and 13% for “basic’ system. Survey measured why physicians adopted EMRs, level of satisfaction, effect of quality, and barriers to adoption.

Why: Many experts regard physician EMRs use in ambulatory care as key to improving and documenting quality of care.

When: The survey was conducted in late 2007 and early 2008 with response rate of 62%.

How: Massachusetts General and Institute of Health Policy, supported by National Coordinator of Health Information Technology. Robert Wood Johnson Foundation, and Dr. David Blumenthal, advisor to Barack Obama, led the survey team..

Who: EMRs were adopted by a few scattered primary care physicians, rarely by independent specialists, and most commonly by large groups and physicians in medical center hospital systems..

Where: Most often in Western U’S; wherelarge groups dominate.


The survey listed these positives among physicians who adopted basic and fully functional EMR systems

1. Timely access to records, 97% and 98%
2. Prescription refills, 85% and 95%
3. Quality of communication with other providers, 86% and 92%
4. Quality of clinical decisions, 63% and 82%
5. Avoiding medication errors, 80% and 86%
6. Quality of communication with patients, 59% and 72%
7. Delivery of quality care that meets guidelines, 56% and 82%.
8. Delivery of preventive care that meets guidelines, 53% and 86%.

Major Barriers

Physicians who choose not to adopt EMRs listed these major barriers. .

1. Amount of capital needed, 66%
2. Finding an EMR to fit needs, 54%
3. Uncertainty about return on investment, 50%
4. Concern system will become obsolete, 44%
5. .Concern about loss of productivity during transition, 41%
6. Capacity to select, contract, install and implement, 39%
7. Resistance from physicians, 29%
8. Concern about illegal record tampering, 18%
9. Concern about inappropriate disclosure of patient information, 17%
10. Concern about physicians’ legal liability, 14%
11. Concern about legality of accepting EMRs from hospital, 11%


Eighty three percent of American clinicians have choosen not to install EMRs. Only 4% have fully functioning systems, and a mere 13% have basic systems. Reasons for non-acceptance are mostly financial (not enough capital and low return on investment), but there are also that EMRs do not fit clinical needs, are not yet ready for prime time, may become obsolete, and pose legal and privacy hazards. Physicians who have adopted EMRs, however, have found EMRs improve quality of care and practice efficiencies.


Catherine DeRoches, et al. “Electronic Health Records in Ambulatory Care – A National Survey of Physicians, New England Journal of Medicine, July 23, 2008

Friday, July 4, 2008

Internet - Maine Notes: A Biggerer Idea for Microsoft, Digitizing Patient Stories as the Basis for Personal Health Records

Kennebunkport, Maine - On June 30 the Boston Globe announced Microsoft is seeking big new ideas. To create these big new ideas; Microsoft is erecting a big new building to be known as the Boston Concept Development Center next to MIT. The Center aims to develop new ideas to compete with Google, its arch rival who at the moment is eating its lunch in the search engine industry.

As I read the newspaper account of Microsoft’s big new building and its search for big new ideas, I thought of Dr. Seuss and his book The Lorax, in which this passage appears,

For your information, I’m figuring
on biggering

It’s apparent Microsoft, already the biggerest of them
all in the Internet space, plans to get biggerer by doing battle with Google in the Personal Health Records (PHR) space. And a biggerer space it promises to be. There are 300 million Americans, 125 million with chronic disease, and roughly 100 million personal computers, most with broad band access, and everybody, sick or well, has a personal health story to tell. PHRs is a very biggerer idea.

Well, for Microsoft, I have an even biggerer idea - an idea that makes its big PHR idea even biggerer. I recommend Microsoft think biggerer in this way. Every American - old and young, well and ill, healthy and unhealthy - has a
personal story about their health to tell. We all do.

These stories will form the essence of PHRs. But Microsoft needs two things to turn these personal tales into PHR realities - simple, easy way for people to tell their stories; and two, a structured way to convert the stories into Microsoft software so the stories can be continually updated.

Fullfilling these two goals is where the Instant Medical History IMH) comes into play. Over the last 15 to 20 years, which is, of course, eternity in Internet time,. Drs. Allen Wenner, a family physician and Internet entrepreneur in Columbia, Sourth Carolina, and his sidekick, Dr, John Bachman, head of primary care at Mayo in Rochester,. have been developing, applying, and perfecting the IMH.

The IMH software has been used by ten of thousands of clinicians in the trenches. It allows patients to tell their stories before seeing the doctor by answering a series of questions based on their chief compliant, current illness (or lack of same), age, and gender. Guided by clinical algorism, anybody can usually tell their health stories in 10 to 15 minutes.

The end product is a clinical narrative containing the essential elements contributing to their health status with the pertinent health data. The patient can take this narrative home with them after leaving the doctor's office. Both patients and doctors can subsequently add to the story, adding new findings and test results and adding to the record.

Patient story telling, and physicians adding to the story, may seem overly simplistic. But let us not forget the story of mankind and of medicine is nothing more than compilations of individual stories.


Robert Weisman, "Microsoft Seeks New Big Idea in Cambridge: Creates New Unit Aimed at Innovation, Boston Globe, June 30, 2008.

Thursday, July 3, 2008

Malpractices - Maine Notes: Physician Concerns under the Radar

Kennebunkport, Maine – This evening I spoke to a female obstetrician-gynecologist in her early forties, a family friend, about the current practice climate. Our conversation, in the context of a casual family gathering, wasn’t formal or even focused on problems of the system. This report consists of snatches of her casual observations of what’s happening out there. I would like to share with you some of her passing thoughts.

• The malpractice climate remains a critical issue among practicing doctors. Critics may say malpractice is only a small part of overall health costs, but high malpractice premiums often dictate choice of specialty and discourage doctors from practicing in litigious states, where those premiums may exceed $100,000 per year. Total malpractice costs may not be that high, but the economic toll of “defensive medicine” cost society dearly.

• A malpractice suit against a physician, who has typically spent 11 to 15 years preparing to serve society, can be psychologically devastating. In the OB world, the greatest fear is a suit triggered by an “imperfect” baby, said by many lawyers to be due to doctor negligence and often an easy case for them to win before a jury confronted with a disabled child.

• Many physicians are cynical about health reform, no matter who wins the election. Physicians feel both parties are beholden to well-heeled special interests, which have incentives to retain the status quo.

• The fact that ½ of medical school graduates are now women, is, in some respects, changing practice and physician marriage relationships. Some women physicians work part-time while growing number of others work full-time and have “house-husbands,” who care for the children, prepare meals, and clean house, while the woman works.

• More and more hospitals “own” practices. Doctors in “owned” practices may feel compelled to act in the financial interests of the hospital, ordering more hospital-based tests and procedures, thus driving up the total cost of care and losing their ability to act independently. Being “owned,” in other words, may change how one acts and practices.

Regional variations , Reece, Personal musings - Maine Notes: What Weighs Three Pounds and Wakes Up Every Morning at 6 A.M.?

Kennebunkport, Maine - Here I am, in the heart of Yankee country. My presence here reminds me of a New England bank once ran bearing the title: What Weighs Three Pounds and Wakes Up Every Morning at 6 A.M.? The answer, if you haven’t already guessed is “The Yankee Brain.”

No region has a monopoly on brains. I’ve practiced and spent time in multiple states – Tennessee, North Carolina, Connecticut, Massachusetts, Florida, Minnesota, and Oklahoma, and I’ve found brains are equally distributed. .

From these experiences and from fiddling around with computers for 35 years, including writing a differential diagnosis program on an early version of the early 1970s, I ‘ve come to understand a number of things.

• Brains are not a regional phenomenon.

• Brains are superior to computers in evaluating patients at the point of care.

• Ordering technologies and consulting the Internet may sometimes supersede taking a history and doing a careful physician examination.

• Doctors are not particularly impressed by the use of computers for differential diagnosis purposes.

• Diagnostic support systems, though highly touted by experts outside medicine, are rarely used by physicians inside.

• Diagnostic and treatment and “best practice” algorithms, though widely thought to be essential tools for improving care and harbingers of the future, are seldom used by experienced clinicians.

• Having computers are every doctor’s fingertips may not be the breakthrough envisioned by enthusiasts.

• Among physicians talking confidentially and off-the-cuff, computers offer few revelations and no miracles,.

Why is this? One reason may be that many doctors think computers simply get in the way and slow patient interaction. Another may be that having a computer between a doctor and a patient changes the human chemistry and depersonalizes the relationship. Yet another may be doctors feel information technologies hinder accurate diagnosis.

Jerome Groopman, M.D. a Harvard Medical School professor, in How Doctors Think,k (Houghton-Miffline, 2007), has written doctor rely too much on snap judgments, often reaching a diagnosis within 20 seconds, This rapid fire decision making can lead to snap judgments and diagnostic errors. Groopman’s solution is more effective communiation betweeb doctor and patient rather than widespread use of algorithms. .

Thirty years ago, Franz Inglefinger, MD, another Yankee Brain, then editor of the New England Medical Journal, in a talk prophetically called “Medical Education: Algorithms or Algebra?” argued relying on algorithms was a bad thing because: one, algorithms are demeaning, requiring few skills, other than swinging from branch to branch on the decision tree; 2) algorithms devaluate the physicians as an independent thinker; and 3) algorithms discourage active use of the mind- pursuing ideas, entering into controversies, ferreting out facts, balancing merits of a case, reading in journals, and exercising a lively intellectual curiosity.

To me, this all boils down to the old Right Brain versus. Left Brain. An experienced clinician may have the knack for sizing up a patient at a fleeting glance and asking precisely the right question. Those addicted to protocols may ask all the right questions and do all the right things – and miss the problem altogether.