Saturday, November 29, 2008

Simple Office Procedures in the Office as an Innovation

To perform minor surgical procedures in the office may seem quaint rather than innovative, for doing so for family doctors of yesteryear was routine.

But innovations need not be complicated or new. They can be as simple as returning to old family doctor tradition of performing simple procedures in the office.
Many primary care physicians across America now perform simple procedures in their offices. They do for multiple reasons: procedures pay more for time spent than cognitive visits, they are often simple easy to do, office procedures save patients time and money, procedures can be thought of as one-stop comprehensive care.
Rather than say anything more, I reproduce here a sample passage from my book Innovation-Driven Health Care (Jones and Bartlett, 2007).

Dr. John Pfenninger is a family practitioner who passionately believes his compatriots in their offices can do more procedures and do them well with more conveniences for patients and less cost to the health system. Here is his story.

“The story of the National Procedures Institute (NPI) is quite simple. I was born and raised on a farm. So I was used to, and enjoyed, working with my hands. Surgical specialties interested me, but the time needed to finish the residency program and the lifestyle afterward were not very enticing. Subsequently, I chose family practice, so that I could ‘could do everything like the old country doctors.’”

Family Practice Residencies Deficient in Teaching Office Surgical Skills

“It didn’t take long to see that family practice residency programs really were quite deficient in teaching office surgical skills. Initially, physicians that were in private practice as ‘GPs’ became residency directors. They tended to do many more of the surgical procedures. They delivered babies, performed appendectomy, set fractures, and so forth. As time went on, however, experienced faculty became few and far between. Salaried physicians had a tendency to do less and less with their hands. Hospital credentialing processes and liability concerns from insurer’s further limited interest in procedures.”

Learning to Do the Simple Things

“Still, there were many of us who wanted to learn how to treat hemorrhoids, inject veins, do vasectomies, put in IUDs, do dermatological surgery, perform the procedures needed of emergency and hospital care, and more. However, there was no formalized training available to learn these procedures! Although state and national academies offered a small smattering of selections once or twice a year, there just wasn’t enough quality education being offered in the procedural skills area.”

Doing Office Procedures Makes Sense

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

Other Advantages

“Other advantages of doing procedures include a reduction in delay of diagnosis. In other words, if a skin lesion looks atypical and the clinicians are comfortable doing a biopsy, it is biopsied on the spot. The alternative is referring the patient away. This may take another r6 to 8 weeks before another evaluation. In the case of melanoma, that puts the patient at increased risk.”

“Physicians who do procedures have a tendency to know more about the disease process. Describing what a rose smells like or what an orange tastes like is difficult. How does one explain the color red to a blind person? Similarly, it is difficult to explain various disease processes.”

“However, if the clinician becomes involved with seeing, feeling, and exploring the innuendoes of a disease process, the diagnostic acumen becomes more accurate. Doing procedures an also break up the monotony of the day-to-day practice.”

“In addition, reimbursements are still are grater for surgeries and procedures, virus nonsurgical areas. Numerous studies are available showing that those who perform procedures have a significantly higher net income. For most family physicians, they choose the specialty not to be case managers and paper pushers, but rather to provide comprehensive care. Doing procedures makes this more likely.”
NPI Born in 1989

“Thus, in 1989, the National Procedures Institute (NPI) was born with the purpose of teaching surgical and procedural skills for primary care clinicians. It has grown from teaching two courses the first year to over hundred in 2006. Over 15,000 clinicians have trained with the National Procedures Institute. After 17 years of teaching procedures skills, NPI remains the leader in educational opportunities in the field of teaching primary care physicians to perform appropriate procedures in their offices.”

“Along with the text Pfenninger and Fowler’s Procedures for Primary Care, NPI seminars have changed the way physicians deliver medical care in the United States, NPI can accessed at”

Thursday, November 27, 2008

Can Innovation Save Primary Care in its Present Form ?

November 27, Thanksgiving Day, 2008

I felt like I was becoming a guideline-following automaton and a documentation drone. It was draining to me, and I didn’t feel it was what the patient wanted either.

Christine Sinsky, M.D. General Internist, Medical Associates Clinic and Health Plans, Dubuque, Iowa, “Innovation in Primary Care- Staying One Step Ahead of Burnout,” New England Journal of Medicine, November 27, 2008

Effective innovation depends on assumptions. If you assume primary care’s troubles are due to poor or uneven physician performance or to woeful lack of use of information technologies, that’s one thing. If you assume the troubles stem from overwhelming and unrealistic demands on time and talents of primary care physicians, that quite another.

It also depends on what you mean by “innovation”?

If by innovation you mean current federal efforts to impose pay-for-performance and electronic medical records on primary care, the answer in my mind-field is “No, these things will not save primary care. Indeed, they tend to cause less time with patients, irritate the practitioner, and aggravate the shortage.

• Other industries learned long ago that annual performance reviews by managers of workers destroys morale, kills teamwork, and hurts the bottom line (Samuel Culbert, “Get Rid of Performance Review!”, Wall Street Journal, October 30, 2008). In health care, pay for performance makes the physician a surrogate to the “boss” i.e., payers, and evokes hostility, and is unlikely to improve performance.

• Why have only 15% or so of physicians installed EMRs? The reasons are legend, but the main one is EMRs take physician and staff time away from seeing patients. The assumption here is that good documentation makes for good doctoring, which is not only silly but fallacious. Physicians and patients alike treasure time spent with each other, not time spent entering or evaluating data.

Promises of November 2008

In a recent article I wrote for Physician Practice Options, which will appear in its December issue, I argued the U.S, may be on the cusp of a primary care renaissance. My argument went like this.

“When the history about American health care is written, November 2008 will be remembered as the month of emerging fundamental truths about the importance of primary care in the U.S. health system.

Five notable November events precipitated, crystallized, and revealed these truths.

1. On November 4, newly elected a president, Barack Obama, promised expanded coverage as a high priority. Shortly thereafter, on November 11, Senator Max Baucus (D., Montana), in a 35,000 word health reform white paper, “A Call for Action,” called for coverage of 95% of Americans. He cited primary care shortages as a barrier to achieving the coverage goal.

2. On November 10, as the U.S. financial meltdown sought its bottom, the American Medical News reported in “Doctors Tally the Economic Value Practices Bring to Communities” that private practitioners in general and primary doctors in particular positively impacted the overall U.S. economy. Health care is a growth industry in the U.S., generating more than 10 million jobs. Each private physician’s office creates 12 to 13 jobs and has an annual economic impact of roughly $1.5 million.

3. On November 12, at the interim AMA meeting, the House of Delegates adopted intact, joint principles of the medical home developed by the four major primary care societies – American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, and American Osteopathic Society ( Among the principles was enhanced pay for primary care through a hybrid system of fee-for-service, pay for performance bonuses, and a capitated management fee for coordinating care.

4. On November 13, the New England Journal of Medicine. America’s most prestigious and widely read medical journal published two articles on the primary care doctor shortage and its implications (T,H. Lee, K. Treadway, T. Bodenheim, A.H. Goroll, B. Starfield =, and M. Roland, “The Future of Primary Care,” and T.H. Lee and Others, “Perspective Roundtable: Redesigning Primary Care.”

5. On November 18, The Physicians’ Foundation, a charitable foundation collectively representing members of state and local medical societies, the majority of America’s 900,000 physicians, released results of an unprecedented survey of 270,000 primary care physicians and 50,000 specialists indicating widespread loss of morale and desires to quit or cut back on practice (see two sidebars, the Physician Foundation and Highlights of Survey). Survey results were reported on CNN and other major media outlets”

November Promises Deflated

I felt self-satisfied with the piece until I sent it to Robert Gifford, MD, formerly head of general medicine and now on the admissions committee at the medical school. Here was his response.

I am not optimistic that the current crop of medical students are about to opt for a primary care career. The lure of high tech specialty training, the high educational debt, and most of all, the desire for a less frenetic life style, time to spend with the family, that will send their children to the best of colleges are all against an effort to fix the primary care shortage, even if salaries should rise (though that would surely help). I see the future of primary care in the hands of ‘managers’ who supervise an army of nurse practitioners, physician assistants and the like. Let’s face it, most of the common issues that take so much time in primary care are the management of diabetes, hypertension, stable coronary disease, congestive heart failure, chronic obstructive lung disease, osteoarthritis, depression, respiratory and pharyngeal infections, gastro-esophageal- reflux, and the like. Much of this can be managed by nurse practitioners as long as three is adequate supervision by a competent and well-trained primary care physician. Of course, I would rather by seen by a doctor, but I am not sure we can turn this awful situation around.

Hopes Engendered by Obama

Well, Gifford’s comments deflated my Renaissance argument about primary care’s future. But surely, I thought, the new Obama administration can step into the breach. Its emphasis on covering the uninsured, fostering primary care and promoting medical homes will have a positive impact on primary care. That what some medical leaders think. AMA Board of Chair Joseph Heyman says, “We think there’s that window of opportunity next year to really accomplish something...” And Ted Epperly. The American Academy of Family Physicians president, says he’s never been so excited about a new president. These comments do not give me confidence. It takes ten years to produce a competent primary care doctor, and medical students will still have the option to practice what and where they please.

Bailout from Burnout

Still, full of hope about the future, I turned to a November 27 perspective piece in the November 27 New England Journal of Medicine, “Innovation in Primary Care – Staying One Step ahead of Burnout.” If the government can’t bail primary care doctors out of burnout, maybe primary care leaders can. The article is based on innovative efforts of Christine Sinsky, MD, and her partner husband, Thomas Sinsky, MD, in the 114 person medical group in Dubuque, Iowa. Among other strategies, the Sinskys have adopted these practical strategies.

• A “minihuddle” with a nurse who has reviewed and summarized the patient’s lab work from a previous visit.
• Extensive advance work by two nurses to organize each visit by summarizing what has gone before on 1 to 2 sheets of paper.
• A brief comprehensive dictated note by the primary care physician summarizing the visit.
• Scheduling routine lab tests for next visit and ending each visit by planning the next one
• Organizing small doctor-nurse teamlets.
• Having the nurse take all calls, deciding which tests merit attention, and perfuming route monitoring tasks such as examining the feet of diabetics.

The author of the NEJM articles also cites the work of Kaiser Permanente Colorado. This group has 300 primary care physicians who have experimented with,
• Monthly sessions with a small group of elderly patients with common chronic disease problems following by individual sessions.
• Walk-in group sessions with a nurse practitioner and a pharmacists
• E-mail and scheduled telephone visits
• Responding to e-mail messages with 24 hours
• Making EMRs easier to use

In the case of Kaiser, the results are a mixed bag. Turnover among primary care doctors is much higher than among specialists, and recruiting primary care doctors for those who leave or retire is still difficult. It takes 10 months to recruit a doctor, only 2 months to hire a physician assistant, and in the past 6 months, Kaiser has converted six physician positions into slots for 9 physician assistants.

The Future

The future of primary care? Who knows? It’s bleak in the short run, perhaps brighter ahead. Innovations from above and below may better the situation and ease physician shortages. Solutions undoubtedly will mix public and private efforts. Only two things are certain, one, concerns will grow on how to meet demands for more primary care practitioners, and two, primary care will not be saved in its present form, with primary care doctors struggling alone to keep from drowning in the swamp or crawling out to reach higher ground

Tuesday, November 25, 2008

Hospitals and Physicians in the Real World

The good news is that bad news may be good news.

When you read or hear of physician-hospital relations, the talk is usually couched in lofty terms – “integrated systems,” “health partnerships, ““hospital physician alignment,” or, even “competition-coopetition.”

In the real world, however, the situation is much more complicated. It is full of tensions, paradoxes, conflicts, and political hardball. It is, well, messy.


This messiness may be why I found a recent e-mail from John McDaniel so intriguing. John is a former hospital CEO. In recent years, has served as president and CEO of Peak Performance Physicians, LLC, a practice management firm based in New Orleans. John, an old friend, often serves in a go-between in the real world of hospitals and doctors. John can attest to the truth of the statement once made by a hospital CEO of doctors,”You can’t live with them, and you can’t live without them.”

Hospital Problems

A host of problems beset hospitals – shrinking margins, Medicare refusing to pay for treating common complications, rampant MRSA and C. Difficile infections, declining reimbursements, dropping admissions, pressures to pay specialists for ER coverage, skyrocketing debts from the uninsured and underinsured, costs of building primary care networks , and rebellious specialists who persist in building competing facilities.

Physician Despair

Meanwhile physicians are wrestling with their own set of problems - declining reimbursements, rising practice costs, longer hours, mounting paperwork, concerns over malpractice premiums, swamped offices, pressures to install electronic medical record systems, inability to recruit new physicians, looming physician shortages, a profound loss of morale, and future uncertainties. A recent survey of 270,000 primary care physicians and 50,000 specialists, conducted by The Physicians’ Foundation, which represents members of state and local medical societies, indicated 78% of physicians perceived there to be a primary care shortage, 90% said paperwork has increased, causing them to spend less time with patients, 76% felt overworked, 49% said they would quit medicine if they could, and 60% would not recommend medicine as a career for young people.

Hospital Strategies

In his e-mail, John outlined the strategies leading hospitals are pursuing to grow and develop their hospital affiliated services.

1. Provide financial support for recruitment of individual practices, 83%

2. Have a written medical staff development plan, 72%

3. Provide training to physician office staff to improve coding, billing, and collections, 56%

4. Provide information system support for independent practices, 53%

5. Have a formal physician relations program responsible for spending time with referring physicians who are not members of the active medical staff in an effort to grow referrals to our physicians and hospital, 50%

6. Provide other types of management support for independent practices, 46%

7. Actively advertise independent physicians, 37%

Source: “Strategies for Strengthening Physician-Hospital Alignment: A National Study” The Society for Health Care Strategy and Market Development of the American Hospital Association.

John concluded his e-mail, “While most hospital leaders who participated in this study seemed to understand they have grow their volume and revenue through the recruitment of additional physicians in order to increase market share, and while hospitals seem to get a better return on investment when recruiting specialists, most hospitals are taking a more balanced approach, resulting in the expansion of their primary care networks in order to strengthen the referral network for current specialists.”

A Conversation with McDaniel

I called John McDaniel about matters relating to his e-mail and had the following conversation.

“We’re seeing more doctors say, 'To hell with it, I’m going to work for the hospital.' And we see more hospitals wanting to employ doctors. We went through this in the early and mid-90s, but that was craziness related to the entry of the public companies into the physician management arena. Now hospitals legitimately want to hire doctors.”

“And the young doctors coming out of training really want employment. It’s a trend I think will continue because of the uncertainties of reimbursement. For sure, reimbursement is not going to increase. I don’t think this country can afford national health insurance, but the Democrats are going to try. That prospect adds to the uncertainty. There would still be a private market, just as in England, but it would be much smaller. “

“There’s just a lot of fear. Fear is driving everything. Even the specialists are fearful. We see urologists, general surgeons, and pulmonologists seeking hospital employment. Doctors wanting to work for hospitals cross all lines. “
“Docs 45 to 55 are especially eager. They know they can’t retire anytime soon, and they’re just so uncertain. It’s a little bit like being in the Mafia. They have had a taste of the good life, but there’s no easy way out. Those over 55 are saying, I can probably ride this out. And the young ones simply want a better life style.”


“Then there are the pressures of installing EMRs. The feds are saying they will pay 2% more for e-prescribing but that’s a drop in the bucket when you consider the cost of EMRs. The feds are also saying hospitals can pay up to 85% of the cost of installing EMRs in doctors’ offices. But hospitals are reluctant. There are 100 EMRs out there, and the cost of writing interfaces for multiple systems would be exorbitant. Most hospitals are saying they would pay X percent of a single system, or endorse 3-5 systems for which they will write interfaces. Only about 20% of doctors have EMRs. I know Obama says he will spend $50 billion to install EMRs in doctors’ office to create a national operative system in two to three years. It just ain’t going to happen.”

A Meeting with a Doctor Group

“I had a meeting with a group yesterday afternoon. I told them, ‘Until the hammer fails, let’s decide how much each of you wants to make each year, how much you want to set aside for retirement each year, and how many more years do you have to do that. Let’s just work our ass off until the hammer fails.’
“In all of our practices, we’re developing fail-safe plans – operational disaster plans. What happens if Medicare/Medicaid has significant changes, and/or we have national health insurance? What happens if your state requires you to see Medicaid patients? Are you going to participate? Basically we’re developing operational disaster plans. The main plan is to do business as usual as hard and fast and long as you can.”

Not a Pretty Picture

“You are going to have fewer and fewer doctors participating in fewer and fewer plans and seeing fewer and fewer Medicare and Medicaid patients. Then you have a real access problem, and you have more and more patients complaining to more and more government representatives about waiting six months or more to see fewer and fewer primary care patients. The very thing the government doesn’t want to address – less and less coverage for more and more people – is going to happen. What happens if 1/3 of doctors stop taking Medicare and Medicaid? “

Physician Extenders

“More and more physician extenders – nurse practitioners, nurse doctors, and physician assistants – will begin to fill the primary care gap. But it will take legislation at the state level to turn them into medical practitioners. And many citizens will prefer to see doctors. I see a political blood bath coming – with extenders seeking more power and physician resisting. Collectively, 900,000 doctors have a lot of potential political power – if only they could get on the same page. If you think driving GM to the table to cut union contracts is a problem, imaging dealing with America’s doctors.”

Catastrophic Insurance for All

How is this country going to able to afford a universal system? One way of doing it is to provide everyone with catastrophic coverage – stop-loss insurance for everything costing over X dollars. Maybe we can develop a strategy for covering the uninsured and under-insured but I can see covering everybody for comprehensive care. The problem is: how do we control expenses? The only people you can control are hospitals and physicians. You can’t control the entitled masses that have come to believe they have a right to the best of care, as long as someone else pays the bill.”

“How in the hell did we get into this mess? We just woke up a couple of weeks ago and found out, ’We got a problem!’ If I had all the answers, Warren Buffett would be in second place. It’s a tough, complicated problem beyond any single person’s comprehension.

The good news is that the bad news may bring hospitals and physicians closer together.

Friday, November 21, 2008

Future - Start Simple, Think Big, Think Polypill, Think Pevention, Think Longevity

In apparently healthy persons without hyperlipidemia but with elevated high-sensitivity C-reactive protein levels, rosuvastatin significantly reduced the incidence of major cardiovascular events.

Paul Ridker, and 14 others, “Rosuvastatin to Prevent Vascular Events in Men and Women with Elevated C-Reactive Protein,” New England Journal of Medicine, November 20,2008

As I read the above, three things popped into mind:

1) A 2003 article on the polypill, a pill containing a statin, aspirin, a diuretic, folic acid, and an ACE inhibitor, which supposedly would prevent vascular disease and prolong life by 15 years by all people over 55 if taken once a day (1)

2) A 2007 piece by Dr. Srinath Reddy, president of the Public Health Foundation of India, Professor of Cardiology at the All India Institute of Medical Sciences, and developer of the Red Heart Pill, a polypill costing $1 for a month’s supply and containing aspirin, a statin, a thiazide, and an ACE inhibitor, and now under clinical trials. (2)

3) The nature of big innovations, such as medical imaging (MRIs and CTs), oral contraceptives, polio vaccines, renal dialysis, statins (Lipitor et al), the Internet (ubiquitous, free information 24/7), and now the polypill (a universal pill for preventing premature vascular death).

No Fool

I am no fool. I appreciate sensible critics who say the polypill is a bad idea, bad science, too good to be true, an egregious example of polypharmacy, a recipe for overpopulating the planet, and akin to using a shotgun where a series of rifle shots is needed to reduce cardiovascular risks.

But I am also aware a team funded by the Welcome Trust in London, the British Heart Foundation, Anthony Rodgers of the University of Aukland is recruiting volunteers for a massive study to test the polypill. I also know of the work of Dr. William Bestermann in Kingsport, Tennessee. Leader of COSEHC (Consortium foe Southeastern Hypertesion Control). Bestermann argues that hypertension, diabetes, obesity, dyslipiemias, coronary disease, and stroke, represent global metabolic disorder and should be approached and treated aggressively. Finally, I’m cognizant pharmaceutical companies would have much to lose with a successful polypill, and would be motivated to kill the polypill in its infancy.

Not for The Timid

Major society-changing innovations are not for the timid or for seeker-of-devils-in-the-details or sludge-in-the-entrails.
Major innovations begin with 2 steps:

1) Start simple.

2) Think big.

What could be simpler than taking one pill a day to prevent future vascular disease for humankind? What could be bigger than warding off premature death in millions of people with interrelated metabolic disease?

This monumental innovation may not happen, but it’s worth a series of clinical trials, already underway. For the polypill manufactured by Dr. Reddy’a of Hyberabad, India, it’s a case of Reddy, Aim, Fire!


• Think future not past.
• Think opportunities not problems.
• Start simple with big idea.
• Do something big that will make a difference, rather than what is safe and easy to do.


1.Wald, NJ, and Law, MR, A Strategy to Reduce Cardiovascular Disease by more than 80%, BMJ, Page 1419, 2003.
2.K.Srinath, The Preventive Polypill – Much Promise – Insufficient Evidence, NEJM, Page 212, January 18, 2007.

Tuesday, November 18, 2008

Massachusetts - Boston Elite Hospitals as Economic Bullies

Portraying Boston’s elite hospitals, Massachusetts General and Brigham, the pride of Partners Health System and legends as academic medical centers, as economic bullies is a politically incorrect thing to do. These are, after all, Harvard teaching hospitals.

But reporting hospital economic bullying is just what the Boston Globe’s Spotlight Team of reporters have done in “A Healthcare System Badly Out of Balance: Call It The ‘Partners Effect,’ Elite hospitals Are Paid Much More for Care That is Often No Better Than Average. It Is the Best Kept Secret in Massachusetts Medicine” in the November 16 edition of the Globe.

But how can this be in this age of “transparency”? Well, write the Globe’s investigative reporters, “The growing payment gap has not been subject to public scrutiny because contracts between insurers and hospitals typically include confidentially agreements.”

That’s why, asserts Charles Blake, president of Harvard Pilgrim, Massachusetts’s second largest insurer, “The same service delivered in the same way with the same outcome can vary in cost from one provider to the next by as much as 300 percent.”

That may be why health care premiums in Boston have jumped 78% since 2000, why premiums in Boston are 30% above the national average, and why the price of inpatient care is going up 10% per year despite drops in utilization, why Brigham and Massachusetts General are paid 30% more for similar procedures than hospitals elsewhere in the state, why Health Partners collected 35% of statewide hospital profits, even though it owned only 16% of the beds.

You may say, these costs increases aren’t fair to consumers or competing hospitals. That may be, but Boston’s culture with its tilt towards academic health institutions permits and encourages it. In Boston, citizens are 2.5 times more likely to pick academic hospitals, where costs are higher. The results of these elite hospitals, say the reporters, are no better on average than in community hospitals, or in less prestigious academic rivals who are less dominant than Health Partners.

Hospitals paid the highest have more bargaining clout – based on brand name, academic reputation, state-of-art technologies, and unique ability to perform certain procedures - to charge more. They charge more simply “because they can.” Or to quote Harris Berman, who was president of Tufts Health Plan in 2000, when it caved into Health Partners demands, because “They’re Partners.”

According to Regina Herzlinger in Who Killed Health Care: America’s $2 Trillion Medical Problem – and Consumer-Driven Care (McGraw-Hill, 2007),

Two or three hospital systems now dominate the markets in many cities. How can you negotiate with a supplier who controls nearly all the capacity in a market? They are non-profit, have no greed owners who demand dividends, and they are doing the Lord’s work. Their presentation is supported by an academic literature that assumes selflessness on the part of nonprofit organizations.”

For these and other reasons, including political leverage as the biggest employer in town and among Boston’s greatest revenue generator, dominant hospitals have tremendous leverage, which makes them capable of suppressing orhwe hospital competition, and even eliminating physician rivals, brash enough to organize and own their own specialty hospitals.

I suppose the moral is: in a city that is bullish on academia, it is easy to be an academic bully. It is even easy to lecture the rest of the world on how to cut costs, as three Partners Health System physicians did recently in the New England Journal; of Medicine. (Morgan, J, Ferris, T, and Lee, T, “Options for Slowing the Growth of Health Costs,” April 3, 2008). The article did not mention high costs of Partners hospitals.


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 elite academic centers,
Pride themselves on being economic mentors.
But where costs are highest in the land,
At least that’s where things now stand.

Sunday, November 9, 2008

Obama strategies - Obama: Outside In, Inside Out

For an insurgent politician, being outside looking in is not the same as the inside looking out. Rhetoric is not the same as reality. With a budget deficit of $1 trillion, Obama’s options on health care will be limited.

Obama admitted as much in a CNN interview in which he said his priorities would be,

1. economic recovery
2. energy
3. health care
4. tax restructuring
5. education

No one seems to know how to fix the economy, and when or how recovery will occur. Making the U.S energy efficient will take years, and so far, wind, solar, and biofuel contributions have been meager and disappointing. Tax restructuring on the backs of the “rich” along will do little to resolve the deficit.

According to Bob Laswewski, a blogger who writes “The Health Care Delivery Policy and Marketplace Review Blog, “ Obama’s best bet will be to take a bipartisan approach on those issues already agreed up both parties. He says it would be a big mistake to “steamroll the Republicans,” as Bill Clinton tried to do in his failed 1994 reform efforts. He concludes “ A big $100 billion comprehensive health care reform plan like the Obama health plan is not realistic in these times of financial crisis.”

Instead, says Lasjewki, Obama should focus on agreed upon bipartisan issues that are “affordable” and “doable,” such as.

1. Reauthorizing the State Children Insurance (Plan (SCHIP)
2. Rearranging Medicare spending by equalizing private and traditional payments
3. Crafting new physician payments to avoid the 21% fee cut due on June 1, 2010
4. Expanding health insurance technologies and personal health records
5. Improving transparency on prices, errors, infection rates, and outcomes
6. Developing best practice studies, requirements for disease management, and comparative effectiveness
7. Assisting small businesses with 3 to 9 employees with federal assistance coverage.

As I add up the costs of these suggestions, I estimate they would probably exceed $100 billion. The suggestions may be “bipartisan,” but they are not necessarily “affordable” or “doable.”

• EMRs have already been on the federal table for 5 years with little progress in widespread installation of EMRs or getting IT systems that permit hospitals, health plans, and doctor systems to talk to each other. PHRs, even with Microsoft and Google pushing them, are still in their infancy. Obama says federal subsidies to help put EMRs would cost $50 billion.
• “Equalizing private and traditional Medicare spending” is not a piece of financial cake either. Medicare spending is often 20% to 50% below federal spending. To raise Medicare levels to private levels would probably cost another $50 billion, and lowering private spending to Medicare levels would devastate the private sector.
• As far as using IT to compare effectiveness, insure transparency on prices and improve outcomes, put me down as dubious, as these goals assume a widespread interconnecting IT system.

In the near term, with the financial crisis and the power of health care lobbyists, comprehensive reform is well nigh impossible, but incremental reforms are worth a try. It is also worth noting that health care remains the only growth sector and the single largest employer among U.S industries.

With high hopes for needed change, nothing is impossible, but it helps if the possible is affordable and doable.

Saturday, November 8, 2008

Data, Use and Misuse - Limits of Data-Driven Health Care

Prelude: A school of thought exists that says information technologies, authoritative information available at the click of a mouse, will rationalize and cut costs, and improve outcomes and quality. I am not a fan of this school. There’s something Orwellian about it to me, and I think that the permutations and combinations of the human condition are so complex they defy categorization. Still, the availability and the instantaneity of clickable information are worth a try. Just don’t expect miraculous results.

My Assumptions
Have a moment to spare? Good. Because I am assuming you, the reader, are a busy clinician with no time to waste.

I am assuming you have reached the end of a long practice day, and you have a few unanswered questions that linger from the 20 or so patients you have seen today.

I am assuming you would like quick, easy, relevant, and recent answers to your questions – and you would like those answers to be authoritative and targeted to your specialty or to problems you confronted today.

I am assuming you are Internet-savvy and have previously gone to the all encompassing or, the massive U.S. government website, for your answers.

I am assuming you have found these sites too often yield long lists of articles or bits of information that take too long to scroll through and are often clinically irrelevant or outdated.

According to Lois Wingerson, content editor of, these were the same assumptions the developers of, made 2 ½ years ago when the parent company, United Business Medica, based in London, and its subdivision, CMPMedica, Ltd launched They assumed busy doctors, most of whom now use the Internet, want clinically focused, timely answers for pressing questions. was such a success that 2 years ago it expanded to the U.S.

Ms. Wingerson operates out of New York City, the U.S. headquarters is in Darien, Connecticut, the project manager is in Framingham, Massachusetts, and the software company, Convera, is situated in California. To make its information authoritative and clinically relevant, vets all of information through clinical experts, located in the U.S. and abroad. has United Kingdom, France, and Spain editions. Each day it has hundreds of thousands “page views,” the criteria by which it judges its acceptance by clinicians worldwide.

Clinician Feedback

According to Lois Wingerson, clinician feedback is essential to keep clinically vital, relevant, and timely. She spends her time entering and deciding upon content, telling the search engine where to go, reading and weighing feedback, and writing the Search Tips Newsletter (to which you can subscribe on the homepage). The newsletter is based on searches being conducted and clinical responses and criticisms. To date, has been almost completely clinical, but Wingerson foresees extending the website reach and contents to socioeconomic issues, particularly in the search tip newsletter.

Visit the Website

But I digress. If you want to know how works, I invite you to visit their website, so you can judge for yourself if this search engine is for you.

First, note the categories listed on the home page: all of medicine, cancer/hematology, cardiovascular, diabetes/endocrine, infections, mental/nervous system, musculoskeletal, pediatrics, practice management, radiology, and respiratory. Note also the search box, which you may want to use to get a specific answer.

The practice management category may interest readers of Physician Practice Options most. It is only several months old, as the interest in practice efficiency has grown and practice profit margins have shrunk.

As Ms. Wingerson observes, practice management is a “different beast.” Much of the practice management information is extracted from another website in the United Media family of websites and publications, which include Searchmedica UK, Searchmedica France, Searchmedica Spain, Cancer network, Consultant Live, Diagnostic Imaging, Physician Practice Management, and Psychiatric Times.

Narrowing the Search

Searchmedica assumes you may not only be interested in some broad topic but in a narrower aspect of that topic, such as.

• Research/reviews of the subject extracted from major journals, such as the New England Journal, JAMA, the Annals of Internal Medicine, Lancet, the British Medical Journal, among others.
• Practical articles/news - This information may come from Trade journals, specialty newsletters, Internet websites or a host of other sources.
• CME – This speaks for itself
• Evidence-based articles – As you well know, evidence-based medicine is the rage these days, and often serves as a basis for reimbursement for pay-for-performance. This material comes mostly from major journals.
• Patient-education – Increasingly, clinical medicine is perceived as a patient-physician partnership, and involves active patient engagement and education.
• Complementary Medicine - There’s no getting around it. Complementary, or alternative medicine, is here to stay, as patients seek answers outside of traditional Western Medicine.
• Evidence-based guidelines - As health expenditures have exploded, so have “best practice guidelines.” i.e, what works and what doesn’t and what should be paid for.
• Clinical trials - The conduction of clinical trials has become an international industry as pharmaceutical companies and device manufacturers seek evidence that their products work in selected populations. Here you will find clinical trials known to the U.S. Government.

In short, searchmedica’s founders believe they have developed a website that allows clinicians to find exactly what they want to know quickly without endless scrolling through long lists generated by such generic websites such as Google or, The founders consider the site “agnostic” in that it does not favor one source over another and neutrally covers the clinical landscape.

A Practice Management Example – Coding

Let’s suppose you are interested in coding – either to maximize acceptable revenues to avoid an audit. If you type in coding in the search engine, you will get these top ten entries. Each contains a brief abstract of what the article is about.

1. Physicians Practice Articles : Coding: Your Top Coding Concerns Solved, November 1, 2008
2 Physicians Practice Articles : Coding: Your Top Coding Concerns Solved, October 1, 2008
3 Physicians Practice Articles : Billing: Finding Lost Revenue, November 1, 2008
4 Physicians Practice Articles : Billing: Billing Problems? Consider Your Charge Ticket. November 1, 2008
5. Physicians Practice Articles : Billing: Finding Lost Revenue, November 1, 2008
6 Physicians Practice Articles : Billing: Finding Lost Revenue, November 1, 2008
7 Physicians Practice Articles : The Law: Third-party Audits on the Rise, November 1, 2008
8 Physicians Practice Articles : Coding: Your Top Coding Concerns Solved, November 1, 2008
9 Color coding aids 3D interpretation in virtual colonoscopy. September 10, 2008
10 Physicians Practice Articles : The Law: Third-party Audits on the Rise, November 1, 2008

So if you have a moment to spare, visit I have. If it has one shortfall, it might be its failure to specifically cover some of the burning broader issues of today - Medicare mandates, shrinking reimbursements, physician shortages, decreasing access to care, and policy issues in general – into one category.

Organizing these issues into one category may be asking too much, for these issues are not solely clinical and cross philosophical, ideological, and political boundaries. They are hard to categorize. Still, does contain abundant source material on the financial, legal, and administrative issues facing individual practices, and these are addressed in its new practice management section.

Health care and the economy - Economic Impact of Private Practice in Georgia

“We are not retreating. We are advancing in a different direction.”

General Douglas McArthur

Prelude: This is an interview with David Cook, CEO of the Medical Association of Georgia, a position he has held since 2001. The Association has about 7000 members. David is interested in advancing the notion that private physicians in their offices are a significantly positive economic force in the community at large. This fact has not been appreciated because most similar economic studies have focused on hospitals.

It should be no secret by now, but I believe an expanded health care system is good for the economy in that it yields increased employment and increased tax revenues for local, state, and national economies.

Q; The Medical Association of Georgia recently released a report on the positive impact of private practice on the general economy. Tell us about that report.

A: The genesis of our report came out of a question we asked ourselves: how do we talk to policymakers about the significant problems physicians were facing. We have the shortage of physicians nationwide, which is particularly acute in Georgia. Other is low reimbursement rates. Others the negative malpractice climate and hassle factors, both of which cast a negative light on the practice environment. We wanted to make the argument to state and national legislators that physicians bring something positive to the health and economic tables.

Access to health care is the primary component, but the economic component, the positive economic activity generated, is important as well. Based on our intuitive understanding of the latter, we did an economic study several years of Hall County. Based on those results, we decided to do a state-wide study.

Q: And who did you do this study with?

A: The study was conducted with the Carl Vinson Institute of Government. They have an economic modeling program at the University of Georgia that county and state officials use to do economic studies for various aspects of governance. We wanted to use the same entity that policymakers already used to make economic decisions, such as what bringing an auto plant to Georgia might mean. They use that information to make policy decisions.

Q: I understand the study focused on private physicians’ offices rather than on hospital employed physicians or on hospitals themselves.

A; That’s right. Hospitals have been doing this for some times to determine economic impact. But to my knowledge, this is the first economic impact study of private practice. We wanted to fill in that piece of the puzzle. When you add in the hospital economic impact, it’s much greater.

Q; So you concentrated on ambulatory care in private offices.

A: Yes, care that is provided outside the hospital. The Bureau of Labor Statistics separates the two kinds of practice activities inside and outside of hospitals. The Department of Labor uses these statistics to track economic impact.

Q: This study seems important since 80 to 90% of ambulatory care is provided by private physicians outside the purview of hospitals. What did you find from the study? Did the economic impact surprise you?

A: We found there was a substantial impact of private practice. It was higher than we expected. What was enlightening was to compare it with other sectors of the economy. We found there was a $20 billion impact on the State of Georgia, and every single physician directly or indirectly generated 12 to 13 additional jobs. We found the private physician impact was roughly equivalent to the insurance and financial industries combined and to one-half the construction sector, which is huge in Georgia, which is a fast growing state. We’re one of the fastest growing states in the country. We added two representatives after the last census, and 6 of the 10 fastest growing counties in the nation are in Georgia. Atlanta has fast growing service and IT sectors.

Q; One of the reasons driving the study, as I understand it, is that you wanted to highlight the growing physician shortage in Georgia in order to catch the attention of policymakers in graduate medical education.

A: That’s right, but we had no objective data to influence policymakers. You’re most effective when you have data to make your point. There’s an argument to be made if you attract high-paying professionals to the state, it will have a strong economic benefit. It’s well-known Governors travel around to influence industries to settle in their state. But not much thought is given to educating or attracting more physicians. We argue if you change the practice environment to make it more favorable, you’ll not only be doing citizens a favor by giving greater access to care but also by generating jobs. One out of every 20 jobs in the state of Georgia is generated by private practice physicians, and those physicians generate $2.2 billion of state taxes.

Q: Your comments bring to mind two stories from other state.
• One is from North Carolina. North Carolina, like Georgia, is a fast-growing destination for retirees. I was told by a physician entrepreneur there, who was setting up multispecialty clinics in underserved areas, that retirees ask two questions: 1) What is the price of property and 2) Where do I get medical care? Health care is a magnet for drawing and retaining retirees migrating to Georgia.
• The other story is from Texas In 2003, the Texas Medical Association persuaded the legislators there to cap medical liability awards at $250,000. This caused thousands of doctors across the country to Texas to practice, and not only that, malpractice premiums dropped precipitously.

Has the Medical Association done anything in the medical liability arena?

A: Yes, in 2005 The Georgia legislature passed on a similar law, putting a $350,000 cap on non-economic damages. Our law is almost identical, and it has had a significantly positive impact in attracting doctors to Georgia. Premiums have been reduced, and we’re attracting more ER doctors and Ob-GYNs. While this legislation has been important, it is not sufficient to resolve the physician shortage problem. We need to do more to raise Medicaid rates and reducing hassle factors.

Q: Are you making any progress on the latter two points?

A; Yes, last year we had a 2% increase in Medicaid payments. We would like to bring Medicaid rates up to Medicare rates. If we did that, would we attract enough doctors to pay for the increased rates? We look at our study and our activities as an investment to encourage more economic activity and to raise state tax revenues.

Q: It hits me that what you’re doing is important. Doctors are often cast in a negative light because of high health care costs, and reformers tend to focus on the negative rather than the positive. You’re simply pointing out that private physicians are a positive economic force.

A: Just a point of nomenclature, if you will. We often talk of costs, not expenditures.. While expenditures on health care have gone up, I’m not so sure costs have. Expenditures have gone up because of new technologies, but costs on things we’ve had in the past aren’t. In fact, costs for many things have gone done. But the rise in the population and new things, expenditures have gone up. I prefer to talk in terms of expenditures.

Wednesday, November 5, 2008

Obama strategies - President Barack Obama’s National Health Care Agenda

1. National “play or pay” employer mandate requiring businesses either to offer workers insurance or to pay a tax (very small businesses to be exempt)

2. Creation of a new national health plan (similar to Medicare) for the uninsured and small businesses

3. Establishment of a new national health insurance exchange that would offer choice of private insurance options for the uninsured and small businesses

4. National mandate that children must have coverage

5. National subsidies for lower-income Americans to help them afford coverage

6. Expanded coverage financed through the payroll tax, letting tax cuts for families making over $250,000 expire, and savings from electronic medical records, disease management, prevention, and other system reforms

7. National regulation of all private insurance plans to end risk rating based on health status

8. National establishment of federal reinsurance programs to insure businesses against cots of workers’ expensive medical episodes

9. Reduction in administrative costs of private insurance

10. National accelerated adoption of medical records

11. Promotion of disease management

12. Emphasis on prevention and public health

13. Payment of providers based on performance and outcomes

14. Reduction of excessive payments to private plans contracting with Medicare

15. Allowing Medicare to negotiate with drug companies

16. Establishment of a national comparative effectiveness research institute

Monday, November 3, 2008

Systems think - Groupthink, Systemsthink , and Health Reform

As the nation gets set to embark on a new health reform era under a new president, doctors across the land worry about what lies ahead. Is a nationalized system dominated by large groups finally at hand? Or will the current chaos persist?

I don’t know, but personally I worry about the hazards of two mindsets - groupthink and systemsthink.


In a 1972 book Groupthink, Irving L. Janis, a Yale psychologist, explained how groups of experts could make colossal mistakes. Experts in groups worry about their personal reputations, their role in the new government, and whether if they deviate too far from the consensus of their peers, they will be ostracized as reckless mavericks. Very few professional economists, who number about 200, for example, warned of the current economic disaster while it was in the making.

There is little room for dissent among experts. An example in health care might be Democratic health experts who have yearned for so long and so desperately for government controlled Medicare-for-all system. To doubt the inevitability of such a system is moral heresy. To say that such a system might deprive citizens of freedom, choice, and individualism it to follow the doctrine of cruel conservatism. To point out that you cannot simultaneously have a robust economy and a pervasive welfare state, or suffer the fate of the stagnant economies of Europe, is unthinkable.

Groupthink exists on the conservative side of the ledger too. To stray from the thought that an unregulated free market with a completely consumer-driven model is to preach the doctrine of centralized command and control socialism is dangerous if you are to be a member of the conservative club.. To say consumers might not have the judgment and information to make responsible health care decisions is anathema.

To assert, as I do, that American want a mix of government control and individual choice, as long as someone else pays for it, is cynicism of the first order.


Which brings me to systemsthink. Read or listen to experts on both government and free-market sides of the aisle, and you will invariably run across systems’ advocates. They say the answers in health care lie not in individuals, be they physicians, patients, or policymakers, but in large organizations deploying systems.

The best explanation of systemsthinking I have run across was not in some arcane academic or management book, but In a sports article in the November 2008 New York Times Sports Magazine by Jeff MacGregor, “Here Goes Nothing: Brett Favre, Freethinking Huckleberry in the N.F.L Industrial Complex, Tries to Make Something Happen One More Time.”

The Jets’ System – and its various subsystems – is just one of 32 such systems currently deployed across the N.F.L .industrial complex. These systems are all differing – systems for offense, systems for defense, systems for special teams. A system of systems.

It’s all very complicated and scientific and dull. For 25 years, the N.F.L – roughly parallel to the rise of the computer – the System has been ascendant. At once the weapon against chaos and a holy talisman against chance. They system is against intellectual human confusion and statistical weakness. It offers digital probability and plausibility. The System promises to abate risk and assuage uncertainty.

Systemsthinking pervades health care too – at Kaiser Permanenti and other large multispecialty groups, among experts in board rooms and corridors of health plans, hospitals, pharmaceutical companies, and academic medical centers.

Systemthink is understandable and necessary. Human beings, patients, physicians, hospital executives, and payers need systems discipline. We all need some system = socme context in which to operate, thrive, survive, and improve.

But as is the case with Brett Favre, there has to be room for individualism and heroism too. – for self-expression, grace, spontaneity, independence, and intuitive thinking and performance. Artists and athletes like Brett Favre and high performing physicians need a system in which to function. But the System needs the Art of Medicine too, wherein physicians can be free of the constraints of the system and its computer models. I worry in the future we will rely too much on groupthink and systemsthink and algorihmicthink, and too little on Humanthink and self-reliance.

Saturday, November 1, 2008

Health care and the economy - Positive Impact of Private Practice on the Economy

The news for private practice has not been good in recent years. Private practice is said to be “fragmented,and its practitioners are deemed responsible for much of the increase in health care spending. Furthermore, private physicians are criticized for being slow to install EMRs. The thrust of criticism of physician economic activities is that these practices drain government treasuries and budgets.

Suggested Solutions

Solutions to slow spending generally impinge on physician’s autonomy. Solutions suggested include

• abandoning private practice to assume salaried positions,
• minimizing fee-for-service incentives through capitation or salaried arrangements,
• relying heavily on “best-practice protocols” to make clinical decisions,
• employment as hospitalists or in hospital “owned” practices,
• joining large groups,
• curtailing utilization,
• ceasing “self-referral” to facilities in which physicians have a financial interest,
• bundling of fees with hospitals,
• limiting payment updates in high-cost areas,
• cutting fees, making it difficult to practice profitability
• extending Medicare payment rates to all of private practice

The Flip Side

As with other economic debates, a flip side exists -
private offices powerfully stimulate local and state economic activities, employment, and tax revenues.

GEMS (Georgia Economic Modeling System) Study

A September 2008 study by the government of Georgia’s
– GEMS (Georgia Economic Modeling System), “The Estimated Impact of Private Physicians’ Offices in Georgia,” byWes Clarke and Adam Jones of the Carl Vinson Institute of Government – indicates that in 2008, private physician offices in Georgia,

• supported nearly 190,000 jobs,
• generated more than $10 billion in private income,
• increased total economic activity by nearly $20 billion.

Impact of Each Private Physician

Each private physician directly or indirectly supported or generated

• 13 additional jobs
• $640,000 in personal income
• $1.5 billion in total economic activity
• More than $1.2 billion in state revenues
• $15. billion in local government revenues.

What Study Did Not Include

These economic impacts are even more impressive considering they did not include hospital-based physicians, hospitals themselves, or other components of the health industry. Private practice office economic activities were almost one-half the size of the entire contraction industry in Georgia and as large as the financial and insurance industries combined.

Purposes of Study

Why was study done? It was a collaborative effort between the Georgia Medical Association and the Carl Vinson Institute of Government. Its purposes were to encourage the Georgia graduate education system to produce more physicians and to highlight the physician shortage in Georgia, which currently has 17,500 physicians but expects to fall 2,500 short by 2020.

Given current economic projections, by 2020 private practice offices will support more than 270,000 jobs, generate $17.8 billion in revenues, and increase total economic activity in Georgia by $32 billion.


In addition to delivering essential health care services to patients, private practice physicians’ offices in Georgia provide jobs and economic activity vital to the communities they serve and the rest of the state.

In 2008, the estimated impact of private practice physicians in Georgia totaled more than $20 billion dollars in
output, supporting nearly 190,000 jobs and producing more than $10 billion in personal income for Georgia’s families. Based on current trends, that figure is expected to grow 43 percent to about 270,000 jobs by 2020.

Each physician in private practice supports between 6 and 20 other jobs, depending on medical specialty, and produces significant economic activity in the state. If Georgia’s graduate medical education capacity is increased to decrease the projected physician shortage, the economic output of private practice physicians could grow to nearly$35 billion by 2020.