Wednesday, December 31, 2008

Effect of complexity -How Will We Remember 2008?

We will remember 2008 as the year complexity, the Internet, and globalization overcame and overwhelmed humankind.

We will remember 2008 as the year complexity humbled us.

We will remember 2008 as the year unlimited credit in the form of a small percent of foreclosed mortgages turned the financial, and finally, the healthcare world, upside down.

We will remember 2008 as the year we learned complexity is more complex than anybody ever imagined when you tie it together as derivatives and when you intimately and instantly connect it to the rest of the world.

The year of our Lord, 2008, was the year, we learned,

Complexity is, well, complex, so complex that not even the “experts” comprehended it or anticipated its consequences.

Healthcare is an intimate part of a complex world, and is not immune, isolated, or protected from its vicissitudes.

Healthcare’s complexity is what makes it so resistant to change, or at least so we think.

In the complex interconnected worlds of humankind and healthcare, not everything, not every little detail can be planned linearly.

Life and human affairs are far from certain and are often dictated from the edge rather than from the center.

Political leadership can be organized and mobilized from the bottom-up through constant online contact with and feedback from supporters, many previously excluded from the political process.

The Web and its algorithms are not a satisfactory or total answer to controlling information flow or enforcing compliance, but it is a powerful tool for tuning to the edge of healthcare events, for understanding diversity and differences, for connecting inside and outside worlds, and for forecasting what works.

The world is full of paradoxes and tensions; these natural phenomena will always be with us, and there is no single answer for resolving them, in healthcare or elsewhere.

You must pursue multiple actions simultaneously and constantly innovate from the top-down as well as the bottom-up, and you cannot be sure of everything before you proceed with anything.

Nothing is absolute, you cannot completely control human behavior, or preach prevention, or plead for rationality in all things, and you must heed informal relationships, gossip, rumors, and sidebar conversations, and these shadow behaviors – these completely human, sometimes irrational, reactions, are important because they foretell workable health and business models and subsequent actions with any chances of success.

The human world, and its healthcare derivatives, work by “chunking,” by allowing complex systems to emerge out of links with simple things, out of convenient, simple, inexpensive, predictable, patient-centered, physician-accepted disruptive innovations capable of operating independently rather functioning seamlessly as dictated by centralized bureaucracies.

Success usually flows from cooperation and competition rather than conflict and conquering rather than one or another.

Many of the thoughts expressed above have their roots in the book Edgeware: Insights from Complexity Science for Health Care Leaders, VHA, Inc. 1998

Tuesday, December 30, 2008

Costs, the physician culture - On Draining the Health Care Financial Swamp

The doctor went on. “I’m curious. You know I’m the most expensive doctor in the city. Why did you come to me?” “When it comes to my health, money is no object.”

Milton Berle

The problem with the chart as surrogate is that the map is not the territory. ..The financial costs of imprecise observations leading to unnecessary and risky tests are not known. In a health system in which the menus have no prices, we order filet mignon at every meal.

Abraham Verghassie, “Culture Shock – Patients as Icon, Icon as Patient,” New England Journal of Medicine, December 25, 2008

Draining the health care financial swamp begins in medical school and in teaching hospitals.

The Good News

The good news? Medical students and residents have good intentions. And they follow their altruistic instincts. They order every test and procedure that might benefit patients, diagnose and treat patients, and please their teachers. These fledging doctors tend to be compulsive, a big reason they qualify as doctors. They don’t want to leave any test undone, any procedure unperformed, or any question unanswered their attending might ask.

The Bad News

The bad news? These same young doctors have little reason to pay attention to costs. There are no rewards for cost consciousness or for economic prudence. Anyway, technologies these days are all powerful, capable of looking inside the body and joints and measuring every metabolic component or function. That’s why looking, listening, and examining the patient often comes last. A third party will pay. Consequently, there are no tables or charts on any hospital ward or in any clinic listing prices for tests and procedures.

The objective of all dedicated physicians is to thoroughly analyze all situations, anticipate all questions from rounding attendings, have answers to all those questions about tests and procedures to back up your answers, and to move swiftly to do whatever was left out. There is always something missing, and the hospital, after all, is the place for quick one-stop analysis.


However, doing all of this leaves little time for listening to patients, conducting a thorough physical exam, or dropping by periodically to check for the latest developments.

When you’re up to your ass in alligators, it is difficult to remember your initial objective was to drain the swamp –listen, diagnose, and treat the patient. Instead, you are unwittingly draining the health care financial swamp.

Monday, December 29, 2008

Reece, personal musings - No Silver Bullets for Health Reform

There are no one, two, or even ten silver bullets. Controlling costs will be very difficult.

Robert Laszewski, Inside-Beltway Consultant, “Naïve Policymakers Need Not Apply,” The Health Care Blog, December 24, 2008

I: Why are you interviewing yourself?
Me: This is my blog, and I will interview whom I please. You might say it’s an I for I, and a truth for a truth. I see I to I, you see, with me.

I: Get serious. What’s this self-imposed blog about?
Me: It’s a history lesson. There’s no mystery to history. It’s the present and future that’s obscure.

When Medicare and Medicaid passed in 1965-1966, the Johnson Administration assured us the combined programs’ cost wouldn’t exceed $9 billion. Now, 43 years later, the cost is approaching $1 trillion, may double in five more years , and threatens to bankrupt the government.

I: What’s the lesson?
Me: There are four lessons.

• One, if you think health care is expensive now, just wait until we have “free” government care. Anytime you have a government program, people will find a way to “game” the system, driving up costs. The government will have to decide selectively what it can pay for, not how it can pay for everything.

• Two, when you expand coverage, you invariably spend more money. As sure as dawn follows darkness, expanded government care will drain the federal treasury.

• Three, money, even federal money, isn’t unlimited with the current budget deficit of $2 trillion or so. No tree, no fee, grows to the sky. There’s no free lunch and no free for service, if you’ll pardon a cliché couplet.

I: Why not pardon you ? It hasn’t stopped you before.
Me: Back to the history lesson.

• Four, complexity science and chaos theory is at work. A butterfly flapping its wings in Brazil can cause a tornado in Texas and 5% of foreclosed mortgages in California can bring down Wall Street. The same forces may be at work in health care.

I: Do I detect a note of cynicism?
Me. No, what you detect is realism based on experience. The only long term solution is to make people pay something out of pocket for health care, with a cap of unaffordable catastrophic care and with unspent tax-free money set aside for retirement. But that will not happen in a society like ours that is afflicted with the entitlement syndrome.

I: So what now?
Me: So universal coverage will become a matter not only or morality but of economics. Take Massachusetts, if you please. Two years after its inception, the Massachusetts universal coverage plan is driving costs out of sight in the second most affluent state in the union and one with one of the lowest rate of uninsured. If it doesn’t work in blue heaven under ideal conditions – affluence, a 10% rate of uninsured, and a liberal culture – will it work in Texas, California, and Florida – with populations of without health insurance estimated at these levels - Texas 24%, California 19%, and Florida 21%

I: So what, if universal coverage is the right thing to do?
Me: Universal health coverage may be the right thing to do, but what good is it if there isn’t any access to primary care doctors – the case in Massachusetts. Universal insurance isn’t the same as universal access. One without the other is meaningless.

I: Look, we can solve the primary care problem by paying primary care doctors more, making primary care doctors debt free by making medical school free for future primary care doctors, erasing the income differences between primary care and specialty doctors.
Me: You are blissfully naïve. According to a recent 400 page report by the Congressional Budget (CBO), we’ll have to attack the following structural problems of U.S care simultaneously and in no particular order for comprehensive reform.

• Change the health insurance system, partly by making health plans offer premiums with pre-existing illness, punishing those profitable HMOs and PPOs and powerful lobbyists , especially those who profit from Medicare drug plans and hundreds of thousands of employees.

• Reform medical malpractice, fat chance with Congress being 70% lawyers.

• Radically alter the tax system, by removing tax-free incentives for corporations and giving it to individuals and small businesses.

• Compelling big business to “pay or play,” meaning fining them is they don’t cover employees, One wonders how this will play politically in a deep recession with big employers already stretched thin and laying off hundreds of thousands of workers.

• Expand access to public programs.

• Incentivize innovations from the private sector without stifling them with foolish regulations.

• Reward health care performers and punish non-compliers, by documenting every health care encounter without creating the illusion that documenting is more important than doctoring.

• Require EMRs for hospitals and doctors and other “providers, to participate in Medicare, even if EMRs cost too much, drive down productivity, have not been shown to cut costs or improve quality.

• Force hospitals and doctors to bundle payments as one entity.

• Insure all children, a no-brainer even for those with no heart.

• Herd those 85% of doctors who now practice independently into multispecialty group practices, put them all on salary, and reduce spending by 30% (Alain Enthoven, “Health Care with a Few Bucks Left ovewr,” New York Times, December 28, 2008).

I: You don’t have to document what you say. I trust you. If you can’t trust me, who can you trust?
Me: Nobody.So I’ll go on.

• Restructure primary care by having doctors serve as directors of medical homes that offer coordinated comprehensive and preventive care.

• Institute cost sharing among hospitals and doctors who perform well and save money..

• Punish fraud and abuse, an inevitable temptation when you’re dealing with federal monies spilling off government printing presses.

• Save and share money from nursing homes, laboratories, and imaging technologies.

• Make having an EMR a condition for participating in Medicare.

• Create a federal technological institute for judging the effectiveness and outcomes of different modes of care.

• And of course, MDR (Mandate, Document, and Regulate) until the cows come home. You can’t trust anyone outside the sacred halls of government.

I: You’re talking about the future. I thought this was going to be a history lesson.
Me: The history lesson is that our health system is a creature of our democratic culture. As a people we desire open-ended access access to the best specialists, latest, and mostl costly technologies, treasure our freedom to choose the specialists of our choice, avoid high taxes for the general social welfare, are leery of big government, and, of course, want someone else pay for it all.

I: Please give me historical examples of what led us to this point, and what makes reform impossible.
Me: I never said reform was impossible, I said “sweeping reform” was difficult. To understand why, I recommend the following readings.

The Social Transformation of American Medicine, by Paul Starr, 1982. Starr described how American taxpayers rewarded the health care establishment after World War II though the Hill-Burton Act of 1946, funding the National Institutes of Health, and pouring money into research and new technologies, mostly created by big institutions and deployed by specialists.

And Who Shall Care for the Sick? The Corporate Transformation of Medicine in Minnesota, 1988, by yours truly. As the title implies, I thought managed care would scare off many doctors and leave too few care to care for the sick, and I believed corporations, with HMOs as their surrogates, would transform medicine. As it turned out, managed care failed, retrained costs only temporarily, and drove primary care into the ground.

• The Road to Reform; The Future of Health Care in America, 1994. An instructive text by Eli Ginzberg a noted health reformer, economist, and critic leading us through the maze of complex forces and special interests that make up health care. The book was a prelude to the smashing crash and burning of health care reform as conceived by the Clintons.

The overall history lesson here is: It’s our culture, Stupid! It may be naïve, it may be overly optimistic, it may depend too much on others paying the bill, but it’s our culture.

I: Is there any way to fix the system?
Me: Sure, but it’s going to incremental, it’s going to be painful, it’s going to be by trial and error, it’s going to be the testing and rejection of entrepreneurial innovations, and it’s going to be through an uneasy symbiosis between government and business, with business leading the way in many instances, because its survival is at stake in the global economy and because business can move quickly and decisively. The prospect of bankruptcy in the morning concentrates one’s attention.

I: What about doctors?
Me: Right now doctors are a discouraged, demoralized, and desultory bunch, looking for leadership, in a profession divided into 190 different specialties. But there is a shortage of ud , thanks to government and managed care policies and third parties in general and underestimates of opultion growth. We are in demand, we are mobilizing, and we are asking for a seat at the health reform table. We have leverage because you can’t run the system without us. I think we will respond to the challenges put before us, we will remain the backbone of the delivery system, and we’re fully aware we need the help of physician assistants, nurse practitioners , and all the other physician extenders to make things work. No physician is an island in this complex health care world.

I: So what will an Obama administration do?
Me: The Obama administration will quickly pass universal coverage for kids and fund stem cell research. From there on, it will be uphill, one battle at a time. Health care for all children and money for stem cell research are “feel good” programs, and I endorse them, but they don’t have any real economic consequences in the overall scheme of things.

I applaud Obama’s pragmatic tone, his sense of what’s possible, and his promises of hope. But given the $2 billion deficit, I wonder what is possible without raising taxes. The “rich,” those making over $250,000, are rapidly shrinking as the sole sugar daddies and the soul source capable of financing health care for all. The tax dollars are where they’ve always been – in the middle class. And I frankly don’t see how we can save enough money through EMRs, prevention, and chronic disease management to make a go at universal coverage soon.

Saturday, December 27, 2008

Book review - Mountains beyond Mountains: A Book Review

I don’t often use this blog to review books. But Mountains beyond Mountains: the Quest of Dr. Paul Farmer Who Would Cure the World (Random House Paperbacks, 2003) is different. It tells the tale of a doctor who works at the intersection of politics, economics, social systems, and medical practice. It is not a pretty tale, for millions of poverty stricken people are starving and dying of malaria, TB, and AIDS around the globe.

To a limited extent, I can identify with Dr. Farmer. I’ve been observing and writing about the interaction of government, the corporate cultures, and the transformation of medicine in the U.S. capitalistic and managerial U.S. culture. We have little TB here, no malaria, and AIDS is under control. Yes, we have political, social, and economic conflicts. Yes, critics say our system is “broken,” an overstatement in my opinion, considering the level of sickness in the rest of the world.

Doctor Paul Farmer is a polymath - an infectious disease specialist, Harvard professor of medicine, medical anthropologist, and world traveler. He treats the poor, the starving, and the sick in the third world – in Haiti, Peru, Russia, Mexico, and elsewhere – wherever he finds them and wherever he is asked to help.
Paul has zero sympathy for American doctors who complain about income, managed care hassles, and government intrusions upon their autonomy. He has other fish to fry. His philosophy is: get off your duff, and go out and treat the people who need you. Rise above politics. Do what you have to do to help the sick, and damn your personal economic consequences.

The Farmer story is remarkable. He was raised in the America South in a nomadic family who lived on a bus, a boat, and in trailers. Farmer, who has a photographic memory and who reads voraciously and omnivorously, early on developed an affinity and compassion for Haitian workers the U.S. The title of this book, Mountains beyond Mountains, is a Haitian expression denoting there is always another mountain to climb in Haiti.

Farmer received a full scholarship to Duke University, where he graduated sum cum laude, even though he spent much of his time in Haiti treating the poor. He continued this pattern of being a student and traveling to Haiti while at Harvard Medical School, where he received a dual MD and PhD in Medical anthropology.

While at Harvard, he helped found Partners in Health, an organization that build a medical complex high on the central plateau of Haiti. He and his followers changed the health system and did a systematic survey of its needs. They studied its interworking and culture, visited and traded the poor, built a hospital, and took all comers. Farmer and his crew had no electricity or running water or other modern conveniences and depend mostly to infusion of cash form benefactors who fell under Farmer’s spell.

As a believer in the American health and political system, I found the book unsettling a t times. Famer deplores and criticizes Americans for their neglect of the poor, consorts with left wing sympathizers like George Soros, and openly admires and praises the work of Communist Cuba who government has provided universal health care, educated thousands of doctors, and effectively eliminated starvation.
Farmer himself is non-ideological. He does not believe in “ologies,”or political movements. Instead he works with whoever supports his cause, whether they are Cuban politicians, Soviet prison managers, Peruvian health officials, and Bill Gates, George Soros, or Boston philanthropists – anybody who will advance his cause to save the poor.

Farmer is tireless – a jet setter shuttling back and further between Boston, Haiti, Misgovern, Lima, or anywhere the World Health Organization is meeting. He can be profane and does not profess to be a saint. He is courageous- exposing himself to drug resistant TB, AIDS, and other infectious diseases, socializing with dictators, wading into crowds of soldiers who are shooting Haitians, all the while studying medical textbooks, conducting clinical trials, and challenging the Boston medical establishment to leave him alone to do his world.

This book will appeal to two audiences: 1) idealistic medical students and young doctor who want to make difference; 2) physicians who toil at the intersection of politics, social systems, and medicine and who wonder if they are making a difference.

Friday, December 26, 2008

Home, business business ideas -Procedures - The Hole in the Medical Home Theory

There’s always a hole in theories if you look closely enough.

Mark Twain

The solution is not an intramural “food fight” over payment.

Allan A. Goroll, MD, “The Future of Primary Care – The Community Responds,“ New England Journal of Medicine, December 18, 2008

Our society tends to place a higher value on technical skills than “cognitive” ones. Being an internist, I think I need to be paid more. And I suspect some of the others need to be paid less. Unfortunately, none of the “proceduralists” have offered to share their wealth with me.

Jane Orient. MD, “What is a Doctor’s Relative Worth,” The Freeman, 2007

I’m beginning to feel a little like Ernie Pyle, a World War II war correspondent. Ernie Pyle reported to folks back home what and how GIs were feeling and doing in European and Pacific theaters.

Medical Wars

As a war correspondent of sorts, I identify with Ernie Pyle. I report what’s happening to frontline clinicians in U.S. medical wars. These wars are subtle and political. They exist between health plans and doctors, hospitals and doctors, and to a lesser extent between specialists and primary care doctors. The battles are rarely public and are mostly unspoken The secretive fights are waged privately over turf – over who does what to whom, and who gets paid, and how much.

Scope of Practice

With primary care doctors, turf wars often boil down to defining the scope of their practices. Most definitions of the scope of primary care practices don’t even mention minor surgical procedures. Nevertheless, I maintain trained and prepared primary care doctors should be free to freeze, cauterize, or curette skin lesions, inject or aspirate joints, tennis elbows or carpal tunnels, and varicose veins; excise or incise skin lesions, and undergo training to do other procedures as outlined in the 2200 page book, Procedures for Primary Care (John Pfenninger and Grant Fowler, 2nd edition. Mosby Books, 2003).

Pfenninger founded the National Procedures Institute in 1989. The Institute and its faculty have trained over 50,000 primary care doctors to do minor procedures. Pfenninger insists primary care doctors doing appropriate procedures for which they are trained improves continuity of care, provides comprehensive care, reduces costs, pleases patients, and enhances practices without compromising patient safety or quality of care.

Seldom Mentioned Procedures

Those who write about primary care procedures seldom mention that primary care doctors in rural areas and in medical homes may also be called upon to perform a variety of diagnostic and therapeutic procedures, some of which must be done as emergencies and in the absence of an available specialist– lumbar punctures, parencenteses, thorancenteses, arterial blood punctures, punch and excision biopsies, suprapubic bladder catherizations, splints and casts, lacerations, central line insertions, endotracheal insertions, and emergency appendectomies and C-sections.

Three Doctors

The other day a primary care physician in New Hampshire told me doing procedures highlighted her day. When she was doing procedures, she felt she was truly being a doctor. She was doing something concrete and often curative, something beyond what physician extenders are qualified to perform. Performing procedures gave her great satisfaction, more so than diagnosing, counseling, and advising patients, all vitally important but in her mind, buy not fulfilling enough for those interested in total doctoring.

A general internist on the Connecticut shore is held in high esteem by patients and conducts a prosperous practice. He has a special interest in lesions and diseases of the skin. Most of his patients are elderly, and like most older patients, they present with various skin lesions. The internist frequently freezes, cauterizes, excises, and biopsies these lesions. These procedures, sometimes of a cosmetic nature but more often are done to rule out malignancy, produce an increased cash flow and leave grateful patients in their wake. Patients don’t have to wait, sometimes for months, to see a specialist.

A primary care doctor in Michigan called and wanted to know why doing procedures wasn’t stressed more as an integral part of the emerging medical home concept. She graduated at the top of her class five years ago and picked family medicine as a specialty because she thought its practitioners could do many things while specialists were limited to doing one thing. She was soon to learn hospital and specialty politics constrain what procedures a primary practitioners can actually do and where they could do them.

A Medical Home Blog’s Shortcomings

The Michigan doctor had read my blog on “Medical Homes: Assumptions and Expectations.” She praised the piece as far as it went. She said what I had said I said well, but I had not said enough. She yearned to do more procedures to hone her skills and to expand her practice horizons.

What could be done to make procedures more routine for primary care doctors? I’m reminded her of a Margaret Thatcher quote, “In politics, if you want anything said, ask a man. If you want anything done, ask a woman.” By getting the word out through me and others, she might get something done.

What I had not said, she said, was that hospitals favored specialists as a greater potential source of future hospital revenues. Consequently, primary physicians were sometimes excluded or bumped from the operating suite schedule She cited the case of a primary care physician in her town who had performed hundreds of colonoscopies in his office partly because he had frequently been denied access to the operating suite.

Possible Reasons Why

Why was this? I asked. She said she thought it might be because hospitals purposefully cultivated specialists. Specialists’ procedures contributed more to the bottom line. Also the “bread and butter” of many young specialists were often minor procedures until specialists got up to speed towards bigger operations. I pointed out that one of the unknown and untold secrets of hospital-done procedures is that the hospitals routinely collect a “facilities fee” just for providing a place for surgeons to do their work. These fees often exceed the surgeon’s fee and contribute significantly to increased health costs. It was best to be cognizant but not paranoid about these economic realities.

“Curious” Omission

She found it “curious” that medical home backers didn’t stress performance of procedures as a fundamental part of coordinated and comprehensive care. The ability to do procedures distinguished primary care doctors from physician extenders. Besides, after all is said and done, there is nothing more coordinated and comprehensive than having a diagnosis made on the spot with lesions removed, diseases treated, and symptoms relieved at one visit. One stop shopping is an important feature of comprehensive care.

Dumbing Down

She perceived (and sometimes resented) primary care was being “dumbed down” by restricting the scope of what primary care doctors could do. In many cases, she added, the distinction between the tasks and skills of primary care doctors and specialists was self-serving. In the process, primary care doctors were being reduced to glorified physicians assistants, perhaps specialists’ assistants was a more apt description, incapable of doing anything more than writing prescriptions, making preliminary diagnoses, giving therapeutic and preventive advice, helping patients navigate the medical maze, managing and coordinating chronic disease, and referring patients to specialists, often for the performance of minor procedures, the primary care doctor could have performed in the first place.

Unfortunately, the result, she said, was a feeling of clinical amd monetary impotence on the part of primary care practitioners, delays in diagnosis, unnecessary expense, anxiety in waiting for minor procedures to be performed, and trivialization and minimization of what the generalist could do.

What Can Be Done?

What can be done? I asked. She said: Get the word out on your blog. Tell the world what we’re capable of doing – competently, safely, conveniently, at low cost for patients. Cut through the politics. Encourage primary care doctors to get their CME credits by attending procedural training courses Plead our case. Help change the primary care paradigm – create a new bottom up framework of thinking.
I said, I‘ll see what can be done.

The Doughnut and the Hole

I’m pessimistic over the near term about incorporating procedures in the medical home because of our byzantine coding system and bureaucratic delays, but I’m cautiously optimistic in the future performing simple procedures in medical homes will render these homes more economically viable, practical, comprehensive, and less fragmented . In medical homes, I see procedures as the doughnut ,the whole of patient care; even though others may see procedures as something that can’t or shouldn’t be done, which is why we have a hole in the medical home concept

Saturday, December 20, 2008

Harvard - No Easy Fix for Financial (or Health Care) Crisis

The December issue of the HBS (Harvard Business School) Alumni Bulletin contains comments by HBS Dean, Jay Light. Using the metaphor of an emergency room, Light explains,

“Just a hospital treats patients by focusing on three tasks, so too should we remedy the financial turmoil.

First, stabilize the patient, in this case the markets. That’s what the $700 billion rescue plan aims to accomplish.

Second, diagnose the problem and treat it. The rescue plan calls for the government to auction banks’ distressed mortgage assets to figure out what they are really worth.

Finally, prepare a long-term rehabilitation plan. For the country’s financial system, this means a new regulatory structure. It, for sure, will be reregulated because the government had to be so deeply involved in the rescue."

President-elect Obama says rescuing the financial system is an emergency and rescuing the health system is a big part of that same emergency.

It will be fascinating to see if his measures to stabilize the patient ($100 million the first year for programs for IT, preventive, and chronic disease management), diagnose and treat the disease (more government spending, though government already pays for 50% of health costs), and rehabilitation (more government regulation and mandates).

To these measures for health care, some will surely assert, government is part of the problem, stymieing all bottom-up innovations to lower costs and increase convenient access.

Friday, December 19, 2008

Hospitals and Doctors - Mutual Economic Crises Force Hospitals and Doctors To Lean Upon One Another

In economic crises, no one is an island. According to an AHA study, “Report on the Economic Crisis, Initial Impact on Hospitals,” released in November, doctors are seeking help from hospitals, and hospitals are less able to offer that help.

Here’s is what doctors seek, say hospital CEOs,

• 83% seek more pay for on-call services.
• 69% seek hospital employment.
• 53% seek financial aid.
• 31% seek to sell practices to hospital.
• 23% seek financial aid to purchase equipment.

Meanwhile, hospital CEOs say these developments make helping doctors more difficult,

• Uncompensated care increase 51%
• Admissions decline, 38%
• Bond expense increases, 33%
• Elective procedures decline, 31%
• Pension funds increases, 31%
• Bond issuer forestalled, 11%
• Debt acceleration, 7%

Resulting in these cutbacks,

• Administrative costs, 59%
• Renovation, expansion, 56%
• Staff, 53%
• Clinical technologies, 45%
• IT technologies, 39%
• Hospital services, 27%
• Asset divesture, 12%
• Mergers, 8%

The moral for doctors: Don’t’ expect as much leverage as in the past when negotiating with hospitals, even though you represent their main revenue stream.

Thursday, December 18, 2008

Physician payment - Primary Care Doctors Seek 10% Bonus over Next 18 Months From Obama Administration

American College of Physicians President Jeffrey Harris sent a letter On December 17 to HHS nominee Tom Daschle asking that the Obama administration’s economic-stimulus package include a 10% pay bonus for all services provided by primary care docs under Medicare for a period of 18 months.

The letter also requests that primary care practices, especially small ones, get a piece of the funding pie for health information technology. Obama has pledged to spend billions of dollars on that endeavor.

The Harris letter says ,in part:

The 18 months when the bonus would be in effect would stabilize funding for primary care practices, especially smaller ones, which are an essential part of the safety net that people rely on for their care, especially in tough economic times. Without funding to stabilize primary care practices, many will go under and have to close. Primary care physicians who own small practices are struggling to survive because of inadequate access to credit, losses in their own investments, slower collections and more “bad debt” and uncompensated care as their patients are unable to pay their bills and the numbers of uninsured increase.

Of the problems of Massachestts patients getting care under the universal coverage plan there, Harris writes,

Providing more people with health coverage doesn’t mean they will have good access to care, when there aren’t enough primary care doctors to take care of them.

Comment: I am sympathetic for the last Harris point, but I'm not confident bailing out primary care would be popular with the public.

Costs - Why the U.S. Spends So Much on Health Care

The December 17 WSJ Health Blog highlights a McKinsey report that purports to explain why the U.D. spends $650 billion more on health care than you’d expect in a nation with our GDP.

The report concludes the scoundrels in our midst are specialists who practice in outpatient settings – office, ERs, surgical, diagnostic, and imaging centers – where $850 billion out of the $2.1 trillion, 42% of health spending, takes place.

The report concludes,

Outpatient care is very profitable, particularly for specialty care and diagnostic procedures, and such profits encourage growth in supply. In addition, physician judgment is involved in determining the best course of treatment for most outpatient care, and current outpatient reimbursement methods reward providers for delivering more care.

Whose judgment should one trust? Health plans, government agencies, HMO medical directors, or the physicians who perform these procedures? I trust doctors most.

Anyway, the blog drew a lot of fire, including comments blaming lawyers, lack of universal coverage, patient irresponsibility, greedy HMOs, and specialists’ greed.

I weighed in by pointing out: 1) patients (and their lawyers) “expect” the very best and highest standards of care, for example, CT and MRI scans for evaluating heart and joint problems and invasive procedures for correcting them; and 2) the U.S. lacks a broad primary care base, which delivers care at 30% less with comparable results in primary-care rich regions of the U.S. and in most other developed countries. Simple math: 30% X $2.1 trillion = $630 billion, almost the precise amount the McKinsey report deplores as excessive. I don’t agree with the nation that specialists are culprits.

Besides, I noted, specialists have a hammer (their skill), and they will use it to hit the nail (evaluate and treat patients who come or who are sent to them).

Procedures are what specialists are trained to perform, and are what patients, lawyers, hospitals, and referring doctors expect them to do. Specialists might do fewer procedures if paid less, and primary care doctors might refer less if they were paid more to spend time advising patients, but that is another issue for another day.

Wednesday, December 17, 2008

Interviews, Reece, personal musings - An Interview with Dr. Goodenough, a Primary Care Bottom-up, Bottom-Line Expert

Despite the conceits of New York and Washington, almost nothing starts there. In the course of my work, I have been overwhelmingly impressed with the extent to which America is a bottom-up society. Trends are bottom-up, fads top-down.

John Naisbitt, Megatrends, 1982

It's all about the health care deficit.

Pat Reignier, “Bottom-Line” Column, Money Magazine, 2008

Build a good-enough vision and provide minimal specifications rather than trying to plan out every detail.

Brenda Zimmerman, Curt Lindberg, and Paul Pisek, Edgeware: Insights from Complexity Science for Health Care Leaders, 1998

Q: Dr. Goodenough, I understand you’re a primary care expert.

A: Yes, a bottom-up, bottom-line expert.

Q: Explain.

A: First, America is a bottom-up society. Care trends begin at the bottom of our society, in neighborhood and local communities, in cities and towns and states far removed from Washington, D.C., where people seek access to care, and that is primarily in primary care doctors’ offices. Care doesn’t begin at the top, in government, corporate, and executive health plan suites. It begins at the bottom, where the doctors and patients are.

Q: Go on.

A: Second, primary care doctors are at the bottom of the doctor food chain, which is why there are so few of them. Don’t take my word for it. Here’s what Dr. Grattan Woodson, an Atlanta primary care physician, has to say in the December 18 New England Journal of Medicine,

The payment system has failed primary care. Payment for procedures provided by these physicians has been restrained, while those for newly introduced ones have been excessive. This inequality in reimbursement is a major factor explaining why new graduates choose highly paid specialties rather than the relative drudgery of primary care.

Q: What has that got to do with the top-down?

A: Top-down policymakers and politicians are saying it’s our moral obligation to have universal coverage of our population, perhaps in the form of Medicare-for-all. Can you imagine what would take place if that happened with not enough doctors to supply the care? Universal coverage without access is meaningless. It would precipitate a monumental political crisis, the magnitude of which is hard to imagine.

Fees for doctors are set from the top-down, by an organization called the Reimbursement Update Committee, an organ of the AMA dominated by specialists that works with government to establish codes for re-imbursement. To quote Dr. Woodson, The only thing that primary care has gotten out of this deal is the economic shaft while our partners in this enterprise have prospered beyond their due.

We don’t need a food fight between primary care doctors and specialists. But we do need to reconfigure the Sustainable Growth Rate Formula(SGR). a creation of Congress that will result in a 21% cut for all physician fees next year. The SGR assumes a fixed amount of money to be divvied up between primaries and specialties. That assumption is faulty.

Q: So what is the answer?

A: An overhaul of the reimbursement system combined with a new way of coordinating care from the bottom-up. The one most commonly talked about is medical homes, whereby primary care doctors are paid through a blended payment system – fee-for-service, a capitation fee for coordinating comprehensive care, including care between office visits in conjunction with nurses and other care professionals, and bonus for responding to patients, such arranging for a same day appointments, and consulting through emails and telephone calls.

The general attitude towards medical homes among primary care doctors right now is positive with these caveats: show me the money and lower the bureaucratic gates, and we’ll climb on board.

Q: Will medical homes work?

A: They’re a good start. Until they kick in, we’ll have to fill in the gaps with more medical students choosing primary care, more care teams, more nurses and physician extenders, more subsidizing and streamlining of EMRs, and more incentives to medical students and residents, with debt relief, more residency slots, and more pay to work in underserved areas. All of this will take a decade if we are to have enough access to primary care.

Q; Anything else?

A: Yes, we’re going to have to be more open to care innovations from the bottom-up. These innovations include: more direct pay and concierge practice models, more productive micro- practices, more care delivered by primary care doctors for self-funded corporations outside of the usual managed care prepaid model, more retail and worksite clinics, and more innovations engendered by consumer-driven care, driven by HSAs coupled with high deductible health plans.

Q: Do these approaches share anything in common?

A: You bet. They’re closer to the patients, more direct, more devoid of third parties, cost less, are more convenient, offer greater access, and have more predictable, reliable, and understandable pricing.

Q: Are there obstacles?

A: Of course, health care is fraught with rules, regulations, and special interests. Specialists, hospitals, health plans, and supply chain vendors – such as drug and device manufacturers – may fear revenue loss and may resist sweeping changes of the status quo.

Q: Any concluding remarks?

A: Yes. It’s all about the bottom-line of the U.S. health system, and indeed, the bottom-line of our whole economy. Medicare and Medicaid, at federal and state levels, programs covering 100 million Americans, are rapidly running out of money, and could go bankrupt by 2015 if present cost trends continue.

Countless studies have shown broad primary care based delivery systems provide better care, with more satisfaction, with 30% less costs and 20% better outcomes. In other words, there’s more bang for the buck, and that’s what the bottom-line is all about. I might add the federal treasury is not a top-down bottomless pit. It needs to be filled in from the bottom-up.

Monday, December 15, 2008

Primary care, physician shortage - Skinning the Small Primary Cat

Prelude: The WSJ ran this piece on December 15. It explains why solo or small practices have such a hard time surviving. It is right as far as it goes, but it assumes that these small practices are in a managed care setting, which carries with it a high overhead. What it does not say is that there are different ways to skin a primary care cat. One can go into concierge practice, close your practice to HMOs and accept only cash, operate out of a small office with no staff and use the Internet as your support system. Or one can offer one's services to corporations at a per diem rate for each patient.

December 15, 2008

Is the Problem Primary Care or Small Medical Practices?

Posted by Sarah Rubenstein

Misery might love company in primary care. Or at least bringing primary care doctors together into larger medical practices might alleviate some of the problems afflicting physicians on medicine’s front lines.

The Los Angeles Times is out with a piece this morning that explores how hard is is for primary care doctors in small practices to make ends meet. Of course, there’s more than one factor that’s made primary care financially unattractive for many doctors, including the fact primary care docs don’t get the kind of fees from insurers that specialists do.

But doctors who go solo or have just one or two partners have scant bargaining power with insurers, LAT notes, and their overhead also makes it tough to be profitable.

“It’s very difficult, even in rich neighborhoods like Beverly Hills, to set up a solo practice,” said Richard Scheffler, an economist at the University of California, Berkeley, told the LAT. “The doctor has to pay rent, a nurse, have a bookkeeper, billing systems, computers. All of those fixed costs are very, very hard for a solo practitioner to have and survive.”

One Beverly Hills primary-care doc, Tanyech Walford, just closed her tiny practice, where she hadn’t drawn a paycheck for herself since February. The practice cost her $40,000 of her own savings, and she had $15,000 in credit card debt along with her medical-school loans. She plans to move to Maryland for a new job at a 200-physician practice affiliated with Johns Hopkins. Her salary will be $115,000, plus bonuses, health insurance and a pension plan.

“I’ve been spent emotionally, financially, physically, and now I need to have someone else worry about the finances,” Walford told the Times.

Ben Brewer, family doc and columnist, wrote recently about his idea for boosting primary care: a federal tax rebate of $1 a day per person to be paid to a primary care doctor of the patient’s choice. The person would get a predefined basket of medical services, and the costs would be locked in like a subscription fee for cellphone service or movie rentals.

Sunday, December 14, 2008

Physician business models, physician shortage - Primary Care: In Search of a Sustainable Business Model

President-elect Barack Obama placed a heavy bet last week that the recession-wracked economy he is about to inherit has finally reached a tipping point on health care… Mr. Obama has begun a careful campaign to frame the issue more as a pocketbook concern more than a moral one.

Kevin Sack, “Necessary Medicine? Health Care and The Economy Share a Sickbed. Maybe They Can Recover Together, “ New York Times, December 14, 2008

Root Cause

Universal coverage without access to primary care doctors is meaningless, and there is a grave and growing shortage of these practitioners, estimated to reach 35,000 to 40,000 by 2020.

The root cause of primary care shortages in America is lack of a visible and sustainable business model to attract and keep primary care doctors in practice.
There is no mystery to these shortages. Why should medical students or experienced physicians enter or stay in primary care, a field promising lower pay, longer hours, more work, more stressful life styles, less ability to pay off educational debts, a wider variety of knowledge to master, and less latitude to do the right things for patients – spending time with them, responding to their urgent needs, and communicating the basics of prevention and good health – than specialty care.

Broad Primary Care Base

Yet it is becoming clearly and increasingly evident that a broad primary care base is the common denominator for an efficient, cost-effective, a health-producing, disease-avoiding health system in the U.S. and around the world.

This reality poses a harsh dilemma not only for recruiting and retaining primary practitioners but for developing cost-sustainable national health systems and expanding coverage for aging populations in an era of recession, contraction, unemployment, and economic deprivation.

Ultimate Answers

What are the ultimate answers to the primary care shortfall? If I knew that, I would be a candidate for a combined Nobel Prize in Medicine and Economics. Here are a few evolving development that may offer incremental solutions.

• Government and organized medicine payment reform (read the latter as a new coding system by the reimbursement updating committee of the AMA) that spills over into Medicare, Medicaid, and health plan payments.

• Government subsidies and incentives that ease educational debt for primary care candidates, reward care for primary care in underserved areas, and offer more extensive support of primary care residency slots.

• Federal, state, and health plan support of medical homes with adequate payments for creating these homes and lowering of bureaucratic barriers for physicians wishing to create medical homes.

• Realistic rising of fees for care of Medicare and Medicaid populations to more closely approximate private fees and to end cost shifting now required maintaining viable practices and hospitals.

• More innovative and sustainable primary care business models , such as,

1. IPAs featuring cost sharing and gain sharing between hospitals and doctor groups that offer bundled fees for episode care and economic rewards for promoting health and patient-centered and patient-responsive care.

2. Broad geographic and regional grouping of primary care physicians with revenues from diagnostic, laboratory, x-ray, pharmaceutical, and other facilities that flow to the group and give the group marketing and legislative clout;

3. Virtual groups with enough revenues to support informational and treatment infrastructures and data to form a rational basis for control and selection of specialist referrals; a openness to innovative new practice designs – concierge care, direct-cash care, non prepaid care, office and home based care, multi-specialty ambulatory care with affiliated care modalities, retail and office based outlets with sufficient EHR support to validate value.

4. Multispecialty groups with salaried primary doctors and specialists, sometimes with owned hospitals, health plans, and often affiliated with doctors outside the system and with ownership of diagnostic, treatment, surgical, ambulatory, and pharmaceutical facilities. This is often called the Mayo model, and is being pursued by physician groups like the Carillion Clinic in Roanoke, Virginia.

End Game

Whatever happens, and it most surely will, is that sustainable primary care business models must offer lower costs, more patient access, tangibly superior results, and greater patient and physician satisfaction, all rooted in economic and clinical performance.

If you give the matter any thought at all, you will realize promised Obama reforms are based on greater affordability and savings from preventive care, chronic disease management, fewer hospitalizations and ER visits, and more linkage of electronic medical records – all of which fall into the province of primary care. You might say, if you were unimaginative political sloganeer, it’s all about health care economies and their place in the larger U.S. economy, stupid!

Friday, December 12, 2008

Physician Shortage, Primary care Where Have All the Doctors Gone?

Prelude: Ordinarily I don't reprint material from other publications. But this piece from The New York Times is timely and so closely related to my work with The Physicians' Foundation, a nonprofit promoting the cause of doctors and their patients, that I couldn't resist. It makes the point: what good is expanded coverage and wiping out the uninsured if there are no doctors to care for them? The key is more primary care doctors. Today only 2% of medical students are going into primary care. Why should they? Compared to specialists, pay is lower, hours are longer, life style is lousier, and respect for their work is dismal.

December 12, 2008, New York Times


Where Have All the Doctors Gone?


One morning during my medical residency many years ago, one of the senior doctors pulled me aside after rounds, as was his routine, to review the status of patients in the intensive care unit. A few had single-organ failure — their lungs weren’t doing well, or their hearts weren’t beating efficiently. A few struggled with double-organ failure. But the majority of patients were battling multisystem organ failure, and their prognoses were not good.

“People can survive one organ system failing and even two,” the senior doctor said to me after we were finished. “But when that third one goes ...”
He leaned forward and looked me in the eye. “Three strikes, and the game is over.”

That remark came to mind recently when I thought about the crisis in primary care and President-elect Barack Obama’s plans to make health care accessible to all.
Primary care is delivered in a variety of settings by a variety of professionals, including nurses and physicians’ assistants, but it is anchored by family-practice doctors, general internists, pediatricians and, for many women, gynecologists. As the nation’s front-line doctors, primary care physicians address everything from chronic diseases, like diabetes, heart disease and high blood pressure, to more acute conditions, like pneumonias, intractable flus and potentially cancerous masses and lumps.

While their initial work in diagnosis often sets the trajectory of care for a patient, they also manage long-term conditions, guard the public’s health and advocate preventive care measures.

For many patients, too, primary care doctors are invaluable guides through the maze of health care options and specialists.

In the last several months there have been reports in medical journals about an impending shortage of primary care physicians. This spring in the health policy journal Health Affairs, researchers at the University of Missouri-Columbia and the federal Department of Health and Human Services published a study that projected a generalist physician shortage of 35,000 to 44,000 by the year 2025. The researchers based their figures on current physician usage patterns and did not take into account increases that might occur because of rising access to health care.

The news got worse in September, when The Journal of the American Medical Association published a study showing that just 2 percent of graduating medical students are choosing to enter general internal medicine. The students surveyed were concerned in part by what they perceived to be a more difficult personal and professional lifestyle, compared with other fields. They felt that the paperwork and charting required of primary care physicians were more onerous, and they were not eager to care for the chronically ill in a health care system that focuses on acute care.

The potentially devastating public health implications of both of these reports rippled out into the medical community. Last month in an official statement, the American Medical Association vowed to support financial incentives for medical students who choose to go into primary care.

What are the consequences of these projected shortages for patients? According to the Health Affairs report, there are about 75 generalist physicians for every 100,000 individuals. By 2025, when the population will have grown by 18 percent and the number of individuals over age 65 by 73 percent, either primary care doctors will be seeing many more patients than they do now, or several million people will be without a primary care doctor, no matter how accessible health care might be for the rest.

Strike one.

But a recent survey indicates that the primary care crisis may not be looming on the horizon; it may already be at our back door.

The Physicians’ Foundation, a nonprofit organization that supports physicians’ work with patients, last month published the results of a survey on current medical practice conditions in the United States. Some 12,000 doctors responded, the vast majority of whom were primary care physicians.

Nearly half of them said they planned in the next three years to reduce the number of patients they see or to stop practicing altogether. While these doctors rated patient relationships as the most satisfying aspect of practice, over three-quarters felt they were at “full capacity” or “overextended and overworked.”

Only one-third felt they had the time to fully communicate with and to treat all patients, and 60 percent felt that paperwork demands resulted in less time spent with patients.

The primary care crisis raises questions not just about future access but about current morale.

“There was a tremendous amount of disenchantment, frustration, all bordering around one thing,” Tim Norbeck, the executive director of the Physicians’ Foundation, said of the survey. "Doctors feel they can’t spend enough time with their patients because of the paperwork and red tape hassles.”

Mr. Norbeck added: “Physicians went into medicine to spend more time with their patients, and that time has just been eroding. There’s serious reason to believe that there won’t be enough doctors to cover people sooner than we thought.”

Strike two.

I won’t envy Mr. Obama as he steps into the White House in January. Any attempt to make health care more accessible will be doomed to failure without an adequate number of primary care physicians and a strong primary care system. The situation in Massachusetts should be a wake-up call. Since a landmark law was enacted in 2006 requiring health insurance for nearly all residents, the state has struggled to provide primary care to the estimated 440,000 newly insured.

Mr. Obama and his team may find ways to give more Americans access to the waiting room, but what if there’s no doctor on the other side of the door?
The crisis in primary care must be addressed before any real change can occur; otherwise, the flood of new patients may instead turn out to be a final strike for our ailing health care system.

And at that point for all of us, doctors and patients, the game would be over

Costs - A Paradigm Shift to a Lower Cost, More Efffective, Affordable, Reliable, Predictable, and Commonsensical Health System?

A Report on the Department of Health and Human Services December 10, Washington, D.C., and Conference “The Innovation Imperative: Aligning Payment Incentives and Reforms to Encourage Health Innovation”

By Richard L. Reece, MD. Sometime Speaker, Occasional Commentator.
And Editor-in-Chief, Physician Practice Options (

Just do it.

Nike Ad

On December 10, 56 national innovators, policymakers, and Health and Human Services (HHS) officials and managers, met at the Madison Hotel in Washington, D.C., to explore innovative ways to save Medicare and Medicaid and the U.S. health system from bankruptcy. The forum focused on ground level innovation, rather than national reform. I know. I was there as a designated innovator. HHS, with the Lewin Group’s help, staged the conference.

Opening Remarks

In opening remarks, Benjamin Sasse, PhD, HHS’s Assistant Secretary for Planning and Evaluation of Health Policy, commented that in Medicare’s last midyear review, experts projected Medicare may go bankrupt by 2015 or so, meaning CMS(Center for Medicare and Medicaid Systems) wouldn’t have money to pay hospitals and doctors. The time has come, Sasse said, to deal with economic and political realities and to honestly exchange views of what innovations are needed and can be done.

Next Six Hours

For the next six hours, presenters, questioners, and participants batted back and forth about what innovative steps might save the system.

Everyone will have a view of what took place, and I will share mine – a veteran physician’s watcher’s take, previously expressed in my book Innovation-Driven Health Care: 34 Key Concepts for Transformation (Jones and Bartlett, 2007) and in 680 subsequent blogs,

A word of warning. I am a physician cheerleader for liberating the right doctors to do the right thing for patients, which is not always the right thing for hospitals, health plans, payers, or politicians.


1. Keynote Address - Jason Hwang, MD, MBA, Executive Director of Healthcare Innosight Institute and co-author of The Innovator’s Prescription: a Disruptive Solution for Health Care (McGraw-Hill, 2008). Hwang gave no overarching disruptive solution, instead choosing to present pros and cons of various business models.

2. Alternative Practice Solutions – William Sage, MD, JD, Vice Provost for Health Affairs, U. of Texas, and Rushhika Fernandopulle, M.D, M.P.P. Founder of Renaissance Health. Sage spoke of retail clinics and noted 50% of Americans live within 5 miles of Walmarts, while Fernandopulle told of how his primary-care based organization had developed low-cost care solutions dealing with Boeing Corp, Atlantic City companies, and Houston janitors.

3. Innovations in Management of Chronic Disease – Ariel Linden, DrPH, MS, President, Linden Consulting Troop, Chad Boult, MD, PPH, MBA, Geriatrician, and Professor Johns Hopkins, and John Goodman, PhD, President and CEO, National Center for Policy Analysis. Linden said disease management doesn’t always work well in the real world; Boult stressed how cuts for the chronically ill with multiple illnesses can be cut by 11% with a structured approach with active nurse guidance; and Goodman spoke of the effectiveness of market forces in cutting costs and improving care.

4. Ideal Meets the Real in Healthcare – Incentives and Uncertainties in Medical Practice Design, Michael Millenson, President, Health Care Advisor, Gordon Moore, MD, And Ideal Medical Practice Movement. Millenson warned and warmed of the negative consequence of the information revolution; Moore said solo doctors with IT help make a positive difference in patients’ lives.

My Conclusions

And here’s what I concluded (others will feel differently) from presenters” remarks.

• We have a genuine cost crisis in the U.S.; it’s pushing Medicare towards insolvency, bankrupting states, and threatening U.S. global business competitiveness.

• The crisis is psychological as well as financial, with feelings that surely we can do better; that current solutions are structurally misguided for patients and providers, and those taking patients’ convenience and affordability more into account is a must.

• The U.S. health system is undergoing profound structural changes with more hospital physician employment, more hospitalist care, more access of patients to information on Internet web sites, more decentralized and even globalized care, more migration to home care , more telemedicine and remote care monitoring, and more care by non-physician professionals.

• A new openness and pragmatism exists towards small and free market solutions – retail clinics; concierge practices; consumer-driven care with HSAs and high deductible health plans; cash-for-care rather than prepaid care; innovative delivery systems aimed at self-funded employers which cover 100 million Americans. In effect, more cost-savings and effective more efficient care can often best be achieved through small scale and solo practices rather than through large integrated multispecialty groups or hospital-based systems.

• A growing and widespread recognition that primary care shortages are a huge. Monumental problem attributable to inequitable reimbursements and negative life style and lack of respect, and that a primary care-based system produces lower costs, more patient satisfaction, better results and outcomes. One consequence of the emergence of the medical home as a coordinating, comprehensive balm for fragmented care

• A mounting sense that universal EMR adoption by physician is unlikely, that its importance as the Holy Grail as an information source for physician compliance and patient instruction is overstated and overrated , but that selective use of EMRs in retail clinics, worksite clinics, innovative delivery systems, and competing physician systems is essential and desirable for quality and value comparisons.

• A consensus that bottom-up innovations by entrepreneurial primary care physicians who are closer to patients and who skillfully use IT are a powerful force for good and compassionate care; and that top-down mandates about pay for performance, compliance with quality indicators, and hospital-physician integration, e.g. bundled billing and phasing out of fee-for-service, may not work well in the real world.

• The practical reality that nurse practitioners and other physician extenders following a more structured approach and with power to treat and engage patients directly in their homes will be absolutely necessary if we are to effectively manage chronic disease in the elderly and other underserved populations.

• Growing evidence that mandated protocols, health risk appraisals, and wellness and health promotional programs at the worksite do not fundamentally change employees or patient behaviors.

• The dawning realization that corporate America, large and small businesses alike, are ready and willing to follow the lead of innovative MD/MBAs and other knowledge workers with deep knowledge of medical , academic, and corporate cultures, to skirt the usual managed care model and other third parties, and to introduce more pragmatic and more innovative delivery approaches to save money and produce healthier workers.

• Recognition that hospitals, specialists, and expanded prepaid insurance are driving costs and may be part of the problem rather than the solution for a cost efficient and health effective system.; and that big institutions and organizations are rewarded for innovations at the expense and ignoring of innovators on the ground.

• Finally, an emerging consensus that we know how to reduce costs and improve care and have shown it can be done through more primary care physicians with higher pay, more active participation of nurses, more market competition by doctors and hospitals, more innovative delivery systems – retail clinics, pay for direct care instead of third party prepaid care, more focus on keeping people out of hospitals and away from unnecessary care by specialists. But the questions are: can we alter the tyranny of the status quo; do we have the political will to do what needs to be done, and why don’t we just go ahead and do it?
One thing that struck me about the presentations and sideline conversations was the lack of talk on any political ideology or single political “fix” for a Pied Piper system, i.e. universal coverage, that would simultaneously cut costs, improve care, or achieve compassion.

I close with this verse on the Washington, D.C, Health Care Merry-Go-Round.

Round and round, faster and faster, she goes,
Where she stops nobody really knows,
But it’s likely to stop at a new paradigm.
The U.S. can no longer afford another dime.
For this time around,
No more money will be found.
For health from high above,
When push comes to shove

Thursday, December 11, 2008

Clinical innovations - Innovations as Game Changers

Innovation is a team sport.

Drew Boyd, Blogger on Innovation, quoted in “For Innovators, There is Brainpower in Numbers,“ New York Times, December 5, 2008

As I write, I am riding from Connecticut to Washington, D.C. on an overnight Amtrak train to attend a December 10 Health and Human Services innovation conference staged by the Department of Health and Human Services

From the invitation letter and a subsequent phone call, I gathered about 50 of us “innovators” were meeting to suggest ways to save the U.S. health system, now hurdling towards bankruptcy in five years or so.

As a word “innovation” has become so abstract, it borders on the meaningless. It is apple pie and motherhood, much ado about something that will save us from good intentions and unintended consequences. Innovation needs to be more concrete. For the concrete, I turn to sports metaphors, for in sport there are always winners and losers, a final score.

• Take statins. Statins are winners. They are largely responsible for lowering heart attack and stroke rates in Americans.

• Take coronary bypass, stents, and hip and knee replacements You can score how many lives have been saved, how may cripples have been restored to full and functional lives, and how much costs have soared.

• Take the current re-emphasis on primary care, closer doctor-patient-nurse relationships, and new innovative systems for delivering care.

These are game changers, and they stem from large and small and constant changes and innovation. Innovation is a process, its group genius; it’s multiple minds meeting to reach a tipping point; it’s generating of ideas by a group – tinkering, experimenting, and building large systems by “chunking” – introducing small changes that work.

In the end, there may even be about some great paradigm shift – a new way of thinking that changes current dynamics, improves care, and produces a financially sustainable system.

Tuesday, December 9, 2008

Physician Foundation, Primary Care Physician Remarks About Present Health System

Help! Remarks of Physicians in Response to National Survey of 270,000 Primary Care Practitioners and 50,000 Specialists. Survey Conducted by the Physicians Foundation, a Charitable Foundation, in the Spring and Early Summer of 2008, Released to Media on November 16, 2008

What follows are 10 comments selected from among 4,000 comments submitted by primary care doctors in response to the Physicians’ Foundation survey. The remarks show anguish, anger, and angst about the present state of primary care in America and does not augur well for the future. Comments were published in December 8, 2008 American Medical News, “Doctors Urge: Rescue Primary Care or Work Force Shortage Will Mount.”

1. “If not for a son who I’m working to put through college and a house mortgage, I would quite medicine in a heartbeat! I’m beat, tired and underappreciated. Sometimes I cry myself to sleep – wondering why I got into all this.”

2. “I cannot continue seeing fewer patients for less money and adding more paperwork requirements. I’ve had one nervous breakdown and would rather not do that again.”

3. “I would invite each government policymakers to spend one day in a primary care office or community clinic to see the current chaos that is American medicine.”

4. I do not see what anyone would go into medicine at this time and very much regret having chosen medicine as a profession. I would never recommend medicine as a profession to anyone.

5. “Can you image what would happen if your plumber handed you a bill for $60 and you replied,’ I think I’ll just pay $32.’ In no other profession are services paid for in such an arbitrary fashion.”

6. “Bean –counters have taken over decision-making in health care.”

7. “We need more primary care physicians, but students are choosing primary care less often. What is the incentive? Our hours are worse, our pay is less, our hassles are greater and we have a legal system that is out of control. I had to leave private practice because I couldn’t make a living. As an employee, I have lost my autonomy.”

8. “With $100,000 in student loans, I do not know how I will ever achieve financial security. Morale is low in general among physicians in our state. I would not choose medicine as a career again.”

9. “Paperwork! Paperwork is killing us!”

10. “HELP”

Monday, December 8, 2008

Acute and ambulatory care - If Health Care and Life Were a Movie

If health care and life were a movie, it would be split into two parts – acute episodic care and chronic epic care.

Acute Episodic Care

Acute episodic care is care you receive in hospitals. It often features procedures or operations – orthopedic procedures to fix or replace hips or knees, cardiac procedures to put in a pacemaker, zap patient to restore a cardiac rhythm, insert a stent, or bypass a blocked coronary artery, or any other surgical operation. Increasingly it also involves use of expensive cancer drugs. Interventional care is the financial lifeblood of hospitals, accounting for as much as 80% to 90% of hospital revenues.

Big Part of Medicare Expenses

Procedures, operations, and cancer drugs comprise a big part of Medicare expenses. That’s why Medicare has embarked on a demonstration project to bundle bills for Acute Care Episodes for 28 cardiac and orthopedic procedures. The idea is to combine hospital and physician costs, issue one bill to one hospital-medical staff entity, and make hospitals and doctors “accountable.”

Theoretically Bundling Makes Sense

Theoretically, this approach not only makes costs more predictable but saves money by “integrating” and disciplining the unified entity. Also Medicare can better judge the performance of hospitals and medical staffs. If the new approach saves money and results in superior performance, the hospital and its doctors could share in the savings, hence, the concept of gainsharing. Finally, Medicare can get a better “fix” on costs, which currently go about 80% to hospitals and 20% to physicians.

Chronic Epic Care

In our movie, chronic episodic care is but a preview or highlight of what is to come. Acute episodic care is just a piece or a slice of the epic and sweep of life – and of an underlying chronic disease. The true costs lie in chronic epic care. As George Halvorson, CEO and Chairman of Kaiser Foundation and Hospitas, and champion of looking at health care as a system, points out, five chronic diseases – diabetes, coronary disease, chronic heart failure, asthma, and depression – account for 80% of all health costs.

How Much is Acute Episodic Care Worth?

How much acute episodic, or interventional, care contributes to the 80% is hard to estimate, but episodic costs are a huge part of costs. There is now an active debate in the U.S, and other developed countries, where government pays much of the health care freight, just how much a procedure – even if life-saving - a gain in the quality of life, or life itself, is worth to society. This debate has focused on a concept known as QALY (Quality of Life Years) gained. In the United States, a figure of $50,000 per QALY is often used as a threshold to assess the cost effectiveness of an intervention. i.e. providing good value for the buck. In Britain, NICE (National Institute for Health and Clinical Excellence), a government-funded organization, puts its estimate for QALY at $34,400. But, alas, NICE has found it isn’t nice to say no to desperate ill patients seeking life-saving drugs or procedures. Saying no takes courage – and provokes outrage.

To return to our movie, acute episodic care is popular for patients and doctors alike because it often has a happy or hope-filled ending. But chronic epic care usually ends sadly – not happily and not popular with the public, for everyone wants to live another day. Chronic epic care does not make for a good movie.


1. G. Hackbarth, R. Reischhauer, and A. Mutt, “Collective Accountrailbity for Medical Care, Toward Bundled Medicare Payments, “ New England Journal of Medicine, July 3, 2008.
2. G. Halvorson, Health Reform Now, A Prescription for Change, Jossey-Bass, 2007

3. R. Steinbrook, “Saying No Isn’t NICE – The Travails of Britain’s National Institute for Health and Clinical Excellence,” New England Journal of Medicine, ”November 6, 2008.

Sunday, December 7, 2008

Physician Payment - Lack of Physician Payment Flexibility

Physicians are different from other professionals by virtue of the ground rules for contemporary medicine. These ground rules are largely determined by the way in which medical services are paid for in the United States. An orthopedic surgeon might be reimbursed $500 by Medicare for setting a simple bone fracture, and $1000 for setting a compound bone fracture. Private insurance companies often set their reiimbursement rates based on what Medicare pays. Physician rarely set their own fees. Their fees are dictated to them by Medicare, Medicaid, HMOs, PPOs, and other third party payers. The money reimbursed to them for services rendered may have little or no relation to their cost of doing business. What can be more aggravating is that sometimes the party payers also dictate what physician can and can’t do for their patients by declining to pay for services physicians also believe patient need. This is not the environment most of us work in.

James Merritt, Joseph Hawkins, and Phillip Miller, Guide to Physician Recruiting, April, 2007

A great deal of political interest is focused on alternative methodologies. Four in particular stand out – bundled payments, under which physicians are paid flat rates per episode of care, rather than per service; gain sharing, under which hospitals and doctors agree to share incentive pay and savings form qualityimprovment; medical homes, under which doctors are paid for coordinating care; and payment for performance, under which doctors are paid for quality measures...Delegates also brought up balanced billing. Balancing billings allows a doctor to charge patients the differences between what Medicare pays and the actual costs of services.

Doug Trapp, “Reforming SGR Tops AMA’s Medicare Agenda for 2009,” American Medical News, December 1, 2008,

This blog is a witch hunt, a brief exploration of under which circumstances physicians should be paid.

When I practiced as a pathologist, my partners and I would send a bill for performing a hip bone marrow biopsy, and back would come back a payment for 1/5 of what we charged from Medicare.

There was no arguing - and no recourse. That was what Medicare paid – no matter if you injected an amnesiac drug to ease the pain or if you used a variety of different stains to nail the diagnosis. This is one small example of rigidity of current billing methods – of hardening of the billing categories, of arbitrary and capricious bureaucratic billing behavior on part of government. It is government’s way of insulating Medicare and Medicaid recipients from the true cost of care.

Still, it’s highly unlikely Congressional Democrats will support billing flexibility. Instead they will raise the SGR (Sustainable Growth Rate) formula.

I predict one of the Great Debates in the upcoming health reform debate from the physician side of the aisle will be how to change the SGR formula, which, if implemented in its present form, will drive more physicians out of accepting new Medicare and Medicaid patients and will create a political nightmare over access to care.

Saturday, December 6, 2008

Electronic Health Records, E-medicine - Obama's E-Based Health Reform Push

One tactic Obama used successfuly to win the presidency was mobilizing support and money over the Internet. He raised a record $750 million and kept e-mail addresses of millions who contributed to this campaign over the past two years. Now Obama has became an e-health reform organizer, perhaps an extension of his knowledge gained from Internet fundraising and his community organizing efforts.

Current E-Reform Efforts

Now he is an engaged in an extensive Internet campaign promising to provide universal coverage by the end of his first term. The dimensions of this e-campaign are becoming evident and include.

1. The Obama Biden website which says.

- Obama will make affordable and accessible health care for all

- Obama will lower health premiums by $2500 per year per family

- Obama will promote public health

In addition, the web site asks for comments (it claims to already have over 10,000 suggests and offers free access clicks to Obama videos on health care.

2. Regular Obama Facebooks, with videos featuring Obama talking health care
Basic Promises

Clicking Away

Through these instantly accessible e-sites, Obama can efficiently click away again and again at his basic promises and premises.

- Savings through prevention, EMRs, chronic disease management, medical homes

- Expanding coverage through private and government-run health plans

- Making large businesses cover employees or pay a fine

- Mandating that health plans accept those with pre-existing illnesses

- Having government negotiate Medicare drug prices

- Reforming health care as an integral part of his economic salvage plan

Prospects for Success

Given his election margin (53% vs 47%), large Democratic majorities in the House and Senate, his successful Internet deployment during the presidential run, his cache of millions of email addresses from supporters, the presence of personal computers in 80% of American homes, and his promise of $2500 premium savings for the typical American family, Obama’s electronic mobilizing tactics for health reform may succeed. I would not bet against it. The only things that might prevent Obama-health reform are the economy, the soaring federal budget deficit, and the Department of Health and Human Services current $708 billion budget, 25% of federal spending and on brink of bankruptcy, but Obama is not one to let billions, even trillions of dollars, standin his way. Let the the government printing presses roll.

Friday, December 5, 2008

Medical Home Badwagon: Expectations and Assumptions

When people jump on the bandwagon, they get involved in something that has become very popular. The term “bandwagon” is usually applied to politics but spills over into other fields. It is also called the herd instinct, or going for the apparent winner.

Various Sources

Have you heard of the wonderful one-hoss shay that was built in such a wonderful way? Logic is logic. That’s all I say. Now in building of a chaise, I tell you there is always somewhere a weakest spot.

Oliver Wendell Holmes (1809-1894), The Deacon’s Masterpiece, or the Wonderful One-Hoss Shay, a Logical Story

Expectations are high. States, health plans, and the Medicare program are making substantial financial bets that implementation of the medical homes will lead not only to improved care but also to long-term savings, largely by reducing the number of avoidable emergency room visits and hospitalizations for patients with serious chronic illness. Some see the medical-home model as a means of reversing the decline in interest in primary care among medical students and residents, and others argue the broad implementation would reduce health care spending overall.

Elliot Fisher, MD, MPH, “Building a Medical Neighborhood for the Medical Home,” New England Journal of Medicine, September 18, 2008

Beware of assumptions! Whatever you assume to be possible, or impossible, may not work in the real world.

Unknown Source

When I think of the Medical Home, a concept introduced by the American Academy of Pediatrics in 1967, but now rapidly gaining speed and traction, two images spring to mind,

• One, a bandwagon.

• Two, Oliver Wendell Holme’s Wonderful One-Hoss Shay, which ultimately collapsed because of minor defects in its construction.


Everybody is jumping on the medical home bandwagon. And for good reason. It’s so damn logical. Health costs are out of control. Countless studies show primary–based systems are politically popular, cost less, satisfy patients, and achieve better quality and outcomes. Besides, American primary care physicians are unhappy with the present system, and so are American patients. It’s time for a change. The problem, logic says, stems from our specialty-dominated, fragmented system and growing shortages of primary care physicians.

Why Not

Why not, then, create a new approach where primary care physicians form a medical home, and with the help of a newly hired care coordinator, and a team of providers operating under the guidance of the doctor, offer continuous, comprehensive, coordinated care of chronic diseases (the 4 C’s of medical homes).

Logic Builds Momentum

The logic of this approach explains why everybody is enthusiastically leaping on the medical home bandwagon.

Leapers include,

• Medicare and CMS, who are paying for a three year demonstration project, to be completed by 2010, to see if this new wagon works , has wheels, saves money on hospitalizations, and makes for a sustainable growth rate for health costs.

• The Obama administration, which has vowed to reform health care and save money through more primary care physicians, prevention, EMR use, and chronic care management – the medical home pillars.

• Major primary care associations – the American Academy of Family Practice, The American Academy of Pediatrics, The College of Physicians, and The America Osteopathic Association –have joined forces under the umbrella of the Patient-Centered Primary Care Consortium to issue a set of Joint Principles and are churning out white papers on medical homes.

• State legislators, who have taken the lead from state medical societies and the Physicians’ Foundation, and are endorsing Medical Home demonstration projects in at least 20 states. The numbers grow each month.

• Academic institutions, such as Johns Hopkins and the University of Rochester, who are pouring money and other resources into building and testing medical homes.

• The American Medical Association, the American Association of Medical Colleges, and societies of medical directors and state medical society executives, all of whom have bought into the concept.

• NCQA, who think medical homes contribute to improved medical care.

• Even the health plans, especially Aetna and the UnitedHealthGroup, who would like to serve as intermediaries in the process, selecting what doctors qualify for being medical home participants and what they will be paid.

Almost Everyone

Almost everyone, in other words, across the political spectrum has concluded medical homes are a significant leap forward and are willing to climb aboard for a bandwagon ride. The key phrase here is “almost everyone.” Forming and paying for medical homes is very much a political process, where “almost everybody” may not include those who want a piece of the action or feel their economic status is threatened.


It is assumed, of course, coordinated, comprehensive, continuous care of chronic disease in an aging population is an overwhelmingly logical thing. I agree, but it may be useful to examine medical home assumptions.

I am reminded of the story of the economist stranded on a desert island with fellow castaways. The castaways are surrounded by thousands of miles of ocean, but areblessed with cases of canned goods from their sunken ship. But, alas, they have no way of opening the cans.

The group turn to the economist for an answer, and he says, “First, assume a can opener.” We’re assuming here that medical homes will serve as can openers to save the system.

The cans, however, may be cans of worms. Perhaps it’s time to examine the assumptions which might cause the wheels of the Wonderful One Hoss Shay, known as Medical Homes, to come off.

The first assumption is that there are enough primary care physicians to make medical homes enough of a reality to make a difference reforming the system. The stark truth is that a desperate shortage of primary doctors already exists, most medical students and residents shun primary care, and we have no idea how many primary care doctors would bother to go through the paperwork to qualify or to build the infrastructure ( an EMR and an a hired coordinator are mentioned as necessary medical home ingredients) or to undergo the scrutiny of being audited for quality or complying with performance compliance markers. Venture capitalists, alert entrepreneurs, and major corporations like Walgreens sense a primary care vacuum and are moving fast to set up primary-care based worksites in major corporate sites having sufficient numbers of employees.

The second assumption is that new payment platforms would help create and sustain medical homes and recruit primary care doctors through a more lucrative “blended” payment system – fee-for-service, a capitation fee for managing a patient panel, and patient-centered bonuses for rapid responds to same day visits and email or phone to patients. Whether this scheme is workable in the U.S. is unknown, as is how much money will be required to win the hearts and minds of primary care doctors or whether money alone is the “turn-off” for medical students or residents considering primary care.

The third assumption rests on the notion that every medical home physician will have an EMR and will be able to talk, refer, and send complete electronic patient information to, other entities in the medical neighborhood, clinical colleagues, hospitals, pharmacies and other care providers. This is a giant leap of faith since only about 15% of physicians currently have EMRs and PHRs are in their infancy. It may be this barrier can be overcome through federal subsidies for EMRs, requiring physicians to meet connectivity standards, and rewarding collaboration through payment increases, pay for performance bonuses, and shared savings, but, in my opinion, the system is at least a decade away from this electronic utopia.

The fourth assumption is that primary care physicians will be comfortable with “managing” the medical affairs of each member of their panel, making the data entries required, and massaging and responding to the data involved in determining the outcomes of a population health model. Many doctors, weary and wary of paperwork and third party hassles, may respond by choosing to opt out by rejecting Medicare and Medicaid participation, retiring, going into concierge, cash-only, locum tenens practices, seeking employment outside the medical home, or seeking medical careers unrelated to direct patient care.

The fifth assumption is that patients would welcome such a model. In his popular blog, KevinMD, Kevin Pho, says many patients will be annoyed by being asked to be in a medical home, when they only have one symptom or one disease that may not need to be “managed.” Also 20% of Americans move each year, and may not be looking for a personal physician or a medical home. Finally, keep in mind that most people who frequent emergency rooms do so because the emergency rooms are “there,” not because they are uninsured, underinsured, or lack a primary care doctors (Myna Newton, et al, “Uninsured Adults Presenting to U.S Emergency Departments, “ JAMA, October 22-29, 2008).

The sixth assumption is that the medical home is a politically and financially neutral concept. This isn’t the case. Nurse practitioners, nurse doctors, physician assistants, and other medical specialists will lobby to set up their own Medical Homes, if for no other reason, than to make up for the primary care shortage. Another, probably more important factor, may the resistance of specialists. Organized medicine, now dominated by specialists, is aware that Congress’s present Sustainable Growth Rate (SRG) is supposedly revenue neutral, meaning if you reward primary care physicians through Medical Homes, you take away from specialists.


The medical home movement is logical and is intended to correct the current costly fragmented specialist dominated system by creating “homes” for patients with chronic disease to receive more coordinated and comprehensive care at less cost with better results. Medical homes are currently riding a political bandwagon, but the assumptions that the system will be transformed by the promising medical home concept remain politically and pragmatically untested. That is why multiple demonstration projects are underway. Meanwhile let us hope for the best and pray that a fundamental shift in the system towards more primary care occura. Making medical homes a reality will take hard work and political arm twisting.

Wednesday, December 3, 2008

Physician culture -Doctors are Human

Be thou as chaste as ice, as pure as snow, thou shall not escape calumny.


Surprise! Surprise! Doctors are not as pure as the fresh driven snow, as chaste as vestal virgins, as invincible as knights in shining armor, as saintly as Marcus Welby, as susceptible to the lure of money as ordinary mortals, as immune to fatigue as Lance Armstrong, or as happy as clams.

• Pure and chaste we are not. Their overall divorce rates are 10% to 20% higher than the general public, and 37% higher among female doctors, partly, I suspect, because of infidelity.

• Invincible we are not. Physician suicide rates over the last 49 years are 28 to 20 per 100,000, well above the general public rate of 12 per 100,000.

• Saintly we are not. A few are even arrogant, abusive, and disruptive (“Arrogant, Abusive, and Disruptive – and a Doctor,” New York Times, December 1, 2008).

• As susceptible to the lure of money we are not. After all, 4 of 5 graduating medical students choose specialties, where the pay is 2 to 3 times that of primary care doctors. And many receive money from health-related companies as consultants and lecturers and advisors (“Cleveland Clinic Discloses Doctors’ Industry Ties, New York Times, and December 2, 2008).

• As immune to fatigue as Lance Armstrong, we are not. The Institute of Medicine has just released a report saying to avoid mistakes from fatigue, medical residents should work no more Thant 16 hours without a taking a 5-hour sleep break, should have one day offer a week, and should have at least 2 back-back-days off each a month ((“Medical Residents should sleep after 16 hours, experts say, Washington Post, December 3, 2008).

• As happy as clams we are not. According to a national survey of primary care doctors conducted by the Physicians’ Foundation released on November 18 to all the major media, 78% of physicians say medicine is either ‘not longer rewarding’ or ‘less rewarding,’ while 76% say they are at full capacity or overextended. Only 6% describe the more colleagues as ‘positive,’ and 42% describe the morale of colleagues as either ‘poor’ of ‘very low.’ “

Why Newsworthy?

Why is all of this newsworthy? Two reasons: 1) we have overstated our case as a noble profession, somehow free of ordinary mortals’ faults; 2) we are victims of our success, leading to overblown expectations of the miracles of medical science.

Corrective Measures

Are there corrective measures we can take to re-establish our humanity? Yes, of course.

• We can admit and apologize for our mistakes immediately.

• We can be open about our financial arrangements and ties.

• We can treat nurses and other care team members respectfully.

• We can follow these rules in a hospital setting: 1) Ask permission to enter the room: wait for an answer; 2) introduce ourselves- show ID badge; 3) shake hands; 4) sit down and smile if appropriate; 4) explain our role as a member of the health care team; 5) Ask how the patient feels about being in the hospital.(“The Six Habits of Highly Respectful Physicians, New York Times, December 2, 2008).

• We can anticipate those moments of human truth when seeing patients in the office; calling the office, making an appointment, receiving directions, meeting the receptionist, waiting in reception, waiting in exam room, meeting the clinicians, giving a history, having an examination, having an invasive procedure, giving a lab specimen receiving discharge instructions, leaving the organization, obtaining test results, receiving a bill.

• We can manage expectations for surgery and procedures by giving patients to a free interactive online expectation of exactly what to expect during and after the procedure (see

• We can acknowledge the importance of ten simple rules for meeting patient expectations as set forth by the Institute of Medicine: 1) Care should be continuous; 2) care should be customized for the patient; 3) patients should be source of control; 4) knowledge should be shared and information should flow freely; 5) decisions should be based on evidence; 6) safety should be a given; ; 6) transparency is necessary; 7) patients need should be understood and anticipated; 9) waste and duplications should be continuously reduced; 1)) cooperation among clinicians is a priority.

• We can be warm human beings.