Thursday, December 31, 2009

Ideology - Goodists Know Who Are Naughty and Nice

As health reform debates proceed and the year ends, you may wonder: Who is naughty and nice?

Who is nice?

The nice guys are Goodists.

Goodists, as defined by Bret Stephens of the Wall Street Journal editorial board, are people who believe,

• All conflicts stem from avoidable misunderstandings. These misunderstandings come from those who refuse to believe a paternalistic government should totally run the health system for the common good..

• The health system’s evils spring from overused technologies, dysfunctional doctors, and medical industrial complexes, who rely on profit to exist.

• Goodists, known for pure hearts where love abides, do not see a place for profits, but in using society’s money.

• Hope and goodness will change the world, as long as all are equal. Universal equity is their destiny.

• High moral intentions are paramount, not the efficacy of their actions.

• Education, as taught by themselves, will solve everything, and the world must be reset around their educational precepts.

• Goodists must yearn and strive and be hailed as Good.

Goodists, above all, know all other Goodists are nice.

Goodists know the naughty are Badists who,

• Question Goodists’ Goodness.

• Criticize Goodists’ intentions.

• Point out adverse consequences of Goodists’ actions.

• Believe human conflicts are inevitable for reasons of belief.

• Think the status quo isn’t all bad.

• Do not seek to be loved for niceness but respected for competence.

So be Good, for Goodist Sake. And remember. Even hard-hearted Badists have some Good in their Souls.

Wednesday, December 30, 2009

Clinical Innovation - Health Reform Threatens U.S. Lead in Medical Innovation

U.S. Lead in Medical Innovation Under Threat from Reform Bills

By: Kishore Jethanandani

Preface: In the following article, in Health Care News, published by the Heartland Institute, the author quotes my views, as well as those of other authorities on innovation on the negative impact of reform. Her main points are; 1) current reform bills undermine innovation; 2) the U.S. outperforms socialized systems in developing new drugs, devices, and information technologies by a wide margin, largely due to market-based compensation incentives.


A new study measuring medical innovation puts the United States at the top of the list for advancements, identifying an area where the benefits of a free market system are clearly outweighing those of socialized medicine, an advantage the health care legislation currently under consideration could seriously undermine.

Outperforming Socialized Medicine

Many proponents of socialized medicine point out the American health care system spends more money and performs poorly compared to government-run systems in Canada and Europe. A World Health Organization study conducted in 2000—which was abandoned after methodological flaws were identified—indicated the United States lags behind countries with socialized medicine in metrics such as life expectancy and infant mortality.

Yet one measure of progress—medical innovation—was conspicuously absent from most studies until the Cato Institute released a new report, “Bending the Productivity Curve: Why America Leads the World in Medical Innovation,” by Glen Whitman and Raymond Raad and published in November 2009.

U.S. preeminence in research is indicated by the number of Nobel Prizes awarded for medicine, and by roughly $30 billion in annual research spending via the National Institutes of Health versus $4 billion in all of Europe.

“Of the 95 recipients in the past 40 years, 57 (60 percent) were from the United States, while 40 (42 percent) were from the European Union countries, Switzerland, Canada, Japan, or Australia—countries whose combined population is more than double that of the United States,” the authors write. [Editor’s note: Two recipients are identified by the authors as being from both the United States and another country.]

Measuring Actual Effects

The study concentrates on truly effective innovations and avoids standard but potentially deceptive measures such as expenditures on research and development or bald numbers of new products launched, in diagnostics, therapeutics, and pharmaceuticals.

“Innovation is best measured by looking at advances that have withstood the test of time and are widely regarded as having had important positive effects on health care,” the authors write.

The researchers took a list of 30 major innovations in diagnostics and therapeutics and ranked their importance based on feedback from 225 leading primary physicians.
“[Of the] 27 innovations for which a country was identified, work performed in the United States significantly contributed to the invention or advancement of 20, including nine of the top 10.” Regarding drugs, “Sixteen of the 29 representative drug classes were developed in the United States, while 15 were developed in the EU or Switzerland.”

A key factor explaining these vast differences is the role market-based compensation plays in the United States, the authors note.

“Single-payer and other centrally organized health care systems, like those in much of Europe, are characterized by a great deal of monopsony [buyer] power that pushes down compensation. Prices for prescription drugs in Europe are 35 percent to 55 percent lower than in the United States,” they explain.

Infant Mortality Myth Busted

The study criticizes certain metrics, particularly references to infant mortality, a measure that has come under fire from other observers.

“Americans are far more aggressive in trying to save the lives of tiny premature babies. In some of the world’s most advanced nations where governments run the health care system, prematurely born infants are viewed as too expensive. It is just not cost effective to allow them to be born,” notes Gregory Dattilo, coauthor of Your Health Matters (Alethos Press 2006, $24.95).

Socialization Hurts

According to Tevi Troy, a senior fellow at the Hudson Institute, a U.S. move toward a more socialized system could erode the incentives that drive innovation in drugs, devices, and information technology here.

“The unlocking of the human genome and knowledge of the micro-level determinants of human health, health informatics and the thousands of records that help us understand what works, and personalized medicine are in jeopardy with price controls and additional fees,” said Troy.

Dr. Richard Reece, a consultant to several innovation-focused health care companies, agrees the reform plans under consideration in Washington could suppress innovation.
“Many of the new innovations, especially in medical devices, are tied to new business models for reducing costs and improving quality”, said Reece. “These devices are often developed or adopted in creative ways by small primary physician groups to save costs by reducing the need for recourse to specialists. Small physician groups can barely afford to set aside the time and financial resources to organize their practices for new technology and will be adversely affected when costs of equipment rise as a result of taxes charged on medical devices.”

Undermining Innovation

According to Grace-Marie Turner, president of Galen Institute, which recently held a conference on health care innovation in Washington, DC, the proposed health care reforms will centralize decision-making within the government and create a climate of uncertainty.

“Comparative effectiveness research will add another layer of uncertainty and costs for emerging biotech companies on top of compliance with FDA rules,” said Turner. “Medical devices such as implantable defibrillators have already encountered obstacles due to a preference for lower rates of compensation by Medicare, and health care reforms will extend these disincentives for innovation.”

Jason Hwang, executive director of the Innosight Institute, a health care consulting firm in Massachusetts, agrees.

“Innovation is possible when patients have choices and are empowered to make decisions,” said Hwang. “The proposed health care mandates and comparative effectiveness research based government decision-making will undermine innovation.”
Kishore Jethanandani ( writes from San Francisco.

Online Resources:“Bending the Productivity Curve: Why America Leads the World in Medical Innovation,” Cato Institute:

Obama Health Reform Grade - Obama: A to C- On Health Reform

President Obama, in a recent Oprah Winfrey interview, gave himself a “solid B+” for his overall performance for his first year in office.

Frankly, it is beyond my pay grade or competence to judge Obama’s overall performance. I will leave that to the American people, who will have their first chance to register their opinion in the November 2010 off-year elections.

I give Obama a weak C- on health reform. This puts me somewhere in the middle of the opinion spectrum.

• Uwe Rinehart, the Princeton health care economist, gives Obama an A- in a Health Affairs blog.

• David Brooks, the New York Times columnist, gives him a B.

• Jeffrey Flier, MD. Dean of the Harvard Medical School, gives Obama a “failing grade” in a November 17 Wall Street Journal Op-Ed piece.

Flier’s article, coming out the rarified pro-Obama atmosphere of Boston, surprised me. Flier reasons, “There are no provisions to substantially control the growth of costs of quality of discussions with dozens of health-care leaders and economists, I find near unanimity of opinion, whatever its shape, the final legislation that will emerge from Congress will markedly accelerate national health-care spending, rather than restrain it...In effect, while the legislation would enhance access to insurance, the trade-off would be an accelerated crisis of health-care costs and perpetuation of the current dysfunctional system– now with many more participants. This will make an eventual solution even more difficult. Ultimately our capacity to innovate and develop new therapies would suffer most of all.”

Flier cites the Massachusetts example, where coverage was expanded and costs exploded over the last three years of a universal coverage plan. In Massachusetts, a “Special Commission” has decided capitation will be needed to replace fee-for-service to control costs. :Unfortunately," Flier says, "The details of such a massive change are completely unspecified...We should not be making public policy in such a crucial area by keeping the electorate ignorant of the actual road ahead.”

Which brings me to my C- grade.

I like certain things about reform proposals- expanding coverage to 31 million uninsured and covering those with pre-existing illnesses. I dislike others - not allowing consumers to shop for plans across state lines. limiting tax deductions for HSAs, taking no real action on tort reform.

Obama and the Democrats are telling us government knows what is best and they are not the slightest bit interested in what people or doctors think. They are not interested in what dissenting authoritative experts have to say; they are not interested in holding hearings on the final proposals; they are not going to let Republicans contribute to the negotiations; they do not give a damn what others thinks.

They ignore overwhelming and exploding public opposition. They believe a new Medicare Commission ought to have the power to overrule doctors, and government has the right to choose cheaper alternatives to expensive care.

Democrats are simply obsessed with making “history,” even in the face of countervailing opinions and empirical evidence that what they propose might not work.

I find such “top-down” power brokering arrogant and ignorant. It is arrogant in that it thinks it knows best while the public and doctors know least and in that it practices financial sleight-of-hand, such as taxing immediately and delaying benefits for 4 to 6 years.

It is ignorant in ignoring such fundamentals as the growing doctors shortage, which grows worse by the day; in believing that all Medicare payments ought to be equal for all regions of the country, no matter what the poverty levels in those regions; in preaching the gospel that EMRs, preventive care, and coordinating care will somehow save more towards the end of the decade, despite evidence to the contrary; in believing you can cut $500 billion out Medicare without cutting benefits; in finessing and hiding such issues as market and consumer-driven care, which has been shown to control costs and enhance quality through competition; and in failing to acknowledge that American medical technologies are the best in the world and that the health care sector is one of the few economic growth sectors.

Monday, December 28, 2009

Ideology - Contrasting Views on Health Reform Bill

What a strange contrast we find ourselves in —a clear majority of Americans is opposed to what health reform bills offer ; congressional representatives know they are acting against the will of the people, and they have just accepted borrowed money for their districts and states to compensate for their unpopular actions. Meanwhile Democrats are proclaiming their vote is historic, and Republicans agree.

“This vote is indeed historic. This Congress will be remembered for its arrogance, corruption and stupidity. In the year of 2009, a Congress ignored the coming economic storm and impending bankruptcy of our entitlement programs and embarked on an ideological crusade to bring our nation as close to single-payer, government-run health care as possible. If this bill becomes law, future generations will rue this day and I will do everything in my power to work toward its repeal. This bill will ration care, cut Medicare, increase premiums, fund abortion and bury our children in debt.”

“This process was not compromise. This process was corruption. This bill passed because votes were bought and sold using the issue of abortion as a bargaining chip. The abortion provision alone makes this bill the most arrogant piece of legislation I have seen in Congress. Only the most condescending politician can believe it is appropriate to force Americans to pay for other people's abortions and to coerce medical professional to take the lives of unborn children.”

Senator Tom Coburn, R, Oklahoma, December 24, 2009

“The United States stands on the verge of the most significant change to our health care system since the 1965 introduction of Medicare. The bill that was passed by the House and a parallel bill before the Senate would cover most uninsured Americans, saving thousands of lives each year and putting an end to our status as the only developed country that places so many of its citizens at risk for medical bankruptcy. Moreover, the bills would accomplish this aim while reducing the federal deficit over the next decade and beyond. They would reform insurance markets, lower administrative costs, increase people’s insurance choices, and provide “insurance for the insured” by disallowing medical underwriting and the exclusion of preexisting conditions. And the Senate bill in particular would move us closer to taming the uncontrolled increase in health care spending that threatens to bankrupt our society.”

“The current bills are not perfect. The Senate Bill has a mandate that’s too weak and doesn’t provide enough insurance to low-income individuals, and the House bill doesn’t do enough to control costs. Nevertheless, passage of a hybrid bill would be a major accomplishment and a turning point for our dysfunctional health care system. We should constructively support Congress’s efforts to create a combined bill, rather than leveling unsubstantiated criticisms from the sidelines.

Jonathon Gruber, PhD, “Getting The Facts Straight on Health Care Reform,” New England Journal of Medicine, December 24, 2009

Ideology, -Notes of An Ideological Pragmatist

I’m an ideological pragmatist. I believe in what works and what suits the temperament of American people, rather than what is politically correct or what passes some moral litmus test.

Public-Private Mix

Whatever reform measure passes, It will be a public-private mix, it will superimpose more government regulations on our private system. It will have uneven effects. It will cost more than the status quo. And it will expose the reality, that when it comes to health reform, Democrats and Republicans have their ideological blinders on.

All developed nations have a mix of public and private systems. The United Kingdom has the NHS (National Health Service) and BUPA (British United Provident Association and other private plans); Canada has its Medicare and private insurance plans to help citizens escape waiting lines .

It comes donw to questions of the socialist-capitalist mix, how much goverment consumes of a nation's GDP, what citizens are willing to cough up in taxes, what choices they are willing to give up, how long they are willing to wait for life-saving and function-restoring technologies, how free they want to be in their personal decision making , and how economically secure they want to be in health care matters.

Everybody in all countries knows if you have money and connections, you can jump the public queue to get care. In the U.S. Medicare and Medicaid cover about 105 million of our 310 million citizens at a cost of about $1 trillion, while private plans care for the rest for roughly $1.5 trillion. Then, of course, there are those “cadillac plans,” which offer rich benefits, mostly of members of powerful unions.

Health Reform as an “Ideological Exercise

Democrats harbor the illusion of a high moral duty to care for all by expanding federal regulations to care for all. It may be more about political power than moral obligation. Nolan Finley, reporting in today’s Detroit News, says the “most tangible fallout of the electorate single-powerful rule in Washington is that public policy making has become an ideological exercise, rather than a pragmatic one.” Translated, this means, by God we Demoorats have unlimited power, and we’re going to exercise it, no matter what the consequences.

Meanwhile Republicans seem to think Democratic power leads to serfdom, and the only solution is freeing the market from federal regulations, letting entrepreneurs innovate , and having consumers pay their money and make their choices. This isn't going to happen, given embedded liberal ideologies of equity and equal outcomes and current political power.

Connections and Ideology

One’s connections shape one’s ideology. I am no exception. I work closely with The Physicians’ Foundation, a nonprofit organization representing some 650,000 practicing physicians in state and local medical societies, and for the last 10 years, I have been on the MedicaL Advisory Board of Castle Connolly’s Top Doctors, which is closely linked to the nation’s top academic medical centers.

From the Foundation, I’ve learned most physicians cherish independence and direct relationships with patients without 3rd party interference. These physicians, contrary to what you might hear about AMA support of current health reform, tend to be profoundly skeptical of House-Senate bills because of their intrusiveness into doctor-patient relationships and constant lowering of reimbursements.

From the Top Doctor organization, made up mostly of more 3000 physicians practicing in America’s 125 academic hospitals, I’ve learned academics are skeptical as well. They are especially leery of the proposed $500 billion Medicare cuts proposed over the next ten years. High tech care of Medicare patients is often the life-blood of these institutions.

The American People

From recent public polls, I’ve learned 60 percent to 70 percent of the public do not believe reform will lower costs or improve care, or change their overall care for the better. At this stage, because of unemployment of over 10 percent, the perceived ineffectiveness of the massive stimulus bill, and soaring federal deficits, public belief in government intervention is at an all time low.

Because of these various factors, I remain pragmatic and skeptical about the ultimate outcome of reform and its political and practical consequences. To me talk of successful reform as “historic” remains mostly political histrionics. Time will tell how reform shakes out and whether criticism from the sidelines is factual or simply political jealousy. We do not yet know the impact or implications of this partisan party line bill, or how its final version will evolve.

Saturday, December 26, 2009

Health Reform By The Numbers

I’m a numbers person. You can talk all you want about effects of health reform. But I won’t be impressed until I see the numbers, provided, of course, the numbers fit my point of view. When politicians start throwing around numbers, it's generally about budgets, and how to fix them to match them to fit your view of the world.

Democrats say they are going to sell their reform bill by talking about those 31million that will now be covered and those 5 million, or whatever the real number is, that will no longer be denied coverage for pre-existing conditions or expensive dieases. This is an important selling point since 133 million Americans are estimated to have chronic disease.

Republicans will seek to discredit health reform bills by saying the bills will cost $2.3 trillion, not $879 billion, taxes will start in 2010 but benefits don’t kick in until 2015, true costs will explode after 2019, and bureaucrats not doctors will be practicing medicine.

The true numbers, as we know them now, before the reconciliation (that’s the term being used to describe the divorce settlement between liberal and conservation Democrats). It's worth taking a numeric stab about what how the numbers might shake out.

According to the Congressional Budget Office, the budget numbers for the years 2010 to 2019, are,

• $395 billion in federal spending to expand the number of people covered by Medicaid and CHIP, insurance programs for the poor. Comment: The feds say these numbers are modest considering benefits to the uninsured ; the states say the numbers are crushing and unsustainable.

• $436 billion in federal spending to pay for health-insurance exchanges that be used by people who don’t get health insurance through work. Most of that money will come as subsidies for insurance premiums for people earning up to four times the poverty level. Comment: Cynics say some families making $96,000 would qualify, depending on how you parse the numbers.

• $398 billion in new taxes. That includes the tax on high-value health-insurance plans, new fees on health insurers and drug and device makers, higher payroll taxes for high earners, and indirect taxes on consumers and the middle class as you pass effects of new high taxes onto new premium costs. Comment: Do the effects of these higher taxes and higher costs leave anyone out?

• $483 billion in cuts to projected spending for Medicare and other programs. This includes reductions in projected costs for privately administered Medicare Advantage programs and a new formula likely to lower annual increases in payments to hospitals. Comment: These are numbers likely never to materialize if the history of Medicare is any guide.

• 31 million additional people would have health insurance by 2019 because of the bill and 23 million people in this country would still be uninsured. Comment: Don’t worry about the 23 million. We’ll cover them later.

So there you have it – a rundown on the numbers. I trust I have helped you understand the effect of health reform through this numbers exercise. Health reform is not rocket science. It is numerical. It is not numerological – a system of occultism based on how many people might abuse, overuse, or be confused by what lies ahead. Health reform is based on hard numbers, subject to two by ifs - human responses to budget incentives and shifts in the political landscape.

Friday, December 25, 2009

Ideology -Health Reform - "Screaming Big Deal" to Progressives, "Monstrous Big Price" to Conservatives

Matthew Holt, a transplanted Englishman, hangs out in San Francisco, where he preaches the gospel of government-directed care and care transmitted to consumers via Health 2.0. He is a co-founder of Health 2.0, and he directs The Health Care Blog, a widely read blog where he occasionally features my work. In any event, here is his take on the necessity of health reform.

Senate Passes Bill, More To Come


It's Christmas Eve and the Senate just passed a major health reform bill. Personally I think the reforms in it are relatively minor, but the passage of the bill itself is a screaming big deal. When I say minor, what I mean is that we’re leaving in place the inefficient employment-based health benefits system, and we’re expanding insurance mostly by putting more people into the separate but equal Medicaid program.
But this bill is a statement, and an important one.

For the first time we’re acknowledging that everyone ought to have health insurance and that those unable to afford it should be subsidized by the government. We’re also saying that insurance companies should take all comers at a consistent price without respect to health condition (and hopefully we’re implying that their job is to manage care not risk-select). Finally we’re saying that the majority of the cost can be paid for by redirecting inefficient spending within the health care system, and by taxing benefits that are only tax-free because of historical accident.
Building on those principles it may be possible to get us to a more equitable and more efficient health care system."

KARL ROVE: "Real Price of The Senate Health Bill," The Wall Street Journal

Karl Rove, the so-called architect of conservative politics thinks differently than Matthew Holt. He calls the Senate Health plan a "monstrosity" - a government "gift that will keep on taking."

Here is his statistical thinking on why government will take more than it will give,

1. It will keep on taking taxes in these yearly increments from 2010 to 2019 (in billions of dollars) - 1.9 (2010) 7.1 (2011), 9.1 (2012), 32.6 (2013), 39.3 (2014), 57.5 (2015(, 75.9 (2016)*, 88.6 (2017), 98.9 (2018), 106.8 (2019)

2. It will keep on cutting Medicare (in billions of dollars) - 0.4 (2010), 9.9(2011), 15.9 (2012), 25.1 (2013), 48.4 (2014),51.3 (2015), 58.8 (2016)*, 74.5 (2017), 80.6 (2018), 106.8 (2019)

3. It will keep on increasing spending (in billions of dollars) - 2 (2010), 4(2011), 5 (2012), 6 (2013), 60 (2014), 99 (2015), 151 (2016)*, 172 (2017), 184 (2018), and 199(2019)

Please note the Rove factors - more taxes, more Medicare cuts, more spending - escalate about 2016, the year after Obama would leave office if he were to be re-elected in 2012. But taxes start up now, Medicare cuts crank up after next fall's election, subsidies for the uninsured and underinsured commence in earnest in 5 years. The total cost is not $871 billion, says Rove, but $2.4 trillion if you count tax credits and Medicaid expansion.

For progressives, the government giveth; for conservatives,the government taketh away.

So much for the give and take of politics, as seen from the left and right.

Health Savings Accounts - Christmas Parties

Men by their constitutions are naturally divided into two parties; 1) Those who fear and distrust the people, and who wish to draw all powers from them into the hands of the higher classes, 2) Those who identify themselves with the people, have confidence in them, cherish and consider them as the most honest and safe.

Thomas Jefferson, Letter to Henry Lee, 1824

This is the time of the year for Christmas parties. This year two sorts of Christmas parties will be taking place.

1) Gala self-congratulatory parties of those who believe in mandates imposed by those of higher intellect for the public good;

2) Doleful but defiant parties by those who believe in the good sense of people to make their decisions for their own good.

Mandate Parties

Mandate, def., An authoritative command, order, or commission, esp. a written one

The mandate parties now taking place are wildly self-celebratory and self-congratulatory, for the mandate-minded have prevailed. They are drinking to the health of the people and the health of the nation, which they have mandated. They have mandated health coverage for individuals; they have mandated health coverage for employees of businesses, large and small; they have mandated the contents of health plans, and the conditions of coverage; they have mandated physicians must have electronic records; they have mandated what surgeons can do; they have mandated how many resources a referring physician can deploy. And they have mandated a Medicare Commission for purposes of cost control, whose decisions patients won’t have the right to appeal.

Mandate mandarins are feeling very good about themselves, for they contend they have issued these mandates based on data, scientific evidence, and their own intrinsic wisdom for the public good. They feel they represent a national third party that protects the populace against predatory third parties and providers. They are the party of government. They insist government that spends the most and governs most governs best. The public at large are like innocent children. Ordinary citizens are basically ignorant about matters of money and science. They must be made dependent to shield them from harsh realities of money, disease, and death. The mandatites are the party of good intentions and function on a higher moral plane than others.

The Market Parties

Market, def. a place, open place, where goods and services are offered for sale.

The market parties are sad affairs this year, for they realize government mandates will marginalize them. Private practice and independent physicians are in disarray. They are threatened by reimbursement and decision-making cuts. To defend themselves, they have formed an American Association of Private Practice. This association is a sign of the times. The private belief systems – that the people are intelligent, capable of competent clinical decision making, will act responsibly when well-informed, know the value of money and what it brings, can function without third party intrusions, welcome choice and competition, prefer independence to dependence, are perfectly able to do their own health care shopping –have been discredited. They imagine a system this is genuinely transparent, competitive, and driven by consumers. They believe this system translates into greater choice, higher quality, and lower costs.

In the debate on how to reform the system, a debate conducted behind closed doors, market beliefs rarely entered the discussion or the public arena of ideas. As a result, the consumer-driven business model – health savings accounts linked to high deductible plans – received little mention from the mandate crowd or from the national media.

They were told one cannot trust uncertain markets emanating from individual patient-doctor exchanges at the point of care. One can only have faith in unequivocal collective mandates issued from above through regulated public exchanges.

Patients and doctors, it is said, cannot be allowed to make uninformed decisions, or direct contract between themselves. Patients partnering with doctors might make mistakes, spend too much money, and do things not scientifically-based with predictable outcomes. The government that governs least governs worst.

Raise you glasses high, you mandarins of mandates. This is your Christmas and your year. And, as for you, you market-minded party poops, you will have to wait for next November, which may precede a happier Christmas in 2010.

Thursday, December 24, 2009

Government reform - Now, The Constituents

Senate Democrats had to pass the health reform bill before Christmas. Otherwise, they would have to face angry constituents with no deed done.

They would have explain,

• Senator Ben Nelson’s reversal of his earlier pledge “My vote is not for sale, period.”

• House leader Nancy Pelosi’s remark, “We have to keep members away from their constituents so we can pass this bill.”

• Why they passed the bill despite a NBC/WSJ poll saying only 32 percent thought Obamacare was a “good idea.”

• Why most constituents feel premium costs will rise.

• Why Medicare will cut benefits.

• Why mandates will force individuals to buy expensive plans.

• Why government boards will decide who gets what.

• Why patients can expect longer waiting lines as doctors get pinched for reimbursements.

• How Medicare will control surgeons’ decisions and how many resources doctors can use.

Be of good cheer, you federal legislators. But be prepared for post-Christmas jeers. Be ready to look your constituents in the eye and say why you said “aye.”

Health Reform Corruption -Yes, Senators, There Is A Santa Claus

December 24, 2009 – Everywhere I go these days – to Staples, the Post Office, the Convenience Store, the Supermarket – people are expressing outrage at the deal Senate Leader Harry Reid cut with Senator Ben Nelson of Nebraska.

Reid agreed to pay for Nebraska Medicaid patients out of federal funds forever. In the minds of ordinary citizens, Reid’s other deals - multibillion dollar gifts to Senator Landrieu of Louisiana, Senator Dodd of Connecticut, Senator Saunders of Vermont, and God knows how many other Senators – pale compared to the unlimited largess Reid bestowed upon the Senator and people of Nebraska. Even the other Nebraska Senator, a Republican, is outraged.

The rest of the country feels husked and hustled.

Be not angry, you people of this great nation. Be astonished. You are witnessing a miracle – the transformation of a wiry and wily Senator leader, known derisively to his critics as Dirty or Dinghy Harry because of evasive tactics and miniscule legislative record to a magnanimous Bingey Santa Claus.

Diminutive, sad-sack, looked-down-upon Harry has suddenly become the esteemed jolly red giant of the Senate. OPM, Other People’s Money, viz, taxpayer money, has become his money for re-distribution to Democratic Senators.

Harry is on a spending binge of unprecedented scale. He is applying skills he may have learned at the Roulette Wheels in Vegas and Dealings at crap and card tables to the backrooms of Washington. He is practicing Wheeling and Dealing as a high art form.

Do not worry about the scruples of it all. As they say in Moscow, when you have the rubles you don’t need the scruples. Harry may not be a bundle of charisma, but he has the position and wherewithal to buy votes to do Obama’s bidding while the President levitates above it all.

Do not concern yourself about Harry’s ultimate fate. He may lose his Senate seat come November. But no matter. His family members are already well-known and established Washington lobbyists, and he can simply join the family firm.

Who knows? Reid may go down in history as a masterful legislative strategist and tactician, how far down no one knows. Maybe Reid's deals will be declared unconstitutional. And maybe history will judge the moral noble ends - 31 million more insured and coverage for pre-existing conditions - as justifying the immoral ignoble means.

Wednesday, December 23, 2009

Obama, Doctors, and Health Reform - Cool Book of the Day

Dan Janal,Founder and CEO of, a national public relations firm in Minneapolis today, December 23, issued this press release on my latest book.

Dan Janal's
Cool Book Of The Day
Interviews With Authors of The Hottest
New Books Coming Out Today!

Obama, Doctors, And Health Reform: Doctor Assesses The Odds For Success, By Richard L. Reece, MD

Posted by Dan Janal, Your Fearless PR LEADER
Pitch reporters with our up-to-date media databases:

Question: Who is the intended audience?

Answer: The intended primary audience is the American public. There are a number of misconceptions about health care in their mind, for example, that doctors set their own fees when in fact Medicare and other third parties set the fees. Caregivers are a secondary audience, and in the book, I seek to give their point of view.

Q: What is the book about?

A: It is about the prospects of proposed health reform, Obama style, passing. And if it passes and in what form, will it be a historic legislative monument or a political monstrosity? The book is respectful but skeptical about the changes for passage. As I write, only 42% of Americans approve of President Obama’s handling of health reform. My guess, as expressed in the book, which was finished in April, is that President Obama will get about 1/3 of what he wants.

As expressed in the book President Obama faces four major reform obstacles. I call them the four “Cs.”

• Culture American style, abhors the word “rationing.” Our health care culture cherishes unlimited choice, quick access to the latest and best in medical “cures,” and proven lifestyle restoring technologies. These traits conflict with a centralized, command-and-control, federal expansion of health care.

• Complexities American health care is a whirling Rubik’s Cube, with millions of interrelated moving parts, institutions, and people, each with agendas, axes to grind, and oxen to gore.

• Costs Obama says prevention, electronic medical records, and paying only for what works, as established through comparative research, will save billions of dollars, yet scant evidence exists that these measures work. Proposed savings remain hypothetical. The estimated cost of the current Democratic health exceeds $1 trillion over the next decade and will likely be more.

• Consequences of curtailing health costs, may be worse than the cure, because health care institutions and private practices in many communities are the biggest and fastest growing employer in town. Collectively, health care profoundly impacts most communities’ economies. Health care’s building blocks can’t be downsized quickly or dramatically.

To these obstacles I would now add public concern over the projected $9 trillion deficit in 10 years, the dreadful state of the economy, the 10% unemployment figure as more overriding concerns than health reform, and the recent defeats in government races in Virginia and New Jersey, which may cause the Blue Dogs to vote against House and Senate health reform bills.

Q: Why are you the best person to write this book?

A: Because I am a physician who been writing on this subject for 35 years – as editor-in-chief of Minnesota Medicine, The Reece Report, and Physicians Practice Options – for 35 years. Also I’ve written 10 books on various aspects of the medical system. In the last two years, I’ve published three books: Voices of Health Reform, Innovation-Driven Health Care: 34 Keys to Transformation, the Obamacare book, and 1131 blogs in Medinnovationblog. The blog focuses on medical innovation and health reform. During the course of these writings, I’ve interviewed over 300 health care authorities and participants and have captured their words in print interviews.

Q: How is this book different from other books on this topic?

A: The book is different because it highlights several things you haven’t heard in the health care debate. 1) Doctors are demoralized and departing from or not entering the ranks of primary care at an accelerating rate; 2) it reports the results of a survey of 300,000 primary care doctors which explores the reasons for physician discontent; 3) it explains the impact of the internet on health care; 4) it points out that health care is a vibrant industry that employs 14 million Americans and is one of the few growth sectors of the American economy; 5) it delineates why the American medical system compares favorably with the health systems of other countries in terms of responsiveness: shorter wait times, faster access to high tech care, and greater amenities of care.

Q: Is there anything else we should know about this book?

A: This is a book containing 41 chapters you can dip in and out of. It has a varied fare – straight reporting, interviews different folk with different points of view – businessmen, health care agents, doctors, government, a self-interview with the author, and a toast and prayer for President Obama. It is indexed, making it easy for you to explore topics you are interested in. It explains what patient-centered care and consumer-driven care are all about, and it explores why America’s individualistic, entrepreneurial, and innovative cultures make America medicine different – sometimes better, sometimes worse – from health care in other nations. Above all, it emphasizes we are a bottom-up society that thinks for itself and relies on the common sense of its many peoples in different regions of the country with different cultures.

Share and Enjoy

Dr. Richard Reece is author, blogger, speaker, and innovation and reform commentator. Dr. Reece’s latest book, Obama, Doctors, and Health Reform ( is available at www.iuniverse and other book websites .. For information on speaking fees and arrangements, call 860-395-1501.

Government Care-Why Reform is Difficult: It's the U.S. Form of Government

Many readers have made "hits"on this previous blog of mine, now nearly 3 years old. 

In today’s The Health Care Blog, Humphrey Taylor, Chairman of the Harris Poll and Harris Interactive, speculates why U.S. health reform is more difficult than in other countries.

He gives these reasons. The comments are mine.

ONE, their systems are much simpler, i.e., they don’t have a thousand points of payment. Comment: In America, we call this freedom and choice.

TWO, they already have universal coverage and can focus on improving care, efficiency, and cost containment. Comment: In other words, government rules and trumps private sector.

THREE, they have parliamentary systems, where a simple majority rules. Comment: “Simple majorities” can lead to social tyranny.

FOUR, lobbies, i.e. special interests, are more influential in the U.S. Comment: The biggest “special interest” of them all is a dominant unchecked politic party.

FIVE, the power of money: in other countries elected officials do not have to raise vast amounts of money to be elected. Comment: I agree. A prime example is Barack Obama, who raised unprecedented amounts of money from Wall Street and Internet followers.

SIX, they only need a bare majority of votes in their legislature and have no such thing as a filibuster. Comment: Good point. Our founding fathers set up a system to frustrate sweeping changes by a “bare: majority.

SEVEN, the U.S. has partisan news networks, especially Fox News, and talk radio that spread emotional, often misleading arguments that fuel populist feelings, and dumb down the debate. Comment: This is typical elistist rhetoric, that somehow those in D.C. and liberal media, have a stranglehold on intellect, wisdom, and objectivity,

Is the U.S. System of Government Desirable?

Some wonder if the U.S. system of government is desirable,

Wouldn’t be just wonderful to adopt a system more malleable?

Such a change would help clean up the health care mess,

End influences of lobbying, money, and partisan press,

And provide health care that’s simple, good, and universal

Tuesday, December 22, 2009

Health Reform Passage: The End of the Beginning

Now this is not the end. It is not even the beginning of the end. But it is perhaps, the end of the beginning.

Winston Churchill, London, 1942

Winston Churchill had a way with words about the future. Little did he know he would be turned out of office in 1946 after being a triumphant war-time president.

This could also be the fate of Obama and the Democrats and their imminent and self-proclaimed health reform bill triumph.

Passage of a health reform bill may be just the end of the beginning. This doesn’t surprise me. I predicted this in my book Obama, Doctors, and Health Reform and in an interview I granted with Dutch TV (see video on right of this blog).

I also predicted President Obama would celebrate its passage, even though it contains only about a third of what he wants.

What I did not predict was the pay-offs (some say bribes, others say compromises) required to secure passage. As one cynic remarked to me,"This bill is like electing the Mafia to clean up the mess."

What we have now is a bill that says it will cover 30 million more people, increase taxes by $400 billion, and slash Medicare by $500 billion. It will also theoretically cut the deficit by $132 billion. I say “theoretically” because Congress has never had the will or the guts to cut spending in entitlement programs.

Instead, we shall probably see patching, compromising, reconciling, backing and filling, and back room dealings as Congress reacts to public outrage. Recent poll averages indicate only 32% of approve of current bills, 66% disapprove of Congress, and 57% say the country is headed in the wrong direction.

Perhaps, the magnitude of the Democrat’s “historic” achievement will sink in and turn these poll numbers around. But perhaps, as was the case with Winston Churchill, the public will suffer from reform fatigue and vote the rascals out of office. And perhaps, a public backlash will occur when the public learns their premiums are going up, they are forced to buy insurance whether they want it or not, taxes begin immediately. benefits will be delayed until 2014, and savings aren’t realized until 2016 or later.

Meanwhile , paradoxes are mounting. Stock prices of private health plans, demonized by Obama and the Democrats, are exploding. From October 27 until December 21, stock prices showed these gains.

• Coventry, up 31.6%

• CIGNA, up 29.1%

• Aetna, up 27.1%

• Wellpoint, up 26.6%

• United Health Group, up 20.5%

• Humana, up 13.6%

Maybe the health plans know something we don't. Who would have thought it? Private profits for the evil-doers are up in the name of the public good.

In the end, health care reform comes down to a series of trade-offs - potentially mediocre government care with shackling of hospitals, doctors, and entrepreneurs, to even the playing field and provide equity; more government oversight, less private innovations; greater coverage with lesser access because of doctor shortages; damned if you do, damned if you don’t; doomed if you do, doomed if you don't; strive for the public good, and you gore someone's private ox; one man's health hope is another man's benefit cut; what's mine is mine, what's yours is negotiable. These trade-offs, and the accompanying cliches contain grains of truth.

What does it all mean? I like the metaphor of Frank Luntz, a Republican pollster, "On health care , we are not on the 1-yard line, be we are on the 20-yard line. It's close enough that Obama can kick a field goal."

Dr. Richard Reece is author, blogger, speaker, and innovation and reform commentator. Dr. Reece’s latest book, Obama, Doctors, and Health Reform ( is available at www.iuniverse and other book websites. For information on speaking fees and arrangements, call 860-395-1501.

Sunday, December 20, 2009

Electronic Health Records: Virtual Medicine: The Lever That Just Might Save Independent Practice

Give me a lever long enough, and a prop strong enough, I can single-handedly move the world.

Archimedes, 1267BC-1212BC

The greatest innovation in the last 30 years is worldwide instant distribution of information. The Internet exemplifies how a small lever can move great weights, like healthcare.

Richard L. Reece, M.D., Innovation-Driven Health Care: 34 Key Concepts for Tranformation, Jones and Bartlett, 2007

Independent medical practice in America is in trouble. It is fragmented, with some 900,000 doctors – 300,000 primary care doctors and 600,000 specialists- practicing in disparate settings. These physicians are located in roughly 580, 000 locations. Some are solo, most are in small groups, and many are clustered around 125 academic medical centers, 100 integrated groups, and 5000 community hospitals.

Doctors are not unified – less than 20 percent belong to the AMA. Some 110,000 are members of Sermo – a social networking organization that tends to house dissident physicians. The MGMA is said to represent 300,000 doctors.

The Physicians’ Foundation, composed of roughly 650,000 doctors in state and local medical societies, in 2008 surveyed 300,000 primary care doctors. The doctors were unhappy. Many said they would leave practice if they could, and the majority said they would not recommend medicine as a career for their children.

Furthermore, doctors are swamped with work, with not enough time for patients, for leisure, or for mastering skills or technologies necessary for their work. Doctors are in short supply, 125,000 to 200,000 short by 2020-2025 depending on whom you ask.

What to do? No easy answers exist. Current reform bills do not fully address the demand-supply crisis. The crisis will be aggravated if 30 million more uninsured and when 78 million baby boomers start coming on board and flooding into doctor's offices and into hospital ERs and wards.

One lever that might lift the gloom and empower independent practicing doctors is virtual medicine. Virtual medicine has various definitions. I look upon it as independent online physicians linked by telecommunications with each other and with patients. The telecommunication tools allow them to collaborate with each other, access online consultations, diagnose and treat patients at a distance, and instantly gather the latest information in their respective fields. I am talking here about the real-time, on-line world.

Don’t get me wrong. I do not view virtual medicine through rosy lens. Virtual medicine has its downsides – medical legal obstacles, payment conundrums, practice disruptions, funding dilemmas, lack of time for training, and absence of workable, flexible, and profitable business models.

But virtual medicine is worth investigating, if for no another reason that the feds contemplate pouring $20 billion into ubiquitous EMRs over the next 5 years, rewarding those hospitals and doctors who have EMRs, and punishing those who do not. Big health systems, with sufficient infrastructure, have already installed EMRs and sing the EMR praises (although it’s a dirty little secret that about 30 percent of EMRs are “dis-installed” for reasons of dissatisfaction and lack of functionality).

But let’s face it. The world is moving on Internet time. Those not moving electronically fast enough are in the doldrums. Look at America’s newspapers. Many are closing shop, others are going on line, and all are searching for a profitable business model to accommodate the Internet. Or witness the travails of the book publishing world. Book buyers are flocking to Amazon’s Kindle or Barnes and Nobles’ Nook. Google is digitizing the world’s libraries. Independent book stores are shuttering their doors.

Why am I carrying on about the Internet and virtual medicine?

Two reasons.

ONE, in my book Innovation-Driven Health Care (Jones and Bartlett, 2007), I gave numerous practical examples of the positive benefits of virtual medicine, and I have my book-selling haton.

TWO, yesterday I had a lengthy collaborative conversation with Ron Pion, MD, a virtual medicine visionary and successful entrepreneur with 30 years or so of hands-on experience and real-world experimentation with virtual medicine. Ron is a clinical professor of Ob-Gyn at the UCLA School of Medicine and heads up Medical Telecommunications Associates, which he uses as a platform to advise these companies. (symptom presentation prior to visit) (e-connecting continuum for the small MD office ) (home-based patient management) (reward for responsible performance) (nurse practitioner in retail location) (J&J acquisition) (Wellness and Prevention) (e-Patient Health Record) (e-Patient Health Record) (collaborative software - low cost, high functionality)) (brings expertise to the hospital ER)

These companies cover much of the virtual medicine landscape. Their central purpose is to help practicing doctors and their patients adapt and adopt to new realities of the new telecommunications world.

As Thomas Friendman, the New York Times columnist, observed in a recent piece on December 12, “The Do-It Yourself World,”

“In case you haven’t noticed, the U.S. economy today is actually being hit by two tsunamis at once: The Great Recession and the Great Inflection.

The Great Inflection is the mass diffusion of low-cost, high-powered innovation technologies — from hand-held computers to Web sites that offer any imaginable service — plus cheap connectivity. They are transforming how business is done. The Great Recession you know.”

The Louisiana Purchase and the Nebraska Negotiation

You’ve got to hand it to Senate Leader Harry Reid (D.Nevada). He is a high stake political gambler. He knows how to cut a deal to get what he wants - to buy 60 votes to get the Senate health reform bill passed.

• He bought Senator Mary Landrieu of Louisiana’s vote by promising her $100 million in federal largess for her state (she insists the real deal included $300 million in government funds.

• He purchased the vote of Senator Ben Nelson (D. Nebraska) by saying the federal government would pick up Nebraska’s share of the Senate bill’s proposed Medicaid expansion, estimated at $100 million.

Senator Richard Burr (R.North Carolina) retorted, “You’ve got to compliment Beb Nelson for playing ‘The Price is Right,’. For people on other states, this means you’ve got to pay taxes to make sure Nebraskans don’t have to pay any portion of Medicare expansion.”

Harry Reid did not apologize. In fact, he said, “I’ve worked with every Democratic senator to make changes in the bill. Ben Nelson was just like the rest of them. That’s what legislation is all about.”

In other words, every one has their price.

Cynics will say this political philosophy bespeaks of “pay-offs” and “bribes” – of crookedness at the core of government. Admirers will insist the a noble end, insuring the uninsured, justifies the mercenary means, a Christmas gift wrapped in a huge ribbon stained with red ink.

I say the Louisiana Purchase, the Nebraska Negotiation, and all those other stately gifts, negotiated behind closed doors in secrecy, gives new meaning to Obama’s promises of absolute “transparency,” conducted in the full flood lights of C-Span TV cameras.

So Much for Transpancy

There once was a President who promised full transparency,

He would not practice the arcane art of political knight errancy.

He would exercise his great might,

By doing what was right in full light,

Not just anything that fulfilled his political fantasy – so much for transparency.

Saturday, December 19, 2009

Four Reasons to Support Health Reform Bill, and Six Reasons Not To

Ours is not to reason why, but to do or die.

Alfred, Lord Tennyson, 1809-1892

The Tennyson quote might also apply to Democrats as they rush to pass a Senate Health Reform bill before Christmas. Their main reason seems to be: this historic opportunity will never come again. Besides, the Senators don't want to go home during the Christmas break and face withering criticism from constituents, only 32% of whom support the current bill, according to national polls. These senators do not want to go through another Tea Party revolt, like they experienced during their August break.

I like better the reasons David Brooks gives for supporting and opposing the bill. In his December 17 New York Times column, “The Hardest Call," Brooks gives four reasons why to support the bill and six reasons why not.

Four Reasons to Support Bill

ONE, it would provide insurance for 30 million more Americans.

TWO, it takes the deficit seriously with serious Medicare cuts and serious, even whopping, tax increases.

THREE, it contains a million little ideas and dozens of gradual programs for cutting costs.

FOUR, if it fails, Obama will fail, and health costs will strangle the nation.

Six Reasons to Oppose Bill

ONE, it will not fundamentally reform health care.

TWO, it will cause national health spending to increase faster.

THREE, it is politically unsustainable because it increase demand without increasing supply of doctors.

FOUR, you can’t regulate 17% of the economy without adverse consequences.

FIVE, it will slow innovation.

SIX, it will not control costs.

Brooks conclusion: “If I were a senator forced to vote today, I would vote no. Unless you get the fundamental incentives right, the politics will be terrible forever and ever.

The Government's Two Five Year Plans

Not so long ago, I was speaking to John McDaniel, President and CEO of Peak Performance Physicians, a physician management firm in New Orleans.

John remarked , tongue-in-check but with malice of forethought,

“Why don’t we just separate hospitals and doctors into government hospitals and government doctors, and private hospitals and private doctors. Doctors who don’t want to be government doctors can simply go into private practice. People can have their choice which hospitals and which doctors to choose.”

John knows this will never happen, but he was expressing a common unarticulated fear among conservatives underlying the current health reform debate, viz, we will get what we wish for, universal coverage dictated, controlled, and regulated by central government with the inherent uniformity and mediocrity of government-run systems but without private choice.

Good Enough for Government Work

We have an expression in America, “It’s good enough for government work.” This means you do your work, you do it competently, you do it unenthusiastically, you do according to government standards, but you do no more.

After all, the work is impersonal, does not demand excellence, and you’re doing it to get through the day. It is not for you, but for the Big Guy.

This is overstated, of course. Government workers in general like their work, they are competent, they are paid well ($75,000 on average, and they are in a growing sector of the economy.

As a government employee, your job is secure, and you are not competing with the private sector. You are simply doing your job as best you know how, according to government plans.

Speaking of government plans, the current House and Senate Reform bills are basically split into two five years plans – 2010 to 2015 and 2015 to 2020.

2010 to 2015 Plan

The 2010 to 2015 plan will be a tax and implementation plan. The idea is; tax now, save later. It will tax Cadillac plans, the wealthy, the insured, the young, drug companies, and device manufacturers; expand Medicaid in all the states; impose federal mandates on individuals and employers backed by the IRS, define the precise benefits of all health plans; give citizens some sort of public option; reward doctors and hospitals who adopt EMR surveillance systems; establish comparative effective research protocols to decide what treatments to pay for; cut out payments for ineffective care or care to those with a limited quality of life; and establish scores of new bureaucracies to make sure everything works according to plan.

There will be no benefits offered during this phase. Government will be too busy implementing and doing demonstration projects. It will be the “money-out” or spending phase, as the government invests in its vision of the future.

2015 to 2020 Plan

That leads us to the 2015 to 2020 plan. That is where the “savings” will kick in.

By “savings” I mean the theoretical returns on investment from EMRs, which will supposedly wipe out duplication and ensure hospitals, doctors, and patients are making the “right” decisions, i.e. those for which they will be paid; the coordinated, comprehensive, integrated primary-based care across the entire care spectrum; and the widespread preventive care programs designed to nip chronic disease development in the bud.

This is the phase in which the government will cover everyone and protect us all against bankruptcies and excessive and unnecessary treatments. During this phase, if current projections hold, Medicare and Medicaid will be in bankruptcy, and it will be necessary to tax all Americans to make up for federal deficits, which will steadily grow under new entitlement programs, as they always have.

But not to worry, your government will be protecting you, and your care, though it may be mediocre, will be uniform, systematic, and provided by those who meet government pay-grade standards. Government care will be your only choice, but that’s alright. If it’s good enough for government, it’s good enough for you.

Thursday, December 17, 2009

Doctor-Author-Editor Seeks Syndicated Column

In “Settling in for a Long Debate, “ John Iglehart, former editor of Health Affairs and national correspondent of the New England Journal of Medicine, says the debate over health reform may just be beginning.

Whether Obama gets his 60 votes for passage of the crippled Senate bill, I believe the debate will continue well into 2010 and perhaps beyond.

That being the case, I would like to make it known I am seeking a paid position writing a rWhat to do with health care is the biggest domestic debate since Social Security in the 1930s and Medicare in 1965. It is, to use President Obama’s words, “historic.”

My credentials are these. I have been writing about the system since 1975, when I became editor of Minnesota Medicine. Minnesota, you may recall, is where managed care exploded and took root in the 1970s. Minnesota is home to United Healthcare, the exclusive managed care agent for AARP. I have composed three recent books on health reform - Voices of Health Reform (2005), Innovation-Driven Health Care (2007), and Obama, Doctors, and Health Reform (2009). I write a blog www.medinnovationblog, and for 15 years I have served as editor-in-chief of Physician Practice Options (see

My stock-in-trade is objectivity and knowledge of issues on each side of the political aisle. As Ed Volpintesta, MD, a primary care physician who himself has written extensively about the health care scene, says of my recent Obama book,

“Dr. Reece takes on most of the issues in his book and puts them into context in simple language. There are no complex academic arguments in the book. To his credit, the author presents a balanced and objective look at both sides of the many arguments informing the national debate.”

In a syndicated column, which will consist of 500 to 700 word commentaries, I will address difficult issues head-on with minimal verbal fluff.

My positions on health reform are these:

• We badly need incremental reforms to bring down costs and expand access.

• It is better to solve problems – health plan design, marketing across state lines, tort reform – one at a time rather than all at once.

• These solutions are best done from the bottom-up rather than the top-down through marketplace innovations, but with federal oversight.

• Federal mandates, executive commands, and dramatic expansion of costly Medicare and Medicaid programs with no history of cost control will not solve government debt problems.

• We must put more of the decision-making in the hands and minds of consumers by making them aware of costs, partially responsible for paying for care, and the quality of care they are receiving.

If any of you out there reading my books or my blogs know of any print or email publication seeking a syndicated voice of reason based on experience in the real world, please let me know through my email, by phone 1-860-395-150l, or by twittering me.

I’ll be waiting to hear from you.

Wednesday, December 16, 2009

Health Reform and Power over People's Lives

I believe in the power of words. I am leery of the power of government to run people’s lives.

I found both of these powers expressed in an article by Senator Grassley, an Iowa Republican, the ranking member and former chairman of the Senate Finance Committee In a December 17 New England Journal of Medicine perspective piece “Health Care Reform – A Republican View.”

Here is an excerpt of what Senator Grassley had to say,

The health care system has serious problems. Costs are rising at three times the inflation rate. Many Americans are uninsured. Millions more fear losing their insurance in a weak economy or because of preexisting conditions. Doctors are ready to close their doors because of high malpractice insurance costs and low government reimbursement rates.

Everyone agrees that something has to be done. But the reform proposals pending in Congress would make a bad situation worse. These bills would cause us to slide rapidly down the slippery slope toward increasing government control of health care. They contain the biggest expansion of Medicaid since the program’s creation. They impose an unprecedented federal mandate for coverage backed by the enforcement authority of the Internal Revenue Service. They will increase government spending by nearly $2 trillion when fully implemented. They give the secretary of health and human services the power to define benefits for all private plans and to redefine those benefits annually. From a new health-choices commissioner to a center for comparative-effectiveness research, these bills create dozens of new bureaucracies, increasing the federal role in health care. All of this amounts to a lot of power over people’s lives.

This excerpt shows the power of simple language. In 195 words, Grassley cogently expresses the Republican case against Democratic health reform proposals. The excerpt's Fog Index is low. The Fog Index is defined as the average sentence length + the number of 3 syllable words per 100 words X 0.4. The resulting number is the average education required to easily understand what is written. A Fog Index of 12 indicates a person with a high school education can comprehend what is being said. The Bible has a Fog Index of about 10, and Time Magazine aims for a Fog Index of 12 to 14.

In Grassley’s piece, the Fog Index is 13.0 + 17.7 X 0.4= 12.2, meaning the language is so simple a high school graduate can understand it.

But the true power lies in its message. The Democratic proposal would give government enormous power over people’s lives. Among other things, it would limit health choices, control the content of all health plans, drive down costs by rationing care and slashing payments to hospitals and doctors, intervene in doctor patient decision-making, and guarantee a staggering burden on U.S taxpayers.

But it’s biggest problem it would do nothing to control costs, either for the system or for the insured. Further, it would raise premiums for those who are young and healthy. In some ways, it is the worst of all possible worlds – limiting access to care by driving doctors out of business and raising health costs through higher taxes and and expensive comprehensive government-dictated and mandated health plans.

Tuesday, December 15, 2009

Questions for Democrats

Does passing something,
beat doing nothing?

Is ramming through an unpopular bill,
paramount if it empties the federal till?

Do unquestionable moral positives,
outweigh obvious political negatives?

Does failure to govern and lead,
compromise your political creed?

Is this a crisis of confidence,
or a crisis of competence?

Who should pay for health reform,
the wealthy, insured, or infirm?

Given this test of multiple choice
My bet is Reform will pass without rejoice.

If passed, two questions will linger,

Was this much to do about something,
or nuch ado about nothing?

Was it truly historical,
or was it mainly rhetorical?

On Democrat Health Reform and Robbing The Federal Bank

Byron York, chief political correspondent for the Washington Examiner, today explains why Democrats are pushing health care, even if it kills them. When you are in the middle of robbing the bank, it is too late to back out.

Democrats are in too deep to do anything else but rob the bank. The cost of failure to rob the bank is too high. They have passed the point of no return in deciding to hold up a bank. Whatever they do, they're guilty of something. They are doomed if they do, and doomed if they don't. They have already spent too much of their political capital.

There once was a federal bank robber named Reid,
He sought to get the reform deed done with speed.
Butdepositors resisted,
Opponents persisted.
Taxpayers turned doomsayers,
Budgeters became naysayers.
And Reid’s gang either had to bleed or recede.

According to York, "They're in the bank, they've got their guns out. They can run outside with no money, or they can stick it out, go through the gunfight, and get away with the money.’

That's it.Democrats are going through with it. Even if it kills them.

Obama, Doctors, and Health Reform - Book Review of Obama, Doctors, and Health Reform

Merry Christmas and Happy Holidays. The following book review explains everything (well, almost everything) you need to know about the premises, promises, ins and outs, beartraps, pratfalls, miscues, monstrosities, and incumbrances of Obamacare. Health reform will be with us for a long time. It is never too late to get your copy. This is an ideal Christmas gift for your friends among the health reform uniformed. You may buy the book at or other book websites.

Book Review: Obama, Doctors, and Health Reform by Richard L. Reece, M.D. iUniverse, New York. 2009, by Ed Volpintesta, for Connecticut Medicine

For most doctors, and certainly most lay persons, the debate on health care becomes daily more confusing. And why not? The hodgepodge of reports appearing in the newspapers, on the radio, and on television come from federal and state agencies, academic medical centers, medical societies, insurance companies, and concerned individuals from all walks of life is mind-numbing. Often, the result is “statistics fatigue” brought on by the endless litany of numbers and percentages that vested interests report as they strive to impose their opinions and achieve credibility and dominance.

Dr. Reece takes on most of the issues in his book and puts them into context in simple language. There are no complex academic arguments in the book’s 291 pages which are divided into 41 chapters. To his credits, the author presents a balanced and objective look at both sides of the many arguments informing the national debate. The format is a compilation of essays and opinions that explain why transforming the health system reform will is difficult. Anyone interested in health care will learn something from it. Physicians will find the information in it helpful when discussing health care reform with patients. Physician advocates, when preparing for interviews by members of the media will also benefit from the concise presentation of the critical issues and conflicts involved.

Among the numerous topics discussed is the shortage of primary care physician which might be reversed by paying them more, thus attracting more students to primary care. But, also mentioned, and aptly so, is whether there might be other factors besides money being, as the author put it, the “turn-off” for primary care. This is a quintessential question that has been ignored. It should be addressed.

The author included a comment by Mr. Timothy Norbeck, a past executive director of the Connecticut State Medical Society and current director of the Physicians’ Foundation. A physician survey of 12, 000 physicians most of who were primary care physicians showed that primary care doctors were demoralized and frustrated because “the paperwork and red tape hassles” in their daily work did not give them enough time to spend with patients. Is it any wonder that so few students are entering primary care?

The chapter on electronic medical records (EMR) makes it clear that although they have the potential to make data easily retrievable, serious breaches of patients’ confidentiality remains a serious problem. The start-up and maintenance costs are prohibitive for many doctors. Dr. Reece points out that significant number of physicians discontinue using EMR. Another side effect is that EMR could be used to monitor and control physicians’ behavior and even make serious misjudgments of their competence. These issues need further study.

The benefits of large clinics like the Mayo Clinic where doctors are salaried and not paid for the number of procedures and patients they see, but rather for the total care of the patient, are discussed; but I was happy to see that the question of whether demographics also play a critical role in the much-touted efficiency of the Mayo clinic.

The future of the “medical home”, health savings accounts, and the spread of physician blogging sites and how they have changed the way doctors communicate with each other and their organizations are other examples of the numerous topics discussed.
In a telling interview, the CEO of the Texas Medical Association explained that it managed to get a $250,000 cap on pain and suffering because the association worked hard on its grassroots network and maintained a close relationship with its county medical societies.

The book’s encyclopedic approach is ambitious but its direct, non-academic style
makes it readable both for members of the public and for physicians.

Edward J. Volpintesta MD. Dr. Volpintesta is a practicing Internist in Bethel, Connecticut. He an expert on the toils and troubles of primary care, and is a frequent contributor to national health care and business publications. Dr. Richard Reece is author, blogger, speaker, and innovation and reform commentator. Dr. Reece’s latest book, Obama, Doctors, and Health Reform ( is available at www.iuniverse and other book websites . His blog is www.medinnovationblog.blogspot.colm. For information on speaking fees and arrangements, call 860-395-1501.

Video on Nova program of Dutch Royal TV

On the right side of this blog, you will see a video that recently appeared on Royal Dutch TV. Among other health reform commentators, it features comments I made on Obamacare and it has a shot of me holding my book Obama, Doctors, and Health Reform. Basically, I say President Obama will get about 1/3 of what he wants, and he will sign something by the end of the year. I believe he has overreached but will achieve incremental reforms, but not some of the big reforms he wanted, such as a public option or expansion of Medicare.

Sunday, December 13, 2009

Comprehensive Reform: Still Too Much Change to Believe In

Four years ago, I wrote Voices of Health Reform (Practice Support Resources,2005). The book consisted of interviews with 42 national health leaders. From those interviews, I concluded national reform – i.e., single payer – would not occur soon. U.S. culture was not and is not there yet.

In the course of writing the book, I ran across two statements about American culture that stood out.

• ONE was by Victor Fuchs, PhD, Stanford health economist, and Ezekial Emanuel, MD, chair of clinic bioethics at NIH and now President Obama’s chief medical advisor, “What might set the stage for comprehensive reform of health care? A major war, a depression, or a large-scale civilian unrest might well set in motion a change a change in the political climate that would overpower the obstacles that prevail in normal times.” (“Health Care Reform; Why? What? When?" Health Affairs, 24 No. 6(2005), 1399-1414).

The U.S. now has a war, but it is not a major one, at least not a world-wide conflagration ; we have a recession, but it is not a depression; and we have moderate civilian unrest but not marches or riots in the streets over health costs and access. The U.S., in other words, has not yet reached the tipping point calling for comprehensive reform. The U.S., with its government system of checks and balances, is inherently resistant to radical change of any kind - economic, social, or political- and radical health reform embodies all three kinds of change.

• TWO, quoted in my book, was an answer by Garry Orren, a professor of political science at Brandeis, who regularly polls for the Washington Post and the New York Times. When asked what was unique about American culture, Orren remarked, “ A good place to start is to remember we are pro-democracy and anti-government. It comes down to ideas that are essentially anti-authority and self-regulatory. It there were an American creed, I think it might begin.

One: A government is best that governs least.

Two: Majority rules.

Three: Equality of opportunity.”

As I view the current reform scene,

One: polls indicate only 35 percent of Americans approve of current health care reform bills, i.e., they distrust government.

Two: Democrats rule, but the margin of overall Obama approval is only 52 percent and Congressional approval 27 percent, i.e., the majority rules but shakily.

Three: Americans approve of “equality of opportunity,” ie. everyone ought to have access to health care opportunities, but not necessarily of “equality of results,” i.e, a redistribution of equal benefits to all.

American culture shapes health reform. This culture distrusts massive government change, and it has not yet seen change, to use President Obama’s phrase, “we can believe in.”

Dr. Richard Reece is author, blogger, speaker, and innovation and reform commentator. Dr. Reece’s latest book, Obama, Doctors, and Health Reform ( is available at www.iuniverse and other book websites. For information on speaking fees and arrangements, call 860-395-1501.

Saturday, December 12, 2009

Saturday Morning Mournings and Moorings

Saturday, December 12
- This morning I find myself mourning for the golden years of a prosperous economy and a productive profession. But at the same time, I see the American people and American physician sticking to their old moorings. Old Saybrook, Connecticut, where I live, is situated near the sea. Moorings are in short supply, and mooring costs are going up. The word around town is: stick to your moorings. This same principle may apply to health care and practice moorings.

ONE, as a nation, perhaps we ought to stick for a while to the old moorings, with a few incremental reforms. It is becoming apparent, we cannot offer deficit-neutral health care entitlements by superimposing a new system upon the old. Now in its 12 day of debate, The Senate found that out again on Friday. Richard S. Foster, the chief actuary of the federal Centers for Medicare and Medicaid Services, said yesterday that under Mr. Reid’s bill national health spending from 2010 to 2019 would total $35.5 trillion. That is $234 billion, or 0.7 percent, more than the amount projected under current law, he added. Mr. Foster noted you cannot expand Medicare, mandate coverage for most, and tax health plans, device makers, and drug firms without having these entities pass increased costs to consumers. There are no silver bullets and no miracles; expand coverage and you expand costs. You pay your money, and you make your choice between health care security and loss of economic vitality.

TWO, with the economy the way it is, more doctors are sticiking to their old practices, but innovating to cut costs and become more productive A reporter from the American Medical News called me yesterday to ask how small practices might innovate to cut costs. This is an important question because small practices provide 90% of care in the U.S. I have these suggestions: appoint a chief innovation officer, either your practice manager or a nurse among you current staff, save on data entry be having patients enter their chief complaint and history electronically using something like the Instant Medical History, hold a weekly innovation meeting and invite “wild and crazy ideas, offer gift certificates for winning ideas among the staff, compile a patient email list of patients and ask for suggestions, hire a scribe for data entry, buy your staff a copy of Meeting Patient Expectations by Susan Kean Baker and have them focus on “moments of truth” in the typical practice.

Cut mourning short. Now is the time to secure moorings.

Dr. Richard Reece is author, blogger, speaker, and innovation and reform commentator. Dr. Reece’s latest book, Obama, Doctors, and Health Reform ( is available at www.iuniverse and other book websites. For information on speaking fees and arrangements, call 860-395-1501.

Friday, December 11, 2009

Health Debate Turns Nasty: Quotes from Right and Left


That is the final and perhaps most compelling reason to kill this bill: the sheer arrogance of the whole enterprise. It is the arrogance of stampeding an unwilling public toward a monstrous 2,000-page piece of legislation while admitting that it still has huge problems, but promising that it will all somehow be fixed later on. It's the arrogance of selling us a bill that expands government spending by hundreds of billions of dollars while telling us that it will reduce the deficit. It is the sheer unmitigated gall of appointing a bureaucrat to run a government-controlled insurance market that takes away all of our health choices-and then calling this bureaucrat the Health Choices Commissioner.

Robert Tracinski, Real Clear Politics

It is hard to believe we are even considering such a Rube Goldberg approach to health insurance. But since we are , what are the most likely consequences? Here are the first ten that come to mind.

1. Millions of jobs lost
2. Major industrial restructuring
3. Emergence of niche markets
4. Very high marginal tax rates
5. Higher insurance premiums
6. Fewer insurance choices
7. Higher than anticipate taxpayer costs
8. Fewer than anticipated people insured
9. New unfunded liabilities
10. Exacerbating problems of cost, quality and access

Worst of all, not only will “reform” not solve any of the problems it is supposed to solve, it will almost certainly undermine the ability of entrepreneurs in the private sector to solve the

John Goodman, The Senate Bill, National Center for Policy Analysis

If Democrats pass health-care legislation — and the most recent CNN poll shows that only 36 percent favor the Senate bill, while 61 percent oppose it (79 percent said the bill would increase the deficit, and 85 percent said the bill would increase their taxes) — it will make that outcome more, not less, likely.

Peter Wehmer, "Doomed if They Do, Doomed if They Don't," Contentions


Immoral villains” Nancy Pelosi

Evil mongers” Harry Reid

“If you misrepresent what’s in the plan, we will call you out.” President Obama

“The recent attacks by Republican leaders and their ideological fellow-travelers are so misleading, so disingenuous, that they can only spring from a cynical effort to gain partisan advantage. They’ve become political terrorists.”

Steven Perlstein, Washington Post columnist

You hate the people enough you want them to die. You are Un-American. Get out of the country. You’d rather heave our people die than provide them with health care that doesn’t bankrupt them.”

Daily Kos Blogger.

So there. Take that, you lefties and righties.

Dr. Richard Reece is author, blogger, speaker, and innovation and reform commentator. Dr. Reece’s latest book, Obama, Doctors, and Health Reform ( is available at and other book websites. For information on speaking fees and arrangements, call 860-395-1501.

Thursday, December 10, 2009

Hospitals and Doctors - Surprise! Surprise! Doctors, Hospitals, Health Plans Resist Medicare at 55

Preface: In their desperation to pass a Medicare bill, Democrats have dropped the public option and proposed starting Medicare at 55 rather than 65. As indicated in a recent Wall Street Journal Health Blog, doctors, hospitals, and health plan resist Medicare expansion to the 55 to 64 year old cohort. No doubt, the reasons are philosophical, i.e., a government takeover. But they are also practical, Medicare tends to cut fees arbitrary and capriciously without warning. And Medicare fees often do not meet the cost of doing business. Hospitals say Medicare only covers 91 percent of costs, and doctors estimate Medicare pays 20 percent to 30 percent less than private plans. There is another reason as well. Medicare is going broke because of fraud, lack of cost controls, and rampant bureaucratic inefficiencies. Extension of Medicare to the 55 to 64 year group is almost certain to add to the national debt.

Docs, Hospitals, Insurers Oppose Medicare at 55. WSJ Health Blog, December 8

By Jacob Goldstein

The details of the Senate Dems’ health-care deal won’t be revealed for a few days, until after the CBO crunches the numbers. But the broad outlines are already clear — a move away from a new government-run health plan, coupled with a Medicare expansion that would allow people between 55 and 64 to buy into the program if they can’t find insurance elsewhere.

Medicare typically pays lower rates than private insurance, and big groups representing doctors, hospitals and health-insurance companies are lining up against the Medicare expansion:

Insurers: “This would add millions of new people to a program everyone agrees is going broke,” said a spokesman for America’s Health Insurance Plans, according to Kaiser Health News.

Hospitals: “Adding millions of people to [Medicare and Medicaid] at a time when they already severely underfund hospitals is unwise and should be opposed,” the American Hospital Association said in an alert sent to members and quoted by Politico.
Doctors: The AMA said it opposes the expansion because doctors face Medicare pay cuts, and because some patients already struggle to find a doctor who accepts Medicare, the WSJ reports.

Dr. Richard Reece is author, blogger, speaker, and innovation and reform commentator. Dr. Reece’s latest book, Obama, Doctors, and Health Reform ( is available at and other book websites. For information on speaking fees and arrangements, call 860-395-1501.

Physician Business Ideas - Why Don't Intergrated Primary Care Based Models Catch Fire?

I’ve been writing about integrated health care for 35 years, first in Minnesota and later from a national perspective, focusing especially in California, the land of Kaiser. I’ve listened to the arguments about HMOs creating primary care gatekeepers, to managed care as a means of reducing specialty and hospital referrals, to paeans about cost-effective capitation would be, to Paul Elwood saying all the nation needed were ten megaclinics like Mayo and Kaiser blanketing the landscape, and to Steve Shortell proclaiming that integrated networks emanating out of hospitals were the future.

If these concepts are so compelling, why haven’t they swept across the land like a prairie fire? Why haven’t independent physicians bought in on a wholesale basis? And why have they resurfaced so forcefully as a main strut of Obamacare?

In the December 10 New England Journal of Medicine, Diane Rittenhouse, M.D. and Stephen Shortell, PhD, of the Department of Family and Community Medicine at the University of California, San Francisco, and Elliot Fisher,MD., of the Dartmouth Institute and Dartmouth Medical School, try again to push primary care and integrated models as the solution to our fragmented system.

All the U.S. needs, they argue, are patient-centered medical homes (PCMH) and accountable health organizations(ASO), which may take the form of large integrated delivery systems, physician-hospital organizations, mutipspecialty groups with or without hospital ownership, independent practice associations, or virtual-interdependent networks of physician organizations.

With medical homes as the base of accountable care organizations, they proclaim, the U.S. can have “ first-contact primary care that is continuous, comprehensive, and coordinated across the care continuum,” aided and abetted,of course, by “electronic medical records, population-based management of chronic diseases, and continuous quality improvement.”

Fine, even noble, words these. But it seems to me these thoughts are nothing more than gatekeeper, capitation, and integrated models in new clothing. Perhaps these two government supported and imposed models will work. Perhaps the multiple demonstration models envisioned for Medicare will save money and improve care.

But I am dubious. Why? For the following reasons.

Primary care doctors,

• are already in desperately short supply, and they do not have the will, or time, or resources to build the team or infrastructure to quickly build medical homes.

• don’t have the leverage to cut referrals or admissions to other providers who benefit from the status quo.

• can’t quickly address the cultural, legal, and resource barriers to create new organizations in most communities.

• would have to overcome already demonstrated patient resistance to being channeled to the specialists of their choice.

• might well resist being coerced by federal agencies to convert their current practices into medical homes and to be employees of powerful accountable care organizations.

Lastly there are issues of privacy, freedom of choice, and restrictions of individual liberties to overcome. There is also the problem of herding a million or more care providers, which operate in nearly 600,000 locations, into more centralized organizations. We should also keep in mind we live in an overwhelming bottom-up rather than a top-down society. Social prairie fires that must leap multiple cultural barriers tend to flame out from lack of oxygen.

Dr. Richard Reece is author, blogger, speaker, and innovation and reform commentator. Dr. Reece’s latest book, Obama, Doctors, and Health Reform ( is available at and other book websites. For information on speaking fees and arrangements, call 860-395-1501.

Wednesday, December 9, 2009

A Ten Tip Guide to Lower Priced Health Care

Bottom line: The only way to get health costs down is when consumers are presented with a range of options in a truly competitive marketplace.

Grace Marie Turner, The Galen Insitute, "More Nutty Ideas from the Senate," December 8

Two thousand seventy-four pages and trillions of dollars later, this bill doesn’t even meet the basic goal that the American people had in mind and what they thought this debate was all about: to lower costs.

Mitch McConnell, Senate Minority Leader, December 8, on Senate Health Care Bill

It’s beginning to look like health care consumers are going to have to take lowering health care into their own hands since no answers are coming down from above.

Here are ten tips for lowering your costs.

One, encourage your employer to offer a health savings account with a high deductible. Encourage the employer to pay half the deductible. Your premiums will be much lower, and your employer will save up to 50% over current HMOs and PPOs.

Two, investigate a company called Simplecare. The SimpleCare story has appeared in U.S. News & World Report, in Forbes, and on NBC News. SimpleCare , a fee-for-service organization, accepts money for medical treatment without the bother and hassle of insurance forms, co-payments, and other third-party payment related procedures. SimpleCare has an alliance of doctors offering cash discounts. Itsmembership includes 38,000 patient members working with 1,500 doctors nationwide. Discounts range from 15 percent to 50 percent for patients paying in cash.

Three, ask your doctor if he or she accepts cash only. About 10 percent of doctors accept cash only. The idea is to pay for care at the time and point of care with cash, check, or credit card without the expense or trouble of going through an insurance company. Dealing with third parties creates a 50 percent to 60 percent overhead, and many doctors are finding they can charge less and make just as much or more money without going through a third party. Often the doctor’s fee is negotiable.

Four, find out if your doctor dispenses prescriptions in the office. Prescriptions dispensed in this way average 50 percent less. A company called Physicians Total Care has installed prescription systems in 30 states and is growing by 170 percent a year. For more information, google Physicians Total Care or read a chapter “Physician Office Dispensing Stages Comeback” in my book Innovation-Driven Health Care (Jones and Bartlett, 2007).

Five, fill your prescriptions at Walmart, Target, or discount stores. Walmart has more than 300 generic drugs and 1000 over-the-counter medications it sells at $4 for a 30 day supply and $10 for a 90 day supply. Fifty percent of Americans live within 5 miles of a Walmart or Target.

Six, ask your primary care physician if he or she performs common procedures like skin biopsies, abscess drainage, joint injections in the office. An organization called the National Procedures Institute ( has trained over 15.000 primary care doctors to perform simple office procedures, and these can be done less expensively without waiting than in a surgeon or other specialist’s office.

Seven, consider visiting a retail clinic in drug store or discount outlet for minor ailments or immunizations. Nurse practitioners using protocols and electronic medical records run these clinics, which may have physician or hospital backups. The charges are listed are transparent and predictable. About 2000 of these clinics are now operating, and their locations may be found at The services of these clinics cost about half as much as a visit to a physician’s office but do not have a physician’s expertise and may miss serious underlying conditions.

Eight, if you work for a larger employer, ask executives if they are considering setting up worksite clinics. About half of the nation’s corporations with headquarters employing more than 100 employers on site are organizing these clinics, which offer the services of a primary care physician and staff, which may include a nurse, nutritionist, and other health professionals. Employees can receive free generic drugs and other treatments or advice on site, or may be referred to cost-effective networks of specialists off-site.

Nine, if you are uninsured or underinsured consider visiting a federally-qualified community health clinic. These were launched by President Bush as a Health Centers Initiative in 2002. These clinics, which are present in all 50 states, have 4000 locations and have served 15 million people. They are administered by Health Resources and Service Admistration (HRSA. Services include checkups when well, treatments when sick, complete pregnancy care, immunizations, dental, and mental care. To find a clinic near you, google HRSA – Find a Health Center.

Ten, in general low cost and convenient care is available at a local primary care physician. There is now a shortage of these physicians. Therefore, these physicians are now very busy, and you may have to wait for an appointment. Because of low reimbursements, some no longer accept new Medicare or Medicaid patients.