Tuesday, March 31, 2009

Health plans, costs - CIGNA to Turn Health Plan Market Costs Upside Down?

In a March 30, 2009 The Health Care Blog, “Will CIGNA Remake the Health Plan Marketplace?”, Brian Kepper, prominent health care analyst from Jacksonville, Florida, asserts that CIGNA may turn the health plan market upside down and capture major market share from competing plans.


By helping employer clients set up worksite clinics to radically reduce health care costs by having services delivered by primary care physicians to employees at the worksite in a medical home environment.

CIGNA, says Klepper, will do this by installing worksite clinics. In 2008, CIGNA opened clinics of its own in 4 Eastern locations. In 2009, CIGNA will encourage employer clients with 1,000 or more employees to set up worksite clinics.

Riding the Rising Worksite Clinic Tide

These clinics, says Klepper, are already growing at an “astonishing rate.” About one-third of Fortune companies with 1,000 or more employees already have clinics in place, and by the end of 2010, one third-more will have them installed.
Furthermore, these clinics will work in other worksites with 150 or so employees – school systems, universities, community colleges, unions, city and country governments, business parks, manufacturers, or service organizations.

How Clinics Lower Costs

These clinics lower costs in four major ways.

•They exchange higher health costs for routine outpatient care for much lower costs inside the clinic.

•They provide face-to-face management of patients with chronic disease, who consume 70% of a typical population’s health costs.

•They allow the primary care physician inside the clinic to select and collaborate with pre-selected specialists outside the clinic who provide expensive outpatient and inpatient care.

•They integrate personal care with occupational health – workers compensation, human resource testing for employement and drugs, retention and recruitment, and productivivity(absentism and presenteeism).

The clinics accomplish this cost lowering by.

•Having a salaried primary care doctor on site who is able to concentrate on delivering care rather than being distracted by practice business issues.

•Removing the usual cost barriers to care – time off and travels to access care off-site, unpredictable outpatient lab, x-ray and imaging costs, and highly priced prescriptions. Most clinics provide free generic drugs or brand name drugs at cost.

•By using onsite EMR systems containing best practice information.

•By deploying databases that direct primary care physicians to pre-selected specialists who achieve optimum results at reasonable fees.

A Conversation with CIGNA Medical Director

After a conversation with Jeff Kang, MD, CIGNA’s Chief Medical Officer, Klepper says,

“Dr. Kang confirmed that CIGNA will aggressively pursue its onsite clinic effort, that they do see primary care and medical homes as keys to creating improvements, and that they have many plans in these and other areas. He emphasized that primary care was only one of many efforts.”

“The proof will be in the results, of course. It is more than possible that other major plans are headed in equally innovative directions.”

“But, so far CIGNA appears to be sincere, focused and far ahead of other plans in creating very powerful model of health care delivery that does actually head the lessons of the last 20 years.”

"If they, or any health plan with similar aspirations, succeed, they will take the market and change the way American health plans operate.”

Hurdles and Opportunities

The hurdles to the CIGNA strategy are self-evident – shortages of primary care doctors, reluctance of many independent doctors who prefer autonomy to become corporate employees, the fact that small business employ 90% of Americans - but the opportunities are there too – primary care doctors seeking security, the chance to focus on care, and higher pay (most clinics pay primary care doctors at 30% above market rates; improved care at significant cost reductions, desperation of employers to lower costs, satisfy workers, improve their health and productivity, and to retain and reinforces their loyalties to their employers.


For CIGNA worksite clinics offer an opportunity,

to slash costs for their employer client community,

to capture greater health plan market share,

to facilitate convenient cost effective care,

and to work with employers in a spirit of unity.

Geisinger - Public Television Lauds Geisinger

March 30, 2009 – This evening public television lauded the Geisinger Health System in northeastern and central Pennsylvania . The system, founded in 1915, has 600 physicians in 55 locations and three hospitals. It provides care for over 2 million in 31 Pennsylvania counties.

The PBS program focused on Geisigner’s “Proven Care” approach to coronary bypass surgery. Geisinger’s bypass surgery comes with a 90 day warranty – i.e., if complications develop with 90 days, Geisinger will fix the problem without any additional bill. The approach is now being extended to cover births and hip replacement.

PBS was not the first to praise the Geisinger warranty. Before PBS, an article in the New England Journal of Medicinehad praised the system’s work (Thomas Lee, "Pay for Performance: Version 2.0"? August 8, 2007) and the New York Times had also favorably weighed in (Reed Abelson, “In Bid for Better Care, Surgery with a Warranty,” May 17, 2007).

In bypass surgery, Geisinger doctors identify 40 essential steps in the bypass process, then develop a checklist with procedures to make sure every step is followed, from risk evaluation to a daily aspirin regimen after discharge. The doctors, in short, stick to a systematic process to make sure everything goes right.

Geisinger’s 90 day warranty is an example of “systems engineering” in health care. A number of large integrated multipspecialty groups - Kaiser, Virginia Mason, Intermountain Healthcare, Partners Health, and various academic centers – are following this approach. Systems engineering advocates say, in essence, if you get enough health care people within a health system working together in an organized and systematic way to achieve specific goals, you will reduce errors and improve performance. This requires data, commitment, infrastructure, computer monitoring, electronic records, and physicians in intergrated large multispecialty groups. In American medicine , systems engineering is not common since only 4% of doctors belong to groups of 50 or more.


Improving care sometimes take systems engineering,

and a critical mass of doctors for team pioneering.

When quality’s good enough you can issue a warranty

to show your level of confidence and certainty

and you can give your results a public hearing.

Future, Prevention - Polypill Arrives Ahead of Schedule

You can’t say I didn’t telI you . One of the great things about writing a daily blog over an extended period of time is that sooner or later, you’re bound to be right.

This, by way of explanation, is my 787th blog dating back to December 2006.

One, on February 6, in a “2020 Blog,” I predicted in 2020 a pill would be developed to prevent many heart attack and stroke deaths.

Here is what I had to say.

One: "The U.S. has virtually ended deaths from heart disease and strokes with a daily poly-pill for everyone over 55. British researchers first described the poly-pill, made up of six medications: a statin, three anti-hypertensive drugs, folic acid, and aspirin.6 This multi-purpose pill reduces cardiovascular disease by controlling LDL cholesterol, blood pressure, homocysteine levels, and platelet function.”

“The poly-pill has extended U.S. life spans by 12 years. Alarmists in 2006 warned poly-pills would harm patients and increase Alzheimer’s cases. Not to worry. The malpractice lawyers have been neutralized, and we now have pills for every side effect, including dementia”

Two: Then on November 21, 2008, in “Start Simple, Think Big, Think Polypill, Think Longevity,” I had this to say.

“Major society-changing innovations are not for the timid or for seeker-of-devils-in-the-details or sludge-in-the-entrails.

“Major innovations begin with 2 steps:

1) Start simple.

2) Think big.

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

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

Well, I’m pleased to say that a March 30, 2009 article “One-a-Day Heart Combo Pill Shows Promise” by the AP from a cardiology meeting in Orlando, Florida, reports the following, and I quote:

“ORLANDO, Fla. – It's been a dream for a decade: a single daily pill combining aspirin, cholesterol medicine and blood pressure drugs — everything people need to prevent heart attacks and strokes in a cheap, generic form. Skeptics said five medicines rolled into a single pill would mean five times more side effects. Some people would get drugs they don't need, while others would get too little. One-size-fits-all would turn out to fit very few, they warned. Now the first big test of the "polypill" has proved them wrong.”

“The experimental combo pill was as effective as nearly all of its components taken alone, with no greater side effects, a major study found. Taking it could cut a person's risk of heart disease and stroke roughly in half, the study concludes.”

“The study tested the Polycap, an experimental combo formulated by Cadila Pharmaceuticals of Ahmedabad, India. It contains low doses of three blood pressure medicines (atenolol, ramipril and the "water pill" thiazide), plus the generic version of the cholesterol-lowering statin drug Zocor, and a baby aspirin (100 milligrams).”

“The study involved about 2,000 people at 50 centers across India, average age 54, with at least one risk factor for heart disease — high blood pressure, high cholesterol, obesity, diabetes or smoking.”

“Four hundred were given the polypill. The rest were placed in eight groups of 200 and given individual components of the pill or various combinations. Treatment lasted 12 weeks.”

Compared to groups given no blood pressure medicines, those who got the polypill lowered their systolic blood pressure (the top number) by more than 7 units and their diastolic (the bottom number) by about 6 — comparable to levels for people who were given the three drugs without aspirin and the cholesterol drug.

“These drops were modest, probably because doses were low and most participants had only moderately high blood pressure to start with, Yusuf said.”

“LDL, or bad cholesterol, dropped 23 percent on the polypill versus 28 percent in those taking the statin drug separately. Triglycerides dropped 10 percent on the combo pill versus 20 percent with individual statin use. Neither pill affected levels of HDL, or good cholesterol.”

“Anti-clotting effects seemed the same with the polypill as with aspirin alone.”

Admittedly, I’m being a little too over self- congratulatory here. The idea for the polypill came not from me, but from two British researchers back in 2003, and a firm owned by a physician from India formulated the pill (1.Wald, NJ, and Law, MR, A Strategy to Reduce Cardiovascular Disease by more than 80%, British Medical Journal, Page 1419, 2003.
2.K.Srinath, “The Preventive Polypill – Much Promise – Insufficient Evidence,” New England Journal of Medicine, Page 212, January 18, 2007).

But as archy the cockroach, the creation of Don Marquis, might say, “whatthehell,,hellsbells, sometimes you have to blog your own horn.”

The Moral

That big innovations have to be complicated,

is a concept that is truly vastly overrated.

Take the heart and stroke prevention polypill,

It fulfills practically every innovation bill,

And it is just what the doctor indicated.

That's teh way I see it.

Monday, March 30, 2009

Liberals vs. conservatives - Answers to Liberal Litany on U.S. Health System "Crisis"

In my upcoming book, Obama, Doctors, and Health Reform, I have a chapter called “The Litany.” The Litany refers to the off-repeated but seldom countered complaints about the U.S. health system – that it costs too much, covers too few, creates too many bankruptcies, and leaves in its wake miserable health care statistics.

These U. S. statistics, compared to other industrialized nations, include: shorter life expectancies, higher infant mortalities, more uninsured. and more rapidly rising cost. Many of these statistics stem from the simple fact that one of every five Americans in now an immigrant or a close relative of one and that these immigrants are often beyond the reach of the health system.

Tone of Criticism

The general tone of critics’ complaints is: as a civilized nation, we ought to be ashamed of ourselves. Our health system is “in crisis,” and our old, poor, disabled, and sick are dying in the streets for want of care.

In response to these litany of complaint. John C. Goodman and Devon Herrick of the National Center of Policy Analysis, Linda Gorman of the Independence Institute, and Robert Sade of the Institute of Human Values in Health Care, have prepared a 20 page rebuttal “Health Care Reform: Do Other Countries Have the Answer?” they back their rebuttal with 87 references.

1. Does the U.S, spend too much on health care? Other countries, they say, “ aggressively disguise costs” and treat long term care, out-of-pocket spending, overhead costs differently than in the U.S.. Per capita, the U.S. uses fewer physicians, nurses, hospital beds, physician visits, and hospital days than median OECD nations. The average growth of our spending per capita is below that of over nations (3.7% vs. 3.8%) and has been so over the last four decades (4.4% s. 4.5%). Further, our waiting times for procedures are far shorter than other countries.

2. Are U.S. outcomes better or worse than those of other countries? The authors argue that U.S infant mortality varies enormously in the U.S. across racial and ethnic groups by factors of 2 – 3: 1 across cities and states for reasons that have little to do with health care. U.S. infants, once born, have high likelihood of survival. Five year survival from cancer in higher in the U.S. than in Europe. Our rates of hypertension and hypertension control are greater. And our rate of adverse events in hospitals is less. Our waiting lists for dialysis, hip replacement, knee replacement, bypass surgery and cataract surgery are much less. The authors comment, “It is not clear whether the U.S. spends too much on health care or other countries spend too little.”

3.Is the large number of Uninsured in the U.S. a crisis? The authors say that uninsurance is often transitory, that 83% to 86% are insured, and that our unprecedented influx of immigrants causes uninsured 2 ½ times that of the native born population. Of the 46 million uninsured about 12 million are illegible for Medicaid and other public programs. 17 million of the uninsured live in households of $50,000 or more, and more than half of these earn more than $75.000.

4.Does lack of health insurance cause premature death? The consensus of economic studies is that “insurance has a relatively small effect on health.” The authors argue that it is not known how much mortality and morbidity is due to lack of health insurance. They also point out that creating universal coverage by having people enroll in Medicaid may cause them to drop private plans, which may cause worse health outcomes.

5.Are medical bills causing bankruptcy? They cite a series of economic studies indicating that only 17% of ‘Medical bankruptcies” are actually so, that there are few statistical links between bankruptcies and health problems,

6.Are administrative costs higher for private insurance than public insurance?

Here is their comment, “The Congressional Research Service has estimated the administrative costs of Medicare at 2% of total program costs, compared to 10% of private insurance and 12% for HMOs. Some single payer advocates have uses this estimate as an argument for a universal Medicare program. These estimates ignore hidden costs shifted to the providers of care, and the social cost of collected takes to fund Medicare. A Millikan & Robertson study estimates that when these costs are included, Medicare and Medicaid spend two-thirst more on administration than private insurance spends on administration: 27 cents, compared to 16 cents, respectively for each dollar of benefits.”

7.Are low-income families more disadvantaged in the U.S. system? In Britain, the National Health Service, despite its 60 years in existence, has done little to equalize health care access. In Canada, the wealthy and powerful have much greater access to medical specialists than the poor. In Canada, low-income Canadians are 22% more likely to be in poor health than their U.S. counterparts. In all OECD countries, higher income people use the system more intensively than at higher costs than lower income people.

8.Can the free market work in health care? The portrayal of the US. as a more market driven system may be more perception than reality. In the U.S. 13 cents of health care money is spent out of pocket, and in OECD countries the average is 20 cents. In the U.S,. cosmetic surgery and corrective visual out-of-pocket costs have declined 30% over the last decade. Retail clinics have proliferated. They post prices, keep EMRs, and prescribe electronically. Systems operating outside of 3rd party payments and constraints have lower costs and better quality. Wal-Mart is and Target are offering $4 prescriptions for generic drugs, and more than 10 million of U.S. families are managing their own care through health savings accounts, and many countries, such as Singapore, South Africa, and Switzerland rely on private insurance mandated by government.


The authors conclude,” Support for government regulation of health care financing and delivery has been based on a narrowly selected data, while all but ignoring contrary data. We have attempted to correct the record by discussing some specific gaps and suggesting the U. S. health care reform would benefit greatly from a careful examination of the current success and future potential of market-based reforms.”

If I may summarize,

Be careful before accepting the prevalent liberal litany,

that the U.S health system should live in eternal infamy

that United States health statistics are uniformly poor,

compared to other nations with coverage door to door,

and that the market is for the few and not for the many.

Pharma, CME-A Piece of the Doctor's Mind and Time

What’s happening is that pharmaceutical companies are realizing there are other ways to reach the doctor instead on the door of a doctor who just doesn’t want to talk to you.

Peter H. Nalen, President of Compass Healthcare Communications, an online drug marketer, Princeton, New Jersey

I read in the March 30 AMA News “Doctors Increasingly Close Doors to Drug Reps, While Pharma Cuts Ranks,” that 33% to 46% % of doctors are turning away drug reps, that this percent jumps to 52% for health systems, and that a third of medical schools require drug reps to have appointments before seeing faculty members or residents.

Consequently, drug companies have cut numbers of drug reps from 102,000 to 92,000. The main complaint of doctors is they simply don’t have time to talk to detail people.

What Now?

So how are drug firms going to get a piece of the doctor’s mind and time? As editor-in-chief of Physician Practice Options, a monthly newsletter devoted to practice management and innovation supported by drug firms, and as author of Innovation-Driven Health Care (Jones and Bartlett, 2007), 4000 copies of which were purchased and distributed by a leading pharma company, and Obama, Doctors, and Health Care (now in publication process), I have a few thoughts on what works and doesn’t work.

1) In these hard times, many doctors still appreciate having free samples to distribute to needy patients who could not afford to fill a prescription. This practice has its ups and downs, but will continue.

2) Some doctors welcome pharma-supported value-added services, such as pragmatic practice-management or coding advice, delivered in print or online by seasoned consultants.

3) Talks at hospital staff meetings or drug-sponsored symposia seem to waning in popularity because of perceived lack of objectivity by speakers.

4) Booths and exhibits at local, regional, and state medical societies continue but may be of limited value because of limited and short exposure to doctors and lack of time to explore details of a product.

5) Social networking sites at Sermon and Medscape gives doctors practical contextual advice from doctor to doctor about effect and adverse side effects of drugs, but is of limited value as promotional vehicle for pharmaceutical companies. Nevertheless, pharma firms are chief financial supporters of these networks

6) Uptoday.com is preferred by many doctors because of its faculty of 4000 and objective evaluations. A trusted, unbiased source of medical information for both patients and doctors.

7) The Internet in general, and firms like Compass Healthcare Marketing, which as great sources of information and marketing of drugs, and are valuable in their own right but of limited value for drug firms because of tremendous dilutional effect of Internet.

8) Physician Dispensing in the Office, by companies like Physicians Total Care, Inc, and AllScripts, Inc, may become more common because they provide physicians an extra source of revenue to prop up low margin practices.

Beyond these thoughts, it is important to keep in mind that over the last thirty years, many of the most important innovations in American medicine have come from the pharmaceutical industry. These include: ACE inhibitors and angiotensin II inhibitors, statins, proton pump inhibitors and H2 blockers, SSRI inhibitors and non-SSRI antidepressants, and more recently the rapidly emerging biotechnology and biopharmaceutical companies targeting cancer, other diseases, and personalized drugs designed to fit a person’s DNA.

Sunday, March 29, 2009

Medicare, Costs - CMS Savings: A Snare and Delusion of Obama Health Reform?

Congress this week took a big step toward clearing the way for passage of President Barack Obama's ambitious plan to overhaul the health-care system. But questions remain over how to pay for it.

The five-year budget plan passed by a Senate committee this week contains a little-noticed provision that would give the government 10 years to cover the cost of the health-system overhaul. That, in effect, would allow the government to spread out the costs and help meet rules that new initiatives don't add to the deficit.
The provision would also give the government more time to generate savings from changes to the health-care system, and allow it to rely less on new taxes or other revenue increases. In essence, lawmakers are hoping they can find a way to make the health-care overhaul pay for itself, even though any substantial savings are likely to take years

John D. McKinnon and Naftak PenDavid, “Congress is Buying Time for Health Care Savings, “ Wall Street Journal, March 27, 2009.

The United States Congress’ Congressional Business Office (CBO) released a two-volume health reform study in December 2008. It lays out the underlying logic, data, and arguments the Obama administration and Congressional leaders are using to move their health reforms forward.

We use these CBO Reports to address the argument that government health care administrative costs is far less than that of private insurers. If this were the case, of course, it would argue for a government-run health payment system. CBO data clearly disputes that argument, and instead, show that insurance companies spend at least 51% less than the government does in its health care programs.

If the government chose to administer Medicare internally, it would increase administrative costs by $1 trillion during the next ten years. A key reason is that private companies externally administer Medicare , while other government programs are internally administered.

Grey Datillo and David Racer, “Comparing Administrative Costs, Private Sector and Government,” Alethos Press, LLC, alethosepress@comcast.net- http-www.freemarket.com, March 28, 2009

The snares and the delusions of the Obama administration may be twofold:

One, that a government-run system would save money;
Two, that if government were to administer health care, costs would be far lower than a system administered by private plans.

Indeed, critics often lambast greedy private plans as the cause of health costs, saying costs of these plans add anywhere from 15% to 30% of total costs. If only we had government administering costs, that percent would plunge to 5% or so, as it is purportedly the case in Canada and European nations.

As someone who has seen U.S. government health costs for Medicare-Medicaid, estimated in 1965-1966 never to grow beyond $9 billion, to somewhere around $900 billion, 25% of the federal budget, I am dubious about the cost efficiency of government controlling administrative costs of CMS.

I am also dubious of claims that Medicare could administer all care for about 5% . Private administration costs are somewhere between 10% to 15%.
Nevertheless, a central tenet of the White House is that it would save money and be more efficient in administering care.

Here is how it plans to save money over the next ten years.

Anticipated Medicare Savings - Savings envisions by President Obama which may make his spending proposals affordable.

Proposal 2010-2019 Savings

Use competitive biddings for private Medicare plans $176.6 billion

Have government negotiate drug rebates for Medicare and Medicaid. $19.6 billion

Link hospital Medicare pay to quality measures $12.1 billion

Set approval pathway for generic biopharmaceuticals $9.2 billion

Reduce Medicare readmissions through pay bundling $8.4 billion

Increase Part D premiums for higher income seniors $8.1 billion

Reduce inappropriate Medicare payments $2.0 billion

Use radiology benefit managers $0.3 billion

Total $236.3 billion

Source: White House Office of Management and Budget

If you look closely this chart, you will see that $205.7 billion out of the total of $236.6 billion in savings, or 87%, are aimed at making private Medicare plans and drug company prices “competitive.” presumably by trimming profits and administrative costs of private plans and drug companies.

Finally, it’s worth looking at the details of President Obama’s Health Spending American Recovery and Reinvestment Act of 2009, signed by President Obama on February 17, 2009. Over $22 billion is devoted to comparative effectiveness research, health information technologies, i.e. EMRS in every doctor’s office and hospital, and prevention and wellness - all of which would presumably save money over the long run but have yet to be proven to do so.

Program Amount of Funding

Comparative effectiveness research $1.1 billion

Continuation of health insurance coverage for unemployed workers $24.7 billion

Departments of Defense and Veterans Affairs $1.4 billion

Health information technology $19.2 billion

Health Resources and Services Administration $2.5 billion

Medicare $338 million

Additional federal matching payments for state Medicaid programs $87 billion

National Institutes of Health $10 billion

In other words, if government were in total control, it could bring down costs of the private sector, and overall costs would decrease significantly.


Saving CMS money may be a snare and delusion.

It rests on the unquestioned but slippery illusion,

that if government could administer and negotiate,

everything with government health care we associate,

reduced costs would be foregone conclusion.

Saturday, March 28, 2009

The Internet - Obama's Political Ace in the Hole for Reform

As we ponder modern politics, it is becoming increasingly evident that the Internet will offer yet another opportunity for a great leap in communications, bringing a customized one-on-one dialogue into the home of each voter. Instead of the one-size-fits-all television campaigns that dominate our politics, the Internet in general – and e-mail in particular – will make possible a conversation between each voter and each candidate about issues and ideas. The interactivity of the Web means the end to “I talk, you listen” politics, and the beginning of a two-way discussion as the basis of political communication. Some feel this is long overdue.

Dick Morris, Power Plays: Win or Lose – How History’s Great Political Leaders Play the Game, Regan Books, 2002

As part of the administration’s efforts to tee off a movement toward legislative action on health care, it also set up a new Web site, healthreform.gov.
Kate Phillips, “White House Plans Regional Health Care Forum,” New York Times, March 5, 2009

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

Current E-Reform Efforts

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

1. The Obama-Biden website which says.

- Obama will make affordable and accessible health care for all

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

- Obama will promote public health

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

2. Regular Obama Facebooks, with videos featuring Obama talking health care
basic promises.
3. Virtual Online Townhalls – On March 25, President Obama held what promises to be first of a series of virtual townhalls. In this first online townhall, he responded directly to six questions winnowed from more than 100.000 submitted directed by emails from citizens. The media dutifully televised the event. It also appeared on online video, and was broadcast it to the nation on mainstream and cable television.

Clicking Away

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

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

- Expanding coverage through private and government-run health plans

- Making large businesses cover employees or pay a fine

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

- Having government negotiate Medicare drug prices

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

Prospects for Success

Given his election margin (53% vs. 47%), large Democratic majorities in the House and Senate, his successful Internet deployment during the presidential run, his cache of millions of email addresses from supporters, the presence of personal computers in 80% of American homes, and his promise of $2500 premium savings for the typical American family, Obama’s electronic mobilizing tactics for health reform may succeed.

Dick Morris Comments
President Obama has a simultaneous top-down , i.e. daily dominating the national radio, mainstream and cable television, and Internet media, and a bottom-up strategy, i.e, while at the same time soliciting and responding to hundreds of thousands, indeed, millions of emails.

In his book Power Plays, Dick Morris asks and answers, ”Will the new techniques and strategies improve our political process? Likely they will. Each development seems to move in the same direction – greater direct democracy and more public participation. Certainly the Internet and the two-way political dialogue it fosters will tend to make our democracy more direct and citizen involvement more consuming.”

Limbaugh View

As with any political development, there may be a darker side. Rush Limbaugh, the conservative radio talk show host, believes the Obama daily dominance of all media has Orwellian, Big Brother overtones, and may lead to totalitarian tyranny of our minds.
I would not go that far. I give President Obama his due. It is a brilliant ongoing political communication strategy, transforms politics, and will have to be countered by his political opponents.

I would not bet against significant incremental health reform. What might prevent Obama-style health reform are the economy, the soaring federal budget deficit, and the Department of Health and Human Services current $708 billion budget, 25% of federal spending and Medicare on brink of bankruptcy, but Obama is not one to let billions, even trillions of dollars, stand in his way. He will persist, and he will
let the government printing presses roll.

Three E-Finishes

One, Obama is our first Internet President.
which is altogether without precedent.
He uses the Web to issue a daily report,
and to mobilize wider political support,
That e-tools help his agenda is evident.

Two, For Obama, Internet politics is good.
For all of us that fact has to be understood.
Obama Internet supporters got him where he is today.
and elevated him above the ordinary political fray.
For Obama the Internet was the little Engine that could.

Three, Say about Obama’s Internet strategy what you will,
Say that it’s shows the mark of remarkable political skill,
Say that it smacks of George Orwell’s Big Brother,
Say that it brings all media under one giant cover,
Say what you will: it’s now routine grist for the political mill.

Obama strategies - Obamanation - Prospects for an American European-Like Health System

While researching Obama, Doctors, and Health Reform; The Health System, from Top-Down to Bottom-Up, As Seen Through Lens of Cultural Complexity, now at the publishers, I ran across a number of articles speculating on whether Obama-care will lead to a top-down centralized European-type system.

Mindset Hopes

If you’re from the Democratic-left, you probably hope so. That would be a long sought-after crowning achievement of the Democratic Party – a signal that government really cares about the American people. If you’re a right-wing Republican, you hope not. That would herald that Socialism, European style, has arrived and will end individual liberties, freedom of choice, an usher in rationing.

Health Reform - Incremental or Sweeping?

Will we have health reform under Obama? Yes, but in my opinion, it will be incremental reform played out over ten years, not universal reform in the next four, or eight years. Here’s what I have to say about the issue in the foreword to my book. It’s important to distinguish what kind of reform you’re talking about.
In any event, here’s what I have to say about reform in the foreword to my book.

“Although President Obama strikes a determined, even combative tone, when advocating health reform, I place odds for sweeping reform at 30/70 in his first term, but as near slam dunks for immediate incremental changes such as coverage for children, stem cell financing, funding for electronic records, setting in motion a Comparative Effectiveness Institute, and extended Medicaid unemployment benefits. “
The obstacles to sweeping reform, i.e, universal coverage, single-payer, or Medicare and Medicaid for-all, are these.

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.

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.

I find myself agreeing with Michael Barone, who, in an article “Not Yet Ready for Welfare State," in Real Clear Politics , has this to day.

“The problem on health care, as on cap-and-trade and card check, is that this is a big and complicated country. America doesn't have one energy system, one employee relations system, one health care insurance and delivery system -- it has many. Members of Congress from different states and congressional districts have constituents who are very differently situated, and those differences cut across party lines. “

“Setting up a welfare state is easier in European political systems, with their centralized governments and rigid parliamentary party discipline. American welfare state programs like Social Security and Medicare were set up and expanded step by step by very shrewd strategists operating over many years. Obama has the audacity to hope that he can jam things through with sizeable Democratic majorities at a time of economic crisis and uncertainty. But he has quickly encountered some roadblocks -- and may yet encounter some more.”

Reece, Personal musings - A Health Care Computer Tale

In these days of health reform, the media is full of grim tales and deadly seriousness. And rightly so. But, as this tale shows, there is still gloom for improvement.

The greatest computer that had ever been designed that could answer any and all questions was finally ready to be put into action. All the world’s greatest politicians, policy makers, software experts, government officials, health plan executives, drug makers, health care supply chain manufacturers, physicians, patients, and consumer groups were gathered to ask the right questions to initiate operations.

President Obama stepped forward and said, “ I have three questions.”

One, “Is there a God?” The vast machine went into action. Lights flashed, and strange clicking sounds whirred inside the great beast. Finally a deep voice from the vitals of the machine emerged and said, “Now there is.”

Second, “Is there a computer than can answer all health system questions?” “Not yet!” groaned the vast machine.

Third, “What is the meaning of life?” “Life,” proclaimed the all-knowing all-seeing computer, “ is a riddle wrapped inside a mystery inside an enigma contained within a conundrum that is itself a great puzzle that does not yield to algorithms or derivatives and that can’t be googled.”

“Well,” said President Obama, “ then I will have to find the answer myself.”

To conclude,

As an all-knowing, all-seeing, all-purpose machine,

The computer has problems not always foreseen.

It can add and subtract and to the routine react,

But when it comes to humans and thoughts abstract,

It has little to add or contribute to the old bean.

Obama, Doctors, and Health Reform, blogging general - Blog Delayed for Obama Book

I haven’t submitted a blog for a while for two reasons: one, my modem crashed, and I’ve been having difficulties finding a replacement; two, I’ve been putting the finishing touches on a new book Obama, Doctors, and Health Reform; The Health System, from Top-Down to Bottom-Up as Seen Through the Lens of Cultural Complexity, before sending it to the publisher.

The former is an annoying technological glitch, but it makes me realize how important the Internet is to my work. The latter has been a bitch to write because of the sprawling, comprehensive nature of the Obama initiatives.

It is tough to summarize the book. But basically I put the odds for sweeping reform, aka, universal coverage, or single-payer at 30:70, and for various incremental reforms as a slam dunk.

The White House proposal calls for an immediate expenditure of $150 billion, a ten-year savings of $253 billion, and a ten year “down payment” of $636 billion.
Frankly, I think Obama’s plans , if carried to their extreme, will cost several trillion more than estimated, but what the hell. To paraphrase the late Senator Everett Dirksen, “ A trillion here and a trillion there, and pretty soon we’re talking real money.” It is my view next year’ s federal deficit of $1.75 trillion will be too steep a hill to climb for radical reform.

As I say in my book’s foreword , “The Congressional Business Office placed an even steeper hill in front of Obama’s tax and spending plans by estimating the White House would create a budget deficit of $2.3 trillion more than Obama’s projections over the next decade. When President Obama says it may take ten years to achieve his goal of universal coverage, he’s hedging his bets.”

“In any event, in his first term, I don’t foresee how Obama can create 3.5 million jobs, redesign the health system, save the auto industry, reinvent the energy sector, revitalize the banks, and reform education with one swipe of his magic wand.”

President Obama may be good. He is certainly eloquent. But he’s not that good pr that eloquent. He is not a miracle man.

Friday, March 13, 2009

U.S. health care system - The Litany

We’ve all heard the litany of problems – skyrocketing health costs. Large medical bills forcing people into bankruptcy, U.S. manufacturers paying twice as much as foreign counterparts, problems with health care quality, 47 million Americans without insurance, too many specialists and not enough primary care physicians (in particular, family docs). We spend more on health care than any other country in the world, and what do we have to show for it? Bupkis!

Allan Wille, MD, Forum on Health Care Reform, February 3, 2009

Spare me the grim litany of the “realist.” Give me the unrealistic aspirations of the optimist any day.

General Colin Powell

I, for one, question the the value of the litany of U.S. health statistics comparing us to other nations. Yet the litany is repeated so often that it has become political folklore among progressives. It is never questioned, just taken for granted.
The litany appears , in the March issue of the HBS Alumni Bulletin, which I receive because I once spent 8 weeks in one of the Business School’s advanced management programs. The litany is part of an article, “Model Patient,” with a subheading that reads “Massachusetts Landmark Health-Care Reform Law is Drawing the Attention of Many Observers, include the Obama Administration. Could It Work On a National Scale?”

Here is the litany.

"There can be no doubt that America’s health-care system is in critical condition. The cost of U.S. health care not only hampers its citizens’ well being and the country’s ability to compete globally, but it also draws funding from other sectors, such as education, where increased investment could strengthen society and enhance competitiveness. Total health care spending as a percentage of GNP is 16 percent, compared with Canada’s 10 percent and Japan’s 7.6 percent. U.S. per capita health –care expenditures are the highest in the world. Versus Canada’s $3,912 or Japan’s $2,690. Meanwhile the United States ranks 34th in the world in life expectancy at 77.9 years. Half the U.S. population does not receive standard preventive care such a cancer screening, blood pressure checks, or vaccinations. A 2007 McKinsey study found that compared with the average for the thirty countries of the Organization for Economic Co-operation and Development (OECD), Americans pay significantly more per unit of health –care services consumed, seven though they see doctors less, take fewer pills, and have shorter hospital stays. Americans are ‘paying more, despite using less and doing worse,’ concludes Health Connector executive director Jon Kingsdale.”

A Flawed Litany

So what is wrong with the litany? One, it is overly pessimistic. Two, it continuously compares U.S. health care to that of other nations. Three, it misuses statistics to portray U.S. health care as an abysmal failure. Four, it implies that health care alone is responsible for the health of a nation. Five, it ignores the unique characteristics of U.S. culture.

The U.S. health system has roots in our national culture. Since our founding more than 230 years ago, Americans have:

• distrusted centralized federal power

• reveled in virtues of self-improvement

• sought freedom of choice

• believed in equality of opportunity, not results, for all citizens.

These beliefs may explain why Americans:

• prefer a multipayer to a single payer system

• reject federally mandated universal insurance

• want to make their own health care decision

• Seek immediate access to new medical technologies

• Allow market-based and public-based institutions to compete and co-exist

These roots and beliefs may be regrettable, but they help create a climate of freedom and opportunity that draws millions of the world’s immigrants to our shores. Our population is now nearly one-third African American, Hispanic, or of other ethnic origins. We consider diversity a good thing. However, interacting variables among various cultures - insufficient education, lower socioeconomic status, fear of being exposed and exported as an illegal immigrant, violence in the streets, mayhem on the highways in our car-rich country, language barriers, and lack of health care access- are beyond the reach of health care professionals, and negatively skew health care statistics and increase costs through delay of care, crowded emergency rooms, and wards of patients with behaviorally-induced disease.

Take one unfortunate but realistic example of what’s different about American health care and why our longevity statistics lag behind other countries. Colonel John Holcomb, the army’s top trauma surgeon is fond of quoting the statistic, that, among U.S. civilians, trauma leads all diseases in terms of life-years lost, more than heart disease or cancer. That’s useful statistic to keep in mind when comparing national health systems, for if one takes trauma and violence into consideration, U.S. longevity statistics are comparable to any other country.

Ethic origins play a role in our longevity statistics compared to other countries.

Ethnic Origin Total Populations Life Expectancy

White 197 million 81.0

Black 36 million 73.6

Hispanic 39 million 74.0

American Indian 2 million 75.5

Asian 12 million 75.2

Interracial Marriage 4 million 75.0

Source: Abstract of the United States, 2000-2004

Now it may well be that some sort of universal coverage would improve health statistics. But the facts are not encouraging. Dr. Leonard Sagan, a Stanford –based epidemiologist, wrote in The Health of Nations: True Cause of Sickness and Well-Being (Basic Books, 1987) that health care systems had little to do with reducing death rates or extending life expectancy. He says social, family, and personal factors play larger roles than health coverage. And Snatcher and Pamies in Multicultural Medicine and Health Differences (Basic Books, 2006) estimate that medical care accounts for only about 15 percent of the health status of any given population, life style for 20 percent to 30 percent, and other factors – poverty, inferior educations, income differences, and lack of social cohesion – for the other 55 percent.

None of this, of course, is to say that U.S. health care could not be improved by a reformed system, but such a system would probably would not fundamentally change our health statistics, except perhaps for our infant mortality rates which hinge more on access to prenatal care. Still, reform is in the air and is worth a try.
Meanwhile we should not forget Mark Twain’s famous remark about Richard Wagner’s music, “It’s not as bad as it sounds.” This applies to U.S. health care, too.

Thursday, March 12, 2009

Hospitalists and Primary Care

Two decades ago, most doctors who chose a career as a primary care physician did not imagine a professional life restricted to the outpatient settings…Today, many primary care physicians work exclusively in the ambulatory setting, relaying on hospitalists to care for their patients when they are admitted to the hospital.

Mary Beth Hamel, MD, Jeffrey Drazen, MD, Arnold Epstein, MD, “The Growth of Hospitalists and The Changing Face of Primary Care, New England Journal of Medicine, March 12, 2009

Alfred North Whitehead (1861-1947), an English philosopher, once observed, “It takes a very unusual mind to undertake the analysis of the obvious.”

To me it is obvious that the hospitalist movement, defined in 1996 by Wachter and Goldman (“The Emerging Role of “Hospitalists” in the American Health Care System,”New England Journal of Medicine, pages 514-517, 1996), has an unstoppable momentum.

The numbers speak for themselves.

From 1995 to 2006, 20% of general internists became hospitalists, and nearly 50% of all hospitals and 84% of teaching hospitals have at least three hospitalists.

Forces behind the hospitalist movement include the following.

• Managed care, which pressures primary care doctors to see more patients and hospitals to shorten stay.

• More hospital patients being seen by subspecialists.

• Malpractice exposure, wherein lawyers demand expertise for doctors in all spheres of practice – outpatient and inpatient.

• Demands by hospital executives to tighten control of inpatient care and discharges.

• The interests of young physicians for a more controlled lifestyle.

• The approval of older physicians who are pleased to hvae more care-free and call-free nights and weekends.

• Heightened demands by government and health plans for more efficiency.

• The drift towards a more European model, where inpatient and outpatient cafĂ© are seen by different sets of doctors.


In retrospect, rise of hospitalists is perfectly obvious.

Pressing needs were there to see for all but the oblivious,

But for most futurist seers,

And their peerless peers,

The obvious proved devious.

Tuesday, March 10, 2009

Rationing - On Being Nice in Health Care, What Is Is

What is is.

Rush Limbaugh, 1951-

It depends on what is is..

President Bill Clinton, 1946 –

People should be taught what is, not what should be.

Lenny Bruce, 1925-1966

That is, is.

Shakespeare, 1564-1616

Be nice to people on your way up, because you’ll meet them on your way down.

Wilson Mizner, 1876-1933

Saying No Isn’t NICE - The Travails of Britain’s National Institute for Health and Clinical Excellence.”

Robert Steinbrook. MD, title of article in New England Journal of Medicine, November 5, 2008

Sorry about the quotation –littered lead-in, but I wanted to establish beyond doubt the reality that reality that being nice is nice, particularly in the politics of health care.

No politician of modern times has been better at this than President Barack Obama, who is universally seen as a nice guy, with a nice family, and nice intentions.

Obama wants to be nice to most of the people most of the time. This is nice politics, but whether is sound policy is not yet known.

Obama’s policies and politics remind me of Winston Churchill’s famous observation, “The inherent vice of capitalism is is the unequal sharing of blessings; the inherent virtue of socialism is the equal sharing of miseries.”

President Obama might rephrase this to read,” The inherent vice of capitalism is the unequal sharing of nastiness; the inherent virtue of socialism is the equal sharing of niceness.'

But alas, universal niceness has its downside – there isn’t enough money to go around. Here is how Robert Steinbrook, MD, appraised Britain’s NICEness policy, i.e, withholding treatments for certain drugs and procedures to make “universal coverage” work.

“Britain’s National Institute for Health and Clinical Excellence, known as NICE, is an indEpendeNt, government-funded organization that advises the British National Health Service. Since 2002, NHS organizations in England and Wales have been required to pay for medications and treatments recommended in NICE “technology appraisals.” The NHS usually does not provide medicines or treatments that are not recommended by NICE – although exceptions are possible.”

“NICE,however, has been criticized for the slow release of appraisals…Some of tis decisions seem unfair, and the institute has been vilified for recommendations to limit coveragefor some high-profile medicines for cancer and other life-threatening diseases. Its decisions are often appealed, --- and one decision has been challenged in court…saying no takes courage – and inevitably provokes outrage.”

What it comes down to is this. If government is to ration care by setting clinical effectiveness standards, it cannot be nice to all the people all of the time. Being nice to people has its limits, even in a non-litigious society like Britain, You can be nice to most of the people most of the time, but you cannot be nice to all of the people all of the time.

Monday, March 9, 2009

Can the U.S. Put The Medical Imaging Genie Back into the Bottle?

You can’t put the genie back into the bottle.

Popular Idiom

Can the U.S. put the medical imaging genie back into the bottle?

I’m not optimistic. We are a technology–oriented nation; medical imaging –CT, MRI, Nuclear medicine, including PET – are superior technologies; and the public and physicians have embraced medical imaging as the new standard of care.

Don’t take my word. Look at the numbers.

• From 2000 to 2006, Medicare expenditure for these imaging services rose from $3.6 billion to $7.6 billion (17% a year).

• The rate of imaging growth exceeded be far that of other service physicians billed Medicare over that period – culmulative change for imaging 70%, all diagnostic tests 53%. All physician services 45%, major services 25%, evaluation and management services, 24%.

• Nationally, some 7000 sites now offer MRI services.

• Internationally, the U.S. offers many more MRIs per million persons than any other country- US 26.5. Switzerland 14.0, Germany 7.7, Netherlands 6.6, Canada 6.2, United Kingdom 5.6, France 5.3, and Australia 4.9.

These numbers raise legitimate concerns that imaging is being overused, that non-radiologists are purchasing imaging equipment, that some imaging equipment is outdated and used inappopriately, that patients are being exposed unnecessarily to excess radiation, that physicians refer patients to facilities they own.

Consequently, Congress has imposed spending caps on outpatient payments for these imaging tests with these differences in rates.

Lumbar spine without contrast material – $557 to $429, 24.6% reduction.
Joints of lower limbs with contrast material - $520 to $413, 21% reduction.
a. Brain with and without contract material, $1023 to i$611, 40% reduction.

• CT
Pelvis with contrast material - $327 to $391, 6.6 % reduction.
Thorax with contrast material - $342 to $310, 9.4% reduction.
Thorax without contrast material - $290 to $245, 15.3% reduction.

• 3.D multiple heart images- $532 to $473. 11.3% reduction

What Does This All Mean?

Basically, it means that government and private health plans have been unable to contain the fee-for-service incentives for imaging technologies and subdue the profit incentives that propel their use.

Some of these incentives not only involve profit, but also include patient expectations that imaging has become an expected standard of outpatient care, that physicians hesitate to act without imaging diagnostic confirmation, that failure to perform imaging make become a malpractice issue. Imaging has become an integral part of coordinated and defensive medicine.

Therefore, without leverage to implement effective utilization constraints, policymakers and private insurers, after these short term fee reductions, are seriously considering “restructuring: or “replacing” fee-for-service” payments with a more “rational approach” which will probably involve bundled-payments to a single entity made up of hospitals and physicians.


Organized medicine will certainly react negatively to bundling since they consider outpatient imaging services and hospital episodes of care as separate and often unrelated to hospital activities. Procedures physicians perform in their offices and outpatient imaging centers may bear little relationship to what occurs in the hospital. In other words, outpatient imaging and hospital services have yet to be “integrated.”

Putting the imaging genie back into the bottle,

After in routine practice it reaches full throttle,

is not nearly as easy as it seems.

Once imaging becomes expected in the fee-for-service scheme.

It becomes routine and irreplacable in the practice model.

Friday, March 6, 2009

Universal Coverge from the Bottom-Up

What we did was ask a profound and simple question? We asked: How do you provide universal coverage to all uninsured San Fransicans?

Gavin Newson, San Francisco Mayor

Rethinking will not give us the answers, but it might force us to ask the right questions…Management is doing things right, leadership is doing the right things.

Peter F. Drucker (1909-2005), Father of Modern Management Theory

When reading a blog like this on health reform, you might legitimately ask, “ All right, h e keeps telling us how complex things are. But does he have any answers?”
It is easy, you see, to criticize but hard to offer constructive solutions. One way to respond is to reframe the question. A logical answer may ensue.

Our Top-Down Paradigm

When speaking of universal health care, we invariably think of universal care from the top-down from the federal government. That’s our paradigm – our mental mindset. We ask our federal government for bailouts. We ask,”Big Brother, can you spare a dime – or a billion or two , here or there?

Moaning and Groaning

We moan and grown about the 15% of uninsured Americans; we mouth sound bites “We’re the only developed industrial society without universal care.” We negatively compare our health statistics on longevity, infant mortality, and health costs to other countries. We talk incessantly of lack of a single payer system as a “moral blight” on America.

But What about River City?

We rarely, if ever, di we stop to ask: “What can we do right here in River City?” Well, back in 2006, San Francisco officials asked the question,"What can we do in the San Francisco Bay ares? They realized they were already spending $150 million or so on the uninsured. Could they do things differently?

Rethinking San Francisco’s Situation

They rethought their situation. In 2006, San Francisco was a city of 750,000 with 82,000 uninsured – nearly 11% of the population, but less that the then national average of 15%. San Francisco had certain advantages – a liberal political climate, a compact geography, a unified city-country government, 22 community and private medical clinics.

Why Not? They Asked

Why not, they asked, get the private sector, the public sector, and the University of California in San Francisco to agreed to cover the 82, 000 uninsured - most of whom were employed but others unemployed,self- employed, homeless, or with AIDs or other pre-existing illnesses - with a reasonable and compassionate fee-schedule to enroll – nothing for those under the federal poverty line, $3 to $20 for those above that, with an average of $35 for most?

Why not offer laboratory tests, X-rays, and hospitalization? Why not publicize it by called calling it Healthy San Francisco, or San Francisco Health Access Plan?

The Answer

The answer to these simple questions was: San Francisco could afford to carry out their plan for $203 million without a huge budget deficit. And they did. After pilot projects to work out the wrinkles, the plan is now in full swing, and San Francisco is happy.

Fulfilling a Moral Obligation

The City on the Bay is fulfilling its moral obligation. It is covering the uninsured at a price it can afford. Its citizens no longer need to worry about access, and the health care establishment - public and private, doctors and hospitals and clinics – by and large feel they are doing the right thing on their own terms, rather than the terms of the federal government.

As it turns out, there may be more than one way to skin the universal coverage cat. And maybe, just maybe, the idea of bottom-up universal coverage might spread to other metropolitan areas.

Closing argument

Does “universal coverage” have to come from D.C.?
D.C. stands for “Darkness and Confusion,” but it sounds free.
Maybe, just maybe, it can come directly from Bagdad on the Bay,
Well local activists innovated and have had their day.
Now universal coverage is everybody’s cup of tea.

Tuesday, March 3, 2009

The Main Obstacles to Obama's Comparative Effectivness Plan: Doctors and Patients, Not Necessarily in That Order

Let me begin with notable and quotable remarks from this week’s press.

What if physicians could make decisions about which drugs, devices, and treatments to use based on objective research into which options were most effective?
Elyas Bakhtari, “The Manufactured Outrage over Cost Effectiveness Research,” Healthleadersmedia.com, February 26, 2009

It’s hard not to scream when you see how many physicians, pharmaceutical companies, medical device manufacturers, and lately hysterical conservatives seem to have science or ignore it. These days the science that inspires fear and loathing is “comparative effectiveness research” CER, which is receiving $1 billion under the stimulus bill President Obama signed.
Sharon Begley, “Why Doctors Hate Science, Newsweek, February 28, 2009

You can make policy changes till you’re blue in the face, but if patients and doctors don’t change the way think about medicine, you’ll never change medicine.
David Newman, MD, Emergency Room Physician and Author of Hippocrates’ Shadow: Secrets for the House of Medicine (Simon and Schuster, 2008, as quoted in the New York Times, March 2, 2009

At the heart of reform is a plan to cut costs, in part by trying to discern which treatments really work. President Obama’s economic stimulus includes $1.1 billion for studies that will ask about the comparative effectiveness of expensive procedures versus less effective ones. For instance, with certain types of injuries, does surgery work better than physical therapy? Are new higher priced drugs any more effective than their generic predecessors?
Tara Parker Pope, “ A Hurdle for Health Reform: Patients and Their Doctors, “ New York Times, March 2, 2009

Most of you reading these quotes might ask,” Why in the world would patients or doctors oppose objective comparative effectiveness data showing what treatments work?

After all, isn’t medicine pure science? No, it isn’t.

Medicine is a mixture of science and art, how to keep and please patients, and how to respond to patients who want something concrete , most often a prescription, done for them. Doctors report that 37% of patients demand a prescription.

Medicine has vast areas of gray which rests on the doctor’s discretion, for which there is no clear cut action. Doctors and patients are creatures of habit and have certain expectations, such as a CAT scan or EMR for joint, back, or mysterious abdominal pain. And many doctors and some patients have a lawyer in mind should something not be done.

It gets even more complicated.

• Some doctors simply like to try new drugs to see if they are more effective than the old ones, such as diuretics rather than the new highly touted anti-hypertensives.

• Some patients demand antibiotics for ear aches, sore throats, upper respiratory infections, bad colds, and bronchitis, even though these problems are usually viral in origin.

• In American society, physicians and their patients, are in a hurry and like to see something concrete done, thus they tend to use prescriptions, procedures, and imaging as surrogates or substitutes for thoughtful discussions about options and preventive measures.

• Doctors are paranoid about the government “practicing medicine,” often called “cookbook medicine,” and not paying for procedures the federal bureaucracy deems inappropriate or ineffective, even though doctors and patients may think otherwise.

• Patients are heavily influenced by advertising, particularly of drugs promoted on television, that promise sexual satisfaction, lowering of cholesterol and blood pressure, or relief of pain.

Life and medical practice get complicated, and these complications may have little to do with science or objectivity and more to do with accustomed behaviors.

Regional variations- Two Cheers for Practice Variation

Two cheers for Democracy: one because it admits variety and two because it permits criticism. Two cheers are quite enough; there is no occasion to give three.

Edward Morgan Forster (1879-1970), Two Cheers for Democracy (1951)

It’s been 36 years since Wennberg wrote his classic paper on small area variation. Hundreds of peer-reviewed papers based on the Dartmouth Atlas Project have followed. These papers focus on Medicare patients and differences in care and costs in high and high cost environments and low growth and low cost environments and often mention overspecialization, over-use of resources in doctor-rich cities, doctor generated-demand, and practitioners striving to meet “target-incomes.

Dasrtmouth studies conclude intensive use of resources does not produce better care, and indeed the opposite is usually true. The differences, saith Dartmouth, are due to discretionary decisions by physicians unduly influenced by availability of hospital beds, imaging centers, and a fee-for-service system that rewards fast growth and high utilization. For his work and that of the Dartmouth Group, admirers have recommended Wennberg as a candidate for the Nobel Prize, either in economics or medicine.

Yet regional variation persists. Health costs still vary widely between cities, the countryside, academic centers, hospitals, physicians, North and South, East and West.

Why? Many factors share the blame – self-serving doctors, too many specialists, too few primary practitioners, too little standardization, sparse regulation, excess fragmentation, neglect of prevention, negative fee-for-service incentives, lack of integrated groups run by salaried doctors with no incentives to do more. All may contribute. If only we could somehow use data to”homogenize “ care, stamp out “unwarranted variation,” have salaried doctors compete in integrated groups, we could save 30% in costs. And government and health plans could use variation data as a negotiating chip to bring outliers and cost abusers into line.

But quelling variation hasn’t happened. What are Wennberg and his followers missing? Richard “Buz” Cooper, MD, professor of medicine at Penn and senior fellow of the Leonard Davis Institute of Health Economics Institute at Penn, has suggested, sometimes indelicately, that the Dartmouth data is biased to support their point of view., in articles in Health Affairs and elsewhere in peer-reviewed articles, that these variations are inevitable. In January/February Health Affairs, Dartmouth dignitaries, including the editor of Health Affairs, rebut Cooper's arguments on the basis of flawed methodologies.

Cooper argues that Dartmouth may be missing fundamental realities of human nature – that doctors gravitate to big cities to make a better living and to access better educations for their children,, that populations of these cities have profound socioeconomic circumstances, that it costs more to care for the neglected, the newly arrived, the poor, and the uninsured, that specialists on the whole enhance rather decrease quality, and that there is rampant and growing shortage of doctors, and that we ought build more medical schools and create more residency programs.

This kind of talk is anathema to Dartmouth folk, who insist more care, more doctors, more “intensive” use of resources, has not and will not eventuate in better care.

And so the debate about variation rages.

Impersonal data from on high supports the Dartmouth position that profound variations exist. But human nature at ground zero ignores the data. It is a classic top-down bottom-up reality test. By minimizing variation by trying to bring about uniform prices by bringing down costs in high cost areas to those of low cost areas, one is trying to repeal certain fundamental forces of human nature – that doctors will migrate where they can make better use of their skills and can make a good living, that the cost of delivering care varies by the socioeconomic status of those being cared for, and that doctors and hospitals will do what is needed to satisfy the demands their organizations to be community leaders and to satisfy cultural expectations of their region.

There is nothing mysterious about this – practices and costs vary by region, and bottom-up economic forces are more powerful than top-down calls for compliance to meet arbitrary standards. To paraphrase former House Speaker Tip O’Neill’s maxim about politics, “All health care is local.” Unfortunately, Democracy. like health care, is messy. Both could stand improvement. But neither will perfect or overcome human nature.

Monday, March 2, 2009

Obama, Doctors, and Health Reform - Prospects for Obama Reform

I'm in heat - the heat of composition. I'm in the throes of producing a book, Obama, Doctors, and Health Reform, with a subtitle of The Health System, From Top-Down to Bottom-Up, As Seen Through Lens of Complexity. The books essential message is: Obama has bitten off more than he can chew and will be reduced to taking small bites.

Here is the tentative foreword,

President Barack Obama has vowed to overhaul the U.S. health care system and to spend more than $1 trillion over the next ten years while doing it. He seeks to lower costs, expand access, increase efficiencies, and cut spending.

I would place odds for sweeping reform at 20/80 in his first term, and odds for immediate incremental changes such as coverage for children, stem cell financing, funding for electronic records, and extension of unemployment benefits to Medicaid as slam dunks.

I expect other issues now being debated and demonstrated at Medicare – such as pay-for-performance, competitive bidding for Medicare Advantage plans, government negotiating of drug prices, medical home expansion, bundling of hospital-physician bills, creating integrated groups, coordinating care, forming a Federal Health Board, creating a Comparative Outcome Institute, and mandatory use of EMRs as a condition for payment – to make slow, uneven, and unpredictable progress with a few setbacks.

Otherwise, the debts incurred by the economic stimuli and the staggering federal deficit ( $1.75 trillion for 2010) will be too steep a hill to climb for those who crave universal coverage or single-payer in the near term.

I do not see how Obama in the next few years can create 3.5 million jobs, redesign the entire health system, save the auto industry, reinvent the energy sector, revitalize the banks, and reform education – with one bold swipe of his political magic wand.

The bold strategy and breathtaking scope of Obama’s health plan became apparent when he unveiled his budget plan on February 26 Obama would use current political power his first 100 days to set in motion a 10 year plan culminating in near universal coverage.

He would set aside $634 billion as a “down payment” for a plan eventually costing over $1 trillion. Half the money would come from higher taxes and lower deductions on those making over $250,000; the other half from Medicare and Medicaid cuts with the biggest hits coming from hospitals, doctors, health plans, drug companies, and home health agencies.

The Obama plan would “tighten” payment to doctors. Translated, this may mean lowering payments to specialists and compelling them to participate with hospitals in “bundled” payments for such high ticket procedures as hip and knee replacements and cardiac stent and bypass.

However, the budget sets aside $330 million for loan repayments and other support for primary care doctors who practice in doctor short areas. For doctors, the budget proposal has a big positive aspect. It protects doctors against across-the-board Medicare budget cuts based on the SRG (Sustained Rate Growth) formula.

How one at the same time covers more Americans while slashing costs eludes me. Expanding coverage always costs more. It goes by the name of the entitlement syndrome, which means cutting costs is the improbable meeting the impossible.

I only know one thing- and it’s a big thing. It will be impossible to superimpose a single-payer system on the current system – and to save money in the process. In the jargon of today, the infrastructure must be changed before we impose a new suprastructure.

I wish the President the best. The present state of affairs – unhappy patients, unhappy doctors, soaring costs, and 15% uninsured – cannot last. At least that’s what we keep saying. Health costs, mainly Medicare and Medicaid, consume 25% of the federal budget, and more cost rises are on the way and are unsustainable.

President Obama faces four towering obstacles to reform. I call them the four “Cs.”

Culture, American style, abhors the word “rationing.” Our culture cherishes unlimited choice, quick access to the latest and best in medical “cures,” and lifestyle restoring technologies.

Complexity, American health care is a whirling Rubik’s Cube, with millions of interrelated moving parts, institutions, and people, each with own agenda and axes to grind.

Costs, Obama says prevention, electronic medical records, and paying only for what works, as established through comparative research, will save billions of dollars, yet little evidence exists that these measures work.

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 only growing employer in town. Collectively, health care has a profoundly positive economic impact and cannot be dismantled quickly – if at all.

Given these truths and consequences, I offer in this book my observations, gleaned in part from my writings, in part from conversations with health care people on the ground, and in part from public discourse in the media.

Someone once said books about Lincoln, doctors, and dogs always sell well, so the perfect book would be Lincoln’s Doctor’s Dog. This observation partially accounts for my title, Obama, Doctors, and Health Reform. President Obama admires President Lincoln; doctors are still doctors, not yet replaced by nurse practitioners and physician assistants; and politically, until now, sweeping health reform has always been a political dog. But not under President Obama. Health reform is coming – ready or not.

A concluding note to members of the general public with courage enough to tackle this book. Health reform is complex because it involves the expectations of our culture. Everyone of us will need health care at some point in our lives; everyone will expect the best American medicine has to offer; everyone, directly out of our pocketbooks, or indirectly thorugh government and employers will have to pay for it.

Health reform is like a duck. It quacks and glides above but paddles furiously below.

• Health reform can be viewed from top-down, from policymakers and politicians point of view. The interests of policymakers, sometimes dismissed as wonks or gurus, are generally directed towards developing an all-purpose system that glides smoothly along the surface with primary physicians, with modern day Marcus Welbys working as teams. delivering more effective, efficient, and affordable services; public and private entities working in tandem to prevent chronic disease through prevention; all making sure that what we pay for works through comparative effectiveness research.

• Or you can look at it from below, where hospitals, patients, doctors, and big suppliers, like health plans drug companies, businesses are paddling furiously to adapt and adopt to government-imposed policies, as the Obama administration rewrites the rules, decreasing pay to hospitals and doctors and health plans and drug companies, while promising to expand coverage through Medicare and Medicaid.

We’re all part of the same duck, joined at the junction of water and sky. Perhaps this book will help observers understand that political idealism meets clinical realities at the interface of water and hot air, and it is there maybe we can keep the health system from becoming a dead duck.

As you read this book, keep in mind two fundamental differences between physicians and those who would fundamentally transform the system.

• Physicians are trained and accultured to treat and cure disease and to alleviate pain. That is what they are trained and paid to do, and they are not as confident as those who have never been in the clinical trenches that they can change unhealthy patient behavior once patients leave the office or the hospital.

• Policymakers, on the other hand, tend to think that prevention should automatically be part of the physicians’ “toolbox, “ and that care should be coordinated across the entire health spectrum from womb to tomb, but physicians should not necessarily be paid for time spent in discussing prevention or in coordinating care outside their realm.

Have a good read – and even a little fun – despite the gravity of the subject matter, the depth of the recession, and the scope of President Obama’s ambitions

Costs - Simple Answers to Complex Questions

For every complex question, there is a simple answer – and it’s wrong.

H. L. Mencken, 1880-1956

Seek simplicity – and distrust it.

Alfred North Whitehead, 1861-1947

If you look to government for answers to complex questions, the answers are simple – more government , or more precisely, re-inventing the role of government.

I was thinking of this simple concept when reading a piece “Re-Inventing Health Care; The Role of the States” in RealClearPolitics.com. The author, David Osbourne, is co-author of Re-Inventing Government and Price of Government and serves as a senior partner in the Public Strategies Group.

Osbourne says the the “core problems” of high health costs are really quite simple.

• Fee-for-service payments that encourage waste.

• Fragmentation of services that makes management of costs impossible and leads to administrative overheads of 25% to 30%.

• Lifestyle abuses that are creating an epidemic of obesity, diabetes, and heart disease.

The answers, according to Osbourne, are equally simple – reward competitive groups, lump their payments, and phase out those who choose not to cooperate, to wit,

• Go around fee-for-service by having integrated groups compete and be paid an annual fee for managing “cycles” of care – 9 months of pregnancy care, one year of diabetic care – or for bundles or packages of hospital care – e.g, joint replacement or heart procedures.

• Get state plans to join with private plans in competitive “purchasing pools.”

• Reward integrated groups , which are said to be more efficient, and phase out “fragmented,” independent practitioners.

• And finally, think of creating a government-sponsored Healthy Lives Trust with the power to define eventto prohiit harmful food and beverages, and to tax the hell out of them. Launch massive public health campaigns to discourage smoking, drinking, over-eating, under-exercising, and drug-use.

In other words, put Big Brother , the federal government, and his Little Brothers, the States, in charge, and all in health will be well, costs will be swell, and the independent private sector can go to hell.

My only problem with all of this is:

it won’t work, and it will compromise choice and individual freedoms in a supposedly free society.

Maybe it would make more sense to curtail the promises of entitled care, and have citizens pay more for care related to behavioral abuses, i.e, dis-incent rather than re-invent government.

Mayo Clinic, interviews - Chat with Retiring Mayo Clinic CEO

I assiduously follow three other blogs – The Health Care Blog, the WSJ’s Health Blog, and KevinMD – in search of material and chances to comment.

Here is my latest comment on a February 27 WSJ blog, Health Blog Q&A: Mayo Clinic CEO Cortese, in which Cortese, a pulmonologist, chats about the changes he’s like to see in American health care.

There once was a Mayo doctor named Cortese,
Who about his future was breezy and hazy,
When his health turns for the worse,
He will email a nurse to relieve the strain on his purse
Careful, Dr.Cortese, lest you end by pushing up a daisy

This is tongue-in-cheek, but many of more than 60 comments on what Dr. Cortese had to say were acid in their comments.

This shows to go you, what a tangled web you weave when you try the health care crisis to relieve. As for myself, I admire the Mayo Model. But given the fact that 75% of doctors practice in groups of ten less and cherish their independence, I just cannot foresee a system run a series of Mayo-like physician organizations.

Health Blog Q&A: Mayo Clinic CEO Denis Cortese
Posted by Jacob Goldstein

Denis Cortese is stepping down later this year from his job as Mayo Clinic CEO, as the clinic’s hometown paper reported this week. Cortese has had the job since 2002, and he’s become more involved in national health policy in the past few years. We were interested to hear what he’ll be doing next, and we got him on the phone today (which happens to be his 65th birthday).

Here are the highlights of our conversation.

Why are you leaving now?

I’d like to get out of day-to-day stuff. I want to have a job trying to foster discussion at the national level. How do we design a health-care delivery system in the United States? It’s not just getting everybody insured — that’s the easy part.

What’s the hard part?

Everybody’s got to lose something here. Physicians may have to have lower salaries. They may have to shift their thinking away from just doing things for patients when they’re sick. Shift over to, ‘I’m in the business of finding ways to keep people healthy so I do fewer procedures.’

Insurance companies may have to insure everybody and quit worrying about pre-existing conditions.

Hospitals are going to have to think that they’re no longer the center of the universe. The center of the universe should be patients. Hospitals should be viewed as the symptom of failure of the health system. I’ve never met a patient who wanted to go to the hospital.

What’s an example of the kind of systems you’d want to create?

I’ve got five chronic medical medical problems.

Wait — are you speaking hypothetically?

No. I have some atrial fibrillation, a little high blood pressure. I don’t need to see a doctor for that. When I’m having a little problem, why can’t I just call the nurse or send an email and ask them what I should do? Or even better, that person hounds me once in a while and makes sure I’m doing what I should do.

Where are you headed next?

There’s an option in Seattle, there’s an option in Arizona. There are academic centers that are interested in having health-policy centers started. [Or maybe] some kind of a social business that’s taking a systems-engineering approach to health care.

What about a job in the Obama administration?

Nobody’s approached me. If the job were right, it would be an option. I’ve not seen anybody yet ready to go the level I’m talking about, which is the design of the delivery system.