Sunday, May 31, 2009

Physician shortage, effect of culture, physician culture - The Baby and The Bathwater

As a doctor, it continues to be amazing to me how the bulk of the Washington-New York-Boston medical and political establishment has gone to war against doctors.

The establishment includes the following: The New York Times, the New England Journal of Medicine, Health Affairs, a wide assortment of policy wonks, the Obama administration, Peter Orzag of the Office of Management and Budget, Senators Kennedy and Baucus, Representatives Waxman and Stark, Karen Davis of the Commonwealth Fund, Dr. Donald Berwick of the Institute of Health Care Improvement. Dr. Fisher of the Dartmouth Group, and Obama’s Boston-based health policy advisors.
The establishment’s message is: as the most visible symbol of the current “broken” health care system, doctors are at fault, and all will be well if only we as a nation can,

• Put into place a public plan closely resembling Medicare and Medicaid to pay doctors less at CMS rates.

• Install EHRs and a Comparative Effectiveness Institute to guide hapless doctors along the path of moral righteousness and what works and doesn’t work.

• Drop fees into a government homogenization blender to bring down costs of high spending regions to low spending regions.

• Use data to erase differences between the most expensive doctors and hospitals to the least expensive doctors and hospitals.

What this assault on doctors fails to mention is, establishment policies will,

• Alienate doctors, causing fewer to enter the profession and more to leave.

• Worsen the doctor shortage, making a mockery of providing more access to the uninsured.

• Create already lengthening waiting lines for doctor appointments, as is occurring Massachusetts.

• Drive more hospitals and doctors out of business as Medicare rates are extended to the private sector.

• Cause more doctors to go underground into concierge or cash only practices, or above ground into nonclinical positions.

• Stifle private innovations with more regulations.

• Substitute bureaucratic judgment for independent clinical judgment.

• Limit choice of doctors, hospitals, and health plans.

Now it may be the political establishment will come up with replacements for independent doctors - physician assistants, nurse practitioners or nurse doctors, foreign-trained doctors, or mega-groups with clinical teams with a doctor here or there.

But until then, I am willing to bet most members of the political and policy-making establishment will seek out a private physician while they are ill while they are trying to answer public’s questions: Where have all the doctors gone? Why can’t I have a private doctor? Why can’t I have access to the very best medical technologies? Why can’t medicine be the way it used to be?

In the end, somehow we must have a vibrant physician community and affordable care for more. This ideal situation will require balance with trade-offs between private and public interests. The health system can't provide it all - collective equality and individual choice. There should be equal opportunity - but results will not be equal for all.

Saturday, May 30, 2009

Health care realities - Dealing with Health Reform Realities

Hell is paved with good intentions.

Samuel Johnson, in Boswell’s Life, 1775

In finance everything that is agreeable is unsound, and everything that is sound is disagreeable. Expenditure is always popular; the only unpopular part about it is the raising of the money to raise the expenditure.

Winston Churchill

If you can’t stand the heat, get out of the oven.

President Harry Truman

As I write, Congress is on vacation, but it will soon be back in the Washington oven to deal with red-hot health care issues – how to pay for it all given anxieties over,

• a continuing recession with rising unemployment,

• mounting federal deficits, unaffordable health care costs,

• making care affordable with harming a growing health care economic sector and its constituents wo supply many of the jobs in their district,

• meeting public demands for easy access to medical technologies,

• creating a public plan that may make health care more inaccessible by driving hospitals and doctors out of business by paying them at Medicare and Medicaid rates.

• Fending off but pleasing lobbyists who fill their political coffers

Political Realities

Senators Ted Kennedy and Max Baucus are split on how to finance President Obama’s ambitious, fold, and unaffordable health proposals. Kennedy favors a public plan that looks like Medicare, while Baucus is reluctant unless the public plan makes private plans more affordable for all Americans. The financial honey-pot is the $300 billion now spent yearly in tax-free benefits that employers now enjoy for providing health benefits for employees. But doing that means making a political U-turn and embracing the Republican plan, which candidate McCain announced and Obama denounced during the campaign. Republicans fear a public plan would drive private plans out of business and lead to a single-payer system, or even worse, a public plan that would pay at Medicare rates, 20% to 40% below private rates.

Financial Realities

How to pay for it all? It is now clear, the Medicare “savings” proposed by President Obama are unproven to work and would only be band-aid in raising capital to cover proposed expenditures, estimated to be $1.5 trillion over 10 years. The alternative to raise expenditure is to raise sin taxes on tobacco, alcohol, and soft drinks, and by extension, anything else fattening, artery-clogging, pleasant, sedentary, or involved in the “pursuit of happiness.” Taxing health benefits at least has the benefit of punishing business. Then there’s VAT. Ezekial Emanuel, MD, the brother of Obama’s chief of staff Rahm Emanuel and Obama’s go-to-doctor, is calling for a VAT (Value Added Tax)to pay for every American not entitled to Medicare or Medicaid benefits with no deductions and no co-payments. Unfortunately VAT is an open-ended invitation to entitlement growth. Then there’s the recession. USA Today reports federal tax money is down 34% over last year, $138 billion less in April alone, making how to pay for federal largess even more problematical.

Personal Realities

Meanwhile I am making final corrections on the proofs of my book Obama, Doctors, and Health Reform. In it I give a kaleidoscopic multiple-points-of –view picture of the U.S. health care landscape. I place the odds for sweeping Obama reform at 30/70.

It’s going to a long hot summer for the reform debate. If you think health care is expensive now, just think of the consequences of a government-run system superimposed on the present system.

One of the great ironies of the current debate is that President Obama says, “We’ve got to get it done this year,” but his administration has yet to introduce a detailed reform proposal, and instead, waits for Democratic allies to work out the specifics – and to take the heat if it fails.

Thursday, May 28, 2009

Goverment vs. market reform, use and misuse - Collectivism, Individualism, and Data-Driven Cost Control

It is not possible to draw a hard-and-fast line between individualism and collectivism. You cannot draw it either in theory or in practice. That is where the Socialist makes a mistake. Let us not imitate that mistake. No man can be a collectivist alone or an individualist alone. He must be both an individualist and a collectivist. Collectively we light our streets and supply ourselves with water. But we do not make love collectively and the ladies do not marry us collectively.

Winston Churchill, 1906

Much of the health reform debate swirls on collectivism versus individualism. To hear partisans on both sides tell their stories, there is no middle ground between socialism on the left and laissez-faire capitalism on the right. The truth is, of course, that the United States has, and will always have, a pluralistic health system featuring both public and private plans.

What the debate is about is a balance between the two. That’s what the folderol is about between the collectivists’ proposal to have a public plan, with a huge built-in constituency and the federal treasury as a financial fallback competing with private plans, against the private sectors pleas to award patient responsibility and physician entrepreneurship.

Both sides naturally talk about “freedom” and “choice,” the hallmarks of individualism. That’s why the conservative stoutly maintain that effectiveness research will result in bureaucrats, not doctors, deciding what care you will get. That’s why President Obama uses this language.” If we want to cover all Americans, we can’t make the mistake of trying to fix what isn’t broken. So if you have insurance you like, you’ll be able to keep that insurance. If you have a doctor you like, you can keep that doctor. You’ll just pay less for the care that you receive.”

Under any federal plan, you will pay less, in the short run.. That’s because Medicare pays doctors and hospitals 20% to 40% less, $89 billion less each year, than the private sector pays. That’s because Medicare has $34 trillion in unfunded benefits for Medicare beneficiaries that will come due in the future. And that doesn’t include Medicaid. Add Medicaid in, and the unfunded benefit cost goes up to $52 trillion.

Reducing Public and Private Practice Variation

One way backers of more government intervention propose to control costs is to reduce practice variation among Medicare recipients and then for the under 65 crowd, lowering practice variation among health plan members. The root idea is to equilibrate payments in “high spending regions” to payments in “low spending regions.” And on the private side, to bring the “most expensive physicians” in line with “least expensive physicians,“ assuming of course they have the same outcomes. The result, according to the Dartmouth Group, is that we can reduce overall spending by 30%, and use the money “saved” to cover the uninsured.

This lovely idea is “data-driven.” It is claimed (no pun intended) you can use claims data, to prove the variations are “unwarranted” and driven by overuse of resources by hospitals and doctors. Data is compelling because data is “neutral” and because it can be effectively used to show that inexplicable variations exist and can be deployed to induce expensive providers to lower their charges and to do what is right and rational for the collective good. If, in the process, it embarrasses the over-chargers or makes them swing to the lower branches of cost, that’s good too because abusers deserve to be exposed.

If you would like to read a beautifully written explanation and justification of the 30% solution, I invite you to read Dr. Atul Gawander’s report in the June 1, 2009 New Yorker, “Annals of Medicine, the Cost Conundrum, Expensive Care Can be Harmful, What a Texas Town Can Teach Us about Health Care”

Dr. Gowanda compares the expensive and practices of doctors in McAllen, Texas, against those of the Mayo Clinic, and says, sadly, “In the war over the culture of medicine – the war over whether our country’s anchor model will be Mayo or McAllen – the Mayo model is losing. In the sharpest economic downturn that our health system has faced in half a century, many people in medicine don’t see what they should to the hard work of organizing themselves in ways that reduce waste and improve quality if it means sacrificing revenue.”

In other words, in Dr. Gawander’s opinion, physician individualism is winning out over the collective societal good.

Wednesday, May 27, 2009

Cost, Herzlinger, consumer-driven care - Health Reform and Cost Control

Regina Herzlinger, the Harvard Business School Professor and Queen-Mother of the Consumer-Driven health movement, feels nothing much will come out of the current health debate, aimed at slowing growth of health costs, unless we have realistic means of cost control. In short, no cost control, no universal coverage.

Here are some of the reasons for her skepticism, as expressed in “Can The United States Provide Health Care for All?, an article written for the McKinsey consulting firm.

Although the Democrats tout various other magic bullets for health care cost control—invigorated health care IT, oodles of prevention, miraculous reversions of destructive lifestyles, and centers for measuring relative cost effectiveness, even President Obama’s budget director pooh-poohed their likely impact when he headed the Congressional Budget Office. Most Americans do not believe these miracle solutions will do the job, either.

• The experience of Massachusetts provides a sobering lesson about the results of expanding universal coverage without paying attention to cost control. As more than 300,000 people gained insurance, costs also increased. Not surprisingly, the number of enrollees who needed subsidies was higher than expected. When the recession hit once wealthy Massachusetts, the increase in health-care costs helped tip the state into a billion-dollar deficit. The Commonwealth is now contemplating cost control through all-payer regulation, in which the state effectively sets the prices for health insurance. If this Massachusetts solution seems like the road to a single-payer system, under which the state government controls all health care expenses, that’s because it is.

She goes on,

Medicare is alleged to be a good cost controller and one that avoids the rationing of the single-payer economies. But Medicare is low cost only because government accountants are permitted to ignore inconvenient truths: $34 trillion in unfunded liabilities plus $89 billion in underpayments to medical care providers, which are ultimately paid by private insurers. With correct accounting, Medicare’s cost would increase by more than a trillion dollars. Further, if Medicare were the sole US health insurer, it would either increase its payments to providers by $89 billion or the current near-shortage in doctors would reach crisis proportions as medical students and graduates, burdened by huge debts and limited financial prospects, chose other professions.

What is the Obama administration’s response to such criticism? To tinker with Medicare by introducing these budgetary “savings.”

• Establish competitive bidding for Medicare Advantage plans, $177 billion
• Reduce home health payments, $34 billion
• Reallocate Medicare Advantabe fund, $23 billion
• Bundle hospital-physician payments, $16 billion
• Base hospital payments on quality, $12 billion
• Reduce readmission rates, $8 billion
• Increase part D payments to high-income seniors, $8 billion
• Speed pathway for generic drugs, $6 billion
• Improve payment accuracy for Medicare contractors, $2 billion
• Minimize cost variations between high spending Medicare and low spending regions, a potentially savings of 30%, roughly $700 billion.

Given the over $1 trillion CMS budget, everybody knows these savings are either tokenism or unlikely politically, and more radical and political unpalatable changes such as eliminating the $300 billion subsidy for employer-sponsored benefits, higher sin taxes (alcohol, tobacco, sweetened drinks, high fat foods), and higher across the board income taxes will be required to cover all.

Another alternative might be to take the Republican approach of giving vouchers and tax credits of $5000 or more, or offering health savings accounts with high deductible plans, to all to spend their own money as they please. But that would require trusting consumers to assume responsibility for spending their own money, rather than depending on the wisdom of Washington.

Or one could change the health care paradigm from a government-entitlement mentality, which John Goodman of the National Center for Policy Analysis dismisses as “an unworkable government Ponzi scheme” – to a market-based consumer mindset.

In her article, “Can the U.S. Provide Health Care for All?, Dr. Herzlinger concludes.

The combination of invigorated supply and demand is the only health care reform plan that will avert the economic disaster that otherwise awaits us and, simultaneously, make health care available to all.

Sadly, it is a solution that the Washington, DC, establishment, which doubts the wisdom of consumers and the competence of entrepreneurs, is most reluctant to effect

Thursday, May 21, 2009

physician demoralization, physician harassment, Bureaucracy - A Beast of Burden for Medical Practices

The administration of government through departments and subdivisions managed by sets of appointed officials following an inflexible routine.

Definition of Bureaucracy

I'm against big bureaucracy in Washington making health care decisions. I just have an aversion to bureaucrats. But it's not just government bureaucrats. I don't like HMO bureaucrats and insurance company bureaucrats either.

Gary Bauer

Doctors often complain of bureaucracy, or red tape, as a drain on their time, a needless expense, and a distraction from patient care. But bureaucracy for many remains an abstraction – an elusive monster with multiple tentacles. The Medical Group Management Association (MGMA) has done us a favor by nailing the specifics of the Bureaucratic Beast.

Total cost of medical practice interaction with insurers is $21-$31 billion a year

ENGLEWOOD, Colo., May 14, 2009 - Physicians spend three hours per week - or 43 minutes on average per workday - interacting with health insurance plans, according to research published today by Health Affairs. The study, conducted by the Medical Group Management Association (MGMA), Weil Cornell Medical College, the University of Toronto and the University of Chicago, found that total staff interaction time system wide converted to dollars equaled $21-$31 billion annually, or more than $68,000 per physician per year, on average. MGMA's Vice President of Practice Management Resources David N. Gans, MSHA, FACMPE and Senior Fellow Terry Hammons, MD, co-authored the study, "The Costs to Physician Practices of Interactions with Health Insurance Plans."

The research found that primary care physicians spend more time on these interactions than medical or surgical specialists. Nursing staff spend nearly four hours per physician per day interacting with plans; clerical staff spend 7.2 hours per day. Solo practitioners and their staffs spend up to 50 percent more time interacting with health plans than physicians in larger practices. Non physicians' staff time did not vary significantly by specialty.

The study classified interactions with health plans as authorization, formulary, claims/billing, credentialing, contracting and quality data. Of those interactions, practices spend the most time dealing with formularies: physicians spend 1.3 hours per week and nursing staff spend 3.6 hours per physician per week. Primary care physicians spend the most time (1.7 hours weekly) on formulary issues. Physicians and their staffs spend the least amount of time on submitting or reviewing quality data.

"These data are yet another indicator of the dire need to streamline health care administration for physician practices," said William F. Jessee, MD, FACMPE, president and CEO of MGMA. "MGMA is committed to being part of the solution and has proposed three basic recommendations that could be enacted by Congress and the Administration right now. Alone they could save physician offices nearly $40 billion dollars over the next ten years. While interactions with health plans by physicians and staff cannot be avoided entirely, we must collaborate on ways to reduce this resource expenditure to an acceptable level."

Physician shortage, primary care - Problems and Promises of Paradigm Shift to Primary Care

Yesterday, along with 17 other bloggers, I participated in an interactive IBM sponsored conference call, “The Patient-Centered Medical Home, What, Why, and How? A Blogger Briefing.”

IBM, the nation’s 4th largest employer, is an excellent example of how large employers are moving decisively to lower health costs.

I won’t go to into details of the hour-long briefing, which was a preview of a 4-author IBM study of prospects and strategies for building medical homes. Paul Grundy, MD., Global Director of Healthcare Transformation at IBM, spearheaded the IBM study and the blogger briefing.

One Conclusion

One conclusion of IBM’s presentation struck me,

It will not be easy to implement medical homes on a large scale even with the current momentum behind them, given challenges such as funding and level of change required.

Indeed, it will not be easy, for it entails a broad paradigm shift from a specialist-driven to a primary care-driven U.S. health system. Given the momentum already achieved through backing by the Obama administration, the AMA, the Association of Medical Colleges, all of the leading national primary associations, and many state legislatures and given the forces crying for fundamental health care reform change, medical homes will the part of the medical landscape in the near future, but there will be startup problems and problems of scale.


1. Paradigm shift magnitude – Two thirds of U.S. physicians are specialists, and one-third practice primary care . It takes 10 years to produce a primary care doctor, longer to produce a specialist. Like it or not, true or not, consumers, hospitals, academic centers, and the public at large are conditioned to think specialty care is superior. Many medical and business organization, including specialist organization, profit from the status quo, and they will resist change.

2. Paucity of primary care physicians – The number of primary care physicians is shrinking rapidly, and less tha 10% of medical students are planning careers in primary care. This makes adoption of a primary-care centered model on a broad scale difficult, particularly in “sophisticated” medical markets long dominated by specialists and among hospitals, whose bottom-line depends predominantly on high tech specialty care rather than on generalist care.

3. Prestige of primary care physicians low - In academic teaching centers, hospitals, and the public at large, primary care prestige is low. This lack of prestige lessens the likelihood medical students will choose primary care careers. In teaching hospitals, you sometimes hear the term primary care doctors dismissively referred to as the LMD, or local medical doctor. Specialists dominate the faculties of leading academic centers and medical students soon learn spciality care is where the power. the glory, and the money resides.

4. Pay of primary care low – Reimbursement rates of primary care sanctioned by Medicare are 55% of what specialists are paid, and Medicaid rates are even lower. Health plans follow Medicare physician payment patterns. Medical students know this. Furthermore, primary practitioners typically work longer hours than specialists. It doesn’t take a rocket scientist to figure out why medical students shy away from primary care.

5. People confuse medical home “gateway” approach with the failed “gatekeeper” of managed care. – The gatekeeper model of managed care, whereby HMOs deemed primary care doctors at gatekeepers to specialists, failed, and in the process, antagonized patients, did not diminish flow of work to specialists, and “disintermediated” primary care practitioners. Explaining why the medical home concept is different, i.e why it empowers primary care practitioners, is difficult.

6. The paragons presented as models of medical homes, i.e, integrated group practices with salaried physicians, are not representative of mainstream physician practices. Certain organizations – Kaiser, Mayo, Geisinger – are often cited as examples of how medical homes could be organized. However, these and similar organizations models only care for 10% of Americans. Expanding these models or creating new ones, and shifting patients to these oragnizations on a large scale will be difficult or impractical.

7. The propensity of the current system geared to doing more generates more revenues. – Let’s face it. The current fee-for-service system rewards most major stakeholders – physicians, hospitals, health plans, suppliers, drug and device manufacturers – to do more and provide more services. It’s difficult to turn this paradigm around – to interpose primary care physicians as brakes and guides for the system. As yet, and despite the favorable rhetoric (who could be against compassionate primary care doctors providing coordinated and comprehensive care), the medical home has not gained widespread traction among most medical stakeholders.


8. Personal physicians produce better outcomes - Studies of health systems with a preponderance of primary care physicians with a broad personal knowledge of their patients, practical preventive measures, and close relationships with specialists consistently show better outcomes – lower mortality and morbidity, lower costs, fewer heart attacks, less smoking, better health habits, lower rates of obesity.

9. Patients respond positively to trusted physician advisors both in matters of health and in fiduciary matters - Reliance on primary care advisors is likely to grow as complexity, contradictions, and costs whelm patients and patients seek authoritative information based on physicians’ practical experience and ability to them navigate through the medical maze.

10. Practical models that truly empower primary care physicians and lower costs as demonstrated by irrefutable data will emerge and will move medical homes forward - It is one thing to tell warm and intimate anecdotes about the power of personal and productive interactive relationships of patients and primary care physicians in a medical home environment.

It is quite another to move health plans, the government, and the medical and technological establishment off the dime to fund medical homes models.

The latter sometimes take impending financial failure and data. Still, the realities that health plans have lost 13-14% of their membership over the last 3-4 years, that hospital admissions are stagnant, that the recession continues to deepen, that the business community has lost their global competitive edge due to exploding costs, that Medicare is on the verge of bankruptcy, may not be sufficient signals for the need of a paradigm shift to primary care.

Desperation and clear irrefutable data - from integrated multispecialty groups, multiple medical home demonstration groups, onsite clinics in corporate settings - showing signficant drops in costs, may be the impetus leading to a fundamental paradigm shift back to primary care.

The levers for this shift are likely to come from business organizations, who can move quickly to save their skins and satisfy shareholders, not from the political establishment, which by its very nature moves with glacial speed.

Tuesday, May 19, 2009

Physician shortage, doctor shortage, physician payment -Slam The Doctors - Lose The Doctors

The spur for this blog comes from the May 18 Wall Street Journal. That issue contains an opinion piece “Soak the Rich, Lose the Rich.” Arthur Laffler, creator of the Laffler Curve, which says that at a certain point, the rich simply stop paying taxes, and Stephen Moore, senior economics editor of the Journal, note that many states are raising taxes on the rich to pay for budget shortfalls,

“Here’s the problem for states who want to take money out of the wallets of rich people. It never works because people, investment capital, and businesses are mobile. They will leave tax-unfriendly states and move to tax-friendly states. Texas has the jobs and the prosperity model exactly right. Texas created more new jobs in 2008 than all other states combined. And Texas is the only state other than the Georgia and North Dakota that lowered taxes this year.”

It’s not that doctors are “rich,’ though many specialists make over the $250,000 set by the Obama administration as the threshold for the “rich.” It’s that doctors are mobile. The U.S. remains a free country, and if doctors don’t like the status of their profession and their practices, they can travel to another state, retire, move to another specialty, refuse to accept Medicare or Medicaid patients, go to work in a nonclinical job, set up a concierge practice, see patients on a “cash-only” basis, accept only patients with health savings accounts in high deductible plans, or go to states like Texas with low taxes, low costs of living, and low malpractice rates. And to Texas, doctors are moving in record numbers, for these and other reasons.

For a number of years, physicians, as the most visible symbol of health care delivery, have been criticized, chastised, and blamed for everything -- as the primary source of exploding health costs, practicing poor quality care, to being computer troglodytes for failing to accept money-losing electronic health records designed to document their every act.

Furthermore, each year doctors must beg Congress not to cut Medicare reimbursements. This June Medicare pay is scheduled to be slashed 21% in 2009 according to an unworkable and unrealistic Sustainable Growth Rate (SGR) formula.

This year’s health reform proposals promise to make practice even more unpleasant by threatening to punish doctors economically who do not adapt EHRs, making them comply with pay-for-performance criteria, and to pay only for those procedures or tests that a federal board proclaims to be effective.

It’s enough to make some doctors paranoid and to induce massive demoralization among primary care physicians, already at the low end of the physician economic total pool. If a 2008 survey of 270,000 primary care doctors is any indication, there is widespread discontent among these doctors, Here are some of the highlights of the survey.

Most physicians—78%—said they believe there’s shortage of PCPs in the United States today. Also, 49% of physicians—more than 150,000 doctors nationwide—said that over the next three years they plan to reduce the number of patients they see or stop practicing entirely. The responding physicians said that by 2011:

• 11%, or more than 35,000 doctors nationwide, plan to retire

• 13% plan to seek a job in a nonclinical setting, which would remove them from patient care

• 20% will cut back on the number of patients they see

• 10% will work part-time.

Also, the survey shows, 60% of doctors would not recommend medicine as a career to young people. Declining reimbursement was rated highest on the list of issues respondents identified as impediments to delivering patient care, followed by demands on physician time.

When asked about the business aspects of their practices, only 17.5% of respondents said their practice was healthy and profitable, 47.9% said their practice was profitable but with low margins, 22.4% said they were breaking even, and 12.2% were unprofitable. If they had the financial means, 45% of responding physicians said they would retire today.

You can tax doctors all you want, reduce their fees, regulate them, blame them for system dysfunction, but these actions taken collectively, are likely to reduce the number of existing doctors, discourage young people from entering the profession, and cause mobile doctors to adopt other options. One of the most common options is not seeing new Medicare and Medicaid patients because of low rates of payments and high burdens of paperwork.

The moral of this tale:
without more doctors, health care reform measures promising greater access is meaningless, and more regulations, more information technology, more cuts in reimbursement, even more token rewards for installing EHRs and meeting quality indicators, are not likely to produce more doctors.

Sunday, May 17, 2009

Blogging, doggerel - The Need for a System to Make Hard Health Care Decisions.

There are those who say to make health decisions,
That will computerize and cure U.S. care divisions,
All we need is a nationalized health care “system,”
A way to decide between the views of “us” and “them,”
Then, we can avoid ideological collisions.

Then, agreed-upon rules will prevail,
Then, we need not heed personal detail,
Then, a neutral numeric system will decide.
Then, we can toss individual disputes aside.
Then, appeals for resolution will be of no avail.

Then, we can rely of data-loaded commonsense,
Then, no longer will we wallow in human suspense,
and squabble about who is wrong and who is right,
Then, it will become as simple as day and night.
The system will choose the right side of the fence.

Fear not, bureaucrats will know exactly what to measure,
What rules to apply to protect the Medicare treasure.
The number crunchers will know what’s effective,
And what treatments are statistically defective,
For the data will decide what is sure and pure.

When it comes to the hard choice,
Do not listen to any other voice,
Count on the federal system.
Do not for a second it condemn,
In its numeric wisdom, rejoice.

Statistics, you will be told, never lie,
You can trust federal figures to the sky.
Unless you distrust data perusers,
And suspect them of being abusers,
Then, you decide what care to buy.

Saturday, May 16, 2009

Data-driven care, heart disease, prevention - Evidence-Driven Care: The SHAPE of Things to Come

By Richard L. Reece, MD, author of Innovation-Driven Care: 34 Key Concepts for Transformations (Jones and Bartlett, 2007) and Obama, Doctors, and Health Reform: A Doctor Assesses Odds for Success (Iuniverse, 2009)

The future is embedded in the present. Only an objective and unbiased study of the present can reveal the future.

John Naisbitt, Author of Megatrends (1982) , and Mind Set! (2006)

How can we move towards a high-quality, lower-cost health system? There are four key steps: 1) health information technology, because we can’t improve what we don’t measure; 2) more research into what works and what doesn’t, so doctors don’t recommend treatments that don’t improve health; 3) prevention and wellness, so that people do the things that keep them healthy and avoid costs assocated with health risks such as smoking and obesity; and 4) changes in financial incentives for providers so that they will be incentivized rather than penalized for deliverying high quality care.

Peter Orzag, director of the White House Office of Management and Budget, “Health Costs are the Real Deficit Threat,” Wall Street Journal, May 15, 2009

I’m not a cardiologist. Rather I’m a retired pathologist and commentator of the role of innovation and the probable impact of the Obama administration’s proposed health reforms. I’m also a hard-nosed pragmatist who believes future Medicare and health plan payments will flow to those who provide hard data to back their claims.

A Beginning

Let me being by stating the obvious. We are in an era of data-driven health care. We are also in an era in which health costs threaten to bankrupt Medicare. To head off this bankruptcy, government will focus on bringing down costs on preventing and treating those chronic diseases – coronary artery disease, heart failure, chronic obstructive lung disease, depression, and asthma – and precursors that consume 70% of costs.

And government will concentrate on high ticket procedures for evaluating and treating health disease – coronary bypass, diagnostic angiography, coronary stents, and cardiac pacemakers – for it there that Medicare expends massive funds, funds it will try to justify, rationalize, reduce, or even deny in any way it can.

Anticipating Government Actions

The diagnostic and invasive cardiology industry should anticipate inevitable government actions to reduce costs – and take constructive, objective, and innovative steps to meet the threat. I belong to the school of innovation that says there’s rarely anything new under the sun. Evaluation of heart disease with or without accompanying pulmonary disease is a good example. Doctors in general and cardiologists in particular have known or sensed the following for a long time.

• Shortness of breath is a common presenting symptom of underlying heart and pulmonary disease.
• Shortness of breath is a sign of underlying disease rather than of normal aging.
• It’s difficult to differentiate whether the cause of dyspnea is cardiac or pulmonary or a combination of both.
• Heart and lung function are interrelated but no devices are available to conveniently available to evaluate both functional relationships.
• Some sort of early warning device to spot heart and/or pulmonary disease would be useful before either disease reaches chronic, and progressive and irreversible stages.
• The traditional coronary treadmill stress test is useful for evaluating cardiac ischemia but carries a small risk requiring the presence of a cardiologist.
• Portable devices for measuring functional heart and lung capacity and producing reproducible data are not available outside of cardiologists’ offices, and do not lend themselves to testing in primary care offices, fitness centers, or in the home.
• Most criteria for staging heart failure are either primitive or subjective - seeing how far one can walk in 6 minutes or even the New York Heart Association’s functional classification (NYHA) – I – No symptoms, II- Mild symptons, III Marked limitation, IV Severe limitation- are not reproducible between cardiologists.
• Despite sophisticated programming and cost of current cardiac pacemakers ($50,000 to $65,000 per pacemaker, not including cardiologist placement costs), it’s still not possible to predict whether a patient’s rhythm disorder will respond to pacing – the failure, or non-responder rate is in neighborhood of 30%

SHAPE Medical Systems

The device developed by SHAPE medical systems, a Saint Paul, Minnesota -based company, helps meet evidence-based criteria – reproducible data, objective measurement of what works and doesn’t work, early data or preventable and reversible disease, portability to different settings – that the government and the provider community will seek to reduce costs.

Among other things, the SHAPE device – consisting of a small gas analyzer, a one step stair, a face fitting mask to capture expelled air, and a laptop computer comparing the patient’s performance to a large database – produces reproducible, easy-to-interpret data.

The data :
1) calculates the risk of hospitalization or death;
2) can be assembled into one cumulative data number that signals early or late stages of disease and need for further evaluation;
3) defines and differentiates the cause of shortness of breath and cardiac and pulmonary function;
4) does so in six minutes or less after a low and steady walk not requiring exertion or risk to patient;
5) determines if a patient is likely to respond to different programming pacing options;
6) can serve as a supplement to traditional treadmill evaluation;
7) can be used at least four times a year to evaluate responses to drugs.

In addition to these features, the device is small (components can be carried in an ordinary duffle bag or its equivalent), can be set in any setting (primary care office, home, or fitness center) with electrical outlets, is cost-effective ($2000 for monthly lease or other flexible arrangements) , has received FDA approval, has been evaluated and confirmed as useful and reproducible at the Mayo Clinic, can be deployed on the frontlines of medicine by primary care physicians, who badly need a device for objectively evaluating early symptoms of heart and lung disease(the number 1 and number 4 killers of Americans), and shows the power of innovation for rationally transforming health care based on both anatomical and functional criteria.

Thursday, May 14, 2009

Regional variations, u.s. health system - The U.S.: A Nation of Nations

I’d like to bring to readers’ attention a blog, www.buz In his May 1 blog, “How is the U.S. Doing?”, Dr. Cooper, a professor of medicine and principal of the Leonard Davis Institute of Health Care Economics at the University of Pennsylvania, makes the point that the U.S. is a “nation of nations” with tremendous regional differences in health outcomes.

Cooper says the rate of preventable mortality in the Confederate States, where blacks account for 20% of the population, is 127/100,000, compared to 95/100,000 for the rest of the U.S. where blacks make up 10% of the population, a 33.7% difference in preventable mortality. Black mortality in the Confederacy is 55% higher than in the rest of the U.S., and white mortality is 15% higher.

Cooper concludes: “ So we should be too quick to malign the U.S. health care system for spending too much and having poor outcomes. We are a nation of nations and must be understood in each of those nations. Real health care reform will have to be built around regional realities and around the realities of wealth and poverty.”
Reform must also be built around the realities of immigration (one of five Americans is a recent immigrant or a close relative of one) and of ethnic origin, as exemplified by these statistics from the Abstract of the United States 2000-2004.

• White, 68 % of population, longevity, 81.0 years
• Black, 12% of population, longevity, 73.6 years
• Hispanic, 14% of population, longevity, 74.0 years
• Asian, 4% of population, longevity, 75.2 years

The U.S. is, in short, a vast continental nation, made up of different regions, with stark differences in culture, ethnic mix, and health outcomes.

Obama strategies - Reform: One Man's Meat in Another Man's Poison

There is no easy way to pay for comprehensive health care reform. Congressional leaders reacted coolly to the Obama administration’s proposal that reform be funded partly by reducing itemized deductions and mortgage interest) for higher income persons. All the funding options contain various levels of political poison.

Jonathon Oberlander, PhD, “Picking the Right Poison – Options for Funding Health Care Reform, “ New England Journal of Medicine, May 14, 2009

It’s become clear combinations of options to fund 30 million uninsured Americans may not be there, and reformers may have to retreat from universal coverage. No solid evidence exists that health information technologies, pay-for-performance systems, and medical homes save much money, and the other options to raise the requisite money to cover Obama’s promises are questions of one’s man’s meat and another man’s poison.

Funding Options

End income tax exclusion on employer sponsored health insurance.

Pros - Could raise $52 billion and would build on current employer based system.

Cons – Controversial. A political U-Turn. Obama opposed this in campaign while McCain supported it. Business, which provides coverage for over 250 million workers, conservative politicians, Democrats and Republicans alike, and workers themselves would oppose.

Raise “sin taxes” on cigarettes, alcohol, and sugar sweetened beverages.

Pros - Could bring in $205 billion to federal coffers. Would have side benefit of preventing disease and improving health.

Cons – Could be politically counterproductive. Americans don’t like moralizing or meddling into their personal lifestyles. May work for paying for children (SCHIP) but not for 50 million uninsured. Could lead to taxes on fast foods and transfats, and anything else perceived to harm health.

Impose employer mandates of $500 per employee to those businesses who don’t offer coverage.

Pros – Could bring in $45 billion but would cause wrath among small business owners who already can’t afford coverage.
Cons - Would infuriate business community, particularly small business, who already are having a hard time competing globally and who already can’t afford coverage for employees.

Long-Term Options

So much for the short-term options. It may be in the long-run, i.e. over the next decade, Congress could save money by funding medical homes, comparative effectiveness research, paying hospitals on basis of quality, reducing payment to high-spending geographic areas (like NYC, Boston, Miami, LA), reducing payment for high tech procedures, establishing competitive bidding for Medicare Advantage plans, and paying hospitals and doctors less- but these measures could create backlash by reducing care availability, producing longer waiting lines, closing hospitals and driving doctors out of practice.

Even if everything goes according to Obama's plan, e.g. a public plan to compete with private plans with Medicare rates for public plan members, there will be the question of who will provide the care. The shortage of doctors and nurses grows daily and unlikely to be remedied soon by armies of physician assistants, nurse practitioners, or nurse doctors.

Still, I’m optimistic. America is a resilient nation, and Americans are a sensible people. We live in the best of all possible countries. Something will turn up that we can afford. In the end, Americans will come to their senses – and to consensus

Liberals vs. conservativesm government vs. market reform -Health Reform Spin

As we anticipate the long hot summer health reform debate, look for these spins to sway the public.

Republicans - There is, indeed, a crisis, and it’s about how we pay for Democrats spending $100 billion, give or take $20 billion, this year and $1 to $2 trillion, over the next decade, thereby plunging your children and your grandchild ere ever moa deeply into everlasting debt. It’s about putting bureaucrats in charge handling the crisis and making your health care decisions. According to Republican pollster, Frank Lutz, the Republican message ought to be, “In countries with government-run health care, politicians make YOUR health care decisions. THEY decide if you’ll get the procedures you need or, if you’re qualified because the treatment is too expensive or you’re too old.”

Democrats - There’s a crisis, alright, and it’s that greedy medical-industrial complex that’s at fault – the health plans, drug companies, and avaricious specialists. We’ll make health care more affordable. We’ll give you more choice. We won't allow you to go bankrupt.. We’ll make sure you still get a choice, public or private, and which doctor, based on performance and effectiveness data, is best for YOU. According to Senator Max Baucus (D-Montana),” You can choose your own doctor. You can choose your own health plans. There’s total choice here. I do not want to say this defensively, but this is not a big government plan.”

Meanwhile, Congress must decide how to pay for government’s big government plan this year and over the next decade. The central questions that should be addressed are: should it come to pass: Where is the money to fund it coming from? Where are the doctors coming from to deliver the promise of expanded access?

Wednesday, May 13, 2009

Reece, personal musings - Explaining U.S. Heath Reform to Rudyard Kipling

I keep six honest serving men
(They taught me all I knew)
Their names are What and Why and When
And How and Where and Who.

Rudyard Kipling, 1865-1936
The Just-So Stories (1892). The Elephant’s Child

If Rudyard Kipling were to return to view today’s health care reform scene, I might have the following conversation with him.

What is health reform in the United States all about? It’s about a deep moral problem – insuring all 310 million Americans – and a profoundly complex economic dilemma – providing this coverage in an affordably without plunging individuals and the nation into bankruptcy.

Why is reform so difficult? It’s difficult because we are a vast continental nation with multiple public and private health systems; with one of five of our citizens a recent immigrant or relative of one; with a capitalistic economic system that stresses individualism, freedom to choose, equal opportunity but not necessary equal results, and distrust of government; and an culture that believes in exceptionalism and the power of technology to help us remain forever young and to fix health problems brought on by unhealthy behaviors.

When are these difficulties being faced? Right now, with a deep economic recession, an activist president and with Medicare facing bankruptcy by 2017 and the Social Security system following in 2037. But the problems have been coming on strong for the last 10 years, with health information outstripping general inflation 3-4:1, health care costs becoming unaffordable, and growing numbers of uninsured.

How is the United States going to fix these problems? Our president says the “big fix” will have to come from government by having an inexpensive public plan competing with excessive private plans and Medicare dictating, regulating, and demanding compliance with federal guidelines, and perhaps even doing away with fee-for-service payment of hospitals and doctors. The loyal opposition to the president insists that only the market and patients using their own money and being sensitive to value and outcomes of that money will modify the economic crisis.

Where will this reform happen? The action this year will be in the U.S. Congress and in the White House, which is orchestrating the legislative action behind the scenes. There are two huge problems; 1) the Obama administration, despite all the sound and fury, has no real leverage over the major players and can only call for voluntary actions to slow the rate of health care inflation; 2) how to pay for sweeping reform without antagonizing Americans without massive tax increases and without driving doctors out of the system with punitive rules and reduced pay and without further weakening the economy, which relies on the health care sector as one of the few growth sectors in the economy. Reform will probably not happen this year in any sweeping fashion, but if President Obama has his way, will be spread out over 10 years.

Who will bring this reform about? Government, business, and health stakeholders, somehow acting together and doing what needs to be done, and somehow modifying the health habits, and somehow lowering but meeting the expectations of the American people.

Tuesday, May 12, 2009

Physician shortage, doctor shortage - Where are All The Internists?

It is generally agreed there’s a desperate shortage of general internists. A recent survey indicated only 2% of medical students pan to enter general internal medicine. The rest are subspecializing in search of higher pay, greater prestige, shorter work hours, and a more balanced life style.

In the May AARP Bulletin, I ran across a table listing the number of internists around the country. I divided the number of internists in each state by the population of each state and came up with the list below. I’m not sure what these numbers mean except internists per capital are concentrated in New England, fade somewhat in the Middle West and South, and are found in fewer numbers in the less populated states.

I’m also not exactly sure why the glory days of Internal Medicine and its differential diagnosis wizards have gone. My own theory is that the attractions and profits of high technology have replaced the workings of the mind. I’m thinking of MRIs and CT scans and other state of the art technologies, including endoscopies, laparoscopies, and intravascular stents and other devices.
I miss conversations and speculations guided by learned logic about diagnostic possibilities. It was akin to Arabian Nights entertainment.

In any event, here is my list of the number of internists per capita, courtesy of the Bureau of Labor Statistics.

States with Number of Internists per capita
1. Rhode Island 1: 2070
2. Massachusetts , 1:2310
3. Connecticut, 1:2339
4. Maine,1: 3146
5. Maryland, 1: 3394
6. Vermont, 1: 4154
7. Ohio, 1: 4230
8. Georgia, 1:4341
9. New Jersey, 1: 4541
10. California, I:5120
11. Minnesota, 1: 1 5132
12. Idaho, 1: 5161
13. South Dakota. !: 5172
14. North Dakota, l 1: 5178
15. Wisconsin, 1: 5243
16. Hawaii, 1: 5544
17. Michigan, 1: 5586
18. Illinois,1: 5828
19. Oregon, 1: 6171
20. Alabama, 1: 6179
21. Kentucky, 1: 6421
22. Pennsylvania, 1: 6577
23. Oklahoma, 1: 6951
24. Indiana. 1: 6969
25. Tennessee, 1: 6700
26. North Carolina, 1: 7684
27. Mississippi , 1: 7687
28. New Hampshire,1: 8187
29. New York, 1: 8230
30. West Virginia, 1: 8652
31. South Carolina , 1: 8684
32. Virginia, 1: 8903
33. Missouri, 1: 9207
34. Nevada, 1: 9288
35. Colorado, 1: 9710
36. Texas, 1: 9853
37. Florida, 1: 9938
38. Washington, 1: 10308
39. Nebraska, 1: 10992
40. Montana , 1: 15595
41. Louisiana, 1: 18095
42. Arkansas , 1: 16438
43. Alaska, 1: 22122
44. Iowa, 1: 24719
45. No statistics available on Arizona,
New Mexico, Utah, and Wyoming.

Monday, May 11, 2009

Costs, health savings accounts - What the Pledge to Curb Health Costs Does (and Doesn't Mean)

Wall Street Journal Health Blog

By Jacob Goldstein

Several big health-care interest groups say they’re going to slow the rise in health costs over the next decade. Here are stories from this morning’s WSJ, Washington Post and New York Times.

Later today, several big players — including the American Medical Association, the Service Employees International Union, and the main trade groups from the drug, hospital, medical-device and health-insurance industries — are expected to meet with President Obama and pledge to slow the growth of health-care costs by 1.5 percentage points per year in each of the next 10 years.

The specifics seem pretty thin. The pledge includes perennial cost-control favorites such as “simplifying administrative costs, making hospitals more efficient, reducing hospitalizations, managing chronic illnesses more effectively and improving health-care information technology,” the WSJ says. All stuff that everybody agrees sounds good, but has been hard to put into practice.

What’s more, even if the health establishment slows the growth as promised, the cost of health care will continue to grow faster than the economy as a whole, rising to 18% of GDP by 2019, the WSJ says. (Health spending was 16.6% of GDP last year.)
Still, the fact that such a wide range of players with often conflicting interests (doctors and health insurers, for example) are speaking as a single group is pretty significant. It shows they all want to look like they’re on board with health reform, a top priority this year in Washington. That’s a big change from the last major health-reform push, in the early 1990s, which failed in part due to fierce industry opposition.

But keeping that broad-based support will become more difficult in the coming weeks and months, as the details of health-reform legislation emerge from Congress. Later today, in fact, the Senate Finance Committee is expected to release several possible options for a public insurance program that would compete with private insurers. That’s one of the most contentious elements of the health-reform plans, and one the insurance industry vigorously opposes.

Reece Comment

Three things are notably lacking and seldom mentioned in Obama administration proposals to reduce growth of health costs.

1) Low physician fees for Medicare and Medicaid patients care causing roughly 35% to 50% of doctors to reject new Medicare patients, just when 78 million Medicare recipients are about to come on line in 2011 and just when new Medicaid beneificiaries when unemployment is 8.9% and more are joining the Medicaid ranks.

2) New market-based innovations - $4 Wal-Mart prescriptions ( 1 of 2 Americans lives within 5 miles of a Walmart), 1000 to 2000 worksite clinics and retail clinics, and 3000 or so discounted care or cash-based practices not requiring 3rd premiums and accompanying overhead- are in or about to be operation and are lowering costs.

3) Health savings accounts within high deductible plans are the fastest growing segment of the health plan market and now have over 6 million members while traditional HMOs and PPOs are losing market share.

I discuss these and other developments in my upcoming book, Obama, Doctors, and Health Reform: A Doctor Accesses Odds for Obama Health Reform, scheduled for release in June.

Richard L. Reece. MD, 860-395-1501,

health care realities - Health Reform Incentives, Positive and Negative

The mind is more cheered and refreshed by profiting in small things than standing at stay in great.

Francis Bacon, 1561-1626

May 11 - Today’s newspapers, television channels, and Internet websites are full of news about President Obama’s health care meeting with executives of the Advanced Medical Technology Association – a lobbying group representing the medical device industry, the American Hospital Association, the American Medical Association, American Health Insurance Plans, the Pharmaceutical Research and Manufacturers of American, and the Service Employees International Union.

Purpose of Meeting

The purpose of the meeting is to announce that this group and the Obama administration will partner in a voluntary effort to reduce the growth of health care spending (6.2% last year), supposedly saving $2 trillion over the next ten years.

This will be done by joint efforts to,

• prevent obesity

• manage chronic disease

• coordinate care

• standardize claim forms

• increase information technologies

Congressional Efforts Below- the- Radar

So much for the above-the-radar, high-profile events to show everybody is on the same bandwagon to provide affordable health care for Americans. What isn’t being said is that Congress is already addressing ways to provide incentives to employers and hospitals to reduce costs.

• Congress is planning tax credits or other subsidies to employers who offer wellness programs. The goals of such programs are to help people control blood pressure, fight obesity, stop smoking, lose weight , eat better diets, exercise intelligently, and manage diabetes and other conditions.

• Congress is considering rewarding hospitals who reduce the number of people being readmitted after discharge. As things now stand, hospitals profit from these readmissions and have little incentives to reduce them. Reducing readmissions cost money, and hospitals feel they should receive financial incentives for readmission reductions.

• The recently enacted stimulus bill- the American Recovery and Reinvestment Act – contains $19 billion to give doctors hospitals and doctors financial incentives starting in 2011 to adopt electronic health records amounting to a one-time bonus of $ 2 million for hospitals plus on add-on for use for every Medicare admission for 4 years and $44, 000 spread over 5 years for doctors who use EMRs.

• Medicare pay for performance projects are underway to offer positive incentives in the form of bonuses or subsidies for medical students who commit to careers in primary care, for primary care doctors who establish medical homes, or doctors in general who meet or exceed quality standards.

More Care, More Money

As admirable as these efforts are, much of them are cosmetic. Let’s face it, the present health system is still rewarded for doing more rather than less. Hospitals profit from more admissions, health plans margins grow with more members, doctors make more money by doing more procedures and tests, device and drug manufacturers gain from more device and drug sales. And frankly, most government efforts focus on the Medicare and Medicaid populations, which represent about 1/3 of the total market and which are not necessarily representative of the whole.

Cost-Reduction Roles of Market Forces

To a large extent, market forces must also play cost-suppressive roles. This is already taking place in the form of worksite clinics, retail clinics, $4 Wal-Mart prescriptions for generic drugs, care outside of 3rd parties where discounted, basic care is being offered. But more could be done – doctor offices could have lists of comparative prices for brand versus generic drugs.

Negative Incentives May Be Counterproductive

Finally, Congress could let up a little on its talk about harsh penalties, i.e. negative incentives, on not paying for common complications, or not using EMRs, on not complying with unrealistic, expensive, and often unenforceable federal standards. Congress should keep in mind that expanded access is not going to possible without more doctors, that this is still a free country, and doctors remain free to accept or reject Medicare or Medicaid patients.

Sunday, May 10, 2009

Blogging doggerel - "Eight Simple Rules for Health System Reform"

Title for American Medical News article, May 11, 2009

Protect families’ financial health.
Health costs shouldn’t destroy wealth,
But today how do you define a family?
What about the extended multifamily?
And what about entitlement stealth?

•Make health coverage affordable.

This sought-after goal is undeniable.
But what’s the catastrophic ceiling?
How much should we pay for healing ?
What’s justifiable and verifiable?

Aim for universality.
Strive, strive for morality.
It’s a wondrous dream;
It’s a lustrous theme,
as elusive as immortality.

•Provide portable coverage
From insurance never disengage.
No matter where you are,
Never to payment to say au revoir
No matter who pays your wage.

Guarantee choice,
Give patients a voice,
Let them have their way,
Let them choose who to pay,
And who to ask for the invoice.

Invest in prevention and wellness.
Nothing beats health awareness,
everybody now agrees.
It requires no fees.
And for each more is less.

Improve patient safety and quality.
These two things have a real affinity.
Hospitals should pose no danger.
Quality should be game changer.
Safety and quality are about serenity.

•Maintain long-term fiscal sustainability.
Health care should be designed for perpetuity.
Bankruptcy from health should be unthinkable.
A nation’s health system should be unsinkable.
Somehow we must achieve fiscal viability

Saturday, May 9, 2009

health care realities, health care truths - Dawning Health Reform Realities

As summer approaches, the health reform debate heats up, and Democrats sense the long sought-after jewel in their political crown, universal health care, is within their grasp, the dawning of certain political realities is beginning to set in.

1. The Democrats might fail - Democrats are anxious not to repeat the mistakes of Bill Clinton. He staked his presidency on health reform, then lost the House in 1994. Obama has cleverly left it to Congress to decide the details. Richard Gephardt, former Missouria Congressman and a major figure in Democratic politics for 28 years and former leader in the House, says universal or near-universal coverage can’t pass this year. He is urging the White House to defer that goal until it enacts cost-saving reforms in health care delivery. Otherwise, he argues, the new president risks the same losing argument about paying for expanded coverage that stymied President Bill Clinton 15 years ago.

2. The health care sector is the biggest single economic sector, and the only growth industry outside of government itself, in the U.S. economy. For example, the Lewin Group studied what would happen if a public health plan were offered as an alternative to private plans, it would cost hospitals $36 billion and physicians $33 billion. Another example: compelling employers to pay for coverage of employees might put employers over the edge.

3. If health care reform threatens your main constituency, your party affiliation may become irrelevant. Peter Rangle, chairman of the House Ways and Means Committee, declared on May 6 came out against taxing employers-benefits for employers, even though the Obama administration has said this might be a good way to finance universal coverage. Reason? Such a move would hurt New York City hospitals, long an economic mainstay of the New York metropolitan area, and for a years a pet project of Mr. Rangle, who sees these hospitals as the main source of care for his constituency – poor people.

4. Democrats are sensitive to accusations that the intent of the Obama administration is to bring about “socialized medicine.” Already Conservatives for Patients Rights, which has a $15 million budget, is hammering on this theme in TV and online ads featuring English and Canadian physicians bewailing care by bureaucrats and stressing freedom of choice and patients’ rights. Visions of people having to wait in long government lines for months and even years for access to MRIs and CT scans, mammograms, cancer treatment, and elective joint or heart surgeries frighten some Americans.

5. Fear of Medicare-for-all causing costs to spin out of control is a concern. This year the budget for Medicare and Medicaid passed the $1 trillion mark and now consumers 1/3 of the total budget. Bankruptcy may be less than five years away. Health costs show no signs of ebbing and there are no incentives for hospitals, doctors, patients, health plans, drug companies, and other suppliers to spend less. In Massachusetts, near universal coverage has produced a 32% increase in costs and a rush to expensive emergency rooms because people have had difficulty finding doctors.The only real alternatives for government are to somehow fix Medicare, pay doctors and hospitals less, or rationing care through comparative effectiveness tactics or paying only for “quality,” which are not so subtle forms of rationing.

6. Six things may kill the deal. The Consensus Group has come out with a list of "6 Deal-Killers For National Health Reform." The group includes, health policy experts from the American Enterprise Institute, the Center for Medicine in the Public Interest, the Ethics and Public Policy Center, the Galen Institute, The Heritage Foundation, the Independence Institute, the Institute for Policy Innovation, the Institute for Research on the Economics of Taxation, the National Center for Policy Analysis, the Pacific Research Institute." The following six items might not kill a bill embodying what Obama asks for but they would certainly prolong the debate, probably until November.

The six “deal killers” with my guess for the odds for success are -

• A government-sponsored health insurance plan to compete with private plans: Odds, 40/60

• A move to force employers to provide health insurance: Odds, 20/80

• A uniform, government-defined package of benefits: Odds, 20/80

• A mandate that individuals must purchase insurance: Odds, 10/90

• A National Health Insurance Exchange that extends federal regulatory powers over private insurance.: Odds, 30/70

• Federal interference in the practice of medicine through a federal health board, comparative effectiveness review or other government intrusions into medical decision-making. Odds, 50/50.

Kondrake View

Here is how Morton Kondrake, a Inside-the-Beltway sage, sums up the Democrats dilemma in May 8 Roll Cal, “Democrats Should Reform Medicare, Not Universalize It.”

“If President Barack Obama really is a pragmatic problem solver and not a liberal ideologue, he will stop pushing for a government-run insurance plan as part of health care reform.

And Democrats in Congress, instead of trying to drive all Americans into a Medicare-style, single-payer health plan, should first figure out how to reform Medicare itself, which is rapidly going broke while failing to serve all the medical needs of seniors.

As several studies show, if health reform includes a "public" insurance plan to "compete" with private insurance, it will mean the end of private insurance in America - all at once or gradually, depending on the design. If the model is Medicare, as pushed by liberals like Reps. Pete Stark (D-Calif.) and Henry Waxman (D-Calif.), it will also lead to the bankruptcy of major U.S. hospitals, including some of the biggest in Waxman and Stark's home state.

In an interview, C. Duane Dauner, president of the California Hospital Association, told me that if half of privately insured patients shift to a public plan paying Medicare rates, each of California's 430 hospitals would lose, on average, $40 million a year.

My View

As I see it, the chances for “sweeping reform” - universal coverage, Medicare-for-all, or for all of the six deal killers – are about 20/80 to 30/70 – largely because of the fragile economy, the massive funds required, and growing fears of the growing federal debt. However, the odds for “incremental, i.e. cosmetic, reform” in terms of IT subsidies, universal coverage of kids, comparative research, and economic punishment of health plans and drug companies, are very likely, in the 80/100 to 100/100 range. The Democrats will need something, and they will get it.

Thursday, May 7, 2009

Expectations - Time is Important for Patients, Too

The supply of time is totally inelastic. No matter how the demand, the supply will not go up. Moreover, time is totally perishable and cannot be stored. Yesterday’s time is gone forever and will never come back. Time is, therefore, always in exceedingly short supply.

Time is totally irreplaceable…Everything requires time. It is the only truly universal condition. All work takes time and uses up time. Yet most people take for granted this unique, irreplaceable, and necessary resource.

Peter F. Drucker, 1909-2005

Time is important for doctors. If they’re paid fee-for-service, time with patients is what they’re paid for. Lack of time is why some doctors must see 25 to 30 patients a day to make ends meet and pay the staff and bills.

Time is important for patients too. Indeed, too much waiting is often patients’ chief complaint about American doctors. Too much waiting for elective procedures is what people complain about in nationalized systems like Great Britain, Canada, and Sweden.

Time was important to me the other day when I was a patient in a cardiologist’s office. After nurses had gathered the preliminary information, I sat on the edge of the examining table for 25 minutes in my Johnny, my bare feet dangling from the end of the table, facing the blank door, waiting for the cardiologist. I had things to do, a blog to write, a conference call to join, a trip to make to go home to field the call. Where in the hell was he? Why didn’t someone tell me how much longer I would have to wait?

A few days later, I received notice of a 2009 survey of physician wait times conducted by Merritt Hawkins & Associates in 15 major metropolitan markets In cardiology, average appointment wait times exceeded 14 days: Minneapolis(47 days), Miami (29 days), San Diego (22 days), Boston (21 days), and Washington, D.C (18 days).

What can physicians do to ease the pain of waiting? How can the address the underlying feeling among patients, who want to cry out, “Doctor, my time is important now?”

Well, doctors can do the obvious, improve scheduling, including an open access day; give the patients something to do while waiting, like installing a telephone line for local phone call; making waiting more comfortable, with soft music, relaxing chairs, tea, or coffee; provide fun things to do, or watch, see, or read.
Or you can follow nine rules of advice offered by Susan Keane Baker in her book, Managing Patient Expectations; The Art of Finding and Keeping Loyal Patients.

1. Make a good first impression by hiring a smiling receptionist.

2. Keep your reception area spotless and comfortable.

3. Provide appropriate and updated reading material.

4. Establish a budget for flowers, mints, and other amenities.

5. Provide relaxing distractions – stationary and stamps for writing letters.

6. Call your waiting room the reception room.

7. Sit in your own waiting room and view it from the patient’s perspective.

8. Keep the patient informed about delays.

9. Apologize for delays.

10. Offer discounts, restaurant coupons, or gift certificates, or rescheduling for excessive delays.


As a doctor, be sensitive about delays. Sensitize your staff about the pain of waiting. Time is important to patients, too. Lost time is irreplaceable. And don't let your patients face a blank door in the examining room awaiting your arrival. A blank door is a pain in the access.

Massachusetts - Doctor Wait Times, Costs, ER Visits in Massachusetts Climb

The best laid schemes o’ mice and men
Gang alt a-gley
(go off the planned line)

Robert Burns, 1759-1796

More people are seeking care in Massachusetts hospital emergency rooms, and the cost of caring for ER patients has soared 17% over two years. This is despite efforts to direct patients with nonurgent problems to primary care doctors instead, according to new state data. Visits to Massachusetts emergency rooms grew 7% between 2005 and 2007, to 2,469,295 visits. The estimated cost of treating those patients jumped from $826 million to $973 million.

“ER Visits, Costs in Massachusetts Climb,” Boston Globe, April 24, 2009

Long wait times in Boston may be driven in part by the healthcare reform initiative that was put in place in Massachusetts in 2006. The initiative succeeded in covering many of the state’s uninsured patients. However, it has been reported that many patients in Massachusetts are encountering difficulty in accessing physicians. Long appointmend times in Boston may signal what could happen nationally in the event that access to health care is expanded through healthcare reform. Increased demand resulting from improved access to care for 47 million uninsured people can be expexted to extend doctor appointment wait timen in many markets.

Merritt Hawkins & Associates, “2009 Survey of Physician Appointment Wait Times,”

Among the political cognoscenti, Massachusetts is considered the Bluest of the Blue States, the Elite of the Elite, the Leaders of the Liberal Health Reform Band. It is the state where President Obama received his law school education, where Senator Edward Kennedy has fought for a single payer system for 40 years, where Obama’s closest health care advisors, Dean David Cutler, PhD, of Harvard and Robert Blumenthal, M.D., of Massachusetts General and National Coordinator for Health Information Technology,reside, and where the nation’s first “universal health plan” was spawned and has been in operation for three years.

Yet, despite this political firepower, something seems to have gone askew. Massachusetts health costs are the highest in the land. Despite the highest concentration of physicians per capita and lowest rate of uninsured among the states (2.6%), people are having a hard time finding doctors, especially primary care practitioners but other specialists as well. Bay State residents are flocking to high-cost emergency rooms for care in unprecedented numbers. And all of this in an affluent states which is supposed to set an example for other states to follow.

The average wait times for appointments in Boston for cardiology are 21 days, dermatology 54 days, obstetrics-gynecology 70 days, orthopedic surgery 40 days, and family practice 63 days.

The average cumulative wait times for the 5 specialties just mentioned are,

Boston, 50 days

Philadelphia, 27 days

Los Angeles, 24 days

Houston, 23 days

Washington, D.C., 23 days

San Diego, 20 days

Minneapolis, 20 days

Dallas, 19 days

New York, 19 days

Denver, 15 days

Miami, 15 days

Portland, 14 days

Seattle, 14 days

Detroit, 12 days

Atlanta, 11 days


In Massachusetts and Boston, expanded access through a near-universal coverage plan has consequences - higher costs, increased ER use, harder times finding doctors, longer waiting times for doctor appointments.

Wednesday, May 6, 2009

Rationing - Yes, CER; The New England Journal of Medicine's Point of View

The American Reinvestment and Recovery Act gives comparative-effectiveness research (CER) a large boost in funding over the next 2 years. Despite a consensus that better information about the relative effectiveness of different medical interventions is needed to improve the quality and value of care, some view CER with skepticism.

Alan Gerber MD, PhD and Sean Tunis, MD, NEJM, May 7, 2009

The New England Journal of Medicine – well-written, well-edited, and well-researched – has a point of view. In the case of health care reform, it believes government reform, not market-based reform, will best solve America’s health care problems. The Journal tends to be dismissive of the other point of view – disruptive innovations from the market.

There is nothing wrong with this, as long as one is aware of how the Journal goes about selecting its content and its contributors. Every publisher is entitled to its point of view, which defines its identity. The Journal is foursquare behind the pillars of the Obama health reform initiatives - a national interlocking interoperative electronic health system, a public health plan competing with private plans, and a comparative effective research institute.

This bias – this point of view – is most evident in the May 7 edition in its Perspective and book review section.

The three Perspective pieces are:

1. “Does Comparative-Effectiveness Research Threaten Personalized Medicine?” The two authors, who serve on the Institute of Medicine’s Committee on Priorities for Comparative Effectiveness Research, conclude “CER is not a panacea, but it is key to individualized care and innovation, not a threat.”

2. “Debate about Funding Comparative-Effectiveness Research. “ Here Dr. Jerry Avorn, professor at Harvard Medical School, “ says, among other things, “The campaign to gut this funding ultimately failed, and the resonance of the oppositions’ in both lay and policy circles reveal much about the issues that will surround such research and its application in the coming years….Fortunately Congress did not let warnings of a dystopian scientific police state undercut the nation’s need to learn what works best in medicine.”

3. “The Neglected Purpose of Comparative-Effectiveness Research.” Two academics from Texas, have this to say, “This comparative-effectiveness research (CER) initiative has generated considerable controversy. Industry and free-market advocates have expressed concerns about the role of cost-effectiveness within CER and subsequent government intrusion into doctor-patient decisions… the primary goal of CER is to enhance the translation of new medical discoveries into safe and high-quality health care for all Americans.

In the book review section, a reviewer of The Innovator’s Prescription: A Disruptive Solution for Health Care, quotes Arnold Relman, MD, former editor-in-chief of the Journal, “We in America have allowed ourselves to believe that health –care is just another industry, that the provision of medical care is a business, and the medical services are an economic commodity that is best distributed by market forces.”

“Their prescription: let people choose the health care they need and use health savings accounts, coupled with high deductible insurance, to pay for it. “
The Journal disapproves of this approach. It does not fit their point of view.

Monday, May 4, 2009

Managed care - Can Medical Costs be Micromanaged?

The notion of micromanagement can be extended to any social context where one person takes an inappropriate level of control and influence over the members of a group. Continued micromanagement can result in disengagement. A disengaged employee puts in time but little else, and their apathy affects not only their own productivity but that of his/her colleagues. Because a consistent pattern of micromanagement tells an employee you don’t trust their work or judgment, it is a major factor in triggering disengagement.

Wikipedia, The neutrality of this discussion is disputed

Physicians often complain about “micromanagement.” By this they mean inappropriate bureaucratic intrusions into their practices by outside third parties like Medicare or health plans. How can these payers make these clinical decisions when they’ve never been in practice and never had a patient in front of them?

Payers can because they can and because they’re responsible for the bills. Medicare and Medicaid now gobble up 1/3 of the federal budget, and rising medical costs are the major factor cutting into health plan profits. But, and this is a huge But, payers can’t possibly account for all permutations and combinations of variables occurring at the level of the patient-doctor relationship and in the medical marketplace.

Social Reality

Still, the reality is, as Peter F. Drucker explained in The Age of Discontinuity “ Every single social task of importance today is entrusted to a large institution organized for perpetuity and run by managers. Where the assumptions that govern what we expect and see aqre still those of the individualistic society of 18th century liberal theory, the reality that governs our behavior is that of organized, indeed organized, power concentrations.”

Inability of Government to Perform.

Yet government, in the case of Medicare, has shown an inability to perform. It can;t
control runawary costs, which may bankrupt Medicare in 5 years. The federal government sees the solutions as better analysis and smarter payment systems designed by the bureaucracy. All that’s needed, Medicare officials bravely say, is more micromanaging of physician and hospital practices. But what’s really needed is reform that shifts financial control from the government to Medicare beneficiaries.

Medicare Reality

That’s not likely to happen since Medicare is organized for perpetuity and run by buureaucrats.

As the conservative National Review observed on May 1.

Medicare looks and operates as it does for a reason — politics. Medicare can’t play favorites. All licensed health-care providers get paid exactly the same. There’s no government-run PPO because that would mean steering patients to certain physicians and hospitals and not others. Moreover, politicians want to insulate their retired constituents from the financial consequences of their health-care decisions. Put it all together and you have an insurance plan that can’t control volume. The only cost-cutting mechanisms available are price controls, which make matters worse.

What Medicare Could Do

So what is the bureaucracy to do? It could means test recipients and make the rich pay more. It could go for “Medicare for all,” which would drive costs down temporarily, drive doctors and hospitals out of business, and end by costing more, as massive entilements always do. Or it could restructure care by rewarding present and future primary care practitioners more and even recruiting specialists to practice more primary care by making it more financially attractive.

The Health 2.0 Solution

Yet another approach is that advocated by the Health 2.0 community – minimizing practice variations by using sophisticated computer algorithms to pay equally for outcomes across the practice spectrum. This would require an EHR in every doctor’s office and in multiple locations within a hospital.

John Wennberg of the Dartmouth Group and followers has been pushing the concept of micromanaging “unwarranted practice variations” for more than 35 years by using Medicare data. Wennberg believes homogenizing payments across the board would save the nation 30% in costs and allow us to cover the uninsured.

The concept, which the Obama administration and his budget director, Peter Orzag, now fervently embrace. Unfortunately, Wennberg's ideas haven't fundamentally changed regional or local variations one iota, even among the academic elite, but making Medicare payments uniform across the board remains a Holy Grail for the information-infatuated crowd.

Surely, the thinking goes, if only doctors, doctors, and consumers were aware of the striking differences in costs, even with equal health outcomes, confirmed by unequivoal data, costs would shrink, either because providers would be embarrassed or payers would refuse to pay the high rollers.

Profound Variations

That profound differences exist can’t be disputed, In original research, Jerry Reeves, MD, chief medical officer of an international union of hotel and restaurant employees and principal of Health Innovation, LLC, studied more than 450 episodes of care among high volume physicians in 4 states and found these variations.

Variation from Low to High Costs, Same Results

Family Practice

Otitis media, $46 to $412, 9.0X variation
Bronchitis, $89 to $771, 11.6X variation

Internal Medicine

Urinary tract infection, $81 to $778, 9.6X variation
Angina, $86 to $743, 8,7 X variation


Angina, $241 to $1389, 5.8X variation

Orthopedic surgery

Knee surgery, $2727 to $9383, 3.4X variation

Presumably, with a big enough computer network and with data on every physician in the land and outcomes information on each patient, the payer could steer patient to the perfect doctor – the cheapest with the best results. One could, theoretically, micromanage costs and the work of John Wenner could be vindicated.

My read on this is: It ain’t goin’ to happen. The socioeconomic differences and relationships between patients and doctors and local and regional markets and doctors and hospitals is simply too profound in an individualistic society like America. You can’t pour data into a homogenization practice blender and expect to have a pureed payment system at the other end.

Reconnecting Vertical Specialist-Filled Holes across the Medical Landscape

But the Health 2.0 folks are onto something. – reconnecting the disconnections over our sprawling and fragmented medical landscape. Which reminds me of the writings of Edward de Bono, MD, a London-based doctors who runs a think tank in Malta who came up the concept of “Lateral Thinking. ” He visualizes the medical landscape as a series of vertical holes, Each hole stacked with specialists with a world-class expert at the bottom of each hole. The trouble is : no connections exist between the vertical shafts.

Maybe the solution is to reconnect the vertical holes with an army of newly trained primary care doctors, better-paid existing primary care doctors, and specialists with high-enough pay to induce specialists to do more primary care. This is more likely to work than micro-management, which may reduce doctors to mere technicians , to drive them out of practice, and reduce the appeal of medicine as an independent-thinking profession


Medical costs can’t be micromanaged.

Sunday, May 3, 2009

Rationing, blooging doggerel - Cold, Cold Health Care

The jewel of his plan is the Federal Health Board:

These government experts would "help define evidence-based benefits and lower overall spending by determining which medicines, treatments, and procedures are most effective--and identifying those that do not justify their high price tags."

Ladies and gentlemen, he's talking about rationing and denying payment. But look on the bright side, America. Physicians will no longer be "burdened" by decision making. And think of all the time doctors can save when they no longer need to explain various treatment options to you or your elderly mom. Life is so much easier when you simply don't care. Ask our cool, cool President.

So get used to health care profiling. Just have your doctor fill out this form with your age, gender, diagnosis, and prognosis, and Washington will let him know what to order. It's medicine by spreadsheet. It's cold, cold healthcare.

Carol Peracchio, “Cold, Cold Health Care,” Real Clear Politics, May 2

Who will be most heartless about the upcoming health reform?

That is the burning hot question with which we will be torn.

Will it be liberals who ration by evidence?

Will it be conservatives who ration by expense?

Who will tell doctors what tests and procedures to perform?

Who among them has a cold, cold heart?

How do will tell who is the most smart?

Will it be a green-eye shaded federal technocrat?

Will it be a jaded official wearing a medical hat?

And how, as patients, will be able to tell them apart

Reform-Related Quotes from Sunday May 3 New York Times

A freeze in Social Security benefits would have major implications for Medicare because the COLA, in effect, puts a cap on premiums for Part B of Medicare, which covers doctors’ services.

If there is no cost-of-living adjustment for Social Security, about three-fourths of beneficiaries will not see any change in their basic Part B premiums, federal officials said. But some beneficiaries do not have this protection and could face substantial increases in their Part B premiums.

In addition, millions of beneficiaries could see higher premiums for drug coverage, provided under Part D of Medicare.

Social Security and Medicare trustees will describe the outlook for benefits and premiums in their annual reports this month.

Officials have already said the condition of Medicare’s hospital insurance trust fund is deteriorating because of the recession, which has reduced payroll tax revenues, the main source of money for the fund. Spending on Social Security and Medicare totaled more than $1 trillion last year, accounting for more than one-third of the federal budget.

Robert Pear, May 3, “ Social Security Benefits Not Expected to Rise in ’10 “

As I have always said, though, that we should not overstate the degree to which consumers rather than doctors are going to be driving treatment, because, I just speak from my own experience, I’m a pretty-well-educated layperson when it comes to medical care; I know how to ask good questions of my doctor. But ultimately, he’s the guy with the medical degree. So, if he tells me, You know what, you’ve got such-and-such and you need to take such-and-such, I don’t go around arguing with him or go online to see if I can find a better opinion than his.

And so, in that sense, there’s always going to be an asymmetry of information between patient and provider. And part of what I think government can do effectively is to be an honest broker in assessing and evaluating treatment options. And certainly that’s true when it comes to Medicare and Medicaid, where the taxpayers are footing the bill and we have an obligation to get those costs under control.

David Leonhart, An Interview with President Obama

Physician shortage, Doctor shortage, primary care -Primary Care Doctors: Doing Good, Doing Well

For primary care doctors, hours are long, waiting rooms crowded, pay is half that of specialists, debts after medical schoolas high as $200,000, their numbers short 50,000 of those needed, and less than 2% of medical students choosing general internal medicine.

Small wonder, a primary care crisis looms.

Relief may be in sight. Medical schools are expanding, some states are paying tuitions of medical students who promise to enter primary care, Congress is considering a 5% bonus for primary care practitioners, and support is growing for primary-care based medical homes.

Unfortunately, since it takes10 years to produce a newly minted primary doctor, a shortage of generalist doctors will persist.. In the meantime, some innovations may help primary care professionals weather the storm. Ideally, these innovations do good for the patient, and do well for the primary care doctor, enhancing their income and leaving more time to see patients.

Here are a few modest suggestions doing good and doing well

1. Instant Medical History – This online tool, driven by the patient, produces a narrative history guided by clinical algorithms. It allows your patient to enter their chief complaint and history from home before visiting the office or even in the waiting room and in the process save 6-10 minutes per patient and get paid a code higher for “complete workup.” This is good for patients because they can tell their history from their point of view and have a complete history and physical findings before the leave the office. It is good for the doctor because he/she can zero in quickly on the problem and have compete documentation of what occurred for billing and referral purposes.

2. National Procedure Institute – Do simple procedures in your office, and in the process, save the system money, offer your patient convenience, and generate more revenues than by cognitive visits alone. This is good for the patient because it saves time, arrives quickly at a diagnosis, e.g. for skin lesions, and takes care of problems at one visit. It is good for doctors because they can be trained to develop important clinical skills.

3. Train your staff and yourself to anticipate “moments of truth” by which patients judge a practice and in the process keep and find loyal patients who will spread the news by word of mouth (see “Managing Patient Expectations by Susan Keane Baker). This is good for patients because it generates satisfaction and humanizes office visits, and it is good for doctors because it sensitizes them and their staff to patient needs.

4. Make it a point to see patients on time or your money back and post a notice in your office to that effect, waiting is the bĂȘte noir and most common complaint of patients. This is good for patients because it assures them won’t waste their time and they will be seen promptly for their problem. It is good for doctors because it shows they respect their patient’s time is valuable.

5. Restructure your practice into three types of visits - simple, medium, and long, and charge predictable fees, e.f., $59, $79, and $99 for 10 minute, 20 minute, and 30 minute visits. Under this structure, you will see more uninsured patients, avoid 3rd party payment, and cut staff. ( See Simplecare. Com). This is good for patients with limited incomes or without insurance because of the predictable pricing. It is good for doctors because it cuts time spend on third party paperwork and reduced\s overhead.

6. Have a member of your group rotate as a hospitalist while at the same time retaining your clinical office skills. Hospitals are the fastest growing primary care subspecialty. This is good for patients because they have 24 doctor coverage in the hospital. It is good for doctors because they become skilled at in-hospital procedures, have regular hours, and have coverage for themselves and their partners on nights and weekends.

7. Dispense drugs from your office using inventory of commonly prescribed drugs and in process make $6 per prescription, save patients money, offer convenience, and assure compliance (see chapter 5 in my book “Innovation-Driven Health Care”). This is good for patients because they can get prescriptions at the doctor’s office, usually at lower prices than at the local pharmacy (Wal-Mart’s $4 generics may be an exception). It is good for doctors because it is a source of extra income and helps make sure patients take their medicine (1/3 of patients never fill their prescriptions).

8. Charge a modest fee for answering email requests for advice on non-emergent problems or for canned advice on common problems. This is becoming common among some insurance plans, especially on the West Coast. It is good for patients because it saves time and money, and it is good for doctors because it cements patient relationships and takes care of some minor problems which do not require an office visit, such as prescription refills.

9. Concentrate on preventing vascular deaths in patients who from part of the metabolic syndrome (hypertension, diabetes, dyslipidemia, obesity) See Bestermann in The big killers in America are heart attack and strokes, and many these can be prevented by diligent attention to preventive –protocols. This approach has been adopted in the Southeastern United States by an organization known as COSHEC (Consortium for Southeaster Hypertension Control). It is good for patients because it prevents many vascular deaths; it is good for doctors because it can easily part of a routine practice and saves many lives.

10. Become a partner in setting up a multispecialty ambulatory care center in underserved physician-short areas. Many retirees in the United States are relocating in states with warmer climate but in doctor-short regions. IN response to this, doctors in North Carolina are setting up multispecialty ambulatory care centers with co-located pharmacies, fitness centers, and physical therapy facilities. This is good for retirees who seek all purpose ambulatory facilities. It is good for doctors who seek new patients and who wish to have an ownership stake.