Monday, August 31, 2009

Health Reform: Setting the Record Right and Getting the Facts Straight

I’m becoming a fan of Jerome Groopman, MD, a Harvard Medical School professor and a staff writer for the New Yorker.

I quoted from his book How Doctors Think (2007) for setting the record straight on the usefulness of clinical algorithms, in my own book, Obama, Doctors, and Health Reform,

Clinical algorithms can be useful for run-of-the-mill diagnosis and treatment – distinguishing strep throat from viral pharyngitis, for example. But they quickly fall apart when a doctors needs to think outside their boxes, when symptoms are vague, or multiple and confusing or when test results are inexact. In such cases – the kinds of cases where we most need a discerning doctor – algorithms discourage physicians from thinking independently and creatively. Instead of expanding a doctor’s thinking, they constrain it.”

“Similarly, a movement is afoot to base all treatment decisions strictly on statistically proven data. This so-called evidence-based medicine is rapidly becoming the cannon… But today’s rigid reliance on evidence-based medicine risks having the doctor chooses care passively, solely on the numbers. Statistics can’t substitute for the human being before you; statistics embody averages, not individuals.”

Another Expression of Thanks

Now I would like to thank him and his co-author, Pamela Hartzband, MD, for getting the facts straight on a number of facts often bandied about by critics of American doctors and the U.S. Health system in the Wall Street Journal,” Fact From Fiction on Health Care,” Here is what they say in part, and I quote.

Consider these myths and mantras of the current debate.”

• “Americans only receive 55% of recommended care. This would be a frightening statistic, if it were true. It is not. Yet it was presented as fact to the Senate Health and Finance Committees, which are writing reform bills, in March 2009 by the Agency for Healthcare Research and Quality (the federal body that sets priorities to improve the nation's health care). The statistic comes from a flawed study published in 2003 by the Rand Corporation. “

• “The World Health Organization ranks the U.S. 37th In the world in quality. This is another frightening statistic. It is also not accurate. Yet the head of the National Committee for Quality Assurance, a powerful organization influencing both the government and private insurers in defining quality of care, has stated this as fact. In fact, the World Health Organization ranks the U.S. No. 1 among all countries in ‘responsiveness.’ Responsiveness has two components: respect for persons (including dignity, confidentiality and autonomy of individuals and families to make decisions about their own care), and client orientation (including prompt attention, access to social support networks during care, quality of basic amenities and choice of provider)”.

• “We need to implement ‘best practices.’ Mr. Obama and his advisers believe in implementing "best practices" that physicians and hospitals should follow. A federal commission would identify these practices. There are domains of medicine where a patient has no control and depends on the physician and the hospital to provide best practices. Strict protocols have been developed to prevent infections during procedures and to reduce the risk of surgical mishaps. There are also emergency situations like a patient arriving in the midst of a heart attack where standardized advanced treatments save many lives.

“But once we leave safety measures and emergency therapies where patients have scant say, what is ‘the right thing’? Data from clinical studies provide averages from populations and may not apply to individual patients. Clinical studies routinely exclude patients with more than one medical condition and often the elderly or people on multiple medications.

“Conclusions about what works and what doesn't work change much too quickly for policy makers to dictate clinical practice. With respect to "best practices," prudent doctors think, not just follow, and informed patients consider and then choose, not just comply.”

• “No government bureaucrat will come between you and your doctor. The president has repeatedly stated this in town-hall meetings. But his proposal to provide financial incentives to ‘allow doctors to do the right thing’ could undermine this promise. If doctors and hospitals are rewarded for complying with government mandated treatment measures or penalized if they do not comply, clearly federal bureaucrats are directing health decisions."

“Private insurers are already doing this, and both physicians and patients are chafing at their arbitrary intervention. As Congress works to extend coverage and contain costs, any legislation must clearly codify the promise to preserve for Americans the principle of control over their health-care decisions.”

Sunday, August 30, 2009

Of Socialism, Government, Rationing and Other Reform Scare Words

The other side has socialism, they have fear of government, they have rationing, and all these…scare phrases.

Tom Daschle, Democrat health reform facilitator, on why Obama’s eloquence isn’t selling his health policy

Why is Obamacare losing momentum? It may be because America is a center right rather than a center left nation. These scare word quotes from Winston Churchill, who considered himself half-American because of his American mother, may also help explain the loss of Obamacare mojo.

Scare words< and phrases


In finance everything that is agreeable is unsound, and everything that is sound is disagreeable.

Expenditure always is popular; the only unpopular part about it is the raising of the money to raise the expenditure.


There is no surer method of economizing and saving money than the reductions of the number of officials.

Bureaucratic management cannot compare in efficiency with that of well-organized private firms. The bureaucrats suffer no penalties for wrong judgment; so long as they attend their offices punctually and do their work honestly they are completely disinterested in the correctness of their judgment.

Deficit Spending

All social reform which is not founded upon a stable medium of internal exchange becomes a swindle and a fraud.

Free Enterprise

If you destroy a free market, you create a black market.

The production of new wealth must precede common wealth, otherwise their only be common poverty.


Those whose minds are attracted or compelled to rigid and symmetrical systems of government should ember that logic, like science, must be servant and not the master of man. Human beings and human societies are not structures that are built or machines that forged. They are plants that grow and must be treated as such.


We must be beware of trying to build a society in which nobody accounts for anything but a politicians or an official, a society where enterprise gains no reward and thrift no privileges.

The inherent vice of Capitalism is the unequal sharing of blessings; the inherent virtue of Socialism is the equal sharing of miseries.

You may try to destroy wealth and find that all you have done is to increase poverty.
Socialism is the philosophy of failure, the creed of ignorance, and the gospel of envy.

“All Men are created equal,” says the American Declaration of Independence, “All men are kept equal,” says the British Socialist Party.


The idea that a nation can tax itself into prosperity is one of the crudest delusions which have ever befuddled the human mind.

Health Reform and Desperate Democrats

I see by the media mouthpiece for Democrats, the New York Times editorial page, Democrats are growing desperate to get “comprehensive health reform” on the books before year’s end. The reasoning seems to be, if we don’t get in now, we’ll never get it, so we’ve got to ram it down the opposition’s throats, even if that opposition contains moderate and conservative Democrats.

Here, in part, and I quote, is the Time’s reasoning.

“Majority Rule on Health Care Reform,” Editorial August 27, 2oo9

“The talk in Washington is that Senate Democrats are preparing to push through health care reforms using parliamentary procedures that will allow a simple majority to prevail in their chamber, as it does in the House, instead of the 60 votes needed to overcome the filibuster that Senate Republicans are sure to mount.”

“Superficially seductive calls to scale down the effort until the recession ends or to take time for further deliberations should be ignored. There has been more than enough debate and the recession will almost certainly be over before the major features of reform kick in several years from now. Those who fear that a trillion-dollar reform will add to the nation’s deficit burden should remember that these changes are intended to be deficit-neutral over the next decade.”

“Delay would be foolish politically. The Democrats have substantial majorities in the House and the Senate this year. Next year, as the midterm elections approach, it will be even harder for legislators to take controversial stands. After the elections, if history is any guide, the Democratic majorities could be smaller.”

“The Democrats are thus well advised to start preparing to use an arcane parliamentary tactic known as “budget reconciliation” that would let them sidestep a Republican filibuster and approve reform proposals by a simple majority.”

“Republicans claim that they want to make medical insurance and care cheaper and give ordinary Americans more choices. But given their drive to kill health reform at any cost, they might well argue that these are programmatic changes whose budgetary impact is “merely incidental.”

“Another hurdle is that the reconciliation legislation covers only the next five years, while the Democratic plans are devised to be deficit-neutral over 10 years. The practical effect is that the Democrats will almost surely need to find added revenues or budget cuts within the first five years. “

“Another Senate rule, which applies whether reconciliation is used or not, requires that the reforms enacted now not cause an increase in the deficit for decades to come, a difficult but probably not impossible hurdle to surmount. “

“Clearly the reconciliation approach is a risky and less desirable way to enact comprehensive health care reforms. The only worse approach would , once the electorate has awoken to what’s at stake.”

“It is barely possible that the Senate Finance Committee might pull off a miracle and devise a comprehensive solution that could win broad support, or get one or more Republicans to vote to break a filibuster. If not, the Democrats need to push for as much reform as possible through majority vote.”

In other words, strike while the iron is hot, and the votes are there. Once the electorate has awoken to what’s at stake, the votes may not be there after the November 2010 election.

Health Reform without Tort Reform is Dead

"Since the days of Harry Truman, Democrats have wanted universal health coverage, believing that if other industrialized countries can achieve it, surely the United States can. For Democrats, universal coverage speaks to America’s sense of decency and compassion. Democrats also believe that it will lead to a healthier and more productive country."

"Since the days of Ronald Reagan, Republicans have wanted legal reform, believing that our economic competitiveness is being shackled by the billions we spend annually on tort costs; an estimated 10 cents of every health care dollar paid by individuals and companies goes for litigation and defensive medicine. For Republicans, tort reform and its health care analogue, malpractice reform, speak to the goal of stronger economic growth and lower costs."

"The bipartisan trade-off in a viable health care bill is obvious: Combine universal coverage with malpractice tort reform in health care."

Bill Bradley, former Democratic Senator from New Jersey, “Tax Reform’s Lesson for Health Care Reform, “ New York Times, August 30, 2009

Bill Bradley has it right - health reform without tax reform is dead. Perhaps it’s the lawyer in him, or maybe it’s the lobbying strength of Trial Lawyers, but President Obama has it wrong. He should stop talking about the “public option,” villainous health plans, and opposing "special interests," and more about establishing medical courts – like bankruptcy or admiralty courts - with special judges to make determinations in cases of medical injuries to reward patients for the compensation they deserve.

No one, least of all doctors, denies medical injuries occur in these days of rampant hospital infections, invasive medical procedures, the rush to get people in and out of hospitals, and hazards high tech medicine, powerful anti-cancer drugs, and cross-reactions between multiple medications.

And no should doubt, as Senator Bradley says, that tort reform “ would lower health care costs, reduce errors (doctors and nurses oftren don’t report errors for fear of being sued, and guarantee all Americans adequate health care.”

There is another aspect to tort reform as well. Tort reform would help abort,and lessen, the next big, imminent health care crisis already upon us – lack of access to doctors because of the doctor shortage and increased demand for their services.

In my book Obama, Doctors, and Health Reform, I feature an interview with Louis Goodman, CEO of the Texas Medical Association. and President of the Physicians' Foundation, which represents 650,000 practicing physicians in state and local medical societies.

In that interview, I asked:

"What do you regard as your greatest accomplishments at the Texas Medical Association?"

Here was his reply:

Our 2003 tort reform effort would fall into the category of a major accomplishment for the state of Texas, and it’s now used as a national model. That reform put a cap of $250,000 for noneconomic damages for physicians, a $250,000 cap for hospitals, and another $250,000 cap for a second hospital or nursing home. This is referred to as a stacked cap, $250,000 for each party. The total is $750,000, but only $250,000 of that falls on the doctor’s side.

This model appeals to legislators because it’s fair and differentiates between physicians and other providers in the system. The model also can help attract physicians to a state. Before we passed our tort reform, Texas was losing all of its liability carriers. But now we have 15 or more in the state, all competing for the business.

Most important, access to care was shrinking in rural and other underserved areas. But during this past year, the number of physician licenses increased from 2,000 to 4,000, and physicians are now settling and practicing in underserved parts of Texas, such at the Rio Grande Valley. Both primary care and specialist physicians are coming to Texas. The specialists aren’t restricting access to high-risk procedures for fear of liability penalties. Patients are getting better care and highly specialized procedures are being done. All of this is attributable to the tort reform legislation.”

Case closed.

Saturday, August 29, 2009

Six Things a Pared-Down Health Reform Bill Should Contain

I advocate incremental but not sweeping reform. Health reform is too big, too personal, too emotional, and too threatening to do otherwise. In my book, Obama, Doctors, and Health Reform, I predict President Obama will get about 1/3 of what he wants in the health reform bill he will end up signing.

But which 1/3? Here would be my six choices.

One, encourage competition across state lines to drive down costs. In this Internet age, I see no reason why data on various plans could not be readily available for all, and why all citizens should not have access to less expensive plans.

Two, end the ability to health plans to deny membership for pre-existing illness. This may raise premiums, but could be offset by wide access to cheaper plans in other states.

Three, have a guarantee that the plan would not increase national debt. This should be concrete guarantee rather than vague proposals about savings through prevention, EMRs, and coordinated care.

Four, a concrete proposal on tort reform. Without such reform, the physician shortage will escalate, and the costs of defensive medicine will continue to soar.

Five, tax breaks, or tax credits, for all citizens, including individuals rather than just for employees.

Six, the ability to choose a plan that fits every individual’s or family’s needs and health status rather than comprehensive plans with every conceivable standard benefit regardless of risk.

Friday, August 28, 2009

The Health Reform Tiger

“They’re predators. Who can really know what’s on their minds? Even though they’re raised in captivity ,and they love us, sometimes their natural instincts take over”.

Kay Rostaire, Big Cat Trainer, Sarasota, Florida, describing why a tiger attacked Roy Horn, of the Schneider and Roy Show, in Los Vegas

"A guiding principle of any reform should be to put the consumer, not the insurer or the government, at the center of the system”

David Goldhill, “What the Government Doesn’t Get about Health Care,” The Atlantic, September, 2009

When you ride a tiger it’s hard to dismount lest you get eaten. So says a Chinese proverb. The tiger is health reform. The trainer is the American health consumer. The health reform endgame is fast approaching. People riding the tiger must decide how to dismount without being eaten. The tiger is hungry. It will consume more and more people, money, and resources until the consumer tames it by training it to act differently.

The Narrator

I am a retired pathologist and long-time commentator on health reform issues. My work includes books – And Who Shall Care for the Sick (1988), Managed Care Memoir (2003), Voices of Health Reform (2005), Innovation-Driven Health Care (2007), and Obama, Doctors, and Health Reform (2009) - and a blog, medinnovationblog, with 955 entries since 2006. Some say pathologists know everything. but it’s too late. I maintain pathologists aren’t mere bystanders. We actively participate in clinical medicine and observe intermediate and final outcomes.

People Riding the Tiger

People riding the tiger include:

• President Obama, who has staked his legacy on health reform

• Democrats, especially Blue Dogs, who wish to remain in power

• Republicans, who seek to regain power

• America’s seniors and the disenfranchised, now covered by Medicare and Medicaid

• America’s 5000 hospitals, who remain at the center of community care

• America’s physicians, 900,000 of them, whose future rests on the outcome of health reform

• physician-led or affiliated organizations – the AMA, state societies, specialty societies, The Physicians’ Foundation, Sermo, MGMA, and integrated health organizations – who try to guide doctors

• American health plans, 1300 of them with their various agents, who desire to remain in business by administering health reform

• the pharmaceutical industry, who is said to have stuck a deal with the Obama administration to stay on the tiger

• the medical device industry, arguably the most innovative health care sector

• American businesses, large and small, whose economic futures depend on taming the tiger

• health information technology businesses, who in their various guises – EMRs, clinical algorithms, predictive models, data mining, and health 2.0 innovations – hope to create a rational dismounting glide path

• Health lawyers and malpractice attorneys, who need to promulgate fewer rules and regulations and who need to be reined in through tort reform

• all Americans, who are growing increasingly restive, distrustful, and skeptical about what governmental comprehensive reform might portend for them

Cracking the Whip

Consumers – patients- in conjunction with knowledgeable doctors, are beginning to crack the whip. After all, it is their health and safety, not the economic health of those riding the tiger that counts. The most important thing that has happened during this latest health reform tiger ride is reawakening of the survival instinct of patients. They have begun to recognize that their survival and restoration of a full life-style function are at stake.

The enduring lesson of the health reform movement is that consumers have a potentially powerful voice. They are unleashing that voice in town meetings as they press politicians riding the tiger on how they plan to dismount without harming consumers and drowning them and the nation in debt.

Dr. Reece’s latest book, Obama, Doctors, and Health Reform is available on,,, and, or can be ordered through your local bookstore.

Thursday, August 27, 2009

U.S, Health System: Different Systems for Different Folks

U.S. Health System: Different Systems for Different Folks
And the dream lives on.

Senator Edward Kennedy, 1980

In Obama, Doctors, and Health Reform (IUniverse.2009), I wrote these words in the preface:

In a way, it is meaningless to talk of “universal health care. “ It may even be misleading to talk of a “national health system.” It is equally misleading to say we have a “non-system.” We have many systems –some public, private, state-wide as in Massachusetts, city-wide as in San Francisco, some regional as practicing in large organizations like the Marshfield, Geisinger, Mayo, Partners Health, Cleveland Clinic and other major health organizations.”

Thhe opinion expressed in that paragraph came back to me this week from three different sources.

• First was in interview with T.R. Reid, a journalist for National Public Radio. Reid has lived on three continents, has spent the last three years investigating various health systems, and has just written a book, The Healing of America: A Global Quest for Better, Chearer, and Fairer Health Care. Here is part of what Reid had to say,

I went all around the world for three years looking at different models of health care. It turns out we have them all right here in the United States. If you're a Native American or a veteran, you live in Britain. They get government health care and government hospitals from government doctors and they never get a bill. If you're an employed person sharing your health insurance premium with your employer, you live in Germany. If you're a senior and you buy Medicare insurance from the government and go to private doctors, you live in Canada. That's the Canadian model.
And if you're one of the tens of millions of Americans who can't get health insurance, well, you live in Malawi or Madagascar or Mali. We've got them all .”

• Second was an interview with Annie Proulx, author of Broke Back Mountain and numerous prize winning short stories and novels, in the Spring 2009 issue of The Paris Review, a literary magazine. Here is one of her comments.

The biggest difference between rural life in Wyoming and Vermount is the difference between liberals and conservatives. There are armfuls of liberal minds and ideas in Vermont, only scant handfuls in Wyoming. And Vermont is small, within a day’s drive of Montreal, New York, Boston, and those nearby urban centers that very much affect rural people, especially the rising tide of urbanites who mythologize Vermont as a rural paradise. Wyoming is huge and sparsely populated. The drives to Salt Lake City or Denver are long. Wyoming likes its isolation and clings to the ideal of the rugged individualism of the nineteenth century as its basic characteristic.”• Third was an interview with Toby Cosgrove, MD, a heart surgeon who is now CEO of the Cleveland Clinic, on the Public Broadcasting System (PBS) .

“One of the very important ways to improve care is to integrate the health care system and make it more efficient. And that means integrating not only the doctor with the hospital, which you saw a great example of here, but also integrating hospitals, so that not all hospitals are expected to be all things to all people, but rather to serve the community in a way that the community needs to be served, and then have the high specialty things located in places where you can get maximum practice and maximum efficiency. It's perfectly possible to expand that. It's not going to happen instantly.”


America is a vast continental nation with vast regional differences and different health systems. If nearly 100 years of failed efforts to institute a national system is any indication, a unified national system will continue to be a tough sell politically.

The dream of a universal system flounders because our complex system is a creature of our culture. This culture is why Americans prefer local solutions, why they reject federally mandated universal coverage with rationing, why they fear government mediocrity, why they feel capable of making their own health care decisions, why they seek equal and prompt access to high technologies, why they prefer pluralistic payment systems and rugged individualism to national uniformity.

U.S. health care is messy, as demonstrated in town hall free-for-alls. Health reform doesn't come neatly wrapped in one ideological package for all , but in multiple packages for different recipients. Freedom of speech, freedom of action, and freedom of choice are their rallying cries. American health care remains a set of subsystems. If you are in pne of these systems, health care can be great. If you do not fall into one of these systems, health care is often inadequate.
Richard L. Reece, MD, is a retired pathologist and a long time health reform commentator. His latest book is Obama, Doctors, and Health Reform (, a Barnes and Noble subsidiary , 2009), and his blog is

Wednesday, August 26, 2009

The Tide Runs Against Health Reform

An accomplished poet I definitely am not,
So a poem like this is with danger fraught.

But the tide is running against health care reform,
As defined by the elements of the gathering storm.

First is a growing sense of fiscal irresponsibility,
A fear debt will drown out any future affordability.

Next comes the intrinsic overall complexity,
And its close cousin, incomprehensibility.

Next is anxiety about losing what one has got,
to the hordes of uninsured who have got it not.

Next to the old comes potential shrinking of Medicare piggy bank,
with shifts to others – illegals, the young - fill in the blank.

Next follows mounting deep skepticism that government can be trusted,
to cover all, raise quality, and lower costs without going busted.

Shakespeare said, there is a tide in the affairs of men,
which, taken at the flood, leads on to fortune.

There is another kind of tide in the affairs of mankind,
which, taken at its ebb, leads on to receding of the mind.

The Obama tide brought in health reform with a shout,
This time, at least for now, the tide may take it out.

Senator Ted Kennedy's Health Care Legacy

Senator Edward Kennedy died last night at 77 of a glioblastoma multiforme – a brain cancer for which medicine has no cure. Kennedy leaves behind a rich health care legacy - Medicare, Medicaid, cae for the disabled, COBRA, childen's health care coverage, care for HIIV/AIDs. He also led a 43 year old losing battle to enact a single-payer system – or its equivalent, Medicare-for-all.

His belief was that government could fix whatever was wrong with the health system by offering comprehensive benefits for all. Whatever such a federal program would cost, it was worth it. Ironically, this dream may die this year because of the projected health care cost, now estimated at $1 trillion to $1.6 trillion through 2019, depending on who you believe, Congress or the Office of Management and Budget. The national debt this year will be $1.8 trillion. It has quadrupled in one year under Obama and is expected to grow to $8 trillion by 2019.

At his point, the day after Ted Kennedy’ death, Obama’s popularity in dropping like a rock in the polls, mostly because middle America is scared to death about personal and national debt. Loose talk of “death squads,” more accurately “death counseling” doesn’t help lighten the mood. Increasingly Americans believe Afghanistan will cost too many lives, without purpose, and health care will cost too many dollars, withot improvement in quality. They fear they will not be able to keep what they have and will not have prompt access to life saving or function-restoring technologies when they need them.

Furthermore, Americans skeptical of Obama delegating health reform to Congress, which now has a disapproval rating of 60%. Congress, through the work of 3 committees in the House and 2 in the Senate, are working their way towards some sort of reconciliation.

As Richard Cohen noted in a column in the Washington Post this day of national mourning for Senator Kennedy, “Congress is a parliamentary Okefenokee swamp in which reform invariably bogs down, rots, and emits toxic gases.” Given this swamp, the public is finding President Obama’s explanation of his health reform vision hard to grasp, to wit: “Choice, competition, reducing costs – those are the things I want to accomplish in health reform.”

Perhaps with Senator Kennedy’s help and his legendary skill at reaching constructive compromise, President Obama could have accomplished his magic three goals– more choice, more competition, and less cost. But the three goals will require innovation-squelching regulation and more consumer freedom and personal responsibility with less dependency on government. And those goals were not Senator Kennedy’s and are not President Obama’s kettle of fish.

Tuesday, August 25, 2009

Health Reform: The Efficiency of the Post Office with the Compassion of the IRS?

Prelude: Ideally town hall forums ought to be a place where ordinary citizens, the silent majority, the voices of reasons, can be heard. What follows is an example of such a voice, as reported in in the August 24 New York Times "Calm, but Moved to Be Heard on Health Care."

Published: August 24, 2009

MONTEZUMA, Ga. — Until Thursday evening, nothing in Bob Collier’s 62 years had stirred in him the slightest desire to take a stand — about anything — in public.

He skipped the antiwar protests of his college years, took a job as a regional salesman of paper and chemical products, and built for himself a quiet life of family and church (and hunting and fishing) in his rural hometown in southwest Georgia.

But on Thursday, Mr. Collier drove more than an hour down Route 19 to attend a health care forum in Albany, Ga., being held by his congressman, Representative Sanford D. Bishop Jr., a Democrat serving his ninth term.

To his wife’s astonishment, as the session drew into its third hour, Mr. Collier rose to take the microphone and firmly, but courteously, urged Mr. Bishop to oppose the health care legislation being written in Washington.

He told Mr. Bishop that his wife of 36 years had survived breast cancer through early detection and treatment, and that he feared that her care would be rationed if the disease returned.

“She’d be on a waiting list,” he said.

“This is about the future of our country as we know it,” Mr. Collier warned, “and may mean the end of our country as we know it.”

The town-hall-style meetings that have so defined the national health care debate during this month’s Congressional recess have produced an endless video loop of high-decibel rants. In many instances, the din has overwhelmed the calmer, more reasoned voices of people like Bob and Susan Collier, who came to Mr. Bishop’s meeting not because they had received an electronic call to action but because they had read about it in The Macon Telegraph.

There are plenty such people among the thousands packing county courthouses and college auditoriums, including some in the raucous crowd of 500 that confronted Mr. Bishop at Albany State University. The cameras may linger on those at the extremes, but it is the parade of respectful questioners, those expressing discomfiting fears and legitimate concerns, that may ultimately have more impact.

What prompted the Colliers to attend a Congressional district meeting for the first time was an almost solemn sense of the magnitude of the health care issue, and its place in determining the scope of American government.

“We both think this is the most important thing we’ve ever seen in our lifetimes,” Mr. Collier said the next day in an interview at his family’s four-bedroom house, overlooking a fishing pond. “I mean, the Vietnam War, which was a big deal in my early formative years, pales in comparison to the way this thing could turn our country.”

“I know we need some reform,” he said, in a deliberative drawl. “I’ve just got questions about how we’re going to do it.”

Ms. Collier, 60, an interior designer, said she had wanted Mr. Bishop, a soft-spoken centrist Democrat who has yet to take a formal position on the legislation, to understand that there were deep concerns.

“I wanted to make sure we were represented,” she said.

The Colliers are committed conservatives who have voted Republican in presidential elections since 1980. They receive much of their information from Fox News, Rush Limbaugh’s radio program and Matt Drudge’s Web site. But they said their direct experience with the health care system had persuaded them of the need for change.
When Ms. Collier’s breast cancer was diagnosed three years ago, Mr. Collier’s employer-provided insurance paid for her office visits, a biopsy and three surgeries. But the insurer covered only a small fraction of her radiation treatments, which it considered experimental, leaving the Colliers with a $63,000 bill. To their great relief, the charge was later written off by Emory Healthcare, whose doctors had recommended the regimen.

Mr. Collier’s employer, Buccaneer Inc., which is based in Atlanta, pays 100 percent of his health premiums but requires $509 a month to cover his wife. That cost has been escalating by at least 15 percent a year, and the couple’s deductibles have quadrupled.

Furthermore, Mr. Collier recognizes that were he to lose the job he has held for 39 years, his wife’s pre-existing condition might well make her uninsurable.
“We’ve got to do something about those people who can’t get insurance,” he said. “There has to be a safety net there. But I don’t want that safety net to catch too many people.”

That is the crux of the issue to the Colliers, who describe themselves as middle class. Since President Obama’s inauguration, their frustration has compounded as the administration expanded the federal government’s reach, seemingly every week. The final straw, they said, was the Democratic proposal to create a new public health plan, which they are convinced will evolve into a nationalized insurance system.
“I’ve never seen the government as intrusive as it is today,” Mr. Collier said, harkening back to President Bill Clinton’s declaration that the era of big government was over.

“Here comes this new guy in town,” he said, “and he wants to centralize everything.
He wants to take over the car companies. He wants to take over the banks. Now he wants to take over health care. It’s a power grab, and if he gets this, there’s no turning it around.”

If everyone is covered, Mr. Collier said, supply and demand will dictate that some must wait for their care. He does not believe the president’s promises that the elderly will not stand in line behind those with longer life expectancies.

“I don’t trust him on that,” he said, and then echoed a phrase used regularly by opponents of government in health care: “I think you’re going to have all the efficiency of the post office with the compassion of the I.R.S.”

The Colliers worry about the financial burden the health care plan may place on their two grown children and young grandson. While Mr. Collier said he did not object to paying more to support coverage for the truly needy, he predicted that a universal coverage system would dole out tax dollars to “lazy and irresponsible people who play the system.”

Doing something, he said, is not necessarily better than doing nothing.
Mr. Collier, who has voted for Mr. Bishop in the past, said he felt proud, in a patriotic way, to have been able to make his case.

“You don’t know what you’re getting when you send an e-mail to those guys,” he said. “You don’t know what you’re getting when you call one of their people. But when you can talk to him face to face like that, it’s a great opportunity.”

Monday, August 24, 2009

Promises to Keep, Miles to Go

The woods are lovely, dark, and deep,

And I have miles to go before I sleep,

And I have miles to go before I sleep.

Robert Frost, “Stopping by Woods on A Snowy Evening,” 1923

Frost’s poem captures the mood of the moment in health care – to stop for a moment and reflect before plunging deeper into the woods. As a nation we are still in the economic woods.

The recession is framing the health care debate because people worry about the national debt. Just today, it was announced the debt may be $9 trillion in 10 years rather than $7 trillion, and a big part of that debt may come from health care.

Of health care reform, people are asking: What’s the rush? Almot overnight, people are calling for delay, details, and reflection. Why do it now when we’re still in the depths of a recession. In CNN’s “State of the Nation,” Senator Joe Lieberman of Connecticut said, “Americans are very worrid about their jobs, about the economic future. They’ve watched us add to the debt of this country. We’re projected to run a $1.8 trillion debt this year. There’s no reason we have to do it all now.”

Speaking on the same show, Senator Lugar of Indiana chimed in, “I would advise the President that the bringing up of the health care stituation in the midst of a recession was a mistake. And therefore he ought to postpone the decision. For the moment let’s clear the deck and try it next year or in subsequent times.”

In other words, Obama ought to start again from scratch and sleep on it. But there is no mood for this in Democratic circles, where thoughtful waiting and thinking through the problem is interpreted as a political defeat of Clintonesque proportions.

Do it now, even if you have to ram it down the Republican’s throats. Do it now before the electorate has time to think about i. Do it now, while the iron is hot. Do it now, even if like Amtrak, it runs the risk of becoming a high-speed boondoggle.

Thomas Sowell, of the Hoover Institute at Stanford, explains the mood among Obamaphiles this way,

"The serious, and sometimes chilling, provisions of the medical care legislation that President Obama has been trying to rush through Congress are important enough for all of us to stop and think, even though his political strategy from the outset has been to prevent us from having time to stop and think about it.”

‘What we also should stop to think about is the mindset behind this legislation, which is very consistent with the mindset behind other policies of this administration, whether the particular issue is bailing out General Motors, telling banks who to lend to or appointing "czars" to tell all sorts of people in many walks of life what they can and cannot do. ”

“The idea that government officials can play God from Washington is not a new idea, but it is an idea that is being pushed with new audacity.”

It is an audacity of hope, combined with ample doses of arrogance, condescension, and hubris. Goverment knows best. To hell with what others think. While some believe in high-speed government as the God of economic salvation, others trust in the people, common sense, and tincture of time.

Obama's Doctor and Medicare Cost Controls

Obama’s doctor for 22 years, George Scheiner, 71, a general internist, practices in Hyde Park, a Chicago suburb. Medicare covers many of his 5000 patients. He says, unnlike private health plans, Medicare never interferes or contradicts his decisions. He favors a Medicare-for-all system.

He dislikes his famous patient’s health care proposals because “he has no cost controls,” doesn’t jettison private plans, and is “too piecemeal.” Which is precisely the problem with Medicare for all. If the past is prologue, it will be unlikely to have price controls.

The Political Dilemma

Therein lies the political dilemma. Medicare is a political plan designed to protect and please the elderly, and Democrats hesitate to further displease the elderly, the only voting bloc to vote for McCain. Moreover, seniors are among the most vocal at town hall meetings.

Medicare has a lousy record of cost control. Medicare, and its sister program, Medicaid, will cover nearly 100 million Americans this year, and its costs will exceed $1 trillion. In 1965, the year of inception of Medicare and Medicaid, LBJ promised costs would never exceed $9 billion. Cost inflation is now running 34% higher than the private sector, and the twin federal programs are hurtling towards bankruptcy in 7 or 8 years. With Medicare, Democrats have a financial tiger by the tail, and they cannot dismount for fear of being eaten by the tiger and the voters.

Administrative Costs

True, Medicare “administration costs”, at roughly 4%, are lower than private plan administrative costs, which average 10-12%. But this is misleading. What administration costs does the government have? Medicare simply gathers data, and pays bills. It does not have utilization review, marketing, negotiation expenses, and it doesn’t need to set aside money for a rainy day. It can always print more money to cover excess costs and budgetary shortfalls. Besides, a dirty little secret is that private plans, particularly the Blue, does the administrative heavy lifting for Medicare.

Small Wonder

Small wonder, then, that critics find promises of federal cost control. hollow. How? '

• By preventing illnesses and delaying their onset to later in life? Not likely. End of life diseases are very costly. Some say the final illness consumers 30% of all Medicare costs.

• By putting electronic medical records and paying only for treatments and diagnostic procedures that “work,” based on comparative research? Or by installing electronic medical record systems to instruct doctors in the rudiments of evidence based medicine and to encourage them to follow federal cookie-cutter protocols. Again unlikely.

The United Kingdom has had a program called NICE (National Institute of Comparative Effectiveness) for 5 years, and its costs have been prohibitive, it is still 5 years behind schedule, two major IT vendors have pulled out in frustration,k and the English have found NICE not nice, igniting protests across the land, especially for not providing drugs to cancer patients. In America, the Obama proposal to cut $500 billion from Medicare to help pay for universal coverage has created Tea Party protests and Town Hall free-for-alls.

The Public Option

Then there’s the public option, the darling of liberal Democrats. The idea is that a public option, run like Medicare , would save money by providing a lower cost plan, estimated at 30% to 40%, below private rates.

This proclaims Obama, would keep private plans “honest” and create a “competitive environment.” Well, maybe, but it would also likely destroy exising private insurance plans in an insurance industry that employs several million Americans. It would probably reduce choice, since employers would likely drop their coverage for employees, and the public option would likely quickly rise to dominance, since private plans could not compete.

It might make more sense to simply allow the insured to shop across state lines for private plans – plans without mandates for all sorts of benefits, like chiropractic care, autism, fertility treatments, and medical equipment. Now that would be “fair competition.”

The Government Bottom-Line

The bottom-line for government cost control boils down to two options.

• One, paying doctors and hospitals less, thereby reducing their numbers and those who would accept Medicare and Medicaid patients and driving many hospitals out of business ;

• Two, rationing, making patients wait for care, restricting care to procedures “that work,” and limiting access to expensive procedures like cataracts, joint replacements, stent placement or bypass surgery, MRIs or CT scans, or expensive biological drugs for cancer or rare diseases.


This might not work well politically. Although America health costs has high costs and covers only 85% of its citizens, it also ranks number one in the world in”responsiveness,” the ability to deliver prompt access to life saving and function restoring medicine, and the freedoms to chose what one wants and to behave how one pleases.

Miles to Go, Promises to Keep

The Obama promises of sweeping health care overhaul with universal coverage, more choice, and lower costs will be hard to keep, given the past federal performance. The administration has miles to go on cost-cutting, and promises to keep – the subject of my next blog.

Sunday, August 23, 2009

Obama's Biggest Mistake- Biggering Government

When I think of President Obama’s present problems with the American people, I think of The Lorax, a Doctor Suess story I used to read for my children.

The Lorax went like this:

Business is business!

And business must grow

regardless of crummies in tummies, you know.

I meant no harm. I most truly did not.

But I had to grow bigger. So bigger I got.

I biggered my factory. I biggered my roads.

I biggered my wagons. I biggered the loads.

And I’m figuring

On biggering,

And biggering,

And biggering.

President Obama’s problem, as I see it, is that he sees Biggering the Government as the solution to America’s problems.

In doing so, he overlooks a fundamental feature of American culture: it distrusts Big Government when Government impinges on individual liberties and freedoms.

So, President Obama, emboldened by Chief of Staff Rohm Emanuel’s philosophy of “Never let a crisis go to waste,” has over-reached and over-biggered.

1. He biggered the government, making it the nation’s largest employer, with a $787 billion stimulus package.

2. He biggered the number of earmarks, with the $410 milliom Omnibus Bill, sometimes referred to as the Porkulus bill.

3. He biggered health care reform by proposing a $1 trillion plus proposal to be spread out over 10 years. In effect, he threatens to completely overhaul 1/5 of the nation’s economy and the nation's largest single and growing private employer.

4. He biggered the future tax burden on the American people, expected to cost every household $1,100 by 2050, and business much more, with a Cap and Trade bill, designed to tax carbon emissions.

5. He biggered the load on the information technology sector, with antitrust lawsuits against Google and Microsoft and other Internet giants.

6) He biggered the role of government in setting executive compensation of executives at firm receiving bailout money, and the federal government is preparing steps for unprecedented regulation of all consumer finance transactions. Already, payday lenders are being chased into the black market, and New York is losing its luster as an international capital for finance.

7) He biggered government’s stake in academic by making Pell Grants a government entitlement. If the Student Aid and Fiancial Responsbility Act is passed, it will make the government the biggest provider of student loans in American.

8) He biggered government’s ownership in the American automobile industry, fired the CEO of General Motors, and pulled off the Cash for Clunkers program.

9) He biggered government’s role in regulating tobacco, and he would like to bigger taxes for alcohol, fast foods, and soft drinks – and perhaps any other product that leads to obesity - and to pleasure.

10) By dint of these activities, he biggered the federal debt to heights not seen since World War II, moved the United States from 10th to 3rd on the list of major industrial countries in terms of total government spending as % of GDP (at 49,6% now behind only Sweden at 57.0% and France at 54.2%), led to polls saying twice as Americans now consider themselves conservatives rather than liberals , and provoked a string of best-selling conservative books accusing Obama of being a socialist or worse – Culture of Corruption, by Michelle Malkin, Liberty and Tyranny by Mark Levin, Catastrophe by Dick Morris, and The Last Best Hope, by Joe Scarborough.

There is nothing wrong with all of this, aa long as it achieves the desired effect, is limited and temparary, deosn't run out of the people's money, doesn't heavily tax the middle class, doesn't hamper innovation, deosn't destroy American's capacity to make more, and as long as it can count on other countries like China to continue invest in the U.S.

The Internet and Community Organizing Are Two Way Dialogues

Dialogue ..should be reserved for the culminating moments, and regarded as the spray into which great wave of narrative breaks in curving towards the watcher on the shore.

Edith Wharton, 1862-1937, The Writing of Fiction

Obama gained the presidency largely through a brilliant campaign featuring two strategies: the adroit use of the Internet and lessons learned from community organizing. Now these techniques are being used against him in the culminating moments of the health care debate.

Obama is Our First Internet President

As I observed in a chapter “Obama’s E-Based Health Reform Push” in Obama, Doctors, and Health Reform,.

"Barack Obama is our first Internet President, which is altogether without precedent. The President uses the Web to issue a daily report and to mobilize wider political support. That e-tools help his agenda is evident. For Obama, Internet politics is good. For all of us that fact has to be understood. Obama Internet supporters helped get him where he is today and elevated him above the ordinary political fray. For Obama the Internet was the little Engine that could. Say about Obama’s Internet strategy what you will. Say that it’s shows the mark of remarkable political skill. Say that it smacks of George Orwell’s Big Brother. Say that it brings all media under one giant cover. Say what you will: The Internet is now routine grist for the political and health care mill."

But Now He Protests Too Much

And as Katherine Kersten, a Minnesota Tribune column wrote in “Left Protests Too Much about the Town Halls, on August 22,

"It's odd to hear Democrats denounce grass-roots organizing as sinister. Their allies wrote the book on "netroots," and groups such as the Association of Community Organizations for

Reform Now (ACORN) and helped put Obama and friends over the top in the 2008 elections. These organizations have eye-popping budgets and Washington offices, while town hall protesters pass on e-mails to their neighbors
from their kitchens after work.

The greatest irony, of course, is that Barack Obama -- our health care reformer-in-chief -- rose to America's highest office by using skills he mastered as a "community organizer."

Obama has written and taught about community organizing, and he has served on foundation boards that support it. Announcing his presidential bid, he said the "best education" he had received was not at Columbia University or Harvard Law School, but in Chicago.

When Obama was elected to the U.S. Senate, Michelle Obama told a reporter, "Barack is not a politician first and foremost. He's a community activist exploring the viability of politics to make change."

And He Counterattacks Too Late

As the American public’s support of Obama’s health care reform plummets in the polls (it’s now under 50% in most polls), it should come as no surprise that he and his followers in Organizing for America (OFA) are desperately turning to their cache of 13 million e-mails gathered during the presidential campaign and to his previous army of volunteers, to organize 12,000 local rallies, and to raise $10 million in a TV, lobbying, and Internet counter-offensive.

Obama himself has responded by blasting the “lies about government take-overs,” "bearing false witness," “willful misrepresentiations and outright distortions,” and “outrageous myths” about death squads, government funds for abortions and illegal immigrants, and “keeping your doctor and your health plan”

As the Obama team remobilizes, it seems not to recognize that its vast health care overhaul in this vast nation with its vast regional subcultures is unpopular with the vast mainstream and may be vastly unworkable. As my father once remarked to me, "Son, don't start vast projects with half-vast ideas."

And It May Signal the Death of a Salesman

Obama's message of righteous indignation isn’t selling well, As Fred Barnes, of the Weekly Standard reports in “Death of a Salesman: The More Obama Talks, the Lower his Approval Rating Drops,"

"In mid-August, after more weeks of barnstorming for his health care program, his approval rating remained in the low 50s. Only Bill Clinton among recent presidents had a lower approval after seven months in office."

"For Obama, there's still worse news. Not only has he lost ground, but public support for his health care proposal has collapsed to the point that a majority of Americans prefer no reform at all to his plan. And the more he stumps for it, the less support it attracts. Rather than a peripheral phenomenon, the noisy opposition in congressional town hall meetings turns out to be a reflection of the deep national suspicion of Obamacare.
"Health care is the big one for Obama, his signature program, the one that's most far-reaching and politically important. It's the real test of Obama. If he can't persuade the country to back it--and so far he's failed miserably--then he's not the spellbinding speaker or the master politician he's been cracked up to be."

What’s Wrong

Seven months into his presidency, Obama is coming across as condescending, angry, accusatory, arrogant, and defensive.

As his health plan falters, one day he’s blasting health insurers, the next blaspheming doctors, the next accusing distracters of spreading false notions about his plan. He's suffering from overexposure. Obama had four prime time press conferences in his first six months. George W. Bush had four in eight years. FDR, who actually was a great communicator, delivered fireside chats on radio every five or six months."

The problem may not be that Obama talks too much about big ideas, but that people are paying close attention to details and that they are furious their Congressional representatives haven't even bothered to read the bill, and they are reacting by adopting the tactics of internet mobilizing and community organizing they learned from the Master.

Saturday, August 22, 2009

Regina Herzlinger Chroncles

Prelude: I owe a debt of gratitude to Regina Herzlinger, professor of business administration at Harvard Business School and editor and author of Consumer-Driven Health Care: Implications for Providers, Payers, and Policymakers, Jossey-Bass, 2004). On consumer-driven care, she has taught me, the What (consumers spending their own money), the Why (they spend it wisely), the When(now, more people have HSAs than HMOs), the How (HSAs/high deductibles), the Where(Switzerland), and the Who (patients, doctors, and entrepreneurs). She has also taught me government care stifles innovation, imprisons ambitious well educated people), and produces mediocre care lacks dignity for its givers and recipients). Finally, she has honored me by writing the foreword to my book, Innovation-Driven Health Care: 34 Key Concepts for Transformation(Jones and Bartlett, 2007).

August 22, 2009
Government Should Get Back to the Basics on Health Care
By Regina Herzlinger

Those who worry about a growing role for government in health care reform have reason for concern: the government already plays a surprisingly large role in our health care system. Like Thomas Jefferson, the father of the Democratic Party, they may feel that: 'Were we directed from Washington when to sow and when to reap, we shall soon want bread.'

Protecting Us

Normally, the government's role in the sectors that provide us with goods and services is to protect us - by enforcing anti-trust and consumer protection laws, guaranteeing transparency through agencies such as the SEC, and preventing fraud and abuse. It also enables income redistribution, so the poor and disabled can participate in society just like everybody else.

Powerful Role

But the government plays a much more powerful role in our current health system. Through the Medicare and Medicaid programs and state government regulations, it sets the prices paid to providers, determines who is covered for what in its insurance plans, and requires that certain benefits are included in insurance policies. The government of Massachusetts, for example, requires 52 benefits, including in vitro fertilization, a benefit that raises the price of every family's health insurance by $850 or so.

Liabilities – Debt, Degradation, Physician Turnoffs, and Cost-Shifting

It is difficult to conclude that the government has attained terrific results with these expanded powers. Despite the government's regulation of the prices, coverage, and benefits in Medicare, the program has incurred a $38 trillion liability - a sum equivalent to nearly three years of the nation's Gross Domestic Product. The Congress has chosen to underprice Medicare to current recipients (and voters) and to stick our children and grandchildren (who do not as yet vote) with the bill. As for Medicaid, although it is better than no insurance, it is a degrading program for its participants because as many as 40 percent of doctors refuse to see recipients due to its stringent provider payment rates. These physicians are not heartless; but because many are burdened with up to $500,000 in medical education expenses, they cannot afford to see patients like these. Increasingly, physicians refuse to see Medicare enrollees too, for similar reasons. To compensate for the government's shortfall in payments to providers, enrollees in private health insurance have been forced to pay about $90 billion more annually.

Practicing Medicine through Cookie-Cutter Recipes

Increasingly, the government even tells physicians how to practice medicine. The movement, disingenuously labeled "pay for performance," does not reward doctors and hospitals who achieve better outcomes. Instead, it rewards those who follow the government's cookie-cutter recipes for providing medical care. It should be labeled "pay for conformance."

Destroying Physician Autonomy

In my classes in Innovations in Health Care, I meet all too many students who are fully certified specialists in their chosen fields, men and women in their 30s. When I ask them, "What are you doing in this class? Although a business career is wonderful, you are fulfilling God's mission as a physician or nurse." I worry when some respond "I can no longer practice medicine. I have lost my professional autonomy by the intrusion of government into the relationship between me and my patient."

Switzerland, Not U.S. Government, Shows How

Despite these less than stellar results, the current health care reform bills would further enlarge government's functions by having it run "Uncle Sam's Health Insurance Market," in which the uninsured would be required to shop, and even creating a new government health insurance program to compete with private sector insurers. Although the authors of this legislation aver that this combination would control costs so that universal coverage could be attained without breaking the back of our economy, the country of Switzerland has achieved universal coverage and excellent health care outcomes at costs 40 percent lower than ours, as a percentage of GDP, without a public program or government-run market. Instead, ferocious competition among the country's 87 private insurers has driven their general and administrative expenses down to 5 percent, a percentage lower than Medicare's.
The key to Switzerland's success is that it is consumer-driven - people buy their own health insurance. No employers or degrading government programs are involved. Instead, the poor receive money from the government so they can buy the same insurance as the average Swiss. The sick among the Swiss are not discriminated against either - the private insurers reinsure each other so that sick enrollees pay the same prices as the average person.

Power to the People and Proper Role of Goverment

In this kind of consumer-driven health care system, the government ceases its artificial price-setting mechanisms and intrusions into the practice of medicine. Instead, the economic power rests with the people.

To enable it, the Congress should:

- Change the tax laws so that all Americans could buy health insurance with tax-free income, a right currently limited primarily to employers

- Help to create information about the quality and prices of medical care providers

- And transfer money to the poor so they can shop for health insurance like all other Americans.

The government should also vigorously prosecute anti-trust and fraud and abuse.
With these legislative changes, employees could either use the funds their employers now deduct from their income to buy health insurance -about $17,000 for a family - or remain under their employer's plan. The uninsured could also use tax-free income to buy their health insurance.

In this system, the government - senators, representatives, and bureaucrats - will stop practicing medicine and setting market prices. They will get out of the way and let the doctors do the doctoring and us do shopping.

Friday, August 21, 2009

Cost of Health Plan Bureaucracies to Doctors

Prelude: Doctors often complain about time and money wasted interacting with health plan clerks, seeking permission to perform a procedure, do an MRI, or order a laboratory test. The following article, based on a press release from the Commonwealth Fund, vividly illustrates why doctors are justifiably frustrated.

Physician Practice Interactions with Health Plans Cost $31 Billion A Year, Equaling 6.9% of All Spending For Physician And Clinical Services,

New Study FindsPhysicians Spend The Equivalent Of Nearly Three Work Weeks On Health Plan Interactions

NEW YORK (May 14, 2009) — As policymakers consider ways to cut health costs as a part of health reform, a new national survey of physician practices finds that physicians on average are spending the equivalent of three work weeks annually on administrative tasks required by health plans.

According to the study by Lawrence P. Casalino, M.D., Ph.D., Chief of the Division of Outcomes and Effectiveness Research in the Department of Public Health of Weill Cornell Medical College and colleagues, physician practices report that overall the costs of interacting with insurance plans is $31 billion annually and 6.9 percent of all U.S. expenditures for physician and clinical services. The study, published in today's online issue of Health Affairs, was co-funded by The Commonwealth Fund and the Robert Wood Johnson Foundation's Changes in Health Care Financing and Organization (HCFO) Initiative.

Activities Requiring Time and Money

The survey of physician practices across the U.S. inquired about time spent by all practice staff on specific activities, including prior authorization, pharmaceutical formularies, claims and billing, credentialing, contracting, and collecting and reporting quality data. This national survey is the first to ask directly about time spent by non-physician staff on interaction with health plans, and the first to provide data by the type of interaction, type of staff, specialty, and practice size.

On average, physicians spent three hours a week or nearly three weeks per year on these activities, while nursing staff spent more than 23 weeks per physician per year, and clerical staff spent 44 weeks per physician per year interacting with health plans. More than three in four respondents said the costs of interacting with health plans have increased over the past two years.

"While there are benefits to physician offices' interactions with health plans — which may, for example, help to reduce unnecessary care or the inappropriate use of medication — it would be useful to explore the extent to which these benefits are large enough to justify spending three weeks annually of physician time or one-third of the average primary care physician's compensation on physician practice-health plan interaction," said Dr. Casalino. "It would also be useful to explore ways to make the interactions more efficient, both on the health plan side and in physician offices."

Other Study Findings

Other study findings include:

• Physicians — especially primary care physicians — in a solo or two-person practice spent significantly more hours interacting with health plans than physicians in practices with 10 or more physicians.

• Across practices, physicians and their staffs spent substantially more time on authorization, formularies, claims and billing and credentialing than they did on submitting quality data or reviewing quality data provided by health plans.

"Because many providers care for patients insured by numerous private and public plans, they must contend with multiple payment schedules, claims forms and credentialing requirements. These complicated requirements create wasteful excess costs and do little to improve the quality of care," said Commonwealth Fund President Karen Davis. "A high performing health care system is only possible with improved coordination and elimination of waste — not only between physicians and insurers but in all parts of the health care delivery system."

"To get to a health care system that is high-quality and delivers better value for everyone, we have to address the skyrocketing price of health care's administrative costs," said Risa Lavizzo-Mourey, M.D., M.B.A., president and CEO of the Robert Wood Johnson Foundation. "Administrative costs will never be zero, but we need to make sure that administrative interactions improve the quality of care by working to make care safer and more efficient and rewarding health care providers who successfully reduce excessive care and provide the right treatment at the right time."

Study co-authors include Dr. Sean Nicholson, Associate Professor of Policy Analysis and Management at Cornell University in Ithaca; Drs. David Gans, Vice President of Practice Management Resources and Terry Hammons, senior fellow, both at the Medical Group Management Association (MGMA) in Englewood, Colorado; Drs. Dante Morra, CTU director at Toronto General Hospital, and Wendy Levinson, Professor of Medicine, both of the University of Toronto; and Dr. Theodore Karrison, Associate Professor of Health Studies, University of Chicago.

The article is available at

Counterproductive Consequences of Bashing Doctors

Prelude: As readers ot this blog know, I make a habit of publishing relevant comments by practicing doctors on the consequences of health reform. The Obama administration has an annoying habit of portraying doctors as over-treating and over-ordering diagnostic procedures for personal gain, while neglecting such societal pressures as practicing defensive medicine to avoid frivolous lawsuits and patient demands to have something done to restore life style function. Probably no specialty is more aware of these pressures than orthopedic surgeons who often perform procedures to restore patients to active and productive life styles.

Here are the comments of an orthopedic surgeon who has been practicing for 40 years from the August 20 Washington Post

Devaluing Doctors -- and Care

By Marshall Ackerman. M.D.
Washington Post, Thursday, August 20, 2009

Physicians have been cast as the villains in the drama that our national health-care debate has become. We stand accused of raising charges to private insurers to compensate for low Medicare and Medicaid reimbursements as well as care of the uninsured or illegal immigrants; doing more to get paid more; seeing patients more often than necessary to increase revenue; and providing inefficient and ineffective care to patients in the hospital. Our motives are impugned. The care we render is being disparaged and our professionalism disregarded -- yet somehow it is assumed that doctors are merely passive pawns to be moved around the chessboard of health care.

Where are the Investigative Journalists When We Need Them?

How many physicians who are not radiologists own their own MRI machine, CT scanner, PET scanner or other sophisticated diagnostic equipment to which they refer their patients? Why would President Obama blast pediatricians for doing tonsillectomies for profit, when any intelligent person knows that pediatricians do not do surgery?
They care for sick children and refer them to ear, nose and throat specialists when surgery is needed. Why does no one seem to be aware that surgeons have functioned under a "global reimbursement" system for more than 35 years? Surgeons are paid a set fee for the care rendered for surgery or fracture care for a fixed period (frequently 90 days) regardless of how often they see a patient or how long the patient remains in the hospital.

For that matter, why would intelligent physicians fill their schedules with unnecessary return visits for Medicare/Medicaid patients, who are the lowest payers in the mix, limiting the number of new patients they could see? And how is it that so many physicians "pass along" the losses of caring for the uninsured or Medicare/Medicaid patients when in fact doctors labor under contracts with big insurers that are basically take-it-or-leave-it with payment rates not much higher than Medicare, which has become the new standard?

Negative Changes since Advent of Medicare

I have been a practicing orthopedic surgeon for 40 years. I have observed profound changes in my profession since the advent of Medicare, changes that have affected patients' access to care. As reimbursements plummeted, internists abandoned hospital care to the new specialty of hospitalists, created boutique practices and stopped participating with health insurance companies. Physicians in all specialties have been retiring at earlier ages than ever before. In my own office, our staff has doubled over the past 40 years to enable us to handle the growing stream of government and insurer mandates. Our reimbursements continue to drop -- with no ability to pass on these costs. We are not the Mayo Clinic. There is no foundation to provide computers and electronic medical records or research grants to supplement salaries. Everything we do must come out of the reimbursement we receive for the care we provide to each patient.

Joint Replacements as Example of Difficulties Physicians Face

Total joint replacement surgery for an arthritic hip and knee is a prime example of the difficulties physicians face and of the implications of health-care reform as envisaged by Congress and academic "experts." In 1971 I was paid $1,000 for a total hip replacement. Today, I would be paid approximately $1,600 for the same service.
There is no multiplier -- a surgeon can only do one patient at a time. We continue in our practice for the immense satisfaction we receive from knowing that this surgery does more to restore a high quality of life to patients than any other surgery, and for the gratitude patients show. We implant devices because we believe, based on medical literature, that they are the best choices for patients. The overwhelming majority of surgeons have not received fees from implant manufacturers -- many times lowering the profitability of our hospitals.

Spiral of Never-Ending Decreased Reimbursements

Consider the implications when a global fee will be paid to the hospital: Then hospital and physician incentives will be aligned, and patients will bear the cost of the search for ever-cheaper implants and techniques, such as a return to cemented total hips. Forget metal-on-metal bearings, resurfacing, rotating platforms, high-flex knees, navigation systems or bilateral replacements. And if our hospitals are financially penalized for occurrences such as infection and deep-vein thrombosis after surgery, who will operate on the obese, the hypertensive or the diabetics among us? Experience with government funding reveals a never-ending spiral of decreased reimbursements in the name of restraining costs. In the end, this will come out of the care we all receive.

Ask Your Doctor about Reform

At your next visit to your specialist, take a tip from the drug company ads and "ask your doctor": Does he or she plan to retire early if reform legislation passes close to its present form? Does he or she plan to continue to participate with Medicare/Medicaid or participate with insurers that will not reimburse adequately? How does your doctor think health-care reform will affect the care you receive in his or her specialty? Access to a waiting list is not access to health care. Let's stop pointing fingers and start considering the real flaws and strengths of our system and how to improve it.
The writer, an orthopedic surgeon, has worked in private practice in the Washington metro area since 1969.

The Over 60 Crowd Gets Nervous about Health Reform

Thc crowd most anxious about health reform these days is not the uninsured, but the people who have insurance already, in particular, the elderly on Medicare. This angst is partly due to lack of trust in President Obama, who said recently, ““If you’re on a public program like Medicare you’ve got something to worry about because we’re going to be running out of money,”

We Medicare recipients may be old, but we’re not stupid. When Obama says he is going to “cut costs” and make health care “affordable” by cutting “waste and inefficiency” out of Medicare to the tune of $500 billion over the next 10 years the “young old” (65 to 75 ), “middle old’ (75-85), and “old old: (85 and older) are listening.

The old (I am one of them) know we take the most drugs, have the most illnesses, undergo the most operations and diagnostic procedures, and consume the most health care resources. It doesn’t take a rocket scientist to know when you grow old, bad things inevitably happen. Your days grow shorter, and the odds against you grow longer. You are vulnerable, and you know it. You’ve had it good up to now, maybe too good, but you’re not going to give it up now without a fight, like the ones now being conducted in town hall meetings.

President Obama has said his administration can make financial ends meet – pay for his $1.6 trillion plan (the OMB estimate) by squeezing $500 billion (his estimate) out of Medicare. Among other things, all we have to do , he claims, is to prevent disease, coordinate care, make care more efficient through ubiquitous EMRs, create a federal institute to compare what things work, and offer end-of-life counseling .

Trouble is the elderly aren’t buying the notion that his plan is either “revenue neutral,” will improve care, or won’t “pull the plug on grandma.” More than hlaf of Amerians believe health reform will worsen care.

Peggy Noonan,writing in today’s Wall Street Journal has gone so far as today tp say, we ought to pull the plug on Obamacare. Also today, August 21, the New York Times ran two articles the anxieties and angst of the elderly, “A Basis is Seen for Some Health Care Fears Among the Elderly” and “Where Elderly Back Obama, Health Care Anxiety,” even among his supporters.

President Obama insists ”Nobody is talking about cutting Medicare benefits.” But the politicians are talking about eliminating “unnecessary subsidies,” Medicare Advantage drug plans, therapies and diagnostic tests that “don’t work,” and dramatically reducing pay to specialists, especially cardiologists.

This Orwellian double-speak makes the elderly nervous, who have the sneaking suspicion that Obama seeks to redistribute care away from Medicare recipients to the young, immigrants, and the poor who have not paid into Medicare.

Thursday, August 20, 2009

An Alternative to Obamacare

The mainstream media, pundits, and the political elite criticize others, mostly Republicans, by saying the opposition never offers alternatives. This isn’t so. The opposition offers alternatives, but the alternatives are ignored. The rule of ruling class is: if it isn't my idea, it doesn't count and is off the table.

The truth is the political, think tank, and political elite shut out news of alternatives. The NYT, ABC, NBC, CNN, CBS editorial filters are powerful. One of the unspoken rules of political partisanship and elite mediaship is: never give your opponents the time of day or prime time exposure.

One function of this blog, which is respectful but skeptical of Obamacare, is to highlight reasonable health reform proposals. The proposal put forth by Shawn Tully, editor at large of Fortune is such a proposal and consists of four parts (“Don’t Like Obamacare” Here’s an Alternative," Fortune, August 20, 2009)

1. End tax breaks for employer health plans.

As an employee, your take home pay will go up, and you will own individual plan. Your premiums will go down. You will have a high deductible, but your will be motivated to shop for the best deal, and if you have cash left over, you will have a retirement nest egg.

2. End the three big inflators of health costs.

One. End the “standard benefits packages,” which too often contain costly special benefits like hearing aids, wigs for cancer victims, chiropractic care, autism care, drug abuse treatment.

Two. End “community ratings” – the same rate for everybody, whether sick, young, old, or healthy. This punishes the young and pushes them out of the market.

Three. End “guaranteed issues” requiring plans to accept anyone who applies. Again this punishes the young and healthy and drives up the number of uninsured.

3.Protect people with pre-existing illness.

Place them in high risk pools of those with such illnesses, and cap their premiums at 150% of average premiums. Subsidize them if necessary them with state-based income subsidies and sales tax revenues.

4.Expand the supply side.

Give consumes control over their own money through HSAs. Protect them with castatrophic insurance. Allow nurse practitioners, physician assistants, and other qualified professionals to provide basic care. Promote retail clinics, worksite clinics, cash-only clinics, concierge practices, and urgicenters.

Townhalls and Catcalls: Storm over Reform

What does it all mean, what does it all portend, these raucous town halls, these loud catcalls of August?

Who knows, but it’s worth trying to capture what’s happening and the mood of the nation.

Congress Representatives and Senators in August recess are pondering,
Why are our well-intentioned Obamacare health reform efforts floundering?

They're asking: what kind of people are these.
these people we’re striving but failing to please?

Are they mean-spirited community organizers on the right,
seeking to put the righteous left in flight or fright?

Why aren’t they civil?
Are their motives evil?

Are they sincere, do they have their deep-seated beliefs?
Or have cynics briefed them on how to express their beefs?

Don’t they know health reform is for the individua good?
Most certainly, our reform is a power for the common good.

Don’t they realize having 46 million uninsured is immoral?
About that simple fact there should be no partisan quarrel?

Aren't they aware we're soaking corporations and the rich,
To give them free care and remove them from every tax niche?

Don’t they know that we-have-to do-it-all-at-once-now?
That we must save the nation from crisis now is our vow.

Why don’t they listen to our voices of reason,
during this once in a political lifetime season?

Why do they ask of we’ve read the 1018 page HR-3200 bill?
Why should we read it? Our political destiny we must fulfill.


Meanwhile, on the other side of the political divide,
Constituents are asking, are we being taken for a ride?

What’s the big rush, why don’t we get it right?
Why do we have to do it in one big bite?

In the end, how are we going to pay for it all?
Why not slow it down, even bring it to a stall?

If to pay for all care, Congress must cut $500 billion from Medicare,
What does that mean to seniors, will there be a rationing nightmare?

If Congress removes tax credits from employer health benefits and HSAs,
isn't that the equivalent and in essence the same a middl3 class tax raise?

Is this a government take-over?
Or simply a cosmetic make-over?

Does it all have to be done by September or even December?
Or is it about elections a year or even 2 years from November?

You ask why we ask bold questions, even shout.
It’s because we have no other political clout.

The mainstream media and political elite don’t voice our basic concerns.
From them it’s mostly condescending criticism with diminishing returns.

Townhalls are one of the few places we can be heard.
We’re not nerds, we’re the voices of the common herd.

Besides, we happen to think our present system is pretty good and elements of it need to be preserved.

A CDC report today, August 20, says, “ U.S. life expectancy has risen to a new high, now standing at 78 years. The increase is due to falling death rates in all major causes of disease.”

That’s good, isn’t it?

Wednesday, August 19, 2009

Joining the Conversation on Healthcare Reform

By Becky Coffey
Harbor News Senior Staff Writer, in Harbor News, August 19
Old Saybrook, Connecticut

When it comes to health-care reform, every pundit and politician seems to be pushing his or her plan or bashing someone else’s. Dr. Richard Reece of Old Saybrook, a retired pathologist, editor-in-chief of Physician Practice Options and author of a new book entitled Obama, Doctors, and Health Reform – A Doctor Assesses the Odds for Success, has joined in this national conversation, weighing on the intended and unintended consequences of the healthcare reforms that President Obama and Congress are discussing.

Reece’s new book was written with the support of the non-profit Physicians Foundation, a charitable organizations representing 650,000 physicians who belong to local, state, and national medical societies. The book was published by IUniverse and is available through online booksellers including,, and It can also be ordered through local booksellers.

It’s Reece’s contention that the best way to contain rising healthcare costs while still providing quality care is to put the daily purchasing decisions about healthcare in the hands of healthcare consumers, the patients. He believes that successful healthcare reform will rely at some level on a market-based approach and a principle he calls patient-oriented care.

An example of consumer-driven healthcare he supports is the high-deductible healthcare insurance plans that are paired with employee-owned health savings accounts (HSAs), a consumer choice-driven program to which Congress gave tax advantages several years ago.

In these high-deductible/HAS programs, health care consumers pay much lower monthly insurance premiums in return for assuming a high annual deductible of $3,000 to $5,000.

Many employers offering these healthcare plans pay form $1,000 to $2,000 for each employee’s health savings account to offset a portion of the high annual deductible. If a consumer is careful, this approach can yield lower inlay healthcare cost than conventional point-of-service insurance plans and also provide the added benefit of incremental tax-free savings in a healthcare savings account. In 2009, employees on high deductible plans could set aside up to $5,750 each year in a health savings account; funds left-over at the end of the year grow tax-free under current rules.

Current Congressional health-care proposals would eliminate these high-deductible programs’ tax advantages.

Reece cites four obstacles to the success of current proposed healthcare reforms: culture (the American desire for unlimited choice and quick access), complexities (the many interrelated institutions and groups that all play a part in the health delivery system), costs (there is little evidence, according to Reece, that universal use of electronic medical records, for example, or choosing to pay only for treatments that work will result in cost savings), or consequences.

Writes Reece, the “consequences of curtailing healthcare costs may be worse than the cure because healthcare institutions and private practices in many communities are the biggest and fastest growing employer in town. Collectively, healthcare profoundly impacts most community economies. Healthcare’s building blocks can’t be downsized quickly or dramatically.”

But it was his praise for the Dutch single-payer healthcare system where private insurance companies sell health insurance and all citizens must buy it that recently brought him international exposure.

On the Dutch Royal TV hour long special on healthcare reform, Reece’s interview clips shared the spotlight with fill clips of conservative commentators like Bill O’Reilly, Sean Sanity, Rich Lowry, Neil Cavuto, Glen Beck, and Karl Rove, all speaking on President Obama’s prospects for success in healthcare reform (To view the Dutch show, go to

Reece will speak about his new book – and his views for achieving healthcare reform this year – in a talk at the Acton Public Library scheduled for the evening of Sunday, Sept. 13.

By Any Other Name, It's Rationing

If you’re a word person, as I am, you think words matter.

And if you listen to words being spoken and words being written, and insults being hurled, you know it’s all about rationing.

As it has to be. The supply of health care is a limited resource, and the demand in an aging population is unlimited. Health care money and professionals don’t grow on trees. It requires human and physical capital, and those resources are in short supply. No matter how hard you try, you can’t repeal the laws of supply and demand. You might be able to innovate your way out of rationing, but not with the current web of private and public regulations.

If you’re on the private side, which covers 253 million Americans, you ration through “co-payments,” “pre-authorization”, “costly premiums,” “individuals and small group payments,” “pre-existing illness,” high cost individual cancellations”, and other maneuvers and tactics to cut costs.

If you’re on the public side, i.e. Medicare and Medicaid, which covers 86 million citizens, or you’re pushing for Obamacare, you unfurl and deploy words or phrases like “public option,””health-cooperatives,” “leveling the playing field,” “honest competition,” “high-cost-low value trade-offs,” “evidence-based medicine,” “ outcome based care,“ implementing a set of performance measures that all providers must adopt, “ standardization,” "pay-for-performance," "quality metrics," “directly targeting individual providers and high-end outliers,” “limiting services to health care that works,” “comparative effectiveness research,” “QALY – Quality Adjusted Life Years.”

On the federal side, it’s about somehow stopping the financial hemorrhage of federal health programs, and it’s about what to do when you run out of other people’s money. And that means it’s about rationing.

On the private side, it’s about staying in business, and that means rationing.

And on the personal side, it’s about knowing what things cost, spending one’s own money, staying healthy, and self-restraint, self-reliance, and self-responsibility. And that means rationing one’s behavior.

Tuesday, August 18, 2009

Hopes Obamacare Would Kill

Prelude: I make a practice of reprinting what other doctors say about health reform when their comments resonates with me. Marc Siegel MD is a practicing internist , an associate professor of medicine at NYU Langone Medical Center. and a Fox News medical contributor. This Op-Ed piece is from the New York Post on August 18, 2009. I may be sensitive to this particular piece because I had drug-coated stents put in place after I suffered a myocardial infarction and have been well and asymptomatic since.

FOR generations, we doctors have promised our patients that medical advances will allow us all to live longer, more comfortable lives. Now that these results are finally arriving, "health-care reform" -- or "insurance reform," as they're now pitching it -- could snatch the rug out from under us.

Cost-control is central to any health-care "reform" along the lines favored by President Obama and congressional Democrats. But new treatments, while ever more precise and personalized, are also costlier.

Anyone who's been saved from cancer by the latest targeted chemotherapy treatment, had a lung or breast cancer diagnosed early by a CT scan or MRI or returned from the brink of a heart-related death thanks to the newest drug-treated stent, understands that some expensive care is well worth the price.

Over a million American patients a year get cardiac stents to keep their coronary arteries open, at a cost of billions. Is that too much to pay to keep patients alive, or at least save them from intractable pain?

The president has largely stopped promoting "cost control" as one of the virtues of his reforms -- but every nation that has adopted anything like that has also adopted measures that kill medical innovation. They buy less cutting-edge technology; won't pay for new, expensively researched drugs -- saving government money at the cost of future patients' lives.

Which recent advances would have been aborted if we'd adopted "reform" years ago? Anti-inflammatory treatments such as Enbrel for corrosive arthritis? Major surgeries made far less invasive through use of a 'scope? More precise and powerful lasers to treat the skin and eyes?

As a practicing physician, I've made a promise to my patients to maintain their quality of life and keep them in good shape as long as possible. But this promise can only be kept with the help of modern discoveries. Pills such as Lipitor help me prevent heart disease, and the latest heart procedure helps me to treat the disease once a patient has it.

I'm bound by the Hippocratic Oath, which tells me to "prescribe regimens for the good of my patients according to my ability and my judgment." Will I see my ability to follow my oath compromised or restricted by the cost-cutting of essential services?

Even current treatments are at risk. Would the proposed one-size-fits-all insurance pay for breast reconstruction for my vital 85-year-old professor patient? I don't think so. Would my 75-year-old artist still get his dialysis? Would my 68-year-old hepatitis patient still get his liver transplant?

Almost half of my patients have worked for decades before they were 65, waiting for the day when they would proudly receive their first Medicare card, testament to their years of hard work. But how much care will the Medicare card buy in the near future, when every "reform" relies on "savings" from Medicare?

How much can Medicare cover if the government reduces payments to hospitals and physicians by hundreds of billions of dollars, as the majority in Congress proposes?
Many of my seniors are now frightened by the prospect of long lines or frank denials, that doctors will be "treating them differently because they have already had more life years," as Dr. Ezekiel Emanuel, an Obama health-policy adviser, coolly recommended in a recent article.

My patients are right to be concerned. I'm concerned, too, not knowing if I'll still have the tools I need to take care of them.

Humanism and Evidence-Based Medicine

Prelude: This is my comment on an article in The Health Care Blog, entitled "Can Social Commentary Save Health Care?" dated August 17, 2009. The article was written by Daniel Palestrant, MD, founder and CEO of

In 1988 I published And Who Shall Care for the Sick? The Corporate Transformation of Medicine in Minnesota. At the time, I was editor-in-chief of Minnesota Medicine, the monthly journal of the Minnesota Medical Association. I was concerned managed care would drive doctors out of independent primary care, reduce them to mere functionaries of corporate interests, weaken doctor-patient relationships, and discourage medical students from entering HMO dominated medicine.

As it turned out, I was partially right. Independent primary care physicians are on the wane; solo practice is dead as a doo-doo bird in Minnesota, most primary care physicians there now work as salaried employees of hospitals; practitioners everywhere are a threatened species, with a current shortfall of 50,000 nationwide , estimated to reach 200,000 in 10 years; current and future medical students are more interested in specialties with better life styles and higher pay.

Meanwhile, partly as a reaction against the time-consuming bureaucracies surrounding data-based pre-authorization policies, the humanism movement, i.e. patient-centered care with doctors engaging patients as partners in shared decision-making is on the rise. Many doctors are pulling out of HMO and PPO contracts, not accepting new Medicare patients, dealing with patients directly in concierge and cash-only practices, or going to work for hospitals in jobs where they don't have to bother with health plans.

Also on the ascendancy is evidence-based medicine, i.e., data-based care. In some respects, care requiring documentation has replaced care requiring clinical judgmetn as a mainstay of clinical practice. In How Doctors Think, Jerome Groopman, MD., a professor of medicine at Harvard, has this to say,

Clinical algorithms can be useful for run-of-the-mill diagnosis and treatment – distinguishing strep throat from viral pharyngitis, for example. But they quickly fall apart when a doctors needs to think outside their boxes, when symptoms are vague, or multiple and confusing or when test results are inexact. In such cases – the kinds of cases where we most need a discerning doctor – algorithms discourage physicians from thinking independently and creatively. Instead of expanding a doctor’s thinking, they constrain it.

Similarly, a movement is afoot to base all treatment decisions strictly on statistically proven data. This so-called evidence-based medicine is rapidly becoming the cannon… But today’s rigid reliance on evidence-based medicine risks having the doctor chooses care passively, solely on the numbers. Statistics can’t substitute for the human being before you; statistics embody averages, not individuals.

According to a recent article in the New England Journal of Medicine (“Keeping the Patient in the Equation – Humanism and Health Care Reform,” August 6, Page 554-555). Groopman and Pamela Hartzband, another Harvard academic say the humanism movement and the evidence-based practice movement are on collision course.

Evidence-based medicine is based on the premise that, given the best available data and clinical protocols and guidelines and standardized procedures and guidelines, outcomes will improve and medicine will rest on a scientific foundation.

Furthermore, evidence-based care plays to the strengths of Interment medicine, viz, health 2.0, clinical algorithms, data mining, and predictive modeling.
Evidence-based medicine has a ring of logic and credibility, and it gives critics rational tools to contain costs while improving care.

But it has hidden flaws too. It is based on retrospective statistical generalities rather than individual patient and doctor expectations during a doctor-patient encounters; it may reduce the patient-doctor exchanges to statistical exercises based on sometimes equivocal cost effectiveness data; it may handcuff doctors who wish to give desperate patients one last hope of cure; it may put federal and private bureaucrats in the position of making clinical decisions based on retrospective data; it assumes ubiquitous data loaded and data acquiring EMRs will improve care and will be cost-effective, which has not been the case in the United Kingdom (“Effects of Pay for Performance on the Quality of Primary Care in England,” NEJM, July 23, 2009, page 368- 377).

According to British researchers in the same article, using computers to meet quality criteria may disrupt the continuity of care. Finally, so-called evidence-based care fails to address the main health reform concerns of American physicians.
As noted above, according to Palestrant, founder and CEO of, the four main health reforms needed as reflected in the opinions of 110,000 physicians participating in Sermo, are:

1. Reducing unnecessary tests and procedures through tort and malpractice reform,

2. Allowing doctors to spend more time taking care of patients by making billing more transparent and streamlined (creating an alternative to CPT codes)

3. Insurance reform to ensure that physicians are making medical decisions with their patients, not insurance company administrators.

4. Revising the methods used for calculating reimbursements so that there will be enough qualified physicians to provide patient care.

These concerns have merit. They are not trivial and are not addressed in the House Bill, H.R. 3200. I would add that unless these concerns are addressed, physician demoralization will continue ; the physician shortage and the number of physicians not accepting new Medicare and Medicaid patients will surely grow. Universal coverage without access to physicians will be meaningless.

Finally, I bring attention of readers to a chapter in my book, Obama, Doctors, and Health Reform, on the work of Dr. Palestrant, in which I make the following observations based on a conversation with him.

1) Through a web of rules and regulations, and outdated reimbursement rules, the deck is stacked against physicians and discourages innovations.

2) A genuine and deep physician “supply and demand” disequilibrium exists for American physicians.

3) The “perfect information" quest, based on retrospective health plan and Medicare claims data, is unrealistic.

4) A shift to consumer-centered care, making them conscious of what they’re paying fork, market transparency of prices and outcomes, and personal responsibility is underway.