Monday, November 30, 2009

Health Reform Should It Be's

Should it be the government elite who are the most strong?

Should it be the skeptical who represent the common throng?

Should it be the left who sings their siren song?

Should it be the right who rings the market gong?

Should it be the center for which we should long?

Should it be about a moral mentality?

Should it be about the market reality?

Should it be about who is right and who is wrong?

Should it depend upon to which party you belong.

Hooray, Hooray, The Health Care Debate Begins Today

I’m a Democrat and fervent Obama supporter. I voted for him twice (and that was just in the Virginia primary). I’m proud of our President. He has first class economic and healthcare teams. He deserves credit for not postponing health reform. He’s right: it’s simply not tolerable, morally or economically, for a wealthy nation to continue having close to 50 million uninsured people.

Jeff Goldsmith, “The Leaning Tower of Jello: Why No-one Believes Health Reform will be Deficit Neutral,”The Health Care Blog, November 39, 2009

Monday, November 30 - Today begins the bruising Senate health care reform debate between multiple political belief systems. Among participants and issues are,

• Democrats and Republicans

• Socialists and Capitalists

• Liberals, Independents, and Conservatives

• Elitists and the Public

• Moralists and Pragmatists

• Strong and Weak Government Proponents

• Collectivists and Entrepreneurs

• Government and Markets Backers

• Security and Vitality

• Equity and Liberty

• Equal Results and Equal Opportunity

• High Tech and High Touch

• National economy and world economy

• Centralization and Decentralization

• Government help and Self-responsibility

• Government options and Personal options

Given this situation and the issues, you might be interested in my comments on a blog that appeared in The Health Care Blog this day. Its author, Jeff Goldsmith, founded Health Futures in Charlottesville, Virginia and is a well-known and widely respected health care futurist , consultant and commentator. He forecasts health trends and medical technology trends. I respect him. He is sincere, informed, and possesses the gift of language.

He and I have different mindsets. This is my response to his blog of today.
As a Republican who did not vote for Obama, I wish to congratulate Jeff Goldsmith , a self-proclaimed “fervent” Democrat, on a splendid piece of writing.

I’m particularly taken by these insights into,

• American health care as a” vast enterprise where powerful political interests intersect: organized labor, capital markets, major manufacturers, doctors, lawyers, hospitals, pharmaceutical companies, health insurers, state governments, employers large and small. “

• Thomas Jefferson who sought to “forestall tyranny by “designing a weak and divided central government” that “deliberately crippled “ the political system.

• "A bitterly polarized and poorly informed electorate and weak Congressional leadership as a “recipe for fiscal incontinence on a grand scale.”

• The Democratic attitude towards the special interests, which he explained with this Lyndon Johnson quote, “ If you can’t take their money, drink their liquor, sleep with their women and then vote against them when you need to, you don’t belong in Congress.”

As any faithful Democrat should, Jeff argues our political legacy is a weak and divided government, and what we need is a powerful central government with a series of legislative teeth to make special interests bite a series of bullets for the common good.

As a Republican, I would counter,

• It is a good thing we have powerful political interests to protect the economic vitality of business and professional interests to protect us against the most powerful political interest in the country, the Democratic party, that promises economic security for all – an impossible dream.

• Thomas Jefferson was right. He believed the people, rather than being a “poorly informed electorate,” collectively had a practical wisdom that would serve as a bulwark against government infringements on individual liberties. The uprising in town hall meetings, capitol protest marches, and tea parties against mounting federal deficits, false promises of deficit neutralities, and invasive government controls over health care,

• The federal government is already taking a huge bite out of society and the economy. It is running enormous deficits, and as a percent of GDP at a 28.5% is spending money at a record pace without any visible impact on unemployment or other economic woes. What we need are tax cuts to stimulate investment, hiring, and government revenues; health care tax credits for all including making patients responsible for spending more of their own money with more cost transparency; expanding health plan choice across state lines; instituting tort reform and neutralizing the American Trial Lawyers influence on the Democratic Party; and wider recognition that the current health bills being taxing immediately while delaying benefits until 2014.

Let the debate begin in ernest.

As David Brooks argued in a recent New York Times column, “The Values Question,"

“Reform would make us a more decent society, but also a less vibrant one. It would ease the anxiety of millions at the cost of future growth. It would heal a wound in the social fabric while piling another expensive and untouchable promise on top of the many such promises we’ve already made. America would be a less youthful, ragged and unforgiving nation, and a more middle-aged, civilized and sedate one."

"We all have to decide what we want at this moment in history, vitality or security. We can debate this or that provision, but where we come down will depend on that moral preference. Don’t get stupefied by technical details. This debate is about values. “

Sunday, November 29, 2009

Medicare as Godfather and Grandmother; Quote and Note


As I tell my students, Medicare is the Godfather when it comes to setting payment rates ( “I have an offer you can’t refuse.), but like my Grandmother serving lunch when it comes to what care a patient can receive (Whatever you would like, dear).”

Donald Taylor, Jr, assistant professor of public policy at Duke University, clarifying factors at work in the national debate over health care reform in an op-ed in Raleigh’s News and Observer.


Paul Grundy, MD, Director of Healthcare, Technology and Strategic Initiatives at IBM Global, pointed out to me the U.S already has, in effect, a single payer system - Medicare sets the rates for the codes and health plans follow. Unfortunately, Medicare has no fraud or cost controls, as evidenced by the $60 billion in annual fraud and the $50 billion spent annually in the last two years of life. Obamacare promises delayed savings – prevention, EMRs, and coordinated care - and $500 billion in cuts over the next 10 years – but observers doubt Medicare has the political will to make savings and cuts stick. Health reform must start with Medicare reform. Medicare is the Devil not the Saint in runaway spending rather than the other way around. If past is prologue, grandma is unlikely to pull the plug on anyone.

"Shocking Decline in Our National Health," Give Me a Break

Inconsistent preventive services and poor lifestyle behavior choices have led to a shocking decline in our national health, threatening not only individuals lives and America’s economic prosperity.

Karen Adams, PhD, “National Priorities Partnership: Setting a National Agenda for Health Quality and Safety,” in Prescriptions for Excellence in Health Care, Fall, 2009

Give me a break. Or, at the very least, give me an honest perspective on the true state of the nation’s health. Sure, it could be better, but it is not all that bad. In fact, U.S, health statistics are improving, not matter what the progressive reform zealots or apocalyptic doomsayers are saying.

Don’t take my word for it. The health of the nation is not at the edge of some horrible abyss, even in the face of the obesity epidemic and an aging population with multiple chronic diseases, some of which may be preventable.

Here is countervailing evidence, compiled by Melinda Beck for the Wall Street Journal, “20 Advances to Be Thankful For,” November 23.

"• Nearly 62% of U.S. adults said they were in excellent or very good health, along with 82% of their children, according to families sampled by the federal government for the National Health Interview Survey, which was conducted in 2007 and released this year.

• Fewer Americans died in traffic fatalities in 2008 than in any year since 1961, and fewer were injured than in any year since 1988, when the National Highway Traffic Safety Administration began collecting injury data. One possible reason: Seat-belt use hit a record high of 84% nationally.

• Life expectancy in the U.S. reached an all-time high of 77.9 years in 2007, the latest year for which statistics are available, continuing a long upward trend. (That's 75.3 years for men and 80.4 years for women.)

• Death rates dropped significantly for eight of the 15 leading causes of death in the U.S., including cancer, heart disease, stroke, hypertension, accidents, diabetes, homicides and pneumonia, from 2006 to 2007. (Of the top 15, only deaths from chronic lower respiratory disease increased significantly.) The overall age-adjusted death rate dropped to a new low of 760.3 deaths per 100,000 people—half of what it was 60 years ago.

• The death rate from coronary heart disease dropped 34% from 1995 to 2005, though it is still the biggest single killer in the U.S. Deaths from cardiovascular disease dropped 26% over the same period. Deaths from stroke dropped 29% since 1999. Average total cholesterol in adults aged 20 to 74 dropped to 197 milligrams per deciliter in 2008 from 222 in 1962.

• The death rate from cancer, the second-biggest killer, dropped 16% from 1990 to 2006. That reflects declines in deaths due to lung, prostate, stomach and colorectal cancers in men, and breast, colorectal, uterine and stomach cancers in women.

• Nearly 40% of U.S. adults have never had a permanent tooth extracted because of dental cavities or periodontal disease in 2004, the most recent data available, compared with 30% in 1994.

• Three out of 10 U.S. schoolchildren aged 5 to 17 in 2007 did not miss a single day of school because of illness or injury during the preceding 12 months.

• Hip fractures—which can rob elderly patients of their mobility forever—are down nearly 30% in the U.S. and Canada since 1985, for reasons not completely understood.
• Thanks in part to vaccines, the rate of acute viral hepatitis A dropped 90%.

between 1995 and 2006, and acute viral hepatitis B dropped 88% from 1982 to 2006, both to record lows. Acute viral hepatitis C is down to 0.03 from 2.4 cases per 100,000 since 1992, though rates have recently plateaued.

• Thanks largely to antiretroviral drugs, U.S. deaths from AIDS dropped 10% from 2006 to 2007, the biggest decline since 1998, and they remain well below the 1995 peak. New cases of AIDS, though static in recent years, also remain well below the 1990s level. Antiretroviral drugs have also helped cut dramatically the number of babies born with HIV in the U.S.; in 2006, there were 28 diagnoses of AIDS among children, down from 195 in 1999.

• Chalk this one up as an advance for mental health: The U.S. divorce rate dropped by one-third from 1981 to 2008, and is at its lowest level since 1970. This may be due to more couples postponing marriage or to economic constraints, as well as to couples' determination to stay together.

• From 2006 to 2008, the median percentage of U.S. secondary schools that don't sell soda rose to 64% from 38%, and those that don't sell candy or high-fat snacks rose to 64% from 46%, in the 35 states that collect data.

• The amount of trans fats in packaged food has declined by about 50% since 2006, when the Food and Drug Administration began requiring food labels to list it. At least 13 jurisdictions, including California and New York City, have restricted trans fats in restaurant food.

• As of this month, 71% of the U.S. population lives under either a state or local ban on smoking in workplaces and/or restaurants and/or bars, and 19 states have banned smoking in all three kinds of places. Research has found that air quality improves and heart-attack rates drop in areas that have enacted smoking bans."

So let’s put the nation’s health in perspective. Overall, we’re doing fine, much better than our greatgrandparents, thanks in no small part to medical innovations, performances of our caregivers, and changing behaviors on part of our citizens. Let’s give ourselves a little credit, even a pat on the back.

Book Review - Have Stethoscope, Will Travel

Staff Care’s Guide to Locum Tenens, by Tomothy Boes, Aaron Ray and Phillip Miller, Practice Support Resources, Inc, www.Practice Support, com, 2008

This little book is a book reviewer’s dream.

• It is short, 108 pages.

• It is authoritative. Its authors are executives in Staff Care, the largest locum tenens staffing firm in the United States.

• It addresses a growing and large locum tenens physician market- $2.1 billion spent in 2009 with 37,000 physicians placed.

• It graphically tells why the market is growing – physician shortages and doctors’ unhappiness in traditional practices.

• It specifies what specialists are in demand primary care 43%, anesthesiology 29%, behaviorial health 16%, radiology 11%, surgery 8%. Fenistry 3%.

• It places doctors who choose primary care into five categories: alternatives (those escaping from troubles and pressures of traditional practices), sunset seekers (experienced doctors who want to cap their careers), test drivers (young doctors who want to see what’s out there), transitionals (mid-career doctors looking for the next step), moonlighter (those seeking extra income).

• It tells of the benefits of locum tenens (freedom 31%, no politics 19%, travel 18%, pay rate 15%, professional development 9%, a way to find a permanent job 7%), and the drawbacks (away from home 31%, uncertainties 25%, lack of benefits 17%, quality of assignments 13%, other 2%).

• It answers a variety of questions that invariably arise in the prospective locum tenens physicians mind.

• It devotes chapters to the licensing process, hospital privileges, and malpractice issues.

• It describes why the doctor shortage and the demand for doctors is growing – aging baby boomers, shrinking supply, exploding population, shortfalls in rural America, technology changes requiring more doctors, feminization of medicine, with women doctors working shorter hours, younger doctors seeking shorter hours and more balanced lifestyles.

• It outlines the 2009 trends in locum recruiting – more primary care doctors, surgeons, and behavior specialists.

• On top of all this, the book is well-written, pithy, with ample charts and survey results, with catchy chapter titlesl and appropriate opening quotes.

• It is grounded in reality. It explains what is transpiring on the ground in American medicine without editorializing, pontificating, or posturing. This is real world stuff.

• Recommended for all of you interested in what is happening in American medicine and what is causing doctors to act the way they do.

Saturday, November 28, 2009

Health Refrom and Loss of Individual Liberties; The Road to Clinical Serfdom

There is no such thing as a little freedom. Either you are all free, or you are not free.

Walter Cronkite

If physicians continue to allow non-physicians and businesses such as hospitals and insurance companies to control them, they will lose their patientsand will be nothing more than over-eduated techniciana.

Donald Copeland, MD

This blog is about loss of individual liberties and the road to clinical serfdom under the best of intentions. In The Road to Serfdom, conservative economist and Nobel Prize winner Friedrich Hayek argued you cannot control or comprehend market transactions between individuals from the top-down through centralized planning or restrictive government rules and regulations.

Hayek's thesis was that one centrally directed intervention inevitably leads to another. The unintended consequences of each market intervention are economic distortions, which generate further interventions to correct them. Interventionist health care mindsets lead us down the road of individual and clinical serfdom subservient to government.

Centralized planning always fails because it lacks the flexibility, efficiencies,innovations, and freedoms of the marketplace. You simply cannot control marketplace transactions through central command and control rules and regulations.

The current reform bills portend to put the federal government in charge of individuals’ insurance choices and data privacy. This is all done, of course, in the name of covering the uninsured. It is also being done without the consent of the governed –only 35% to 40% of whom approve of what Obamacare proposes.

Buried, for example, in the Senate’s 2,074 page health bill are multiple provisions that undermine the patient’s health freedoms and privacy. The bill contains sections that mandate insurance for individuals, force them into those plans dictated by government, reveal financial data of patients to third parties, use personal data without consent of individuals, and requiring individuals to be seen by only those doctors using electronic medical records.

Not only are these government invasions into personal freedoms and privacy being done in the name of covering the uninsured but also in the names of reducing waste and overuse and, of course, in improving quality, safety, efficiency.

An organization called the National Priorities Partnership, convened by the National Quality Forum, proposes to help President Obama achieve his goals within 3 to 5 years by reforming payment, introducing a national interoperative medical records system, accrediting and certifying providers, measuring performance, implementing comparative effectiveness measures, and publicly reporting quality outcomes.

To reduce waste and overuse, the National Priorities Partnership recommends dtastically curtailing,

1. inappropriate medication use, such as antibiotics or multiple drugs

2. Unnecessary laboratory tests, such as panels of tests or special tests for Lyme disease

3. Unwarranted Cesarian sections

4. Unwarranted CT and MRI scans, bone or joint x-ray, endoscopies

5. End of life nonpalliative services

6. Unwarrated procedures – spine surgeries, knee-hip reppalcments, coronary artery bypasses, hysterectory, prostatectomies

7. Unnecessary consultations

8. Preventable ER visits and hospitlaization

9. Potential harmful preventive services, BRCA mutations to screen for breat and ovarian cancer, coronary artery screening, carotid artery screening, paper smears over 65, PSA tests over 75

As I read this list, I found it impractical, unenforcible, invasive, and restrictive of individual freedomes. To begin with, many of those who compose these lists have never practiced medicine and seem unaware of patient pressures and expectations, Two, patients rarely if ever complain of overtreatment. Three, the list assumes doctors are either self-serving or unaware of the consdquences of their actions, Four, patients have come to expect many of these tests to be done. Five, many of these tests, e.g, laboratory lipid panels, SMA panels, CT and MRI scans yield valuable diagnostic and treatment information. Six, who is to judge retrospectively if tests or procedures done prospectively at the point of care are inappropriate, unnecessary, unwarranted, harmful, or lead to preventable events, such as ER visits or hospitalizations.

Tuesday, November 24, 2009

Ten Ways to Boil Health Reform Oceans

I keep asking the same question: How can the Democrats ram anything as big and complex through as these health care bills with approval ratings--now in the 35% to 40% range--so low?

They seem intent on showing us

Robert Laszweski, “Public Anxiety Meets the Democratic Effort to Get Health Care Done at All Costs,“The Health Care Blog, November 23, 2009, Robert Laszweski has been a fixture in Washington health policy circles for the better part of three decades.

Dear Robert:

You ask how Democrats can can get reform done in the face of soaring costs and disapproval of the American people. From out of blue heaven, this inspired ten part Eureka and Nirvana-based answer came to me.

One, kill the lawyers! Shakespeare and the American people distrust lawyers, especially lawyers in the House and Senate. Americans consistently rank lawyers down there with used car salesmen. As I write, Congressional job approval is at a minus 65 percent, meaning nearly two-thirds of Americans disapprove of the job Congress is doing. Therefore, we can start reform by ridding ourselves of lawyers, particularly incumbent lawyers who double as politicians.

Two, ban the lobbyists! Everybody knows special interest lobbyists shape health reform legislation. For every legislator, there are over 30 lobbyists collecting roughly $300 million in misbegotten fees. Lobbyists are even writing the press releases and talking points for Congressmen and Senators. Politicians, in turn, are gathering contributions to assure their reelection. Outlaw lobbyists!

Three, put doctors on salary! Remove incentives for doctors to do more for patients. Herd doctors into large groups, into integrated organizations like Mayo, Kaiser, and Geisinger, salary them, strip them of incentives to make more money, regulate them. Remember: once you’ve got them by the tender part of their anatomy – their wallets – their hearts and minds will follow.

Four, put Washington in charge of who gets what at what price! Only Washington knows what constitutes “rational” thinking; how federal dollars should be distributed and for what reasons; and who should get the money. Reform is about social and redistributive justice. Patients and doctors, in short, who get the short end of the stick, must bow to superior beltway wisdom.

Five, adopt health systems of other countries! Everybody knows other countries are morally superior. They cover more people at half the cost that we do and with better results. Ignore the fact that these countries have more homogeneous populations; have lower rates of violence; supply health care by suppressing access to life-saving and life-style restoring technologies; and offer services that aremuch less responsive to patients with fewer amenities.

Six, move lower-cost health systems off shore! Follow the example of an India physician who is building a high tech hospital in the Cayman Islands, one hour by plane from Miami that will perform open heart surgery for $2000, versus $20,000 to $100,000 in U.S. Focus on volume. Restructure. Introduce new business models. For details, see “Indian Doctor Tagged ‘Henry Ford of Heart Surgery’ Drives Down Costs,” WSJ, November 23.

Seven, digitize health care! Everybody knows that the American economy is moving at Internet time, that the computer promotes transparency, clinical efficiency, outcome effectiveness, price comparisons, relevant provider value, and empowers consumers to make the right choices for the right reasons at the right places with the right results. Never mind that it may be personally intrusive, violate privacy, and disrupt the patient-physician relationship. Data uber alles. Digitize upper alles.

Eight, Base everything on scientific evidence! Everybody knows medicine is Science not Art, and that government, health plans, and consumers should pay only for what works and what is rational in the eyes of payers. Never mind that what is paid for may not fit the hopes, needs, and expectations of patients and that human values, such as the quest for individuality and personal freedoms, may be subjective and irrational.

Nine. standardize everything! In a top-down system, everybody knows that everything must be certified, standardized, and homogenized - the contents of every plan, the benefits provided, the choices offered – regardless of age, sex, socioeconomic conditions, cultural or health status. Everybody is equal, but some are more equal than others, depending on your politics.

Ten, end the profit motive, and you can’t end it, tax it! Everybody knows profit is the root of all health care evils. Therefore, all incentives to innovate to make more money must be eliminated. If the profit motive persists among hospitals, doctors, health plans, device makers, and drug firms, tax their profits. Let no good innovation go unpunished.

Caveat: If you plan to boil health reform oceans, boil one ocean at a time.

Monday, November 23, 2009

The American Way of Dying

November 23 – Last night on CBS’s 60 Minutes, I learned much of what I knew already, most of it obvious.

I learned,

100 percent of Americans will die eventually;

one day in a hospital intensive care unit costs $10,000;

the last two years of life of Medicare recipients costs Medicare $50 billion each year;

it is human natture to want to live yet another day, no matter what the cost as long as it is Medicare money;

Medicare is rapidly growing broke because it never questions paying for what is done;

Americans overwhelmingly want to die at home, but only 15 percent do while 75 percent die in hospitals;

most relatives, dear ones, and significant others of dying patients support dying in the hospital;

many living wills are ignored, and doctors, backed by patients and relatives and significant others, encourage doctors to to everything they can do sustain life;

the mission of doctors, by law, custom, and training, is to prolong life, and they have the technologies to carry out their mission;

profit margins of hospitals, and fee-for-service payment of doctors, encourages hospitals and doctors to support the prolonging of life;

if paying for health care is to be sustainable, it may be necessary to ration care based on age and cost, to set limits based on clinical and cost effectiveness, quality of life, and estimates of how long life is likely to last, and that, figuratively, society may have to “pull the plug” on people destined to die in the near term;

Americans tend to the deny the realities of inevitable death;

it will be extraordinary difficult to cut Medicare spending because of cultural and political backlash;

cutting Medicare spending is a miasma of moral, monetary, cultural, professional, and personal dilemmas;

Slashing medicare benefits is akin to boiling the polital ocean;

what I did not learn is America is maturing in its attitudes towards dying and death, and through its growing use of hospice services, particularly, end of life care is being administered in homes;

home is where the heart is, and ideally home is where more Medicare money is best spent spent for comfort and compassion for the dying.

Sunday, November 22, 2009

Health Reform Debate and the Embers of December

Ah, distinctly I remember it was in bleak December;
And each separate dying ember wrought its ghosts upon the floor.

Edgar Allen Poe, 1809-1849

As we look forward to the December health care debate, it is important to remember other issues – other burning embers – besides health care smolder on the Senate floor and must be dealt with. These embers could flare up, complicate, and even derail the health care train.

The glowing embers are,

• raising the national debt limit, which is very much on the public’s mind and which could create the impression Democrats are out-of-control spenders;

• shutting down the Patriot Act, which could result in accusations of lack of patriotism;

• extending highway construction, part of the controversial Stimulus package;

• Prolonging unemployment programs, a reminder that the Obama administration programs have had no effect on unemployment;

• Continuing the federal estate tax, another burning ember that Democrats are devoted to high taxes;

• Deciding how much to fund the troops in Afghanistan, another potential political firestorm.

On these burning issues, Republicans are sure to argue Congress ought to scrap the health care issue and focus on more pressing spending bills and bills relating to national secuity.

December promises to be a dark and messy month.

Health Reform, Gallows Humor, and the Louisana Purchase

November 22 - The Senate voted last night, 60-39, on a strictly party line vote, to bring the health care debate to the Senate floor, thereby nipping a Republican filibuster in the bud. The debate will start after the Thanksgiving holiday and run through December, perhaps even into the New Year.

The opening of the debate is a serious matter, making the first time health reform has reached this point in the history of the Republic.

• Democrats are deadly serious and regard the whole matter as an historic event. Senator Max Baucus, Democrat of Montana and chief architect of the legislation, declared, “Tonight we have the opportunity, the historic opportunity to reform health care once and for all. History is knocking on the door. Let’s open it. Let’s begin the debate.”

• The Senate Republican leader, Mitch McConnell of Kentucky, was eqaully serious. He declared, “The battle has just begun.” He warned of massive deficits, intrusuve government-run health care, and Medicare gutting.

I’m surprised McConnell did not quote Winston Churchill, who so famously said, “Now this is not the end. It is not even the beginning of the end. But it is, perhaps, the end of the beginning.”

Maybe, at such a serious juncture in the health debate, said by Democrats to be a historic moral imperative and by Republicans a horrid economic disaster, it is time for a little graveyard humor.

Dana Milbank, a Washington Post columnist , supplies this humor in a November 22 column, “Sweeteners for the South.”

“Staffers on Capitol Hill were calling it the Louisiana Purchase. “

“On the eve of Saturday's showdown in the Senate over health-care reform, Democratic leaders still hadn't secured the support of Sen. Mary Landrieu (D-La.), one of the 60votes needed to keep the legislation alive. The wavering lawmaker was offered a sweetener: at least $100 million in extra federal money for her home state.”

“And so it came to pass that Landrieu walked onto the Senate floor midafternoon Saturday to announce her aye vote -- and to trumpet the financial "fix" she had arranged for Louisiana. "I am not going to be defensive," she declared. ‘And it's not a $100 million fix. It's a $300 million fix.’"

Dana went on to explain how Senator Reid has also purchased the vote of Blanche Lincoln of Arkansas and other Democratic Senators, lest they stray from the party line,

“Landrieu and Lincoln got the attention because they were the last to decide, but the Senate really has 100 Blanche DuBoises, a full house of characters inclined toward the narcissistic. The health-care debate was worse than most. With all 40 Republicans in lockstep opposition, all 60 members of the Democratic caucus had to vote yes -- and that gave each one an opportunity to extract concessions from Senate Majority Leader Harry M. Reid.”

Dana concludes:” By the time this thing is done, the millions for Louisiana will look like a bargain.”

For those of you out there who are unfamiliar with the Louisiana Purchase, in 1803 the United States paid France $15 million dollars for over 800,000 square miles of land, more than doubling the size of the United States. This land deal was the greatest achievement of Thomas Jefferson's presidency.

Similarly health care deals struck with wavering Senate Democrats, like the $300 million for the Landrieu vote, may be the greatest achievement of Barack Obama’s presidency. In this case, Obama hopes to more than double the size of government control over health care and double the cost to government,now running more than $1 trillion for Medicare and Medicaid. As Shakespeare might say, "Double, double, toil and trouble; fire burn and cauldron bubble." Well, Will, the cauldron is bubbling.

Saturday, November 21, 2009

Health Reform: It's Cultural Expectations Stupid!

This week, the science of medicine bumped up against the foundations of American medical consumerism: that more is better, that saving a life is worth any sacrifice, that health care is a birthright.

Kevin Sack, “Screening Debate Reveals Culture Clash in Medicine,” New York Times, November 20, 2009

For at least three years, starting with Voices of Health Reform and more recently with Obama, Doctors, and Health Reform, I have been writing American Culture and American’s Health Care Expectations profoundly influence the health reform debate. This is no secret, but you don’t hear much about these cultural expectations in the media or in the Congressional debates. Now that the august New York Times has brought up the culture issue, perhaps I can talk about it again.

Although Americans are in a funk right now over the economy, unemployment, and the national debt, they retain their belief in the powers of modern medicine. This belief explains why so few Americans believe they are “over treated” or that doctors do “too much.”

If anything, people feel doctors don’t do enough. Americans expect doctors to prescribe a drug, order a mammogram, do a pap smear, or refer them for a CT or MRI scan. Americans expect access to the best, to the brightest, and to those death-preventing, life saving, or function-restoring, even sexual-preserving technologies.

And why shouldn’t they? America has the best high medicine in the world. The media talks incessantly of the latest medical advances, of lives miraculously saved, of erectile dysfunction resurrected, or people diagnosed with some rare and exotic disease. Hospitals market their high-tech wares on television – robots that perform surgery, gamma knives that cut like a laser to the cause of the cancer, surgeons that operate bloodlessly and non-invasively.

There is plenty of hype and hope abou modern medicine’s wonders. Expectations run high.

And to doctors, there always some mythical future lawyer out there who might ask, “Why didn’t you do this procedure, doctor?” “If you had, wouldn’t my client be alive and well? Didn’t you know this test was available?” “Why didn’t you discuss all the options with my client” "Why is there no record of your having done so?” "Why and Where do you go to medical school?" "Didn't they teach you what to do?"

Besides, in the words of the New York Times reporter, “For decades, the medical establishment, the government and the news media have preached the mantra of early detection, spending untold millions of dollars to spread the word. Now, the hypothesis that screening is vital to health and longevity is being turned on its head, with researchers asserting that mammograms and Pap smears can cause more harm than good for women of certain ages.”

The reports of the federally-sponsored and paid-for Preventive Services Task Force on new rules for mammography and pap screening are raising the specter of government health care rationing. And, in the minds of the public, it may be a stick in the eye to the concept of comparative research effectiveness and the government paying only for “what works.”

Medicine is highly personal and emotional. It does not lend itself to detached objectivity or to “scientific based evidence.” As Sally Fields says in her TV Boniva ads, “It’s my body, and I’m going to take care of it.” This might be paraphrased in the present health reform climate to read, “ It’s my health, and I don’t care what the government says. I am going to do what I consider best for me.”

Friday, November 20, 2009

Cooking Health Reform Books

How does one cook health reform books?

One, you make costs seem less than they really are.

Two, you announce OMB-estimated 10 year costs at $849 billion from 2010 to 2019.

Three, you don’t start real spending until 2013. From 2010 to 2013, you spend only $9 billion – a drop in bottomless federal bucket.

Four, in 2014 you start real spending. By 2016, OMB estimates you are pouring $147 billion out of the bucket.

Five, from 2014 to 2023, you know the OMB says costs will run $1.8 trillion, but you don't say to and you don’t care because this is 2009, and you have a bill to pass. Besides, by 2023 the present Congress and present president will be gone. That is for future legislators and generations to worry about.

Six, from 2014 to 2023, you can covertly hike taxes by $892 billion, drain more than $500 billion from Medicare, freeze doctor pay, and increase the federal budget deficit. But you don’t tell the American people you are cutting existing programs and creating higher deficits, and raising taxes.Your mission is to cook the books now, not to be concerned about future thens and theres.

There once was a Senate majority leader named Harry Reid,
He waved his magic wand to accomplish this political deed.
To make true reform costs appear low,
He would start true spending very slow,
By waiting until 2013 to bring true costs up to speed.

Let the "Historic" Debate Begin

November 20 - When the Senate votes tomorrow whether to engage in further health reform steps, the stage is set for an historic debate. Before we engage in this debate, let us be clear what this debate is about.

It is about,

• the balance of power between government controls and individual freedoms.

• how to make health costs for government and individuals “ sustainable" and how to manage those costs for perpetuity.

• cost controls and how government may be forced to adopt techniques of private plans to limit fraud and abuse and expenses of paying for pre-existing chronic disease and experimental drugs and procedures.

• use of statistics to limit and manage costs versus individual needs and expectations - there is no better example of this conflict than the current flap over mammography guidelines suggesting delay to screening until after age 50.

• the status of the United States as a “moral nation” and whether universal coverage should be the leading indicator of that morality.

• who should care for the sick - government bureaucrats or physician and nurse caregivers.

.whether the United States needs a public option, an alterntive government plan, when 1300 private plans are available and await to opened across state lines for competitive bidding.

. whether is the obligation and duty of the federal government to help subsidize care of 62% of American families making up to $88,000 each year.

• the constitutionality of government to impose mandates on employers and individuals who do not buy insurance and the right of government to fine or imprison non-payers for tax evasion.

• power of government to burden states with Medicaid expenses state budgets cannot tolerate; to restrict payment of Medicare strictly to Medicare – and to not allow patients to contract with doctors separate; to pay the same Medicare rates in locations without regional variations and to homogenous and standardize care regardless of poverty levels and hospital and practice expenses; to dictate the contents and comprehensiveness of health plans and to impose the same premiums on all individuals regardless of age, sec, and health status; to tax “Cadillac” health plans, medical device companies, the pharmaceutical industry, hospitals, and those providing or paying for cosmetic procedures to pay for increased coverage.

• the ability of those health care entities who are taxed to pass on their increased expenses to consumers and how average Americans will tolerate increased costs and decreased access when they were promised otherwise.

• the diversified United States culture, its status as the greatest immigration destination in the world, and its ability to handle and pay for this diversity.

• “health care” versus “medical care” and the expenses therein; only about 15% of a nation’s “health” depends on its medical system, the remainder rests on socioeconomic conditions, personal behaviors leading to obesity and other health threatening disorders, and social cohesion and expectations.

• our legal and malpractice system, which increases health costs by roughly 10% through the practice of defensive medicine and excessive malpractice premiums and drives many specialists to other states or to early retirement and non-clinical careers.

• the doctor shortage and the mal-distribution of primary care doctors and specialists and the looming political health care crisis as aging boomers and greater numbers of the now covered uninsured seek access to doctors.

• how to explain to Americans that taxes and expenses will go up in 2010 but benefits will not kick in until 2014.

• The wishes and ambitions of politicians – 60% of whom say overall reform is necessary – and the will of the people - only 40% of whom approve of current health reform bills, 17% of whom say health reform is not their first priority, and most of whom who regard the economy, unemployment, and the national debts as greater threats to America.

• who should make clinical decisions - government, caregivers, or the people themselves – the latter through health savings accounts and high deductible plans that encourage them to spend their own money wisely, to insist on cost transparency. and freedom to chose their own doctors and hospitals.

Thursday, November 19, 2009

Not Fit To Be Tied

The list of things to avoid during flu season includes crowded buses, hospitals and handshakes. Consider adding this: your doctor's necktie.

Neckties are rarely, if ever, cleaned. When a patient is seated on the examining table, doctors' ties often dangle perilously close to sneeze level. In recent years, a debate has emerged in the medical community over whether they harbor dangerous germs.

Several hospitals have proposed banning them outright. Some veteran doctors suspect the antinecktie campaign has more to do with younger physicians' desire to dress casually than it does with modern medicine. At least one tie maker is pushing a compromise solution: neckwear with an antimicrobial coating.

Rebecca Smith, Doctor’ Necktie Seen As Flue Risk, Wall Street Journal, November 18, 2009

As a doctor veteran clip-on bowtie wearer, I say out with tied long ties,

Out with the tied long size, in with the untied short size, you long tie guys.

To the young and casual,

I say be more professional,

Get a new guise, and above the flu rise.

Dr. Richard Reece is author, blogger, speaker, and innovation and reform commentator. Dr. Reece’s latest book, Obama, Doctors, and Health Reform ( is available at,, and for $31.95 (hardcover), $21.95 (softcover), and $6.95 (electronic). For information on speaking fees and arrangements, call 860-395-1501.

Keeping Abreast of Health Reform: Government in a Clash All by Itself

Preface: Reprinted below are excerpts from a medical weblog, dated November 19, on the current furor on mammography guidelines. Kevin Pho, MD, America’s best known medical blogger, makes a valid point: how is government reform going to work if government doesn’t even listen to its own non-partisan experts. The answer, I suppose, is : there’s nothing objective about politics.

"What if a non-partisan, authoritative entity wrote a robust, evidence-based guideline, but nobody followed it?"

"That is precisely what’s happening with the USPSTF’s recent revision of their breast cancer screening recommendations. The change most find problematic is their recommendation that women younger than 50 not undergo any breast cancer screening, such as with a mammogram."

"What’s fascinating is how mammogram screening has now turned rabidly political, with conservatives making the ridiculous link to “rationing.” And Kathleen Sebelius, the secretary of health and human services, tried to distance herself from the USPSTF, stressing that, “I would be very surprised if any private insurance company changed its mammography coverage decisions as a result of this action,” and that, 'our policies remain unchanged.' ”

"What, then, is the point of making any guidelines at all, if our government urges everyone to ignore them?"

"Progressive reformers, who generally espouse comparative effectiveness data and evidence-based medical practice as a means to control costs, should be very worried about the backlash these guidelines are eliciting.

"If recommendations from an entity like the USPSTF – as non-partisan and robust as it gets – gets so much resistance from doctors, patients, and even the government itself, findings from a comparative effectiveness body stand absolutely no chance of changing medical practice."

Senate Health Reform Specifics for the Listless

November 19 – In case you’re wondering about the specifics of the new and final version of the Senate health care bill and you’re feeling listless, here are some specifics.

Final Provisions

•A government-run insurance program similar to Medicare that would compete with private insurers. Individual states could opt out of offering the public plan, and the government would negotiate, rather than dictate, how much to pay for medical services.

•Prohibitions against using taxpayer money to pay for abortions. Insurance companies would be required to segregate private premium money from government subsidies and to use only private money to pay for abortions. The same rule would apply to the public option.

•A half-percentage-point increase in the Medicare payroll tax for individuals who earn more than $200,000 and couples who take in more than $250,000 a year. Insurance plans that exceed $8,500 for individuals and $23,000 for couples would be taxed 40%, and elective cosmetic surgeries would be taxed 5%.

Final Numbers

•Companies with more than 50 workers that do not offer insurance would pay $750 for each employee that receives a government subsidy for insurance.

. The bill would cost $849 billion over the next decade, according to the Congressional Budget Office, putting it under Obama’s $900 billion target ceiling for the overhaul.

' The federal budget deficit would be cut by $127 billion over the decade, according to a congressional aide, and reduce the deficit by a $650 billion in the second 10 years after adoption.

' Some 31 million uninsured people would get coverage, raising covered Americans to 94%, according to CBO projections cited by an aide

New Taxes

• Tax on high-end health insurance plans: $149.1 billion

• Capping flexible spending accounts at $2,500: $14.6 billion

• Fees for drug makers: $22.2 billion

• Fees for medical device makers: $19.3 billion

• Fees for health insurance companies: $60.4 billion

• Higher floor for deducting medical expenses: $15.2 billion

• Higher payroll tax for top earners: $53.8 billion

• Tax on cosmetic surgery: $5.8 billion

Sources: USA Today,Wall Street Journal Health Blog

There you have it – Everything you wanted to know, but had no list for.

Wednesday, November 18, 2009

Harvard Medical School Dean Gives Obamacare a Failing Grade

November 18 - Many stereotype the Harvard medical establishment as a bastion of Obamanites with an usually high concentration of elitist thinkers campaigning for a single-payer system.

Therefore it may come as a surprise that the Harvard Medical School Dean, Jeffrey Flier, MD, gives current health reform bills a failing grade in today’s WSJ with these well-chosen words,

“In discussions with dozens of health-care leaders and economists, I find near unanimity of opinion that, whatever its shape, the final legislation that will emerge from Congress will markedly accelerate national health-care spending rather than restrain it. Likewise, nearly all agree that the legislation would do little or nothing to improve quality or change health-care's dysfunctional delivery system. The system we have now promotes fragmented care and makes it more difficult than it should be to assess outcomes and patient satisfaction. The true costs of health care are disguised, competition based on price and quality are almost impossible, and patients lose their ability to be the ultimate judges of value.”

“Worse, currently proposed federal legislation would undermine any potential for real innovation in insurance and the provision of care. It would do so by overregulating the health-care system in the service of special interests such as insurance companies, hospitals, professional organizations and pharmaceutical companies, rather than the patients who should be our primary concern. “

Dr. Richard Reece is author, blogger, speaker, and innovation and reform commentator. Dr. Reece’s latest book, Obama, Doctors, and Health Reform ( is available at,, and for $31.95 (hardcover), $21.95 (softcover), and $6.95 (electronic). For information on speaking fees and arrangements, call 860-395-1501.

Electronic Medical Records - Technology-Enabled Primary Care Doctors

There’s no question the deck is stacked against primary care. Its rates are too low, its hours too long, and its prestige too lagging. Yet everybody agrees a vibrant and broad primary care base is essential to a smoothly functioning and effective health system.

I’m optimistic about primary care. I believe primary care doctors are capable of pulling themselves up by their technological bootstraps. In Innovation-Driven Health Care (Jones and Bartlett, 2007), I devoted several chapters to primary care clinical innovations - having patients create their own histories electronically before visiting the doctor to save time and enhance coding revenues, being trained to perform more procedures and produce more revenue in the office, dispensing medications in the office to improve compliance, using the Internet creatively to reduce staff costs and overhead, doing their own coding, and using protocols to manage metabolic diseases leading to vascular deaths.

Most of these are “disruptive technologies,” meaning primary care doctors can execute them in their office rather than referring them out or depending on someone else.

Now there’s a new technological kid on the block – digital handheld ultrasound devices. These devices are small, less than ½ a pound; handheld and portable; will soon be available for less than $5000; will be marketed by organizations, large (GE and Phillips) and small (Sonasite); FDA approved; emit no radiation, as CT and MRI scans do; and are aimed squarely at the primary care market.

Not only can these devices keep many procedures “at home,” rather than being referred to imaging centers , pharmacies, or other specialists, but they can be performed simply,safely, and more conveniently and more cheaply for patients and the system as a whole.

Handheld ultrasound devices are useful and versatile and can be used to monitor fetal development, guide needle injections, joint aspirations, and lumbar punctures; identify coronary atherosclerosis, peripheral vascular disease, abdominal aneurysms, and intra-abdominal and thoracic masses.

Tuesday, November 17, 2009

Health Reform: Will January Be Another August?

Preface: What follows is from a New York Times November 17 blog. I basically agree with what is being said here. What is not being said is: what will happen if no reform bill is passed before January, and legislators go home and find the same intense opposition to reform that exploded in the town hall meetings last August. What happens if the unemployment and underemployment figures are even higher than the current 17% figure? What then? Right now only 17% consider health reform as the nation’s biggest problem. Stay tuned.

Analyst Doubts Health Overhaul Can Pass


Arguing that the political winds are shifting away from the support necessary for an overhaul, one Wall Street analyst is now predicting Congress will not pass any significant health care legislation anytime soon.

In a report to investors on Tuesday, Richard Evans, an analyst with Sector & Sovereign in New York, writes, “We no longer expect Congress to pass impactful health reform legislation this year, or even in this political cycle.”

Mr. Evans cites several factors that he believes makes passage less and less likely, including the increasing public opposition to the overhaul, as well as the emergence of politically divisive issues like abortion and immigration in the debate over the legislation’s specifics.

He also notes that the House and the Senate take very different views on how the overhaul should be paid for, with the House favoring a tax on the wealthy, and the Senate preferring a tax on the most generous insurance policies, the so-called Cadllac plans.

The result is what Mr. Evans sees as irreconcilable differences in opinion about where to get the money for reform, with the House and Senate “settled on a plan that the other cannot pass.”

“In short, we don’t think health reform is failing because someone hasn’t written the right bill; health care reform is failing because no one created a durable coalition in the first place, and potential members of such a coalition have been drawn into other (abortion, immigration, class) battles,” Mr. Evans writes. “For the time being, it‘s simply over.”

Health Care Waste or Paying for the Sick Poor?

The verse that follows is based on a November 16 Philadelphia Inquirer report “Health-Care Heresy,” that read, part,

“As he raced through the U.S. Capitol this fall, Dr. Richard “Buz” Cooper, a 73-year-old University of Pennsylvania medical school professor, didn't mince words. He denounced as “malarkey” a reigning premise of the health care debate -- that one-third of the nation's $2.5 trillion in annual health spending is unnecessary -- and said that the idea came from “a bunch of clowns.”

“The harsh language underscores Cooper's disdain for highly regarded work -- as close to a sacred cow as anything in health care -- developed over two decades by the Dartmouth Atlas of Health Care. The work by Dartmouth Medical School researchers shows huge geographic variations in the amount of care that hospitals and doctors provide, with spending in some areas running three times as much as in others. Dartmouth argues much of the high spending is due to extra procedures and tests that often don't help patients, but bring in more money for doctors and hospitals.”

“The argument has been embraced by President Barack Obama's administration and several lawmakers, who have repeatedly said that the nation could save as much as $700 billion a year -- if only doctors and hospitals in high-spending areas, such as Philadelphia, Los Angeles and Chicago, would end their profligate practices and adopt the thriftier ways of say, the Geisinger Health Systems, based in Danville, Pa. The House has inserted provisions in the health bill that could punish high-spending hospitals in Philadelphia and elsewhere, while rewarding low-spending facilities in places such as Albuquerque, N.M., Madison, Wis., or Portland, Ore.”

The Poverty Factor

“But Cooper and some allies say that would be a disaster and hurt efforts by doctors and hospitals to care for the poor. Cooper says the Dartmouth research doesn't take into account the high cost of helping the impoverished, who often spend more time in hospitals because they don't have people to care for them at home and often return to the hospital when they can't afford needed medications. “

“There is abundant evidence that poverty is strongly associated with poor health status, greater per capita spending, more hospital readmissions and poorer outcomes,” he wrote in an Oct. 24 post on his blog. “It is the single strongest factor in variations in health care and the single greatest contributor to 'excess' spending.”

How much of U.S. health spending is waste?
How much of this spending is poverty-based?
The Dartmouth people says unwarranted waste is 30% of health care.
Cooper says caring for the poor is something hospitals have to bear.
Dartmouth says eliminating excessive regional variation,
Will be the American health system’s economic salvation.
Professor Cooper of Penn says this is unadulterated malarkey,
Dartmouth studies are the work of a statistical sharkey.
But who is right and who is wrong,
You can argue that query all day long.
But when you have a sacred cow to gore,
It helps if you do it to protect the poor.

Monday, November 16, 2009

Clinical Innovation - Predicting Odds of Sudden Cardiac Death and Preventing Them

When I started this blog, 1082 blogs ago and three years ago, I focused on clinical innovations that made a difference. Then along came the health reform debate. It consumed and sidetracked me. It should not have. Reform and innovation are interrelated because a so-called government takeover, with its rules and regulations and hostility to private enterprise, dampens innovation.

In any event, I periodically return to the subject of clinical innovation because I believe it is a way out of the health care pit. Over the last two decades, cardiologists have reduced sudden death odds from 30% after heart attacks to 6%, thanks to bypass surgeries, angioplasties, beta-blockers, ACE inhibitors, rhythm regulating and defibrillating devices, and new-found awareness of factors predictive of sudden cardiac death.

To track cardiovascular innovation, I follow the writings of Ron Winslow, chief Wall Street Journal reporter, who reports on developments of the annual meetings of the American Heart Association, and the progress of SHAPE Medical Systems, a St. Paul, Minnesota company that has created an FDA approved system that, among other things, predicts odds of sudden death from heart disease.

Here is the latest news, in the words of Ron Winslow and Alan Price, MD, and Abraham Kocheri, MD, of the department of cardiology at the University of Illinois at Chicago.

“Researchers said men at age 40 in the U.S. have a one-in-eight chance of suffering sudden cardiac death over the rest of their lives, a stark indication of the toll cardiovascular disease exacts on society.

For women, researchers said, the risk is 1 in 24. The prevalence has long been of concern to heart and public-health experts, but lifetime risks for the condition haven't previously been estimated, researchers said.

Some 300,000 Americans a year suffer sudden cardiac death, an event generally defined as death resulting from coronary heart disease within an hour of the onset of symptoms. Heart attack is the most common cause, but valve disease, infections and heart-beat irregularities can also result in sudden cardiac death.”

‘It's fairly astonishing data,’ said Muriel Jessup, a cardiologist at University of Pennsylvania who headed the program committee for the American Heart Association's Scientific Sessions here, where the findings were presented Sunday, and who wasn't involved in the study.

The condition may get less attention because of a belief that little can be done to prevent it, she said. But she and other scientists said steps can be taken to prevent the problem.”

Source: Ron Winslow, “For Men at 40, Risk of Cardiac Death 1 n 8, Wall Street Journal, November 16, 2009

• "Shape Medical System, which gained FDA approval earlier this year and was introduced at the 2009 Heart Rhythm Society (HRS) in Boston, allows physicians to quantify shortness of breath while tracking and measuring patient progress and response to therapy. Its test parameters offer criteria for patient functional classification, correlate with biochemical markers of heart failure (BNP and ANP), and provide data that are predictive of patient mortality and hospitalization risk, according to the company.

The test takes 15 minutes and involves measuring ventilation parameters while the patient exercises on a treadmill at a very low intensity of one mile per hour with a treadmill set at a 2% grade. The device includes five components : a data analyzer, disposable patient interface or mask, a pulse oximeter, and a computer and a printer.”

Source: Cardiovascular Business, June 10, 2009, and EPLLab Digest, “He Shape-HF Carioplulmonary Exercise Testing System, “ November, 2009.

Why do these two pieces of news intrigue me? Because the health system has within its grasp an affordable realistic cardiac testing system to predict sudden cardiac death and response to drugs and rhythm devices. Further, individuals at risk – those who faint, develop sudden shortness of breath, or who are involved inexplicably in accidents or collapse for no apparent reason – can be tested in decentralized settings, such as a physician’s office or even a health club – by a nurse or tech – at no risk to the patient because only suboptimal exercise is required.

Sunday, November 15, 2009

Medical Innovation, Health Reform, and The Counterintuitive, Irrational, Improbable, Unconventional, Unintended, and Unpredictable.

A third of the essays are portraits of “minor geniuses” — impassioned oddballs loosely connected to cultural trends.

Another third are on the hazards of statistical prediction.

The final third are about augury, about individuals rather than events. Why, he asks, is it so hard to prognosticate the performance of artists, teachers, quarterbacks, executives, serial killers and breeds of dogs?

New York Times Review of Books, “What The Dog Saw; And Other Adventures ,” by Malcolm Gladwell, November 15, 2009

Malcolm Gladwell – author is Outliers, Blink, The Tipping Point, and What The Dog Saw – is my favorite non-fiction writer. I suppose the reason why is that he defies conventional logic. I suppose I like his writings because they fit my own counterintuitive views:

• that most medical innovations comes from impassioned, creative, tinkering, doctors on the ground seeking pragmatic solutions rather than from purposefully managed large institutions or individual doctors following evidence-based protocols;

• that doctors at the point of care know better what to do from their own intuition and what they know of the patient before than from predictive modeling databases.

• that doctors generally do what they think is best for the patient rather than what is best for their wallet;

• that prognoses and effectiveness are unpredictable and cannot always be foreseen statistically.

• that everything in health reform in a government regulated system is obvious and that universal coverage will improve the health of the nation and can be reduced to zero in a complex managed system .

• that the expectations of doctors and patients from what they know and read of medical science, and what society and malpractice lawyers expect, is more important factor in decreasing costs than data on comparative cost effectiveness.

• that American culture - its faults, its violence, its freedoms, its attitudes towards opportunity and outcomes, and its skepticism toward Big Government – are far more important in determining the nation health than sweeping reforms.

• that incremental pragmatic reforms from the bottom-up over time that fit the nation’s culture will be more important and far less expensive than sweeping reforms from above.

Conventional wisdom from Washington would have us believe we can force the system to be more productive , tax our way to efficiency, simplify medical forms, end fee-for-service, bundle and capitates services, innovate through government demonstration projects, manage completion, lower costs through public plans, compare, control, and dictte treatments, negotiate drug prices, and extend coverage before we control costs.

Malcolm Gladwell and I might beg to differ.

Saturday, November 14, 2009

The Health Reform Train

The health reform train is nearing its final station. The nearer the station gets, the slower the train goes, the more remote the station seems, the more the station seems to be one of those political dreams, Obstacles litter its path. Barriers are political – only 17% of Americans list health care as their top issue; financial – the Office of Management and Budget has yet to clear the tracks; and legislative - getting 60 votes and traversing procedural terrain grows more difficult. The train is running behind schedule. It may not reach its destination before Christmas Eve or New Year's Day.

Democrats on board are restless. Their staffs are texting and screaming on cell phones. Constituents are emailing, tweeting, and face booking to complain. As athey read damning polls, Democrats support dropping for midterm elections. Republicans are of no help. They sit glued to their seats. Occasionally they stand and sneak off to pull the emergency brakes. Democratic legislative leaders troll the aisles, trying to rustling up a vote or two. The Engineer-in- Chief stands in front of the train, seeking to talk and charm the litter off the tracks. His close crew is coaxing, promising, bribing, and even threatening the opposition, to remove litter that blocks the rails. Every litter bit counts, they argue, better to be part of history than lose your seats.

Friday, November 13, 2009

Medicare Plagued by Waste, Fraud, and Abuse

Preface: One of those seldom little secrets no one talks about is this: to minimize Medicare fraud and abuse, now estimated at $60 billion a year, Medicare will have to adopt private health plan tactics. This is ironic because the Obama administration has portrayed private plans as the arch villains behind health care inflation. The source of what follows is John Goodman of the National Center of Policy Analysis abd Thomas Cheplick, "Medicare Plagued by Waste, Fraud, Abuse," Heartland Institute, December 2009.

Cost savings through reduction of waste, fraud, and abuse in the Medicare system being offered as a key funding source for health care reform currently under consideration on Capitol Hill. Eliminating this corruption could require Medicare to adopt private-sector reforms, says the Heartland Institute.

The proposal authored by Sen. Max Baucus (D-Mont.), currently pending in the Senate, relies on such reductions for more than $400 billion in funding over the coming decade.

"Officials estimate that Medicare is annually cheated out of some $60 billion in improper claims payments -- an eighth of its entire budget," says Kevin Wrege, regional state affairs director for the Council for Affordable Health Insurance in Alexandria, Virginia:

o Fraud is rampant and unchecked throughout the Medicare system, while private carriers do a much better job of preventing it.

o Private carriers spend a lot on efforts [to prevent fraud,raising their administrative expenses in the process.

o By contrast, the Medicare program does not regularly review bills for accuracy and to prevent fraud.

Medicare typically pays claims in full, and the Department of Health and Human Services' Office of Inspector General (OIG) operates as a post-claim payment cop, flagging and investigating only those that appear suspicious, Wrege notes.

"Recovered funds, if any, are often only a fraction of the often millions of dollars taken," Wrege added.

Many Medicare abuses happen in the market for durable medical equipment (DME), such as wheelchairs and oxygen equipment. A draft OIG audit released in August 2008 flagged almost a third of the 2006 DME claims sampled as having been improperly reimbursed.

According to a July report by the Government Accountability Office:

o Medicare paid as much as $92 million since 2000 for equipment purportedly prescribed by doctors who were dead.

o Claimants have submitted counterfeit documents, forged doctors' signatures, and filed bills on behalf of patients who were dead or had never been seen by the prescribing physician.

Health Reform - Too Big To Fail?

I awoke this morning thinking big.

I thought of Peter Drucker (1909-1995), who wrote,”Every major social task ,whether economic performance or health care, education or the protection of the environment, the pursuit of new knowledge or defense, is being entrusted to big organizations, designed for perpetuity...On the performance of these institutions, the performance of modern society – if not the survival of each individual – increasingly depends."

I thought of President Obama and his big plans to reform everything big in sight. In the preface to Obama, Doctors, and Health Reform, I wrote, “ President Obama vows to overhaul the health system. He seeks to lower costs, expand access, increase efficiencies, and cut spending. He proposes spending more than $1 trillion over the next ten years to reform it. He seeks to lower costs, expand access, increase efficiencies, and cut spending …Under any circumstances, I don’t foresee how Obama in the next few years can create 3.5 million jobs, redesign the health system, save the auto industry, reinvent the energy sector, revitalize the banks, and reform education with one swipe of his magic wand. “

I thought of the big health care debate now raging in Congress, with the fate of 1/6 of the big $12 trillion American economy and the health of 310 million Americans at stake.

I thought of the big national debt, now projected at $9 trillion by 2019, and I thought of the big unemployment figure of 10.2% for the entire economy, and the big employment figure of 14 million Americans employed in health care.

I thought of big business and an email I received yesterday from Brian Klepper containing a blog from The Health Care Blog entitled,”Will Business Force Reform Back to the Drawing Board?" which contained this passage,

“Non-health care businesses comprise about six-sevenths of the economy - meaning they have six times the heft and influence of the health care industry - and financially sponsor coverage for more than half of Americans. Year after year, employers have borne the lion's share of onerous health care cost increases, 4 times general inflation over the last decade. Endless reports have described how health care, business' largest and most unpredictable benefit cost, has sapped America's global competitiveness and placed its employers at a severe disadvantage.”

I thought of the string of big new bureaucracies, estimated to be 32 in all, that will be required to implement either the House or Senate plans.

I thought of big words and phrases, all abstract, all three syllable or more, that you hear so often and that are said to be needed to restructure the health care system.

Among these words and phrases are,

• Transparency

• Competition

. Infrastructure

• Information technologies

• Meaningful implementation

• Comparative effectiveness

• Evidence-based medicine

• Independent commissions

• Regional variation

• Comprehensive coordination

• Universal coverage

Finally I thought of the growth of health care businesses, as exemplified in 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

But if biggering reform fails, you run the risk of harm, whether you meant to harm or not, of setting back needed reforms for years.

As that point, I thought of another polysyllabic word, “incremental.” Rather than run the risk of big failure, which might take years to repair, why not grow into bigger reforms by “chunking,” building towards larger reforms by putting into place smaller doable reforms – like tort reform, opening up health plan markets across state lines, giving people choices of plans with basic benefits and small premiums

Thursday, November 12, 2009

A Bump on the ROAD to Health Reform

Preface: These notable and quotable remarks appeared in today’s New York Times.

In today’s Doctor and Patient column, Dr. Pauline W. Chen writes about the image problem that primary care specialists face. Dr. Chen recounts the story of a respected medical school colleague who chose the primary care route, and the disparaging comments that followed.

Unfortunately those comments would not be the last ones I would hear disparaging primary care. Even today, similar beliefs persist among medical students and trainees, though they have long since been condensed, reduced to an oft-repeated acronym among those choosing specialties: I’m heading for the ROAD (radiology, ophthalmology, anesthesia and dermatology).

That ROAD has had devastating effects on the physician work force in the United States. … According to one study published last year in The Journal of the American Medical Association, as few as 2 percent of medical students are choosing to step away from the ROAD or from other similar “high prestige” and competitive specialties in order to pursue general internal medicine. The statistic has the power to bring even the best efforts at reform and universal coverage to a grinding halt.

Reducing Health Costs, More for Less

How do you reduce health costs?
Who – gov or markets -will be the boss?
That is the real question.
That is the real obsession,
No belief system wants a loss.

But where do you go to cut?
You go to where there’s a money glut.
You go to programs of big gov,
To the political powers above,
But there’s one great big but.

You have to execute a delicate finesse.
You have explain with big gov, more is less
The more big gov has to tax and spend,
The less care the old get in the end.
That’s the big secret, more for less.

This takes a tricky explanation,
For it is a sticky proposition.
Less care, you explain, is more.
When it has big gov at its core.
It's magic math, subtraction is addition.

The Curious Case of The Health Reform Cost Reduction Discussion

Everyone with any sense at all knows the present health reform bills expand coverage but fail miserably in reducing costs. In fact, the House and Senate reform bills estimate it will cost some $840 billion to $1.3 trillion over the next 10 years to cover the uninsured. And, everybody with any experience or knowledge of the history of entitlement programs know these are underestimates.

Tapes of President Lyndon B. Johnson reveal he maneuvered every step of the way getting the Medicare bill through Congress. One of the things he did was suppress talk and estimates of costs. Johnson advised a new Senator from Massachusetts, Ted Kennedy, to never project costs out too far. Such projections, Johnson said, would scare people and get them talking about socialized medicine, a sure loser among the American people.

This brings us to the current state of the reform discussion. Republicans warn of a “government overhaul,” i.e., socialized medicine in drag, and the American public is rightly concerned the projected costs will drag down a fragile economy and drag up the national debt, now projected to be $9 trillion by 2019. Furthermore, most sensible observers acknowledge that the current bill expand coverage but do essentially nothing to contain costs.

Given human nature, this state of affairs is easy to understand. It is easy to talk about caring for disenfranchised people. Health care is a social good. But it is quite another thing to discuss hard decisions to cut costs, for example, cutting $170 billion out of Medicare Advantage Plans or $500 billion out of Medicare.

That’s hard, so to glide over it, you talk glibly about long term “savings” through prevention, health information technologies, and coordinating care for chronic disease patients.

So where, you may ask realistically, do the true “savings” lie? I do not know, but a group of experts at the RAND corporation , using optimistic and pessimistic assumptions, have had a crack at the potential of cost savings.

Here is what the RAND experts came up with,

Estimated Cumulative Percentage Changes In National Health Care Expenditures, 2010-2109 , Given Implementation of Possible Changes.

Best Case, first number, Worst Case, second number

1. Bundled payment, -5.4%, -0.1%
2. Hospital rate regulation, -2.0%, 0.0%
3. Health information technologies, -1.5%, +0.8%
4. Disease management, -1.3%, +1.0%
5. Medical homes, -1.2%, +0.4%
6. Retail clinics, -0.6%, 0.0%
7. NP-PA scope of practice expansion, -0.5% -0.3%
8. Benefit design, -0.3%, +0.2%

Source: Peter Hussey, et al, “Controlling U.S. Health Care Spending – Separating Promises from Unpromising Approaches,” New England Journal of Medicine, November 11, 2009

What is curious about this list? Simply this. Other than retail clinics, there is no mention of market-based approaches - opening up competition for buying health plans across state lines, health savings accounts with high deductibles to lower premiums, individual tax credits allowing people to shop for plans that fit their needs, encouraging individuals to spend their own money as they see fit.

Current reform plans for reducing costs assume the only way to slow costs is from the top-down, from Washington, not from the bottom-up, by putting choice and dollars back in the hands of individuals. And the best way to discourage such talk is to suppress mentioning it, lest people come to their senses. As Alice in Wonderland might say, talk of reducing health costs gets curiouser and curiouser.

Wednesday, November 11, 2009

Health Reform History Lesson: Lest We Forget

A Reminder of What Health Reform is All About And Why It Is Necessary
From: “Health Reform’s Moral Hazard,” by Steven Malanga, RealClearMarkets, November 11. 2009

Prelude: The italics are mine.

It has now been some 70 years since the federal government shifted the landscape in health care by bestowing on employers tax subsidies for providing workers with health insurance. And it has been 45 years since the federal government got directly into the act by creating two vast public health plans, Medicare and Medicaid. Both moves have helped to transfer health care bills from the individual to third-party payers, so that many of us are now used to not paying individual bills from doctors or hospitals.

Over time, healthcare has come to seem less like a service we purchase than like an entitlement or worse, a right bestowed on us by government or by our workplace. After all, the government designed Medicare, the public health plan for seniors, to cover hospital care for seniors but eventually under pressure expanded it to pay for virtually all non-elective doctor and hospital visits as well as drugs for every senior.

And private enterprises like the Detroit auto companies negotiated their health benefits for employees with unions because it was cheap to do so using government tax subsidies. The companies rarely asked whether the additional services and coverage they were providing were essential to their employees' health. These services were perks that were affordable in the post-World War II era, and employees came to expect them until the auto companies could no longer afford them.

Now, nearly two-thirds of Americans surveyed by a Quinnipiac poll say it is government's responsibility to ensure that everyone has "adequate health-care." But does providing $90 mammograms to an uninsured person who would rather spend $400 on Botox treatments amount to a responsibility of government?

The question is ever more important as the health reform debate rages. The New York Times reports that a battle has broken out in the White House between those who want reform legislation to have more cost-saving initiatives and those like Chief of Staff Rahm Emanuel, a master of realpolitik, who think it's not politically possible to pass a bill that Americans will see as limiting their health care choices.

What both sides in this White House debate don't understand is that they are at loggerheads because the legislation being considered in Washington will attempt to reform the system from the top down, by fiat from the government. As a result, any cost savings will be those dictated from Washington after decades when individual Americans and health providers have grown resistant to such mandates
. To take just one recent example out of dozens: some White House advisers want more savings in the legislation from hospitals, but the administration has already promised hospitals that it won't demand more of them in exchange for their support of health reform. This is the way our health system is being revamped, one political favor at a time.

This is why the only truly effective way to reform our health system, including slowing the growth of costs, is not from the top down, as mandated by Washington, but from the bottom up, by putting health care dollars and choices back into the hands of individuals. We can do that by eliminating the business deduction for health insurance and transferring tax credits to individuals who can use them to purchase their own insurance. We can establish health savings accounts where people can accumulate the money they save on health insurance to pay big bills. If we feel we need a safety net, we can establish government pools that protect people against the most catastrophic costs.

In these ways we would slow the growth of health costs not by gigantic, unpopular mandates from Washington but through millions of individual decisions by people acting with their own money and in their own best interests. Under such a system there should be no need for the White House to cut Machiavellian deals with hospitals or doctors or AARP for their support in exchange for political favors that undermine the greater goal of reform.

Dr. Richard Reece is author, blogger, speaker, and innovation and reform commentator. Dr. Reece’s latest book, Obama, Doctors, and Health Reform ( is available at,, and for $31.95 (hardcover), $21.95 (softcover), and $6.95 (electronic). For information on speaking fees and arrangements, call 860-395-1501.

Health Reform: Remember The Maine!

Preface: As we go to press, Maine has become the 5th state to allow retail pot dispensaries for selling medical marijuania. Maybe the pot tax revenues will help Maine pay for health reform, or health deform, depending on where you stand. Critics will surely say Maine is going to pot. On the other hand, with a little pot luck, Mainiac health reformers will achieve peace of mind.

Before we get overly excited about the power of government to reform health care, it may be worthwhile to consider the example of the state of Maine. It is a liberal state, it contains two swing RHINOs (Republicans in Name Only) senators, both of whom may determine the destiny of national health reform, and its government has been trying for decades to reform its system.

What has Maine learned? It has learned health care is a balloon. You push down on the balloon from the top to expand coverage, you squeeze it to reduce costs, the balloon’s sides pop out, and the balloon continues to expand.

As Gardiner Harris explains in yesterday’s New York Times in Maine Finds a Health Care Fix Elusive,”

“Maine is the Charlie Brown of health care. The state’s legislators have tried for decades to fix its system, but their efforts have always fallen short: health insurance premiums are still among the least affordable in the nation, health care spending per person is among the highest and hospital emergency rooms are among the most crowded. Indeed, many overhauls to the system have done little more than squeeze a balloon — solving one problem while worsening another.”

The problem with the health care balloon is one of expansion and contraction. You cannot expand the balloon by blowing more uninsured into it while at the same time contracting its costs. If you are a state balloon, you have another problem. You are part of a national balloon called Medicare and Medicaid and other federal programs, which already pay for 46% of all health costs.

We are already getting a sense of this expansion-contraction dilemma at the national level. If you pump 36 million more people into the balloon, as Speaker Pelosi proposes, you are going to expand costs by an estimated $1.3 trillion over the next decade. The question becomes: When is the balloon going to burst?

To Senator Olympia Snowe, ironically the key to passage of a Democratic health bill this year, Maine’s past shows that change, while needed, may be should be incremental. This is among the reasons she opposes an immediate public insurance option. “I mentioned to the president that people can’t digest everything at once.”

National Democrats ought to change their strategy from “Give me Total Victory, or Give me Failure and Debt!” to “Give me Small Victories, and Give me something to Crow About!”

What I am suggesting it that perhaps Democrats should shrink the health care balloon by pushing tort reform and by expanding coverage across state lines.

Polls indicate the public and doctors would embrace these moves, costs would be cut, premiums would drop, affordable access would expand, and the balloon might begin to deflate.

Until then the expanding Democratic health care balloon may be all hot air surrounded by hype made for TV and designed for sudden collapse.

Winston Churchill once said “"I cannot forecast to you the action of Russia. It is a riddle, wrapped in a mystery, inside an enigma.” Likewise I cannot forecast to you the action of Congress on health care reform. It is a balloon, wrapped in a blimp, inside a zeppelin, floating like an airship. Where it comes down, no one knows.
Dr. Richard Reece is author, blogger, speaker, and innovation and reform commentator. Dr. Reece’s latest book, Obama, Doctors, and Health Reform ( is available at,, and for $31.95 (hardcover), $21.95 (softcover), and $6.95 (electronic). For information on speaking fees and arrangements, call 860-395-1501.

Tuesday, November 10, 2009

Health Reform, Rednecks, and Bluenecks

I was speaking to a dear friend from Missouri this week. He informed me Americans attending town hall meetings, tea parties, and protesting health reform bills in the capitol in Washington, were nothing more than rednecks.


When I asked him to show me what what he meant by rednecks (Missouri is the Show-Me State), he explained,

” Rednecks are loud, bigoted, racist, even fascist. They are close-minded. They tend to be fat, white, old, conservative, and Republican. They are for the rich, of the rich, and exploit some capitalistic affluent niche.”

”Most come from Red States. They dress up in ties and white shirts, worn especially for protest occasions. They either lie or spout misinformation. They are close-minded. Their heroes are Bill O’Reilly, Sean Hannitty, Glen Beck, Mark Levin, Dick Morris, and Rush Limbaugh. They get all of their talking points from Talk Radio and Fox News.

They never think for themselves. Given our moral and intellectual power, we must act and think for them. They are essentially right wing robots parroting slogans drilled into them by their conservative mentors and masters.

They are mean-spirited and as cruel as junk-yard dogs. They keep insisting the money they earn should be their own, to be spent as they please, not at the whim of a compassionate government. They talk endlessly or freedom and choice."

Brainwashed Grassroots

When I pointed out that polls indicate only 42% of Americans, 33% of Seniors support Obamacare, and 20% say they are liberal, 40% conservative, 40% independent, he replied, “ The Grassroots has been brainwashed. They do not know what is good for them and good for the country."

Only we know what is good for their health and well-being. Only we have the collective wisdom and the comprehensive data to bring more coverage to more people at an affordable price. We will snuff out greedy, profit-making businesses who should never be in health care. ”


Your problem, I countered, is that you are a Blueneck.

What, he asked, is a Blueneck?

A Blueneck, I explained, is not a Blue Dog. A Blue Dog is a conservative or moderate Democrat. A Blueneck is an Independent who takes any position that is good for mankind. A Blueneck is color blind, tolerant, multicultural, secular, fair, open minded, and above all, politically correct.

A Blueneck never takes a position that might offend his political base. A Blueneck is inherently and incessantly progressive. He is always politically correct and believes everyone is a victim of society’s injustices. With a Blueneck, anything and everything goes, as long as it doesn’t offend anybody in his under-privileged and overly-abused constituency. He is for the hopeless, the helpless, and the oppressed. A Blueneck never discrimates, except against those who disagree with him or who challenge his self-righteousness or hypocrisy.

A Blueneck believes what is good for the Government is good for the People, even though the people do not yet understand his magnanimity.

A Blueneck believes in change. He does not, for example, believe that the Constitution, or the Declaration of Independence, or the Bill of Rights are set in concrete. These foundations of our Democracy as articulate by our Founding Fathers are subject to interpretation as long as they contribute to humankind’s progress and world peace.

A Blueneck does not necessarily live in a Blue State. He lives in academia, in educational establishments everywhere, in corridors of state and federal government, in the Halls of Congress, in law firms serving the public good, in industries that profit from government contracts, and everywhere where people live and work for the common good and for the common use of redistributed common money.

A Blueneck seeks and speaks only the Truth, reads, views, and listens to and responds only to those publications and news outlets and politicians that promote the Objective Truth as he sees it. He is always open minded and receptive to those arguments that fit his world view.

I respect the sincerity, integrity, and intelligence of both rednecks and bluenecks and everybody in-between. There is room in America for different opinions.

Dr. Richard Reece is author, blogger, speaker, and innovation and reform commentator. Dr. Reece’s latest book, Obama, Doctors, and Health Reform ( is available at,, and for $31.95 (hardcover), $21.95 (softcover), and $6.95 (electronic). For information on speaking fees and arrangements, call 860-395-1501.

Monday, November 9, 2009

Health Reform: Measurables and Immeasurables

Our scientific age demands that we provide definitions, measurements, and statistics in order to be taken seriously. Yet most of the important things in life cannot be measured..

Dennis Prager, 1948 - , radio host, lecturer, columnist, ethicist

My first goal for Intermountain is that anytime a physician or nurse says, ‘In my experience’ when they’re talking to a patient, they mean ‘In my measured experience.’ ”

Brent James, MD, Chief Qualify Officer, Intermountain Healthcare, as quoted in “Dr. James Will Make It Better,” by David Leonhardt, New York Times Magazine, November 8, 2009

It all sounds simple enough. You measure everything you do. You gather claims data. You measure what works. You show measures of what works to doctors and nurses. You write protocols for doctors and nurses to follow what works. You pay more for what works. You pay less for what doesn’t work. You remove pay incentives that cause doctors to do more. You gather together doctors who lead organizations with track records for providing better care at lower costs at the White House.

You trot out the theory of evidece-based care.

1. For any given diagnosis, the doctors has a number of options, and you assume most diagnoses fall neatly into diagnostic bins.

2. Committees of doctors and others, such as health plans and Medicare medical directors, track data outcomes related to these options and develop protocols for best results.

3. Doctors follow protocols, and outcomes improve.

Voila! You have the rudiments of a national policy for providing higher quality care at lower costs.

But, as always, simply measuring care to achieve better results has sticking points. The devil is in the details. Doctors are the devils. Protocols disrupt pratice flow. Protocols don't catch it all, particularly the vague folderol The scientific method and the political realities conflict. Physician and patient human nature keeps muddying the big picture. They insist on doing what they think is best based on experience. Critics say you cannot extend one organization’s results to the nation as a whole when salaried physicians dominate that organization and independent fee-for-service doctors take care of 90% of patients.

In any event,

• Doctors resist protocols, preferring instead their clinical intuition based on their experience.

• Hospitals and doctors lose money when they improve quality and reduce complications for which they were previously paid.

David Leonhardt, a New York Times economics expert, brilliantly explains these sticking points and how to side-step around them in his portrait of the life and works of Brent James, MD, the 58 year old chief quality officer of Intermountain Healthcare, a hospital system in Utah and Idaho, with an overwhelmingly Mormon patient constituency.

According to Leonardt,

“James’s answer to such skepticism — and there is a lot of it, especially beyond Intermountain — is to show results. Intermountain has reduced the number of preterm deliveries, as well as the number of babies who must spend time in the neonatal-intensive-care unit. So-called adverse drug events, which include overdoses and allergic reactions, were cut in half in the mid-1990s. A protocol for dealing with one broad category of pneumonia cut its mortality rate by 40 percent over several years. The death rate for coronary-bypass surgery was cut to 1.5 percent, from the national average of about 3 percent. Medicare data on heart-failure and pneumonia patients show that Intermountain has significantly lower-than-average readmission rates. In all, James estimates that the changes have saved thousands of lives a year across Intermountain’s network. Outside experts consider that estimate to be fair. “

James gets results by being deferential to doctors and by appealing to their sense of idealism, which he calls “the flame.”

“That flame burns brightly within the heart of any physician. It’s what brought us into medicine. That’s what defines us as a profession. And that’s your real leverage point. There are a few outliers, but don’t let those outliers get you off track.”

James notes that many medical questions still have no data-proven answer. Many never will. When patients have conflicting symptoms, statistics and protocols won’t always help. Sometimes, intuition is the only good tool a doctor has.

Besides, intuition, other immeasurables exist. How do you define and measure“quality” with patients and doctors when quality is in the eyes of the beholder? How do you measure the quality of physician and hospital performance, when outcomes depend mostly on patient behavior outside doctors’ offices and hospitals? How do you define compassion, bedside manner, patient expectations, trust, efficiencies and understanding of communication, promptness and convenience of access, and amenities at the point of care?

To sum up,

Government can mandate what the doctor measures,
What it will pay docfors from its tax treasures,
But it does not have the retrospective perspective,
To define or measure the unclassifiable subjective,
Or patient-doctor intangible relationship pleasures.

Dr. Richard Reece is author, blogger, speaker, and innovation and reform commentator. Dr. Reece’s latest book, Obama, Doctors, and Health Reform ( is available at,, and for $31.95 (hardcover), $21.95 (softcover), and $6.95 (electronic). For information on speaking fees and arrangements, call 860-395-1501.