Friday, December 31, 2010

New Year's Resolutions for 2011

1. I resolve to continue this blog on health reform and health innovation matters, but to be more full of pith about it.

2. I resolve to increase my SEO (Search Engine Optimization for those of you who are IT impaired).

3. I resolve to more fair-minded, to present both sides of the partisan divide, but not to be a wimp about it by showing where where I stand.

4. I resolve to warn readers the next four years will be a time of unprecedented health cost rises from $2.7 billion of GDP in 2010 to $3.6 billion of GDP by 2014. This will be huge issue in the 2012 elections.

5. I resolve to publish my new book, Good Intentions: A Health Reform Handbook,, which will detail the consequences of Obamacare, in 2011.

6. I resolve to help physicians became a more central part of the health care debate which will reach white heat intensity in 2011 and 2012 leading up to the Presidential election.

7. I resolve to be non-political in my writings, which borders on the ridiculous because as George Orwell said, “All writing is political.”

8. I resolve to make no personal resolutions about bad habits, because at my age I know these habits are too deeply ingrained to change.

9. I resolve to give more praise to those I love.

10. I resolve to reread volumes I and II of Life’s Little Instruction Book, which contain 1028 suggestions, observations, and remainders on how to live a happy and rewarding life. When opportunity knocks, I will invite it to stay for dinner.

Health Reform and Resuscitation of Death Panels

During the health reform debate, on August 7, 2009, to be precise, Sarah Palin wrote on Facebook.

“The America I know and love is not one in which my parents or my baby with Down Syndrome will have to stand in front of Obama's "death panel" so his bureaucrats can decide, based on a subjective judgment of their "level of productivity in society," whether they are worthy of health care. Such a system is downright evil.”

This Palin Facebook posting, as we all now know, promptly became partisan political fodder.

Democrats and the mainstream media assailed mention of “death panels” as a right-wing scare tactic, as a distasteful and unseemly manifestation of a malicious Republican campaign to make seniors fearful of widespread govenment rationing, and later even as a “lie” concocted by Tea Party extremists.

Republicans, said what Palin said was perhaps overstated, but nevertheless signaled a drift toward government rationing of Medicare services.

The actual facts are these. An early version of the health reform law, contained a Medicare provision authorizing payment for doctors for end-of-life consultation to plan for “advance directives “ to avoid extraordinary and unnecessary measures to prolong life.

Which made sense. End of life care consumes somewhere between 10% to 20% of all Medicare spending. But because of the political controversy and posturing engendered by the Palin comment the Medicare provision was removed from the final bill. Democrats feared death panels would sink the bill.

The “death panel” debate has resurfaced because of actions by HHS Secretary Kathleen Sebelius and CMS Administrator Donald Berwick approving a regulation permitting consideration of annual Medicare payment for such consultations – which the last Congress explicitly rejected. So too will the new Congress.

Republicans and conservatives regarded this this re-insertion of pre-death consultations in Medicare as an end-run around the will of Congress, a "recess" dodge, if you will. Under the new Medicare policy, outlined in a Medicare regulation, and endorsed by the Obama administration, Medicare will pay doctors who advise patients on options for end-of-life care, which includes advance directives to forgo aggressive life-sustaining treatment.

This decision may re-ignite the end-of-life debate, with inflammatory talk about killing Grandma. This is a tempest in a teapot. Most sensible people would agree advanced planning for end-of-life care is a good thing. Laying out the options after consultation with patients and families consistent with the elder patients’ moral value is a good idea.It is a variation off the living will concept.

The problem, as I see it, resides in the wording. “Death” is a word , and anticipation of death, is a concept, that makes Americans uncomfortable, particularly when coupled with the thought of government “rationing.”

A larger problem is that we as a people, do not want to make every medical problem a political matter. This is exemplified by the recent decision by Medicare not to pay for Avastin, an anti-cancer drug, for advanced cancers. This is already a raging controversy in Britain which rations cancer drugs for patients.

Another problem is the danger of spouting off on Facebook, now read by 500 million members across the globe. As they used to say in World War II, “Loose lips sinks ships.” Political slips on Facebook, may also sink political battleships ships.


1. Robert Pear, “Obama Returns to End-of-Life Plan That Caused Stir,” New York Times, December 25, 2010.

2. Review and Outlook, “Death Panels Revisited: The Left Won’t Admit that Sarah Palin Had a Point about Rationed Care,” Wall Street Journal , December 29, 2010.

3. David Rivkin and Elizabeth Foley, “ ‘Death Panels’ Come Back to Life; The FDA’s Restrictions on the Drug Avastin is the Beginning of A Long Slide Toward Health-Care Rationing,” Wall Street Journal, December 30, 2010.

Comments on Yesterday’s Value (Outcomes/Cost) Blog

Preface: Yesterday I posted a blog on the value of measuring outcomes of various diseases based on cost. The Health Care Blog, probably the most widely read of blogs pertaining to health care policies, reran my piece. In my blog,I expressed skepticism about the practicality of value measurements based on outcome measurements on a broad scale across the medical care spectrum. I closed with these questions. Here are the comments from readers of The Health Care Blog.

I ended my blog with these questions.

1. Is overall health care value measurable?

2. Are the organizational, societal, and individual costs required to make this value measurement worth it?

3. Will the measurement of value unify ideological factions competing to advance the cause of health reform?

I have my doubts.


I AM SKEPTICAL OF YOUR SKEPTICISM. My colleagues and I created as a means to test this hypothesis, and the response from the industry was remarkable. It didn't cost the government, taxpayers or you anything, and it didn't require HITECH or ARRA or Meaningful Use funding. Not a single academic was distracted from research and not a single patient's care was rationed.

What VALUE does is help all constituents re-frame their thinking around the complex issues that you describe, without giving up on the ultimate goal. Thousands of management teams have learned from this perspective, and it was FREE.
Advancing this concept to the breadth you describe is attainable and it will soon shape how we think about measurement. BTW, Porter/Teisberg went on to say so much more than your selected skeptical quote, and inspired me to find meaning in Value that much sooner. I think it is the kind of innovation we all deserve.

Posted by: John R. Morrow | Dec 30, 2010 7:57:18 AM
In response:

1. Potentially yes. Currently we lack 'outcomes' standards for measurement of the value numerator. Mere reporting of compliance and broad based definitions are too variable and do not necessarily address the relevant consumer i.e. the patient. There must be a clear definition of the appropriate outcomes which may not always be 'survival' 'infection rate' etc.

2. YES. The cultural advancement that is required to empower the patient to realize their role in determining the structure of value-based care will be difficult. Additional positive externalities though might relate to improved overall health, prevention and responsibility. Perhaps unreachable, but worth the investment.

3. Doubtful. To follow on Porter/Teisberg, the ultimate focus should be at the disease and patient level. This may directly contradict some of the goals of our insurers, hospitals and pharma/device least initially.

Posted by: Stephen J. Motew, MD, FACS | Dec 30, 2010 1:29:42 PM

yes, yes, and see below.

I think one can argue endlessly over what metrics to measure, how to measure them, whether measuring them is feasible, etc. etc. etc. and, in fact, these arguments have already been going on in health care for many years. It is tatamount to the arguments in my childhood between the US and Soviets (I believe they were the other party) over the size and shape of the negotiating table before they would sit down to negotiate - which held up progress for quite some time.

The bottom line is that all parties have to come together at some point and agree on what to measure and how to measure it - and this will inevitably be somewhat arbitrary. The point is that the same yardstick will be used for all, and that we will progressively evolve these measurements as we go. Right now every insurance company, hospital, doctors' group, and any other group in health care is measuring its own things in its own way, resulting in the present chaos.

See this post from Paul Levy's blog as a rather stunning example of one hospital's required "quality" measurements, without even the value calculation (note he says it is only a partial list):
Posted by: bev M.D. | Dec 30, 2010 2:35:18 PM

1. How is value defined? Whose values? Physicians and HC researchers may agree on, say QALY or other outcome parameters (or surrogate parameters). Patients may care more about access (both financial access as well as local care with good parking), ill-defined and ill- understood "innovation", physician rapport, comfort incl. luxurious birthing suites ... the sick do care about outcomes, but they may be skewed towards hope (for example, take the advocacy for useless ALS drugs, or the research on MS of disease of impaired venous reflux).

The only way to make real (outcome based) value count and to preserve choice would be a value based plan in competition to a conventional 3rd party pays all plan, with financial interest of the insured in cost.

3. Seriously? That ideological factions (incl. death panel republicans) stop using HC reform for political ends?
Posted by: rbar | Dec 30, 2010 3:58:06 PM

My Response to Comments

I find these comments instructive and helpful.

First of all, I am pleased to learn John Morrow and his team have been able to implement Porter’s value concept. Perhaps I overestimated the difficulties.

Secondly, I note De. Motew, a surgeon, is considerable more guarded but nevertheless open-minded. Maybe there is a complex solution for every complex problem

Thirdly, I found Paul Levy’s comment realistic, “The bottom line is that all parties have to come together at some point and agree on what to measure and how to measure it - and this will inevitably be somewhat arbitrary. The point is that the same yardstick will be used for all” and that we will progressively evolve these measurements as we go. Right now every insurance company, hospital, doctors' group, and any other group in health care is measuring its own things in its own way, resulting in the present chaos.” Anything that brings order out of chaos is welc.oem

Fourthly, I found the last comment about ideological factions and their use of HC reform to advance their political cause a bit off-putting. He mentions “death panel republicans’ but fails to cite the “historic achievement democrats.” We all have ideological axes to grind, and we will continue to grind them.

Wednesday, December 29, 2010

Value (Outcomes/Cost) –A Unifying Concept for Health Reform?

In health care, stakeholders have myriad, often conflicting goals, access to services, profitability, high quality, cost containment, safety, convenience, patient-centeredness, and satisfaction.

Michael Porter PhD, Professor, Harvard Business School, “What is Value in Health Care, “New England Journal of Medicine, December 23, 2010

Those who support the new health reform law and those who seek to repeal it look at the new law through vastly different ideological lenses. Each ideological camp has its own implacable, rarely movable spin on what’s important.

But, according to Thomas Lee, MD, associate editor of the New England Journal of Medicine and networks president for Partners Healthcare System in Boston, the search for value (outcomes relative to cost) unites and provides a path forward for competing ideological interests.

In Lee's words, “The value framework offers a unifying framework for provider organizations that might otherwise be paralyzed by constituents’ fighting for bigger pieces of a shrinking pie (“Putting the Value Framework to Work," New England Journal of Medicine, and December 23, 2010).

As an ideological and idealistic concept, I would like to think a utopian vision focusing on value is achievable. But I remain dubious because of the nature of American culture. I am also skeptical partly because the concept originates in Boston, which has the highest health costs in the nation but which has scanty evidence that its outcomes are superior. Finally, I am leery because it takes large organizations with interoperable and expensive electronic systems that communicate with each other to measure value (outcomes/costs) for a bewildering number of different diseases with different outcome dimensions (survival, degrees of health recovery, time to return to work, side effects, pain, complications, adverse effects, sustainability, long term consequences) all measured over a longitudinal time frame among diverse stakeholders. Bringing such scattered data points into a single focus with a common understanding among diverse participants over a long time frame strikes me as nearly impossible.

It takes a large integrated organization, or a virtual organization with standardized measuring systems to do this, and I simply do not see this happening soon in America. In Doctor Lee’s words, it means “capturing data in different parts of the delivery system, which means that we all have to use the exact same terminology. And it means sharing accountability for performance.”

To paraphrase Hillary Clinton, “It will take a extremely large village,” or a unified homogeneous nation, and I do not see that happening soon in a country as diverse as America.

My wife, my son, and I have just returned from New Hampshire. The state's motto is “Live free or die,” perhaps the best known of state slogans. The slogan reflects an assertive independence grounded in the American political philosophy of small government, individualism, freedom of choice, freedom of behavior, all which bear on outcomes and costs.

In New Hampshire we stayed at a bread and breakfast inn that served a communal breakfast. At our table was a Brazilian physician, a general practitioner, who now works as a faculty member in a university philosophy department. She espoused the philosophy of a universal health system shared by all nations based on the concept of health care as a “right” for every citizen of the world regulated by the World Health Organization. In other words, she believes in a worldwide health care utopia.

As a pragmatist and a student of American culture, I thought her concept was unworkable for the world in general and American in particular. So we fell into a discussion on the obstacles of sweeping health reform in continental, multicultural, individualist nations like the U.S. or Brazil, each with vast differences between the rich and the poor.

We disagreed agreeably, and I referred her to the work of Porter and Lee in Boston, emanating out of the Harvard medical academic complex. She liked what she heard. We agreed to have further discussions via email on seeking common ground for all patients.

For me the problem is not philosophical but practical. How does one control costs while meeting American's and their lawyer's expectations. No matter how stringent government regulations are, Americans have high expectations. We want more rather than less care. We are easily satisfied with the best.

Besides. with regard to cost, the poorest in America are the sickest and most expensive. Poor people are and will not able to afford or may not have sufficient information or funds to seek preventive or routine care. They will show up on the doctor’s or hospital’s doorstep with advanced disease, and costs to treat them will be high, as they are now in southern states like Mississippi and in America's inner cities. The government now pays for them with Medicaid or Medicare funds but sooner or later Americans will tire of paying higher taxes, and doctors will tire of government regulations and low Medicare and Medicaid reimbursements. and may not be there to care for them.

I close with three questions.

1. Is overall health care value measurable?

2. Are the organizational, societal, and individual costs required to make this value measurement worth it?

3. Will the measurement of value unify ideological factions competing to advance the cause of health reform?

I have my doubts.

Wednesday, December 22, 2010

Loser Pays

Preface: On December 19, The Health Care Blog, arguably America’s most visited website and the repository of blogs by people more famous than I, e.g. George Halvorsan, CEO of Kaiser, posted a previous blog of mine. I reprint the blog here and the comments it drew.

Tort reform is a hot-button issue among physicians. It distorts the practice of medicine by compelling doctors to order tests, the lack of which, might be used against them. It makes each patient a potential enemy. It forces doctors to spend time in extensive documentation. It imposes extensive, often unnecessary, costs on the health system. And it received little attention in the new health reform law, other than being kicked down the road through a demonstration project, which will further delay the need for further action.

Well, Texas acted on tort reform back in 2003-2005, and the fruits of that reform have since become apparent. A WSJ editorial on December 15 , which I shall quote listed these benefits.

“This Texas upgrade would build on reforms in 2003 and 2005 that have vastly improved the legal climate in what has not coincidentally become the country’s best state for job creation. Texas rewrote everything from class-action certification to product liability. One success was rationalizing the asbestos-silica litigation scam. Another was an overhaul of medical malpractice laws, ending the practice of venue shopping for friendly judges and putting a $250,000 cap on noneconomic damages like pain and suffering.”

“Before the reform, Texas was a kind of holy place on the tort bar pilgrimage. Now it’s a Mecca for doctors, especially the emergency physicians, obstetricians and surgical specialists who elsewhere can face blue-sky malpractice premiums.
Liability rates have fallen by 27.5% on average since 2003. The number of doctors applying to practice in Texas has increased 60%, even as the overall population grew by 14%.”

“All of this is helping to end an acute Lone Star physicians shortage, especially in rural areas. Twenty-three counties now have their first E.R. doctor, 10 their first OB-GYN. Hospitals are reinvesting the malpractice savings in scarce services like neurosurgery and neonatal units and expanding access to care. This Texas success has opened eyes in nearby Oklahoma, where even Democrats have been forced to agree to some legal reforms.”

Source: “Loser Pays, Everyone Wins, Texas pushes the British rule on tort reform,” Wall Street Journal, December 15, 2010

Richard L. Reece, MD, is pathologist, editor, author, speaker, innovator, and believer in abilities of practicing doctors and their patients to control and improve their health destinies through innovation. He is author of eleven books. Dr. Reece posts frequently at his blog, Medinnovation.
December 19, 2010 in Policy/Politics, Richard Reece | Permalink


I think the state in which I live, Illinois, is a great example of why federal legislation is our physicians' only hope. Earlier this year tort reform (as it pertains to judgment caps) was yet again declared unconstitutional by our Supreme Court, but the case is unreviewable because it deals with our state constitution.
And as a result more potential doctors choose Dallas over Chicago...
Posted by: Richard B. Wagner, JD | Dec 17, 2010 1:41:27 PM

What we're not seeing here is the effect of tort reform on injured patients. Sure, less malpractice suits shift money from lawyers and their clients, to doctors, hospitals and insurance carriers, but who bears that cost. Capping non-economic awards means lawyers get paid from direct economic settlements, which reduces money needed by injured patients. As well the most serious injuries with the most reasons for a law suit don't get a fair hearing in court because they are too expensive to litigate given the pay back. I can only assume that non medical people who support tort restrictions and patient access to legal help have never been injured and have never needed a lawyer. Of course Richard Reece supports tort reform because (guess what) he is a doctor, but the real affects of taking away patient rights is not the rosy picture painted by Dr. Reese.

"It's a way of life in much of rural Texas, where a shortage of doctors and obstetricians means that residents must often rely on volunteer paramedics during the sometimes-harrowing drive to the hospital. And it doesn't appear likely to change anytime soon."

"Although Texas is being held up as a national example of success in limiting medical malpractice damages -- with a 51 percent increase in new doctors and a 27 percent drop in malpractice insurance rates since a law went into effect in 2003 -- the impact on consumers has been far less clear."

"The number of new doctors in family practice, the area most in demand, has increased by only about 200, about 16 percent, and more than 130 counties still did not have an obstetrician or gynecologist as of October, according to a Fort Worth Star-Telegram analysis of licensing data from the Texas Medical Board."
"At the same time, the number of specialists in Texas has increased sharply, with 425 psychiatrists, more than 900 anesthesiologists and five hair transplant physicians among the more than 13,000 new doctors in Texas in the five years after the Legislature's approval of the liability caps, the analysis found."

"More than half the new doctors settled in the state's largest urban areas, not in rural areas, where the shortage has been most apparent."

"Health care costs, meanwhile, have continued to rise in Texas. Proponents of malpractice caps predicted that costs would drop along with lawsuits and malpractice insurance rates."\

"Consumers are much worse off today," said Alex Winslow, executive director of Texas Watch, a consumer advocacy group in Austin. "Not only have they not seen the benefits they were promised in health care, but now they've lost the ability to hold someone accountable. I think that puts patients at greater risk."
And has tort reform reduced costs for patients - NO

And this:
Posted by: Peter | Dec 18, 2010 3:16:26 AM

Why not use your legislators to protect your business?Business is buying security by using legislators to provide laws that protect their interests. Patients are purposely being shoved aside from the ability to make institutions and individuals accountable.

So patients fend for yourselves because the used Car Salesman known as Lawyers won't take your case.Profits are not big enough? We all know the Texas has more than their share of hacks and quacks,but the real loss is and always will be the patients rights of having accountability.

The health industry wants to be held Harmless for absolutely everything! Even Medical errors and Hospital Acquired Staph Infections that are Preventable!!!!! So why would patients trust a bunch of liers who refuse to meet these challenges.Why should they Not be Held accountable? Why would Doctors and Hospital Administrators be so happy to have tort reform? Other then to continue their assault on the population without being accountable.

While this author prides themselves on reducing and capping injury.The author should remove his head from between his butt cheeks and clean up the industry that is becoming a disgrace and a source of infections amd medical errors.
Posted by: Gary Lampman | Dec 18, 2010 9:19:10 PM

Have health care costs dropped in Texas? Have outcomes improved? Interesting that a state with no income tax and low local taxes could not attract docs until you reformed malpractice.
Posted by: steve | Dec 19, 2010 2:20:09 PM

Looks like the butchers from the butcher shops (that have been outsourced )and the Hacks have gone to Texas because gross negligence has been rewarded with sanctioned murder. To add insult to injury, Texas has capped awards to such a small amount that a side winding snake of a lawyer doesn't see fit to strike for their next Check.

THE STATE OF Texas has permitted citizens to be cut up in chunks, removing limbs and causing life altering disabilities at the patients expense. Leaving them on the streets and destitute. It is a sad day when people are thrown out like trash and compensation for medical Errors are treated like a crime.

What is criminal, is the legislatures wrongful legislation and criminal conflict of interests. Siding solely with a profession that fails to police their own and has a proven record of Medical Errors. Ah, Maybe Mexico will invade Texas. It just may be a step up considering the Corruption in Texas.
Posted by: Gary Lampman | Dec 21, 2010 8:00:48 PM

The magical '250k' hard cap on pain & suffering as a panacea to practitioner's woes & healthcare overall. If only it were so. Yeah, it has attraced more physicians to Texas vs. other states but has it really been its most notable effect but as Peter points out it has done little to address the numerous problems that wide areas of rural Texas face in regards to access to physician services, medical cost increases, or other that proponents of the $250k cap push.

$250k cap has less to do with actually improving the malpractice process for patients and doctors alike than to handicap one of the Democrat Party's key financial contributors (e.g., trial lawyer lobby). That's it real goal.

The Pruning of Reform Christmas Tree and Castration of Santa Claus

I do not understand all the machinations of this lame duck congress when it comes to health reform. I do understand, however, two things.

One, the stage is being set for the monumental health reform-repeal debate, which will take place starting in January 2011.

Two, because they cannot repeal the reform law with a Democrat Senate and a Democrat president, Republicans will seek to slow implementation by starving the law of funds.

You can see this starvation strategy at work with defeat of the $1.1 trillion Omnibus spending bill on December 16. Senate Majority leader, Harry Reid, elected to ditch the bill. It included $8.3 billion for 6000 earmarks and more than $300 billion in health-related funds. Reid caved after Republicans threatened to read aloud its 1924 pages and to delay other bills by 50 hours.

Health-related expenditures included these additional funds above current spending levels.

• $750 million more for NIH research, partly outcomes research for treatment effectiveness.

• $565 million for a public health initiative to reduce and prevent chronic disease related to obesity

• $160 million to combat Medicare and Medicaid fraud and abuse

• $577 million for OSHA

• $224 million for health training networks

• $ 5 million for collaborative care networks, such as medical homes

• $750 million for a new Prevention and Public Health Fund

• $176 million for CMS Program Management Account to implement Medicaid Expansion and Medicare Advantage cuts

• $81 million for new mandates and regulations

• $3 million for a national health care network

As the late Everett Dirksen, the Republican Senator from Illinois, might say, “A million here and a million there. Pretty soon, we’re talking about real money.”
What we’re talking about here is the power of the purse to slow reform by throwing sand in the reform machinery gears until Republicans can get a handle on how to repeal or modify sections of the law. More astute political analysts are saying Republicans are bowing to the wishes of the Tea Party, which was dead set against earmarks and other forms of federal largess.

As for me, I look upon the defeat of the Omnibus Spending Bill as pruning of the Congressional Christmas tree, or, if you look upon the bill's downfall as painful for the reform cause, as castration of Santa Claus.

Thursday, December 16, 2010

Tangible Benefits of Texas Tort Reform,

Tort reform is a hot-button issue among physicians. It distorts the practice of medicine by compelling doctors to order tests, the lack of which, might be used against them. It makes each patient a potential enemy. It forces doctors to spend time in extensive documentation. It imposes extensive, often unnecessary, costs on the health system. And it received little attention in the new health reform law, other than being kicked down the road through a demonstration project, which will further delay the need for further action.

Well, Texas acted on tort reform back in 2003-2005, and the fruits of that reform have since become apparent. A WSJ editorial on December 15 , which I shall quote listed these benefits.

“This Texas upgrade would build on reforms in 2003 and 2005 that have vastly improved the legal climate in what has not coincidentally become the country’s best state for job creation. Texas rewrote everything from class-action certification to product liability. One success was rationalizing the asbestos-silica litigation scam. Another was an overhaul of medical malpractice laws, ending the practice of venue shopping for friendly judges and putting a $250,000 cap on noneconomic damages like pain and suffering.”

“Before the reform, Texas was a kind of holy place on the tort bar pilgrimage. Now it’s a Mecca for doctors, especially the emergency physicians, obstetricians and surgical specialists who elsewhere can face blue-sky malpractice premiums.

Liability rates have fallen by 27.5% on average since 2003. The number of doctors applying to practice in Texas has increased 60%, even as the overall population grew by 14%.”

“All of this is helping to end an acute Lone Star physicians shortage, especially in rural areas. Twenty-three counties now have their first E.R. doctor, 10 their first OB-GYN. Hospitals are reinvesting the malpractice savings in scarce services like neurosurgery and neonatal units and expanding access to care. This Texas success has opened eyes in nearby Oklahoma, where even Democrats have been forced to agree to some legal reforms.”

Source: “Loser Pays, Everyone Wins, Texas pushes the British rule on tort reform,” Wall Street Journal, December 15, 2010

Tweet: Texas tort reform in 2003-2005 benefits: better business climate, more jobs, lower malpractice costs, more doctors moving to Texas #PPACA

Congress Hoisted On Its Own Petard

For ‘tis the sport to have the enginer
Hoist with his petar.

Shakespeare, Hamlet III

December 15 - Petard is a French word meaning firecracker. The English phrase To hoist on one’s own petard has come to mean To be harmed by one's own plan to harm someone else or To fall into one's own trap, literally implying that one could be lifted up (hoist, or blown upward) by one's own bomb.

The SGR is a Congressional bomb. It has been ticking since 1997 when Congress created it to rationalize physician Medicare payments based on the national inflation index, among other things.

Starting in 2002, the SGR has said physicians should be paid less than the previous year. For the last eight years, Congress has sought to detonate the bomb with a temporary “fix,” usually a small increase.

This year, however, doctors were slated to take a 25% “hit” in income. But today, in an act of quiet desperation, signed into law HR 4994, “Medicare and Medicaid Extenders Act of 2010,” a 1 % increase to “stabilize” doctor payments for one year beginning on January 1, 2011. Officials from the AMA, AARP, and the Military Association of America were present at the signing ceremony.

President Obama had no choice. Among AARP’s more than 40 million members, mostly seniors, 80% said they fared loss of access to doctors if SRG were not suspended or fixed. And 60% of doctors in various surveys, the most extensive of which was sponsored by the Physicians Foundation, indicated they would cut services or not accept new Medicare and/or Medicaid patients , if SGR went through as planned. On the AMA’s part, it faced further loss of physician members, now down to 15% or so of practicing physicians.

According to Lee Stillwell, former head of AMA lobbying in Washington, writing for The Physicians Foundation, in his Washington Report, “While no permanent fix appears on the horizon, the 12-month extension gives organized medicine and its allies time to devices a new game plan or gain a longer extension next year.” Until then Congress will remain hoisted on its own petard. That firecracker will go off precisely in one year if nothing is done.

Tweet: AARP and fear of seniors that doctors would pull out of Medicare forced Congress to increase rather than cut pay for doctors #PPACA

Tuesday, December 14, 2010

Virginia Decision Declaring Individual Mandate Unconstitutional is Big News of Day

As you can see from the media list below, the decision by a federal judge in Virginia declaring the individual mandate unconstitutional is the big political news of the day.

Predictably, the articles break down along partisan lines. Federal government officials, Holder and Sebelius, consider the news of only passing interests. The state attorney general of Virginia, Cuccinelli, says the news is of great import. Liberal publications say it’s negative news; the conservative press says it’s great news.

As usual, where you stand depends on where you sit. It is now apparent the Supreme Court will decide who is right and who is wrong, and what is legal and what is illegal.

Real Clear Politics
Tuesday- December 14, 2010

Health Law Will Survive Legal Fight - Holder & Sebelius, Washington Post

You Can't Force Citizens to Buy Govt-Approved Insurance - Ken Cuccinelli, Real Clear Politics

Cynical Maneuvering on Health Mandate - Peter Wehner, Commentary

Repeal Would Be Dangerous to Our Health - Derrick Jackson, Boston Globe

Is Obama Better Off if Health Law Repealed? - Michael Tomasky, Guardian

Uncertain Mandate on Health Care - Chicago Tribune

Health Reform Isn't Yet Down for the Count - San Francisco Chronicle

Victory for the Constitution in Virginia - Wall Street Journal

DJP Update on Physicians Foundation Survey

Donald J. Palmisano, MD, JD, is a former AMA president , who now heads Intrepid Resources, Inc, a medical risk management company.

He writes a newsletter, DJP Update, which you can assess at http://twitter/DJPNEWS or

DJP Update goes to 2317 leaders in medicine representing all of the State Medical Associations and over 100 specialty societies. It has a potential audience of 800,000 physicians.

Here are three excerpts from the December 10 DJP Update.

Nation’s Frontline Physicians Unhappy With Health Care Reform Measures

The Physicians Foundation today released the results of a national survey of physicians that finds strong negative feelings towards the new health care reform law and fear that patient care will suffer in the months and years ahead. The survey was intended to gauge physicians’ initial reaction to the passage of health reform and to learn the ways in which they plan to respond to it.

The research, conducted by Merritt Hawkins, a national physician search and consulting firm, on behalf of the Foundation, comes on the two-year anniversary of the Foundation’s first national physician survey that found growing dissatisfaction among doctors as they struggle with less time for patient care and increased time dealing with non-clinical paperwork, difficulty receiving reimbursement and burdensome government regulations. The new research reinforces those findings and shows that the new health care reform could intensify existing problems for doctors and worsen the shortage of primary care doctors, making it more difficult for patients to access quality care.
The new research reinforces those findings and shows that the new health care reform could intensify existing problems for doctors and worsen the shortage of primary care doctors, making it more difficult for patients to access quality care.
“Physicians support reform; in fact, we were the ones leading the fight against the status quo. But this new research shows that doctors strongly believe the law is not working like it needs to – for them, or for their patients,” said Lou Goodman, PhD, President. “For any health care reform effort to be successful, it must include the viewpoint of our nation’s doctors. Their perspective from the front-lines of patient care is critical in determining what’s broken in our system and how we can fix it.”
Key research findings include:

• The majority of physicians (60%) said health reform will compel them to close or significantly restrict their practices to certain categories of patients. Of these, 93% said they will be forced to close or significantly restrict their practices to Medicaid patients, while 87% said they would be forced to close or significantly restrict their practices to Medicare patients.

• 40% of physicians said they would drop out of patient care in the next one to three years, either by retiring, seeking a non-clinical job within healthcare, or by seeking a non-healthcare related job.

• The majority of physicians (59%) said health reform will cause them to spend less time with patients.

• While over half of physicians said health reform will cause patient volumes in their practices to increase, 69% said they no longer have the time or resources to see additional patients in their practices while still maintaining quality of care.

• 67% of physicians said their initial reaction to passage of the 2010 Patient Protection and Affordable Care Act was either “somewhat negative” or “very negative” and a great majority (86%) believes the viewpoint of physicians was not adequately represented to policy makers during the run-up to passage of the law.

• Physicians are almost evenly divided over the relative importance of SGR (36%) and health reform (34%) to their practices, while 30% are unsure which will have the greatest impact.
End of excerpts.

P.S. You might want to read an interview I conducted with Dr. Palmisano for Modern Medicine. To read go to and type in Palmisano in the search box.

Monday, December 13, 2010

Physician Access Crisis – I Told You So

I have predicted repeatedly the next big health care crisis will be access to doctors. Now, I am pleased to say, an economist, Tyler Cowen, a professor of economics at George Mason University, agrees with me (“Following the Money, Doctors Ration Care,” New York Times, December 11, 2010).

Here is a sample of his reasoning,

UNEQUAL access to health care is hardly a new phenomenon in the United States, but the country is moving toward rationing on a scale that is unprecedented here…The underlying problem is that doctors are reimbursed at different rates, depending on whether they see a patient with private insurance, Medicare or Medicaid. As demand increases relative to supply, many doctors are likely to turn away patients whose coverage would pay the lower rates.

It is common, the professor says, for Medicaid to reimburse at only 40 percent to 80 percent the rate of Medicare. Medicare, in its turn, may pay at only 70 percent to 80 percent of what private insurance pays.

What Professor Cowen fails to say is:

One, doctors “ration” because they have no other choice. Neither Medicare or Medicaid may pay sufficiently to cover the expenses of doing business or staying in practice.

Two, the ultimate legacy of the Accountable Care Act (ACA), with the express purpose of covering 34 million more uninsured, may be that the ACA decreases access to doctors for the rest of us. Expanding access may be meaningless without doctors.

The paradox comes down to supply and demand. The demand for medical services will go up under the Accountable Care Act, but the supply of doctors to supply those services will go down.

Doctors, says the good professor, are “highly regulated and in that manner restricted in supply. The Association of American Medical Colleges estimates that the United States could face a shortage of 150,000 doctors in the next 15 years.”

This reality does not bode well for the 78 million baby boomers who will enter the Medicare ranks over the next 16 years, at the rate of 13,356 each day. Nor does it bode well for the political establishment. Seniors are a potent voting bloc. Medicaid recipients, who tend to be Democratic, may also rebel.

The current health reform bill gives token bonuses to doctors entering primary care specialties, but that will not be enough to increase the supply by 2014, when the 34 million newly insured will expect to see doctors.

Other alternatives to ease the access crisis to doctors are to increase the supply of nurse practitioners and physician assistants, reform malpractice, promote retail clinics, import more immigrant doctors, shift more costs to Medicare and Medicaid patients to stem demand, make Medicare and Medicaid less of a blank check by issuing vouchers for a fixed amount of money for care.

Or we could pay doctors more, lessen their regulatory burdens, and institute health and flexible savings accounts with high deductibles and catastrophic ceilings, thereby encouraging patients to be more prudent while spending their own money while putting aside savings for essential care while the government takes care of catastrophic expenses.

If all else fails, we could raise taxes and let government take over. In the present political environment, given the current tax climate, that does not seem to be an option.

Sunday, December 12, 2010

2011: Health Reform-Repeal Tipping Point

When considering the outcome of upcoming debate over whether to repeal, replace or retain the Accountable Care Act, it is important to put things in historical context.

2011 will be the tipping point of a debate that has been growing in intensity since the HMO Act passed under Richard Nixon in 1973. In a book I wrote back in 1988, And Who Shall Care for the Sick? The Corporate Transformation of Medicine in Minnesota (Media Medicus), I described events leading up to this tipping point with these words,

“ I shall discuss the struggle now going on for control of health care. This struggle is mainly between the management of corporations and physicians. It is a struggle for power. To be effective in the marketplace, corporations have to harness physicians to corporate goals, thus creating internal discipline and compliance; to be independent professionals, physicians have to be free to choose what they want for patients. The government, economists, and leaders of large organizations favor the corporate strategy because it is a way of making physicians behave economically.”

My fear then, as now, was that the corporate and government strategies would alienate physicians, harm their job satisfaction, make their economic situation untenable, discourage bright young people from entering the profession, create a physician shortage, and precipitate an access crisis.

Sad to say, these events are now unfolding. Since 1970, managed care corporations and government health care forces have steadily grown in power. United Health Care, started in Minnesota, now proclaims in its ads that it employs 78,000 people caring for 78 million Americans. The federal government in 1970 provided 35% of funds for personal health expenditures in the United States; that number is now approaching 50% and promises to grow even greater under the Accountable Care Act. We have reached the tipping point.

Perhaps I should say “flash point” rather than” tipping point.”

In its lead editorial today, AOL asks,”What’s the No. 1 issue for GOP in 2011?” It answers, “Forget tax cuts, gays in the military and even immigration. The hot-button issue for newly ascendant Republicans will be the health care law.”

The outcome may hinge on how the Supreme Court rules on the constitutionality of the individual mandate. Other issues will be costs, tax reporting requirements, and health insurance exchanges.

On a deeper philosophical level, the debate will be about government unleashing and refining managed care techniques to harness and harass doctors versus the virtues and faults of free market health care. It will be a struggle for power between corporate managers, government bureaucrats, and physicians. It will also be a struggle for freedom for patients and their physicians.

Saturday, December 11, 2010

Health Reform and the Big “D”

When it comes to my health, money is no object

Milton Berle, American comedian, 1908 to 2002

Ask experts what health reform is all about, and they will say,” Cost, Access, and Quality,” generally in that order.

They seldom mention the Big “D” – Demand. It drives the other three.

I am thinking of these health reform factors because I’m in the process or organizing a book, tentatively named, The Perfect Reform Storm,” based on some of my 1586 blogs. The book will include blogs from March 2010, when the Accountable Care Act passed, to the present when talk of its repeal is in the air. A Republican-dominated House is about to assume power, and the 2012 Presidential campaign will soon be underway.

Writing on demands for care is not politically correct. To do so shifts attention and responsibility to health consumers and patients. Conventional wisdom says patients are relatively helpless when faced with doctors with superior knowledge. This is sometimes called "information asymmetry."

Doctors, in other words, control patients’ health, cost, and outcomes destinies. This may be true in certain situations, such as the use of expensive technologies to treat cancers when less expensive and equally effective treatments are available (Medinnovation Blog, December 9, 2010,“Costs Rise When Patients and Specialists Embrace a New Technology for Treating Prostate Cancer”). Patients are often equally responsible for their health, sometimes more so if they do not change behavior, follow doctors' orders, and do not become health literate.

Larger forces are at work that foster increase health care demand.

• The most inevitable and biggest of these is simply aging populations which demand more medical resources for treatment of chronic diseases.

• Second are life-saving and life-style improving technologies . Cancer drugs and treatments, cardiac stents, joint replacements , and cataract surgeries spring to mind.

• Third is media-spread and Internet-disseminated news and information of medical “breakthroughs,” be they weight loss products, botox injections, erectile dysfunction corrections.

• Fourth is our litigious society which compels doctors to practice “defensive medicine," to ward off malpractice suits or a future day in court.

• Fifth is third party coverage of health care, with no upfront costs or small co-payments, which make patients unaware or insensitive to true costs.

• Sixth is the “entitlement mentality,” which perpetrates the belief that health care is a universal “right” and that all care ought to virtually free to all individuals, no matter what their socioeconomic status.

I do not decry these fundamental realities of human nature. They are part of our society, our mental mindsets, and our belief in egalitarianism, which we preach but seldom practice. They contribute to the quantity of services delivered. They affect quality and outcomes. In general, they increase costs if providers are not allowed to compete on price or design and packaging of services.

They are impossible to regulate totally. No amount of bureaucracy or number of protocols can stem the demand tide. When the demand exceeds the supply, e.g. the number of physicians available, the government or the market will in the end do the right thing by increasing the supply, but decreasing the demand is an altogether different and more difficult thing.

Friday, December 10, 2010

Grace-Marie Turner and the Galen Institute

I would like to bring to your attention the work and words of Grace Marie Turner, president of the Galen Institute, a 15 year old non-profit, free-market oriented, public policy think-tank in Alexandria, Virginia.

Today, December 10, in her Health Policy Matters post (see, she had this to say after reading a December 9 blog of mine.”Playing the Percentages Leading up to 2012 elections.”

Doctors ready to quit: If we needed any more evidence that things are about to come tumbling down, a recent survey shows that many doctors are ready to quit medical practice altogether. “

“And it's probably just a coincidence that doctors are thinking of leaving practice in about three years, which would be 2014… “

“Most physicians who actually see patients work in small private practices of 10 or fewer doctors. If even half of those contemplating leaving practice do so, it would have a serious impact on patients' access to medical care. “

“Here are the findings by The Physicians Foundation of its survey of nearly 2,400 practicing physicians:

• 40% of doctors plan to stop providing patient care within three years. They will retire, seek a non-clinical job within health care, or leave the health care field entirely.

• 60% say reform will force them to close or restrict their practices to certain subgroups of patients. Of these, 93 percent say that decision would affect Medicaid patients, and 87 percent say they'd exclude some or all Medicare patients.

• 59% believe that reform will cause them to spend less time with patients.

• 74% will make significant changes in their practice in reaction to reform.

• 68% think reform will reduce the viability of their practices, and a whopping 80% say that it will hurt private practice specifically. “

“Specialists, in particular, expect to lose income because of the payment changes under the health overhaul law, making finding a specialist especially difficult.”

“Our friend Dr. Richard Reece blogged that this wholesale rush from private practice would be a death knell for the health overhaul law. Politicians simply cannot risk imposing changes that will threaten access to care on anything like this scale.

In closing, a few words about the Galen Institute’s mission. It is dedicated to putting individuals rather than corporate or government bureaucrats in charge of health care decisions.

Its beliefs are:

1) Consumers and their physicians should have authority and responsibility over health care decisions:

2) The vibrant free market will encourage research and innovation and provide better access to new medical technologies:

3) A market that supports innovation will lead to lower costs, expanded choice, and increased access to better medical care."

Other than Grace-Marie, its scholars and trustees include:

Joseph Antos - Wilson H. Taylor Scholar in Health Care and Retirement Policy, American Enterprise Institute; former assistant director for health policy, Congressional Budget Office

James Capretta - senior fellow, Ethics and Public Policy Center; former associate director, White House Office of Management and Budget

Brian Lee Crowley - founder and managing director, the McDonald-Laurier Institute in Ottawa, Canada; former president, the Atlantic Institute for Market Studies (AIMS)

John Hoff - former deputy assistant secretary, United States Department of Health and Human Services.

Douglas Holtz-Eakin - former fellow, Manhattan Institute; former director, Congressional Budget Office

Accountable Care Organizations (ACOs): Negative Reaction Among Physicians

Preface: In Health Reform and the Decline of Physician Private Practices, a white paper released in October, 2010, based on a study and survey sponsored by the Physicians Foundation and carried out by Merritt Hawkins, 2400 physicians were asked this question,

”Health Reform provides pilot projects to test ‘bundled payments’ for episodic care. What is your view of bundled payments with these results."

• A generally good idea 11%

• A generally bad idea 68%

• Unsure 21%

“Bundled payments” are a euphemism for "capitated payments,” fixed federal reimbursements to doctors and hospitals for providing care for defined Medicare populations. The health reform law encourages pilot projects to test the effectiveness of accountable care organizations (ACOs) in improving quality and reducing costs by aligning the financial interests of doctors and hospitals.

Doctors are skeptical about ACOs. Among the skeptics is Daniel “Stormy” Johnson, MD, former AMA president who wrote this assessment of ACOs for the Heritage Foundation, for which he is a visiting fellow.

Patient: Beware of Accountable Care Organization

Published on October 27, 2010 by Daniel Johnson, M.D.

There is much to dislike about this year's massive federal overhaul of the nation's health care system. One of Obamacare's potentially most dangerous — and least discussed — features is its call for government-sponsored accountable care organizations (ACOs).

What exactly is an ACO? What are the potential problems?

Conceptually, a typical ACO would be a health care cooperative involving a group of physicians, allied health care professionals and one or more hospitals, all working together to deliver appropriate care in the appropriate setting at the appropriate time in a person's illness or injury. Treatments would rely on evidence-based protocols and cost-effective preventive measures wherever possible. Moreover, the carefully integrated ACO would rely on a state-of-the-art electronic information and patient medical record system.

The payment method is much less clear — primarily because medical payment issues are radioactive. But "capitation" seems the most likely mechanism. Under this approach, the ACO receives, upfront, a set amount of money per beneficiary for the provision of all services. Beneficiaries would have no out-of-pocket expense, with the possible exception of a small co-payment.

It all sounds wonderful and, in fact, ACOs should be one of the options available for patients to choose in a new free market for health insurance. But ACOs may prove far more popular among certain physicians, wonks and bureaucrats than among the general population of health care consumers.

Physicians in primary care specialties such as family practice, internal medicine and pediatrics find ACOs appealing because their services have been historically underappreciated and undercompensated. They have a strong and understandable interest in pursuing a mechanism that may correct this problem.

Many health care policy analysts feel that current physician payment incentives are wrong. Physicians are paid more for doing more work. The tacit assumption: This encourages physicians to pad their wallets by doing more than necessary. These analysts want to reverse the incentives so physicians are paid more for doing less work.

If you assume all want to "game the system," it's a tricky call. Suppose you were ill. Would you rather have a doctor who'll give you the care you need, plus a little extra, or one who'd skimp a bit on the care? Both doctors would be wrong, of course; each should give the appropriate care. But to say one is ethically, morally or otherwise superior to the other is simply not correct.

Among the power elite in Washington, ACOs have great appeal as a mechanism through which they can exercise benevolent control. The unspoken premise of Obamacare is that government officials know far better than we do what is good for us. In their heart of hearts, most Obamacare proponents probably prefer a single-payer system. ACOs may be used as a cornerstone for building just such a system.

Consider how capitation, as opposed to fee-for-service, lends itself to promoting a single-payer-style treatment system. A capitated system requires both physicians and patients to be more sophisticated and knowledgeable about treatment options and the cost of each service. If a patient has back pain and the physician suggests an MRI, a patient with a health savings account (HSA) can ask, "How much does that cost?"

In a capitated system, if the system won't cover MRIs, the physician may not even suggest it; thus, the patient may not know that the option exists.

If ACOs become the only possibility for organizing, financing and delivering care, physicians and patients alike will find themselves in a treatment straightjacket. Thus, government should not give ACOs a competitive edge. If the ACO is such a good idea, let it develop in an open pluralistic market with no subsidy or other government advantage.

Recall that under President Nixon, the HMO concept was introduced with a significant financial advantage provided by Congress. As the government-assisted mechanism moved along, it ultimately became necessary for state legislatures across the country to enact laws protecting patients from this good idea.

Certainly our system needs major improvement. But Obamacare is not the answer. The three main issues in health care reform are cost, access and quality — and cost trumps the other two.

The heart of the cost problem is a simple dilemma: The person consuming the services (the patient) is insulated from the cost of those services because someone else is paying for them. Neither Obamacare in general nor ACOs in particular address that very important point.

Instead of limiting beneficiaries' choice to a mechanism that will insulate them from actual costs and permit paternalistic central control over every decision made by physicians in the care of their patients, we should be advocating expanding choice. Instead of assuming that patients are too stupid to choose how they receive treatment, we should put them in the driver's seat. With their doctor riding shotgun.

Dr. Daniel H. Johnson Jr. is a visiting fellow at the Heritage Foundation

Tweet: 68% of doctors dislike the idea of physicians sharing revenues with hospitals for treating Medicare patients @rreecemd

Health Reform Law Tells No Story

Why is the Affordable Care Act (ACA) so unpopular with such an uncertain future?

• It is misnamed. It is not “affordable.” It contains few cost controls.

• It is misunderstood.
Critics have successfully mislabeled it as a “government takeover of health care” and as containing “death panels.”

It has grave consequences. Sixty percent of doctors say reform will force them to close or restrict their practices - 93 percent say that decision would affect Medicaid patients, and 87 percent say they'd exclude some or all Medicare patients

• It tells no story.
The public does not understand it.

On the last bullet point, Jonathan Oberlander, PhD health analyst at the University of North Carolina has this to say(“Beyond Repeal – The Future of Health Reform," New England Journal of Medicine, December 9, 2010).

"The law suffers from something of an identity crisis. After all, unlike Medicare or Social Security, the ACA is not a single program. Rather, it is a collection of mandates, public insurance expansions, subsidies, and regulations that affect different groups of Americans in different ways and at different times. During the reform debate, Democrats were never able to stitch those disparate elements together and give insured Americans — including Medicare beneficiaries, a politically crucial constituency — a simple, coherent story about how the ACA would benefit them."

Given the lack of a story line, what is future of health reform?

Its future hinges on politics- the politics of the Obama Administration versus the Supreme Court, the politics of the federal government versus state governments, and the politics leading up the 2012 presidential election and thereafter.

How the then president interacts with both houses of Congress, both likely to have Republican majorities, will determine the future of health reform.

Tweet. The health reform law’s future is cloudy. Republicans will try to repeal or slow it, and after 2012, they may be able to. @rreecemd.

Thursday, December 9, 2010

Costs Rise When Patients and Specialists Embrace a New Technology for Treating Prostate Cancer

Roughly one in three Medicare beneficiaries diagnosed with prostate cancer today gets a sophisticated form of radiation therapy called IMRT. Eight years ago, virtually no patients received the treatment.

The story behind the sharp rise in the use of IMRT—which stands for intensity-modulated radiation therapy—is about more than just the rapid adoption of a new medical technology. It's also about financial incentives.

Expensive new procedures like IMRT play no small role in the relentless rise of Medicare expenditures. This year, the federal health-insurance program for the elderly and disabled is expected to spend $524 billion on the care of its 47 million beneficiaries—a 40% increase from 2006. The Congressional Budget Office recently projected that federal spending on Medicare could double as a share of gross domestic product to as much as 7% by 2035.

“A Device to Kill Cancer, Lift Revenue, “ Wall Street Journal, December 8, 2010

The main problem with the health reform law is that it does not contain costs.
One reason may be that when a non-invasive, painless , effective technology for treating cancer comes down the health care pike, word quickly gets around among specialists and patients.

When patients are on Medicare and are unaware of costs, and specialists deploying the device profit from using it, cost is no object and no impediment.

Such is the case with IMRT (Intensive-Modulated Radiation Therapy) machine. The Wall Street Journal ran a 3100 word front page piece yesterday on IMRT, pointing out that that its treatment costs run up to $40,000 for a full course of treatment and questioning whether deploying it is necessary for treating many patients with slow growing tumors.

Four options exist for elderly patients with prostate cancer.

1. Watchful Waiting – Regular visits with monitoring but no treatment. Cost: Minimal

2. Surgery – Prostatectomy. Has risks of erectile dysfunction. Cost: Up to $16,000

3. Seeds – Seeds implanted in prostate to irradiate tumor. Costs: Up to $19,000

4. IMRT - Use of X-ray machine with attachment to direct radiation beam to specific area of tumor. 45 daily treatments over 9 weeks with treatments lasting 10-20 minut

Critics question whether the increase in IMRT increases cure rate, and what role financial incentives play in its popularity. Urologist groups purchase equipment used in the therapy, hire radiation oncologists to operate it, and refer patients for in-house treatment.

Are these groups doing so to capture the procedure’s big Medicare reimbursements. The urologist groups say they are just responding to patient demand, that the arrangement improves the coordination of care and that they also offer other treatment options.

Tweet: Urologists use IMRT (Intensive Modulated Radiation Therapy) to treat prostate ca at costs of up to $40,000. Is this necessary when other Rx may work as well @rreecemd

Playing the Percentages Leading Up to 2012 Elections

If you were a politician looking at the following percentages as revealed by a survey of 2400 physicians in a Physicians Foundation Survey (Health Reform and the Decline of Physician Private Practice, October 2010), what would you do in preparing for the 2012 elections?

• 60% said health reform will compel them to close or significantly restrict their practices to certain categories of patients.

• Of the above, 93% said they will be forced to close or significantly restrict their practices to Medicaid patients, while 87% said they would be forced to close or significantly restrict their practices to Medicare patients.

• 40% of physicians said they would drop out of patient care in the next one to three years, either by retiring, seeking a non-clinical job within health care, or by seeking a non-health care related job.

• 59% said health reform will cause them to spend less time with patients.

• While over half of physicians said health reform will cause patient volumes in their practices to increase, 69% said they no longer have the time or resources to see additional patients in their practices while still maintaining quality of care.

One, risk alienating over 500,000 physicians by not arranging for a permanent fix of the Medicare formula for paying physicians.

Two, risk alienating 47 million seniors by depriving them of access to doctors.

You decide. All of you in the House, and 33 of you in the Senate will be up for re-election in 2012. Meanwhile in the next two years, 10 million more baby boomers will become Medicare eligible.

Two Quotes and Two Tweets on Health Reform

Quote One

“Healing relationships can be handled in many new and wonderful ways. If we suspend the old ways of making sense of care...The health care encounter as a face-to-face visit is a dinosaur.. I think it rarely means reliance on face-to-face meeting between patients, doctors, and nurses...Tackled well, this new framework will gradually reveal that more than half of such encounters – maybe as many as 80 percent of them – are neither wanted by patients or deeply believed in by professionals.”

Donald Berwick, MD, CMS Administrator, from his book, Escape Fire: Five Lessons for The Future of Health Care, written while CEO of Institute of Health Care Improvement

Tweet One

Donald Berwick, MD, CMS Administrator, believes doing away with up to 80% of doctor patient visits will save Medicare a lot of money @rrecemd

Quote Two

“Physicians provide a lot of care for which they are not paid. Phone calls, e-mails and discussions with other doctors take time but are not reimbursed by Medicare or other insurance companies. As a result, many doctors feel as if they are at their limit — working hard but making less. Overhead costs of practicing medicine are so high that even a small tip of the scale can make a doctor's office unprofitable, particularly the small private practices that make up the fabric of medical care in this country."

"It's no surprise then that doctors are up in arms about the latest "doc fix" — the fourth temporary postponement of a 23% cut in their Medicare reimbursement. But patients and taxpayers should also be worried because if a permanent fix doesn't happen in a month, access to health care will be threatened while Medicare's money problems won't be solved."

"Doctors argue that the planned 23% cut would force them to stop seeing Medicare patients. There is certainly truth to this claim. According to a recent survey by the American Medical Association, 60% of physicians are looking at ways to opt out of Medicare because of the potential cuts. “

Tara Bishop, MD, “Medicare Needs Sustainable “Doc Fix.” USA Today, December 8, 2010

Tweet Two

If Medicare doesn’t fix its formula calling for a 23% cut in MD pay in January, access to care will be a crisis in the U.S. @rreecemd

Tuesday, December 7, 2010

Heart Disease and Health Reform

The test of a first-rate intelligence is the ability to hold two opposed ideas in the mind at the same time, and still retain the ability to function.

Francis Scott Fitzgerald, 1896-1940, The Crack-up (1936)

Two themes run through the health reform bill as a means to improve care while cutting costs.

One, consolidation of care into large centralized entities managed and monitored through interoperable electronic systems.

Two, entrepreneurial innovations that render care cheaper, more convenient, and more effective.

In the words of David Kibbe, MD, and Brian Klepper, PhD, who launched a new online health forum, Cost &, on December 1, .."two overarching themes" are emerging . One is the health care cost crisis, which remains very much with us and threatens the stability of both the industry and the US economy. The other is the countervailing trend, the explosion in innovative solutions - tools, programs and designs - aimed at making health care better, cheaper and more available.”

Here I will focus on health reform and hearth disease – easily the number killer of Americans and arguably the most preventable.

The latest mortality figures for the U.S. are:

• Number of deaths: 2,423,712
• Death rate: 803.6 deaths per 100,000 population
• Life expectancy: 77.9 years
• Infant Mortality rate: 6.75 deaths per 1,000 live births

Number of deaths for leading causes of death:

• Heart disease: 616,067
• Cancer: 562,875
• Stroke (cerebrovascular diseases): 135,952
• Chronic lower respiratory diseases: 127,924
• Accidents (unintentional injuries): 123,706
• Alzheimer's disease: 74,632
• Diabetes: 71,382
• Influenza and Pneumonia: 52,717
• Nephritis, nephrotic syndrome, and nephrosis: 46,448
• Septicemia: 34,828

The Comprehensive Organizational Approach - Kaiser Permanente Heart Disease Prevention and Management

Kaiser Permanente, the prototype of the large integrated health organization with 8.6 million health plan members,167,300 employees,14,600 physicians 35 medical centers,and 431 medical offices. Kaiser has reduced death rates from heart disease to 30% below the non-Kaiser population in California. Kaiser has done this through a broad-based educational program of its members based on understanding about living the healthy life – plenty of exercise, eating right, not smoking, managing stress – and understanding treatment options based on evidence of personal health risks.

In a study of 628 heart patients at Kaiser Permanente Colorado, Kaiser achieved a 88% reduction in cardiac mortality compared to a control group. Cost reductions were $60 less per day compared to contro0ls, or $21,900 per year.

The Individual Private Physician Approach - Shape Medical Systems, Inc, St. Paul Minnesota

It is one thing to be a huge, sophisticated integrated health organization like Kaiser with a $3 billion electronic medical record system It is quite another to be an independent physician in private practice, the dominant mode of practice in the United States. These physicians must evaluate all incoming patients, some with puzzling symptoms. One of these symptoms is shortness of breath. Is this dyspnea due to coronary disease, heart failure, or chronic obstructive lung disease? Shape Medical Systems, Inc., founded by a couple of exercise physiologists, has developed a small, compact, portable, risk-free device, the Shape-HF Cardiopulmonary Testing System, that can be used in private offices, in place of traditional heart stress treadmill machines, to test for coronary disease, heart failure, and COPD. It offers accurate diagnostic, prognostic, and drug-response information. It gives physicians options for early stage therapeutic intervention to control disease progression and to monitor patients suffering from chronic conditions over the long term.

Monday, December 6, 2010

Private Practice Doctors Health Reform Dilemmas

Doctors face two major dilemmas in dealing with the crush of health reform: One, what to do about it in the present? Two, what new practice models will they enter to replace their current modes of practice?

With regard to the first question, doctors over the next one to three years say, in a survey of 2600 physicians sponsored by the Physicians Foundation and carried out by Merritt Hawkins (Health Reform and the Decline of Private Practice), they will exercise the following options - 26% of physicians will become employees, part-time workers, and administrators, operate cash-only. The remaining 74% say they will retire, work part-time, close their practices to new patients, become employed and/or seek non-clinical jobs. For now, the safest and most popular havens are becoming employed by hospitals or becoming part of larger groups or integrated health organization.

The answer to the second question is more elusive. Most of the new models - medical homes, accountable care organizations, new alignments with hospitals , community health centers, worksite clinics, and concierge and cash only practices are untested on a broad scale and entail major financial risks , loss of autonomy, practice style changes, and an unprecedented level of trust in corporate leaders in hospitals or other large corporate organizations.

Another Strategy

Another strategy, seldom mentioned, is for physicians to appeal for understanding among policymakers, politicians, and the public at large for consideration of the profound consequences of reform.

Present Trends

If present trends continue - abandonment of private practice by those currently delivering care, inabilities of private practice physicians to economically sustain their practices, physicians dropping out of caring for Medicare and Medicaid patients, medical students seeking employment with 40 hour work weeks, growing shortages of primary care physicians and certain broad based specialties - the nation will face an unprecedented access crisis to physicians.

One Question followed by Others

These trends raise a fundamental question; what good is expanded access without physicians? And that question leads to other questions: What incentives can we offer to encourage medical students to enter primary care? How do we stem the exodus from private practice? What are effective market-based alternatives to onerous government regulations? How do we make patients and health consumers more sensitive to the true costs of care? What steps can we take to make medicine a more attractive profession to bright young people? What draws people into medicine? How can we change the system so doctors can spend more time with patients and less time with paperwork and requesting, or even begging for permission to perform diagnostic and therapeutic procedures? How do we encourage disruptive innovations to make health care cheaper, more convenient, in decentralized settings?

For Answers

To answer these questions and to inform the American public what is at stake at ground zero when they seek medical care, we need more objective studies and surveys like those conducted by the Physicians Foundation. And we need the cooperation of the media to inform policymakers, politicians, and the public.

Sunday, December 5, 2010

A Premature Autopsy on Obamacare

In the tumultuous history of postwar American liberalism, there has been a slow but steady decline of which liberals have been steadfastly oblivious. The heirs of the New Deal are down to around 20% of the electorate, according to recent Gallup polls. Conservatives account for 42% of the vote, and in the recent election the independents, the second most numerous group at 29% of the electorate, broke the conservatives' way. They were alarmed by the deficit. They will be alarmed for a long time.

Liberalism: An Autopsy, Wall Street Journal, December 4, 2010

Liberalism may be a candidate for autopsy, but Obamacare is not.

For the next two years at least, the new health reform law will be alive and kicking. If it is not repealed, which is unlikely, its major provisions will begin in earnest in 2014.

As a pathologist, I know there is no such thing as a premature autopsy. Either you are dead, or you are not. Yes, the midterm election results deeply wounded the health care law. And yes, Republicans have vowed to repeal it, or pieces of it. But there is no such thing as a partial autopsy either.

We await the process and outcome of the next legislation session, 2010 to 2012, the run-up to the Presidential election. to see if Accountable Care Act will be repealed and if President Obama will be re-elected. Until then, the President can wield the veto pen over any repeal of his most cherished signature domestic program. If it goes down, so does he.

As the debate proceeds, keep in mind the liberal dream – universal coverage given credit to, paid for, and controlled by the federal government. This, progressives say, is the morally imperative hope for America, a change that would make us morally equivalent to other progressive nations. That's what "hope" and "change" in health reform is all about, as viewed from the left.

In this week’s New England Journal of Medicine is a piece entitled “Government Payment for Health Care – Causes and Effects,” Victor R. Fuchs, PhD, professor emeritus of health economics at Stanford, articulates and justifies the dream.

Fuchs argues:

• Eight European nations provide wider access to health care at lower costs with better outcomes than the U.S. These nations pay for 70% to 90% of health costs, We spend 50% and more per capita yet have lower average life expectancies.

• This increased government financial clout allows these nations to constrain costs through controlling the number and specialty mix of physicians, limits on facilities and acquisition of expensive technologies, hard bargaining over prices charged to medical suppliers, and restraints over physician fees and incomes. The Fuchs agenda does not engender enthusiasm among physicians. They do not like being tools for government policies.

But certain quirks of U.S. culture, Fuchs maintains, stand in the way: our cumbersome political system, the influence of “special interests,” our insistence on quick access to diagnostic and therapeutic procedures, our desire to have these procedures close to home, our superior health care amenities, the heterogeneity and diversity of our population, our individualism, our dedication to “life, liberty, and pursuit of happiness,” and our lack of sacrifice for the common good .

Wouldn’t it be better, Fuchs asks, to redistribute a “greater equality of access and sharing of costs through taxes on income or payroll, value-added tax or sales tax?”

Fuchs is worth listening to. Since his seminal 1974 book Who Shall Live? Health, Economics, and Social Choice (Basic Books), he has emerged at the dean of academic, bicoastal elites on health care issues.

What he and his followers seem to forget is that this is America, not Europe.

To judge from the midterm election, most Americans, rightly or wrongly, think of the U.S. as an exceptional nation, as a haven from an intrusive, centralized, debt-producing, arrogant government.

It is too early for an autopsy on Obamacare, but it is not too late to evaluate and debate its impact on the American dream versus the liberal dream.

Saturday, December 4, 2010

A Private Physician's Viewpoint on Health Reform

Preface: Private physicians deliver most health care in the United States. They will be responsible for carrying out the health reform law's mandates. Yet, according to a Physicians Foundation survey of 2400 private physicians, 86% felt politicians ignored them during the process leading up to passage of the Accountable Care Act in March 2010. Here ,in a article, Walker Ray, MD, head of the research committee for the Physicians Foundation, gives a private physician's view of the merits and demerits of health reform.

Physicians Harbor Outrage, Survey Shows

Joe Cantlupe, for , December 2, 2010

The nonprofit Physician Foundation bills itself as a "grassroots" organization that examines doctors' attitudes and takes their pulse. "We know pretty much what's going on," says Walker Ray, MD, head of the organization's research committee.

The foundation, a nonprofit grant making organization committed to improving the "medical practice environment" for physicians and patients, released a survey last month that took a look at physicians' opinions about the state of health care. Short version: not good.

The physicians' frustrations with health care reform, and a host of other issues, as Ray puts it, "tort reform not being addressed, the viability of medical practices jeopardized, the time spent with patients jeopardized, the SGR formula issue" are among the concerns addressed in the survey.

There's a "tsunami out there," Ray says. While many physicians want to leave practices, there is a pressing need for primary care, while younger physicians are "wanting a life" and not long hours and seeking to join hospitals. And in the years ahead, there is the looming reality of millions more now uninsured into the system, never mind the crunch of aging baby boomers eventually needing not only medical help but also government assistance.

The Physician Foundation's latest report, Health Reform and the Decline of Physician Private Practice, conducted and compiled by physician recruiters Merritt Hawkins, includes results from a national survey of 2,400 physicians, only 26% of whom said they would continue practicing the way they are in the next one to three years.

Instead, the survey and report predicts that physicians will become employees, part-time workers, and administrators, operate cash-only. The remaining 74% said they would retire, work part-time, close their practices to new patients, become employed and/or seek non-clinical jobs as John Commins reported Nov. 22 in HealthLeaders Media.

The importance of the survey /report was reflected in a simple fact: "We just want to get our viewpoint acrosss," Ray says of physicians.

It hasn't been?

Physicians don't think so, not before and during health care reform debate, at least, Ray says. The Physicians Foundation report noted that in its survey "physicians approached unanimity in believing their viewpoint was not conveyed to policymakers during the preamble to the health reform debate.

Years before Congress was considering health care reform, and he was helping with the report for the Physician Foundation, Ray was seeing the proverbial handwriting on the wall for his own medical career. It gives him a broader understanding of the responses to the Physician Foundation report.

Ray, who is based outside of Atlanta, GA had been in solo pediatric practice for 25 years and 13 years in a group practice prior to that. Three years ago, at age 67, still in good shape, playing tennis several times a week, he maintained that he loved working with patients.

But that year, he decided to retire, walk away what he had been doing for 38 years. "I could have gone on, but it wasn't possible," he says. He was still in good shape, playing tennis, and most importantly loved working with patients.

"The reimbursements were getting to the point that it was untenable" to continue working, Ray says. As he was dealing with personnel issues at the office a top assistant told him, "you are going to be broke in two years."

That didn't happen, but the fiscal climate prompted his retirement, or he might have considered concierge medicine. "I'm angry that I was forced to stop working," he says. "So many physicians don't want to work, and I was going 'til I almost fell over. I would have gone on several more years. Now I don't miss the hassle, but I miss the patient care."

But Ray keeps working for the Physician Foundation to keep getting the issues out front, that "viewpoint across," he says.

Of the many issues upsetting physicians, one of the most nagging is the SGR formula debacle in Congress. Congress has repeatedly put off proposed cuts, the latest reprieve for a scheduled 23% Medicare cut is now slated to begin January 1.

"It's been a broken promise from the government difficult feelings and mistrust, both parties have never stepped to the plate. Physicians cannot absorb the Medicare cuts. There needs to be a political will."

The largest group in organized medicine, the American Medical Association, has routinely criticized the SGR formula. Recently, the AMA asked Congress to stop the cut for a year. The AMA favors a repeal of the SGR to be replaced by a system that more closely tracks the Medicare economic index.

But the Physician Foundation's report notes that the AMA endorsed healthcare reform "though many physicians at the grassroots level were not in favor of the law." As a result, the report stated, there has been a "disconnect" between those physicians and the AMA, which has been essentially a disappointment in engaging physicians in the wake of healthcare reform, in Ray's view.

"It's so sad the AMA sold us out and how this legislation was rammed down our throats against the will of the majority," says one of the 1,200 physician comments submitted to the Physician Foundation for its report.

Others also criticized the AMA, but the organization was not the only target. "The state of medicine is in need of significant improvements but a rushed, sloppy policy that does not include the input of physicians is akin to malpractice," says another.

"No one," says yet another, "in the policy making world understands the problems physicians face. I wish they could follow me through my practice for one full week."

Physicians need to be heard, Ray says, not only to discuss the issues but also to influence others to be doctors, and physicians to stay on in their profession.

"By golly, I want people to be motivated to go into the medical profession," Ray says. "I'm 70 years old and I'll be needing a doctor myself."
Joe Cantlupe is a senior editor with HealthLeaders Media Online. He can be reached at

Friday, December 3, 2010

On Heath Reform Costs and Human Nature

I am on a train from New York City headed to points north. I have just finished reading John Adams, David McCullough’s epic biography of our second president. Adams was an astute observer of human nature.

To Adams nothing had changed about human nature since the time of the ancients. Inequities within society were inevitable, no matter what the political order. Human beings were capable of great good, but also of great evil. Thus it had always been, thus it would always be…Such were the weaknesses and folly of mankind.

Which brings me health reform and its costs.

There are three great “weaknesses” or “inequities” besetting mankind.

One, the first “weakness,” perhaps “inevitability” is a better word, is “aging.” All of us will age, all of us will die, and most of us will develop chronic diseases towards the end of life. Such is the human condition.

Two, a second “weakness,” perhaps “inequities” is the better word, is “poverty.” In health reform, these weaknesses and inequities, translated, are Medicare, Medicaid, and the costs they incur. This weakness accounts for most regional variation in Medicare cost.

Three, a third weakness, perhaps “susceptibility” is the more appropriate word, is our tendency to engage in fraud, abuse, and overuse when federal entitlement programs beckon. If man perceives something to be “free,” with other people paying for it, he will take advantage of it. It should surprise no one that fraud and abuse eat up 15% of the expenditures of CMS (Centers for Medicare and Medicaid.

The older we get and the poorer we become, the more health care we require, and the higher the costs. The more compassionate we become, the more we spend, especially if a third party is paying. We will continue to do so until we run out of other people’s money. This may simply be the cost of running a civilized society. It is not because we are a venal people; it may be because spending other people’s money is the politically correct and humane thing to do, or because ripping off the government is easy. It may be because we do not do anything until we perceive the expenditure directly affects us. It is human nature at work.

One remedy for managing high costs is to have people spend more of their own money and thus to know the true cost of things. This is the principle of health savings accounts with high deductibles and money set aside for retirement. Unfortunately, the high reform bill curtails and complicates health savings accounts. This may be because of another law of human nature. Politicians and others in power feel they have superior knowledge to the people and to the average health consumer. That is also human nature at work.

A Physician's Message to the Media

In the next two years leading up to the presidential election, you will be writing, interviewing, blogging , televising, podcasting, and webinaring about the health reform.

It will be hand-to-hand combat between the political parties and between health care participants, which includes all of us. There will be plenty of slings, arrows, and clubs unfurled, thrown, and abused. Confusion will reign because of the complexities, controversies, and sheer magnitude of the issues.

Perhaps we doctors can help guide you through some of the issues by telling you what we see from the ground and how reform affects us and our patients.

For you, times are a’changing. The Internet, cable news clashes, and the insatiable appetite for continuous news may have turned your world upside down, or downside up, whichever you prefer.

The demand for instant news may have robbed you of time to do your job. Newspapers can’t keep up. Ad revenues are plunging. Readers are getting their information “free”. The social media is rampaging. Kindle, Nook, and other e-readers are replacing print newspapers and magazines. You may have lost your job, or you fear you will.

The practice of journalism is not what it used to be. Neither is the practice of medicine. Because of plethora of factors - lower reimbursements , rising practice costs, demands for documentation, and insurance hassles - physicians no longer have time to spend with patients. Doctors want more time with patients, and less time with paperwork and phone calls to insurers.

Time is a perishable asset. They are not making any more of it. Once gone, it will never come again.

As an educated professional on deadline, faced with meeting the accelerating pace of change, you know the importance of time. Perhaps we can help you conserve your time while helping you get your job done quickly, efficiently, and effectively.

When you call or email us for an interview, please leave us your name, state briefly the purpose of the interview, and tell what you want us to comment on. We will return the call and tell you what we know as seen from the clinical trenches.

Tuesday, November 30, 2010

The Media and the Physician Reform Message

In 1967 Marshall McLuhan and Quentin Fiore wrote The Media and The Massage (Bantam Books). McLuhan, the principal author, said it is often the media itself, not content, that transmits the meaning of most messages.

McLuhan frequently punned on the word “message,” by changing “message,” to “massage age, “ “mess age, “ and “massage.” In other words, depending on the media used, you can “massage” the “message” to mean what you want it to mean for a mass audience.

Think about this for a moment. The media is not impartial. The New York Times routinely “massages” its “message.” So does CNN, the Wall Street Journal, The New York Post, Fox News, MSNBC. ABC, and all those bloggers, left and right out there, including me.

My bias is to defend private practice and patients they serve.

No matter what your political leanings, the media has been reluctant to highlight the plight of private doctors, caught in the squeeze between declining revenues, rising expenses, high educational debts, the physician shortage, overwork, government penalties for noncompliance, malpractice threats, and reform uncertainties. Yet, amongst the media, little sympathy exists for reform’s impact on physicians.

Few media outlets recognize the stark reality that without private physicians to provide care, without adequate compensation to cover practice expenses to care for Medicare and Medicaid patients, health reform may be a sham – a delusion that federal entitlements to cover 34 million more citizens, and probably 50 million more through health exchanges, while cutting costs and redesigning the entire system, at one fell swoop, defies the laws of economic reality. Universal coverage without universal access to physicians is meaningless.

But that reality may be dawning. The vehicle for change is a thoughtful 110 page white paper, Health Reform and the Decline of Physician Private Practice, a collaboration between the Physicians Foundation, a 501C3 corporation representing physicians in state medical societies, and Merritt Hawkins, the nation’s largest physician recruiting firm. These physician advocacy organizations know their facts on the ground, and through careful studies and surveys, they have been monitoring and documenting how physicians are reacting and will react to the health reform law. The reality is that anywhere from 10% to 50% of private physicians may opt out of Medicaid and Medicare if Congress doesn't modify, "fix," or scrap scheduled Medicare SGR (Sustainable Growth Rate) cuts, which would lead to a massive physician access crisis.

National Public Radio (NPR), government subsidized outlet generally considered to be “liberal” by conservatives, broadcast this message on November 29. Message is in italics.

Doctors Blame New Health Law For Death Of Private Practice

Of all the scary scenarios predicted for the new health law this is among the scariest: A new survey of doctors predicts the rapid extinction of the private-practice physician.

A survey of some 2,400 MDs from around the country found nearly three quarters said they plan to retire, work part-time, stop taking new patients, become an employee, or seek a non-clinical position in the next one to three years.

But are these changes really the result of the new law?

Doctors responding to the survey seemed to think so. “Doctors strongly believe the law is not working like it needs to – for them, or for their patients,” said Lou Goodman, president of the Physicians’ Foundation, who conducted the survey.

But most of the provisions of the new law affecting doctors and patients haven’t taken effect yet.

And slightly more doctors said that the lack of a fix to the Medicare physician pay issue is a bigger issue for them than the actual overhaul; by 36 to 34 percent.
The paper that accompanied the survey says all those docs leaving their practices will be replaced by a managed care employee or “concierge” doctor who will require an upfront annual payment.

The bottom line, however, is buried at the bottom of the news release about the study. It comes from the advisory panel commissioned to write the paper on the effect of the new law on doctors:

Despite its many problems, healthcare reform was necessary and inevitable and many of the changes mandated by the ‘formal’ reforms likely would have occurred on their own within the ‘informal’ delivery of care, owing to economic and demographic forces.

In other words, things were changing anyway, with or without the passage of the Patient Protection and Affordable Care Act. Blaming the new law just gives doctors a convenient scapegoat.


Note the “massage” of the “message, ” particularly the use of the words “blame” and “scapegoat.” NPR implies that doctors are unfairly attacking government health reform for physician failures. In this era of “mess age,” I suppose everybody needs a “scapegoat.” With NPR, private physicians are the “scapegoat” and are to “blame.”