Sunday, January 31, 2010

Medical Trends - News Doctors Can Use

Why do I write? Why have I written ten books? Why have I produced 1185 blogs over the last three years at a one/day clip?

Fundamentally, as warty bliggens, a toad in the Archy and Mehitabel stories said, it is because “expression is the need of my soul.” Secondly, I want to put material out there my fellow physicians can use, Thirdly, I want others to understand what makes doctors tick.

Producing material doctors can use isn’t as easy as you might think. I try to be specific . Doctors don’t like generalizing, editorializing, or pontificating. “Just the facts, Mame! “ as Sergeant Joe Friday used to say in the TV series.

Specificity works best when telling stories about successful innovations doctors have brought into the world. These innovations must save time, solve problems, please patients, increase efficiencies, improve care, or generate more revenue, or doctors aren’t really interested. I give a number of specific examples in my book Innovation-Driven Health Care (Jones and Bartlett, 2007), and in my blog series, which is called medinnovationblog for a reason.

But specificity has its limits unless put into a larger context. A physician’s mindset is terribly important too, e.g. whether one wants to be an independent soloist or part of a group effort, whether one wants to put one’s eggs in the office practice basket or hospital-physician joint efforts, or whether one wants to become engaged in practical, philosophical, political issues of health reform.

Drucker Priorities

When it comes to priorities , I invariably fall back on Peter Drucker’s advice on what makes one effective in this crazy-quilt world.

• Pick the future against the past;

• Focus on opportunity rather than problem;

• Choose your own direction.

• Aim high, aim for something that will make a difference, rather than for something that is safe and easy to do;

This is easy to say, hard to do. You have to know your time limits, ask yourself what you can contribute, make your strengths productive, take first things first, and check your biases at the door.

Writing in Context of Trends

Writing In terms of trends adds context. It allows you to present news physicians can use – or at least think about. In this sense, I still find John’s Naisbitt’s ten megatrends useful.

The ten megatrends are,

1. Industrial society to information society - Get used to the computer as your right arm. Here I am not thinking about EHRs, which are overrated, but of broad band access, googling, and search engine use.

2. Forced Technologies to High Tech/High Touch
– Forced EHRs and medical technologies are not your sole salvation. Use the human touch lavishingly. Maximizing those moments of truth in doctor-physician encounters count for more new and loyal customers than technologies.

3. National Economy to World Economy - Some of your patients may go abroad for lower costs, and you may need to compete.

4. Short Term to Long Term
- Consider joining with other doctors in virtual groups, and using telemedicine and monitoring devices. This will be long term trend.

5. Centralization to Decentralization - Mini-practices, concierge practices, and cash-only practices are coming. People will seek more personal and private care.

6. Institutional Help to Self-Help - Don’t fight it. As costs rise, patients will treat themselves with OTC medicine, use home remedies, believe in herbs, antioxididants, and nutritional supplements, and frequent offices of alternative practitioners. Help them choose the right things, even consider offering alternatives yourself.

7. Representative Democracies to Participatory Democracies – This is what the Town Hall and Tea Parties are all about.

8. Heirarchies to Networking - Twittering, Facebooking, social networking, retail and worksite clinics, and office websites are all forms of networking and communicating with patients.

9. North to South - As the recession eases, people and physicians will begin anew to flock to the South, Florida, and Southwest. Since Texas passed tort reform, doctors are flocking to the Lone Star State in record numbers.

10. Either/Or to Multiple Options
- This is why comprehensive national health reform is tanking. People fear losing their plans, having limited options, or having plans forced upon them.

Sources of Information

For credible, timely, topical material, I find it helps to have good, continuing and continuous sources of information. I use health care business sources - WSJ health blog,, ,,, American Medical News, Modern Medicine, – to name a few.

I use medical networking sites -,, ,, The Physiciansfoundation. org – and a few others too.

I also read The New England Journal of Medicine and JAMA.

For general information on the flow of health reform, I use The New York Times, The Wall Street Journal, and to a lesser extent, USA Today.

Lastly, and frankly, I turn to a website called is an American non-partisan political news and polling data aggregator, and conservative-leaning blog based in Chicago, Illinois. The site aggregates columns and news stories as well as election related transcripts and videos. The site also carries the most recent poll data, and compiles averages of major political polls on various elections throughout the United States to give a national view of what's going on.

The site was founded in 2000 by former options trader John McIntyre and former advertising agency account executive Tom Bevan. Forbes Media LLC bought a 51% equity interest in the site in 2007.

I like because it is commonsensical, posts a variety of articles and editorials , 25 or more a day, with a variety of opinions, both left and right, from leading thinkers and columnists, and contains tracking polls, based on averages of national polls. It gives you a sense of where the country is headed.

Here, for example, are its aggregate poll results for today.

RCP Poll Averages

President Obama Job Approval

Spread +2.3

Congressional Job Approval

Spread -40.0

Generic Congressional Vote

Republicans +3.2

Direction of Country

Right Direction
Wrong Track
Spread -20

Because I track this information daily, these poll averages tell me a lot.

• That President Obama still has positive job approval, but that it has dropped rapidly over the last year.

• That the public massively disapproves of Congress’s performance, which may lead to loss of Democrat majorities in November 2010.

• That more people now identify with Republicans than Democrats, a dramatic switch over the last year.

• That there is genuine and deep concern over the direction the country is headed because of such issues as unemployment, a faltering economy, the national debt, and health reform.

These are not trivial matters. This is news I can use. This is news physicians can use as we try to adapt to the new realities that face us and make a positive contributions that make a difference.

Saturday, January 30, 2010

Satire - The State of the Union and the Arrival of the Lilliputians - A Fable

As President Obama was lecturing the Republican summit meeting about the merits of his health care program and the deficits of theirs, I thought of the story of the Lilliputians, who now loom large after the Scott Brown victory in Massachusetts. If you will recall, the Lilliputians, the small people of the nation of Lilliput, in Jonathon Swift’s Gulliver’s Travels, brought down the giant Gulliver by tying him down in countless places while he slept.

The Fable

Imagine an entity exists called the Government –Reactionary Union (GRU). The GRU president is an intellectual called Obama. He has an amiable vice-president named Biden. His intimate inner circle consists of Rahm Emanuel, a former Chicago Congressman , a human hammer who runs the show; Dr. Ezekiel Emanuel, an NIH- based earnest ethicist who consults on medical affairs; David Axelrod, a soulful and skillful Chicago policy guru; Robert Gibbs, a smiling unflappable native of Alabama who briefs the media; and Peter Orszag, an accountant dandy and a dandy accountant from Texas decked out in cowboy boots who explains and justifies the budget.

GRU, The Biggest and Fastest Growing Game in Town

GRU, pronounced “Grew,” is the biggest and fastest-growing game in town. GRU has grown the federal budget from $2.9 trillion in 2008 to $3.8 trillion in 2010, a 30 percent increase and the highest percent of GDP since 1945. When President Obama took office on January 20, 2009, the National Debt stood at just under $10.627 trillion. On his one-year anniversary of January 20, 2010, the National Debt totaled just over $12.327 trillion. That means the National Debt has increased by a whopping $1.7 trillion during his first year in office. That is the largest single year increase of any President in the history of the United States. Based on the 2010 U.S. budget, total national debt will nearly double in dollar terms between 2008 and 2015 and will grow to nearly 100% of GDP, versus a level of 80% in early 2009 and less than 25 percent over the last two decades. By statute, GRU is obligated to care for anybody 24 hours a day entering hospital doors. GRU cares for all of the elderly, and many of the poor. GRU is the caretaker of last resort. The disenfranchised represent a heavy and growing financial burden for GRU.

GRU, A Misnomer

The word “Union” is a misnomer. GRU is in a clash all by itself. GRU is American partisan politics at work. The G part consists of the CEO’s fellow followers. They are loyal to the President. The R portion is made up of reactionary renegades. The renegades resent and resist Obama. They seek to pin down the President. Obama’s job, as he sees it, is to grow GRU in perpetuity and care for all of the people all of the time. Some critics, tongue-in-cheek, call GRU gruesome and far too growsome.

Major Medical Programs

President Obama inherited two major medical programs , Govcare for 45 millon elderly, and Govcaid for 60 million more. Obama has yet to name a head of Govcare, a job originally intended for a powerful lobbyist and former Senator, Tom Daschle. Daschle withdrew for tax violations. Govcare has been headless for a year. But Obama‘s vision still guides it. Eventually Obama would like to grow Govcare and Govcaid into a single, an all-embracing, integrated entity, tentatively called Omnicare,. Omnicare will have Govcare at its core. Govcaid care will be farmed out to 50 states.

The Reactionaries

Unfortunately, reactionary Lilliputians, backed by big and small businesses. private health plans, the medical industrial complex, the America’s middle class, and Tea Party upstarts are not cooperating. Public polls show sixty five percent do not approve of Obamacare. They have made up their minds on their own. They persist in developing innovative, and effective life-saving and lifestyle-saving technologies sought after by the public. They claim outside. bottom-up market forces, rather than inside top-down bureaucracies, can do the job –cheaper and better. But because of third parties – Govcare, Govcaid, and Privicare plans – the public has no idea what things really cost and cries for more care.

Obama argues: if only me and my team could take over administrative functions of Privicare, the U.S. could offer a cheaper Govcare -backed option, and all would be well. We could reach our long sought goal of affordable care for all of the people all of the time . But, alas, through their incessant criticisms, says Obama. the Lilliputians have tainted and distorted my message. All that is needed now is more explanation of its benefits.

The Independents

Meanwhile, say Obamanites, independents in the lower middle class have gone berserk. They have elected a reactionary over a progressive in a deep blue state. They claim to be independents,, rather than fellow followers or reactionary renegades, but Obama followers say they are uniformed, small-minded red-necked, rabble-rousing Lilliputians. The Lilliputians seem to think they collectively ought to have a voice in running GRU, which affects all of them sometime in their lives.

They resent being forced to buy insurance and paying higher taxes and shouldering the growing debt necessary to carry out the mission of caring for all of the people all of the time. They also say that those operating outside of the GRU could provide cheaper more effective care in closer proximity to premium-payers, who, if they were spending more of their own money, would take better care of themselves and know what care to buy.

But Obama Knows

Obama knows these market based Lilliputians may bring down his vision. That would be tragic. Only he and his inner circle have the intelligence, wisdom, data, and good intentions to do what is cost-effective, operationally efficient, and morally right. But the R side insists, because they receive and pay for the care, they ought to be able to enter the inner G circle and to have a say in G decision making.

So the stand-off continues within GRU. Obama has suggested the solution lies in bundling and integrating the services of G and R , putting partisanship aside, and having the two sides cooperate and agree.

But so far, no go.

Friday, January 29, 2010

Physician Business Ideas: The Cost of EHR Fear - Low Physician Adoption and Alienated Doctors

In response to yesterday’s blog, “Universal Electronic Health Records – The Right Thing To Do?” which questioned the value of EHRs and the right of government to impose their use on doctors, I received this comment.

Beth said...

“I have been enjoying several of your recent posts.

In regards to this particular question, when is using government force to implement a program like this EVER doing the ‘right thing’? Doesn't the means (coercion) negate whatever good might be achieved? “

“In other words, some things, because of means employed, can never be the ‘right thing’.”

To which I responded,

”There are limits to government bulldozing and to imposing forced technologies on hospitals and doctors. I'm reminded our failure in Vietnam to root out the guerillas with napalm and airpower. One critic observed, "You can't weed a garden with a bulldozer." Federal intervention into private affairs has limits.”

Then I stumbled upon a wonderful piece, "The Cost of Fear," by Rob Lamberts,M.D., a primary care physician “somewhere in the Southeastern United States. “ The piece was a blog in The Health Care Blog, one of the most widely read blogs which has been going strong since 2003. The Health Care Blog is a gathering place for Health 2.0 aficionados, who tend to believe Internet-generated data is the do-all and be-all for solving, or at least ameliorating, health care quality problems.

Rob, a devotee of EHRs and a user, says, among other things,

“My best guess is that it (Fear of misuse of computer-generated data) is the overwhelming sense of pessimism most doctors feel about their profession. Docs are second-guessed by lawyers, patients, TV shows, insurance companies, and the government. The fate of medicine is not in the hands of doctors, it is in the hands of politicians, corporate executives, and malpractice attorneys. It seems to me that the only way to avoid more scrutiny and to hang on to some control is to hold tightly to what we’ve got: our information. Once that information is on computers it is far more accessible by others, and this is a bad thing if the goal is to retain full control.”

“So are docs just power hungry, wanting total control because of their inflated egos? Some are, but most are not. Even the most technologically-minded of us, however, have an increasing unease about the intrusion of others on our ability to do our job.

I don’t want to be thinking about attorneys when I am prescribing medications. I don’t want to withhold information important from the chart because I know patients will be reading it. I don’t want to be forced to include a lengthy justification of a procedure in my notes to make the insurance company happy. As it stands, it sometimes feels like anything we include in our records ‘can and will be used against us.’ ”

“If someone like me, a physician who embraces technology, feels increasingly penned in by the increasing number of people peering at what I do, it is very understandable that other physicians reject technology outright. They’ll quit before they give up their independence.”

“Is it stupid? In some ways it is. It certainly is a rejection of the centrality of what’s good for the patient. But our system can’t afford to alienate physicians at this time. If technology is going to be pushed, there needs to be a reassurance that this won’t be used against them. I am frustrated at the lack of acceptance of technology, but even more frustrated at a system that is hostile that forces docs into this foxhole.”

Low adoption rates of EHRs may not, in other words, be due to physician technophobia, but to lack of reassurance that EHR-data will not be used against them.

To My Readership: I am looking for more work writing about health reform and innovations that would help physicians. I have a 35 year history of writing for doctors on major health system issues. If you have enjoyed my writing, please let me know of any opportunities in the medical writing or editing fields. My phone number is 1-860-395-1501, and my email is

Thursday, January 28, 2010

Electronic Medical Records: Universal Electronic Health Records - The Right Thing to Do?

The January 21 New England Journal of Medicine contains an article entitled “Accelerating the Use of Electronic Health Records in Physician Practices.” Two physicians from the Columbia University Medical Center wrote it. The article says the North Shore Hospital System on Long Island has announced it will pay an incentive of up to $40,000 for each physician in its network to adopt its EHR – paying 50% of the cost to physicians who install an EHR that communicates with the hospital and up to 85% of the cost if the physician also shares de-identified data on the quality of care.

The article contains a figure showing this data.

Physicians who have not adopted EHRs by size of group.

• 1-3 doctors, 92%
• 4-5 doctors, 88%
• 6-10 doctors, 78%
• 11-50 doctors, 71%
• 50 doctors or more, 49%

EHRs Not Popular Among Doctors Who Deliver Most Care

All told, 85% of doctors in practices of 10 or less have not adopted EHRs. It is important to note these doctors supply 85% to 90% of American health care.

These numbers caused the authors to observe,” The decision by North Shore to provide a financial incentive as well as the software license suggests that many physicians still do not believe that current –generation EHRs will offer a return on investment directly to physicians.”

In the minds of the government and information technology establishment, EHRs are the only way to go, the key to physician efficiency and effectiveness and to better care.

Their minds are made up. Yet after nearly 10 years of EHR promotion, physicians remain profoundly skeptical about their use and are installing EHRs in limited numbers. Less than 15% have installed EHRs despite all the hype and promise of incentives.

Politically-Incorrect Questions

In any event, the NEJM numbers caused me to ask a series of politically incorrect questions: Is it possible that the physicians are right – that EHRs are not the right thing to do? Is it possible EHRs will not offer a return on investment, will not improve care, will not lower costs, will invade patient privacy, will disrupt practice efficiencies, and will be used to second-guess physicians?

Is it possible, in short, that EHRs are not what they are cracked up to be?

Drucker Aphorisms

The late Peter F. Drucker, 1909-2005, was famous for making pithy observations like these: "Efficiency is doing things right, effectiveness is doing the right thing." "Doing the right thing is more important than doing things right." "Management is doing things right, leadership is doing the right thing?"

Are EHRs, widely acclaimed as being the key to practice efficiency, really effective? EHRs may be “doing things right” among the political and wonk gentry, but are EHRs “the right thing to do” for practicing physicians? Are they more trouble than they are worth? Is it possible EHRS are not worth the $20 billion proposed to be spent on EHRs? Is it possible the herculean effort to implement universal,inteoperable EHR adoption between hospitals and doctors will be a failed boondoggle of the first order and a monumental waste of taxpayer money? Is it possible EHRs will drive up costs with no quality gain?

Just Asking

I am just asking. Somebody has to ask the tough questions.

Before you answer, keep in mind we are nearly a decade into this effort, and physicians who deliver care are still profoundly skeptical of EHRs in terms of efficiency and effectiveness. Could they be right?

Do-or-Die - Obama "Will Not Walk Away from: Health Care"

What He Said

In his State of the Union speech last night, President Obama addressed the state of health care. He touted the advantages of his plan and urged Congress to pass it.

Here are the 515 words he devoted to health care.

"And it is precisely to relieve the burden on middle-class families that we still need health insurance reform.

Now let's be clear - I did not choose to tackle this issue to get some legislative victory under my belt. And by now it should be fairly obvious that I didn't take on health care because it was good politics.

I took on health care because of the stories I've heard from Americans with pre-existing conditions whose lives depend on getting coverage; patients who've been denied coverage; and families - even those with insurance - who are just one illness away from financial ruin.

After nearly a century of trying, we are closer than ever to bringing more security to the lives of so many Americans. The approach we've taken would protect every American from the worst practices of the insurance industry. It would give small businesses and uninsured Americans a chance to choose an affordable health care plan in a competitive market. It would require every insurance plan to cover preventive care. And by the way, I want to acknowledge our First Lady, Michelle Obama, who this year is creating a national movement to tackle the epidemic of childhood obesity and make our kids healthier.

Our approach would preserve the right of Americans who have insurance to keep their doctor and their plan. It would reduce costs and premiums for millions of families and businesses. And according to the Congressional Budget Office - the independent organization that both parties have cited as the official scorekeeper for Congress - our approach would bring down the deficit by as much as $1 trillion over the next two decades.

Still, this is a complex issue, and the longer it was debated, the more skeptical people became. I take my share of the blame for not explaining it more clearly to the American people. And I know that with all the lobbying and horse-trading, this process left most Americans wondering what's in it for them.

But I also know this problem is not going away. By the time I'm finished speaking tonight, more Americans will have lost their health insurance. Millions will lose it this year. Our deficit will grow. Premiums will go up. Patients will be denied the care they need. Small business owners will continue to drop coverage altogether. I will not walk away from these Americans, and neither should the people in this chamber.

As temperatures cool, I want everyone to take another look at the plan we've proposed. There's a reason why many doctors, nurses, and health care experts who know our system best consider this approach a vast improvement over the status quo. But if anyone from either party has a better approach that will bring down premiums, bring down the deficit, cover the uninsured, strengthen Medicare for seniors, and stop insurance company abuses, let me know. Here's what I ask of Congress, though: Do not walk away from reform. Not now. Not when we are so close. Let us find a way to come together and finish the job for the American people."

What The Polls Say

Here is what three major polls said on the day of President Obama’s address on Obama’s health plan:

• NBC/WSJ, For/Against, 31%/45%, Against/Oppose +15%

• CNN Opinion Research, For/Against, 38%, 58%, Against/Oppose, +20%

• NPR-ROS/GQR, For/Against, 39%/55%, Against/Oppose, +16%

Taken together, these polls say 17% more Americans oppose Obamacare than favor it. In another poll, 55% of Americans said he should start all over again.

In his 71 minute address, President Obama rebutted this opposition. He said, in essence, I have been right all along, I will stay the course, and once people understand what I am trying to do, the bill will pass, and you will be grateful forever more.

Will His Words Change Minds?

Will his words cause the people, the middle class, and independent voters to change their mind about health care?

I do not know. But I do know Obama does not truly understand the complexity of the American health care system and why the middle class resists sweeping change.

In Obama, Doctors, and Health Reform, I described this complexity as a whirling Rubik’s Cube with thousands of moving interrelated parts, each with an agenda, an ax to grind, and an ox to gore.

What President Obama did not say was, he was foolish to think he could reform 16% of the nation’s economy, particularly when the health care sector remains a vibrant job-producer in a down economy, and everybody knows it.

Besides, as Daniel Henninger puts in today’s Wall Street Journal, “Why Obamacare Isn’t Flying,”

"American health care, whatever its defects, is today unimaginably complex. What the Democrats are trying to do isn't just difficult. It's impossible.

Why would anyone think it possible in 2010—as politics, economics or mere practical feasibility—to reorder 16% of a $14 trillion economy of 300 million people living in 50 separate states whose geography is 16 times larger than France?"

Henninger goes on,

:According to data compiled by Hoover's business research from the U.S. Census, the health-care industry consists of 340,650 separate establishments employing 5,508,926 people. I leave it to a mathematician to calculate the number of possible economic relationships this would produce every day, much less annually .

We have 512,000 physicians and surgeons, 2.2 million registered nurses and a galaxy of different jobs orbiting around them. Some 36% of these are in individual physicians' offices."

The American people are a skeptical bunch. They know Obamacare would effect each and every American. In the main, they do not see how Obamacare would help them personally by expanding access, improving quality, or lowering costs. And they still trust their doctors more than they trust Big Government. They know the local medical industrial complex – hospitals, doctors, and related health care facilities, - are often the biggest employer in town.

President Obama has a lot of persuading to do.

Wednesday, January 27, 2010

Political language - A Student of Political Words

I am an avid student of political words.
Be they nouns, adjectives, or verbs.

My current favorite word is pivot,
Intended attention on “change” to rivet.

Pivot signals a change of direction,
It is a sure sign of political rejection.

Closely related is reset,
To make the public forget.

What you said in the first place,
When you’re losing the race.

There is bipartisan – on being politically unsociable,
Bipartisan really means what’s mine is mine, what's yours is negotiable.

And don’t neglect that magic word prioritize.
Prioritize depends on your party’s majority size.

I’m also enamored with hubristic.
Obama speaks more often and uses "I" more than any president and may be narcissistic.

The adjective I find the most distasteful,
Is the omnipresent and omnipotent meaningful,

It is a favorite of the self-perceived deep thinking political elite,
It indicates only they can sift chaff from wheat.

Doctor Shortage, The Medicare Meat Ax

Medicare is not subtle when it comes to paying doctors. Medicare swings a meat ax rather than carving with a scalpel.

Medicare actions have a profound effect, not the least of which is that private plans obsequiously follow the Medicare lead in reimbursing doctors.

Medicare has almostsinglehandedly created a primary care shortage by underpaying primary care doctors by 300 percent compared to specialists. Only one of 50 medical graduates now enters primary care because of low payments.

Now Medicare has decided to chop the head off specialty fees by up to 40% for many cardiology procedures by 45% of imaging services. The idea? If specialists are paid less, the Medicare budget will go down along with demand for services.

Never mind that the public knows imaging is a superb technology. Never mind cardiologists have helped drop death rates from heart attacks by 50% over the last decade. Never mind patients (and lawyers) think of imaging and cardiology procedures as the standards of care. Never mind that specialists’ practice expenses are outstripping inflation.

Medicare experts, operating at a distance from practices and with little knowledge of what transpires on the ground, have decided to arbitrarily and capriciously dictate what doctors are paid.

Now for the latest news about Medicare specialty cuts for cardiologists and radiologists. Both specialty groups have protested the aforementioned cuts which may be superimposed on a 21.2% Medicare cut scheduled for March 1. Both have said these cuts will cut access and drive many outpatients based specialty groups out of business, in effect, driving patients into the arms of higher priced hospital facilities, where facility fees and regulations will drive up costs even more.

The American College of Cardiologists filed a lawsuit against the cuts. But a U.S. District Court in Florida ruled against the Cardiologists, saying it, the Court, had no authority to countermand Medicare.

Jack Lewis, the CEO of the College, responded, the decision “sets the precedent that CMS has complete and unchecked control over physician reimbursement for patient care even where its determinations are based on faulty data. “

In support of the cardiologists, the Americab College of Radiology, commented, “Here there was no give-and-take a far as sharing data and inn transparency of the information from the proposed rule to the final rule.”

Oh, well, when you’re Medicare, and you have unfettered access to a meat ax, your instinct is to swing it and severe the head of the cost monster, no matter what the consequences to the body below.

Interview with health leaders - Interview with Senator Tom Coburn, Democratic Food Fight

Yesterday I had the privilege of interviewing Senator Tom Coburn, M.D., a Republican Senator from Oklahoma who is up for re-election in November 2010. He is a family obstetrician and still practices three hours each Monday morning to stay in touch with the real world of clinical medicine. The interview will appear soon in I will not reproduce it here.

I shall simply say Doctor Coburn was even-minded and ever-handed. He did not gloat over Senator Scott Brown’s win in Massachusetts. He thought it had an impact for today, but did not know how it would affect November’s elections. If President Obama would swing back to the center, he said, he could reverse his political losses.

Coburn favored a market-driven system as the best way to allocate care and costs, but predicted liberal Democrats would never give up their DNA issue - their single-minded quest for a single-payer universal system. He said he honestly did not know if any health reform bill would pass, nor did speculate on chances for passage.

So much for the interview.

The news for today, as discussed interminably in, the Washington Post, the New York Times, and the major television networks is about the food fight among Democrats. This fight is occurring among the more liberal House and the more conservative Senate, among those who don’t want to give up the health reform ghost ; among those who either want to pass a smaller bill; among those who want to declare it dead; among those who want to postpone it and to move on to what really concerns the American people - the economy, the national debt, the distressed middle class.

Reporters are gleefully tossing around bon mots of the past – Will Rodgers comment, “I do not belong to an organized political party, I’m a Democrat.” President Lyndon Johnson’s remark after emerging from a Democratic caucus, “ The difference between a caucus and a cactus is that with a cactus, all the pricks are on the outside.”

At this point, no one knows what solutions or political agendas will emerge. Perhaps President Obama will clarify things tonight in his State of Union address. Perhaps he will “reset” his aims. Perhaps he will carry on with his ambitions unchanged from before.

Meanwhile Senator Coburn says whatever happens, “What is ultimately good for patients will be good for doctors. If doctors are most concerned about their patients and the care they give, they will do just fine.”

Tuesday, January 26, 2010

Federal Employee Health Benefit Plan - "Just Give Us What You've Got, " The Simplest Health Reform of Them All

Whoopie Goldberg, the host of The View, says the solution to health reform is quite simple. Just tell Congress to give us what you’ve got, namely the health care benefits Congress persons and Senators receive.

She may have a point.

After all, the Federal Employee Health Benefit Program (FEHBP) has been in existence for nearly 50 years, is marketed across state lines, covers those with pre-existing illness, gives over 10 million employees a choice of health plans, is administered by government agency overseeing private plans, is efficient, and would give great comfort to those who think Congress gets special favors.

Why Not FEHBP? What's good for the goose is good for the gander

The major sticking point of the health care debate appears to the “public option.” The liberal Democrats can’t live without it, and the Republicans can’t live with it.

My question is: why not open the Federal Employee Health Benefit Plan (FEHBP) to every one, rather than remaining stuck on the public option?

FEHBP has been operating successfully since 1960, covers 9 million people, has lower costs than most private plans, and offers a choice of 283 competing private plans - HSAs with high deductibles, FFS, HMOs, and PPOs.

Furthermore, FEHP cannot exclude people with pre-existent illness, rescind policies of those who become sick, or discriminate on basis of age and sex.

FEHBP is, in essence, a health exchange open to 10 million permanent government employees, government retirees, and, perhaps most importantly from the political point of view, to Congressmen and elected government officials.

The public would welcome such an option. After all, what’s good for the goose – their congress persons and their senators – ought to be good for the gander – the great American public.

Sorry, Whoopi. It will never be. Health reform, like life, it too damn complicated for answers to be easy.

Monday, January 25, 2010

Scott Brown Effect -Lessons Learned from Brown

Prelude: Carol Platt Liebau, in “Lessons for the GOP in Brown’s Victory,”, January 25 says, Republicans should learn these six lesions for Scott Brown’s Senate win in Massachusetts.

One, give it the light touch.
Be of good humor and good cheer,
Thank those independents very much,
Tell them you heard their message clear.

be specific.
Stop Obamacare, cut taxes, be strong on defense,
Tell independents their insights were terrific,
Full of immense sense, free of false pretense.

Three, don’t overpromise,
Don’t promise to boil the Democratic ocean.
Independents will see you as another doubting Thomas,
Filled with partisan enmity, an unproductive notion.

Four, forget abstract ideology,
People could care less if you’re liberals or conservatives,
Or harbor some other political theology,
Independents want solutions, not ideological preservatives.

Five, don’t fall for “big business.”
Wall Street is part of the Nanny State,
Part of the same Messiness,
Fairness for all is your Template.

Six, Grace matters,
Remember Scott Brown evoked Jack Kennedy,
The rising tide of low taxes lifts all boats,
That was grace, that was about what matters.

Sunday, January 24, 2010

Govrnment Reform - Health Reform Mandates - A Sleeper Issue

“I won’t pay it! And I’ll shoot the first person who tries to make me go to jail because I will not buy health insurance.”

Response of 55 year old customer in New Hampshire cafĂ© when asked about idea of forced insurance coverage, “In New Hampshire, An Angry Tide Swells, “ New York Times, January 24, 2010

Every legislative act has a sleeper issue. With health reform, individual and employer mandates is that issue. The very term, “mandate” runs against the grain of individualism, a strong trait in American culture.

Mandates put our individual destinies in the hands of government, where many feel it does not belong. Attorney generals in multiple states are preparing law suits to challenge the constitutionality of these mandates.

But the issue of mandates runs deeper than possible violation of the constitution.

It involves the intrusiveness of government into individual lives. People don’t want to be told what to do with their money, or what’s good for them. People feel they are more qualified on how to spend their money than government. They would rather control their own destinies, rather than have government control their destinies.

In the words of New York Times reporter, Katherine Seelye, who interviewed neighboring New Hampshire residents over the meaning of the Massachusett election of Scott Brown,

“The anger that boiled over in Massachusetts last week is bubbling up here. It is rooted in a combination of factors, including fear over the proposed health care legislation, anxiety about the flailing economy, and distrust over an overreaching government.”

Small business persons feel employer mandates will be the final straw that may put them out of business. To them a health care payment for employees personally represents, “A car payment. Rent. Student loans.” They can’t afford it. It represents money they could better spend elsewhere, saving money for college, or for a rainy day for personal matters.

As one person, a Democrat, observed of Democrats in Massachusetts, “They already have universal coverage. So they were in jeopardy of paying twice to everyone else. I’m a middle class person, but something is going to happen. I can’t help but look around and be concerned about the people who need help. And more and more, it’s the middle class.”

What we're seeing is an uprising of the American middle class who perceive, rightly or wrongly, that government is acting in its own interests, not in theirs.

Saturday, January 23, 2010

Government vs. Market Reform - Gov-Check.Com

We face a choice here. We can choose to rely entirely on the federal government to allocate resources in the health-care sector, or we can choose to make decisions in a decentralized marketplace with the government providing oversight ant enforcing consumer protections.

James Capretta, “What the Health Care Debate is Really All About, “ RealClearPolitics, January 23, 2010

I have agonized about what to title this blog.

Should I call it “Gut Check?” The Scott Brown election in Massachusetts, it seems to me, may force the nation to choose between government-run health care and market-driven care.

Going forward, as we reassess health reform, will we choose to have government elites allocate health resources? Or will people and institutions on the street determine what we spend on health and how we spend it?

Gut-Check Time

It is gut-check time. Government-driven or market-driven care? The answer has profound implications. Both political parties know it, not just for the economy but for our democracy and our philosophy of government. The stakes are high. There is no backing off. That is why the two parties have been so intransigent and divided in opposition on which way to go. No one dares cross the line.

Not about Reform or Coverage

The debate is not about expanding coverage for the uninsured or cutting costs for everybody. Everybody agrees something has to be done. It is about whether to put government in the cost-control driver’s seat, and suffer consequences – price setting, rationing, and who decides who gets what at what price – or to trust care to the marketplace’s uncertainties.

Gov-Check. Com

Hence, my title – It is about checks and balance, as envisioned by the Founding Fathers., and what role electronic checking of providers will play in overseeing the scheme of things. It is about the current standoff between political parties on how to control costs. Both sides agree the current cost trajectory is unsustainable, both agree we need to cover the uninsured, but neither is willing to give an inch on how to do it.

Medicare and Medicaid Policies as Clubs and Curbs

The present House and Senate Bills would use Medicare and Medicaid payment policies as curbs and clubs to force doctors and hospitals to change how they practice medicine. The bills would penalize hospitals who readmit patients for care, punish doctors who provide too many services, and establish an Independent Medicare Commission with arbitrary powers to cut payments to hospitals and doctors to meet payment targets.

According to the Congressional Business Office and based on demonstration projects so far, these measures would not save much money. But government aficionados still have unbounded confidence the government can centrally plan and control a complex process. Half a century of Medicare and Medicaid experience has shown this confidence is unfounded as these government programs skydive towards bankruptcy.

Giving Market Forces a Real Try

The other side of the equation is to give market forces – competition across state lines, health care tax credits for every citizen, HSA plans with high deductibles and catastrophic lids to prevent bankruptcies, and malpractice reforms offering capped objective payments for medical injuries a genuine try.

These approaches have been suggested but never tried on the broad basis as means of providing universal coverage and reduced costs. Perhaps the time to give market forces works on a real try without putting government dampers on them at every twist and turn. Better than Gut Check strikes me as a better title than gut check. Gut check implies a simple choice between government and the market. Gov check is more complicated. means not only a philosophic al check against government centralized power, but electronic checks by the government on market costs and quality of competing providers. Government oversight will be necessary if we are to opt for a market driven system.

Scott Brown effect - What Does Brown Mean?

Here is what Charles Krauthammer, MD, who was chief resident in psychiatry at Massachusetts General, and briefly a practicing psychiatrist before turning a national syndicated columnist at the Washington Post, had to say about Senator Scott Brown’s Massachusetts special election victory.

Democrats are delusional: Scott Brown won by running against Obama not Bush. He won by brilliantly nationalizing the race, running hard against the Obama agenda, most notably Obamacare. Killing it was his No. 1 campaign promise.

Bull's-eye. An astonishing 56 percent of Massachusetts voters, according to Rasmussen, called health care their top issue. In a Fabrizio, McLaughlin & Associates poll, 78 percent of Brown voters said their vote was intended to stop Obamacare. Only a quarter of all voters in the Rasmussen poll cited the economy as their top issue, nicely refuting the Democratic view that Massachusetts was just the usual anti-incumbent resentment you expect in bad economic times.

Brown ran on a very specific, very clear agenda. Stop health care. Don't Mirandize terrorists. Don't raise taxes; cut them. And no more secret backroom deals with special interests.

These deals -- the Louisiana purchase, the Cornhusker kickback -- had engendered a national disgust with the corruption and arrogance of one-party rule. The final straw was the union payoff -- in which labor bosses smugly walked out of the White House with a five-year exemption from a ("Cadillac") health insurance tax Democrats were imposing on the 92 percent of private-sector workers who are not unionized.

The reason both wings of American liberalism -- congressional and mainstream media -- were so surprised at the force of anti-Democratic sentiment is that they'd spent Obama's first year either ignoring or disdaining the clear early signs of resistance: the tea-party movement of the spring and the town-hall meetings of the summer.

With characteristic condescension, they contemptuously dismissed the protests as the mere excrescences of a redneck, retrograde, probably racist rabble.

You would think lefties could discern a proletarian vanguard when they see one. Yet they kept denying the reality of the rising opposition to Obama's social democratic agenda when summer turned to fall and Virginia and New Jersey turned Republican in the year's two gubernatorial elections.

Krauthammer went to medical school at Harvard and did his psychiatry residency at Massachusetts General. Having spent all those years in Boston, the cocoon of Democratic liberalism, you might think he would staunchly support Obamacare.

But no. He says the Democrats “must take democracy seriously.”

If, as the latest polls indicate, 68% of Americans oppose Obamacare, as it is currently understood, there must be something to the opposition. As Krauthammer puts it, “If people really don’t want it, could they possibly have a point?”

Friday, January 22, 2010

Market Reform - Five Health Care Reforms That Make Sense

Prelude: As readers of this blog know, I periodically reprint material written by other physicians who make sense to me. Here is an example.

Massachusetts, the bluest of states in our union, stunned the nation on Tuesday when it voted to end Washington's unbridled spending and plan for government-run health care. Americans still want health care reform, but they are looking for clear, patient-centered, fiscally responsible solutions. There's a way to make this work, says Dr. C.L. Gray, president of Physicians for Reform.

Sell insurance across state lines:

• State mandates drive up costs; health insurance for a 25-year-old male in New Jersey costs nearly six times what it does in Kentucky, largely because of state mandates.

• Allowing businesses to purchase insurance across state lines empowers consumers, not Washington, and does not cost a dime.
Let individuals purchase health insurance with pre-tax dollars:

Insurance companies serve businesses, not patients; businesses purchase employee health insurance with pre-tax dollars while individuals purchase insurance with post-tax dollars making their insurance far more expensive.

• This reform lets patients buy products that meet their needs and makes insurers more accountable to patients.

Encourage Health Care Savings Accounts (HSAs):

• HSAs reduce health care costs without rationing (cutting Medicare); they also let patients control their own money, decreasing health care spending by 13 percent.

• During 2005 and 2006, traditional insurance rose 7.3 percent annually while lower cost / higher deductable plans combined with HSAs rose only 2.7 percent annually.

End abusive medical litigation:

• Frivolous litigation drives physicians out of medicine; bringing tens of millions of new patients into the system requires more physicians, not fewer.

• Frivolous litigation reform lowers cost and improves access to care; Americans spend approximately $124 billion every year because physicians practice defensive medicine.

Cover the uninsured:

• We can insure the uninsured without expanding American debt; approximately 25 percent of patients who visit the emergency rooms do not have health care coverage.

• A system of tax credits can help the uninsured purchase coverage; this would cost approximately $80 billion annually.
Source: Dr. C.L. Gray, "Five Health Care Reform Solutions That Make Sense," Fox News, January 21, 2010

About Dr. C. L. Gray

Dr. C. L. Gray is a practicing Board certified internal medicine physician in North Carolina. Previously, Gray served as Chief Medical Resident at Bassett Healthcare, an affiliate of Columbia University. Upon completion of his training in 2000, he received the E. Donnall Thomas Research Award, presented annually for exceptional research. Gray has two scientific publications to his credit. He graduated from the University of Minnesota Medical School in 1995 where he served as president of the Christian Medical and Dental Society (CMDS) and as an honorary member of the CMDS graduate board of ethics.

Gray earned his combined Bachelor of Science degree from University of Minnesota in the areas of electrical engineering, life sciences, and officer training. He was recognized with numerous Air Force ROTC awards for academic excellence. His undergraduate research led to six patent disclosures in the area of fiber optics, robotics, and data acquisition.

Gray's interests include medical ethics, politics, philosophy, medical missions, and writing. Since 1998, he has completed ten international medical trips to Peru, Ecuador, Venezuela, Romania, India, South Africa, and Zambia. The Battle for America’s Soul, Gray’s upcoming book, is the result of years of research and analysis of the history and philosophy of medical ethics leading to Post-Hippocratic medicine in Western culture, as well as our present cultural divide. His second book, Courage to Live, explores the basis for hope while living in a fallen world

Doctor Shortage - Health Reform - Hindsight and Foresight

A health care reform prophet must be something of a contortionist. He must have one eye on the horizon, one eye in the rear view mirror, his nose in the air, his ear to the ground, and his finger in the wind.

He may claim selective 20/20 hindsight, but his foresight is more likely to be 20/200.

In hindsight, my book OBAMA, DOCTORS, AND HEALTH REFORM, written in the Spring of 2009 and published in June 2009, possessed some 20/20 insights. I predicted, among other things, that President Obama would,

• get only about one-third of what he wanted in health care: I did not say which third but I did say the changes would be incremental rather than monumental;

• underestimate the complexity and adaptability of the system ( I called the system a “whirling Rubik’s Cube with interchangeable moving parts, each with its own agenda, axes to grind, and oxen to gore.”);

• overestimate the power of electronic medical records and their “meaningful use,” indeed that the $20 billion devoted to IT might be an unprecedented boondoogle or boongoogle;

• overlook the realities of the looming physician shortage which will be the next health care crisis, which will be all about lack of access to doctors;

• misunderstand the American culture’s center-right nature and its proclivity for access to technologies, its impatience with waiting for care, its desire for personal private choice, its distrust of government bureaucracy

• sign something into law rather than allow nothing happen and claim an historic legislative victory.

• Not achieve simultaneous restructuring of the health, financial, automobile, energy, and educational sectors because it is simply too much too soon and costs too much.

But I did not foresee,

• Persistent unemployment, officially 10% but effectively 17%.

• Dropping of Obama approval ratings from 70% to 50% or less.

• Decline of public approval of health reform bills to the 32% level.

• The rise and potency of the Tea Party Movement.

• The Scott heard around the world, viz. Republican Scott Brown’s astonishing Senate victory in Massachusetts, the bluest of the blue states.

I have no idea of what will evolve with health reform. The political dynamics are uncertain. President Obama has indicated Senator Scott Brown must be part of the process, and House Leader Pelosi says she does not have the votes in the House to approve the Senate Bill. I expect a pared-back, deliberative, bipartisan bill to arrive over a greater time span. That may be more of a hope than a prediction.

But to get an educated guess of what might happen, next Tuesday, January 26, I will interview Senator Tom Coburn, Republican of Oklahoma. In addition to being a Senator, Coburn is a practicing physician ( he spends 3 hours each early morning see Ob-Gyn patients) and possesses deep insights into the implications of the Scott Brown factor and what it portends for physicians and patients and the health care industry.
We shall see how his views jibe with those of President Obama, who, on January 27, will deliver his first State of the Union address.

Wednesday, January 20, 2010

Conservative Revolt - Declaration of Independents - "Can You Hear Me Now!"

Mike Barnacle, the quintessential Boston Irishman and astute TV commentator, said it best. When asked what the message of the Scott Brown victory was, he nailed it by replying. “It reminds me of the Verizon Wireless ad, ‘Can you hear me now!’”

The special election to replace liberal lion, Edward Kennedy, turned out to be “historic” for health reform, but not in the sense that President Obama had hoped. Even liberal Democrats, like Representatives Barney Frank of Massachusetts and Anthony Weiner of New York, are saying,”Health reform is dead.”

I’m not so sure of that, but I do know the night was historic in the colonial sense of the word.

To begin with, there was the Declaration of Independents. Of the voters, 52 percent declared themselves Independents, and they went for Brown by a 69-21 margin.

There were the Tea Party folks. They flooded into the Bay State from all over the country. They cried out in Tea Parties last August they represented the true middle class, the center of American public opinions. It turned out they spoke for the center in Massachusetts too. They identified with Scott Brown, who was just like many of them. He drove a truck. He spoke their language. I have little doubt that Brown got the vote of most 45,000 Massachusetts truck owners.

There was the No Taxation without Representation crowd. They harbored a grudge against the political elites, those on the left representing Big Government and those on the right parading as Big Business, and they knew full well Big Taxes and Big Debts down the road would be needed to pay for Big Health Care Reform – estimated at $1 trillion over 10 years and $2.5 trillion over 15 years.

There was the stark reality that Independents had won in Massachusetts, just as they had in Virginia and New Jersey. The three states were part of the original thirteen colonies.

There were the Massachusetts citizens who had experienced first hand three years of universal coverage in an Obama-like plan. Although it covered 97 percent of the populace, they knew Massachusetts health care had runaway costs, the fastest rising premiums in the land, and the longest waiting times to see a doctor anywhere . They were not enthusiastic about having national reform imposed on their own reform in a state with large budget deficits, high taxes, persistent unemployment. The double irony was that the birthplace of universal coverage might become its death bed and that Independents, not Republicans, who comprised only 11% of the citizenry, dealt the potential death blow.

Then, of course, there was the Modern Day Paul Revere, riding a truck rather than a horse, who sounded the alarm. In one hand, he swung a light saying “41st Senator,” meaning he would vote against health reform, and break the 60 vote filibuster proof Democratic majority. In the other hand, he swung a symbolic light signaling a political sea-change in Massachusetts and the rest of the nation. His message was, The Skittish are coming, The Skittish are coming, most by land, absentees by sea and air.

Poll averages indicate 66.3 percent of Americans disapprove of the job Congress is doing, and 56.8 percent say the country is headed in the wrong direction.

Congress is listening to that message. It has its ear to the ground. It can hear the re-election hoof beats and truck tire noise. Next time around, it may fix what needs to be fixed rather than trying for a complete Rube Goldberg overhaul.

Dr. Richard Reece is author of two recent books - Obama, Doctors, and Health Reform (IUniverse, 2009) and Innovation-Driven Health Care (Jones and Bartlett, 2007) Both books are available at,, and other book websites.

Tuesday, January 19, 2010

Conservative Revolt - Losing Control of Our Destiny: Middle Class Unrest and the Massachusetts Election

Pundits are struggling to define what is happening in Massachusetts. There, a moderate Republican, state senator Scott Brown, has seemingly come out nowhere to challenge and perhaps even defeat the Democratic quasi-incumbent, Martha Coakley, for the late Senator Edward Kennedy’s seat. We’ll know the result tonight.

The Meaning of It All

What does it all mean? Everyone has their theory. Mine is that Brown’s rise represents pent-up frustration of the American middle class and Democratic over-reading of their mandate and ignorance of American history and culture.

Consistent Ideology

In today’s Wall Street Journal, columnist Gerald Selb says the Massachusetts election shows the difficulties of governing from the left in a center right country.

In his piece, “US Shifted Party, Not Ideology,” Selb cites WSJ polls since 2006 showing Americans have a consistent ideology - about 21% liberal, 38% moderate, and 34% conservative. What is happening, says Selb, is that liberals are marginally decreasing, moderates are shifting to the right, and conservatives are staying about the same.

Habits of the Heart

I have been reading a book Habits of the Heart: Individualism and Commitment in American Life (University of California Press, 1984). Five sociologists wrote it. They say America is a middle class country, made up mostly of ambitious individuals. These individuals believe in self-reliance, economic progress, private independence, religion, historical traditions, social activism, decentralization, and distrust of government elites telling them what constitutes the “public good” or “common good.”

Basis of Our Culture

Because of this set of values, which forms the basis of our culture, Americans are leery of a large, controlling central government expending trillions of dollars , either to bail out the rich, or subsidize the poor. Americans seek to take governance back into their own hands.

Democracy in America

Alex de Tocqueville, a French nobleman who wrote Democracy in America (published in two parts, in 1835 and 1840), coined the terms “habits of the heart” and “individualism.” Tocqueville saw the great importance of Americans “who have gained and kept enough wealth and understanding to look after their own needs. Such folk owe no man anything and hardly expect anything from anybody. They form the habit of thinking for themselves in isolation and imagine their whole destiny is in their hands.”

Middle class Americans are restless, frustrated, angry, and acting out, in health care and other matters, because they feel others are trying to do their thinking for them and because their destiny suddenly seems to be in the hands of others.

Monday, January 18, 2010

Do-or-Die - Obama Punching Tactics and Health Care

As I watch the health care political boxing match, I’m reminded Obama attack tactics on health care cuts two ways.

Fight tactics on the Left

Obama's attack tactics are clear enough.

He will claim,

• Uncontrolled health costs are driving the U.S. economy into the ground.

• Health costs are propelling millions of Americans into bankruptcy.

• The U.S health status compares badly to other world health systems.

• Americans are dying in the streets and in ERs because of lack of insurance.

• Villainous and venal private health plans are denying care to sick Americans with pre-existing illnesses.

• D.C. elites know more than people in the streets.

• Only big government, with its infinite resources and good intentions, can expand access and cut costs.

Fight Tactics on the Right

Obama's opponents counter-attack tactics are obvious, too.

Health reform will,

. cause you to lose your current coverage;

• ratio care for Medicare recipients, particularly for those who seek expensive treatments or care at the end of life;

• mandate care for the young and pursue them with harsh IRS fines if they do not pay;

• mandate that small businesses “play for pay,” imposing further burdens on small enterprises;

• create a situation in which federal bureaucrats, not doctors, make critical medical decisions;

• force the middle class to pay higher taxes for the poor, illegal immigrants, abortions, and many who could afford to pay;

• raise the national debt to insurmountable and unpayable levels for future generations.

Political Rope-A Dope

As I view the thrusts and counter-trusts, Muhammad Ali’s rope-a-dope boxing tactics come to mind. A boxer assumes a protected stance, in Ali's classic pose, lying against the ropes, and allows his opponent to hit him, in the hope that the opponent will become tired and make mistakes which the boxer can exploit in a counterattack.

In competitive situations other than boxing, like politics, one party purposely puts itself in what appears to be a losing position, attempting thereby to become the eventual victor.

In this case, Republicans are against the ropes, but the Democrats are making mistakes - refusing to have proceedings televised on C-Span after Obama promised eight times in his campaign to do otherwise; buying off Senator’s votes in Louisiana, Nebraska, Montana, Connecticut, Vermont, and Massachusetts, to name the most precious and egregious few; delaying taxes on Cadillac-health plans of unions until 2018 while other Americans in such plans must start coughing up taxes in 2013; in general, doing anything and everything in secret, incognito, and in cloak-filled rooms behind closed doors; and now plotting how to get their health plan through by hook or by crook even if they lose the special election in Massachusetts and cannot avoid a Republican Senate filibuster.

A Knockout or a Split-Decision

Will the Republicans win by a knockout, or will the Democrats prevail in a split-decision?

Dr. Richard Reece is author, blogger, speaker, and innovation and reform commentator. Dr. Reece’s latest book, Obama, Doctors, and Health Reform ( is available at www.iuniverse and other book websites. For information on speaking fees and arrangements, call 860-395-1501.

Sunday, January 17, 2010

Government Reform - Universal Coverage - Universal Bondage?

To hear conservatives tell it, government “overhaul” of health care, would enslave Americans to power-hungry elites in D.C.

Liberals see it differently. They say universal coverage would be a high water mark for the conscience of a compassionate people, would ward off national bankruptcy, and would bring to heel private sector greed.

As a pragmatist, I think both sides are over-reaching and over-reacting. We may not be able to afford the status quo, but we can’t afford proposed reforms either.

We need sensible incremental reforms – tort reforms, competitive reforms, and reforms that turn loose, rather than hamper the American genius for innovation and entrepreneurialism.

And, Yes, we need responsible government oversight, too.

But we do not need crushing costly mandates, political favoritism for selected politicians and unions, and feckless Medicare and Medicaid expansion that would drive doctors out of practice and limit public choices.

A January 15 blog by Matthew Holt “Thinking the Unthinkable – No Health Care Bill?" shows the debate’s dimensions.

Matthew is a gifted health care strategist. He founded The Health Care Blog in 2003. It has become the most influential policy wonk blog. He co-founded Health 2.0, whose members believe Health IT will revolutionize health care. Matthew is witty, amusing, irreverent, and a reform champion. He speaks with a silver tongue.

Here is his opening paragraph in The Health Blog two days ago,

“After a resounding Democratic Presidential election win, a terrible recession, and a bruising year of politics, it would be just like America that a crazy election result torpedoes the health care reform bill. It would be the first Republican Senator win in 43 years in Massachusetts, a state that’s bluer than blue, and the actual seat being elected on Tuesday hasn’t been won by a Republican since 1947! But it’s becoming more and more possible, and the latest polls are all over the map.”

Matthew believes the American health system itself is “crazy,” and a Democratic loss in Massachusetts that “torpedoes the health reform bill” would be an act of absolute insanity.

Here is my comment on his blog,

" Matthew, Your summary is a little overwrought,

You say,

‘To sum up: no bill means in 5–10 years a huge rise in uninsurance, no reform of the delivery system, and no prospect for a rationalization of health care spending. That will mean the collapse of large parts of the health care system in a spasmodic unplanned fashion.‘ "

I say,

“The American people seem to believe the current reform bill would raise premiums for the insured, mandate individuals and employers to march to the beat of the federal drummer, bankrupt state treasuries, ration rather than rationalize care, saddle their grandchildren with an unpayable debts, drive doctors out the system because of being unable to keep their practices open with low Medicare and Medicaid payments.”

Both of us, I suspect, are overwrought and are overplaying prospects of success or failure of the health reform bill. An effective, quality health system, American-style, lies somewhere in-between our beliefs.

The United States is a culture of unprecedented diversity in a vast continental nation. Ours is not an Either/Or society. We seek Multiple Options. We are fractionalized. We do not believe in uniformity of outcomes. We have different tastes and values. For better or worse, we are segmented and decentralized, and we believe in checks and balances against a command and control government.

I thought of ending this blog with a pithy verse.

But when I went to the rhyming dictionary and looked up “coverage,” the dictionary said, “No perfect rhymes were found.” Ditto for “bondage.” Is it possible there is no perfect system, governed from above, or generated from below, for all of the people all of the time?

Saturday, January 16, 2010

Medical Academic Reform - The Perspective of The Medical Academic Political Complex

As Displayed in the New England Journal of Medicine

January 16 - As I write, two big events are taking place.

• Democrats are desperately trying to put together the final version of their health care bill by reconciling the House and Senate versions of the reform bill so President Obama can sign it before delivering his State of the Union Address on late January or early February as a triumph of unprecedented historic significance.

• Next Tuesday, Massachusetts will hold a special election to replace Senator Edward Kennedy’s Senate Seat. To everyone’s astonishment, a Republican, Scott Brown, may beat the Democrat, Martha Coakley. Polls indicate the election is close enough that Presidents Obama and Clinton are in Massachusetts to save the Democrats’ health care bacon. The main issue is the health reform bill. If Brown wins, he may cast a decisive 41st vote against the bill, thereby scuttling it.

A Muddled Muddy Picture

To muddle and muddy the picture even further, a scandal is brewing because of a conflict of interest on the part of Jonathan Gruber, PhD, a MIT professor of economics. Gruber writes often in The New England Journal of Medicine. His latest article on Decmeber 24 was "Getting the Facts Straight on Health Reform, " which supposed corrected critics' misrepresentations of Obamacare. Last June 12, Gruber wrote a piece in The New York Times favoring increased taxation for universal health insurance. He failed to reveal he had received a $392,000 Health and Human Services (HHS) grant. Times felt obligated to apologized, “Had the editors been aware of Professor Gruber’s government ties, the Op-Ed page would have insisted on disclosure or would not have published the article. Also Gruber is a Board member of the Massachusetts Health Connector . The Connector oversees the Bay State’s universal health plan, which many say is the model for

Gruber is said to be President Obama’s health care economist. Republicans claim Gruber is Obama’s health care propagandist, lacks objectivity, and should not be writing articles in The New York Times and New England Journal of Medicine. Gruber is a frequent contributor to the New England Journal’s “ Perspective” Section, now over a year old. In 2009, the section, which leads off each issue of the Journal, contained 197 articles by 275 authors, 81% of whom bearing advanced degrees (MDs 43%, PhDs, 23%. Masters 12%, JDs 5%, 8% others with assorted post-bachelor degrees ), and most of whom hold forth in Boston or New England 40%, Washington, D.C, 18%, California 13%, or the New York –Pennsylvania corridor 10%).

The Perspective of Perspective Authors

What can one say about the perspective of those who inhabit the Medical Academic Political Complex? Overwhelming they are either academics, policy wonks, or government officials. They tend to be bitter enemies of the
Medical Industrial Complex,” a term coined by Arnold Relman, former editor of the New England Journal, who espouses universal coverage and salaried physicians working in nonprofit organizations.

The authors are political liberal, overwhelmingly favor Obamacare, view market forces with deep skepticism , distrust profit-making innovative organizations, and believe the health system can be reformed from the top-down by a well-intended, highly moral government. They dismiss possible unintended consequences of sweeping reform.

Contents of Perspective Section

Their papers concern information technologies 3%, research on various subjects, such as comparative effectiveness research 14%, the FDA 5%, physician practice issues 6%, global health issues 6%, health care legal problems 8%, epidemics 6%, health safety 3%, and health reform 54%.

The perspective throughout is that centralized government has do something about health reform. Not until November 18, 2009, does an article appear by an unabashed Republican, Senator Chuck Grassley of Iowa “Health Care Reform – A Republican View.”

The New England Journal’s “Perspective Section” shows a consistent pro-Obama care bias. One redeeming feature of the series of articles is 24 submissions by John Iglehart, former editor of Health Affairs and national correspondent of the Journal. His pieces show balance and objectivity and chronicle in detail the struggle of Democrats to make “history” by passing reform. Iglehart has written the history of reform, as seen from his Washington, D.C. perch. Taken together his series will be a classic book on health reform.

Friday, January 15, 2010

Doctor Patient Relationships - Of Time, Health Care, and Doctor -Patient Communications

Yesterday’s blog “Medinnovationblog Joins “Waste-Not” Movement" elicited this exchange of comments between Steve Wilkins of Healthcommunications.pressword. com and me,

Steve said...

There is another contributing factor to the "waste" in health care today not addressed in your post. I am speaking of the sub-optimal state of physician-patient communications in the U.S. Since the late 1970's, researchers have written about the deleterious effects of biomedical-dominated communication style on patient adherence, trust and outcomes. If physicians and patients could do a better job "communicating" with one another many of the other problems cited in your post would resolve themselves.

I said...

You are mostly right. Doctors don't do a good job communicating with patients and vice versa. But I would argue, there is not a complete vacuum. Physician websites containing patient education information and platforms for interactive exchange are growing. And the Health 2.0 movement, featuring electronic patient empowerment is in full swing. Patient-doctor email exchanges are on the rise. And there are websites, like, which allow patients to share their complaints, history, and demographics before visiting the doctor. Also many doctors are now engaging in remote monitoring of patients once they are out of the office, at home, or at work.

Neither of Us Mentioned Time

One thing neither of us mentioned was time, more precisely lack of it, and the lack of physician rewards for providing more of it for patients, in patient-doctor communications.

Time is everything. As the late Peter F. Drucker, so cogently observed,

“The supply of time is totally inelastic. No matter how high the demand, the supply will not go up. There is no price for it, and no marginal utility curve for it. Moreover, time is totally perishable and cannot be stored. Yeterday’s time is gone forever and cannot be stored. Time is, therefore, always in exceedingly short supply.”

Time is Critical in Health Care

Nothing shows the importance of time more than the Haiti earthquake disaster. We have 72 hours to rescue the living and to supply food, water, and medical supplies. After those precious 72 hours, survival rates drop precipitously.

Take survival rates in heart and stroke. The earlier you open those clogged arteries, and the earlier you get oxygen to the heart and brain, the greater the chances of life and long-term viability.

Take access to physicians. In the U.S., we have a growing problem with time of access to primary care doctors. Universal coverage, Massachusetts style, now four years in the making. has made this access worse, if you go by these statistics, comparing waiting times in Boston and Atlanta.

The city with the longest average wait times to see a doctor, as you may already have deduced, is Boston. Average wait times to schedule a doctor appointment in Boston for the five medical specialties examined in a Merritt Hawkins’ survey are as follows:

Average Time To Schedule a Doctor Appointment
Boston, Massachusetts

Specialty Days

Obstetrics/Gynecology 70
Family Practice 63
Dermatology 54
Orthopedic Surgery 40
Cardiology 21

Source: Merritt Hawkins & Associates 2009 Survey of Physician Appointment Wait Times

By contrast, Atlanta, Georgia has the shortest average patient appointment wait times of the cities surveyed, as the numbers below indicate:

Average Time To Schedule a Doctor Appointment
Atlanta, Georgia

Specialty Days

Obstetrics/Gynecology 17 days
Family Practice 9 days
Dermatology 15 days
Orthopedic Surgery 10 days
Cardiology 5 days

Source: Merritt Hawkins & Associates 2009 Survey of Physician Appointment Wait Times

Responsiveness, Costs, and Inequities

Take national health system responsiveness. According to the World Health Organization, the U.S. has the most responsive system in the World, in terms of quick access, waiting times, and to such medical technologies as CT or MRI scans, open heart surgeries or stent placements, hip and knee replacement, or cataract surgeries. But responsiveness comes at a heavy price and lack of equity for some, as critics are quick to point out (C.J.L. Murray and J. Frank, “Ranking 37th – Measuring the Performance of the U.S. Health System, “ NEJM, January 14, 2010).

Where is Time for Communicating Going to Come From?

Which brings me to the question: “Where is the time going to come from for communicating with patients? “ Some of it may come from time saved by electronic communication - emailing, tweeting, facebooking, googling, automated telephone answering, or Q &A’s on practice websites – but that is not the same as face-to-face communications. Some of it may come from organizing or delegating time better. Some of it may come from the system supplying more doctors ( there will be an estimated 37 percent deficit of primary care physicians by 2025 and a 33 percent shortfall of surgeons).

Time and Primary Care Doctors

But for present primary care doctors, time is of the essence. In a 2008 survey of 300,000 primary care doctors conducted by the Physicians’ Foundation, 94 percent of doctors said the time they devote non-clinical paperwork in the last three years has increased, 63 percent said that the increasing paperwork has caused them to spend less time per patient, and 76 percent of physicians said they are either at “full capacity” or are “overextended and overwhelmed."

Give us more doctors and give doctors more time, incentives, and rewards for communicating with patients, and perhaps they will do the job better.

Thursday, January 14, 2010

Fraud, Abuse, Waste - Medinnovationblog Joins Waste-Not Movement

Medinnovationblog has joined the “Waste Not” blogger movement. My blog , I’ve decided, is a terrible thing to waste on my small audience of 12,000 to so. Other bloggers – such as The Health Care Blog and KevinMedblog – are now reprinting some of my 1164 blogs, before much larger blogger audiences.

Not New

The “Waste Not” movement isn’t new.

Euripedes (c. 485 – c. 430 BC) started it by declaring “Waste not fresh tears over old griefs.”

Over the past 40 years, the municipal waste industry has proclaimed we shouldn’t let waste go to waste. Instead we should convert waste to beneficial ecologically friendly products. The recycling industry even has a website.

The United Negro College Fund picked the waste-not theme up with its 1972 advertising slogan, “A mind is a terrible thing to waste.”

Not to be outdone, Rahm Emanuel, Obama’s chief of staff, helped persuade the President to launch massive federal financial stimulus programs, takeover over of the automobile and financial and energy industries, and overhaul of health care, by saying, “You never want a serious crisis to go to waste.” Perhaps Emanuel borrowed the idea from Paul Romer, a Stanford economist, who observed, “A crisis is a terrible thing to waste.”

Unfortunately, for Obama, if you judge by Presidential approval polls, which have dropped his approval ratings from 70 percent to less than 50 percent, over the last year, the public considers excessive government spending as waste. Government haste, in other words, makes for waste. Too much money, too much waste, too soon.

By far the biggest “Waste-Not” news in recent years has been highlighting waste in the health care industry.

In 2006 The Dartmouth Atlas of Health Care, after studying Medicare data, concluded one third of U.S. Medicare expenditures, roughly $700 billion, was “waste,” due overuse of resources in certain parts of the country, with one-third more spent in some Medicare regions than others. Dartmouth concludes we can stamp out waste by stamping out regional variations.

In October 2009, the Thomson- Reuters company, an international communications conglomerate, detailed this health waste in a white paper.

Here are some of the study's key findings:

Unnecessary Care (40% of health care waste): Unwarranted treatment, such as the over-use of antibiotics and the use of diagnostic lab tests to protect against malpractice exposure, accounts for $250 billion to $325 billion in annual healthcare spending.

• Fraud (19% of health care waste)
: Healthcare fraud costs $125 billion to $175 billion each year, manifesting itself in everything from fraudulent Medicare claims to kickbacks for referrals for unnecessary services.

Administrative Inefficiency (17% of health care waste): The large volume of redundant paperwork in the U.S healthcare system accounts for $100 billion to $150 billion in spending annually.

• Health Care Provider Errors (12% of health care waste
): Medical mistakes account for $75 billion to $100 billion in unnecessary spending each year.

• Preventable Conditions (6% of health care waste)
: About $25 billion to $50 billion is spent annually on hospitalizations to address conditions such as uncontrolled diabetes, which are much less costly to treat when individuals receive timely access to outpatient care.

• Lack of Care Coordination
(6% of health care waste): Inefficient communication between providers, including lack of access to medical records when specialists intervene, leads to duplication of tests and inappropriate treatments that cost $25 billion to $50 billion annually.

Presumably, all-knowing, efficient,and effective government, an oxymoron, can stamp out health care waste. Government, unfortunately, has little clue at what occurs at the medical marketplace level or at the edges of the patient-physician relationships, or that one doctor’s waste may be one patient’s hope.

There are many and various and sundry things that are terrible to waste,

Small blogs, lost causes, crises, minds, garbage, health care misplaced,

But when big government wastes untold trillions,

To pay off Senators and to cover all civilians.

That’s not waste - even when the federal deficit becomes a basket case.

Wednesday, January 13, 2010

Physicians Foundation, Book Review

In Their Own Words; 12,000 Physicians Reveal Thier Thoughts on Medical Practice in Anerica, (Morgan James, 2010)

Occasionally a book appears guaranteed to rivet the attention of doctors, patients, policy makers, and Americans as a whole. In Their Own Words is such a book.

This is a highly authoritative, deeply personal, and fully documented account of the state of primary care doctors in America. The book is of fundamental importance as we debate health reform. The primary care physician shortage makes it unlikely reform will be able to provide timely access to the 31 million newly insured Americans slated to enter the health system, or to the 78 million baby boomers scheduled to start becoming Medicare recipients in 2011.

Authoritative Authors

The book‘s three authors have dealt with the problems, turmoil, frustrations of primary care physicians throughout their careers.

• As Vice President of Communications for Merritt Hawkins & Associates, the largest physician search and consulting firm in the United States and an AMN Healthcare company, Phillip Miller has 20 years of corporate communications and public relations experience. Miller has authored numerous articles on health care staffing and is co-author of four books - Will the Last Physician in America Please Turn Off the Lights? A Look at America’s Looming Physician Shortage; Merritt Hawkins & Associates’ Guide to Physician Recruiting, and Have Stethoscope, Will Travel: Staff Care’s Guide to Locum Tenens.

• As Executive Vice President and Chief Executive Officer of the Texas Medical Association , comprised of more than 43,000 physicians and medical students. Dr. Louis Goodman is a 21-year veteran of the TMA staff . Before that he spent eleven years with the American Medical Association. Under his leadership, the TMA was recognized as “America’s Best Medical Society” by Medical Economics magazine. Goodman now serves as President of The Physicians Foundation, which represents an estimated 650,000 physicians in state and local medical societies.

• As Executive Director of The Physicians’ Foundation, Timothy Norbeck brings over 40 years of experience in organized medicine to the table. From 1977 to 2006 he served as Executive Director of the Connecticut State Medical Society. In 1993, the Connecticut State Medical Society awarded Mr. Norbeck an Honorary M.D. in recognition of his significant contributions to the medical profession and for his diligent advocacy on behalf of physicians and patients. Mr. Norbeck has served in a variety of other leadership positions, culminating in the Presidency of the American Association of Medical Society Executives.

Together, the three authors have nearly 100 years of first-hand, on-the-ground experience dealing with primary care doctors - their problems and frustrations, their strengths and weaknesses, and their central role as the foundation of the American health system.

My Preface

In the preface to the book, which I wrote, I have this to say,

“If you have any interest in what doctors think or how they feel about the practice of medicine, this is a book you should not put down until you have read it from cover to cover.

Drawing on one of the largest surveys of physicians ever undertaken in America, PHYSICIANS: IN THEIR OWN WORDS gives patients, policy makers and others a bird’s eye view into the hearts and souls of today’s medical men and women.

The book asks readers to conduct an experiment – to switch places with the physician examining you and to imagine what it is like to be a doctor for a day.

It invites readers to consider why what doctors think about their profession matters to the patient’s own health.

It raises a vital question in this era of healthcare reform debate – will there be enough doctors to go around and will doctors be given the latitude to actually treat the patients they see?

Most important, it lets readers sift through hundreds of comments written by physicians themselves who reveal exactly what they think about the way medicine is practiced in America today .

Part wake up call, part fact finding mission, and part remedy plan, PHYSICIANS: IN THEIR OWN WORDS makes a powerful statement about medicine today and is vital reading to anyone who has ever been a patient or who is likely to be one – and that means all of us.”

Contents of Book

The 143 page book has six chapters.

Doctor for a Day

Two, A Matter of Access

Three, Troubling Questions

The Physician Perspective, Medical Practice in 2008

Five, In Their Own Words

Who Will Save Primary Care?

Examples Given and Lessons Learned

Basically, the book gives examples and shares lessons learned from a massive unprecedented survey conducted by The Physicians’ Foundation of 300,000 primary care physicians – the largest of its kind ever attempted. The book categorizes results of that survey in a series of pithy, fact-filled tables.

Meat of Book

The meat of the book lies in the nearly 90 pages containing 250 quotations of personal written comments of 12,000 primary care physicians who were moved to share their angst with the system in response to the survey.

Comments are organized into four sections: The Breaking Point, What about Access?, Electronic Medical Records, and Treatment Plans. The authors highlight the most striking comments in bold print. This makes it easy to grasp the depth and breadth of primary care physicians’ concerns.


The book concludes with suggestions for addressing problems of primary care and supply of primary care physicians. These suggestions include rethinking graduate medical education; bridging the income and prestige gap between primary care doctors and specialists; removing the cap on the amount of money the federal government spends on physician training; and letting doctors be doctors by lightening paperwork burdens, freeing doctors to exercise their clinical autonomy, and permitting them to contract directly with patients without third party interference.

Richard L. Reece, MD. Editor-in-Chief, Physician Practice Options, Author, Obama, Doctors, and Health Reform. Blogger, His book is available at,, and

Tuesday, January 12, 2010

Medical Trends - Hospitals and Doctors, Twelve Medical Megatrends - A Seat of the Pants Analysis

I’ve been exploring the recesses of my mind. I have come up with this seat of the pants analysis of what to expect in 2010. There is nothing scientific about these views. This analysis is anecdotal and based on what I hear, see, and feel.

For practicing doctors who wonder what 2010 portends for them, here are twelve megatrends to ponder.

One, there will be an unprecedented demand for physician services, in anticipation of 31 million more uninsured being insured, 78 million more baby boomers starting to enter Medicare in 2011, and what reform means in the physician scheme of things.

Two, because of fear of physician shortages, real and growing, compensation for newly recruited doctors and locum tenens, will go up while third party reimbursements, from Medicare and private plans, will go down.

more doctors , young and old, will join health systems, eschewing solo practices and bailing out of old practices, seeking employment for security, forgiveness of educational debt, sign-up bonuses, and saner life styles.

Four, hospitals will buy out established specialty practices in record numbers, as specialist groups seek funds for infrastructure, recruiting, and IT expenses, and as hospitals seek to bolster bottom lines and marketing cachet from high profit specialty lines.

Five, pharma will shift from drug marketing and new product development to provider partnerships, as in the $3 million Pfizer deal with Stanford to sponsor CME with “no strings attached” and, as prevention advocates, as seen in Pfizer Chantix marketing , an anti-smoking aid.

Six, employers will shift costs and responsibility for personal health to employees, push HSAs with high deductibles, set up worksite clinics featuring EMRs, specialty referral networks, free generic drugs; promote wellness and prevention programs, and avoid hiring smokers and obese individuals.

Seven, physicians will revolt against government mandates, reforms, moves to ration care through comparative effectiveness research and pay for performance, by pointing out lack of results of these approaches on social networking sites such as and Modernmedicine. com, as unnecessary intrusions into patient-doctor relationships.

Eight, physicians and hospitals will scramble to adopt EMRs and health IT to gain bonuses in 2011 under the federal American Recovery and Reinvestment Act, but results will be mixed because EMRs aren’t ready for primetime, slow and disrupt practices, and because only six percent of hospitals and doctors have “fully functioning systems.”

Nine, more hospitals and health systems will join the burgeoning Kaiser-based Innovation Learning Network, as they seek to cut costs, ensure safety, show social responsibility, increase efficiencies, collaborate with physicians, meet new reform regulations, improve care, and meet new public demands.

Ten, uncertainties will grow on how to meet demands and constraints of reforms, as Democrats throw partisan dirt and lose political ground, the opposition gains strength over lack of transparency, runaway government spending, growing deficits, mounting health costs, and who to tax to pay for it.

Eleven, the consumer movement will gain momentum in the form of worksite clinics, retail clinics, cash only practices, concierge practices, health food store patronage, more visits to alternative medicine practitioners, self-care, as well as IT technology strategies to promote virtual visits, telemedicine, and remote monitoring .

Twelve , there will be a push to replace fee-for-service with bundled payments for disease episodes and for hospital-physician care in hospitals in Massachusetts, integrated systems elsewhere, and in Medicare and Medicaid circles.