Notes and Remarks of a Health Reform Poll Watcher

Poll watching has its beartraps, pitfalls, and shortfalls. Polls vary. They depend on sample size used, questions asked, the media connection employed, and audience composition.

Still, if one averages multiple national polls over time, one can get a sense of where the public is headed. How the public reacts to the passage of the health reform bill is a case in point. The bad news for President and the Democrats is that a week after passage of the “historic” bill, the gap between those “against” over those “for” is widening. Although the public likes “pieces” of the bill, the public is dubious about it as a whole.

In any event, here are the lastest poll figures.

Average , “for”, 40.7%, “against”, 50.8%, spread “against”versus” for”, +10.1%

• Rassmussen Reports, against, +12%
• USA Today, against, +3%
• Washington Post, against, +4%
• Quinnipiac, against, +9%
• CBS News, against, +4%
• Bloomberg, against, +12%
• CNN/Opinion Research, against, +20%
• Democrat Corps(D) against, +12%
• Fox News, against, +20%
• PPP (D), against, +4%
• NBC/WSJ, against +12%
• Pew Research, against +10%

Source: Real Clear Politics average of health care polls

Not a favorable poll in the bunch. The public may grow to love the bill, to become instantly addicted, as President Obama explains the glories of its benefits of its particulars, as he and his followers hope. On the other hand, those opposing something tend to have more passion than those favoring something.

Either way, President Obama has his work cut out to explain why this is such a fine bill and not the “monstrosity” its critics describe. Obama’s silken rhetoric may prevail, but maybe not. It depends on the state of the economy. We will know in November.

For Fans of Electronic Health Records

Nuance, a very slight difference in meaning, feeling, or tone

Dictionary definition of Nuance

I have never been a big fan of electronic health records. EHRs lack nuance. With EHRs physicians can’t express themselves in plain English, just in data bytes. EHRs too often generate unreadable numeric gibberish. They fail to pass the test of useful narrative information.

So much for my electronic angst.

As always, I may be wrong. Now, there may be a technological breakthrough. In the March 14 NEJM, Drs. Gorden Schiff and David Bates of Harvard write “Can Electronic Clinical Documents Help Prevent Diagnostic Errors?”

Their answer is "Yes". Improved speech recognition technology now makes it possible for physicians to clearly describe and communicate the patient’s story without typing or handwriting, while a the same time, as a bonus, decreasing diagnostic errors.

The two authors then list other benefits of EHRs speech recognition technology.

• Gain access to information in narrative context
• Record and share clinical assessments in plain language
• Maintain a dynamic and current patient history
• Maintain problem lists
• Track medications
• Track tests
• Coordinate and control care
• Enable follow-up
• Provide follow-up to clinicians upstream
• Offer second opinions
• Increase efficiencies

The biggest benefit of computerized speech, from my perspective, is that speech recognition allows physicians to tell the patient’s story, past and current, without scanning reams of data. Perhaps I am impressed with Nuance Healthcare software because I believe in old-fashioned story telling and the power of narrative.

In any event, here’s how Nuance Healthcare, speech recognition software developers, and a disruptive player in the HIT space, interpret the work of Drs. Schiff and Bates.

“Dr. Schiff and Dr. Bates struck a particularly relevant chord with their paper on the impact that electronic clinical documentation can have on preventing diagnostic errors,” said John Shagoury, executive vice president and general manager, Nuance Healthcare. “More than 150,000 physicians use our speech recognition technology to document patient encounters without having to type or handwrite. The majority of these doctors will tell you that speaking their medical notes, is not only faster, but it allows doctors to include more information on their patients. It’s wonderful to see the free-text narrative, along side EHR point-and-click templates, being recognized as highly important and valuable to improve patient care, as well as to improve physician and patient interactions. One customer of ours, The Fallon Clinic, saw the quality of medical notes improve by 26 percent when they were created with speech recognition.”

I close with this verse, which tells the story more succinctly than prose

With EHRs, there really nothing like human speech,
To capture nuances beyond ordinary data’s reach.
There’s more to telling a patient’s story beyond data,
Which unwittingly may produce unexpected errata.
So now of EHRs I can advocate and solemnly preach.

Donald Berwick, MD, Prospects for Success as Head of CMS

CMS, the Centers for Medicare and Medicaid, has a new director – Donald Berwick, MD, MPP, FRCP. Dr. Berwick is Clinical Professor of Pediatrics and Health Care Policy in the Department of Pediatrics at the Harvard Medical School and Professor of Health Policy and Management at the Harvard School of Public Health. He is also a pediatrician, Adjunct Staff in the Department of Medicine at Children's Hospital Boston, and a Consultant in Pediatrics at Massachusetts General Hospital.

As if that were not enough, he is Founder, President, and CEO of the Health Improvement Institute in Cambridge where he has focused on issues such as pay-for-performance, continuous quality improvement, the success of Medicare demonstration projects, hospital safety, and the role of electronic personal health records in improving the system. He has been extremely active in helping the Institute of Medicine write its groundbreaking reports, e.g, Crossing The Quality Chasm and To Err is Human. Furthermore he is an inspiring motivational speaker, and author of many books on how to make the system better.

He is a charter member of the Boston Medical Academic Complex. He is a graduate of Harvard College, the John Kennedy School of Government, the Harvard Medical School, a pediatrician at the Harvard –affiliated Children’s Hospital in Boston, a Harvard associate professor of Pediatrics, a big academic dog at the Harvard School of Public Health. He has, in short, an impeccable Harvard pedigree.
His philosophy of medicine and its management can be summed up in his six “No Needless List:

--No needless deaths

--No needless pain or suffering

--No helplessness in those served or serving

--No unwanted waiting

--No waste

--No one left out

Furthermore, he is close to and familiar with the work of other Obama advisors and admirers, including David Blumenthal, MD, Obama’s, National Coordinator for Health Information Technology David Cutler, PhD, chief medical advisor and professor of applied economics at Harvard, and Elliot Fisher, MD, Professor at Dartmouth Institute for Health Policy and Clinical Practice and Professor Of Medicine and Community and Family Medicine at Dartmouth Medical School.

Berwick is a world-class policy wonk. I would classify him as a pragmatic idealist and a genuine humanist. His academic peers respect him and honor him, and under his leadership, the Institute of Health Care Improvement has carried out a number of successful projects on the ground in a number of settings.

He has earned the admiration of many in the academic and government sector, and he is being widely praised by prominent liberals such as Maggie Mahar, a former Yale English professor who wrote Money-Driven Medicine: The Real Reason Money Costs So Much, and Bull! A History of the Boom 1982-1999, which denigrates market-driven capitalism. In The Health Care Blog, March 30, “Who is Don Berwick and What Will He Mean for Health Reform?” she waxes enthusiastically about the prospects of Obama transforming and reforming the U.S. health system.

Among other things, Berwick is said to have the experience and savvy to:

1. Reduce medical errors
2. Make your hospital stay more pleasant.
3. Make preventive care more effective
4. Help hospitals provide high-quality care without high costs.=
5. Has a realistic attitude, He knows talk is cheap:, but changing cultures is hard.

Berwick would appear to be the ideal candidate as head of CMS. Certainly his admirers in the academic and government establishment think so.

I am not so sure. The job of simultaneously transforming and reforming U.S. health care, altering the complex U.S culture, and managing a huge bureaucracy covering100 million Americans may be beyond the reach and talents of any single individual. Berwick has not practiced medicine “in the trenches” for 15 years, and many physicians are skeptical that he appreciates the difficulties of sustaining a viable practice given government regulations, extensive health reforms, the influx of 32 million more patients, and the expense and disruptions imposed by electronic medical records. Lastly, his Boston health policy perspective and the Massachusetts experience with universal coverage may not apply to the rest of the U.S. which may be more conservative and resistant to Obamacare than the rest of the U.S.

Patients Will Have Coverage, But No Doc

Preface: The following Op-Ed piece has appeared in The Chicago Sun Times, The Boston Herald, and The Tampa Tribune in recent days. I reprint it here because I have recently interviewed Louis Goodman and Timothy Norbeck for Modern Medicine, and I work closely with The Physicians Foundation.

BY LOUIS J. GOODMAN AND TIMOTHY B. NORBECK

Now that the health-care bill has passed and the smoke has cleared from the acrimonious debate -- if only for a little while -- it seems appropriate to reflect on how this significant legislation will impact our health-care system.

We don't know anyone who would oppose, on moral grounds, insuring everyone, and that includes us at the Physicians Foundation. Some have argued that the overall cost of the legislation may be prohibitive. While that argument goes beyond our expertise, we do believe that there is an important issue that has been ignored.

Many groups and think tanks seem to agree that there is a shortage of practicing physicians in the United States, especially those in primary care. These entities, including the Association of American Medical Colleges, point to what they see as serious shortages of as many as 100,000 physicians over the next 10 or 15 years.

The Physicians Foundation is a nonprofit organization created in 2003 to help physicians, in an increasingly difficult practice environment, to continue
delivering high-quality health care. In 2008, the foundation, in collaboration with Merritt Hawkins & Associates, undertook a comprehensive survey of all primary care physicians in the U.S.

The results were dramatic and distressing regarding difficulties they are encountering in sustaining their medical practices.

What was also telling and relevant to the discussion on the physician work force were the following:

• 63 percent said increasing paperwork has caused them to spend less time per patient.

• 76 percent said they were either at "full capacity" or are "overextended and overwhelmed."

• Less than 6 percent assessed their colleagues' morale as positive, and 78 percent reported that over the past five years, the practice of medicine has become less satisfying.

Because of these factors, 49 percent of physicians reported that, over the next one to three years, they intended to reduce the number of patients they see or to stop seeing patients entirely due to retirement, working part time or seeking non-medical jobs.

The entire survey is at www .physiciansfoundation.org. It is also available in a new book, In Their Own Words, in which physicians explain growing impediments to the delivery of patient care, including difficulty working with managed care organizations; liability insurance/defensive medicine; non-clinical paperwork; increasing demands on time; onerous government rules; declining reimburse- ments as their practice costs are escalating, and a shortage of primary care physicians.

In view of the influx of 30 million more insured patients into our health-care system, these findings are sobering. How will there be enough doctors available to take care of everyone?

For the past 25 years, the number of physicians completing training in the U.S. has remained flat at about 24,000 a year. During that time, a handful of new medical schools has been added, and enrollment is gradually increasing. The Association of American Medical Colleges has initiated a plan to increase medical school enrollment 30 percent by 2015, but that won't help unless the number of medical residencies available for them, now fixed by law, is increased as well.

To its credit, Massachusetts attempted to insure all of its citizens in 2006. According to the Massachusetts Medical Society, the state is now suffering a critical shortage of primary care physicians." Not surprising is that expanded insurance coverage -- regardless of its noble objective -- has caused an increase in demand for medical services. But there hasn't been a corresponding increase in the number of doctors.

Many Massachusetts residents now have insurance coverage but can't find a physician. The medical society also found in its 2009 survey that 56 percent of Massachusetts physicians in internal medicine aren't accepting new patients. And new patients fortunate enough to secure an appointment with a primary care doctor have an average waiting time of 44 days!

It is obvious that the U.S. physician work force and the number of medical residencies available must be increased -- and rather quickly -- in order for physicians to cope successfully with 30 million new patients. Washington has basically ignored an issue that will greatly affect patient care and that must be addressed now.

Louis J. Goodman is president and Timothy B. Norbeck is executive director of the Physicians Foundation, a Boston-based nonprofit that works with physicians to improve the health-care system.

Notes and Remarks of a Health Reform Provocateur

I see by my blog counter that 99 people visited this medinnovation blog in the last few days – 84 from the U.S, 4 from India, 3 from Europe, and the rest from elsewhere. I am encouraged people are reading my blog, but I am discouraged by the few comments. I suppose this is because everyone agrees with what I have to say.

To provoke more comments, I shall make a few incendiary remarks. These remarks go against my nature because I believe both sides of the health reform issue harbor deep and serious convictions.

But here goes anyway.

• President Obama’s historic achievement proves the end – government-directed care to guarantee near universal coverage – justifies the means – back room deals, ignoring the will of the people as expressed in countless polls, shutting out the political opposition until the deal was done, budget gimmicks, and federal debt as far as the eye can see.

• President Obama and the Democrat Congress failed to tackle head-on the staggering cost of care, $2.5 trillion, 17% of the national economy. Instead, Obama and followers chose to avoid the $250 billion doctor-fix (after all, doctors only provide the care needed to fulfill the political promises), doubled down their Medicare bet ( cut $500 billion while promising more benefits), skillfully executed a financial sleight-of-hand(counting 10 years of revenue with only 6 years of outflow), radically expanded Medicaid( adding 16 million to state-rolls), and pretended defensive medicine engendered by malpractice fears had nothing to do with costs (while doctors surveyed said defensive medicine accounted for 26% of costs).

• These political maneuvers all rested on the ludicrous promise that these costly measures will save the government and the public money through unproven cost-saving strategies that will not take effect for years ( paying on basis of comparative effectiveness, bundling hospital-doctor fees, electronic medical record efficiencies, rewarding high performance, and wellness and prevention programs).

. The adverse consequences of Obamacare are already starting to roll in. less than a week after its passage. As a result of the bill, AT&T announced it will write down $1 billion in profits. The write-down wave includes Deere & Co $150 million, Caterpillar $100 million, AK Steel $31 million, 3M $90 million, Valero Energy $20 million. All of these corporations have informed their employees they will be forced to reduce or drop health benefits.

• I agree with Charles Krauthammer (“The VAT Cometh,” Washington Post, March 26) that a U.S. VAT (Value-Added Tax), a consumption tax on most goods, will inevitably be necessary to pay for this comprehensive bundle of health-care goodies and to reduce the national debt.

If you doubt the last remark, I invite you to look at the history of Medicare. In 1966, after Medicare’s passage, government financial experts assured us medical expenditures would not exceed $12 billion by 1990, when on that date in actuality costs reached $107 billion, a mis-estimate 9 times off the mark.

Maybe the current CBO estimate of slightly less than $1 trillion or so by 2020 is on the mark, and maybe it will not be off by a factor of nine times by 2045. but I am not optimistic. Already critics like Paul Ryan (R-Wisconsin) says the actual cost will be $2.5 trillion or more in the next decade.

But let us not quibble over a $ trillion here and a $ trillion there. As a nation we are already $8 trillion in debt. And the CBO projects another $12 trillion by 2020.

Why a VAT? Because history, not only here but in Europe and other Western countries, shows that government entitlement programs are always instantly addictive, wildly popular, and politically irreversible.

A U.S. VAT is a logical way to reduce the federal debt. The VAT is a federal cash cow. Every 1% of VAT produces yields $1 trillion per decade.

So why not VAT? It is for a noble cause. It is a moral imperative for the social good. A U.S. VAT may not be as high as in Europe – 19% in Germany, 20% in France and Italy, and 25% in Scandinavia because of our vibrant but fading capitalistic economy.

Whatever the VAT level, it will be needed to feed the entitlement beast. This is not all bad, of course, if we want to emulate European social welfare programs, and if we are to assure egalitarian equity and social justice among all classes. If the VAT starves the private sector and stifles private innovation, so be it.

Gut Check on HealthReform

To which camp do you belong?

1) Do you believe it is the function of government to insure the health of all citizens against the vicissitudes brought on by sickness, aging, and misbehavior? Do you believe government has the power to force all citizens and all businesses to buy insurance for themselves or their employees? Do you believe government has the competence , resources, and knowledge to implement, administer, and control costs and decision-making at the level of the patient-doctor relationship, and to remotely micromanage that relationship at the individual level? Do you believe a paternalistic government knows more about what’s good for the people than the people themselves? Do you believe the Internet and interoperable electronic systems containing full information on your medical histories , and monitoring doctors’ clinical decision-making will improve care and quality? Do you believe more rules and regulations will correct health care abuses, bring down costs, bolster quality, and improve the health of the American people?

2) Do you believe it is the function of government to stimulate private health care markets and to oversee those markets to prevent abuses and monopolies? Do you believe markets and private enterprise are the source of most employment? Do you believe most health care innovation comes from the bottom-up rather than the top-down? Do you believe ordinary citizens, given health care tax relief, like employees of corporation, would have the common-sense to choose what care is best for them, especially if they were spending more of their own money? Do you believe doctors have the best interests of patients or their own self-interests at heart? Do you believe computerized systems at levels of care may have human limits and are over-rated? Do you believe market competition based on value is effective at bringing down costs and improving quality ?

3) Do you believe a government- centered system, which now pays for roughly 45% of health coasts, using payment based on performance and therapy based on data-driven comparative effectiveness, with government paying 90% of the bills and deciding what to pay, is the best way to control costs?

4) Do you believe an employer-based market system, which now pays for roughly 45% of costs with patients paying 10% out of pocket, based on competition between providers and informed patients making mutual decisions based on value, is the best way to control costs?

Check here (1) or (2)or(3), or (4)a combination of the above, to indicate to which camp you belong or (5) don't know.

How Doctors Feel About and Will React to Health Reform

It is difficult to get a fix, and perhaps too early, about how doctors feel about comprehensive health reform , as embodied in the just passed health reform bill.

It is even more difficult to ascertain how doctors will react – how many will gear up to take in the 32 million more insured patients, how many will become employed, and how many will quit or choose other careers.

What we do know, as indicated in a 2009 Physician Foundation survey of 300,000 doctors, and a just released survey of 1000 doctors by Athenahealth and Sermo.com, is that doctors are deeply unhappy about the present system and profoundly skeptical about the future, including more government involvement.

We know, from the four year old Massachusetts universal care experiment, which Obamacare is said to emulate, that higher taxes, higher premiums, longer waiting lines, increased ER traffic, decreased access to doctors, and resistance to national health reform, as exemplified in the Scott Brown election, lies ahead.

We know, as documented in today’s (March 26) NYT (“More Doctors Giving Up Private Practice’) that the health care landscape is already trending towards more care delivered within hospitals and large health care organizations rather than private physicians.

This trend, driven by young doctors seeking the security, tranquility, and benefits of salaried employment, and by older doctors escaping from the insecurity, turbulence, and economic insecurities of private practice, and the associated loss of morale, is accelerating.

We know demands for installing expensive, often money-losing EHR systems in private doctors’ offices, propelled by $20 billion in federal dollars, are a concern among private physicians . EHR systems are expensive, time-consuming, and disruptive, and their benefits accrue almost exclusively to large organizations.

We know costs are higher in large health organizations and hospitals, where a costly infrastructure is required to assure authorities of quality, safety, and system efficiency.

What we do not know at this point is the unknowable -how the public and voters will react to changes legislated from above.

Physician Sentiment Index

Preface: What follows is the essence of a press release by Athenahealth and Sermo.com, based on a survey of 1000 Sermo members. In general, physicians are pessimistic about health reform and more government involvement, the future of independent practice, Medicare and Medicaid reimbursements, necessity of doctors to double as businessmen, and current usefulness of electronic health records.

As the country girds for the biggest transformation of health care in a generation, few have bothered to ask the U.S. physicians what they think of all this change. Will their ability to offer quality care improve or be hampered? Is practicing medicine getting easier or harder?

To find answers, Athenahealth partnered with Sermo, the world’s largest online community for physicians, to conduct a first of its kind Physician Sentiment Index (PSI).

In this first annual index, 1,000 physicians – representing a range of specialties, regions, and practice sizes – responded to questions revealing pains and frustrations with the business of medicine, reimbursement protocols, government’s hand in health care, EHRs and other variables.

Top-level Sentiments

• 92% agree getting paid by insurers has become burdensome and complex.

• 83% agree: This is the case with Medicaid.

• 81% agree: This is the case with Medicare.

• 64% believe their clinical decisions are based more on what payers will cover than what is best for their patients.

• 59% think quality of medicine in the U.S. will decline in the next five years.

• 54% strongly disagree that more active government involvement in health care regulation can improve outcomes; less than a quarter feel otherwise

Pessimism about Quality in America Health Care

Among physicians the feeling exists physicians have lost control over their own profession.

• 64% cited the health care climate as somewhat or very detrimental to their delivery of quality care.

• Only 22% are optimistic about the ability of the American physician to practice independently or in small groups.

• 59% say the quality of medicine in America will decline in next five years; only 18% believe the quality of medicine will improve.

• 54% disagree that more active government involvement in health care regulation can improve outcomes; less than a quarter feel otherwise.

• A shift from fee-for-service to pay-for-performance gives hope to almost half (49%) who think it will have a very/somewhat positive impact on quality of care.

.However, 53% believe pay-for-performance will have a negative impact on the effort required to get paid.

Physicians vs. Insurers -- An Uneven Fight

Frustration with payors' changing reimbursement protocols and regulations is universal among physicians. They want to render service and care, not worry about third parties influencing decisions about who they can treat, how they treat, and, ultimately, the kinds of outcomes they can affect:

• 77% agree that time spent with payors and third parties inhibits their ability to spend time with patients (5% feel differently) .

• More than three-quarters believe payors inhibit the care physicians would like to provide their patients; just 7% feel the care they would like to provide is unaffected by payors.


• Only 16% say they are basing their clinical decisions on what they think is best for the patient rather than what payors are willing to cover .

• 83% agree that administrative costs incurred to comply with payor rules and regulations significantly affects their bottom line

MDs Shouldn't Need MBAs

Despite their calling of caring for patients, many physicians are required to step into a front-of-office role if they want to practice independently. Almost a quarter of doctors responding to the survey are primary decision makers with respect to billing and administrative decisions. Yet few exhibit a clear understanding of the business end of their practices. This is extremely telling of the sheer complexity that is healthcare administration:

• Conceptually, physicians struggle to understand cash flow--only 25% could correctly define the term.

• 33% don't know their average length of time for accounts receivable (for 51%, the average length of time is somewhere between 30 and 90 days).

• 82% feel challenged in hiring and retaining qualified staff.

• Though income has been trending lower for many practices, 34% believe their financial situation will be worse or much worse next year versus this year.

• Nearly half (43%) don't know what their insurance submission rejection rate is. Among physicians who know their submission rejection rate, a range of 5-10% was most commonly cited. If one considers that, for the practices of responding physicians who claimed to know their income, the average income is $2.5 million, this rate could mean $125-250,000 in deferred or lost income per practice.

Investing in the Promise of Electronic Health Records (EHRs)

Doctors' opinion on EHRs is highly favorable, but it's clear that current solutions are not where they need to be--particularly given the government's $19 billion push to get physicians to adopt EHRs:

• 81% expressed a very favorable/somewhat favorable opinion on EHRs.

• Yet only just 51% feel EHRs are designed with them in mind.

• 54% strongly agree that EHRs slow down the doctor during patient exams.

• 5% feel EHRs are alleviating the effort to stay on top of changing payment requirements/incentives.

• 60% strongly agree/agree that EHRs distract from face-to-face interaction with patients (21% feel face-to-face time is not being compromised by EHRs)

Attention: Physicians and Hospitals Treating Poor Children

A strong link exists between poverty, poor health outcomes, and high health costs. The poorer patients are , the greater their odds of being uninsured, the more likely they are to delay seeking care, the more advanced their disease is likely to be, and the higher their costs of care will be.

That is why health costs are highest in America’s urban ghettoes, which are fraught with domestic violence, substance abuse, the homeless, the unemployed, the uninsured, and disintegrating or non-existent families, as graphically shown in the movie Precious. These problems often weigh most heavily upon children in the pediatric age group and unwed mothers.

The Social Support Gap

Because of lack of doctors in inner cities, the very young may have nowhere else to turn than to emergency rooms, hospitals, and outpatient clinics. Once these children are discharged, they may have no roof over their head, no family support, no one to help them understand their medications, no food or just fattening food to eat, and no transportation to ferry them back and forth to hospitals, clinics, or doctors. Parents or caregivers may be unemployed or financially destitute. Social workers or visiting nurses assigned to these problems are overwhelmed. Consequently, health outcomes among the pediatric population are poor. Malnutrition, obesity, diabetes, and inadequately treated asthma are rampant.

What is Wrong: The Social Disconnect

What is wrong is the disconnect between health care and community support. This is what critics talk about when they speak of “fragmentation” and” lack of care coordination.” It does little good to prescribe antibiotics if there is no one to assure the child takes them. It does little good if an asthmatic child does not understand how to use a bronchodilating device, or if a diabetic child does not know how to inject insulin or when to take diabetic oral drugs.

Limits of Government, Doctors, Nurses, and Social Workers

As Hillary Clinton wrote “It takes a village to raise a child.” In some of America’s inner cities, there is no village. With his health plan, President Obama, known for his community organizing efforts, is seeking to start to address the problem of children by guaranteeing insurance coverage

That is a good start, but it is insufficient.

There are limits to what government can do. Connecting social services to support the sick child is not a government strength. There are also limits to what doctors can do, in following patients on an outpatient and home basis, providing domestic support, arranging for housing and employment, and connecting social services are some of these limits. And there are limits to what overworked nurses, social workers, and other health professionals can do outside of their jurisdictions.
Good outcomes and improved health often depend more on what happens once patients leave the hospital or doctor than what happens within an institution or medical office.

Help Is On The Way to Correct the Social Disconnect

If you are a family with a sick child, or a doctor working in a pediatric outpatient clinic, a newborn nursery, a clinic for adolescents, an obstetrics practice, a pediatric emergency room, or a community clinic, an overburdened social worker, or a hospital executive wishing to improve the health of your community, help is on the way.

Project Health

The help comes in the form of Project Health, a nonprofit 501 (c) 3 organization. This organization is emblematic of a profound social innovation. Rebecca Onie, JD, a young Harvard-trained lawyer, cofounded it at the Boston Medical Center P in 1996 with Barry Zukcerman, MD, chairman of the Pediatics Department at the time. Project Health serves pediatric patients, their families and caregivers in Boston, Baltimore, Chicago, New York City, Providence, and Washington, D.C., and will expand to two new sites in the next three years.

These urban centers feature two things in common: one, they have large populations of poor inner city kids; and two, they have large populations of idealistic college students who want to make a positive contribution to the health system by volunteering to help sick children

How Project Health Works

Project Health works like this. Its staff trains college student volunteers to connect those in need with community resources – to arrange for housing, food stamps, employment, transportation, and other social services.
Project Health trains students who volunteer for 60 hours on the problems of sick children, the community services and resources available, and how to connect with them. It then sets up a Family Help Desk in the various pediatric settings. Student volunteers sit at the desk and responds to services that doctors “prescribe” for needy patients.

Last year, Project Health's corps of nearly 600 volunteers assistdc over 4,000 families a year in accessing the resources they need to be healthy.
Over a five-month period last year, Family Help Desk clients at Boston Medical Center received the following resources:

• 205 families secured housing, including Section 8 and market rate units and shelters

• 154 clients obtained slots in child care, after school, and Head Start programs.


• 135 clients accessed food stamps, food pantries, dollar-a-bag programs, or farmers' markets,

Across 16 Family Help Desks, an average of 52% of families actually obtained at least one resource they need - i.e., receive food, secure child care, find an apartment - within 90 days of receiving services at the Desk, with the remainder receiving ongoing follow-up until they obtain the resource.

Project Health’s vision is to create the nation's first corps of student volunteers to connect low-income patients with the resources they need to be healthy and, in doing so, create the next generation of leaders committed to tackling this country's greatest health challenges. It seeks to break the link between poverty and poor health outcomes. It is the equivalent of a Domestic Health Peace Corps.

Health Reform and the Anger of the Silent Majority

Richard Nixon coined the term “silent majority” in 1969. He was referring to the majority of people who do not agree with government policies but do not express their opinion.

Today, if you believe public opinion polls, the “silent majority” do not approve of President Obama’s health reform bill.

Here are the “average” poll results, based on 10 or more national polls, after passage of the bill.

• President Obama approval, Approve 47.4%, Disapprove 46.8%, +0.6%

• Congressional job approval, Approve 17.4%, Disapprove 77.0%, -59.6%

• Generic party approval, Republicans 44.8%, Democrats 42.2%, +2.6%

• Direction of country, Right Direction 33.0%, Wrong Direction, 60.6%, -27.6%

• Obamacare, For 39.7%, Against 50.4%, - 10.7%

These percentages mean different things to Democrats and Republicans.

• Democrats say results not public opinion are what counts, they know better than the people what is good for them, people will understand and approve once the plan’s details are explained, the vote is “historic” in that it begins to erase wealth inequality.

• Republicans believe the the bill may be unconstitutional in that you cannot force people to buy insurance or force states to establish exchanges, that its passage may incite a widespread civic rebellion against an overreaching government, and that the high costs involved without cost controls will end in a financial debacle.

You decide.

The risk for Democrats is going against the will of the “silent majority” and losing their political majorities.

The risk for Republicans is being labeled as the “Party of No,” with no feasible alternatives to the unsustainable status quo.

Health Reform: Just The Facts, Ma'am

Just the facts, Ma’am

Catchphrase of Dragnet TV Series

Joe Friday, the cop star created by Jack Webb, used to cut short those he was interviewing or investigating by saying, “Just the facts, Ma’am.”

Here I shall cut short the rhetoric, pro and con, on the health reform bill's signing, by giving the immediate facts as written in the bill.

Individuals will be required to buy health insurance or face a fine. Government subsidies will be available for people making up to $43,000 per year (or $88,200 per year for a family of four). Those who don't qualify for government subsidies will pay about $5,000 a year for a policy on the exchange, while families will pay about $15,000. Penalties start in 2014 at $95 or up to 1 percent of income for individuals, whichever is greater, and rises to $695 by 2016 or 2.5 percent of income, whichever is greater. Families pay heftier fines - $2,085 or 2.5 percent of income by 2016.

Within six months to a year after bill is signed.

• Health insurers will no longer be allowed to cap lifetime coverage.

• Parents who have insurance through their employers can continue coverage for unmarried dependents up to age 26.

• Health insurers will cover certain preventive services like osteoporosis screening for women over 65, smoking cessation counseling and interventions, and screenings for diabetes and sexually transmitted diseases.

• People with serious health conditions that have prevented them from getting coverage will be eligible to purchase a policy from a high-risk pool in a government-subsidized exchange at a cost similar to healthy individuals' premiums.


• Insurers can't deny coverage based on pre-existing conditions.

• Maternity support will go up for women in the workplace.

• Less expensive insurance options will be available when you lose or quit your job.

What Obama Got: A Whirlwind

They have sown the wind, and they shall reap the whirlwind.

Hosea, 8:7

In my book, Obama, Doctors, and Health Reform (IUniverse, 2009), published in the Spring of 2009, and in an interview with Dutch TV in June, I predicted President Obama would get something, perhaps one third of what he wanted.

He got more than a third but less than a whole. Among other things he did not get a public option, he did not rid the system of employer-based care and of private health plans, and he did not institute effective cost controls.

But he likely salvaged his presidency by passing his signature domestic initiative – a massive government-directed health reform bill. And he overcame daunting political odds – a 20% plunge in political approval to below 50%, united Republican opposition, a revolt among seniors, persistence unemployment, and concerns about a government take-over and a skyrocketing national debt, and polls indicating 60% to 67% of the public disapproved of the bill, and 77% disapproving of a Congress controlled by large Democratic majorities.

Now comes the whirlwind. What form it will take no one knows.

--Will the public be satisfied when they learn of the specifics in the bill and how it effects them individually?

--Will the individual and employer mandates appall those who believe in individual freedoms?

--Will seniors gracefully accept Medicare cuts, with shifts of benefits to the young and the uninsured?

-- Will we have more raucous town meetings when Congressmen return to their districts? Will there be violence?

--Will we have Tea Party marches on Washington and state capitals?

--Will the efforts of state attorney generals succeed in efforts to declare portions of the bill unconstitutional?

--Will the unpopularity of the bill cause voters to elect a Republican majority in the House, and maybe even in the Senate?

--Will a centralized government be up to the task of administrating and implementing the particulars of the bill, and containing the costs of what it has sown?

Or, as President Obama hopes, will this new vast entitlement programs be instantly addictive to a public who he thinks yearns for more and bigger government protections with more interventions into the private sector and into their lifes?

He who rides the whirlwind cannot always direct the storm.

Obama Statements and Contrary Facts

Specific Negatives of Various Versions of Obamacare according to John Goodman, conservative economist at the National Center for Policy Analysis

Preface: What follows are specific facts and comments of what others had said about where Obamacare will lead. There are, of course, many sides to the reform coin, and "facts" are always open to interpretation and positive and negative spin.

Here Goodman juxtaposes Obama statements against evidence by authoratative sources of how many people are likely to lose their current plan, tax implications, impacts on small businesses and entrepreneurs, premium increases, cost inflation, marriage penalties, the deal of Cadillac plans, and increase in the federal deficit. Obama statements are in italics.

“If you like the plan you are in you can keep it.”

19 million Number of people predicted to lose their employer plan (Lewin Group)


8 to 9 million Number of people predicted to lose their employer plan (CBO)


$11,543 Employer incentive to drop coverage for a $30,000 a year worker with family [Tax subsidy in the exchange minus tax subsidy at work minus $2,000 fine] (IRET)


8.5 million Number of seniors and disabled people at risk of losing their Medicare Advantage plan (Medicare Chief Actuary)


3 million Additional people who will likely lose Medicare Advantage plan benefits (Medicare Chief Actuary)


$816 Average annual benefit loss for 11 million seniors and disabled in Medicare Advantage plans (CBO)


33 million Number of people in traditional Medicare at risk of losing access to care because of $523 billion in cuts in Medicare spending (Medicare Chief Actuary)


20% Fraction of hospitals that would become unprofitable after Medicare spending cuts (Medicare Chief Actuary)


“There will be no tax increases for anyone who earns less than $200,000.”

73 million Number of people who earn less than $200,000 who will see their tax bill rise (Joint Committee on Taxation)


40% Tax rate on “Cadillac” plans (Reconciliation Summary)


2.3% Hidden tax on wheelchairs and other medical supplies (CBO update)


$27 billion Hidden “medicine cabinet” tax on drugs (Reconciliation Summary)


10% Tax on tanning salons (Reconciliation Summary)


$60 billion Hidden health insurance tax (Reconciliation Summary)



“Health insurance reform is…about creating a climate where our entrepreneurs and small businesses can succeed [and] about giving you the chance to prosper and grow.”

$100 million Cost of ObamaCare mandates for Caterpillar, Inc. in the first year alone (Caterpillar, Inc.)


60% Implicit marginal tax rate for workers earning as little as $25,000 (IRET)


65% Implicit marginal tax rate for families earning as little as $50,000 (IRET)


0.9% New payroll tax on the wages of entrepreneurs and small business owners (Reconciliation Summary)


3.8% New tax on the capital income of entrepreneurs and small business owners (Reconciliation Summary)





“The average family will save $2,500 in health care costs by the time I complete my first term as President of the United States.”

111% Premium increase for individual insurance (AHIP)


54% Premium increase for individual insurance (BlueCross BlueShield)


106% Premium increase for individual insurance (Wellpoint)


$2,100 Premium increase for the average family (CBO)



“Over the past year the House and the Senate have been working on an effort to provide health insurance reform that lowers costs …”

$220 billion Rise in national health care spending over the next 10 years (Medicare Chief Actuary)


“… that guarantees access to care …”

15 million Number of new people added to Medicaid, where care is increasingly rationed and where provider choice is increasingly restricted. (CBO)


0 Number of new doctors and nurses trained and number of new hospitals built to meet the needs of 32 million newly-insured (CBO)

” … and enhances the quality of health care for all Americans.”
24 million Number of people who will enter a health insurance exchange where health plans will have an incentive to underprovide to the sick. (CBO/NCPA)



“This is not about big government …”

16,500 Additional IRS auditors needed to enforce the legislation (Ways and Means Minority Report)




“This legislation will protect families …”

$6,000 to $10,000 Marriage penalty if two $32,000-a-year workers say “I do.” (Ways and Means Minority Report)




“We are going to get rid of the special deals …”

$7,300 Extra exemption from the Cadillac premium tax for members of labor unions. (Ways and Means Minority Report)




“This bill will reduce the federal deficit …”

$562 billion Increase in the deficit after removing budget gimmicks and unrealistic tax increases and budget cuts relegated to future Congresses (CBO former director)

Democratic Health Bill - Winners, Losers, Doctors

I congratulate President Obama and the Democrats on their “historic achievement.”

It was indeed “historic.” The House passed the Senate version with polls showing less than 50% presidential approval, less than 20% approval of a Democratic-dominated Congress, a 40% public approval of the health bill, and without a single Republican vote. That's quite a remarkable political achievement.

The only remaining questions are: Will this bill be able to win approval as it runs the parliamentary gauntlet? Is it an act of political suicide that will become manifest in November? Will it bankrupt the country because of lack of cost controls?

Regardless of where one stands, the bill is a political act of vast ambition and colossal risk.

Now may be a good time to pick winners and losers.

Winners

The winners are likely to be:

• Drug companies, which backed Democratic efforts and will have 32 million more new customers, financed by government.

• Hospitals, which heretofore have had to accept non-paying patients and now will have patients paying money-losing Medicaid rates.

• The uninsured, with the possible exception of the young and healthy who now buy insurance or be penalized by the IRS by failing to comply with the Individual mandate.

• Those with pre-existing illnesses, those whose payments were capped by insurance companies, those who had to pay full costs of preventive care or high deductibles, and children who will now be covered by their parients’ insurance policies until their 26th birthday.

Losers

• The biggest loser is likely to be private insurance companies, which will be heavily regulated, restricted from raising rates, obligated to accept all comers, unable to rescind coverage , and the target of higher taxes.

• Middle-class taxpayers and patients, who, if Massachusetts with its universal coverage can be used as an example, can expect higher taxes because of lack of cost controls, higher premiums as health plans pass through their increased expense. , more limited access to doctors because of primary care shortages, and longer waiting lines to see a physician.

• Medicare recipients, who among other things, will see about $500 billion cuts in benefits, higher fees, reduction in Medicare Advantage plans, and more controls over what tests and procedures doctors can order.

.The states, many already on the verge of barkruptcy because of high Medicaid costs. and Medicaid providers, physicians, pharmacists, and others, who cannot continue losing money based on low reimbursements. State attorney generals in nine states, are taking actions by mounting efforts to declare the bill unconstitutional.

Doctors

The results will be mixed.

Negative

• The practice load of 32 million more uninsured entering the system, coupled with the influx of new Medicare recipients, will strain the capacity of already overloaded practices.

• Low Medicare rates, and even lower Medicaid rates, will tax the ability of practices to survive economically.

• The doctor shortage, particularly of primary care physicians, now estimated at 50,000, will be exacerbated, partly because more doctors will decline to accept new Medicare and Medicaid patients.

• The bill does not address the problems that concern physicians the most – tort reform and the Sustainable Growth Rate formula, which calls for an annual reduction in Medicare Physician fees, this year 21%., and which is always reversed.

• The creation of an independent payment advisory board, free from Congressional oversight, is regarded as a negative, because it can make arbitrary decisions.

Positive

• Medicaid rates are likely to be increased to Medicare rates for primary care physicians . This will be plus for primary care doctors and will tilt the table towards primary care over specialists,

• Another plus is a “modest increase” in funding for training programs.

• The American Medical Association, the American College of Physicians, and family practice and pediatric associations have supported the Obama administration’s position on reform. The members of these organizations and physicians in general support expansion of insurance coverage for the uninsured.

I predict this bill will be the start of a long and bitter debate on how to fund generous federal health benefits – coverage for pre-existing illnesses, free preventive care, guaranteed comprehensive health plans, mandated benefits with no caps, and subsidies for 32 million uninsured , up to $88.000 per family.

As history has shown with Medicare and Medicaid, costs will surely far exceed projections. As a nation, we shall have to grapple with the economic consequences of the universal coverage moral imperative.

Perspective: Who Speaks for America's 650,000 Independent Private Physicians

Who,

-observesthat independent physicians care for 80% of America’s patients,

-describes the physician culture – its belief system, desire for autonomy, and reliance on clinical judgment,

-deplores independent private practice decline, which has shrunk by about 10 % over the last 10 years? (See “The Independent Physician: Going, Going ….” NEJM. February 12, 2010),

-explains accelerating departures of private doctors into retirement, non-clinical careers, hospital employment, and new practice models devoid of 3rd party interference.

- comments at length on a fast-growing movement, locum tenens, traveling physicians for hire.

-says that much of American medicine’s costs stem from lack of competition, open-ended comprehensive plans, mandated guaranteed benefits, restrictive regulations, physician malpractice expenses, ensuing defensive medicine practices, and litigious practice environments,

- discerns that much of the so-called fraud and abuse occurs in Medicare and Medicaid and is perpetrated by non-physicians using stolen identities, rather than physicians in their practices,

-notes that hospital-based medicine, with salaried physicians, as opposed to ambulatory-based medicine conducted by private physicians, drives costs up,

-warns the American people about the impending doctor shortages, the coming access crisis, and longer waiting lines for doctor appointments,

-highlights polls indicating patients trust their doctors more than government data-wielding bureaucrats,

-tells Americans that only 2% of medical students are entering primary care, and that these are the physicians they are expected to visit to sort out problems and to coordinate care,

-points out to Americans that many of the new 31 million who may gain insurance will be assigned to Medicaid rolls and that fewer and fewer doctors will accept new Medicaid recipients because of low reimbursements,

-explains problems imposed by third parties that erode time spent with patients,

-documents that for every hour spent seeing patients, another hour is spent on paperwork and getting permission to perform a test or a procedure,

-talks of doctor’s desire for more personal patient relationships and the patient’s distaste for doctor switching , both caused by health plans changing physician networks,

- appreciates that most patients do not know doctors are forbidden to enter into private contractual relationships with patents should patients desire treatment outside of Medicare,

-contradicts the often-heard liberal message that the U.S. system ranks 37th in the world is based on a deeply flawed 10 year old WHO study that has since been repudiated by WHO itself,

-has ever heard of another WHO study ranking U.S. health care number one among other nations in “responsiveness” – more attention to patients, shorter waiting times, more amenities, and greater access to world-class care,

-reveals shortcomings of evidence-based care, i.e., care based on statistical data on large populations, which may have little relevance to individual patients,

-talks of diagnostic uncertainties, that vast gray zone of vague symptoms of unknown cause, which may require multiple tests and procedures before a diagnosis surfaces.

-informs patients that physicians can spend little time with them in order to gain the revenue to pay malpractice fees, staff overhead, rent, and other costs of doing business,

-has the courage to say that poor outcomes may rest on what patients do after leaving the doctors, i.e., returning to adverse life styles, not filling prescriptions, resorting to ineffective alternative therapies, rather what the doctor does or recommends in the presence of the patient.

-speaks of shortcomings of electronic medical records among doctors – the expense, maintenance costs, lack of return on investment, practice disruptions, 30% dies-installment rate, 25% drops in productivity, mixed records of efficiency and quality improvement, and lack of relevance to solo and small practices.

- forewarms government policy wonks that electronic medical records are virtually useless to doctors as communication tools unless physicians are able to enter progress notes using speech-recognition information, or to have access to useful diagnostic support information,

- to sum up, informs the outside world of the story of independent practitioners - the backbone of American medicine?

Who articulates these things?

Medinnovationblog does.

Coming blog: the Physician Leadership Problem, Reality-Based Health Care, and the Role of the Physicians Foundation

I welcome comments - bad, good, and neutral, and I shall comment on your comments.

What Are Doctors Worth to Hospitals

As a physician, what are you worth to the hospital where you practice or wish to practice? That figure may be useful if you wish to sell your practice to the hospital, or if the hospital approaches you for employment. It may be useful in other negotiations with the hospital as well. The answer will depend on a number of factors – your age, your specialty, your past performance, and the section of the country in which you wish to practice.

To find some of the answers, Merritt Hawkins & Associates, the nation’s largest physician recruiting firm, recently conducted a survey of U.S. hospitals, and 114 hospitals responded.

In terms of annual revenues, the average doctor is worth $1.54 million a year. Revenue is defined as net inpatient and outpatient dollars from referrals, tests, and procedures done in the hospital. Also included below are the average annual salaries of the specialty.

Specialty, annual salary
• Neurosurgery, $2,815,650, $571,000
• Cardiology, invasive, $2,240, 366, $475,000
• Orthopedic surgery, $2,117,764, $481,000
• General surgery, $2,112,492, $321,000
• Internal Medicine, $1,678, 341, $186,000
• Family Practice, $1,622,832, $173,000
• Hematology/Oncology, $1,485,627, $335,000
• Gastroenterology, $1,459,540, $393,000
• Urology, $1,382,704, $401,000
• OB/GYN, $1,364,131, $266,000
• Cardiology, non-invasive, $1,319, 658, $419,000
• Psychiatry , $1,290,000, $200,000
• Pulmonology, $1,204,919, $293,000
• Neurology, $907, 317, $$258,000
• Pediatrics, $856, 154, $171,000
• Ophthalmology, $842,711, $282,000
• Nephrology, $696, 888, $240,000

Health Reform Buffet Syndrome

As the climatic vote on health reform approaches, permit me, if you will, to indulge in a play on words, namely the word, “buffet,” which allows feasting at a fixed price for comprehensive mix of goodies. As everybody knows, and Democrats keep reminding us, there is something for everybody in the current health care buffet, and we'll make it affordable in the short run, never mind the long-term costs.

The word “buffet” brings to mind Warren Buffett, the sage of Omaha, who has made a fortune on investing in companies with predictable returns on investment.

In a recent interview with CNBC, Buffett, said the current health reform bill does not control costs. He sees cost control as the central problem that must be addressed to reform the system, and he thinks we ought to start all over on health reform.

“What we have now is untenable over time,” said Buffett, an early supporter of Obama’s candidacy. “That kind of a cost compared to the rest of the world is really like a tapeworm eating, you know, at our economic body.”

“We have a health system that, in terms of costs, is really out of control,” he added. “And if you take this line and you project what has been happening into the future, we will get less and less competitive.”

That’s where the “buffet,” or “Buffett,” syndrome comes in. As long as Americans receive comprehensive benefits at the point of care, for benefits that personally cost them 10% or less personally, they will continue to feast at the health care table.

Expansion of costs of care will escalate, appetites for high tech solutions will rise, more people will congregate at the government buffet trough, and the federal budget will fatten.

The solution may be a la carte dining with health care customers paying more out of their own pocket to restrain spending on health care browsing. But that approach may be unacceptable politically for those who have become accustomed to a free-lunch free-entitlement mentality, and who believe health care is a right and a moral imperative.

Everybody, including those of us on Medicare, finds irresistible the idea of the health care buffet. When it comes to our own personal health, money is no object, particularly when we’re spending other people’s money. Unfortunately, as Margaret Thatcher observed, “The problem with socialism is that eventually you run out of other people's money.’

The Individual Mandate - A Shaky Foundation for Obamacare

Should Obamacare pass this week, it faces a shaky future because of its call for an individual mandate. This mandate requires people to buy insurance or face income tax penalties, which the IRS would presumably enforce.

As I write, attorney generals in 35 states are in the process of challenging the individual mandate as unconstitutional.

The individual mandate issue is important.

Kill it, and you kill Obamacare.

Why? Because the individual mandate is the political mechanism for controlling costs by spreading risk and dropping cost. The mandate allows the government to bring enough people into the insurance pool to make it affordable. It is a form of universal taxation.

The only other way to spread the risk is by changing the tax code to bring about universal coverage through a single-payer system, which is politically unpalatable to most Americans.

Feelings run high on the individual mandate issue. In a previous blog, “Health Reform Mandates – A Sleeper Issue, “ January 24, 2010, I led off with a yell from a New Hampshire café customer, who shouted,

” 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.”

Then, I added,

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

It is a sleeper issue because,

One, conservatives and independents strongly oppose the mandate because it will be unpopular with their constituents, whose main issues are an overreaching government depriving us of our individualism and driving us into deeper and deeper national debts.

Two, the legal issues are murky and muddled with lawyers deeply divided about whether the mandate is or is not constitutional. There’s a mare’s nest of legal opinions out there, meaning the issue is untidy and confusing and political. As Timothy Jost, a lawyer explained in the March 11 NEJM of the resistance of states to the individual mandate, “These resistance efforts are not about law – they are about politics.”

Three, it will difficult and expensive for the IRS to enforce a tax penalty on individuals who do not comply with the mandate, which starts in 2014 and is fully phased in on 2016. There are a number of exceptions, including those who cannot afford it and those who oppose it on religious grounds. Also the Senate bill waives criminal penalties and prohibits the IRS from imposing liens on taxpayer’s incomes or property for failing to pay. In other words, it invites individuals to flaunt the law and may well be unenforceable.

Name of New Book on Health Reform

I am preparing the sequel to my 2009 book Obama, Doctors, and Health Reform. Congress will vote this week to decide if health reform goes forward. The outcome of the vote will determine the title of my new book.

Here are title possibilities.

1) The Great Health Reform Debate, 2008-2010: Coverage and Cost

2) The Great Health Reform Debate, 2008-2010: The Obama Obsession and The Economic Recession

3) Health Reform Debate, 2008-2010: The Party of “Yes, We Can” Versus “No, You Won’t”

4) Health Care Debate, 2008-2010: Truths and Consequences

5) Health Care Debate, 2008-2010: Comprehensive or Incremental Reform

6) Health Care Debates, 2008-2010: The State of the Union and the State of the States

7) The Triumph and Tragedy of Obamacare

8) The Rise and Stall of Obamacare

9) Obama Versus Republicans: Too Much Too Soon or Too Little Too Late?

10) Government Reform: Immediate Taxes and Delayed Cost Transfers

11) Health Reform: Government-Controlled Versus Market-Driven Health Care

12) The Historic Health Care Debate, 2008-2010: What Kind of People Are We?

13) The Health Care Debate, 2008-2010: Cultural, Complexity, and Geographic Factors

14) The Health Care Debate, 2008-2010: The Elites Versus the People

15) The Health Care Debate, 2008-2010: Where Do We Go from Here?

16) Health Reform: Top-Down Versus Bottom-Up

17) Health Reform: The Scott Browning and The November Drowning

18) Health Reform: Tea Parties Versus Incumbent Parties

19) Health Reform: Your Money or Other Peoples Money

20) Health Reform: Government Control Versus Private Innovation

Government-Based Health Reform Isn't Easy

Preface - As I was reorganizing my 1240 blogs, I ran across the January 3, 2008 blog. It is appropriate to reprint it now as President Obama and Congressional Democrats scramble to put together enough votes to get a health bill passed.

____________________________________________________________________
Medinnovation Blog, January 3, 2008

Why Health Reform Is So Hard

I’ve been writing about American health reform for 30 years. It never gets any easier. I started in the 1970s when HMOs bloomed in Minnesota, thanks to Paul Ellwood. Ellwood convinced Preside Nixon HMOs were the thing. In 1973 the HMO act was born. The pace accelerated in 1976 when I attended an 8 week course on Health System Management at Harvard Business School.

A single payer system seemed imminent, and Senator Edward Kennedy got government money to support the course so Harvard could meet the major players in the new system. But reform was not to be. In 2005 I interviewed 42 national authorities for my book Voices of Health Reform. I concluded health care gridlock would continue because reform always geared someone else’s ox.

Hard for Many Reasons

Health reform is hard for many reasons. We distrust centralized government. We believe in equal opportunity not equal results. We think the majority rules even though minorities may suffer. We see freedom of choice and access as God-given rights. No “socialized medicine,” rationing or queuing for us. We’re not a cruel people. We just don’t believe government is the answer. Markets and self reliance are.

Vast, Diverse, Individualistic, Continental Nation

We’re a vast continental nation with vast regional differences, but our reform ideas tend to be half-vast. We have a mixed population of 310 million. Our people include 31 million recent immigrants with different cultural expectations. This creates barriers and confusion. We have a history of individualism. Our Wild-West mentality creates the illusion that all things are soluble as long as we move to the horizon and seek new frontiers of cure.

No Sugar Daddy, No Savior, No Silver Bullets

We all hold strong ideas of what health care should be, especially when someone else pays for it. Given this sense of entitlement, we expect, even demand, the health care we think we need. Damn the expense.

We yearn for a political savior, but there is no savior. The problem is bigger than politics. It’s being hooked on technology, behaving as we please, rushing to satiate to relieve anxiety and stress, riding rather than walking, believing vitamins, immune system builders, herbs, hormones, and other nostrums will do the trick, and, if all else fails, turning to specialists for a quick fix.

Body as a Machine

We see the body as a machine. If the machine’s face or frontal knobs sag, lift them; if pipes plug, bypass them or put in Drano; if joints wear out, replace them; if organs fail, cannibalize other machines for substitutes. Stress body owner’s manuals, artificial hearts and parts, and mechanical devices. We can’t replace one organ , but we’ve got Al (Algorithm) and Art (Artificial Intelligence) working on it.

Opportunists And Capitalists

We’re opportunists. Lift ourselves by our own bootstraps. Talk of safety nets, as if life were a high-wire act, but don’t dig too deep in our own pockets to pay taxes to weave new nets or to sew up holes in old ones.

We’re capitalists. Solve problems by letting markets reign. Let Big Management and Big Ideas solve social problems. In the end, blame Big Government. But distrust Big Government. As a conservative society, we suspect no nation can support a robust growing economic and a generous welfare state at the same time. We cite Europe as an example. Health costs for Europe’s aging peoples are growing as fast or even faster than ours. Their economic growth has been half ours over the last 25 years. Their unemployment is twice ours over the same period.

Meanwhile, Until Reform Comes

These are some of the reasons health reform is so hard. Meanwhile, until reform comes, we’re living longer. Deaths from cancer, heart disease, and stroke, and our cholesterols, are dropping. Things could be better, but we’re getting healthier every day even without reform. So don’t despair. Hang in there. Americans and their doctors are doing something right.

Physician Business Ideas - Getting You and Your Staff on the Same Page

“We must all hang together,
Or assuredly, we shall hang separately.”

Benjamin Franklin, 1706-1790

For the solo doctor, who make up 30% of America’s practitioners, success often depends on teamwork with your staff. Simply stated, it is less “me” and more “we”.

In these days of declining reimbursements and rising practice expenses, it will help if you and you staff work from a common set of principles.

To identify these principles, I suggest the following.

1) Appoint a chief innovation officer – a nurse, practice manager, physician assistant, your spouse – someone you trust.

2) Meet once a month with your staff to elicit and discuss innovative ideas.

3) As an agenda for these meetings, go to amazon.com or similar website and order these books.

• Practice Enhancement: The Physician’s Guide to Success in Private Practice

• Managing Patient Expectations

• The Successful Physician: Productivity Handbook

• Marketing Your Clinical Practice: Ethically, Effectively, Economically

4) Make copies of a chapter from one of the books that is relevant to your practice and use it as a the agenda and basis for discussion for your money meeting.

5) Relax. This is commonsensical, human, non-technological way to unite you and your staff. It works well for solo and other small practices.

President Obama and The Health Reform Time Machine

In 1936 Charlie Chaplin produced a classic film “Modern Times ” at the height of the Great Depression. The film’s theme was – “A story of industry, of individual enterprise - humanity crusading in the pursuit of happiness.” The film featured a Time Machine, which fed worker automatically so they didn’t have to stop for lunch and to make sure the workers kept producing. A Big Brother foreman incessantly drove them, depriving them of their humanity and their health.

The modern version might go like this.

The hero is President Obama. The time is the Great Recession, featuring unemployment and hard economic times. Our hero, decked out in a cape and yielding a magic wand, flits from backroom to backroom, handing out money and favors, telling workers they are being deprived of health care by evil employers, imploring workers to accept him as their savior, promising to stamp out fraud, abuse, and waste, and blasting health plans and other profit-making health industries as the enemy of the People. And so the story goes: Profit is your enemy. Government largess is your friend.

It is a compelling narrative. Our hero is a magnificent speaker. He speaks loftily of social protest – of organizing the American community to throw off the forces of the health industry. He will restore the people’s humanity and their happiness by insuring their health and by extracting money through high taxes from their oppressors – the rich, profit making businesses , particularly those in health care – private health plans, drug companies, device manufacturers.

The message is: Government is your friend. I will set you free from the shackles of free enterprise, which is not free and which imposes upon you unaffordable health costs.

But alas, our hero has distractions – a unified opposing political party, a skeptical public that supports individualism, a Tea Party movement that keeps citing Constitutional rights, and a political Time Machine, which feeds his supporters and keeps his administration ticking.

Unfortunately, the hands of the Time Machine indicate - in September, December, and now March – that our hero is not meeting his deadlines for getting the job done. The Machine says he must get it done before November, or else, he may never get it done.

P.S. I welcome comments – good, bad, and neutral. I will comment on your comments.

Doctor Patient Relationships - Milk of Human Kindness

Sometimes we medical bloggers focus too much on technical issues of doctor relationships with patients when little acts of human kindness would do.

I was reminded of this when I received Susan Keane Baker’s newsletter “Exceptional Patient Care.”You may sign up to receive a free copy by visiting www.susanbaker.com.

Susan gives talks across the country on the art of finding and keeping loyal patients, based partly on her two books Managing Patient Expectations and “I’m Sorry to Hear That….:”

In her newsletter, she tells how to express this kindness in two minutes or less.

If you have two minutes

• Encourage the patient to take the lead in your conversation.
• Stop in to say “hi” to a patient you had previous contact with.
• Evaluate patient’s coping system (humor, sotthing, withdrawal) and mirror it in your interactions.

If you have one minute

• Offer a snack.
• Share something that caught your attention.
• Explain what will happen next.

If you have 30 seconds

• Ask,”Do you have a favorite television show?”
• Share a joke..
Q: What did the sick baby banana say to its mother.
A: I don’t peel good.
• “Thank you for choosing us for your care.”

If you have 10 seconds

• Ask if patients has all of his/her belongings.
• Introduce yourself with name and title.
• Offer a business card.

Susan asks you to follow her on Twitter (www.twitter.com/hcahpsbooster) and quotes this Leo Tolstoy piece.

Kindness flows, anger bottlenecks.
A warm smile is the universal language of kindness.
Even if your kindness is not acknowledged, it is noticed and over time can soften the hardest hearts.
Kindness is in our power even when fondness is not.
The kinder and more thoughtful a person is, the more kindness they can find in other people.

P.S. I welcome your comments – good, bad, or neutral.

Call for Comments

I welcome comments - good, bad, or neutral. I will comment on the comments.

Richard L. Reece, MD

Electronic Health Records Use by Hospitals and Doctors

Great in Abstract Theory , Small in Concrete Practice

There’s a story of a husband and wife watching their children play in the newly laid concrete sidewalk. The husband is furious, screaming, red-faced, facial veins bulging. The wife says, “But Dear, I thought you loved children.” The husband replies, “ Yes, in the abstract, but not in the concrete.”

Electronic Health Records are like that. In the abstract, government officials love EHRs , but in the concrete world of practice, few hospitals and doctors use them, and even when they do, hospital and doctor EHRs rarely speak to one another.

Here is David Blumenthal, MD, National Coordinator of Health Information, speaking in the abstract He is responsible for implementing the government’s HITECH Act, designed to put EHRs in every doctor’s office and every hospital’s clinical unit.

This is a eloquent abstract statement, but as yet HITECH is failing to move health professionals to make concrete moves,

“Information is the life blood of modern medicine. Health Information Technology (HIT) is its circulation system. Without that system, neither individual systems nor health care institutions can perform at their best or deliver highest-quality care, any more than an Olympians can excel with a failing heart.” (1)

Then comes Blumenthal’s concrete conclusion,

“Yet the proportion of U.S. health care professionals and hospitals that have begun to transition to a electronic health systems are remarkably small.”

Blumenthal then cites two NEJM articles indicating only 1.5% of U.S. hospitals had comprehensive electronic records (i.e, present in every clinical unit), and only 4.0% of physicians reported having an extensive, fully functional electronic-records systems, (2,3),

The common denominator for hospital and physician resistance was the capital required for implementation and maintenance. Physicians feared a permanent loss in productivity and a disruption of practice flow.

To overcome this resistance, the government is promising generous bonuses to hospitals and doctors for implementing systems, with hospitals being given additional monetary incentives to help doctors install systems that interact with hospital systems.

There are signs government incentives may be working. Today I received this press release from MedCity, Inc. a company helping hospitals install EHRs.

March 9, 2010- Medicity, Inc. announced today that top-ranked health system Trinity Health, comprised of 44 hospitals and healthcare facilities in eight states, went live with the first stage of its Novo Grid deployment - establishing electronic health information exchange (HIE) with 297 affiliated physician practices and 991 physicians in three months.

The patented Grid technology distributes patient information directly to computers at the physician practice. Medicity's streamlined deployment technology and processes facilitated this rollout on a mass scale.

The Novo Grid will improve patient care coordination by offering community physicians secure, real-time electronic access to the health system's clinical data. The Grid deploys intelligent software agents that enable physician offices to receive patient information directly into an electronic health record (EHR) or, for paper-based practices, into an electronic "dropbox" accessible via a standard web browser.

Conclusion

If you are a physician interested in installing a system in your office, you may want to talk to your local hospital about its plans for implementing a system for its medical staff.


References

1. Blumenthal, D, “Launching HITECH,” NEJM, December 30, 2009.
2. DesRoches, CM, et al, “Electronic Health Records in Ambulatory Care – A National Survey of Physicians,” NEJM, July 3, 2008.
3. Jha, AK, et al, “Use of Electronic Records in U.S. Hospitals, “ NEJM, April 16, 2009.

Dichotomy between National Unemployment and Health Care Employment

Would someone out there among my readership help me understand?

President Obama keeps saying a big problem behind the nation’s troubled economy and our dire unemployment picture is rising health costs.

I have a problem.

I understand Obama’s point of view to a limited extent. Employers, particularly small businesses and start-ups, can’t afford to hire new workers because of health benefit expenses, so they do not hire new people, let go the old, or end health benefits all together.

What I do not understand is this: the latest Labor Department report indicates the U.S. lost “only” 36,000 jobs last month while the health sector gained 12,000 jobs. For February, the subsector for ambulatory health-care services posted the largest runup, adding 6,700 jobs. During this deep recession, the U.S. has lost 7 million jobs while health care has added 700,000 jobs.

Are job gains in health care bad? Are gains in health employment, and added taxes for local and state budgets, bad for the economy?

In many communities, health care is the dominant employer – the only place to go for a job, even a new career.

Is this bad? Please explain.

Signed,

A Dismal Economist

Health Savings Accounts - Medical Trends: Physician Mindsets and Microtrends as Reform Decision Nears

President Obama has called for an up and down vote of health reform this March before he departs on an Asia trip on March 17. Whether that vote will occur and what its results will be is uncertain.

The betting among conservatives is that Speaker Pelosi does not have the 216 votes needed to push reform forward. That bet may be based on wishful thinking.

Liberals and many moderates say, “Go ahead and make our day. Do not miss this historic opportunity.”

The final decision rests among Democrats, split among fiscally conservative Blue Dogs, who fear for their electoral lives and may vote “No,” and liberal members who think Obama has not supported their cause and who sense a historic opportunity slipping away.

Obama is seeking to split the difference and even to mollify a Republican or two by giving lip service to a few of their cherished ideas.

In the words of Drew Pearson, that famous columnist of yesteryear, “The Washington Merry-Go-Round goes round and round and where it stops no one knows.”

America’s physicians are divided between resignation and defiance. In 2012, or thereabout, government will pay for more than 50% of health care, and some 40% of doctors, more primary care than specialists, see a one-payer system as inevitable – even desirable.

But 60% of doctors, more specialists than primary care doctors, prefer a market-driven, consumer-centered system featuring health plan marketing across state lines, malpractice reform with caps and health courts, private contracting between patients and doctors, and health savings accounts with high deductibles.

Among doctors what is missing is national leadership. The AMA, with only 15% of doctors belonging and the other 75% saying the AMA does not represent them, has fallen into disarray. Some physician organizations, such as Sermo.com, the social networking site with 115,000 participants, and the Association of Physicians and Surgeons with only 3000 members but a loud voice, are dismissive of the AMA.

Other organizations, such as The Physicians Foundation, born out of a winning settlement with national HMOs in 2003, are seeking through a relationship with Northwestern’s Kellogg Management Institute , to form a national leadership center to train doctors to be national leaders. The Foundation’s strength is that it represents some 650,000 doctors who belong to state and local medical society. Its weakness has been getting its message out that doctors can make a positive difference to improve care on the national scene.

Out of this climate of uncertainty, indecision, and political paralysis has arisen anti-government forces and attitudes as manifested in the raucous town halls of last August, the rapidly emerging Tea Party movement, 75% of whom are college graduates, the voice of angry conservatives and independents as seen in the Virginia, New Jersey, Massachusetts, and Texas elections, and the widespread perception that an election debacle awaits Democrats in November.

Out of this chaos have also emerged some micro trends among physicians. I hesitate to call them megatrends because of the fragmentation and division among physician camps and among younger and older physicians. The things these camps share is a sense of frustration and the feeling that something, almost anything, has be done to rein in costs, raise reimbursements for Medicare and Medicaid, slay the malpractice beast, and give doctors more voice in their own business and private lives.

These micro trends, positive and negative for the national health and well-being,rest on these choices.

• A choice for a more remunerative, less stressful practice environment and more satisfying lifestyles. Towards these ends, young doctors are choosing the ROAD (Radiology, Ophthalmology, Anesthesia, and Dermatology) specialties, and the young. mid-career physicians , primary care and specialists alike, are opting for hospital employment.

• A choice not to enter primary care specialties - family practice, general internal medicine, and pediatrics. A recent survey indicates only 2% of medical students are entering these specialties.


• A choice not to see new Medicaid and Medicare patients, or those HMO/PPO members, who do not adequately pay for the cost of doing business.

• A choice to opt out of third party relationships – cash only and concierge practices, non-clinical employment, or hospital employment - to reduce overhead, to relieve themselves of the burdens and hassles and time required to deal with those third parties, and to avoid malpractice expenses and worries.


• A choice to choose a career at a Locum Tenens physician, a growing under-the-radar movement whose opportunities, enjoyments, and beartraps are explained in a recent book Have Stethoscope, Will Travel. Staff Care Guide to Locum Tenens (Practice Support Resources, 2009).

• A choice, or perhaps I should say a myriad of choices, to adopt and apply the new Internet-based information and marketing technologies – EMRs, IPods, all-purpose handheld computer phones, remote monitoring devices, data entry algorithms software, Twitter, and Facebook, and all manner of wireless gadgets – as essential tools of practice.

Lack of Cnsumerism - Why Health Care Costs So Much

I have two author friends in St. Paul, Minnesota, Greg Datillo, a health care agent, and Dave Racer, a publisher and author. They have an ambitious project – to write six pithy books on why health care costs so much. Their two immediate audience are health care agents throughout the land and consumers who pay the health care freight.

Greg and Dave have sent me their first two books of Why Health Care Costs So Much; Book One, The Solution: Consumers, 76 pages, and Book Two, The Government’s Role , 92 pages.

You can purchase them by calling 651-340-1911, or by emailing them at alethosepress@comcast.net. The books sell for $3.50 each with hefty discounts of 70% for volume orders. You can send checks to Althose Press, LLC, PO Box 600160, 55106,

Greg and Dave believe Government and the Private Sector have roles to play. Govcare for those who do not own private health insurances, and the private system for those who either own their health insurance or prefer to pay their own way.

For Govcare, they suggest three steps: 1) quit forcing ERs to act as medical clinics; 2) increase use of Community Health Centers; 3) make sure uninsured have access to public hospitals. Government, they say, must protect consumers from monopolies by enforcing anti-trust laws, and must protect the consumer’s right to see the price of care before they receive it.

For private care, they recommend; 1) portable health insurances, 2) an affordable, consumerized price-transparent system, 3) a stable method of paying fo the most expensive medical procedures; 4) non-insurance methods to cut costs of care and to improve outcomes.

Throughout the first two books, the authors maintain costs will come down dramatically if : one, before receiving care, consumers ask: How much does this cost?, two, if consumers pay more of their own money upfront, in the form of a higher co-pay or higher deductibles. The most logical way to do this on the private side is through Health Savings Accounts, already owned by more tha 10 million Americans.

To Readers of Medinnovationblog

This is my 1230th blog on the vital subjects of health innovation and health reform. I started this blog in November 2006, and it has been cited in national blogs, on TV, and in national print publications. I have written a book, Obama, Doctors, and Health Reform (Iuniverse.com, 2010). It accurately predicted Obamacare’s likely fate.

I am now in the process of interviewing 12 national authorities for Modernmedicine.com on where the system is headed.

As savvy observers of the health scene, no doubt you are acutely aware decisions on health reform now hang in the balance. Will the House of Representatives vote to go forward with Obamacare? If so, what’s next? If not, what’s next?

I daily address these questions in my blog, and I seek to answer them.

I am looking for additional sponsorship of my blog. I now have 26 sponsors, but I am looking for more to help me give you a more accurate picture of the future of care.

If you are interested in placing an ad for your organization for my blog , or if you would like to be interviewed or highlighted in my blog’s contents, please contact me at rreece1500@aol.com, or call me at 860-395-1501.

Richard L. Reece, MD
Friday,
March 5, 2010

Do-or-Die - "If" Questions about Reform Goals

Is the goal comprehensive or incremental?
If the goal is to be comprehensive,
Will that be too big and expensive?
If the goal is to be incremental,
Will that be too small and experimental?

Is the goal access or cost?
If the goal is to institute broad access,
What will constitute too few – or excess?
If the goal is to decrease cost,
How much needed care will be lost?

Is the goal to set care standards?
If the goal is monolithic government,
Will the rest of us be treated as sediment?
If the goal is prolific markets,
Who will judge each market’s merits?

Is the goal is to make everyone pay?
If the goal is to mandate individuals,
Who will chase down nonpaying criminals?
If the goal is mandate employers,
Enforcement will take a lot of lawyers.


Is the goal to expend $950 billion or $2.3 trillion?
$950 billion includes 10 years of taxes and 6 years of spending,
It requires gimmicks and budget bending
$2.3 trillion includes 10 years of taxes and 10 years of paying,
It reflects total budgetary outlaying.

In the long run perhaps it really doesn’t matter.
If you think of yourself as some political mad hatter,
Just pay your money and take your choice,
A future generation will pay the final invoice.