Dr. Reece’s Pieces, 24/7, Friday, April 30

Key words - on-call payment, on-call payment rates, physician opt-out rates for Medicare and Medicaid, concierge practices, cash-only, open-access scheduling, house calls, virtual medicine, bundled hospital-physician payments

Daily summary – Almost half of doctors do not receive pay for being on call; more doctors are not accepting Medicare and Medicaid patients; small practices are going into concierge practices with specialized services; hospitals and medical staffs are experimented with bundled payments.

FOR ALMOST HALF OF DOCTORS, IT DOESN”T PAY TO BE ON-CALL -MGMA, Health Leadersmedia.com -Nearly Half of Primary Care Docs Get No Additional Compensation for On-call “- Nearly half—44%—of primary care physicians received no additional compensation for on-call coverage, according to the Medical Group Management Association’s Medical Directorship and On-Call Compensation Survey: 2010 Report Based on 2009 Data. In addition, 49% of nonsurgical specialists who answered Englewood, CO-based MGMA’s survey reported no additional compensation for on-call coverage, while 72% of surgery specialists received additional on-call compensation. Most survey respondents said the compensation was in the form of a daily or annual stipend.The daily rate of on-call physician compensation varied greatly among specialties. Family practitioners with and without OB/GYN earned $110 and $100, respectively, per day. Neurosurgeons earned $1,671 daily. Ophthalmologists earned $500 in additional compensation per day while general surgeons earned $905 and urologists earned $283. The holiday rate for general surgeons was $3,000, and family practitioners received $588 per day.

WHY WOULD YOU ACCEPT MEDICARE OR MEDICAID PATIENTS IF YOU LOST MONEY ON EACH TRANSACTION? – Wall Street Journal, New York Times, ABC, CNN, FOX News - The story of doctors opting out of Medicare and Medicaid is all over the news these days, but the Obama administration doesn’t seem to notice. There is little in their health plans to encourage doctors to accept patients on government rolls or to create more doctors. Instead, the government is cutting reimbursements for specialists and for Medicare, and giving token increases for Medicaid beneficiaries. This at a time when the government is promising to add 16 to 18 million Medicaid patients, and 13,000 baby boomers each day will be joining Medicare ranks in 2011. In New York City, only 37 of 93 internists affiliated with NT-Presbyterian accept new Medicare patients. In Texas, only 38% of doctors take new Medicare patients. Nationwide, less than 50% of doctors accept Medicaid patients. It does not seem to have occurred to government that doctors must pay staff and business expenses, that getting paid and harassed by government agencies is a horrific harassment, and that doctors, like other ordinary mortals, have creditors who listen with a deaf ear to doctors who complain of poor reimbursement. Like other businesses, you don’t make up for payments below your cost of doing business by seeing more patients.

YOU CAN MAKE YOUR SMALL PRACTICE SUCCEED – ModernMedicine.com, “Physician's Focus: Make Your Small Practice Successful,” Whether you see it as small practice revolution or evolution, Modern Medicine thinks you'll be interested in the stories of physicians who have found innovative ways to make a small practice successful, starting with the experiences of several cash-only practitioners to help explain the concept and then the accounts of two others, one who has thrived and one who failed in cash-only practices. Next, discussion and perspective on concierge medicine, the open-access office and micropractices are presented, wrapping up with Modern Medicine blog posts and a CME opportunity for professional development.

• Cash-only medical practices skip the middleman - It's possible to walk away from third-party payers and still create a satisfying practice. In cash-only medicine, practices collect .

• from patients at the time of service (cash, check, or credit card), and don't accept private insurance. If a patient has coverage, it's the individual’s responsibility to get reimbursed.

• How to run a cash-only practice and thrive - This family physician runs a cash-only practice, sees 16 patients a day, goes home at 5, and takes home more than $250,000 a year.


• Why my cash-only practice failed -The author and her partner bet that patients would pay out of pocket for extra service. They were wrong.

• Making the switch to concierge medicine- If you want to spend more time with your patients, consider a retainer practice. However, unraveling your current practice to become a concierge doctor isn't for the faint of heart. This article explores the benefits (and drawbacks) of this type of practice and may help you decide if you're a candidate and tell you what steps to take to make the switch.

• The open-access medical office -By giving same-day or next-day appointments to people who desire them, an open-access practice can become a patient magnet. Seeing patients when they want to be seen helps you respond to their needs and stay competitive.

• Does an open access medical practice reduce risk? -By shifting responsibility to patients, true open access can also shift liability. The key is to be sure patients realize that it's up to them to comply with your guidance and recommendations.


• The medical micropractice -Using technology, doing without staff, and spending more time with fewer patients characterize the micropractice model. A micropractitioner typically works alone in a space that's drastically smaller than used by the average soloist. Such austerity reduces the customary overhead by 40% to 50%, thereby lowering the break-even point and enabling a physician to spend more time with fewer patients.

SURVIVING IN SMALL PRACTICES MAY DEPEND ON CREATING CONCIERGE NICHES – Healthleadersmedia.com – The newly redesigned practice of pediatrician, Natalie Hodge, is thriving. She has developed a concierge practice, renamed it Personal Medicine, avoiding 3rd parties, and specializing in house calls and “virtual medicine.”

LUMP AND BUNDLE IT. ANOTHER WAY TO GET PAID. Los Angeles Times and Dallas Morning News. Hospitals and medical staffs in California, Texas, New Mexico, and Oklahoma are experimenting with bundled payments for big ticket hospital procedures, like joint replacements. Hospitals and doctors negotiate on how to split a single payment for the procedure. As someone who has been there and done that as a PHO chairman I can attest that bundling is doable, not only for big but for common procedures and episodes of care as well. Its success depends on hospital-physician trust, physician leadership, and whether the bundled payments gain market share and health plans go along with the arrangement. Medicare has bundled payments on its innovation list, and Massachusetts is exploring this as a cost-cutting option.

Dr. Reece’s Pieces -24/7, April 29, 2010

Key Words - emergency rooms, ERs, medical homes, primary care, medical specialists, electronic medical records, imaging, CT, EMR, PET scans, Obamacare approval, Obamacare disapproval


EMERGENCY ROOM WOES - MSNBC: In as many as 42% of cases, ER patients give fake or inaccurate phone numbers, making it impossible or difficult for ER physicians to follow-up on patients with serious diseases or injuries when lab or x-ray results are delayed. Problems are due to short-term cell phone contracts, declining use of landline telephones, and patients who fear big bills or checks on immigration status. New York Times – ER use is exploding as millions lose jobs and medical insurance and turn to ER. This leads to long waiting lines and overworked doctors and nurses. New federal funds of $11 billion to 1200 community health centers for low-income patients may help relieve pressure.

SPECIALISTS SAY WE HAVE MEDICAL HOMES FOR PATIENTS TOO -New England Journal of Medicine. From California comes news that 45% of three specialist groups – cardiologists, pulmonologists, and endocrinologists – already serve as primary care physicians- and are therefore skeptical about medical home concept (L. Casalino, et al,” Specialist Physicians Practice as Patient-Centered Medical Home”).

WHO WILL CARE FOR 34 MILLION NEWLY INSURED PATIENTS? KevinMD.com, in “Primary Care Shortage Solutions after Health Care Reform,” Toni Brayer.MD, an internal medicine physician who blogs at EverythingHealth, reports that Obamacare will create access crisis to primary care doctors. Brayer says solutions are: *increase primary care residency program slots effective 2011 at teaching hospitals and pay more for those programs to increase.* Enact forgivable loans for all medical students who choose primary care and practice it for at least 5 years. * Raise the Medicare reimbursement by 40%. Even that may not be enough to turn this ship around. The inequities are just too large.* Allow even higher reimbursement for primary care doctors who practice in rural communities or under served areas. The pressures in those areas are magnified and should be rewarded.* Develop true systems of care where physicians treat the most complicated patients and nurse practitioners handle routine care.

ELECTRONIC MEDICAL RECORDS – "MEANINGFUL" FOR WHOM? -April issue of Health Affairs – “Health IT.: The Road of Meaningful Use.” The Obama administration has put a lot of its eggs, $20 billion worth, in the HITECH basket. When American Recovery and Reinvention Act passed in February 2009, only 6% of doctors and 2% of hospitals had fully functioning EMRs, yet EMRs, says David Blumenthal, MD, national coordinator of HITECH, says EMRs are a critical part of health reform puzzle. Yet what is meaningful to policy wonks and government managers may still be meaningless to doctors in small practices and hospitals. Combination of “free” EHRs, based on outsourcing to Internet , cloud computing concepts, new business models where advertisers pay freight based on Google methodology , and financial installation incentives for doctors and hospitals make constitute breakthrough for increased EMR use. I have always been suspicious when word “meaningful” is used. It usually comes from mouths or pens of self-righteous elites who think they, and only they, have answers to what society needs.

DO CT, MRI, AND PET SCANS REDUCE CANCER DEATH RATES? THESE IMAGING PROCEDURES MAKE UP 57% OF COSTS OF TREATING CANCER. ARE THEY WORTH IT? National Bureau of Economic Working Paper “Has Medical Innovation Reduced Cancer Mortality? Yes, the working paper says. It has caused a 40% drop in cancer mortality between 1996 and 2006 due to imaging innovation, and only 25% decline due to drug innovation. But investigators in Duke study in current JAMA are not so sure about imaging costs and drops in cancer mortality. They say it is impossible to tell if costs of CT, MRI, and PET scans help in reducing cancer mortality. Laurence Baker, professor at Stanford and Head of Health Services Research says, “No one wants to live in a world without MRI or PET scans. We have had a hard time figuring out when to use them and when not to.”

IF OBAMA HEALTH PLAN IS SO GREAT, WHY DO MUST AMERICANS DISAPPROVE? Real Clear Politics, Here are the facts, as shown by average of major polls, of Approval and Disapproval Obama and Democrats' Health Care Plans

Poll, Favor, Oppose, Spread

RCP Average 40.2, 52.7, +12.5

Rasmussen Reports 38, 58, +20

Democracy Corps 42, 49, +7

Quinnipiac 39, 53, +14

Associated Press 39, 50, +11

GWU/Battleground 44, 52, +8

FOX News 39, 54, +15

Conclusion: No Obama bump yet, but it’s a long way from April to November.

Modernmedicine.com - A 24/7 Website Physicians Can Wake Up To

Key words - physician news, Washington politics, politico.com, 24/7 Politico playbook health reform, Obamacare polls, kevinmd, , modern medicine, wsj health blog, the health care blog, kaiser daily health news, health leaders media fierce healthcare real clear politics


News is breaking fast on multiple health reform fronts in Washington and elsewhere. So fast we physicians cannot keep up with it. Newspapers, physician print publications, physician social networking sites, TV networks, Internet bloggers, and scattered online sites cover the health care landscape in general. However, these media outlets do not focus specifically on the impact of fast-breaking news developments on physicians in small practices who deliver 80% of the care in the United States.

Politico.com

Physicians may need an analogue of Politico.com If you are unaware of Politico.com, it is a 24/7 online Washington-based publication devoted entirely to insider political information from insider sources on what’s happening in D.C., short for “Darkness and Confusion.”

Some of this information is gossip, some of it is rumor, some of it is trivia, some of it is fact, and some of is a forerunner of trends to come.

The 24/7 Politico Playbook

The most widely read column in Politico.com is “The 24/7 Politico Playbook.” Its author is Mike Allen, a journeyman reporter who spends his waking hours communicating, collecting, and consolidating late-breaking information from his extensive insider network of informed sources and translating it into a 4AM email news blast.

The April 25 New York Times Sunday Magazine cover ran a piece on Allen “The Insider’s Insider: Mike Allen and the Politico-ization of Washington.” Each morning, the article says, Allen writes his column and at 4AM sends out an email blast to 3000 influential readers. The Sunday New York Times Magazine article claims the White House staff and other Washington insiders read Allen’s words the first thing each morning before all else. It is like an early morning political Gospel reading.
Health Care Online Sites.

Nothing Comparable in Physician World

The physician world has nothing comparable to Politico.com, although a number of daily online sites exist that talk about health care in general. My favorites are the WSJ Health Blog, The Health Care Blog, HealthLeadersmedia.com, Fiercehealthcare.com, and RealClearpolitics.com. Real Clear Politics features, among other things, a daily health care poll on approval and disapproval of Obama’s health plan.
A few online sites, like physiciansfoundation.org, sermo.com, and modernmedicine. com, address the concerns of private independent physicians.

Other sites, which I call Lone Ranger physician blogger sites, e.g.., Kevinmd.com, produce a blog a day on pieces of the health care puzzle. I am one of these blogger sloggers. I have composed 1302 blogs in the last three years on various aspects of the system.

Unfortunately, no one, including myself, has the time, intellect, technological know-how, political savvy, or insider sources to address all health system complexities or to acknowledge that American health care is a whirling Rubik’s Cube, with millions of interrelated, fast-moving parts, changeable institutions, and niche-seeking entrepreneurs, each with agendas, axes to grind, and oxen to gore.
Modernmedicine.com, an online Web presence has taken 17 print publications and a number of national physician organizations under its online wing. Modern Medicine aggregates information for independent private physicians . It is rapidly evolving into a site where physicians can find almost everything they want to know about late-breaking and useful clinical, political, business, technological; and research information, including interviews with physician leaders and leading physician bloggers.

Unnatural Human Communication, The Main Barrier to Electronic Medical Records

To hear the electronic online crowd tell it, EHRs are the Holy Grail for improving and rationalizing the health care system.

At one stroke (and multiple key strokes), EHRs will,

• Reduce medical errors

• Narrow disparities in care delivery

• Engage patients in their own care

• Spark coordination of care

• Give access to doctors to best practice information

• Enhance communication across the health care spectrum

Besides, EHRs will replace and overcome those dreadful paper records, which are,

• Space-occupying

• Irretrievable

• For physician-eyes only

• Private, personal, and secure

• Individualistic

• Fragmenting the system

Order Out of Chaos

EHRs are, in short, a way to bring order out of chaos and to reduce the world to a series of electronic bullet-points, around which everything can be organized, everything is logical,everything can be encapsulated, and everything can be presented and understood as a kind of Powerpoint Presentation.

The main trouble with all of this is that EHRs and PowerPoint presentations cannot capture all the subtleties, permutations, and combinations of human interactions and reduce these exchanges into data bytes and bullet points.

As observed in today’s New York Times, “We Have Met the Enemy and He is PowerPoint, “ PowerPoint Presentations are akin to “hypnotizing chickens,” i.e., they look good, feel good, and mesmerize viewers, but lack the subtleties and nuances of humankind. Still, the chickens are crossing the communications road and seem to be in command of the road.

In today’s The Health Care Blog, Robert Rowley, MD, chief medical officer of Practice Fusion, Inc, writes in “Challenges in EMR Adoption by Doctors Offices,” that his company’s’ “free” EMR system, which allows small practices to install an EMR , quickly, with minimal training at no cost to the practice except having a computer with broad band access to the Internet, may be a starter for overcoming physician barriers to EHR adoption. These barriers include direct and indirect costs of installation and maintenance, diversion and distraction from seeing patients, and drops in productivity and income.

Dr. Rowley should know: his practice has been “paperless” since 2004.
and he may be right. The world is moving on Internet time at Internet speed, the paper world of newspapers and book publishing is going paperless, and we paper-bound creatures are groping for new paperless business models to survive.

Obamacare Impact , as Cited in the Medicare’s Chief Actuary’s Report

Rick Foster, Medicare’s Chief Actuary, states the following in his just released Actuary’s Report.

• Health care costs will go up. National health expenditures will increase from 17 percent of GDP now to 21 percent under the new law and will be higher than without the legislation. [Page 4]

• Health care shortages are “ probable.” Because of the increased demand for health care, “ there may not be enough doctors to provide services desired by the additional 34 million insured persons.” [Page 20]

• 14 million employees will lose their employer coverage. Employees of small firms are especially at risk. [Page 7]

• 2 million employees who lose coverage will have to enroll in Medicaid. [Page 3]

• A Medicaid insurance card will not guarantee care. An estimated 18 million people will be added to Medicaid, AND there will not be enough doctors to care for them.. [Page 3]

• However, because there is no corresponding increase in the supply of caregivers, “it is reasonable to expect that a significant portion of the increased demand for Medicaid would be difficult to meet, particularly over the first few years.” [Page 20]

• One in ten insured workers will see their health benefits taxed. By 2019, more than 10% of insured workers will “be in employer plans with benefit values in excess of the thresholds (before changes to reduce benefits) and this percentage would increase rapidly thereafter.” [Page 13]

• Higher taxes will lead to higher premiums. The new taxes on medical devices, prescription drugs, and insurance plans “will be passed on through to health consumers ias higher drug and device prices and higher insurance premiums.” [Page 17]

• More than one-half trillion in Medicare cuts will occur. The new health law cuts “$575 billion” from Medicare. [Page 4]

• Medicare cuts will make almost one in every seven hospitals unprofitable . About “15 percent of Part A providers would become unprofitable within the 10-year projection period.” [Page 10]

• Overall access to care for seniors will go down. Because of the law’s payment reductions, “providers for whom Medicare constitutes a substantive portion of their business could find it difficult to remain profitable and, absent legislative intervention, may end their participation in the program. [Page 10]

• 7.4 million people will lose access to Medicare Advantage plans. Enrollment in MA plans will be cut in half (from its projected level of 14.8 million under the current law to 7.4 million under the new law). [Page 11]

• The new “Medicare Tax” doesn’t go to Medicare. “Despite the title of this tax, this provision is unrelated to Medicare; in particular, the revenues generated by the tax on unearned income are not allocated to the Medicare trust funds.” [Page 9]

• Budgetary double-counting will not improve Medicare’s solvency. Medicare cuts “cannot be simultaneously used to finance other federal outlays (such as the coverage expansions) and to extend the [life of the Medicare] trust fund, despite the appearance of this result from the respective accounting conventions.” [Page 9]

• The new long-term care insurance plan (CLASS Act) is unsound. The program faces “a significant risk of failure” because the high costs will attract sicker people and lead to low participation. [Page 15]

Conclusion

Medicare’s Chief Actuary says the government will create more Medicaid recipients, take away Medicare benefits, increase overall costs, tax to defray costs, decrease access to care by reducing doctor pay and driving them out of practice.

The Ideal Health System

Key Words - patient ownership of health plans, consumer driven health care, private contracting, malpractice, shopping for health plans across state line, free market competition, independent physicians

Summary of interview with Donald Palmisano, MD, former AMA President and Founder of Intrepid Resource®

Preface: Donald Palmisano, MD, JD, is perhaps organized medicine’s most articulate spokesman, and one of the few who equally grasps medicine and legal issues He served as president of the American Medical Association in 2003-2004. Dr. Palmisano speaks often on malpractice’s hidden costs. He is Founder and President of Intrepid Resources ®, a risk management and patient safety company.

“Q: Doctor Palmisano, have we reached a watershed moment in American health care?”

“A: Yes, we have reached a critical moment, Government and third party intervention is disconnecting the patient from the physician and the decision making from the patient’s best interest. The ideal system is one where patients own their health insurance and makes decisions with the doctor as trusted advisor.”

“Q: What system do we have now?”

“A: We have third parties saying what treatment will be allowed. We have government taking away the right of private contracting between patients and physicians. With Medicare, doctors must accept what government pays because if you do a private contract the physician is removed from Medicare for two years. We are moving towards more government control, a system that will not lower costs, and one in which physicians are being paid less than the cost of delivering care. “

“Because a patient has a Medicare or Medicaid card does not mean that patient will find a physician in his or her hour of need. Fewer and fewer doctors accept Medicare or Medicaid patients because federal and state government pays less than the cost of delivering care. Price fixing has never worked, and it is not going to work in medicine.”

“I recommend expanding coverage through tax credits, consumer choice, market enhancement, low cost health savings accounts, individual ownership of insurance, extending subsidies to those who need financial help, the right to privately contract between patients and doctors, and purchasing insurance across state lines.”

“These free market principles would take care of the monopsony power of health insurers, what they allow patients to receive, and what they pay the doctor.”

“Q: Can independent doctors in small practices do anything to change the dynamics?”

‘A: Independent physicians represent 80% of practices. They have to be engaged in the political process by contacting their representatives in Congress and their two Senators and telling them how adversely this interference is effecting their practice. They should encourage their patients to do the same.”

“Otherwise folks in Washington will remain in their bubble. They don’t hear enough about what’s happening in the actual practice of medicine. They are just listening to talking heads and think tank wonks.”

“The public is being given bad information. When the President of the United States says a physician would amputate a leg to get $50,000 rather than treating the patient medically, he is getting bad information from advisors. When he says a doctor will do a tonsillectomy rather than treating a child for tonsillitis, it is not appropriate. We need to get the real fact and to identify what the problems are.”

“First, some health insurers ignore patients and physicians Their misplaced monopsony power allows them to dictate terms. We fix that by competition across state lines.”

“Second, we need to get insurance for people with pre-existing conditions. We can do that with voluntary purchasing cooperatives so people can get together in groups of 10,000 or more. Everybody can be accepted when they have the options of getting bids on large groups, just as in a large company like IBM.”

“Third, Why should people on Medicaid have less than ideal access to care? Convert Medicaid into a defined contribution. Give them the same advantages as people in the Federal Employee Health Benefits (FEHB) Program. Give them a voucher, and allow them to choose from an array of choices.”
“Government should not assume the American public is not smart enough to make their own decisions. We need more control given to patients, the same tax advantages for every American.”

“ With this government plan, we will end up with Medicaid-for-all, with long waiting lines, and no doctors to treat them. Physicians will do something else. They will limit their practice, or switch to concierge or cash practices and directly contract with patients.”

“They will get out of Medicare, Medicaid, and all insurance programs. That’s not good for anybody.”

Medical Licensure as a Condition for Seeing 34 Million Government-Subsidized Patients

From Daniel Palestrant, MD, founder and CEO of Sermo.com, a social networking company with 115.000 physician members headquartered in Cambridge, Massachusetts, comes this word. The Massachusetts legislation is considering making accepting government-subsidized patients a condition for medical licensure ("(More)Madness in Massachusetts, " The Health Care Blog, April 22, 2010). Palestrant's fear is that the Massachusetts Madness will spread to the rest of the nation.

Palestrant puts it this way,

“Lately I have been watching with complete horror the events playing out in my home state of Massachusetts. A bill currently under review by the state legislature will make participation in the state and federal Medicare/Medicaid programs a condition of medical licensure, effectively making physicians employees of the state. “

“This is particularly alarming because Massachusetts is essentially a leading indicator of what will happen in the rest of the country. Several years ago the state passed a series of laws mandating health coverage. Like the recently passed national health reform bill, the Massachusetts law did not address any of the well known causes of runaway costs, including tort reform, drug costs, or insurance regulation.”

Can Massachusetts Impose This Mandate on Doctors?

Is it constitutional? After all, America is a Democracy. Like other citizens, physicians have individual rights . Will the Massachusetts government risk imposing its power over the rights of private physicians and the will of the people?

A recent joint survey of 1000 physician across the U.S. by Athenahealth, another Massachusetts health firm, and Sermo indicates 59% of physicians thought the quality of care after Obamacare would deteriorate over the next five years while 54% said further government intervention would not improve care.

Then there is the election of Senator Scott Brown in Massachusetts. Exit polls indicate his opposition to Obamacare sealed his victory. As it turned out, of course, Brown’s opposition to Obama’s health plan was not enough to ward off the Obama health plan passage.

Furthermore, an average of these national polls – Quinnipiac, Associated Press. Rasmussen Reports, GWU/Battleground, FOX News, CBS News, USA Today/Gallup, Washington Post, Bloomberg, and CNN/Opinion Research – reveals that 52.8% oppose the Obama Health Care Plan while 40.0% favor the plan. Will the percentage of those against the plan increase when the public sees cost increases (Robert Pear, "Health Care Cost Increase is Projected for New Law," New York Times, April 23, 2010.

Pallstrant is not optimistic about physicians’ prospects for independence.

“We will no doubt see the same sequence of events play out across the country as the current versions of health care reform are implemented. The net effect of these laws is that it will make it close to impossible for physicians to stay in private practice. Patient access to physicians will suffer as more and more physicians retire and/or move to different states. “

These events raise a fundamental question. Does government, at either the state or federal level, possess the power to impose its laws over the will of physicians or the American people?

Not a Trivial Question

This is not a trivial question. It strikes at the core of the American democratic experiment – balancing the power of a collectivist government against the will of scattered individuals and ordinary people. Mandating doctors to accept patients in government programs represents a struggle for power of control of health care resources.

No one knows how this struggle will play out over the next ten years, but the midterm elections in November 2010 may indicate how the struggle will go and in what direction the country is headed.

National Health Outcome Rankings: It’s the Culture Stupid!

Deciphering That 2000 WHO “Zombie Number” Ranking the U.S. 37th in the World

Philip Musgrove, PhD, who was editor-in-chief of the 2000 World Health Report, Health Systems: Improving Performance, says the report, published under his editorship, ranking the U.S. 37th in the world was a mistake (“Health Care Rankings, “ Letter to the Editor, New England Journal of Medicine, April 22, 2010). “It is long past time,” he says,” for this zombie number to disappear from circulation.”

Musgrove was responding to a New England Journal article critical of U.S. health care by two medical academics, Murray, C;l. and Frenk, J.: Ranking 37th – Measuring The Performance of the U.S. Health Care System,” N Engl J Medic 2010, 362:98-88.

Mosgrove argues that 37 is a”zombie number”because it predisposes national health outcomes depend only on access and ignore cultural, geographic, and historical factors.

I’m with Mosgrove. These examples supporting his position spring to mind.

• Medical care accounts only for about 15 percent of the health status of any given population (Leonard Sagan, The Health of Nations: True Causes of Sickness and Well-Being, 1987). Life style accounts for 20 percent to 30 percent, and income differences, and lack of social cohesion for the other 55 percent(D. Satcher, and R, Pamies, Multicultural Medicine and Health Differences, 2006).

• If one were to eliminate violence and accidents from the statistics, the U.S. would rank near the top in longevity. John Holcomb, M.D., the U.S. Army’s top trauma surgeon is fond of quoting the statistic, that, among U.S. civilians, trauma leads all diseases in terms of life-years lost, more than heart disease or cancer. That’s a useful statistic to keep in mind when comparing national health systems. If one takes trauma and violence into consideration, U.S. longevity statistics are comparable to any other country. Civilian trauma and deaths are largely beyond the health system’s reach.

• The U.S. is the number one destination for the world’s immigrants. The U.S. receives some 85 percent of the world’s immigrants. Because of such things as poverty, cultural differences, poor prenatal care, and discrimination, the non-white population, a disproportionate number of whom are immigrants, have lower life expectancies as follows; whites 81.0 years, black 63.6 years, Hispanic 74.0 years, Asian 75.2 years. (Abstract of the United States, 200-2004). From 1993 to 2003, the U.S. population exploded by 12.3 percent, due in large part to newly arrived immigrants with and their subsequent fecundity. This unexpected growth contributed to the physician shortage, lack of access to care, and dismal statistics.

• Life expectancy in the United States, a vast continental nation, depends on where you live . If you are black man in Harlem, your chances of surviving past 40 are less than if you lived in Bangladesh or other third world countries. If you live in Minnesota, you will live on average to 80.5 years. If you live in Mississippi, you are likely to die by 73.9 years. These various statistics are largely due to socioeconomic factors beyond the reach of health care professionals, who do not control what goes on in the streets or immigration patterns.

Top-down health care social engineering is a fine and wonderful bundle of good intentions worth pursuing, but it has its limitations - such as achieving uniform improved outcomes across all cultural groups.

Solo Doctor with Solo Nurse: Blast from Past with Plea for More Personal Future Care

Key Words: solo practitioner, office nurse, primary care, medical home, comprehensive care

Summary of Interview with Donald Copeland, North Carolina primary care physicians



Prelude: Dr. Donald Copeland and I go back a ways. We were among the early organizers of the High Performance Physician Institute. We were dedicated to the proposition that information technologies could be a boon to medical practice. Now Don is not so sure, nor am I, nor is he confident that bigger organizations or tighter management are the answers to the doctor shortage, and to addressing the problems of primary care.

“Q: You have strong views on primary care. For example, you think people are making it more complicated than it needs to be.”

“A: When I first started practice 1965, the main thing was to have a doctor and a nurse. We took care of everything, we managed our practice, admitted and discharged patients from the hospital, and referred them to the proper specialists.”

“Q: I have heard you say you think the medical home is nothing more complicated than the nurse and the doctor.”

“A: Not exactly. There are other people needed to support a practice. It depends on the economics. It’s expensive to hire a lot of people. In my other practice, I had a lab girl, a radiology girl, and a business office. “'

“But the key person is a personal nurse to communicate with my patients, get the chief complaint, to set up the room, take vital signs. The idea of a team approach in the medical home is not anything new.”

“Q: The medical home people say you need to hire a chronic care coordinator to put the team together.”

“A: That’s a nurse. I conduct a chronic care clinic over at Lincoln County, I have a nurse, and that’s it. I have a great lab, but not a lot of other people and a receptionist. That’s the team. You don’t need a patient coach, a nurse educator, and a nutritionist. The people following up patients on the outside don’t need to be in my office. The social service people can do that.”

“Q: You have said the solution to the primary care dilemma is quite simple. You just double the coding rate for office visits.”

“A: I was talking about Medicare rates. Those rates are too low, and barely cover overhead. The overhead rate is about 60%. I’m a firm believer that everybody who graduates from medical school should make at least $200,000 a year. I think of that figure when I’m paying my lawyer $300 an hour when I make a 10 minute phone care. He charges a minimal hourly rate. It’s ridiculous. A hospital CEO in Charlotte makes $4 million a year.”

“Q: President Obama has recommended the government spend $50 billion over the next five years to make electronic medical records mandatory, and there is underlying threat to restrict payment only to those doctors with electronic records. What do you think?”

“A: I think it’s ludicrous. You and I know that I know enough about electronic records to know that all EMRs are just a way to keep records. You can teach how to practice primary care or judge how they perform with medical records How can EMRs transform medicine? EMRs advocates say EMRs are a way of teaching or telling us how to practice medicine, but most of the people promoting them have never practiced medicine.”

“Q: You’ve practiced solo, you’ve practiced in large groups, and you’ve trained people to practice it.”

“A: At Bowman Gray, we trained our doctors to practice in rural areas. The problem with some of these residency programs they are training people to be half-trained internists. You have to train people to deliver babies, perform minor surgeries, even an occasional appendectomy, sew up lacerations, apply a cast, inject a joint, biopsy a suspicious skin lesion, treat a skin rash, make a tough diagnosis. That goes with the territory.”

“A: In other words, you teach them to practice comprehensive medicine. You teach them to practice in modules as personal doctors with personal patients with a personal nurse to help. Our residents had personal patients, and they took personal care of them."

Is Obamacare An Attack on Seniors? A Google Doodle

I do not know if Obamacare is an attack on seniors. But in his “Health Alert: “War on Seniors,” John Goodman, a conservative economist who founded the National Center for Policy Analysis, asserts,

• "More than half the cost of health reform will be paid for by $523 billion of cuts in Medicare spending over the next ten years."

• "Although there are some new benefits for seniors (mainly new drug coverage), the costs exceed the benefits by a factor of more than ten to one."

• "As many as 8.5 million of the 11 million seniors in Medicare Advantage (MA) plans may lose their coverage, according to Medicare’s Chief Actuary."

• "Those lucky enough to retain their MA coverage will face steep cuts in benefits or hefty increases in premiums or both."

• "In addition to these direct costs there are indirect costs, including new taxes on drugs and medical devices. Although these taxes don’t single out senior citizens, who do you think are the heaviest users of wheelchairs, crutches, artificial joints, pacemakers, etc.?"

• "To make matters worse, severe rationing problems lie ahead, as 32 million newly insured people double their consumption of medical care under a reform bill that produces not one new doctor or nurse or other paramedical personnel."

. "Because many of the newly insured will be in private plans paying market rates, they will be more attractive to doctors than Medicare enrollees paying about 20% to 30% less."

Do Goodman's assertions reflect the prevalent opinion?

Yes, among seniors. according to various polls,seniors oppose Obamacare by about a 60:40 margin. And yes, among the American public. Thirteen percent more of the public now “oppose” health reform current health reform bill than “favor” it ( see average poll results among 20 national polls on Real Clear Politics).

But I am still not convinced that a "war" exists. So I have gone to Google to see what it listed as the top 10“Obamacare and Seniors" articles to get a sense of what is being said out there among the media.

Here is what I find.

Results 1 - 10 of about 204,000 for "Obamacare and Seniors."

Search Results

1. GovernmentCare's Assault on Seniors. - WSJ.com
Jul 23, 2009 ... The assault against seniors began with the stimulus package in February. ... ObamaCare will undo that. Ms. McCaughey is chairman of the ...
online.wsj.com

2. How Obamacare Will Cost Many Seniors Their Private Drug Insurance ... Jan 2, 2010 ... The Wall Street Journal writes about the Senate's destructive change in the way retiree health benefits are taxed.
online.wsj.com

3. Obamacare For Seniors – The Gift That Keeps On Taking ...
Apr 6, 2010 ... Obamacare for seniors equals higher costs, limited access to services and ultimately rationed care.
libertyssong.wordpress.com

4. Exempted From Obamacare: Senior Staff Who Wrote the Bill
Mar 22, 201.newledger.com

5. The Catholic Thing - Obamacare: Will Seniors Have a Duty to Die?
Jul 29, 2009 ... The Catholic Thing: cultural and political commentary grounded in Catholic Tradition, George Marlin on Obamacare and the denial of treatment ...
www.thecatholicthing.org/content/view

6. Morning Bell: Obamacare's Effect on Seniors | The Foundry ...
Jul 28, 2009 ... Why is there not more commentary about the fate of seniors under obamacare? That should be the subject of a national ad campaign and ...
blog.heritage.org

7. Poll: Majority says repeal ObamaCare, especially among seniors ...
Apr 5, 2010 ... Fifty-four percent of Americans want ObamaCare repealed, Rasmussen reports. Moreover, the trend is moving in the wrong direction for ...
www.washingtonexaminer.com

8. Obamacare: Why Seniors Protest The Public Option (health care ...
Aug 22, 2009.."Some would say seniors are misinformed or even brainwashed by cable news. After all, Medicare doesn't ration care, neither does it have a ...
www.city-daily, Politics and Other Controversies

9. The Strata-Sphere » Obamacare Broke Medicare Part D – Seniors ...
Tweets that mention The Strata-Sphere » Obamacare Broke Medicare Part D – Seniors Losing Coverage -- Topsy.com on 27 Mar 2010 at 9:44 am ...
strata-sphere.com/blog

10. » Report: ObamaCare Would Reduce Care For Seniors - Big Government Nov 15, 2009 This post was mentioned on Twitter by biggovt: Report: ObamaCare

Conclusion

This google doodle is a small sampling. It merely reflects 10 of the 2004 articles devoted to seniors and Obamacare that rose to the top using Google’s formula for listing widely read articles.

A doodle does not make a oodle, as in saving oodles and oodles of money on Medicare. But it worth noting that 50% of the money spent on health care goes to seniors and that is where oodles of money will be saved.

Women in Medicine: When Gatherers Become Hunters

Key words - women physicians, house husbands, malpractice, midwives, hospital employment of doctors

Summary of interview with Elizabeth Chase, MD, obstetrician-gynecologist in Dover, New Hampshire

Preface: Elizabeth Chase, better known as Betsy, is a close and enduring college friend of my son, Spencer. She is a solid, pragmatic, hard working obstetrician-gynecologist, with two sons, and an architect husband, who spends his time caring for their children and their house in Dover, New Hampshire. She represents many of changes that occur when women become full-time physicians. The purpose of this interview is to give insight into trials, tribulations, and joys of being a woman physician in a transformed health care system.

"Q: Dr. Chase, when did you graduate from medical school, and how old are you?"

“A: I graduated from Tufts University School of Medicine in 1992. I am 46 years old, and I have practiced for 12 years.”

“Q: Has your career lived up to your expectations? Has anything surprised you?”

“A: From the standpoint of the joys of being part of patients’ lives, listening to their stories, and the pleasure of doing surgery, it has lived up to my expectations.”

“Q: And what have been your disappointments?”

“A: The hardest part in my early years of practice in Pennsylvania was a combination of things – the shock of low reimbursements paying me half of what I expected to make, the negative malpractice environment, and inadequate amount of time I had to spend with patients to make up the difference. I just could not justify spending so little time with patients.”

“I left Pennsylvania for partly personal and partly professional. I was part of an exodus of doctors from Pennsylvania. I recall a full-page ad in the Philadelphia Inquirer, listing all the doctors who had fled Pennsylvania. I moved to Dover, New Hampshire.”

“Q: Give us some context of the community you’re in, the hospital you use, and your practice setting.”

“A: I practice in a community hospital with a level 2 nursery. We have about 900 births per year. Dover has 50,000 people, and its primary industries include the headquarters of Liberty Mutual insurance company and we have some high tech firms. The hospital employs a lot of people. We have a private practice, five doctors, and all women.”

“Q; You’re part of the gender revolution. “

“A: Yes, but Tufts was one of the first medical schools to accept women, and my class had 50% women. And OB/GYN at this point is something like 80/20 women/men entering the profession.”

“Q: That changes medical practice dynamics. Women require pregnancy leaves, spend more time with family, are more likely to be employees, retire earlier, and sometimes women doctors are working and the husbands are not. How many women in your practice have “house husbands?”

“A: All four of us, including myself, have a “house husband.” It gets a little hectic, but we manage very well. We’re on call every fourth night, but we make our call easier by working with midwives. About half of our on call time is back up call, with the midwives taking primary call.”

“Q: Describe to me the hospital –physician practice environment. As you know, hospitals are hiring more and more primary care doctors these days and even specialists. How large is your hospital?”

“A: We have 155 beds and 10 Operating room suites.”

“All primary care practices are ‘owned.’ There are no independent generalists working out of our hospital. We have a fully staffed hospitalist program. And all primary care practices participate in the hospitalist program. We have 13 hospitalists on staff at this point. We have 24 hour ICU coverage by hospital-employed doctors. None of the surgical practices or sub-specialty practices is owned. There appear to be some collaborative agreements with plastic surgeons. “

“Hospitals like to own the physicians because they can control them. We are not owned, but the hospital has often suggested to us the only solution to any financial problem we might have is to be owned.”

“We feel much more comfortable with owning ourselves. We prefer the independence we have. We’re making it financially. We’re 5 women, and 4 of us have kids. All our midwives have children.”

“We call ourselves a ‘lifestyle practice,’ and we try to blend being mothers with a sustainable way of being a doctor. We give ourselves 6 weeks of vacation a year and we give ourselves 2 weeks of CME. We do not believe in working 24 hours a day, 365 days a year. Our salaries are not as high as the national average, but we are happy this way. We look after each other and we collaborate and cooperate with the town’s other OB/GYN practice.”

“I’ve learned how to deal with adversity, and not make it kill me. I like medicine too much to stop. We truly love our patients, and try to develop positive relationships with them.”

Reeling, Writhing, ‘Rithmetic, and Health Reform

“Reeling, and Writhing, of course, to begin with, the Mock Turtle replied, ‘and the different branches of Arithmetic – Ambition, Distraction, Uglification, and Derision.’ “

Lewis Carroll, 1832-1898, Alice’s Adventures in Wonderland

Lewis Carroll was a mathematician in real life.

Maybe the time has come for us to think like mathematicians and to do the math on health reform.

For examples, the nonpartisan Congressional Business Office, says,

• the budget shortfall this year will be $1.5 trillion – a post-World War II record at 10.3 % of the national economy

• Obama’s proposed budget will grow to more than $9.7 trillion for the next decade to 90% of the economy

• by 2030, health care will add $3 trillion or so to the debt.

• Medicare is scheduled for bankruptcy by 2016, or sooner, if the economy does not pull itself out of its present ditch.

Furthermore

Furthermore is an appropriate word to use in explaining these projections. We know further that 78 million more baby boomers will start qualifying for Medicare in 2011 at the rate of 13,000 a day. These further numbers add more fodder to the national debate about unsustainable national debt, passing this debt onto our grandchildren, and overgrowth of a “socialistic” government.

Furthermore, we know these numbers lead to all sorts of political arithmetic – ambitious politicians saying we need more or less government, distracting us with budgetary gimmicks, uglifying their arguments by accusing the other side of inflammatory extremism, and using derision to demean opponents.

No More Furthermore

We cannot continue on this furthermore course. We must look at the math and make fundamental decisions to reverse the numbers – such as, moving the entry age of Medicare from 65 to 67 or even 70, acknowledging the reality that most Americans will soon live to 80 or beyond; means testing Medicare so that affluent elders pay more; allowing private contracting between patients and doctors so that patients of means can access care outside of Medicare; giving more leeway to health saving accounts with catastrophic caps so consumers can use their own money to decide what care they want and can afford; and recognizing that “free” government entitlement programs have always and will always exceed government projections.

Otherwise, we will continue reeling, writhing, and defying the rules of ‘rithmetic. Otherwise, furthermore may become forevermore.

Keeping the Medical Home Fires Burning

Key Words – medical homes, patient-centered home, physician-directed care, coordinated and integrated care, enhanced access, lower health costs, improved outcomes, personal physician, primary care

Summary of interview with Paul Grundy, MD, Director of Health Transformation at IBM and President of Patient-Centered Care Collaborative

Preface: Dr. Paul Grundy believes empowered primary care physicians will change the U.S. health system for the better. Grundy oversees buying of health care for IBM employees worldwide. He maintains other countries with primary care- based systems with physicians using electronic records deliver better care at lower prices. The complete interview will appear in www.modernmedicine.com

“A: Why is IBM involved with the medical home concept?”

“Q: Basically the IBM approach is about taking the health care we now get as a buyer of care, which we consider to be of high cost and low quality, and migrating it to a lower cost, higher quality care. We want to get better value out of the health care we buy for our employees.”

“When we look at the data and read the reports, we find that an ongoing relationship with a primary care doctor, and the patient knows the doctor’s name, it costs us one-third less money, has lower mortality, and patients are 12% less likely to be obese or to smoke. A close doctor-patient relationships are powerful.”

“Q: How is the Medical Home concept progressing?”

“A: On October 12, 2009, the Veterans Administration defined the Medical Home concept, and the set of principles surrounding it, as the standard of care. Before that on September 18, 2009, the Department of Defense declared the Medical Home as the standard of care. The DOD sent out a directive saying that every DOD member would have a Medical Home.”

“I just left a wonderful meeting in North Carolina, where the 25 residency training programs in North Carolina, South Carolina, and Virginia , the I-Three Collaborative, agreed to work together to migrate towards the Medical Home.”

“The Medical Home, and its principles have been agreed upon by the major primary care societies, and are endorsed by the American Association of Medical Colleges, the AMA, and most Fortune 500 companies as a good path to follow to migrate towards a more robust system with affordable accessible primary care. “

“Primary care doctors should focus on two issues: patient relationships and diagnostic dilemmas. Instead they spend two-thirds of their time looking for rubber gloves, tracking down laboratory results, answering phones calls from insurance companies, and doing everything but focusing on their core business."

"Interesting results are occurring in Medical Home pilots. In Pennsylvania, the Medical home rollout is now moving into its third year. We’ve seen a 15% reduction in costs in ambulatory sensitive conditions. More interestingly in all of those practices that were full and closed have opened their doors and are seeing more patients. This is happening everywhere because in the Medical Home model of care, where everybody works as a team, the Model Home is adding efficiency.”

“Q: So there’s an increase in throughput and productivity?”

“A: Absolutely, an increase in quality and income as well. Two or three years down the road, physicians in these practices are saying, “Thank God, I did this.” They are thinking about quality improvement and are asking themselves, “How can I do this better?” “How can I center more on my patient’s needs?” In our demonstration projects with the American Association of Family Practice, we found Medical Home practices were making, on average, a 14% better income.”

“Q: Are you optimistic reform will come?”

“A: Yes. There are two issues: reform and transform. There are a tremendous number of tools, of ammunition, that have already come down the pike and point to transformation. Health Information technologies (HIT) will be a powerful transforming force. HIT will do for doctors’ minds what X-rays did for their vision. It will change how they look at things, the way they analyze data. “

Med Page Today's KevinMD.com, Social Media's Leading Physician Voice

Preface: Kevin Pho, MD, America’s most prolific and most-widely read blogger, today reprinted a previous blog of mine, written on March 22. Since I wrote the blog, several things have happened: 1) President Obama did not get the “bump” in the polls he expected: instead the number “opposed” compared to those “in favor” jumped to 12.3%, a record high; 2) it became apparent the health care overhaul will cost U.S. companies more than $75 billions and will make 3500 companies more likely to drop prescription drug coverage for retirees and shift the cost to Medicare because of a change in how the government subsidizes those benefits; 3) hundreds of thousands of disappointed “uninsured” have flooded the White House and health plan switchboards in search of “free” coverage, only to find out the coverage does not take effect until 2014; 4) opposition to Obamacare has become the focal point of the Tea Party and Republican efforts to unseat Democrats in the November 2010 mid-term elections.

Health reform winners and losers, and how it affects doctors

April 19, 2010

by Richard Reece, MD

I congratulate President Obama and the Democrats on their historic health reform achievement.

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 of health reform.

Winners

• 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 parents’ 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 bankruptcy 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.

Richard Reece is the author of Obama, Doctors, and Health Reform and blogs at medinnovationblog.

Systems Thinking and the Minnesota Medical Model: Or, It Takes 10,000 Practicing Physicians to Tango

Key Words – system thinking, multispecialty groups, hospital systems, electronic records, protocols, evidence-based care, outcome based-care

Summary of interview with Kent Bottles, MD, President of Institute of Clinical Improvement, St, Paul, Minnesota

Preface: I practiced in Minnesota for 25 years and served as editor-chief of Minnesota Medicine fo 15 years. During these years, the penchant of Minnesota physicians to congregate in multispecialty groups and in large hospital based systems always impressed me. The average sized medical group, at least those salaried or functioning under the umbrella of a parent organization, is over 150 physicians. These organizations, and their physicians, tend to pride themselves on their discipline, and their ability to learn, to act together and to improve care.
Here are excerpts of an interview with Kent Bottles, MD, President of Institute of Clinical Improvement (ICSI). Kent has been president of the Institute of Clinical Improvement, in St. Paul, Minnesota for two years. The complete interview will appear in www.modernmedice. com.
\
"Q: What does the Institute of Clinical Improvement do, and how long has it existed?"

"A: Health Partners, the Mayo Clinic, and Park Nicolette founded ICSI in 1993. It started out as an evidence-based medicine shop to provide physicians with scientifically-valid guidelines. That didn’t totally transform medicine, so ICSI got more involved. So then it began helping doctors and hospitals redesign in how they do work, using Six Sigma, Planned Do Study Act, and Lean. Most recently, we’ve become engaged in payment reform and health care reform. Basically we’re a collaborative of hospitals and physicians, for-profit health plans, and employers in the upper Midwest. We seek to decrease per capita costs and increase quality."

"Q: Has ICSI transformed the culture in some way in its 17 years of existence?"

"A: What ICSI has done is that you created a safe place to bring in different constituents – government, health plan physicians, patients, employers, primary care physicians, and specialists. Most health system problems are difficult because there are no simple answers, but somehow if you can aggregate the wisdom of the crowds of all those people, you can do exciting things."

"We’ve got a Diamond program for treating depression in primary care that uses case managers and liaison psychiatrists in which all health plans pay for this new way of delivering care. We’ve achieved tremendous clinical outcomes."

"We also have a high-tech diagnostic imaging program with has replaced pre-authorization for CT and MRI scans with embedded decision support in the EMR that allows the doctor and patient to discuss the imaging procedure that’s about to be performed. This has eliminated the need for prior authorization because people agree about what’s to be done."

"By convening all the parties and having everybody understand each person’s point of view, we’ve solved tough problems you couldn’t solve on your own."

"Q: The use of imaging has increased in recent years about 15% to 17% annually for the Medicare population. Has the ICSI approach cut the growth rate?"

"A: Absolutely. It has decreased costs about $60 million a year and reduced unnecessary radiation. Because of our positive results, we’ve been called back to Washington to brief the Medicare folks and Senators about our success."

"Q: How has ICSI changed the conditions for independent doctors on the ground? Minnesota is now in an advanced state of consolidation, with most doctors either belonged to large groups or working as salaried employees of hospitals."

"A: There still are independent doctors in Minnesota, but the trend has been toward consolidation and integration. One of the things ICSI has done has been to allow smaller groups to have a voice into how we implement baskets of care or medical homes. We have on our board the administrator of a 7 person family practice."

"Q; I now live in Connecticut, where the average sized group is 4 while in Minnesota the typical group is now 100 or more. That difference changes the dynamics in how doctors practice."

"A: Absolutely. The pressure towards large groups are incentives to get electronic medical records, to participate in pay-for-performance, and to deal with all this money coming out of the Office of the National Coordinator. These pressures are why more doctors are joining multispecialty groups or becoming employed by hospitals."

Virtual Medicine, Better, But Not Perfect

Key Words – Virtual medicine, virtual reality, virtual simulation, perfect information, telemedicine, electronic health records

An Interview with Ron J. Pion, MD. Chairman of Medical Technology Group’s Advisory Board

Virtual – Being in force or effect, not actually or expressively so, for the most part.

Dictionary definition of "Virtual"


Preface - Virtual is not the real thing. It is simulated and occurs in the absence of a real person. For the most part, Internet-based virtual medicine and telemedicine lacks the personal element.

But, according to Ron Pion, MD, a 78 year academic, entrepreneur, consultant to Internet medical companies, medical Internet use will lift all clinical boats.

These days we’re all moving on Internet time. This full interview of this summary will appear in www.modernmedicine.com, an online site that has acquired 17 print publications, including Medical Economics. The Modern Medicine website signals a profound shift from print to online, and the need for new business models, not only in medical publications, but in medical practice itself.

Ronald J. Pion MD, is principal in the Pion Group, a special advisor to the Galen Capital Group, and chairman of the Medical Telecommunications Group‘s advisory board. As the founder of the Hospital Satellite Network, he provides programming for hospitals and patients, and is a leading authority on telecommunications in the health care industry. Dr. Pion oversees the Pion Group, where he serves as a health care consultant on issues related to improving clinical outcomes and patient care. Dr. Pion believes the Internet, and its telecommunications applications, will improve patient care and outcomes, virtually link physicians with each other, and virtually bond physicians more closely with patients.


“Q: The focus of this interview is how to help doctors in solo or small group practice succeed through the use of the Internet and telecommunications. How can doctors become more efficient and effective through the use of new telecommunications media?”

“A: Doctors have to begin to talk in terms of computers, smart phones, and IPods just as easily as they talk of stethoscopes, otoscopes, and proctoscopes. We must talk of telecommunication tools currently available to physicians in any specialty and to any primary care doctor, now becoming known as realtors who own medical homes. “

“As doctors, we have to realize we see patients episodically. Now we must begin to keep tabs on that patient every single day. Automated telecommunications will help us do that. When the patient understands that the doctor cares, he or she will supply that information – gladly, willingly, and constantly.”

“Q: How does the doctor get into automated telecommunications game? “

“A: The doctor does that by outsourcing a lot of his time to competent professionals just like him. These competent professionals create Google, Microsoft, software, and hardware. As Larry Weed pointed out 50 years ago, you can’t practice medicine without a computer. Today we have much more than a computer. We have knowledge and wisdom accumulated from data and information.”

“You need data to gather information, you need information to gather knowledge, and you need knowledge to gather expertise.”

“Computers help us keep up with what’s going on in the world. We must advantage ourselves by trying to capture the world’s knowledge. “

“Q: So your point is the Internet and telecommunications can lift all boats?”

“A: Yes, and all boats will be lifted. There is no doubt in my mind.”

“Q: How do these artful applications of computers help doctors in the short term as they scramble to survive and even thrive?”

“A: In the short term, it’s difficult. No doctor likes to change his routine if he’s going to lose time and money. That’s a major problem, and if he doesn’t see that day-by-day opportunities to keep renovating the kitchen and the house, he is going to hate clinically-oriented computers. Many doctors hate clinical computers now, because they costs money to use. They have heard all these nasty stories about failed promises made by computer companies over the years. They don’t understand, but the youngsters coming out of medical schools do with their PCs, blackberries, smart phones, and other wireless gadgets do.”

“Q: Is there any hope for us old dogs?”

“A: Yes, because you can teach old doctors and old patients new tricks. All you have to do is make it valuable to them. They will learn what needs to be done and will buy what it takes to do it, especially those with discretionary income. Leave the people alone who can’t afford a computer, and let’s focus on success. Let’s focus on those successful practitioners who have done what others are afraid to do.”

Survey: Patients May Lie if Electronic Records Are Shared

Preface: So much for perfect information to be gathered and distributed by EHRs.

By Katherine Hobson

Patients already lie to their doctors. And almost half of respondents in a new survey said if there was any hint their health information — even stripped of identifying details like name or date of birth — would be shared with outside organizations, they might be even less forthcoming.

A study on electronic medical records use by the California HealthCare Foundation, a philanthropic group, found that 15% of the 1,849 adults surveyed said they’d conceal information from a physician if “the doctor had an electronic medical record system” that could share that info with other groups. Another 33% would “consider hiding information.”

Privacy concerns still hover around EMRs, with 68% of survey respondents reporting some degree of worry about what happens to their personal information once it’s stored in a doctor’s computer. EMR use by consumers is rising, though, with 7% of Americans reporting having used one, compared with 2.7% in a 2008 survey conducted by another organization. (Those that did use EMRs said they were helpful, and a significant number of them said the electronic records prompted them to ask questions about or take steps towards improving their health.)

Of course, not being completely honest with doctors is practically an American tradition, with or without EMRs. Another study out earlier this year, conducted by General Electric, the Cleveland Clinic and Ochsner Health System, broke down what patients generally lie about. Lack of exercise led the pack, with 13% of respondents, followed by compliance with medication instructions (9%), dietary habits (9%), drinking (7%), smoking (7%), use of illegal drugs (4%) and unprotected sex (4%).

Short Notes on Innovative Dictation Savings

High health costs represent big ticket things - like heart surgery, hip and knee replacements, and MRIs - but also thousands of little things piled on top of each other.

One of these little things is physician dictation – an essential ingredient for documenting and charging for what the doctor did.

• Physicians often dictate what occurred during an office visit for future reference, for referral letters, or to justify a code.

• Hospitalists often dictate notes after seeing a hospital patient or performing a procedure during a patient’s hospital stay, again to tell a story or to justify a code.


• Surgeons are obligated to dictate a post-operative note for “the record” to document what was done, what was found, and for reading by doctors or lawyers or coding consultants.

Dictation is expensive. It takes a doctor’s time, it takes a receptionist’s time, and it takes money to pay the firm, often outside the doctor’s office or hospital, to process the dictation, before making it a permanent part of the patient’s record.

Yet there are obvious ways to obviate or end the need for human dictation.

• One of these is to provide “canned notes,” generic summaries in the form of check lists, that the doctor can simply check off and produce statements or paragraphs that cover something routine that is done over and over and needs not to be repeated. Canned notes save time and money and can be used to cover post-op notes, progress notes, hospital procedure notes, pre-op notes, and post-op notes.

• Another is notes entered electronically by patients, nurses, an doctors before and during a visit. These notes include patient demographics, age and sex, chief complaint, present history, past, family, and social history, vital signs, and physical findings. Using a clinical algorithm in software called The Instant Medical History can turn a computer-directed patient interview into a clinical narrative, and nurses and doctors can use checklists to fill in the rest. The patient can leave the office with a complete electronic record in hand of his or her visit.


• Finally, there is new and improved voice recognition software – Dragon Naturally Speaking and others – that allow doctors to dictate on the spot without referring dictation to transcribers or others. An additional benefit is that physicians can dictate thoughts and observations directly into the electronic medical record.

Obamacare and Physician Bloodbath

Key words – Obamacare, bloodbath, mid-term elections, physician surveys, quality of care, physician reimbursements, physician access, physician shortage

We are Democratic pollsters who argued against the health-care legislation ["Democrats' blind ambition," Washington Forum, March 12] that the Obama administration chose to pursue. Instead, we advocated incremental health-care reform. With the passage of health reform, some harsh political realities have emerged.

Recent polling shows that despite lofty predictions that a broad-based Democratic constituency would be activated by the bill's passage, the bill has been an incontrovertible disaster. The most recent Rasmussen Reports poll, released on April 12, shows that 58 percent of the electorate supports a repeal of the health-care reform bill -- up from 54 percent two weeks earlier. Fueling this backlash is concern that health-care reform will drive up health costs and expand the role of government, and the belief that passage was achieved by fundamentally anti-democratic means.

Douglas Schoen and Patrick Caddell, “ How the Democrats Can Avoid a November Bloodbath,” Washington Post, April 16, 2010

When two loyal Democrats warn Obama of an impending “bloodbath” in November because of passage of health reform, it is big news.

What Schoen and Caddell did not mention was that a physician bloodbath that may follow could be part of the toxic anti-Democrat mix.

In the main, physicians do not believe there is much in Obamacare for them.

• Athenahealth and Sermo surveyed 1000 physicians across the land, and found 59% thought the quality of care would decline over the next 5 years, 54% said more government involvement would not improve care, and 83% and 81% respectively indicated they were having trouble collecting low Medicare and Medicaid reimbursements.

• In a Physicians Foundation survey of 270,000 primary care doctors, 60% said they would not recommend medicine as a career, and 78% said their colleagues suffered from low morale.

In interviews I conducted for Modern Medicine, and from other sources, I find increasing number of physicians leaders are advocating that practicing physicians either cease seeing or reduce services for patients in government programs or drop out of Medicare and Medicaid and private third party arrangements altogether and opt for private concierge or cash-only practices in which patients pay yearly fees for access.

According to Daniel Palestrant, MD, founder and CEO of Sermo, Obamacare does not meet any of the reform conditions physicians recommended. ) tort reform; 2) streamlined billing; 3) reform of health insurance; 4) simplified billing with more billing for prevention.

And as everybody knows, Congress is dithering and fiddling about fixing the SGR formula. As in 13 previous years, SGR called for Medicare physician cuts. This year SGR calls for a 21% cut, which would surely cause a massive exodus of physicians from Medicare and Medicaid programs – and a political bloodbath for Democrats.

Politicians will no doubt “fix” the SGR temporarily, but this band aid will leave a bad taste in physicians’ mouths for government manipulation of their incomes.

Government, of course, could and may mandate acceptance of government patients as a condition for medical licensure. But, as with individual and small business mandates for coverage, this mandate would be perceived as “anti-democratic” by liberty-loving Americans and would exaggerate the physician shortage.

Practice Fusion, Inc - An Innovative Web-Based EHR

Key Words - Practice Fusion, EHRs, Electronic Health Records, Meaningful use, certified, innovation, speech recognition, e-prescribing, Internet, cloud computing, business model


When the government passed its $787 billion stimulus in February 2009, it included $20 billion for Health Information Technology and up to $44,000 for each doctor adopting certified EHRs with “meaningful use.”

This government act set off a chain of innovations for EHR companies and physicians.

There's nothing mysterious about successful medical innovation - it is about attracting venture riches, filling niches, adding sons of niches, anticipating physician bitches, and satisfying government hitches.

Practice Fusion, Inc, a San Francisco –based EHR startup had all of these ingredients when it was founded in 2005.

• It attracted venture “riches,” i.e. funding from Band of Angels and Felicis ventures

• It filled “niches” - 1) appealing to Primary care doctors and specialists seeking easy-to-use, easy-to-install, free, certified systems to capitalize on the $44,000 federal largess; 2)adding multiple practice management features its management team was familiar with; 3)relying on the Internet, which allowed doctors to off-load all their needs to the Internet using nothing but personal computers and broad band access without installing hardware and software in the office. On top of all those niches, it was free, web-based, and no-risk.

• It added “sons-of-niches” - Those multiple other features such as new speech recognition programs – Dragon Naturally Speaking, MacSpeed Dictating, scanning paper documents, e-prescribing programs, and Personal Health Record programs.

' It anticipated physician "bitches" - complaints such expenses of installing, training,difficulties of data entry, loss of productivity.

• It satisfied “hitches ” for government reimbursement – such as those hard to understand conditions such as what EHRs qualified for “certification” and what constituted “meaningful use.”

And if that were not enough, it could be installed quickly , required no lengthy training or instruction, could be up and running in five minutes, and it had a business model, similar to Google’s Adsense, that allowed it to be “free” for clinicians. The business model is based on advertisements from insurers, suppliers, and drug companies when certain keywords appeared during Practice Fusion use.

Small wonder, then, that Practice Fusion has grown rapidly and now has 30,000 users.
Here is how Ron Howard, CEO of Practice Fusion explains its acceptance.

“Practice Fusion is an electronic health record, which is provided to Physicians at no cost for licensing, hosting, support, and training of the application. Right now we’re the fastest growing physician practice community in the country.”

“Every feature that’s included with the product in any capacity is offered at no cost, so it’s truly free. It’s offered with support, training, and hosting. It’s the only totally free model on the market.”

“ Practice Fusion competes with most major systems in the marketplace. It’s fully-featured. It has everything from front office scheduling to patient management to full-charting templating, prescription writing, lab management, the entire gamut of services. From a major competitor standpoint, we compete with them relatively well, especially over the next few months where we’ll be extending our products to include Quest Lab integration and e-prescribing.”

“Within our product we have a vast template library. We are servicing over 25 specialties today. Templates are created by everyone from our Chief Medical Office to our Physician Advisory Board to our end users. It’s one of the things that’s unique about the product. The product is not only free and web-based, but we have a process called Live in Five. If you go to our website and register, you can actually start using the products within five minutes.”

Sermo.com – A Physician Social Networking Innovation

Key words - innovation, physicians, social networking, online communities, virtual medical communities, adverse drug reactions, medical politics, physician sentiment

Summary of interview with Daniel Palestrante, MD, founder and CEO of Sermo.com

Preface – Daniel Palestrant, MD, a surgeon, founded Sermo, a Latin word meaning conversation, four years ago. It has grown to the largest physician networking site and now has 115,000 participating physicians. Fast Forward managine named Sermo as one of the five most innovative health care companies, along with Athenahealth, GE Cisco, Patientslikeme, and Kaiser Permanente. With athenohealth, semor recently released a “2010 Physicians Sentiment Index, a survey of 1000 physicians, revealed some of the following: 92% agree getting paid by insurers was more difficult, 83% agree this was case with Medicaid, 81% agree this was case with Medicaid, 59% agreed quality of car will decline over next 5 years, and 54% disagree more government involvement would help.

“Q: You have written the four necessary legs of reform, from the physicians’ point of view, are:

1) tort reform;

2) streamlined billing;

3) reform of health insurance;

4) Simplified billing with more billing for prevention.

"Q: Are these the four things you still emphasize?"

"A: Yes, I do. What’s so striking about health reform efforts to date is how totally they differ from what physicians recommend. Sermo has surveyed tens of thousands of physicians as to what we believe is necessary to improve care and reduce costs. Not one is even mentioned in reform bills. On tort reform the current bills are a step backward."

"Two trends have emerged.

First is antitrust warfare. Nancy Pelosi’s first priority is repeal of insurance companies’ antitrust protection. She is right that this exemption causes major problems because it allows monopoly pricing."

"Antitrust has become a lightning rod for health reform. It is showing how gamed the system is by entrenched parties, in this case the insurance companies and Medicare."

"A: The second trend I’m seeing accelerating is physicians, either by decision or desperation, opting out of Medicare. On Sermo, we see this trend exploding. Physicians are saying, I can no longer accept Medicare because I can’t afford it. They’re moving quickly and decisively to cash practice models"

"Q: In a sermon blog, you made this statement, “We must begin to withdraw from Medicare, Medicaid, and all contractual insurance.”

"A: Not only is this trend possible, it is inevitable. It is inevitable because of a fundamental economic tenet."

"Our society works because in the marketplace supply must match demand. As the demand for a product or service increases, the price of that product or service increases."

"What’s happened in the health care system is that intermediaries have been introduced into that supply-demand equation that creates artificial islands of profit. Our system has become like a communist economy, where you have central planning with profiteering at the margins."

"Insurance companies have seen their profits increase year after year, yet physician compensation has gone down year after year. The supply of physicians has been flat to down, yet compensation has decreased in the face of an aging population while the demand of physician services has gone up."

This interview will appear in full in www.modernmedicine.com

Tort Reform – In Texas, A Legislative Innovation that has Cut Costs and Eased the Doctor Shortage

Key Words – Innovation, Tort reform, Malpractice, Defensive Medicine, Health Costs, Doctor Shortage

Summary of Interview with Louis Goodman, Texas Medical Association CEO

Preface: Democrats say malpractice costs are overstated. They cite a CBO estimate, based on settled malpractice awards, that tort reform would cut only 0.5% of health costs. Republicans and doctor retort by saying malpractice fears, defensive medicine, and a litigious practice climate account for 25% of health costs.

A survey of 598 cardiologists, just published online in Circulation, found 27% of cardiologists say colleagues order catherizations for defensive purposes . In other words, cardiologists do catherizations they might otherwise not have have done to ward off potential malpractice suits, “Doctors Still Say Malpractice Fears Add to Health-Care Costs,” WSJ Health Blog, April 13, 2010.

Which leads to today’s blog on innovation – in this case, a legislative innovation by Texas legislators which capped malpractice awards in 2003. This legislative act lowered doctors’ practice costs and malpractice premiums, It doubled the number of doctors outside of Texas applying for a medical license in Texas. More people ought to look to Texas, the nation's leading state in job creation. One Austin, Texas, hospital company, Seton Family of Hospitals, is building three new medical centers and hiring 2300 people, many of them doctors and nursed drawn by its innovative health care climate.

“Q: What do you regard as your greatest accomplishment at the Texas Medical Association?”

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

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

“Most important, access to care was shrinking in rural and other underserved areas. But during this past year, the number of physician licenses increased from 2000 to 4000, and physicians—both primary care and specialist--are now settling and practicing in underserved parts of Texas, such at the Rio Grande Valley. The specialists no longer restrict access to high-risk procedures through fear of liability penalties. Patients are getting better care, and highly specialized procedures are being done. This is all attributable to the tort reform legislation.“

Q: “Is it true that medical malpractice insurance premiums also have dropped in Texas?”

“A: Yes, premiums have dropped by 50% or more, and the largest carrier, Texas Medical Liability Trust, is actually providing a dividend to physicians. Also, carriers have been able to rebalance their reserves. So we can stabilize the market, and bring more doctors in to provide coverage.”

Health Care Jobs as an Innovative Solution to National Unemployment

Key Words – Innovation, health care employment, unemployment, hospitals, doctors office, outpatient facilities

Summary of Interview with David Cook, CEO of Medical Association of Georgia

Preface – This is an interview with David Cook, CEO of the Medical Association of Georgia, a position he has held since 2001. The Association has about 7000 members. David is interested in advancing the notion that private physicians in their offices are a significantly positive economic force in the community at large. He believes an expanded health care system is good for the economy. It yields increased employment and more tax revenues for local, state, and national economies.

Problems and their innovative solutions are in the eyes of the beholder. In the eyes of the Obama administration, health care is a major problem bringing down the national economy and contributing to economic woes. These woes include falling government tax revenues and rising unemployment. In Cook’s eyes, doctors and the health care sector add taxes and jobs, easing the recession.

Cook has a point. According to Bureau of Labor Statistics, health care provides over 15 million jobs for wage and salary workers. Ten of the 20 fastest growing occupations are health care related. Health care will generate 3.2 million new wage and salary jobs between 2008 and 2018, more than any other industry, largely in response to rapid growth in the elderly population.

Innovation depends on grassroots attitude as well as federal altitude. As President Reagan observed, government is often the problem rather than the solution. Many federal jobs are short-lived make-work, such as census takers. And as Reagan noted in his story of the boy buried up to his neck in horse manure, “There’s got to be a pony in here somewhere.”

“ Q: The Medical Association of Georgia recently released a report on the positive impact of private practice on the general economy. Tell us about that report.”

“A: We wanted to make the argument to state and national legislators that physicians bring something positive to the health and economic tables."

"Access to health care is the primary component. The positive economic activity generated is important as well. Based on our intuitive understanding of the latter, we did an economic study several years ago of Hall County. Based on those results, we decided to do a state-wide study."

“Q: I understand the study focused on private physicians’ offices rather than on hospital employed physicians or on hospitals themselves.”

" A: That’s right. Hospitals have been doing this for some times to determine economic impact. But to my knowledge, this is the first economic impact study of private practice. We wanted to fill in that piece of the puzzle. When you add in the hospital economic impact, it’s much greater.”

“Q: So you concentrated on ambulatory care in private offices. “

“A: Yes, care that is provided outside the hospital. The Bureau of Labor Statistics separates the two kinds of practice activities inside and outside of hospitals. The Department of Labor uses these statistics to track economic impact. “

“Q: Eighty to ninety percent of ambulatory care is provided by private physicians outside the purview of hospitals. What did you find from the study? Did the economic impact surprise you?”

"A: We found there was a substantial impact of private practice. It was higher than we expected. What was enlightening was to compare it with other sectors of the economy. We found there was a $20 billion impact on the State of Georgia, and every single physician directly or indirectly generated 12 to 13 additional jobs. We found the private physician impact was roughly equivalent to the insurance and financial industries combined and to one-half the construction sector, which is huge in Georgia, a fast growing state."