Wednesday, June 30, 2010

Never More, Never Mind: Contempt for U.S. Health System and Private Practice

Among policy makers, government officials, and the media, there is no other word for their attitude towards the U.S. health system in general and private physicians in particular. That word is “contempt.”

You hear the same message again and again. The U.S. is first in costs, and last or next to last in efficiency, equity, access, outcomes, infant mortality, longevity.

Don’t take my word for this “progressive” bias. The liberal Commonwealth Fund last week announced in its latest “Mirror, Mirror” study that the U.S. ranked last or next to last among seven industrialized nations in every health care category. Read these headlines.

Reuters: "U.S. scores dead last again in healthcare study"

Los Angeles Times:
"U.S. is No. 1 in a key area of healthcare. Guess which one ...
NPR: "US Spends The Most On Health Care, Yet Gets Least"

The Week: "US health care system: Worst in the world?"

The underlying message in most of these articles is: “Don’t trust individual private doctors. They are in this for the money. They do more than less for cash. If only if we could get the U.S. government, like other countries, to rein them in, provide them oversight, dictate what they can and cannot do, and treat them as government employees, results would improve and costs would drop.”


Never more should we trust doctors to practice autonomously, using their knowledge of the patient and clinical judgment . Instead, we should trust government, using comparative data bases and statistical averages to determine what is to be done.

Never mind that the typical physician has had 10 to 15 years of intensive education and training after high school, or that he or she finished near the top of their class. Or that most are motivated to help people and cure their illnesses.

Never more should we allow doctors to practice solo or small groups. No physician, practicing alone or with a few others has the encyclopedic knowledge to know everything about everything. That can only come from practicing in a larger group with access to multiple resources.

Never mind that 30% to 40% of doctors practice solo or in two person groups, and that 80% are in groups of 6 or less. Never mind that practically every physician has Internet access, and that most clinical problems are mundane and require only common sense and knowledge gained from face to face confrontation.

Never more should we allow doctors to practice without electronic medical records . These records contain the data that allow us to judge their performance, to pay them appropriately and to permit them to practice having access to evidence based best practices.

Never mind that 80% or so of doctors have not invested in EHRs because electronic systems are often expensive, unworkable, clinically useless, slow productivity, are either unreadable or hard to interrupt, and don’t connect to other systems. Never mind that doctors are not trained to be data entry clerks, and make ends meet by seeing patients rather than documenting every detail of the encounter.

Never more should we allow doctors to be paid on a fee-for-service basis, like lawyers, accountants, other professionals, and independent tradesman. We should place them on salary, removing the incentives to do more, and putting them on budgets where managerial oversight can be exercised.

Never mind that ending fee-for-service requires 3rd party oversight, with administrative overheads of 15% to 30%, depending on the size of the bureaucracy or health plan. And never mind that most doctors’ fees are already set, directly and indirectly, by Medicare and the Reimbursement Update Committee (RUC).

Never more should commercialism or market forces, or God Forbid, profit be allowed to pervade the sacred halls of medicine. Health plans should be outlawed, care should be offered gratis, and doctors should not be allowed to practice or profit from activities outside benevolent government systems. Those at the top know what’s good for those at the bottom, whether doctors or patients know it or not.

Never mind there is no health system in the world where patients do not go outside the system to get the care they need. Never mind that medical tourism is exploding around the globe. Never mind that most medical innovation comes from the private sector, and from the bottom-up, rather than government. Never mind that most patients, given their choice, would rather be treated by a private doctor they trust, rather than a doctor paid by the government working in a Medicaid or other government clinic.

Never more should the U.S. try to stand alone as a unique health system. It should try to emulate other countries, where government is the only or dominant payer. In all these countries, citizens should come to expect equality of care for all classes, in all regions of a given country, with rationing if necessary.

Never mind that the U.S, health system has evolved since World War II into a mixed employer-government-based system and central-government and state governed system and into a vast medical-industrial complex, and into the largest single employer in the nation. Never mind that the U.S. is a vast continental nation with marked regional differences. Never mind that our high-tech system is the wonder of the world and the training ground for many of the world’s specialists. Never mind that the expectations of our citizens and our culture differs from that of other countries. Never mind that our citizens have come to expect advanced imaging, routine cataracts, coronary stents, open-heart surgery, and joint replacements as the standard of care. Never mind that we have some of the world’s best outcomes for heart attacks, strokes, and cancer. Never mind that the health care “product” of the U.S. differs from the rest of the world, with its immediate access to high tech and specialty care, and with most of the 250 million Americans with coverage satisfied with the care they get and trust their doctors.

Tuesday, June 29, 2010

Diabetes, Obesity, and Government

Obesity and its stepchild, type 2 diabetes, have replaced smoking as the leading health hazards. Yet despite government and public health pleadings to eat less, move more, lose weight, the obesity and diabetes epidemics are on a tear.

Here is how the WSJ Health Blog assesses the situation:

“Editors of the Lancet didn’t mince words when they weighed in on the epidemic of type 2 diabetes — they said the fact that the mostly preventable disease has become so prevalent is “a public health humiliation.”

“Medicine might be winning the battle of glucose control, but it is losing the war against diabetes,” the authors write."

“ ‘Lifestyle interventions’ is another name for efforts to convince people to lose or maintain weight, eat a more healthful diet and get more physical activity. When people do make changes, good things can happen - even a 7% weight loss can produce much as a 58% improvement in the risk of progressing from prediabetes to diabetes.”

“It’s not like the diet and exercise message hasn’t been broadcast loud and clear, especially in the U.S. and other western countries, but public-health entreaties don’t always work. Most adults aren’t supposed to eat more than a teaspoon of salt per day, for example, but a CDC study released yesterday says only 10% of us do that. And other CDC statistics released recently show that in 2009, 29% of Americans were obese. “

Hapless Government

Why is government so hapless in persuading people to change for their own good?

I suspect the answer lies in complexity of human society and its desire for personal freedom.

In his classic The Road to Serfdom (1944), conservative economist Friedrich Hayek wrote that the economy and society are too complicated for centralized government to control and intervene at marketplace or lifestyle levels. That is why the economic stimulus package of February 2009 has failed to raise employment and why the health bill is unlikely to change patients’ lifestyles.

Hayek contended political freedom and economic freedom are inextricably linked. In a centrally planned economy, the state infringes on what we do, what we enjoy, and where we live. When the state has the final say on the economy, we need permission of the state to act, speak and write. Economic control becomes political control.

The problem with political control is that it attracts people who relish running the lives of others. Further, powerful politicians take care of their friends first and the people second.

Americans are suffering from top-down overkill. President Obama has expanded federal control of health care. By doing so, he has left fewer resources for the rest of us to direct through our own decisions. In a a free modern society, we cooperate with others to produce the goods and services we enjoy, all without top-down direction.

This holds true in everything that makes life worthwhile —when we sing and when we dance, when we play and when we pray. Leaving us free to join with others as we see fit—in our work and in our play—is the road to true and lasting prosperity.


Katherine Hobson, “ ‘Type 2 Diabetes Epidemic Called a ‘Public Health Humiliation’” Wall Street Journal Health Blog,, June 25, 2010.

Russ Roberts, "Friedrich Hayek Is Making a Comeback , “ Wall Street Journal, June 28, 2010.

Monday, June 28, 2010

Real-Time Claims Adjudication: The Secret for the Doctor Getting Paid on Time

Here’s how real-time claims adjudication – or instant payment of claims for doctors -works.

The doctor has an EHR. A data entry clerk in the office enters the claim data. The claim is submitted through the EHR.

And Presto! The doctor is paid.

By the time the patient reaches the check-out desk, the doctor has received a payment commitment from the insurer, just as Visa and Mastercard does after a customer swipes a card.

Unfortunately, it doesn’t work that way in most doctors’ offices.

In the first place, they don’t have an EHR.

Secondly, they don’t have a data entry clerk. Thirdly, they or their staff don’t have time to wade through 4500 diagnostic codes and 1500 procedure codes to find just the right codes for appropriate reimbursement.

If you’re a generalist, with a high volume of patients with a myriad of conditions, finding the right code can be a nightmare. So the office may take a few days before submitting a claim.

The key to instant payment is an EHR, says the Obama administration. Furthermore, install these electronic records, and we will reward you with a 2% bonus for being good boys and girls electronically, and for saving “The system” up to $250 billion to $350 billion in administrative costs.

Of course, there are catches. You may save "the system," but it costs doctors. They must meet certain conditions, convert from paper to electronic records, use EHRs only for “meaningful use,” pay high fees for installation and maintenance, disrupt their usual routines and cut back on their productivity by up to 30% over the first year while adapting electronically. Never mind. It's all for government good.

Nevertheless, instant processing of claims is an attractive concept. For one thing, all the data is submitted upfront, and insurers do not have to come back for further documentation. Meanwhile, until the documentation is done, doctors will just have to wait to get paid.

Sunday, June 27, 2010

How and Where U.S. Physicians and the U.S. Health System Go from Here

The health care bill’s passage sets a framework for reform. It will roll out over the next 10 years. How it goes and where it stops no one knows. It will require multiple mid-course corrections and compromises. It may result in the political transformation of American medicine and the remaking of a vast industry. It may even slow the momentum towards higher costs. By 2020, the health system will consume 20% and $4.5 trillion of the GNP. I’ve been wondering: how do we go from here to there.

Given lack of national physician leadership, how do U.S. physicians become more visible and credible in the reform effort?

Physicians feel marginalized in the reform effort. They think of themselves are political playthings and afterthoughts. The physicians’ main problem, rarely articulated, is that every single social task of importance is entrusted to large organizations run by politicians or managers. Only about 15% of doctors belong to the AMA, and physicians have lost trust in the ability of the AMA to get things done – such as tort reform and getting paid by Medicare. One path being pursued by the Physicians Foundation, a nonprofit organization representing physicians in state medical associations, is educating the public and politicians to the consequences of reform- primary care shortages, lack of physician access, long waiting lines, rationing, invasion of privacy, clinical decision making by bureaucrats and technocrats. Yet the only organization big enough to address society-wide problems is CMS (Centers for Medicare and Medicaid). It covers 100 million Americans, soon to be many, many more. For government, the answer is paying doctors and hospital less, rationalizing (read that as rationing) care for high-ticket items, and making the system more “efficient” and “equitable” through collaborative “systems” of care. The more likely solutions are moving the age of Medicare entry to 70, charging middle class and wealthy Americans more through means testing, and allowing those who can pay to privately contract with physicians.

How does the U.S, cope with the “success” of the system, namely the flocking of U.S. citizens to specialists for first-time care, consumers’ reliance on high-tech life-style fixes (joint replacements, cardiac stents, cataracts), and dependence on third party payment?

It is a very difficult to take back what has been given for “free”(Medicare and Medicaid coverage) or” nearly free” (Americans pay 12% for “out-of-pocket” for care). This problem afflicts the publishing industry. It is going broke because of “free” Internet access. Like the publishing industry, the medical industry needs a new business model. One answer may be the Google approach, namely, have the advertisers pay for the number of hits or visits to a site. This model is being pioneered by Practice Fusion, Inc, an EMR company that offers doctors “free” EMRS by having vendors to physicians advertise.

And how does one steer Americans away from specialists, who have the expertise to perform wonders? After all, we are a country who admires “experts” with the expertise to fix our health problems, many brought about by our bad own health problems, which have lead to obesity, diabetes, cardiovascular disease, and cancer. Keep this in mind. Patients rejected the managed care “gatekeeper” concept. They feel perfectly capable of using the Internet, now in 70% of U.S. households, of picking their own specialist. Perhaps medical homes, integrated multispecialty groups, patients and doctors acting as partners to choosing the right course of action, accountable care organizations, operating on a budget to care for Medicare patients and offering bonuses for “savings ” to doctors and hospitals are alternatives for direct specialty care.

• How do you convince people that market-forces – retail clinics, tax-free health savings accounts with high deductibles and money left in retirement accounts, and physicians and hospitals competing for business - are the way to go?

Given the current political administration – with its almost visceral disdain for businesses, large and small, its trashing of anything related to health that relies on “profit,” and its unshakable beliefs that it knows what is good for the people rather than what people choose for themselves - “market forces” are a hard sell. This set of political attitudes may change. Recent polls indicate two-thirds of Americans oppose Obamacare, 60% do not “connect” with the President’s beliefs, and two of every three American now consider themselves more “conservative” than “liberal,” But the President’s decision to “sell” his health plan to the American public before November may succeed. Given his golden tongue, he may yet convince us his benevolent good intentions outweigh the adverse consequences of the health bill.

Maybe, just maybe, the political transformation of American medicine will re-make the vast health care industry. This will not occur overnight. It is simply too difficult for a left-of-center president to govern a right-of-center country and to wean its citizens from a culture of individualism to a culture of collectivism.

Friday, June 25, 2010

Disruptive and Eruptive Changes in Medicine

The word “disruptive” usually has a negative connotation. It usually means an unwanted, unwelcome, or unexpected break in normal routines.

But as applied to medicine, the word “disruptive” is now coupled with the word ”nnovation.” A “disruptive innovation” has come to mean doing things in a better, simpler, faster, more convenient, more efficient, safer, usually in a less invasive way.

Often disruptive innovations entail less sophisticated people doing things in less sophisticated settings, sometimes outside of traditional institutional settings or in less traditional ways. Examples would be nurse practitioners treating minor problems in retail clinics, physician assistants taking care of routine matters in a medical office and leaving the complicated to the doctor, primary care physicians using portable ultrasounds to search for masses or abdominal aneurysms, or medical technicians doing modified safe coronary stress tests to diagnose or access coronary artery disease and cardiac function.

But such is not always the case. Sometimes the level of sophistication required goes up, such as surgeons using surgical robots to perform urological, gynecological, or cardiac surgeries. Another example is the use of laporoscopic c instruments to do surgery through the umbilical or other body orifices. And then there is the use of imaging guidance to identify colon lesions, to locate critical blood vessels, to biopsy a remote lesion in a less accessible space, like the retroperitoneum.

I thought of this the other day when a friend had three feet of cancer-bearing transverse colon removed through the umbilicus. She was out of the hospital in four days, with only a 2 inch incision to show for it.

From my vantage point, these new innovations are not “disruptive.” Rather they are “eruptive” in the sense they represent a breakthrough in thinking and safer, better medicine.

However, what may be truly “disruptive” for physicians are the changes imposed in the new reform law – requiring them to abandon and paper for electronic records, compelling them to join “accountable care organizations,” forcing them to forsake fee-for-service medicine, and sometimes subjugating clinical judgment to clinical protocols, clinical algorithms , or “evidence-based medicine” approaches imposed by others.

Some of these new disruption innovations, such as medical homes and team-based medicine, hold promise but for those physicians seeking autonomy and intensely personal relations with patients, there are pitfalls, bear traps, pratfalls, and privacy and security issues as well.

Mounting Tensions between Washington and the States over Health Reform

“Done right, the implementation of ACA (Affordable Care Act) can achieve the advantages of minimum national standards for coverage and greater equity among Americans without sacrificing the states’ tradition roles, responsibilities, and flexibility. Done wrong, implementation will create excess layers of bureaucracy, and delay will ensure that his historic health reform legislation falls far short of its goals.”

Christopher C. Jennings and Katherine J. Hayes, J.D., “Health Insurance and Tensions of Federalism,” New England Journal of Medicine, June 17, 2010

When the New England Journal of Medicine, which in general staunchly supports Obamacare, carries an article questioning whether the new law can be implemented, you know something is afoot. What’s afoot are mounting tensions between Washington and state capitols over the details, timing, roles, and revenue sharing required for reform.

Reasons for these tensions are straightforward.

• State budgets are severely stressed. The single most burdensome budget item is invariably Medicaid. Obamacare will shift 16 million more Medicaid recipients, and perhaps millions more, to the state, to be covered by state budgets and only partially paid for by the federal government.

• In November 2010, if current polls are predictive, political power in the states and in the House of Representatives nationally, will shift to Republicans. Republicans now stand to control over 30 state governments.

According to the authors of the NEJM piece, the realities facing implementation of Obamacare, now increasingly dubbed the Affordable Care Act (ACA), a misnomer of the first order, are:

• Many, if not most states, have little experience or expertise with high-risk pools, or insurance market reforms, which are part and parcel of the new law.

• Many states – for policy, political, and other reasons, “have little or no interest in collaborating with the federal government in implementing the ACA.” Already more than 20, soon to be 30, governors and attorney generals have filed lawsuits to block individual mandates, upon which ACA depends to succeed.

• At least 19 states have declined federal dollars to create high-risk pools, designed to provide coverage for those denied overage of pre-existing illness.

• The federal government has yet to answer questions about hoe $5 billion federal dollars will be spent to support states creating high-risk pools. What happens if the money runs out? How will the feds enforce formation of these pools? How should premiums be set? If a state declines to set up pools, how and when the federal backup be established? How will federal pools be administered?

To overcome state resistance and to answer these questions, the authors say, the administration will have to work “quickly, competently, and decisively,” or the federal government will have to pick up the total cost.

The Obama administration does not have a reputation of moving “quickly, competently, and decisively,” at least in the case of the oil spill in the Gulf.

Yet deadlines loom.

January 1, 2010 deadline

 Creation of high-risk pools
 Creation of state insurance exchanges or federal fallback exchange
 Adoption of insurance-market reforms, with the application of standards to all new health insurance plans and to many grandfathered plans (i.e., those that were in force as of the date of enactment of the reform law)

October 1, 2010 deadline.

 Permits parents to keep children on their insurance plans up to age 26.
 Prohibits lifetime limits on benefits.
 Restricts annual limits on benefits.
 Prohibits exclusion of preexisting conditions for children
 Establishes medical loss ratios by limiting percent of premiums used for overhead, marketing, and profit.
 Prohibits plans from rescinding coverage.
January 1, 2004 deadline
 Prohibits plans from denying coverage because of an individual’ heath status
 Prohibits plans from varying premiums for any reason except for family size, geographic locations, and age.
 Prohibits exclusions for preexisting conditions.
 Establishes minimum “essential benefits” that must be offered.
 Eliminate lifetime annual limits on essential benefits
 Prohibits plans from rescinding policies, except in the cast of nonpayment of premiums.

Summing Up

If I may sum up, federal-state tensions are mounting as the political landscape shifts with concerns over spending, debt, and government intrusion into private lives. Whether leaders; will have a meeting of the minds and wallets is uncertain. The Obama administration may have bitten off more than it can chew, or the states can digest.

Thursday, June 24, 2010

Mirror, Mirror, on the Wall, Where is the Fairest Health System of Them? And Is Criticism of U.S. Health System Fair?

Personally, I am growing weary of criticism of the U.S. health system from policy wonks and liberal think tanks about the abysmal state of U.S. This criticism rarely mentions our system is a creature of our culture – our expectations, our desire for immediate access to high tech care, our quick treatment by specialists, the heterogeneity of our culture with its marked regional differences, our toxic litigious practice environment.

The latest criticism comes from the Commonwealth Fund, a New York City progressive think tank. The Commonwealth Fund’s press release reads, “New Seven-Nation Study Ranks Last on Health System Performance,’ and is based on its report “Mirror, Mirror on the Wall, How The Performance of the U.S. Compares Internationally.”

As I read the report- comparing the U.S. to Australia, Canada, Germany, The Netherlands, New Zealand, and the United Kingdom, I thought of asking its authors, “Mirror, Mirror on the Wall, do you realize your conclusions precisely mirror your political belief – that centralized governments offering universal coverage are best?” As in your previous Mirror, Mirror reports, in 2004, 2006, and 2007, you say government-led systems are always best in access, quality, efficiency, patients safety, coordination, equity, and cost while the U.S.ranks last.

Your conclusions are always predictable. I have the sneaking suspicion you structure your conclusions to justify your assumptions going into the report. It is a superb example of selective reporting to support one's point of view.

Your PR blitz is familiar. Karen Davis, the lead author of the report and President of the Commonwealth Fund, hosts a conference call to national media reporters. She then informs them that things are in bad way in the U.S. and the new health care law will improve our international standing by expanding coverage to 32 million without coverage, enhance affordability to those already covered, and slow the annual increase in costs.

It will achieve lower costs through new regulations, medical homes, patient-centered care and bundled bills between hospitals and doctors.

The expansion to 32 million of the disenfranchised is true, but what isn’t said is that we are woefully short of primary care doctors and general surgeons, among others, to take care of them. And what also isn’t said, is that current evidence suggests the new law will increase premiums for those with coverage, will cause many employers to drop coverage, and will escalate, not decrease, overall costs. And so far, the patient-centered medical home and bundled bills between hospitals and doctors in accountable care organizations is a figment of wishful thinking policymakers.

I hope, as the Commonwealth Fund does, that the new health law will help the U.S. “close the gap, and, in some cases, lead.” But I fear the report is more a product of wishful ideological thinking rather than reality.

The Commonwealth Fund’s thinking is predictable in their conclusion.

“The most notable way the U.S. differs from other countries is the absence of universal health insurance coverage. Health reform legislation recently signed into law by President Barack Obama should begin to improve the affordability of insurance and access to care when fully implemented in 2014. Other nations ensure the accessibility of care through universal health insurance systems and through better ties between patients and the physician practices that serve as their long-term "medical homes." Without reform, it is not surprising that the U.S. currently underperforms relative to other countries on measures of access to care and equity in health care between populations with above-average and below-average incomes.”

Wednesday, June 23, 2010

Saving Medicare Through Accountable Care Organizations: It’s A Long, Long Way to Tipperary

The primary purpose of accountable care organizations (ACOs) is to save Medicare by cutting costs for sick seniors. Medicare now costs $500 billion. It will pass $1 trillion by 2019. ACOs are the darling of policymakers. They see ACOs as a the primary mechanism for restructuring Medicare through increased efficiency and quality and “accountability” on part of physicians and hospitals.

According to the government, An accountable care organization is an health system that pays doctors and hospitals, to keep people well, when they're sick. This may seem like a contradiction. But it is not. Chronically ill patients – with heart disease, hypertension, diabetes, emphysema, and cancer – consume more than 60% of the Medicare budget.

Theoretically, if you could prevent these conditions, or minimize complications once the disease horse has left the barn on an outpatient basis through teams of primary care doctors and their helpers , you could keep the sick elderly out of the hospital, out of the hands of specialists, and out of Medicare’s pockets.

ACOs can be defined as integrated groups of physicians and hospitals providing care for Medicare patients. ACOs is the latest buzzword for managing Medicare. It is gaining traction among policymakers desperate to control costs and boost quality. The incentive for physicians and hospitals is to share the savings produced by ACOs.

In 2009, the Medicare Payment Advisory Commission (MedPAC), Congress’s Medicare-policy advisory arm, identified ACOs as a tool for restructuring Medicare . A group of physicians , usually including a hospital, would assume responsibility for annual Medicare spending for a defined patient population.

ACOs would be compensated through an arrangement combining traditional fee-for-service payments with financial incentives to reduce costs, improve quality, and achieve greater information transparency. The success of the model would depend on adopting clear quality standards combined with a payment methodology that rewards quality while reducing current financial incentives for uncontrolled practice and volume expansion.

So Much for the Rhetoric

So much for the rhetoric, now for the reality. How would ACOs work?

Theoretically, organizations exist that could easily qualify as ACOs.

These include:

• professionals in group practice arrangements;

• networks of individual practices of professionals;

• partnerships or joint venture arrangements between hospitals and professionals;

• hospitals employing professionals;

• other groups of providers and suppliers of services that the Secretary deems appropriate.

And what would these groups have to do to qualify as ACOs?

• Agree to provide care for a defined population of Medicare fee-for-service beneficiaries;

• agree to participate in the program for at least three years;

• have a formal legal structure allowing it to receive and distribute payments for shared savings;

• include enough primary care professionals to cover the Medicare beneficiaries assigned to it;

• have in place leadership and management structures that include clinical and administrative systems;

• define processes to promote evidence-based medicine and patient engagement;

• demonstrate to the government that it meets patient-centeredness criteria.

And what are the obstacles to implementing a system of ACOs?

Number One, it would require plenty of capital – for consultants to set up the administrative structures, lawyers to make sure it doesn’t violate antitrust rules, managers to define the processes for practicing evidence-based medicine and engaging patients. Capital is something most physicians do not have.

Number Two, because of the time required to surmount the bureaucratic barriers, physicians, whose incomes coming from seeing patients rather than attending meetings, would likely to be on the sidelines.

Number Three is simply dealing with the ponderous federal bureaucracy. CMS claims it will work closely with the Agency for Healthcare Research and Quality to develop pilot quality measures , the Office of the National Coordinator for Health Information Technology on criteria applicable to health-information and meaningful-use capabilities, and the Health Resources and Services Administration on developing ACO criteria for entities operating in or serving medically underserved communities.

• Number Four
is a host of other things, such as
establishing ACO qualification, dealing with federal antitrust authorities, meeting state insurance regulations, establishing payment methodologies, safeguarding patients against abuse, getting multiple doctors and payers to participate, standardizing performance measurements, and selecting and expanding pilots.

It’s a long, long way to Tipperary – and to a widespread system of accountable care organizations caring for exploding Medicare and Medicaid populations.

Meanwhile the federal bureaucratic monster will be on the prowl, concocting new ways to “restructure” medicine to “save” Medicare.

Tuesday, June 22, 2010

Coming Health Reform Summer Storms

June 21 - This is the first day of summer. Health reform storm clouds, harbingers of political lightning strikes, loom on the horizon. How bad the storms will be and what form they will take is unknown, but here are thoughts on their shape and ferocity.

Summer Storm One, the inevitable physician access crisis - Today USA Today described one coming storm on its first page “Doctors Limit New Medicare Patients: Surveys Point to Payment Concerns.” The U.S. now have 41 million seniors on Medicare. In 2015, it will be 50 million, in 2020 58 million. An AMA survey indicates 31% of primary care physicians restrict the number of Medicare patients they will see. The reason for this is basic: Medicare currently pays only 78% of what private plans pay. If Congress goes through with its 21% cut in doctor pay, or passes a temporary fix, the number of doctors closing their doors to Medicare patients will escalate. And there will be plenty of them. Seventy eight million will start to become Medicare eligible in 2011 at the rate of about 13,000 a day over the next 15 years. And beginning in 2014, 34 million Medicaid patients will come on board the federal entitlement train. At that point, and probably before, the Obama administration will have a genuine physician access crisis on its hands. What good is Medicare and Medicaid if you have too few doctors to care for you, or waiting times exceed two months, already the case in Massachusetts.

Summer Storm Two, the possible November tsunami . In its Op-Ed page today, the Wall Street Journal warns of another approaching storm “Obamacare and the Independent Vote.” Its authors, three Stanford University Professors who are members of the Hoover Institute, after citing and analyzing multiple national polls, conclude, “Voter opposition hasn’t changed, and it could be decisive in November.” The president, they say, faces an uphill battle selling his health care bill, which is opposed by up to 70% of independent voters. Among voters who oppose the health bill, voters are 20% more likely to vote for the Republican than the Democrat candidate. Voters oppose more federal spending and fear for the future of their children and grandchildren because of the $13 trillion dollar federal debt, which will grow at $1 trillion a year for the foreseeable future.

Summer Storm Three, confirmation hearing for Donald Berwick, MD, as head of the Centers of Medicare and Medicaid. CMS has not had an acting director for four years. Obama has nominated Dr. Berwick for the post. Berwick is a professor of pediatrics at Harvard Medical School and is the founder and president of the Institute of Health Care Improvement in Boston. Berwick is a charter member of the health care elite. According to the New York Times, “ He is a man with a mission, a preacher and a teacher who has been showing hospitals how they can save lives and money by zealously adhering to clinical protocols for the treatment of patients. “ Berwick might be called the Pious Pied Piper of liberals. He is four-square for a government-run health care, detests market-driven care, promotes government-imposed rationing, openly admires Britain’s National Health Service, and has a long paper trail of articles and speeches outlining and defining his position. Republicans will use well-known political positions to revive their arguments against the new health care law, which they see as a potent issue in this fall’s elections. Dr. Berwick has given them plenty of ammunition.

I do not know if these issues will be a passing lightning storm, or will evolve into political hurricanes, tornados, or even a tsunami. But I know storm clouds are gathering. They are not favorable to the health bill and challenge the nation that it will lead to a more affordable and more widely accessible system.

Sunday, June 20, 2010

Health Reform - Ten Checks and Balances

June 20, Father's Day - What follows are ten thoughts on checks and balances in health reform. I am writing from Oak Ridge, Tennessee, where I am attending a high cchool class reunion. My son Spencer, a nationally known poet and a candidate for the Episcopal priesthood, is with me. He is checking on my past, and I am trying to provide balance so he can understand his father's legacy.

There were 251 in our graduating class. Two of us became physicians. I have been fielding questions about health reform and other health care matters. Our class is equally split between Democrats and Republicans, and I've been talking about checks and balances between the two parties and other participants in the health reform battle.

One, Democrats and Republicans
- Democrats won the first round with passage of the health bill. But two thirds of Americans still oppose the bill, and it is a long way between 2010 and 2020. Obama is spending $125 million in a pre-November PR blitz to sell the good parts of the bill. Democrats control the spending and sending of checks for now but come November, if Republicans take back the House, they may begin to cut off health reform checks.

Two. The President vs. Congress - It has become clear the President has very short political coat tails, and endangered Democratic politicians are not rushing in to ask the President to campaign for them.

Three, Centralized vs. Limited Government
- A recent Gallup polls indicate most Americans think government is "too liberal," and resistance to excessive government spending and too much federal debt, now $13 trillion, is palpable and growing each passing day.

Four, Specialists vs. Primary Care Physicians -
Two thirds of American doctors are specialists. That is the way Americans seem to like it. Despite all the rhetoric about primary care shortages, the health bill did little to correct the situation, and 98% of medical students are voting with their feet by becoming specialists. Universal coverage without universal coverage to primary care doctors may be meaningless.

Five, Proceduralists vs. Cognitive Doctors - Americans prefer doctors who do something concrete to physicians who advice caution, watchful waiting, and conservative therapies. We remain a nation of doers. We prefer action to inaction, and specialists who do what they are trained to do.

Six, Government vs. Market Reforms
- The health bill is heavily skewed towards government reform. Market reforms, e.g, health saving accounts, be damned. This is generally presented as government benevolence vs. market greed. In short, it is better to spend other people's money rather than your own.

Seven, Doctors vs, Consumers - This is often characterized as the Health 2.0 or patient-centric care vs. doctor-directed care. The idea is that the Internet will empower consumers to challenge their doctors,become equal partners in the decision making, and separate the the good doctors and hospitals from the bad. Not a bad idea, but patients still trust doctors more than outside sources.

Eight, the Old vs the Young - Politically the Medicare crowd dislikes the bill because it cuts $585 billion from Medicare, and through the individual mandates, the young and haalthy must buy coverage at the same rates as others to support the old and sick.

Nine, Hospitals vs. Doctors - To make the Medicare budget balance, government will have to cut hospital and doctor pay. Since hospitals and doctors often compete for the same piece of pie, this will upset the competitive equilbrium between hospitals and doctors and will force them to collaborate.

Ten, Inpatient vs Outpatients - Two forces are at work here: one centripetal forces driving consolidation of care into large institutions; and two, centrifugal forces, pulling consumers and patients into ambulatory settings and to home care. The two forces can be complimentary, but don't count on it. Hospital administrator and physician egos are strong, and so are incentives to control care and cash flow.

Wednesday, June 16, 2010

Fourth and Last of Four Parts. Interview with Lori Schutte, President of Cjeka Search, Inc., A National Physician Recruiting Firm.

The Physician Landscape: Turn-Ons, Burnouts, Leadership, and Physician-Led Innovation Issues

Preface: I conducted this interview on behalf of The Physicians Foundation, a nonprofit charitable organization representing physicians in state medical societies. Most of these physicians are in independent, physicians-owned practices. The Foundation is interested in what attracts physicians to new practices, why and when they leave these practices after being recruited, what characteristics organizations employing physicians are looking for, and how the physician practice landscape is changing.

Q: Let’s get back to brass tacks. I see from your survey that the three big recruitment draws, not surprisingly given the state of the economy, are: one, compensation, 65 percent, income guarantees, 61 percent; signing bonuses, 42 percent. That makes sense to me.

A: I think that’s very, very accurate.

Q: It’s got to be. After all, it’s your data.

A: Everybody wants market-based compensation, not necessarily security.

Q: I work closely with The Physician’s Foundation, which represents all the state medical societies. We surveyed 300,000 primary care doctors. What was tangible about the survey was the tremendous loss of morale among physicians. Do you see that, or is the impact softened by the security of being in multi-specialty groups?

A: I spoke at MGMA, and I got questions from the audience about groups were handling physician burnout, which is more prevalent than it used to be. How is that impacting the physician workforce? During the Q and A, the question of sabbaticals to combat burnout came up.

Q: There’s a lot of comment in your survey about the demands of physician leadership and administrative duties. Is that more important than in the past?

A: The desire for physician leadership is growing. The number of physician executives is increasing. The questions are; How do you spot emerging leaders? And how do you develop them? And how do you pay them?

Q: I’m a student of physician culture. One of our tenets is: we all put on our pants, or our girdles, in the same way, and why should we pay colleagues more when they are not doing the clinical grunt work in the trenches. How does one compensate leaders?

A: There is a bigger question than that. What does the organization value? If someone has leadership abilities, you have to compensate them fairly. Those leadership skills, in combination with clinical knowledge, Are more valuable than clinical skills alone.

Q; I’ve interviewed Mayo leaders through the years. They want their leaders to keep one foot in the clinical trenches so they can retain their credibility among colleagues.

Earlier in this interview, you said the survey contained few surprises, and it was comparable to findings in previous years. Any second thoughts?

A: The biggest surprise was the spike in number of physicians desiring part-time work. The other surprise, so to speak, was that what physicians want and need will vary from group to group, and from individual from individual. The savvy groups are going to look at the heterogeneity of physicians, and are not going to try to look at one-size-fits-all solutions, but will ask: what’s important this individual, and how we can accommodate him or her? They will tailor packages that are important to that individual.

Q: I am interested in innovation. Three years ago, I wrote a book Innovation-Driven Health Care. There is a pervasive interest in developing innovation strategies within groups. Kaiser, for example, is trying to develop an innovation culture and started a national organization called Innovation Learning Network. There is the feeling we can innovate our way out of some of our problems – through open scheduling, or group meetings with patients with the same disease, or new practice models. Do you hear much about this among AMGA members?

A: They talk a lot about they can continuously evolve in terms of the use of mid-level providers, the use of electronic medical records, sharing of information to stay on top of a patient’s condition.

Q: So innovation falls under the mantra of continuous improvement of efficiency and care improvement. By the way, your survey mentions the importance of hospitalists, especially to primary care doctors seeking relief from night calls and weekend call. Do you see the hospitalist movement, now about ten years old, continuing to evolve?

A: When we are recruiting primary care physicians, we find they are either going one way or another. I want to be a hospitalist, or I want to do outpatient medicine only. Very few want to blend the two, and do things the only fashion way- my patients are my patients, I want to follow them from beginning to end, and I want to do both. Many groups are hiring groups of physicians just to be hospitalists.

Q: Well, the landscape she is a-changing. Do you have any closing comments?

A: No, we live in interesting times, as the Chinese are fond of saying.

Third of Four Parts. Interview with Lori Schutte, President of Cjeka, Search, Inc., A National Physician Recruiting Firm.

The Gender Factor: How Women Physicians Are Transforming Medical Practice

Preface: I conducted this interview on behalf of The Physicians Foundation, a nonprofit charitable organization representing physicians in state medical societies. Most of these physicians are in independent, physicians-owned practices. The Foundation is interested in what attracts physicians to new practices, why and when they leave these practices after being recruited, what characteristics organizations employing physicians are looking for, and how the physician practice landscape is changing.

Q: I have a blog called, formerly, and I have written there several times how women physicians, who now constitute 50 percent of medical graduates, are changing the dynamics of practice. The impact is profound. Dr. Buz Cooper says by 2020, 60 percent of medical graduates will be women.

A: You are right. There are now 24,000 American medical school graduates, and one-half are women. We know for a fact women physicians work fewer hours. We are not only going to have a physician shortage, but less physician hours. It’s a reality we have to live with – this desire for a balanced life style.

One of the questions we asked in our survey was: how many physicians are married to another physician. The 2008 survey asked:

How many physicians in your group are married to a physician also working in your group?

• 7% of groups had 10 or more married couples
• 35% of the groups had 4-9 married couples
• 57% of the groups had 3 or fewer married couples

In recruiting you have to deal with how to place dual career couples.

Q: That reminds me. These days about 80 percent of obstetricians and gynecologists are women. I recently interviewed a female obstetrician/gynecologist in a group of five, and four of the five female partners had a house-husband.

What other impact do you think women physicians have on practices?

A: The disconnect is in what female physicians are looking for and what practices are offering. Women are going to locate where they want to locate and live where they want to live. If I have a highly desirable location, I don’t have to offer as much as I do if I have a more rural setting. Practices have to get in line with what candidates are looking for. We have to say to practices; part-time may be out of your norm, but let’s find a way to make this a win-win. This is a great candidate, and if you don’t find way to hire her, your competitor will.

There are many variations off this theme. We had a couple of physicians with a baby, and their proposal to the group was, we want to job-share one spot. The group said, that’s OK.

Tuesday, June 15, 2010

Second of Four Parts. Interview with Lori Schutte, President of Cjeka Search, Inc, a National Physician Recruiting Firm.

The Importance of the Presence of EHRs and Hospitalists as Recruiting Draws for Young Physicians, Their Indifference to Reform, Practice Acquisitions by Large Entities, and Need for Practice Flexibility.

Preface: I conducted this interview on behalf of The Physicians Foundation, a nonprofit charitable organization representing physicians in state medical societies. Most of these physicians are in independent, physicians-owned practices. The Foundation is interested in what attracts physicians to new practices, why and when they leave these practices after being recruited, what characteristics organizations employing physicians are looking for, and how the physician practice landscape is changing.
Q: From my vantage point, a couple of things surprised me about survey on physician recruiting and retention.. One was that it was important for young physicians being recruiting that the group they joined have an electronic medical record platform. That surprised me perhaps because I have been talking to older physicians who are much more skeptical about electronic medical records. Yet that is one of the top issues for young doctors.

A: Yes, that’s because young doctors are very technologically savvy. Having EMRs says something about the organization. They want to be with someone that is on the cutting edge. And it plays to their strengths.

Q: The other thing that surprised me was the muted response to reform issues. In my world, there is genuine alarm about the implications of reform and how it will negatively impact the practice of medicine. In your survey, there was more uncertainty, but not alarm about reform. Do I read that correctly?

A: I think you read it correctly. They know issues are looming but they don’t know the impact on organizations they may be joining.

Q: On reform, they seemed to be most interested in whether reform would provide bonuses to primary care doctors.

A: This survey was conducted in the fall of 2009, fairly early in the reform process, so it may be the issues were not well-defined at that point. Another issue was the future of Medical Homes, which to this day remains unknown.

Q: As I read your survey, another question sprang to mind. From various sources, I keep hearing hospitals are acquiring primary care and specialty groups at an accelerating rate. But I gather from your MGMA constituency, which consists mostly of medium and large sized multispecialty groups, this may not be the case.

A: Well, groups are interested in expanding their reach by acquiring existing practices. The groups are getting bigger. I think both hospital-based and independent groups are growing. Consolidation is occurring because there is a distinct competitive advantage in being larger and acquiring existing practices is the easiest way to grow.

Q: That would indicate to me that integrated delivery systems are likely to grow.

A: Yes, I think in many communities you will see hospitals partnering with medical groups in order to grow. In many instances, many of those smaller groups are going to the big groups and hospitals and saying, we want to be acquired. We want to work for you because it minimizes our risks. They want to on salary with a guaranteed income.

Q: In titling this interview, I thought of calling it, “The Political Transformation of American Medicine, the Making of a Vast Industry,’ after Paul Starr’s 1982 book, “The Social Transformation of American Medicine, The Making of a Vast Industry.” It seems to me what’s happening is a vast consolidation of American Medicine to meet the uncertainties over the next 4 to 10 years.

A: Yes, and in addition, there are other undisputed facts. What physicians want is flexibility and life style practices. This is reflected in our data showing the desire for part-time practices going from 13 percent to 21 percent. One of our recommendations to the membership was: be prepared to address the part-time issue. Don’t be rigid with fixed work hours and you will have to work every third weekend.

Q: I notice in your survey, you split doctors into three groups: early career, mid-career, and late career. As physicians approach late career, this need for flexibility grows.

A: Yes, and this is particularly true for male physicians. In early careers, it’s females who want more flexibility. We surmise for females that are because of family issues.

First of Four Parts. Interview with Lori Schutte, President of Cjeka Search, Inc., A National Physician Recruiting Firm

Part One, Background of President with Her Observations on Physician Turnover

Preface: I conducted this interview on behalf of The Physicians Foundation, a nonprofit charitable organization representing physicians in state medical societies. Most of these physicians are in independent, physicians-owned practices. The Foundation is interested in what attracts physicians to new practices, why and when they leave these practices after being recruited, what characteristics organizations employing physicians are looking for, and how the physician practice landscape is changing.
Q; What is your background, leading up to the Presidency of Cjeka Search?

A: My whole adult career has been in health care. Most of it was in the field of transplantation. I worked for seven years at the American Red Cross, and then for fifteen an one half years I worked for Mid-America Transplant Services, which is the organ procurement service here in St. Louis.

Q: That sounds like a strange background for physician recruiting, but I suppose you are in the physician transplant business.

A: Yes, but while I was in the transplant business, I received a MBA from Washington University. While I was in the transplant business, I was in charge of everything non-clinical – professional education, PR, marketing, everything to do with promoting donations.

Q: Today I would like to talk about the Retention and Recruitment Survey in partnership with AMGA- The American Medical Group Association, the organization representing medical groups. This is the fifth year these two organizations have conducted this survey. Let’s chart about the highlights, the insights, and the surprises of this fifth annual survey. I understand you conducted it by sending an email questionnaire to all the members of the AMGA, and you had a response rate of about 12%, which is considered good.

A: Before we got the survey results, I said I hoped there’s something dramatic in terms of retention really going up or turnover really going down. But there was nothing like that. Overall turnover stayed at 5.9 percent down from 6.1 percent. Everything was pretty much the same, which surprised me, considering the state of the economy.

Q: I noticed physician turnover generally peaks in three years. Why is that?

A: I think what happens is that individuals when they are hired, they get sign-on bonuses that are tied to years of service. It takes a while for the bloom to come off the rose, By the time you get to year three, you know whether your job is a fit for you or not. Or they want to be closer to their families.

Monday, June 14, 2010

The Whats, Whys, and Hows of Accountable Care Organizations (ACOs)?

An ACO is a local health care organization and a related set of providers (at a minimum, primary care physicians, specialists, and hospitals ) that can be held accountable for cost and quality of care delivered to a defined population.

Definition of Accountable Care Organization

A friend, a patient interested in health reform, asked: “Accountable health organizations are the rage. They’re hot, but what the hell are they?”

My short answer was,”ACOs are different ways of herding doctors together to make them behave economically.”

He was not satisfied with that. He said, “Be specific.”

I replied, specifically, with this physician herd list.

• Independent practice associations (IPAs)
• Multispecialty groups
• Hospital medical staff organizations
• Physician hospital organizations
• Organized and integrated delivery systems
• Virtual extended hospital medical staffs

My friend persisted, “Why herd doctors together?”

"That’s easy," I said, “If all the doctors who take care of you – your primary care doctor, specialists, and your hospital – work together financially, you will get better care, and it won’t cost as much.”

“Why?” queried my friend.

I replied, “To keep Medicare from going bankrupt.”

“But how?” said he.

I gave him this laundry list.

1. By keeping people healthier across care boundaries
2. By educating people to their risks and reducing costs to high risk older patients through the use of clinical teams
3. By forcing doctors and hospitals to work under a budget and to manage resources
4. By paying doctors under different arrangements, e.g. salaries, rather than fee-for-service, which encourages them to do more

“That’s not good enough,” he said, “Be more specific.”

“OK, I countered, “ I’ll try. “How is this?”

1. To bring down Medicare costs, so you will have Medicare in your old age.
2. To shift costs and accountability for care away from insurance plans to doctors and hospitals, where actual costs occur.
3. To gain the cooperation of doctors and hospitals by having them share in savings produced by ACOs.
4. To pay doctors in such a way that they will not treat you in what they regard as their and your best interest but in the best interest of quality and cost to the system.

My friend was dubious. He pressed, “But how do ACOs work? Will they save money and raise quality?”

I replied, “ I do not know. ACOs have great promise, but obstacles as well.

• Doctors treasure their autonomy and do not like to be “bossed”, even by peers.
• Doctors are skeptical about being paid and rewarded for not delivering care.
• Doctors fear getting stuck with high risk patients with irreversible conditions over which they have little control and for whom they care, may be asked to take a financial bath.
• Doctors may regard ACOs as capitated HMOs in drag, a failed cost-savings approach that made everybody miserable.”

Saturday, June 12, 2010

Electronic Health Records – An Obsessive Compulsive Technological Disorder in Which More is Less

There’s an electronic obsessive compulsive sickness out there.

Its symptoms are: the more information you provide, the more prolix, the more filled with boilerplate, the more templates, the more details, the more compulsive clutter, the more “documented,” the more “perfect” the electronic health record becomes, and higher its levels of reimbursement.

Presumably, if EHRs contained every piece of personal health data from cradle to grave, these electronic-information carriers would transform medicine for the better.

Unfortunately, more can be less.

This obsessive-compulsive preoccupation with documentation borders on the non-commonsensical. A specialist told me he routinely receives 6 to 10 page EHR reports from primary care doctors containing everything he doesn’t need to know and nothing of what he wants to know, containing a pithy note saying why the patient was referred, expressed in plain English.

Paul Sax, MD, clinical director for infectious diseases at Brigham and Woman’s Hospital, says specialists writing consult notes, are guilty of the same electronic longevity. In a contribution to a recent, blog, Sax wrote,

“Electronic medical records have, if anything, made matters even worse for the detail-obsessed. The ability to cut and paste endless reams of data into a note is irresistible to most ID docs.

It leads to a bizarre paradox where the more information in the note, often the less useful it is — a phenomenon expertly dissected over here on Says guest writer Jaan Sidorov:

‘[A doctor] had received a copy of a lengthy consultant-physician’s documentation involving one of his patients and was astonished by the blob of past data, prior notes, test results, excerpts, quotes, interpretations and correspondence that had been replicated word-for-word in the course of “seeing” his patient. The terse portions describing what the patient actually said, what the consulting doctor actually examined and what the diagnosis and plan were were inconspicuously buried toward the end of the EHR document.

And you know what’s most maddening? Under the current “guidelines” for coding and billing, there are true incentives — both financial and regulatory — to write this kind of text-heavy note, one heavily infused with templates and boilerplate language. The more complexity the better!’

“Here’s a proposal: the goal of a consult note should be concise documentation of what you think, and why, then what you’re recommending, and why.”

To sum up,

EHR proponents proclaim, “Cut and paste"!
Never let data lie fallow and go to waste!
If there’s a template, paste it!
If there’s boilerplate, paste it!
Never never, never, let anything be erased!

EHR proponents seek chart perfection,
They seek full and utter documentation.
Obsessively, they say leave no stone unturned.
Compulsively, they say data must be re-churned,
To add to their data and coin collection.

They say more is better for the bottom line,
More and more data suits them just fine.
Force physicians to click and send it.
Sure, others may not be able to read it,
But what’s good for computers is good for mankind.

But I say EHRs should have a place for brevity,
for a speech recognition succinct documentary.
In short, a place to be terse,
for nothing is worse,
than electronic longevity.

Friday, June 11, 2010

The Obama Comprehensive Health Reform Offensive

As Editor-in-Chief of Minnesota Medicine, I once wrote a satire “Healthcaremanship.” I began by quoting Stephen Potter of Oneupsmanship fame. Potter said, “Ordinary health, remember, is highly gambit-prone.”

Little did I realize my little essay would prove prophetic in the Obama era. Little did I realize the health care gambits I described then would become essential political tools.

The gambits were:

The Saxon Sidestep - Words of Saxon origin are short. Their Latin versions are long. Never use a short word when a long one will do. Always say care coordinator (18 characters) rather than nurse (5 characters). implementation (14 characters) rather than start(5 characters), integrated delivery system (27 characters) rather than hospital ( 8 characters). In other words, always twaddle rather than tweet. Go for the long ball, perhaps I should say elongated spheroid.

Management Maneuver – This gambit is more subtle because it rests on this assumption – your opponent knows so little about the arcane art of management that you can baffle him with managerial terms. This works well on physicians. The physician can make decisions on one person. That’s what diagnosis and treatment are about. But he can’t grasp decisions that involve many people. That’s management.

The Management Maneuver is a variation of the Double Dawdle. Maneuver the situation, e.g. a political debate to where a decision must be made involving more than one person. Then drop a pair of managerial words out of the blue. Useful pairs are - feasibility studies, demonstration projects, long-term planning, integrated objectives, coordinated resources, systematic analysis.

Computer Connection – It is always good gamesmanship for the Healthcareman to show what he’s saying has some connection with computers. In the first place, not many physicians know how computers work. Second, computer talk is impressive for its own sake. Thirdly, the computer is a logic machine – impersonal, objective, impartial. There is nothing subjective – or human – about it. Any of the following words will do (in any combination): adjectives (digitized, programmed, binary, compatible, algorithmic,electronic ), nouns (systems, programs, records, feedback, bytes, memory, interface).

Science Screen - Here you simply send up a scientific smoke screen so your opponent will not know what you are saying. Medicine , after all, is a Science not an Art. It is evidence-based. It rests on comparative-outcomes data. Use words or phrases with a scientific ring. Parameter is a good word to unfurl. A parameter is a mathematical concept meaning a variable constant which varies with the circumstances of its application. A scientific word connoting a variable constant is an ideal Science Screen. It will keep your opponent going around in circles.

• Comprehensive Offensive -
This is the single most powerful gambit at the political gamesman’s command. It has rational appeal, it puts the opponent on the defensive, you rarely have to define what you mean, and it produces documents so long nobody has time to read them. Here you use words like universal, international, regional, complete, organized, and, of course, comprehensive. Never say incremental. Obfuscate, do not illuminate, Complicate, do not simplify. Do not gamble, ramble.

Here is the comprehensive offensive at work in the Obama administration, as explained by George Will, the conservative columnist.

“Progressives generally, and Obama especially, encourage expectations as large as the 1,428-page (cap-and-trade), 1,566-page (financial reform) and 2,409-page (health care) bills they churn out as "comprehensive" solutions to this and that. For a proper progressive, anything short of a "comprehensive" solution to, say, the problem of illegal immigration is unworthy of consideration. For today's progressive president, the prospect of a jobless recovery is a comprehensive nightmare. “

In all events, use these gambits often. You’ll find them ideal for obtunding sharpt-witted opponents. Indeed, if you use these gambits often enough, you may even induce complete cerebral shutdown.

Thursday, June 10, 2010

Interview with Lee Stilwell, Founder and CEO of The Stillwell Group, a Washington, D.C. Public Relations Health Care and Health Policy Consulting Firm

Lee Stillwell is founder and CEO of The Stillwell Group, a full-service global public affairs company with a strong life sciences practice. Mr. Stillwell has worked on both sides of the aisle in the U.S. Senate as a key aide first for an eastern Democrat and later in his career for a western Republican. For more than 18 years, Mr. Stillwell was the chief advocate for the American Medical Association (AMA). As senior vice president of the AMA Advocacy Group, he managed a staff of more than 120 employees in Chicago and Washington, D.C.

Q: What do you do for a living now?

A: I am consultant, founder, and CEO of the Lee Stillwell Group. We are located in Washington, D.C, and we are a public relations group specializing in health care and health policy issues.

Q: What is your political background in the nation’s capitol?
A: I started out as a journalist. That took me to Washington, where I was a national correspondent. From there, as my friends say, I went over to the dark side. I got involved in politics. Early in my career, I worked on the Democratic side for Senator Abe Ribicoff of Connecticut. Then I worked for the National Confederation of Business. Then I went to work for Senator Bill Armstrong, a Republican from Colorado.

So I have covered the whole philosophical territory from different sections of the country. I prefer to look at issues from a 360 degree angle. I worked for the AMA advocacy group for 18 years, so I understand the physician perspective. I was in charge of the AMA Washington office, as well as some of the Chicago office.

Q: In March, the health bill, The Patient Protection and Affordability Act, passed. It will roll out over the next ten years. Sixty percent of Americans view it with skepticism Physicians are anxious about health reform. They do not think they have had a central voice in shaping the legislation. Do you agree that politicians have marginalized doctors in this effort?

A: I do. You are right on. It has been an amazing and tortuous process. It is legally guaranteed we are going to have a decade of disruption for physicians in their practices. Frankly, that would be the case no matter who was president or who controlled Congress. It will disrupt physician-patient relations. There is no doubt about that.

Q: How can physicians better contribute to this reform? What constructive measures can we take to make this a better system and to help shape this debate, which will continue for ten years?

A: One positive development is the large number of physicians running for Congress. What we desperately need in these distinguished legislative chambers is more doctors. That we have so many doctors running, 47 in all, symbolizes physician reaction to reform.

The last time I counted there were 106 specialty societies, and most have political action committees. I highly recommend physicians get involved in those committees.
Q: One hundred and six political action committees. That’s physician fragmentation in action.

A: That’s why the AMA needs to exist. The reality is that we need the AMA no matter what the AMA membership is or what it purported to be. In one way or another, 99% of medicine is represented in these various physician organizations. It is not necessary fragmentation. It is democracy at work. Everybody ought to go see how the AMA House of Delegates works. It is a very democratic process, messy at times, but democratic.

Forty seven physicians, 41 Republicans and 6 Democrats, are running for the House and Senate this year. That is nearly 3 times the number of physicians serving in Congress today. Physicians start with at least one political advantage – voter confidence. If you looked at a Gallup poll in March, you would have found 77% of Americans trust doctors compared to 23% who trust incumbent Representatives and Senators.

Q: So?

A: So physicians need to get involved. I left the AMA five years ago, but , as a participant in Washington politics, I have watched first hand the toxic political environment of health care for decades. The thing that has always amazed me is how naïve politicians are about health care and how little they understand about health care.

For better or worse, what has occurred in this last “episode,” what I like to call the health reform bill, is that a great many politicians learned a great deal more about health care. The sad thing, of course, is that you still have too many policymakers who do not understand, yet they are making crucial decisions that impact the physician-patient relationship.

Q: Give me an example.

Q: Electronic medical records- a hot issue right now. EMRS have huge implications for practices. Yet have policymaker really seriously considered how much it will cost to transcribe old records? Will these new records improve care? Will they save money? No one knows, but EMRs will impact every physician in this country. That is why, over the course of a decade, you will see many different mid-course corrections as realities dawn of the consequences of sweeping health reform.

Q: Any other cautionary comments?

A: Beware of the “invisible government.” This massive legislation will lead to new rules and regulations, the magnitude of which we are barely aware. No one knows how these rules and regulations will come down. Most physician organizations are just beginning to focus on the “second wave” – the new regulations that are just surfacing.

To be honest, I am not a big fan of big government. If you’re talking about this huge new piece of legislation, you’re talking about more than 100 new commissions and advisory boards. On my side, this is about intruding on medicine. On the other side, they would say it’s about improving and controlling care.

Let’s look at a couple of the huge new bureaucratic entanglements. Right now, we have the SGR issue of how much you’re going to pay doctors. Later, because the House and Senate bills, didn’t take care of extended Medicaid funding, that will come back to haunt us. Then we will have all of these unfunded mandates. Washington is requiring states to do something about these mandates, but the federal government is not funding the mandates. The governors are very unhappy because they are being told to do something for which they have no money.

Now they are talking about the physician payment issue being settled by the Debt Commission President Obama just named. Congress is hoping the Commission will take a hot potato off their plate - how to pay doctors. If that was not enough, you’ve got the Medicaid Payment Commission, which has just been launched. Then there is the Medicare version of that Commission, which is called the Independent Payment Advisory Board, which is supposed to address Medicare solvency.

I have just mentioned three Big Commissions. Imagine adding another 100. That’s what we are facing in Medicine.

Q: I like your term “Invisible Government.” You seem to be saying dealing with Big Government is like dealing with a Huge Phantom Octopus whose tentacles reach everywhere and wrap us all within their grasp.

A: Yes, and that is why most medical organizations have armies of lawyers to grapple with the Monster. The worst thing about these multi-armed and multi-layered bureaucracy is that it is does not run for election. Bureaucrats are there for the long haul, and they all have their own fixed and deep philosophical opinions. Their beliefs often run contrary to those of physicians and patients.

Q: Let me ask you three other questions.

One, yesterday, the Obama administration announced it will spend $125 million to “sell” health reform, even though the reform horse has already left the barn. Do you have any thoughts about the chances for success of this effort?

A: The public has made up its mind. This initiative is a propaganda campaign, or as the administration would say, it is providing consumer information. My guess is that this “information” will not move the public opinion needle at all. Patients are pretty smart. They look upon how it impacts them, and how it changes their relationship with their physician. In most of their minds, Obamacare is not a positive.

Q: The second question is: What happens in November should the Republicans take back the House?

A: If you want a brutally honest opinion, it will have no impact. Obama will still be President, and he will have veto power over anything and everything. He has drive, energy, and commitment to this issue. This is his issue, and he does not want anything to happen to it. You need 2/3 of the vote to overturn a veto.

Republicans will never have that, and it will be very hard to undo what has been done. What you are going to see is a series of minor course corrections, with maybe even some major course corrections, but there will be no repeal and replacement. Most things don’t happen until 2014. We have time to think about what can be done.
Q; What can the Physicians Foundation, which represents physicians in state medical societies, do to shape policy and to mobilize their members to make positive contributions?

A: The Physicians Foundation is already is doing the right thing –educating their members and the public to what’s at stake here. It is doing what it can to help physicians and patients deal with the consequences of this legislative act. What The Physicians Foundation can do is translate, transform, and recommend what to do when operating in an unfriendly political environment. That requires educating policymakers, physicians, and the public about the far reaching implications of this bill.

Tuesday, June 8, 2010

Obama Launches $125 million Campaign To “Sell” Health Reform

The Obama administration today kicked off a multimillion dollar effort to sell health reform to the American public as a lead-up to the November midterm elections and before his possible re-election campaign in 2012. Its purpose is to correct misinformation and disinformation about the health reform bill and to fend off efforts to repeal and replace it.

My dictionary defines “misinformation” as providing people with incorrect information, and “disinformation” as deliberately disseminating misinformation to influence or confuse rivals.

Obama and his followers say political rivals have been spreading malicious gossip, even outright lies, about his health reform bill. For example, rumor mongers have leaked word out that the Office of Management and Budget has announced costs will exceed $1 trillion instead of the $940 billion as advertised. Obamanites say distortion of this truth is now officially at best a misinterpretation, and at worst, a mistruth.

To counter misinformation and disinformation, the Obama team will spend $125 million to correct mistruths about health reform. A $125 million here, and a $125 million there, and pretty soon we’ll be talking about real money. Think of the $125 million as a mis-mini-stimulus.

Former Senate Majority Leader Tom Daschle (D-S.D.) and Victoria Kennedy — widow of Sen. Ted Kennedy (D-Mass.) — will co-chair the $125 million campaign. White House allies will roll out their PR initiative to defend health care reform amid growing signs Democrats are failing to get political traction on the issue.

Two-thirds of the American people who oppose the bill have apparently misunderstood, misinterpreted, and misconstrued the facts. They have misunderstood individual mandates will require the young and healthy to buy high priced insurance at the same rates as more sickly elders. They have misunderstood those 21 state attorney generals who want to declare Obamacare unconstitutional, partly to protect individual freedoms, partly because their states can’t afford Obamacare. They have misunderstoo those American corporations who say reform will cost them $350 billion and cause them to drop drug benefits for retirees. And they have misunderstood those seniors who misplaced fears the $535 billion cuts in Medicare will effect their benefits. These people are obviously collectively and individually misinformed.

White House heavy hitters will raise $25 million from party donors, unions, foundations and others to broadcast their message through new tax-exempt groups. The Health Information Center will explain the new law which will kick in between now and 2014. The separate Health Information Campaign will work the political side, answering Republican barbs about "ObamaCare" in this fall's election and beyond.

A memo by presidential pollster Joel Benenson is being circulated by the Democratic National Committee says, "As misinformation about President Obama's health care reforms give way to Americans' real-life experience with it, voters are slowly becoming increasingly comfortable with the law and resistant to Republican efforts to repeal it." The operative word here is “slowly,” too slowly for fearful Democrats facing misinformed voters with misplaced political loyalties in November.

"The problem is ObamaCare itself," said Michael Steel, chairman of the Republican Committee, "The American people don't want the higher taxes, higher costs, Medicare cuts, and payoffs to Washington special interests. No glitzy PR campaign bankrolled by their special-interest allies will change that."

Evan Tracey, who tracks political and public affairs advertising, said the administration has a "branding problem.” Derogatory "ObamaCare" comments has drowned out efforts to explain what the law entails. He notes groups opposed to health care reform have spent $21 million in ads. Supporters have spent only $18 million, most of it earlier this year in "soft messages" that have been drowned out by the antis' "much harder and to the point" spots.” The message is: Democrats are compassionate, Republicans are cruel.

Obama will host a tele-town-hall-meeting Tuesday with seniors to tout the $250 rebate checks that those who have fallen into the Medicare prescription drug doughnut hole will receive this week. The event, which will include more than 100 watch parties nationwide, is part of a renewed effort led by Stephanie Cutter, a veteran Democratic communications expert guru.

Other Inside-the-Beltway Obama supporters, Families USA and AARP, will launch their own campaigns to correct misinformation and disinformation.

This extraordinary PR blitz is intended to defuse those landmines of mistruths deliberately laid by misinformed rivals. The campaign, phrased in politically correct language, will have a Washington office, a staff picked by the White House, and will feature over 100 events, all to be held before November elections to correct misconceptions that have misled American public, misguiding them to mistaken misconclusions. It will persuade them of the wisdom of Obama’s ways and where his heart resides. It will restore mislaid minds.

The idea behind this campaign, as I perhaps misunderstand it, is to realign misaligned voters who have misconceptions about this mishmash of a health reform bill. I trust the $125 million will not be misspent.

Monday, June 7, 2010

U.S. vs. Global Health Care: Who Has Most Influence?

An intermediate or transitional phase

Definition of “ In Limbo”

The last 556 visitors to include,

• United States, 479, 86%

• Canada, 9, 1.6%

• India, 7,1.3%

• Korea, 5, 0.9%

• U.K, 5, 0.9%

• Germany, 5, 0.9%

• Australia, 4, 0.7%

• France, 4, 0.7%

• Others, 39, 7.0%

These figures reflect my preoccupation with U.S. reform and innovation and simple fact that most of my readers are Americans. Nevertheless, the numbers led to three questions.

1. Which country has the most influence over the world’s health trends?

The U.S., for many reasons. We remain the most affluent, and we spend the most on health care- 16% of GDP. We are the most innovative – with 80% of Nobel Prize winners. Twenty five percent of practicing U.S. physicians are internationally trained. We train many of the world’s specialists. I recently spoke to an academic cardiologist, and he told me 90% of candidates applying for cardiology were foreign-born. Because the Web is English-language based, we dominate it, especially when it comes to health-information technologies. We ae home to the world’s biggest IT firms – Google, Yahoo, Microsoft, Apple. But our dominance and influence may be about to change, as indicated by the world’s top Internet users.

Top Internet users, population, Internet penetration

1. China, 1.3 billion, 27%

2. U.S., 307 million, 74%

3. Japan, 127 million, 76%

4. India, 1.2 billion, 7%

5. Brazil, 199 million, 34%

6. Germany, 82 million, 66%

7. U.K. 61 million, 76%

8. Russia, 140 million, 32%

9. France, 62 million, 69%

10. South Korea, 49 million, 77%

2. Should the U.S. health system perform more like the rest of the developed world with its national health systems which spend about half as much as the U.S. on health with similar results?

I do not know, but I know the present president and his administration want us to be more like Europe, with its cradle to grave social welfare benefits. The troubles of this scenario are three-fold; one, most U.S. health participates will continue to act locally, rather than globally, for the U.S. is where the money is; two, voter resistance in America – two-thirds of Americans oppose Obamacare; and three, due to aging populations ,overly-generous pension benefits, and skyrocketing debts, the social welfare systems of those countries, and probably of the U.S., verge on collapse.

In the U.S., the U.S. will have to increase the age on entry into Medicare and perhaps means test Medicare recipients, by charging the more affluent more and raising Medicare participation fees and co-pays.

3. How is the world of health care likely to change for the U.S. and rest of the world’s health care systems?

Changes are underway. Over the last few years, medical tourism has gained popularity. American patients seeking health care abroad numbered between 500,000 to 750,000 in 2007. Medical experts estimate 200,000 to half a million Americans traveled out of the country for medical procedures. The medical tourism market may reach $100 billion by 2012.The medical tourism industry is booming, with Americans going abroad for less expensive procedures - hip and knee replacements, angioplasties and bypasses, cosmetic and dental procedures. Foreign-run hospitals are moving offshore near the U.S. to perform these procedures. American drug and device manufacturers are moving aggressively into the emerging markets like India and China. Drug companies are conducting clinical trials abroad to lessen their expenses. Internet users in other countries are reading U.S. websites about medical breakthroughs and demanding their governments offer more access to these advances.

The U.S. system is in limbo. We are bending backward to get under the bar. Other countries are bending forward to get under the bar. Both hope to emerge on the other side of the bar upright.

Sunday, June 6, 2010

Moving Doctors Front and Center in Reform Debate: Redirecting and Correcting the Health Care Follies

In the last three years, I have written two books and 1348 blogs on health reform and innovation.


Because I believe reform, American style vs. European style, is necessary. And because I believe American ingenuity is the best path out of the cost morass.

It’s my ambition to redirect the health care debate - towards innovation, and towards doctors and patients and away from government control, administrative concerns, and third parties interventions.

The health system should focus on doctors who deliver the care and patients who receive it. Everything else is ideological sound and fury. So far the health debate has marginalized the 650,000 doctors who provide care. The debate has yet to impact what takes place on the ground. Ditto for 250 million insured patients who receive care. Government reformers, policy wonks, and members of the health care industry and their lobbyists have dominated the debate proceedings . They have left practicing doctors and paying patients out in the cold. Doctors face declining reimbursements and more 3rd parties telling them to how to practice medicine, and patients will face less access to doctors and to technologies, and higher premiums, higher costs, and higher taxes.


What do doctors and patients want?

• Doctors want assurances that they will be paid enough to meet their expenses, they will be freed from paperwork so they will have more time to see patients, and they will be relieved from the constant anxiety and expense of a toxic, litigious, malpractice environment.

• Patients want assurances that they can afford care, they can trust their doctor to provide the right care, and they can have reasonable access to the best medicine has to offer,; They want these things without second guessing by remote and privacy intrusion s by federal and health plan bureaucrats .

Assurances Not Forthcoming

Instead Congress has dithered again on tort reform and on fixing the Sustainable Growth Rate (SGR) formula.

Here is how The New York Times sees the SGR fix problem in its lead editorial today,“The Doctor Payment Follies,” June 6, 2101).

“The formula that is used to pay doctors who treat Medicare patients is producing increasingly absurd results. If it were to be followed this year, doctors would face a 21 percent cut in payments for the tests, procedures, office visits and other services they provide to elderly Americans.”

“That would be a disaster, driving many doctors to stop accepting Medicare patients. Luckily, nobody is seriously contemplating that. As it has done repeatedly in recent years, Congress is readying a short-term fix that would provide a modest increase in physician fees for the next 19 months. “

“There will likely be no real solution until the American health care system moves away from unfettered fee-for-service payments that encourage doctors to perform unnecessary and costly tests and procedures and pays them instead for better management of a patient’s care over time."

The U.S. vs Other Nations

And here is how the Times sees health costs problems of American Medicine compared to other nations,

“Doctors visits, medical procedures and prescription drugs cost vastly more in the United States than other countries.”

The Times quotes Coleen Grogan, a professor of health administration policy at the University of Chicago, who says,

“We have known for a long time that health care is a market failure,"
(Hanna Fairfield, “Health Spending vs Results,” NYT, June 6, 2010).

A Market Failure?

Of health care being a market failure, I am not so sure – it has never really been tried. Americans pay an average 12% of their health care bills, and Congress is trying its best to discourage use of health savings accounts, in which patients pay a high deductible and save the rest for a rainy day. For consumers, the economic incentives are for more care and for doctors to provide it.

What Congress never talks about that health systems account for only about 15% of a nation’s health. The other 85% can be attributed to socioeconomic conditions, poverty, family unity, immigration patterns with ethic mix, and violence and accident rates – most beyond the health system’s reach.

The Congress also never addresses the customer’s demand and expectation for certain procedures as an expected standard of care in the U.S. – CT scanners per million people(34.3 in the U.S. vs 12.7 in Canada and 56.0 in Australia, Angioplasty procedures per 100,000 people 437 in the U>S., vs 192 in France and 560 in Germany.

Health spending, its nation’s health, and its longevity are functions of a nation’s culture, not necessarily its health system. What we need to do to move the health debate forward reality is more frank talk about the individualism of U.S. culture and economic, psychological, and legal demands on doctors, and less glib answers such as “moving away from an unfettered fee-for-service system.”

Saturday, June 5, 2010

Who Will Care for the Newly Insured and New Medicare Patients?

This question bedevils national policy makers. Not much time remains for answers. Seventy eight million baby boomers start qualifying for Medicare in 2011 at the rate of 13,000 per day. Thirty two million insured by the health reform act will come on board in 2014.


• Primary care physician shortages grow every day.

• Only 2 percent of medical students are entering primary care specialties

• Primary care residency programs are capped

• It takes eight to ten years to produce a newly minted primary care doctor.

Community Health Centers (CHCs)

What is the answer? Authors from Brown University, Health-AccessRI, and New York Medical Center, say a partial solution may exist in Community Health Centers. (“Health Care Reform and Primary Care – The Growing Importance of the Community Health Center, “NEJM, June 3, 2010).

Eight thousand of these centers already exist. The Centers care for 20 million Americans, 5% of the population. The patient load includes 35% on Medicaid, 25% on Medicare and private plans. The rest are uninsured.

Federal Funding

The 2009 Stimulus bill directed $2 billion to CHCs. The recently passed health reform bill poured another $47.6 billion into CHCs. Beginning in 2011, another $300 million will go to support the National Health Services Corp (NHSC)to recruit and place health professionals in care-short areas. According to the authors, “In their new steady state, with 15,000 additional primary care provides in HPSCs, the CHCs may well be entrusted with the primary health care of 40 million Americans – thereby ensuring that most medical disenfranchised Americans receive care.”


The authors describe these “challenges” confronting CHCs.

• inadequate funding of state Medicaid and CHIP programs

• lack of infrastructure capital

• inability to pay enough to attract primary care doctors

• insufficient electronic health records and other information technologies

• difficultiesof securing specialty referrals because of geographic isolation

• insufficient compensation

• federal red tape

• increases in specialists preferring not to participate in Medicaid or
Medicare sponsored programs

The attractiveness of “key values of the CHC model – a whole person orientation, accessibility, affordability, high quality, and accountability”may overcome these challenges. And it may be health reform demonstration projects – backed the Commonwealth Fund, Qualis Health, and the MacColl Institute for The Research Institute, will overcome obstacles. who knows? Maybe good intentions may yet trump implementation barriers.

Staffing of Community Health Centers

But an elemental question remains- who will staff these community health centers? Internationally trained physicians who want to live in America? American physicians whose educational debts will be guaranteed to be paid? Locum tenens physicians who are adequately compensated? Nurses, nurse practitioners and physician assistants? Who will fund these health centers?

Until these questions are answered, the full potential of community health clinics will not be realized.

Finally, from whence will physicians spring to provide care? Even in more affluent America, there are not enuugh physicians. In Massachusetts, with its four year old universal coverage plan and with the second highest per capital number of physicians in the U.S., waiting lists to see primary care physicians, cardiologists, and obstetricians are the longest in the land.