Saturday, July 31, 2010

Sickness of Government: Has Anything Changed in the Last 42 Years?

In 1968, Peter F.Drucker, father of modern management, wrote The Age of Discontinuity: Guidelines to Our Changing Society (Harper and Row). His theme was: The nature of society has fundamentally changed. We no longer trust government to perform. We have become a global shopping center and an information and knowledge economy driven by the computer. Government is too big, cumbersome, and inefficient to provide for or protect its citizens.

As I review today’s average national poll numbers, I get a sense of déjà vu.

Obama job performance
Approve
45.2%
Disapprove
49.8%
Spread -4.6%

Congressional Job Approval

Approve
21.2%
Disapprove
72.2%
Spread -51.0%


Direction of Country
Right Direction
32.8%
Wrong Track
61.5%
Spread -28.7%

Apparently, the more times change, the more they remain the same.

The following quotes are from Drucker’s chapter “The Sickness of Government” in his book.

Drucker’s comments call to mind that old chestnut, “He who ignores history is doomed to repeat it.” His remarks also raise these questions. Has the capacity of government to change society for the better really changed? Is government capable of doing things right for everyone? Can government, among other things, manage a vast pluralistic health system, which now consumes 17% of GDP, without increasing costs, creating a huge bureaucracy, rationing care, and decreasing quality. Can government do so without demoralizing physicians by turning them into underpaid 40 hour a week civil servants?

History will tell if government is up to the job.

Drucker Quotes


Of attitude towards government


Now our attitudes are in transition. We are moving to doubt and distrust of government.

Of illusions of the educated and intellectuals


Once the “wicked private interests” have been eliminated, the right course of action will emerge, and decisions will be rational and automatic. Private business and profits are bad – ergo, government ownership must be good.

Of “free” health care and taxing the rich

The British in adopting the “free health service” believe that medical care would cost nothing. All the health service is and can be is, of course, “prepaid” health care. Nurses, doctors, hospitals, drugs and soon have to be paid by somebody. But everybody expected this “somebody” to be somebody else. At the very least, everyone expected that under a “free” health service the taxes of the rich would pay for the health care of the poor. There are, of course, never enough rich people to carry the burden of any general service.

Of government performance


The greatest factor in the disenchantment with government is that government has not performed. Government has proved itself capable of doing only two things with great effectiveness. It can wage war. And it can inflate the currency.

Of government and the welfare state


The best we get from government in the welfare states is competent mediocrity. What is impressive is the administrative incompetence. Every country reports the same confusion, the same lack of performance, the same proliferation of agencies, of programs, of forms, and the same triumph of accounting rules over results.

What is difficult for government
?

Certain things are difficult for government. Being by nature a protective institution, it is not good at innovation. It can never really abandon anything. The moment government undertakes anything, it is entrenched and permanent. Every beneficiary of a government program immediately becomes a” constituent.”

Of government and management

Government is a poor manager. It is, of necessity, concerned with procedure, for it is also, of necessity, large and cumbersome. It must administer public funds and must account for every penny. It has no choice but to become “bureaucratic.”Every government is, by definition, a “government of forms.” This means high costs. For “control” of the last 10 percent of phenomena always costs more than control of the first 90 percent.

Of what is needed in government

What we need in a pluralistic society is not a government that “does”. It is not a government that “administers,” It is a government that governs.

Summary

Only history will tell if government is up to the job. History is not optimistic.

Friday, July 30, 2010

Divergent views: New England Journal of Medicine Intelligentsia vs. Practicing Doctors

It amazes me how the views of NEJM authors in its “Perspective” section diverge from the views of practicing physicians.

NEJM pieces favor federally directed care and look kindly on the health reform law. Practitioners are profoundly skeptical and negative about many provisions of the new law. In different surveys, some 80% to 90% of physicians say they will severely restrict or refuse to accept Medicare or Medicaid patients.

Perhaps this divergence is inevitable. NEJM contributors tend to be lawyers, PhDs, or MD academics hailing from the Boston-New York- Washington- West Coast policy making, academic, progressive metropolitan complex. Practitioners are MDs or DOs, who come from everywhere – the South, Midwest, Southwest, the outlying East, and rural regions in between.

As I ponder differences in points of view, I recall the words of General George Patton when asked if he read the Bible. He responded,”Every God Damn day!” Likewise I read the NEJM every God Damn week. It is the Bible of America’s policy making elite. Its aim is to politically transform health care and to remake a vast U.S. medical industry into its image of how things ought to be, as directed from Washington.

NEJM authors trust Washington to do the right thing. Practitioners do not. Nearly 90% of doctors feel they were not adequately represented during the debate running up to passage of the health bill.

To make my point, here are three articles appearing in the July 29 NEJM.

One, S. Rosenbaum and J. Gruber, “Buying Health Care, the Individual Mandate, and the Constitution.” Rosenbaum is from the Department of Health-Policy, School of Public Health and Health Services, George Washington University Medical Center, Washington, D.C. Gruber hangs out at the Massachusetts Institute of Technology in Boston. Rosenbaum is a lawyer, and Gruber is an economist. The thrust of their article is that the health reform act is necessary is “to end pervasive discriminatory insurance practices while making health care affordable.” Attaining this goal, they maintain, is not possible without the individual mandate. The law, they say, ensures access to affordable coverage for most and rationalizes economic behavior for all. Practitioners disagree. They feel the new law will limit access because doctors do not have the time or resources to deal with the flood of new patients, and Congress does not and will not provide them with what it takes to carry out health reform mandates.

Two, Henry Aaron, PhD, “The SGR for Physician Payment – An Indispensable Abomination,
” Aaron is from the Brookings Institute, a well-known think tank in Washington, D.C. It is usually described as “liberal.” The SGR was enacted in 1998 to hold down growth of Medicare physician fees. It ties fee growth to the GDP. As usual because of physician outcries about SGR unfairness, Congress has extended SGR for 6 more months. Congress, Aaron says, will never abandon the SGR entirely because of the necessity to reduce the federal deficit. Further, the threat of letting it take effect is a useful leveraging point to compel doctors to join accountable care organizations, promote bundle payments, and cooperate with health reform. His attitude is that the SGR is an “indispensable abomination” - something Congress needs to enforce reform. In surveys, practitioners indicate the SGR is indeed an abomination, or Obamanation, that stiffens their resistance to health reform.

Three, Yuting Zhang, PhD, Katherine Baker, PhD, and Joseph Newhouse, PhD, “Geographic Variation in Medicare Drug Spending,
” The three authors are from Departments of Health Policy at Universities of Pittsburgh and Harvard. In their opening sentence, the PHDs assert, “The widespread geographic variation in Medicare spending has garnered a great deal of attention in the health care debate, both as a marker of inefficient resource use and a window into potential strategies for improving the quality of value of U.S. health care.”

The idea, which has evolved from the Dartmouth Institute, is that if only we could homogenize and standardize treatments and fees in different sections of the country, quality would improve and costs would drop. The authors note that pharmaceutical spending accounts for 20% of Medicare costs. They do not reach any conclusions as to how Medicare can reduce pharmaceutical spending or overall regional variations, nor do they suggest how physicians can help. As for practitioners, they are skeptical centralized Medicare programs can ever reach down to the level of physician-patient interactions or will ever take into account or understand differing socioeconomic or practice conditions in different sections in the country.

Thursday, July 29, 2010

Americans Spend Less on Health Care, Follow Laws of Economic Gravity

Conventional wisdom says health care defies laws of economic gravity. Other economic sectors may fall, but health care demand never drops. An aging, sicker population and growing entitlement programs assures demand will always trump gravity. The laws of supply and demand don’t apply to health care.

The prolonged recession and intractable joblessness may be turning conventional wisdom on its head. Since last year, hospital admissions are down 2%, and patient visits to doctors have declined nearly 5%, and by 7.6% in May alone.

The trend may be picking up, as jobs with accompanying health insurance disappear.

More Americans are visiting retail clinics and urgent-care clinics, or treating themselves, in search of lower prices.

And another gravity-defying phenomenon is exploding. Last year the number of Americans with health savings accounts with high deductibles grew from 13 million to 18 million, a 38% jump. Project that growth rate out five years, and 63 million Americans will own high deductible plans.

Again, the laws of economic gravity are at play. HSA premiums are some 20% less than for comparable HMOs and PPOs. And when you are spending more of your own money for care, you visit doctors less, and you become chary about paying for elective procedures, like knee replacements.

The laws of economic gravity may apply to health care after all.

Source: “Americans Cut Back on Visits to Doctor,” Wall Street Journal, July 29, 2010.

Health Reform in Perspective, Chapter One

This is first chapter on my new book Health Reform in Perspective.

Prologue:
Health reform affects 310 million Americans. It is too big for most of us to grasp. Yet we all have our bias. This chapter is about seeing health reform in perspective – the good, bad, and ugly.

Six Positives and Six Negatives of Health Reform Bill


In fairness, it is essential to put Health reform in perspective. This is especially true of physicians, who must abide by its provisions.

I see six positives and six negatives to the recently enacted health reform law. As with all contentious issues, it’s six of one and half-dozen of the other.

Positives

The six positives are:

1) 32 million more Americans will be insured.

2) Patients with pre-existing coverage will be covered.

3) Adult children can stay on patients’ policies until 26.

4) Arbitrary lifetime (coverage) caps will go away.

5) The Medicare Part D “donut hole” will be closed over ten years.

6) The bill provides a ten year framework for testing, changing, and even reversing its various provisions.


Negatives

The six negatives are:

1) Given past government performance and politic timidity to cut Medicare costs and to offend senior voters, its costs are likely to explode.

2) It fails to fix the Sustainable Growth Rate (SGR) formula, which calls for a 21% cut in physicians Medicare reimbursement, and more in subsequent years.

3) It fails to address the growing problem of physicians opting out of Medicare and Medicaid, which will surely take place when its provisions are implemented for cutting physician payments, rationalizing, and rationing care.

4) It fails to tackle the problem of tort reform, which, according to the OMB, costs the system $54 billion, and many times more, if one factors in the practice of defensive medicine.

5) It fails to acknowledge the growing physician shortage, not only in primary care but in specialties like general surgery, nor does it offer funding to stimulate more medical students or residency slots in primary care.

6) It fails to offer solutions or funding to address the looming physician access crisis: Who is going to care for those 32 million newly insured and for those 78 million baby boomers, who will begin enter the Medicare ranks at the rate of 13,000 a day in 2011?

Ten Checks and Balances

Here are ten thoughts on checks and balances in health reform.

One, Democrats vs. Republicans - Democrats won the first round with passage of the health bill. But nearly 60% of Americans still oppose the bill, nearly half want to see it repealed, 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 –As his approval ratings drop, 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 two-thirds of 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 law does 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 healthy 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 equilibrium 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.

Twelve Politically Correct (and Twelve Politically Incorrect) Health Care Ideas and Beliefs

Political correctness (or incorrectness) is using (or avoiding) expressions or actions the might be perceived to marginalize or insult groups who are socially disadvantaged or discriminated against.

Political correctness is about telling people what you think they want to hear in an ideal world. Political incorrectness is about telling people what they are reluctant to believe in the real world.

ONE

• It is politically correct to believe that everyone, no matter what their class or income or health status, deserves and should receive government guaranteed health coverage.


• It is politically incorrect to say that this is difficult in America because it superimposes a cumbersome, politically unpopular reform upon a complex, fragmented system without controlling costs.


TWO

• It is politically correct to say that the U.S. health system compares unfavorably to health systems of other developed nations.


• It is politically incorrect to say that the U.S. health system is a creature of our culture that reflects America’s values.

THREE

• It is politically correct to blame high health costs and discriminatory policies of profiteering health plans that exclude those with pre-existing illnesses, children, and disadvantaged individuals and social groups.


• It is politically incorrect to point out that profits are necessary to run a health plan and satisfy stockholders, the new law with its taxes and rules will raise premiums, and government plans could not function without health plan administrative help.

FOUR

• It is politically correct to say 30% of American health care is “wasteful” and “unnecessary” because of regional variations and provider greed.


• It is politically incorrect to say regional variations largely result from poverty and cultural conditions that combine to produce high costs for treating neglected or advanced diseases.

FIVE

• It is politically correct to say that centralized government programs and regulations will save the health system money.

• It is politically incorrect to observe that never in the history of the Republic have government entitlement programs saved money.

SIX

• It is politically correct to believe health outcomes, e.g., obesity and diabetes, are due to physician inattention, failure to advise patients properly, or misguided treatments.

• It is politically incorrect to say adverse outcomes may more often stem from lack of patient compliance, bad personal habits, poor nutrition, and sedentary life styles.

SEVEN

• It is politically correct to say we can solve our health care cost problems by broadening the primary care base and coordinating care.

• It is politically incorrect to say only 2% of medical students select primary care careers, most Americans prefer to go directly to specialists, and concepts like medical homes are untested.

EIGHT

• It is politically correct to say that doctors are responsible for high care costs and if we could only herd them into cost-accountable groups costs would drop.

• It is politically incorrect other factors contribute to high costs, many doctors prefer to practice independently outside of managed groups, and dominant larger groups negotiate favorable contracts not intended to lower costs.

NINE

• It is politically correct to assert that the health system is so complex consumers lack the intelligence, information, and knowledge to select the right doctors or right hospitals.

• It is politically incorrect to say health savings accounts, now owned by 10 million Americans, cut premiums by 20% or more without producing negative outcomes.

TEN

• It is politically correct to say with omnipresent, interoperable electronic health records, we can standardize and homogenize physician, hospital, and consumer health practices and behaviors.

• It is politically incorrect to say in America, freedom of choice of doctors, open selection of hospitals, latitude to live as one wishes, and personal privacy are considered God-given constitutional rights.

ELEVEN

• It is politically correct to insist a wise and benevolent government can fine-tune, direct, and coordinate care in all economic sectors, including health care.

• It is politically incorrect to point out centralized governments more often produce economic stagnation, unemployment, long health care queues, than dynamic economies reflecting the individualistic , entrepreneurial, pragmatic, adaptable, and innovative nature of its most enterprising citizens.

TWELVE

• It is politically correct to say that within the next ten years (the time frame for implementation of Health reform) we will know and appreciate government overhaul of health care.

• It is politically incorrect to note health reform is patterned after Massachusetts’ four year old universal coverage plan, which has raised premiums to the highest level in the country, produced the longest waiting lines in the land, overcrowded ERs, caused many physicians to close practices to new patients, and doubled state budget costs.

Wednesday, July 28, 2010

Foreword to Book on Health Reform

This is the foreword to Health Care Reform Perspective, my new book on health reform. Basically I describe physicians’ initial reaction to the newly passed health reform law.

Foreword

The date was March 23, 2010. After a year-long partisan political struggle, pay-offs to wavering Democratic Senators, and doubts about long-term costs, Obama’s health reform bill passed.

For Democrats, it should have been the best of times. Obama supporters proclaimed a “historic achievement.” President Obama was heralded as the most “consequential “of Democratic Presidents, more so than FDR or LBJ.

Finally

His party had finally passed a sweeping, unprecedented health reform bill, thanks to a single minded commitment by the President, and the legislative skills of Nancy Pelosi, leader of the House, and Harry Reid, leader of the Senate.

Democrats all voted for the bill. Republicans were unanimously against it. For a bill of this magnitude affecting every American to pass without a single opposition vote was indeed unprecedented. It may have been its greatest political flaw.

For Republicans, it was a bitter pill to swallow. They felt Democratic had snookered them. Under cover of darkness, Senate Democrats persuaded the House to approve the Senate version. And it was done amidst public opposition to the bill, mounting skepticism about a faltering economy, soaring national debt, and gathering gloom over government growth and skyrocketing national debt.

To add insult to injury, in a July recess appointment, Obama named Doctor Donald Berwick, staunch admirer of Britain’s National Health Service and advocate of rationing, as head of CMS (Centers for Medicare and Medicaid Services). Berwick said he had seen the errors of some of his socialistic ways, but Republicans were not convinced.

Consequences


Republicans called for Repeal and Replacement of the health law. The Tea Party movement grew. Obama approval ratings sank. Democrats lost millions of white male, elderly, and independent voters. Calls for “take our country back” were heard. In a July 26 Rasmussen poll, Most voters (58%) still favor repeal of the health care law. By a 44%-28% margin, voters believe repeal of the health care law would be good for the economy.

Among physicians, there is broad opposition to the health reform law, as exemplified by multiple surveys indicating one-third to one-half of physicians say they will cease seeing Medicare or Medicaid patients if the health law passed and implemented as written. If carried out, lack of physician access would create a political crisis of unimaginable scope.

For many Democrats legislative triumph may have been a Pyrrhic victory. There were ominous polls indicating Democrats might lose the House, even the Senate, in the November mid-term elections.

The Trophy

Still, in the heat of it all, Democrats still had their trophy, the health bill. It was now the law of the land. The law was called the Patient Protection and Affordability Act (PPACA). For short, it became known as the Affordability Care Act (ACA). But to most critics, it was simply Obamacare. The law’s proponents claimed, perhaps rightfully, that the term “Obamacare” was a perjorative term, code indicating opposition to health reform.

In 2010, the new law quickly covered those with preexisting illness, all children, and “children” up to 26 and closed the “donut hole” for Medicare medications.

Beyond the cherished few million who received immediate benefits, most of the rest of the populace failed to grasp whom the bill “protected,” outside the 32 million waiting to be covered on 2014. Certainly, Medicare beneficiaries did not feel protected, nor did taxpayers, American businesses, or physicians, for that matter. Meanwhile, after passage, the number of uninsured grew steadily to 47 million by the summer of 2010.

No one, not even its supporters, seriously believed the bill was “affordable,” not even the office of Management and Budget. The cost was variously estimated at $1 trillion over ten years (Obama estimate) to $2.6 trillion by Republicans over 15 years.

"Savings"

Besides, the Democratic estimate rested on the assumption that “savings” would be achieved by gutting Medicare of $575 billion, ending fraud and abuse, rationalizing care by doctors and hospitals, and cutting care utilization through comparative research analysis. Skepticism about these “savings” was understandable. Never in the history of the Republic had Congress cut spending while expanding entitlement programs.

The final irony was: nobody really understood what was in the over 3000 page health bill or what its consequences might be. Very few even read it. Yet the law applied to every American citizen.

Basic Assumption

Furthermore, it was based on this assumption: a small trained, technocratic, professional elite knew what they were doing, spoke for the people, and were smarter than the masses, who did not know what good for them. Their approach and ethos sprang from their belief that studies of statistical analysis of data outcomes of masses of people, rather than on individual concerns, held the clues and was the secret for improving the system.

The Best of Times, The Worst of Times

Politically, for Democrats, enactment of the health law was at first the best of times. But it soured, as the economy continued to falter, and joblessness and as casting the blame on President Bush receded as a credible political tactic.

For Republicans it was at first bad, then the best of times. But they had no credible leader and no credible message. Perhaps both would come before midterm elections in November.

What was lacking was perspective of what Health reform really meant for Americans - and for physicians who cared for them.

That is what this book is about. It rests on the thesis that a little perspective goes a long way.

Richard L. Reece, MD
Old Saybrook, Connecticut

Saturday, July 24, 2010

“Meaningful Use” of EHRs: Clinically Useful or Bureaucratic Boilerplate?

People who use the word “meaningful” put my teeth of edge. “Meaningful” conveys social significance. It captures the big picture, is beyond the pale of ordinary mortals, improves the lot of humankind, or, in the case of health reform, advances the overall cause.

That is how I reacted when I heard David Blumethal, MD, national coordinator for health information technology at the Department of Health and Human Services, announce the “meaningful use” regulations for electronic health records.

Blumenthal did so with fanfare by saying “The widespread use of electronic health records (EHRs) in the United States is inevitable. EHRs will improve caregivers’ decisions and patients’ outcomes. Once patients experience the benefits of this technology, they will demand nothing less from their providers.”

Here is how the WSJ Health Blog announced the news,

“The final regulations — all 864 pages of them –on what will constitute “meaningful use” of electronic medical records are now here.”

“As part of the stimulus package passed last year, up to $27 billion will be paid out by the Centers for Medicare and Medicaid Services over 10 years to providers that meet a series of requirements for EMR use.”

“ Providers will now have to meet just 14 or 15 “core” requirements dealing with EMR basics, such as being able to enter patient data and use a computer-based system to record medical orders.”

“Then they can pick an additional five objectives from a menu of ten options. Those include incorporating some lab tests results into records and providing a summary of care record for patients transferring to another facility.”

Blumenthal listed these “core set” and “menu set” of “meaningful objectives.”

Core set.

1. Record patient demographics.
2. Record vital signs.
3. Maintain up-to-date problem list of current and active diagnoses.
4. Maintain active medication lists.
5. Maintain active allergy lists.
6. Provide patients with clinical summary after each office visit.
7. On request, provide patients with electronic copy of their health information.
8. Generate and transmit prescriptions electronically.
9. Computer Provider Order Entry (CPOE) for medical orders.
10. Implement capability to electronically exchange key clinical information among providers and patient-authorized entities.
11. Implement systems to protect privacy and security of patient data into EHR.
12. Report clinicall quality measures to CMS or state

Menu set

1. Implement formulary checks.
2. Incorporate clinical laboratory test results into EHRs as structured data.
3. Generate lists of patients by specific condition for use for quality improvements, reduction of disparities, research, and outcomes.
4. Use EHR technology to identify patient-specific education resources and provide these to patients as appropriate.
5. Perform medication reconciliation between care settings.
6. Provide summary of care record for patient referral or transition to another provider setting.
7. Submit electronic immunization data to immunization registries or immunization information systems.
8. Submit electronic syndromic surveillance data to public health.

All of this, maintains Blumenthal, is necessary to improve care, assure patient safety, and reduce clinical errors. Maybe, but it also comes at a price, $30,000 to $40,000 or so, to be covered by the federal government over the next five years.

What does this all mean? What does it not mean? And how is it likely to play out among practicing doctors?

• It means that nothing is dearer and nearer to the heart of federal bureaucrats and technocrats than a “meaningful” national ubiquitous interoperable EHR system that allows doctors and hospitals to communicate with each, with patients, and with the federal government, which will have mountains of data to play with.

• It means that government will have to create new bureaucracies to make sure EHRs systems are standardized, credentialed, monitored, regulated, and implemented.

• It means that within five years, the government, through payment incentives and support systems, hopes to have most clinicians on board the EHR train.

• It does not mean, however, that clinicians will find EHRs contain useful clinical information or help communicate that information. Many clinicians tell me that current EHRs are simply data boilerplate and do not convey why a patient was referred, or help to transmit either patient-friendly, colleague-friendly, or hospital-friendly information.

• It does not mean that this transition from paper to electronics will happen without pain. Keep in mind that less than 10% of doctors and 5% of hospitals currently have fully functioning EHR systems, and many of these systems do not talk to each other; that many doctors, especially those in small groups, or solo specialists, will opt to pay the penalty for non-use of EHRs rather than install systems; that many doctors may drop Medicare and Medicaid patients rather than follow the CMS-Piper; that the $27 billion devoted to meaningful EHR use could turn into a massive federal boondoggle that neither patients or doctors will use or appreciate.

But whatever the price and inconvenience and clinical distractions, government bureaucrats and technocrats will be happy that” meaningful use” has been achieved. The only question will be: “meaningful use” for whom?

Thursday, July 22, 2010

Health Reform - Ten Checks and Balances. Obamacare in Perspective

What follows are ten thoughts on checks and balances in health reform.

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, July 21, 2010

Complexity of Obamacare. Obamacare in Perspective.

In today’s July 21 reading of The Health Care Blog, I ran across this passage by Alan Weil, JD,, director of the National Academy of State Health Policy. In his piece, Weil comments,

“The Affordable Care Act’s guarantee of coverage is actually a patchwork quilt that includes Medicaid, the Children’s Health Insurance Program, employer-sponsored coverage, and plans purchased with subsidies through the new insurance exchanges. While almost everyone will be eligible for some form of coverage, the source of coverage matters because it determines the benefit package, the cost-sharing provisions (deductibles and co-pays), and how costs are allocated between state and federal governments.”

“This complexity must be invisible to the person seeking coverage. We need to build a system where a person provides basic information about his or her own circumstances and linked databases instantly verify that information and convert it into a set of coverage options. Manual processes, reserved for complex functions like determining if someone has a disability, must become the exception, not the rule.”

“Simplification of the enrollment system is the linchpin of success for the reformed health care system. Failure to achieve this vision will leave millions of people without insurance coverage even though low cost or no cost options are available to them. And failure to achieve this vision will mean more money spent on administrative processes when we need every available resource devoted to providing needed health care services.”

What are the lessons to be learned from Obamacare – now redubbed at the Affordable Care Act?

Here is my take:

• Complexity is, well, complex, so complex that not even the “experts” comprehend or anticipate its consequences.

• Health care is an intimate part of a complex world, and is not immune, isolated, or protected from its vicissitudes.


• Health care’s complexity is what makes it so resistant to change.

• In the complex interconnected worlds of humankind and healthcare, not everything, not every little detail can be planned linearly from the top.

We will remember 2010 as the year Obamacare passed, and complexity, the Internet, and globalization overcame and overwhelmed humankind.

Everything is complex, and not everything can be simplified. You cannot cover everyone, completely control human behavior, or preach prevention, or plead for rationality in all things, and you must heed informal relationships, gossip, rumors, and sidebar conversations, and these shadow behaviors – these completely human, sometimes irrational, reactions, are important because they foretell workable health and business models and subsequent actions with any chances of success.

The human world, and its health care derivatives, work by “chunking,” by allowing complex systems to emerge out of links with simple things, out of convenient, simple, inexpensive, predictable, patient-centered, physician-accepted disruptive innovations capable of operating independently rather functioning seamlessly as dictated by centralized bureaucracies.

Success usually flows from cooperation and competition rather than simplifying complexity.

Reasoning Behind Growing Health Care Bureaucracy


Preface:
Everybody complains about the growing health care bureaucracy, but few analyze it and tell the reasons why it exists. That’s why we should be grateful to David Brooks, NYT columnist, for explaining what is going on.

Here are a few excerpts from a July 19 column ”The Technocracy Boom” on the bureaucratic mindset that has seized the imagination of the ruling party elite. The mindset is metastasizing in Washington. It is sucking the lifeblood and joy out of American business and health care enterprises. It says that those at the top can dictate what goes on at the bottom.

The italicized sentences are my doing. They explain the reasoning behind the new bureaucracies and the cultural backlash if they fail to do the job they are intended to do.


“In the second part of the period, Democrats were in control. They augmented the national security bureaucracy but spent the bulk of their energies expanding bureaucracies in domestic spheres."

"First, they passed a health care law. This law created 183 new agencies, commissions, panels and other bodies, according to an analysis by Robert E. Moffit of the Heritage Foundation. These include things like the Quality Assurance and Performance Improvement Program, an Interagency Pain Research Coordinating Committee and a Cures Acceleration Network Review Board."

"The purpose of the new apparatus was simple: to give government experts the power to analyze and rationalize the nation’s health care system. A team of experts on the newly created Independent Medicare Advisory Council was ordered to review and streamline Medicare. A team of experts within the Office of Personnel Management was directed to help set standards for insurance companies in the health care exchanges. Teams of experts serving on comparative effectiveness boards were told to survey data and determine which medical treatments work best and most efficiently."

"It’s a progressive era, based on the faith in government experts and their ability to use social science analysis to manage complex systems."


"This progressive era is being promulgated without much popular support. It’s being led by a large class of educated professionals, who have been trained to do technocratic analysis, who believe that more analysis and rule-writing is the solution to social breakdowns, and who have constructed ever-expanding networks of offices, schools and contracts."

"Already this effort is generating a fierce, almost culture-war-style backlash. It is generating a backlash among people who do not have faith in Washington, who do not have faith that trained experts have superior abilities to organize society, who do not believe national rules can successfully contend with the intricacies of local contexts and cultures."

"This progressive era amounts to a high-stakes test. If the country remains safe and the health care and financial reforms work, then we will have witnessed a life-altering event. We’ll have received powerful evidence that central regulations can successfully organize fast-moving information-age societies."

"If the reforms fail — if they kick off devastating unintended consequences or saddle the country with a maze of sclerotic regulations — then the popular backlash will be ferocious. Large sectors of the population will feel as if they were subjected to a doomed experiment they did not consent to. They will feel as if their country has been hijacked by a self-serving professional class mostly interested in providing for themselves."

'If that backlash gains strength, well, what’s the 21st-century version of the guillotine? “

Tuesday, July 20, 2010

Physicians: The Need for a Messenger and a Message

This is my 1400th blog. This means, I suppose, that I’m in it for the long reform slog.

In my blogs, I have sought, not always successfully, to speak for physicians, a heterogeneous profession that shares common rites of passage: medical school, a common medical language, and a common goal - first do no harm.

What do physicians need to do to get back into the reform game? So far we been marginalized, in part because we represent a small voting bloc. We need a messenger and a message.

The messenger has to be a large organization, preferably non-profit, representing the joint interests of physicians and patients. For this purpose, I like The Physicians Foundation (physiciansfoundation.org). It represents physicians in state medical societies, most of America’s practicing physicians.

What is the messanger's message? The message is that the messenger must help physicians help physicians, and physicians mist help patients understand what’s at stake with health reform. The message must be balanced. It must put Obamacare in perspective.

Obamacare has good points and bad, half-dozen of one and six of the other. It is cumbersome and unwieldy. Some of it is necessary, but much of it is adverse and perverse.

Say what you will. The new reform law is consequential. It is the law of the land. It represents the political transformation of U.S. health care, and the potential remaking of the vast medical industrial complex.

Reform will occur in increments, many open to political challenge, over the next ten years, with the big changes coming in 2014. It is a work in progress, not a done deal.

What can the Foundation and America’s physicians do in this environment? What positive contributions can we make to modify the new health care law in the best interests of physicians and patients?

• With its resources, the Foundation can conduct thoughtful studies exploring and documenting the effects of reform on practicing physicians and highlighting the accomplishments of American medicine.

• The Foundation can take an activist role, as it already does, in issuing grants to help physicians improve care and patch up some of the deficiencies in care.


• It can encourage members to take more politically active and positive roles in the reform movement, through closer contacts with political representatives, by running for political office, by contributing to political causes, by writing letter to the Editor, by composing Op-Ed pieces, and even by blogging. Like it or not, health reform is political at its core. But, at the same time, the Foundation must recognize it is not a political, but an educational, organization.

• It can repeatedly make these points: America faces a looming physician shortage, current doctor graduation rates of 24,000 doctors a year are insufficient, primary care training programs must be expanded, the new law is woefully short in incentivizing medical students to enter primary care fields, and failure to achieve a permanent SGR fix is a blot on Congress and a disincentive to enter and remain in the medical profession.


• It can educate the public to the reality that America needs more primary care doctors and specialists, that there are primary care doctors who perform specialized procedures and specialists who practice primary care, that more nurses and mid-level practitioners are vital but will supplement but never replace medically trained practitioners.

• It can educate its physician constituents in how to use electronic media and to understand the interactive role the Internet and the social media will play in educating, informing, directing, and guiding patients . In the future, the Internet will be an essential and efficient means of connecting, influencing patients, and improving care.

The opinions expressed here are those of the author and not those of The Physicians Foundation.

Monday, July 19, 2010

Twelve Politically Correct (and Twelve Politically Incorrect) Health Care Ideas and Beliefs. Obamacare in Perspective


“Politically correct (or incorrect) the use (or avoidance) of expressions or actions the might be perceived to marginalize or insult groups who are socially disadvantaged or discriminated against.


Wikepedia

Political correctness is about telling people what you think they want to hear in an ideal world. Political incorrectness is about telling people what they are reluctant to believe in the real world.
_________________________________________________

ONE

• It is politically correct to believe that everyone, no matter what their class or income or health status, deserves and should receive government guaranteed health coverage.


• It is politically incorrect to say that this is difficult in America because it superimposes a cumbersome, politically unpopular reform upon a complex, fragmented system without controlling costs.


TWO


• It is politically correct to say that the U.S. health system compares unfavorably to health systems of other developed nations.


• It is politically incorrect to say that the U.S. health system is a creature of our culture that reflects America’s values.

THREE

• It is politically correct to blame high health costs and discriminatory policies of profiteering health plans that exclude those with pre-existing illnesses, children, and disadvantaged individuals and social groups.


• It is politically incorrect to point out that profits are necessary to run a health plan and satisfy stockholders, the new law with its taxes and rules will raise premiums, and government plans could not function without health plan administrative help.

FOUR

• It is politically correct to say 30% of American health care is “wasteful” and “unnecessary” because of regional variations and provider greed.


• It is politically incorrect to say regional variations largely result from poverty and cultural conditions that combine to produce high costs for treating neglected or advanced diseases.

FIVE

• It is politically correct to say that centralized government programs and regulations will save the health system money.

• It is politically incorrect to observe that never in the history of the Republic have government entitlement programs saved money.

SIX

• It is politically correct to believe health outcomes, e.g., obesity and diabetes, are due to physician inattention, failure to advise patients properly, or misguided treatments.

• It is politically incorrect to say adverse outcomes may more often stem from lack of patient compliance, bad personal habits, poor nutrition, and sedentary life styles.

SEVEN

• It is politically correct to say we can solve our health care cost problems by broadening the primary care base and coordinating care.

• It is politically incorrect to say only 2% of medical students select primary care careers, most Americans prefer to go directly to specialists, and concepts like medical homes are untested.

EIGHT

• It is politically correct to say that doctors are responsible for high care costs and if we could only herd them into cost-accountable groups costs would drop.

• It is politically incorrect other factors contribute to high costs, many doctors prefer to practice independently outside of managed groups, and dominant larger groups negotiate favorable contracts not intended to lower costs.

NINE


• It is politically correct to assert that the health system is so complex consumers lack the intelligence, information, and knowledge to select the right doctors or right hospitals.

• It is politically incorrect to say health savings accounts, now owned by 10 million Americans, cut premiums by 20% or more without producing negative outcomes.

TEN

• It is politically correct to say with ubiquitous, interoperable electronic health records, we can standardize and homogenize physician, hospital, and consumer health practices and behaviors.

• It is politically incorrect to say in America, freedom of choice of doctors, open selection of hospitals, latitude to live as one wishes, and personal privacy are considered God-given constitutional rights .

ELEVEN

• It is politically correct to insist a wise and benevolent government can fine-tune, direct, and coordinate care in all economic sectors, including health care.

• It is politically incorrect to point out centralized governments more often produce economic stagnation, unemployment, long health care queues, than dynamic economies reflecting the individualistic , entrepreneurial, pragmatic, adaptable, and innovative nature of its most enterprising citizens.

TWELVE

• It is politically correct to say that within the next ten years (the time frame for implementation of Obamacare) we will know and appreciate government overhaul of health care.

• It is politically incorrect to note Obamacare is patterned after Massachusetts’ four year old universal coverage plan, which has raised premiums to the highest level in the country, produced the longest waiting lines in the land, overcrowded ERs, caused many physicians to close practices to new patients, and doubled state budget costs.

Health Care and the Groundswell

Groundswell is a book about the welling up of Internet- based social networking media sites – Facebook, U-Tube, Twitter, Flickr, and other sites – as transforming forces in our society.

Its authors - Charlene Li and Josh Bernoff – are executives at Forrester Research. They conduct surveys to determine how people use technology. Using their extensive database, they discuss the whys, whats, hows of the impact of the Internet on social and corporate behavior.

The book’s purpose is to teach corporate clients how to use the Internet, the blogosphere, and social network sites to market products. They define the groundswell as a powerful social trend in which people use information technologies to get the things they need from each other rather than from traditional institutions like government, corporations, and the medical industrial complex.

They argue the Groundswell is an irresistible, completely different way for people to relate and to connect with one another.

Three forces propel the Groundswell:

One
, people, who have always depended on one another to get what they need and to rebel against institutional power

Two, Technology which has changed everything because 73% of people are now online and have broadband connectivity

Three, Online Economics, which make it possible to get information virtually free, and which for marketers, makes it possible to influence millions of people through online research and online traffic reports.

“The groundswell,” say the authors, “has changed the balance of power. Everybody can put up a site that connects people with people. If it is designed well, people will use it. They’ll tell their friends how to use it. They’ll conduct commerce, or read the news, or start a popular movement, or make loans to one another. Or whatever the site is designed to facilitate.”

The groundswell is about power – the power of social connections between people, the power of the Buzz, the power of word of mouth, the power of opinion, the power of free information, the power of personal marketing, the power of online advertising, and the power of the Internet to make obsolete, and radically reform existing business models.

What does this have to do with health care? Plenty.

• Getting health care information is the number one reason people visit the Internet. Where most people find information about their health decisions, Here is where people get their information: Health web site: 48%, doctors: 43%,through friends or family: 30%, magazines or newspapers: 27%, TV or radio: 24%, the hospital: 22%, government: 21%, social networking websites: 17%, ccmmunity services: 14% ,health clubs (e.g. gymnasiums, yoga studios): 8%, schools: 7%, and
grocery stores/supermarkets: 7%


• People use the Internet to assess from what doctors and what institutions they will get their care, which is why sites like America’s Top Doctors have been so popular.

• Health care institutions – like Mayo, the Cleveland Clinic, Johns Hopkins, and Sloan Kettering - have entire divisions devoted to Internet markets.

• Certain companies – like Practice Fusion, Inc, an EHR firm – can offer EHRs “free” because online marketers interested in reaching doctors subsidize the EHRs rather than doctors.

• Medical practices – through physician bloggers and practice websites – can connect personally and in targeted ways to their patient constituencies.

• Sites, like Carepages.com, can offer support information for patients, families, and friends about almost any given disease or medical situation.

• Sites like the Healthcare Blog can start movements like Health 2.0 designed to empower consumers .

One well-known physician blogger, Kevin Pho, MD, has staked his career and made his name as "the social media's leading physician voice." In today's blog, he lists these previous blogs addressing the inpact and the use of the social media on and for physicians.

1. End of life blogging benefits and the questions it raises

2. Social media starts the patient dialogue with doctors and nurses

3. Social networking impact on patients, doctors, and non-profits

4. Twitter can spread inaccurate medical information

5. Twitter for doctors, a guide for health care professionals

6. Twitter habits of pharmaceutical companies

7. Twitter has problems in the operating room

8. Why doctors should blog with their real name

9. Quit smoking by using Facebook

10. Twitter and Facebook can help conduct group patient visits

11. Doctors using social media to talk to patients, but where's the evidence?

I recommend you visit Kevin at Kevinmd.com and click on one of these eleven blogs on the social media to appreciate the power of the Groundwell.

Sunday, July 18, 2010

Obama Puts All Eggs in Medicare Basket. Obamacare in Perspective

The Obama administration has put all its eggs for health reform in the Medicare basket.

Medicare is where Obamacare's leverage is. That is what it can control. That is where it can reduce physician and hospital payments. That is where it can ration services based on comparative research of outcomes. That is where savings are presumed to be($132 billion in Medicare advantage cuts, $200 billion in increased provider productivity, more than $200 billion in physician and hospital fee cuts). That is where entitlement-induced health costs are driving the government over the financial cliff. That is where the ultimate path to a single-payer system lies.

There are political risks, i.e. breakable eggs, to the Medicare strategy.

• Seniors, 14% of the U.S. population, are the group most opposed to Obamacare, and seniors are the most reliable voters.

• Seventy eight million baby boomers will become Medicare eligible starting in 2011 at the rate of about 13,000 a day over the next 18 years.

• Obamacare rests on the assumptions that “savings” will salvage Medicare though history shows Congress has little stomach for saving on federal programs.

• Medicare “innovations” like medical homes, electronic health records, and bundled payments to accountable care organizations will make the system more efficient.

• Medicare can set rates of all-payers, commercial payers will follow Medicare, and payment differentials between Medicare and commercial plans will shrink, leaving physicians little choice but to stay in Medicare.

• The states will willingly absorb their share (about 20%) of the costs of expanding coverage to 16 million more Medicaid recipients and will form health exchanges to help the federal government.


• Health plans, which Obama has demonized as the villains of the health system, will meekly follow the Obamacare game plan, can survive with federally imposed profit caps, and are capable of negotiating Medicare-like rates with hospital and physician organizations who dominate local and regional markets.

None of these assumptions are sure things. Indeed, the country’s current anti-government mood makes them “problematical,” a word you may be hearing often until the recession lifts, the economy and jobs return, and the November election approaches. If current polls are predictive, Republicans stand to gain 7 senate seats, 11 governorships, and 30 to 60 House seats.

The big enchilada, the biggest egg-breaker of them all, may well be the physician access crisis. Here is how Robert Berenson, MD, vice-chair of the Medicare Payment Advisory Commission (MedPac) describes the problem.

“Medicare beneficiaries could experience problems obtaining important physician services, as physicians seek the greener pastures of the privately insured, turning away Medicare patients as they do Medicaid patients.” ( “Implementing Health Care Reform – Why Medicare Matters,” New England Journal of Medicine, July 8, 2010)

Saturday, July 17, 2010

The Philosopher King and His Subjects. Obamacare in Perspective

President Obama is the new Philosopher King of America. We are his subjects. Philosopher Kings, according to Plato, are ideal rulers. They are suffused with wisdom. They know what their subjects know not.

They combine social engineering with idealism. They have the political skills to govern perfectly. The new King will take care of us. He will tell us what is right for us. We will come to depend on him. He will tax us for the privilege of being his loyal, obedient subjects.

Eighteen months ago, he began his rule. He hopes his reign will last eight years.

He started by focusing on universal health care reform. This makes sense. All of us, being ordinary mortals, are inevitably subject to illness and old age. We will respond, he thought, to social engineering. Health care, he said, is too complicated. The King will make it simple. He will end the immoral fee-for-service marketing free-for-all. It helps too few, namely, the haves. not the have-nots.

During his benevolent reign, health care will be free for all. With his wise guidance, he will set the rules for all from his castle in Washington, D.C. A media moat surrounds the castle. The moat keeps the good news in and the bad news out.

Consider what the King has already achieved. Obamacare makes his kingship historic. He has irrevocably changed the economy of one-sixth of the kingdom , put it inexorably on the road to single-payer Kingcare, and begun the most massive health and wealth redistribution in the kingdom's history.

No longer will the lords, earls, barons, ordinary merchants, or the subject themselves control health and wealth. He will spread the goodies throughout the kingdom. He will issue a kingdom-wide tax, consolidate the money in the castle, and decide how and to whom to distribute it. He will institute a VAT (Vast Added Tax) to assure that his dream for his vast kingdom, which stretches from sea to shining sea, comes true.

But, alas. His subjects are growing restless over growing tax burdens, soaring deficits,and burdensome rules imposed by the king. They resent their miserable existence and an economy that has failed. They have no work except for jobs the kingdom supplies.

They worry about the kingdom's debts and the future of their children. Being intelligent and of sound mind and body, they wonder whether “free entitlements” are really “free." They muse whether they will be “free” to spend their own money. They ponder whether they will be “free” to do what they want to do without the King’s blessings. They fret about what happens when Kingdom comes.

Fear not, says the King, all will be well, for I am wise and all-knowing.

Then an errant young knight, Paul Ryan, from Wisconsin, the middle part of his vast kingdom, rises to joust the King and his philosophy. Ryan says the subjects should exercise the power of the people and their choices as health consumers. They should choose the fork in the road they want to follow, even if it is not the left fork.

"Nonsense," says Donald Berwick, the King's philosophical spokesperson,""I cannot believe that the individual health care consumer can enforce through choice the proper configurations of a system as massive and complex as health care. That is for leaders to do." In other words, the King has spoken and brooks no opposition.


The King's subjects, according to Ryan’s Rules of Order, should be able to fend for themselves, to choose what kind of health care they want, to pay for it with King-granted and guaranteed vouchers, and to reclaim the freedoms of free people to make their own free decisions. It is bottom-up Freedoms, says Ryan, not a top-down Kingdom, that should reign.

Ryan makes this Declaration of Freedom,

"Are we going to reclaim the American idea -- an entrepreneurial economy where you make the most of your life, you tap your potential, we reinvigorate the principles of liberty, freedom, free enterprise -- and defend the morality of that -- or are we going to abandon that and switch over toward a European-style, cradle-to-grave welfare state where we drain people of their incentive and will to make the most of their lives and make them more dependent on the government?"

"Progressives believe that we ought to have the government so much more involved in our lives, as the more determining factor in our lives, rather than ourselves. So we have to ask ourselves a question: Do we want an entrepreneurial society that gets prosperity turned back on in the 21st century, where individual merit, entrepreneurial activity defines the American economy, or are we going to have more and more people dependent on the government for their livelihoods? And that is going to drain them of their ability and their will to make the most of their lives.

That's sort of the fork in the road we are at, and it's really being precipitated by the current direction of our government and the debt crisis because of entitlement explosion that's coming in the future. Those things are coming together. We've got to make a decision in 2010 and in 2012 what kind of country we want to be in the 21st century economy."


As Yogi Berra says, "When you come to a fork in the road, take it." I would add, "Or be taken."

Friday, July 16, 2010

Milstein- Kevin Debate: Obamacare in Perspective

Preface: I often interview national thought leaders from both sides of the political aisle. Recently I conducted a four part interview with Arnold Milstein, MD, and a West Coast physician leader who founded the Pacific Business Group on Health, the Leapfrog Group, and who is now a professor of Medicine at Stanford. There he will lead an innovation center bringing together the best minds from the Stanford Medical School, Engineering, and Management Schools. In general, Milstein is a proponent of consumer and business empowerment, top-down management of physicians through government regulation, management constraints, and creative new business models focusing on primary care physicians coordinating care.

As my four-part interview rolled out, Kevin, an anonymous blogger weighed in with a series of comments questioning Dr. Milstein’s wisdom and conclusions on how to restructure the system. My guess is that Kevin is an internist from California.
It is important to present both sides of the health reform argument. The latest national polls indicate these margins of opposition against Obama care: CBS 49/36, Public Survey 53/40, and Pew 47/35. Further, 88% of Americans are satisfied with their existing coverage, and only 6% feel health care is the number one major problem facing the U.S. It is the Jeffersonian belief that the people, not the political aristocracy, should rule
.

"Since when has central planning improved any system? Farms in Russia or China? As you stated, it is only the hubris of the planners that makes them think with enough rules and regulation they can somehow control things. I have not come to this conclusion without considerable thought but MEDICINE IS DIFFERENT!! It's different than banking and other forms of business in so many ways. It is personal, local, intimate. Just wait, once a critical mass of physicians withdraw from Medicare it will quickly become a tsunami and physicians will start fleeing en masse to free themselves from the intrusive regulation and constant second guessing. I wish they would implement the mandated SGR cuts so I would have a good excuse to do that right now. I think the AMA should take the same stand. They got rolled on HCR so they should stop being the mouse in the government's game of cat and mouse. Let them try to run their system when all the doctors have opted out."
____________________________________________________________________
"I doubt that oversea surgery will ever amount to anything other than a small niche for middle class patients who want more cosmetic surgery than they can afford in the US. However, if you were to try to convince Grandma to travel to Korea for a hip replacement or Junior for a valve replacement, it will only be possible if you offer them a substantial financial reward (or penalty) - there's that patient/consumer accountability again.

As for the A-ICU, I think that is what most patients got from their primary care doctors before MEDPAC/RUC started to systematically destroy it by increasing payments for specialists at the expense of cognitive services. Every internist had an RN and a panel of patients about half the current panel size. Now, the specialists have even better trained NPs and the primary care docs have MAs. Rather than A-ICU calls it E-PC (Enhanced Primary Care) and you have the same thing. Let me take care of your sickest 250 or 300 patients for 60% of what the average dermatologist or radiologist makes and I would easily save you hundreds of thousands of dollars in avoided hospitalization costs. The only model which allows this now is retainer medicine which ironically voids most private insurance contracts and of course is not paid by insurance or Medicare. That is what I always wanted to do. But current RBRVS payment for cognitive services pays twice as much per hour for low-level visits compared to more complex visits. So 60-75% of my practice is healthy people with low-acuity problems who subsidize the time I spend on the sicker Medicare patients. And it's not just me; the Mayo Clinic has said the exact same thing. The fact that the Stanford Professor hasn't figured this out yet is disturbing to me."

_______________________________________________________________

I doubt that oversea surgery will ever amount to anything other than a small niche for middle class patients who want more cosmetic surgery than they can afford in the US. However, if you were to try to convince Grandma to travel to Korea for a hip replacement or Junior for a valve replacement, it will only be possible if you offer them a substantial financial reward (or penalty) - there's that patient/consumer accountability again.

As for the A-ICU, I think that is what most patients got from their primary care doctors before MEDPAC/RUC started to systematically destroy it by increasing payments for specialists at the expense of cognitive services. Every internist had an RN and a panel of patients about half the current panel size. Now, the specialists have even better trained NPs and the primary care docs have MAs. Rather than A-ICU calls it E-PC (Enhanced Primary Care) and you have the same thing. Let me take care of your sickest 250 or 300 patients for 60% of what the average dermatologist or radiologist makes and I would easily save you hundreds of thousands of dollars in avoided hospitalization costs.

The only model which allows this now is retainer medicine which ironically voids most private insurance contracts and of course is not paid by insurance or Medicare. That is what I always wanted to do. But current RBRVS payment for cognitive services pays twice as much per hour for low-level visits compared to more complex visits. So 60-75% of my practice is healthy people with low-acuity problems who subsidize the time I spend on the sicker Medicare patients. And it's not just me; the Mayo Clinic has said the exact same thing. The fact that the Stanford Professor hasn't figured this out yet is disturbing to me.
___________________________________________________________________

Wider bundles that encompass longer time periods than a single patient encounter will shift accountability for quality and total costs more squarely onto the shoulders of doctors and hospitals."

There we go! Shift accountability. How about making the consumers/patients accountable? This has already been tried and failed. Pay doctors fairly and hold them accountable for quality for the pay they receive. I want to deliver quality health care services. But hold me accountable for costs? No way! Not unless I get to be paternalistic when the daughter of an 80 year old with advanced dementia, bedridden insists on "everything" for her Mom including ICU, ventilator and CPR despite numerous conversations about appropriate end of life care. (I guess I should also mention that the patient is an immigrant on Medicare/Medicaid who never worked a day in the United States or paid a single cent in taxes yet has access to all the expensive, unnecessary treatment her daughter can demand).

So the government gives them this entitlement to "everything" and I'm supposed to be the bad guy and say no or take a pay cut? Wow, that's real innovative! I guess we need a Stanford Professor to tell us this time it's different and the genius flowing out of his ivory tower will change human nature.

Perhaps the good Professor should seek the counsel of one of his Stanford colleagues who actually treats patients, Abraham Verghese, MD.

Writing on The Atlantic.com he said:

"What helped create our present mess is a payment system that rewards procedures and expensive diagnostic testing, but does not reward primary care; it has necessarily resulted in a profusion of people and places who do things that are well reimbursed and a dearth of physicians doing primary care. We don't need comparative effectiveness research as much as we need a retooling of the payment system and some caps on spending. Let's pay for what works right now, and stop paying for what's not needed."

Given that he helped create this mess with his MEDPAC activity, I have a feeling he will continue to pursue his failed cost shifting theories.
While I suspect that such research is necessary and may be useful, if the good Professor is going to try to develop a model of care where care is "free" for the patient (consumer) and cost containment is the responsibility of the doctor, insurer, government or some other agency or organization it will fail. Ironically, the single most important policy that has driven patients to cost effective generic drugs, the Medicare Part D "donut hole" was repealed in the HCR bill. Without the donut hole, No one is going to ask to change from expensive Lipitor to generic simvastatin. I believe this is a cynical political "poison pill" added to the bill to prevent wholesale repeal of the bill for fear of taking something away from the AARP set.

The models to control costs and ensure quality are already available, high deductible HSA-linked insurance. I have already seen this model resulting in significant decrease in utilization where I work, the East Bay. The decrease has affected specialists so much they are getting more and bolder with unnecessary testing on Medicare patients (no significant cost to the patient, no prior auth required). Of course it's much more fun to give away care for free and then blame the doctors for over-utilization.

As a member of the MEDPAC, which has systematically destroyed primary care in this country (the midlevel’s haven't stepped up and the physicians are dwindling) I suspect the good Professor's research will result in a great big waste of time and money. Patients get treated by doctors who work in offices and hospitals who expect a decent salary for a 60 hour work week - not by Stanford MEDPAC paper pushing policy researchers. I predict that in 5 years or less most doctors will have abandoned Medicare and private insurance for cash pay and offer enhanced service, more time and higher quality and satisfaction. The PBGH should have figured this out many years ago.

Thursday, July 15, 2010

Confused about Obamacare? Go To HealthyChat.com for Answers. Obamacare in Perspective

Preface: Confused about what Obamacare means for you? Fret no more. Wellpoint, Obama’s favorite health plan villain, the largest in the land, has opened a new website, HealthyChat.com to answer all your questions. Here is the story as explained in Wall Street Journal’s health blog.

“WellPoint’s Anthem unit has launched an online community to answer questions about health reform. The website, HealthyChat.com, Anthem says. is the first of its kind.

The idea behind HealthyChat.com is to provide a forum where people can ask questions about the new federal health-care overhaul bill and their health coverage more broadly. Anyone can log on and post a question, not just Anthem policyholders.
Anthem says the site has gotten about 60,000 pageviews since it launched May 1.

The questions being asked are things such as, “I have a child under the age of 26. When can I add her to my policy?” Anthem moderators, whose areas of expertise range from public policy to nursing, post answers to the questions, a spokesman says. The company decided to launch the forum after being inundated with questions following the new law’s March passage, he says.

On one of the forums, Anthem was asked why one policyholder’s premiums went up 31%. The company has been under fire from the Obama administration and state regulators for rate increases, which critics say are the result of industry profits and the industry contends are caused by rising medical costs.

WellPoint used the forum to reiterate the industry’s message, saying: “By law, premiums must reflect the anticipated medical costs of health plans’ members — which means rising health care costs do make a difference when it comes to premiums.” The moderator then ticked off the drivers of health costs, including an aging population and medical inflation.”

Berwick in His Own Words. Obamacare in Perspective

Preface: Several readers have asked for a fuller glossary of Donald Berwick quotes so they can judge where the good doctor stands and what his appointment as head of CMS portends for U.S. health care. I do not know about the latter, but I will let him speak for himself on the former.

"I cannot believe that the individual health care consumer can enforce through choice the proper configurations of a system as massive and complex as health care. That is for leaders to do."

"You cap your health care budget, and you make the political and economic choices you need to make to keep affordability within reach."

"Please don't put your faith in market forces. It's a popular idea: that Adam Smith's invisible hand would do a better job of designing care than leaders with plans can."

"Indeed, the Holy Grail of universal coverage in the United States may remain out of reach unless, through rational collective action overriding some individual self-interest, we can reduce per capita costs."

"It may therefore be necessary to set a legislative target for the growth of spending at 1.5 percentage points below currently projected increases and to grant the federal government the authority to reduce updates in Medicare fees if the target is exceeded."

"About 8% of GDP is plenty for 'best known' care."

"A progressive policy regime will control and rationalize financing—control supply."

"The unaided human mind, and the acts of the individual, cannot assure excellence. Health care is a system, and its performance is a systemic property."

"Health care is a common good—single payer, speaking and buying for the common good."

"And it's important also to make health a human right because the main health determinants are not health care but sanitation, nutrition, housing, social justice, employment, and the like."

"Hence, those working in health care delivery may be faced with situations in which it seems that the best course is to manipulate the flawed system for the benefit of a specific patient or segment of the population, rather than to work to improve the delivery of care for all. Such manipulation produces more flaws, and the downward spiral continues."

"For-profit, entrepreneurial providers of medical imaging, renal dialysis, and outpatient surgery, for example, may find their business opportunities constrained."
"One over-demanded service is prevention: annual physicals, screening tests, and other measures that supposedly help catch diseases early."

"I would place a commitment to excellence—standardization to the best-known method—above clinician autonomy as a rule for care."

"Health care has taken a century to learn how badly we need the best of Frederick Taylor [the father of scientific management]. If we can't standardize appropriate parts of our processes to absolute reliability, we cannot approach perfection."

"Young doctors and nurses should emerge from training understanding the values of standardization and the risks of too great an emphasis on individual autonomy."

"Political leaders in the Labour Government have become more enamored of the use of market forces and choice as an engine for change, rather than planned, centrally coordinated technical support."

"The U.K has people in charge of its health care—people with the clear duty and much of the authority to take on the challenge of changing the system as a whole. The U.S. does not."

“ I Feel Like A Million Dollars.” The Case of the 80 Year Old Driver. Obamacare in Perspective

Yesterday, because of a broken Tie-rod which rendered my car’s steering inoperable, I paid a driver to take me to a doctor’s appointment.

During the ride, the driver confided to me he was 80 years old. I asked about his health. He replied,” I used to be totally disabled. I couldn’t walk. But thanks to a spinal fusion, two hip replacements, two knee replacements, two cataracts, and a heart pacemaker, I feel like a million dollars. Now I can work, I can see, I can drive, and I can even run.”

Give the matter any thought at all, and you will realize.

• The driver’s experience is what differentiates the U.S. from other nations, who ration these procedures. In the process, they create waits of months to years.

• Why seniors are so leery about Obamacare, which calls for $575 billion cuts in Medicare over the next ten years, and why remarks of Doctor Donald Berwick, Obama’s designate as head of CMS is so provocative to critics, “The decision is not whether or not we will ration care -- the decision is whether we will ration with our eyes open.”

Only time, the ten years it will take to roll out Medicare reform, will tell if this skepticism is justified.

In the meantime, we can ask these questions: Why is U.S. health care so expensive? Is it worth it? One reason is that U.S. citizens, no matter what their age, have quick access to high tech procedures that restore them to normal or near normal function.

Our driver, disabled and unable to walk, was restored to employment, to feeling well, and to being able to run.

It is useful to consider the cost of these various procedures, among the commonly performed in the U.S.

• Hip and knee replacements, about 1 million of these will be done this year in the U.S., at the cost of about $50,000 each. This amounts to $50 billion to the U.S., and $200,000 for the driver, who had four replacements.

• Spinal fusion, about 150,000 patients will undergo this most common spinal operatio.n. At $70,000 per fusion, this will cost the U.S roughly $3.5 billion.

• Cataracts, 3 million per year, at a cost of about $4000 each.
This totals about $12 billion, and $8000 for our driver.

• Heart pacemaker and heart support implants, 100,000 per year, at a cost of about $100,000 each (pacemaker costs + operative + inpatient costs). $10 billion to U.S. and about $400,000 for the driver.

These costs are approximations. They are averages. They will vary with the complexity and nature of the various procedures. Nevertheless, they represent huge expenditures, $75 billion to the U.S. and $400, 000 for the driver. If one factors in such additional expenses as drugs, lab tests, and imaging (CTs, MRIs), the costs are undoubtedly much greater, perhaps even double, maybe close to $1 million for our driver.

Are these expenditures worth it? They are to the driver, who feels like a million dollars. And they are to the 47 million Medicare recipients who expect these procedures to be done when they need them.

How can the government reduce these costs?

• One, by overt or covert rationing.

• Two , by reducing fees for physicians , hospitals, and rehabilitation facilities.

These will not be easy decisions for the Obama administration to make. The fact that indications for these procedures – pain, disability, immobility, and heart failure – are usually clear cut makes decision-making even more difficult.

The case of driver who, thanks to effective medical care that made him fully-functional, puts the matter in perspective.

Wednesday, July 14, 2010

On Resetting the Physician Reform Agenda: Obamacare in Perspective

The Obama administration has done a good job resetting and explaining its agendas towards international and domestic affairs.

On international affairs, it promises be less imperialistic, less jingoistic, more self-effacing and more modest.

In domestic affairs, it says it will be more “redistributive” with taxes and health benefits, evening out class differences.

On reform issues, the medical profession has been less effective explaining its position. Too often , we come across as too protective of our incomes and our jurisdictional privileges.

This is too bad. We have good stories to tell of our profession, of how our profession has improved care and outcomes, of why the American health system stands out among other nations, and how we can protect and extend the benefits of what we have to offer.

Among these stories are the following.

• As a profession, we are overwhelming for affordable universal coverage.
Somehow in the raucous health debate this has been overlooked. We are for extension of benefits to 32 million Americans, and for covering children, those who cannot afford to pay, those with pre-existing illness, and those up to 26 under their parents’ plans.

• As a profession, we are proud of our accomplishments
in treating heart disease, hypertension, diabetes, cancer, and other chronic diseases, and in developing technologies to save lives and to restore Americans to full-function.


As a profession, we are proud of our training programs and our medical research, which are the wonders of the world and which draw health care patients from around the world for treatment and health care professionals from other nations for advanced training.

As a profession, we know that nothing brings you closer to the realities of the imperfections of our system than being a physician. Among these imperfections are third party administrative costs in the order of 15 to 20% of all costs, a “toxic” litigious legal system that may account for 10% of costs due to defensive medicine practices , a pervasive mindset that says managers, technocrats, and politicians, all far removed from care sites, know best how to save money and improve care, and the belief that thousands of rules, such as 130,000 pages of Medicare regulations, will somehow cut costs and set things right.


As a profession, we are aware that the American health system is a creature of our culture – its affluence, its wants, its expectations, its behaviors, and its desires for the very best Medicine has to offer. Individual freedom, the American way, has its downsides. Among these freedoms are the freedom to live, eat, exercise, behave, have access to technologies in a diverse market-driven capitalistic society.

• As a profession, we are skeptical that a coercive government-centered system controlling all options and promising universal coverage is the only way to go. We need look no further than Massachusetts universal plan, now four years old. In Massachusetts, health premiums are the highest in the land, waiting times to see doctors are the longest, and legislation is in the works to make accepting Medicare and Medicaid patients a condition for medical licensure. Massachusetts is also the ideological home and residence of many of the leaders and drivers of health reform – President Obama, president advisor, David Cutler, Obama's chief advisor, Robert Blumenthal, MD, Obama’s HITECH czar, and Donald Berwick, MD , the newly appointed head of CMS, It is a legitimate question to ask: If health reform, Obama-style, doesn’t work in Massachusetts, will it work elsewhere?


As a profession, we wonder if a universal system of obligatory, government-imposed, interoperable electronic records is worth the estimated price of $27 billion over the ten years. The government has just announced its conditions of “meaningful use” of EHRs, which will require doctors meeting 25 and hospitals 23 conditions for “meaningful use” by 2015, or else, or else being excluded or penalized if EHRs are not adopted and made operable by said date. Given that only 20% of doctors now have even primitive EHRs and hospitals less than 10%, we wonder if this target date is realistic or simply another example of government arrogant overreach. We also worry about privacy and security issues and whether EHRs will become an instrument for electronic police action and federal compliance to the wishes of a ruling elite.

As a profession, we believe and have always believed in “patient-centered care.” That is what practicing medicine is all about. We agree with critics that that care could be better coordinated and less fragmented and that patients should have personal primary care physician or specialists practicing primary care, but we question whether achieving these goals requires federal legislation.


As a profession, we believe the current health system and its proposed reform will drive many doctors out of medicine and fail to attract sufficient numbers of new doctors. Current federal law to pay primary doctors more, to carry out tort reform, to expand the number of training programs, and to assure predictable payments for paying for doctors who care for those in federal programs are inadequate. We believe the new 32 million uninsured, and the 130,000 new Medicare patients entering the system each day in 2011, will simply overwhelm the ability of doctors to care for them and to stay in practice.

Tuesday, July 13, 2010

The U.K. Revamps the NHS

According to today’s WSJ, the British government has decided to make the biggest changes in the NHS since its inception in 1948.

Here is the WSJ reporters describe this turn of events.

“The U.K.'s new coalition government, grappling with weak public finances and rising health-care costs, announced an overhaul of the state-funded health system that it said would put more power in the hands of doctors and save as much as £20 billion ($30.12 billion) by 2014. “

“The revamp essentially involves cutting huge swaths of bureaucracy and reinvesting the savings in urgent health-care services. As a result, the government said, it will still increase National Health Service spending in real terms every year for the next five years.”

“In one of the biggest changes, the government said it plans to eliminate a layer of financial managers and ask doctors instead to decide how the bulk of the National Health Service's £105 billion the NHS simply cannot continue to afford to support the costs of the existing bureaucracy; and the government has a moral obligation to release as much money as possible into supporting front-line care."annual budget should be spent. “


Put more money in the hands of doctors? Cut huge swaths of bureaucracy? Eliminate managers?

This is radical stuff, indeed. It is tantamount to decentralizing the national health service. Next thing you know, the Brits will decide to set aside rationing, now conducted by NICE, the National Institute of Clinical Excellence.

I can’t help but wonder what Donald Berwick, MD, President Obama’s appointee to head CMS, the Center of Medicare and Medicaid Services would think of this announcement of the revamping of the NHS.

If you can judge from his statements, Berwick believes wholeheartedly in centralized government control of health care, in rationing of care, in the evils of market-driven care, and in the moral superiority of the British system. He seems to like the NHS just as is. For the British government to say the NHS after 62 years isn't performing well must be unsettling to Dr. Berwick. The NHS has had ample time to work out the kinks.

Here, in his own words, are a few examples of the Wit and Wisdom of Donald Berwick.

“I am romantic about the NHS. I love it. All I need to do to rediscover the romance is to look at health care in my own country.”

“Please don’t put your faith in market forces. It’s a popular idea: that Adam Smith’s invisible hand would do a better job of designing care than leaders with plans can. I find little evidence that market forces relying on consumers choosing among an array of products, with competitors fighting it out, leads to the health care system you want and need. In the US, competition is a major reason for our duplicative, supply driven, fragmented care system.”

“In America, the best predictor of cost is supply; the more we make, the more we use — hospital beds, consultancy services, procedures, diagnostic tests, Here you choose a harder path. You plan the supply; you aim a bit low; you prefer slightly too little of a technology or a service to too much; then you search for care bottlenecks and try to relieve them.”

“Cynics beware, I am romantic about the National Health Service; I love it. … The NHS is one of the astounding human endeavours of modern times. It is a national treasure. It is an international treasure.

“It’s not a question of whether we will ration care. It is whether we will ration with our eyes open.”


Any health care funding plan that is just, equitable, civilized and humane, must, must redistribute wealth from the richer among us to the poorer and the less fortunate. Excellent health care is by definition redistributional.”

We shall see if Dr. Berwick can reconfigure CMS to mimic his beloved NHS, if Obamacare will save money, if it proves to be morally superior, and if it leads over time to a single payer system he admires so much.