Tuesday, August 31, 2010

Harvard Mindsets and Health Reform

Mindset – 1. an intention of inclination. 2. Deposition or mood.

Dictionary definition of Mindset

Over the next few years, the U.S. healthcare system will be in the hands of academics from Cambridge, Massachusetts. New CMS Czar Donald Berwick was a member of the Harvard Medical School faculty. Joe Newhouse, who has been the senior adviser to Medicare for as long as I can remember, holds appointments in three different schools at Harvard. David Cutler, Dean of Harvard’s Undergraduate College, seems a good bet to lead the Independent Medicare Advisory Board.

Countless of their colleagues and former students have taken key policy making positions in Washington… Whether they realize it or not, they are the vanguard of a movement bringing socialized medicine to America…The Obama administration has hired an army of academics to implement the new reforms. They bring with them the finest Cambridge pedigrees and promising ideas. They will write the first draft of the rules and academics everywhere will nod in approval at the cleverness of our colleagues.

David Dranove, “The Accidental Socialists,” The Health Care Blog, August 30, 2010

I once attended an 8-week course on health system management held at the Harvard Business School in Cambridge, Massachusetts with 60 other health care stakeholders. I was the only practicing physician. In 1994 the Hillary Clinton-led health care task force of 1200 or so contained not a single practicing physician or hospital administrator. The Obamacare team, centered in Cambridge, is about to make the same mistake of excluding health care participants on the ground.

The health reform law might be called the “Harvardization” of American health care. President Obama, a Harvard-trained lawyer inspired the reform law, weighed in when it is was in jeopardy, and pushed it across the finish line to passage. David Blumenthal, MD, a Harvard medical man, is Obama’s health information czar. Blumenthal is responsible for implementing and spending $27 billion on HIT to achieve a universal inoperative system of electronic health records.

The monumental, sprawling, massively-bureaucratic health reform effort rests on a set of Harvard mindsets. According to John Naisbitt, author of Megatrends (1982) and Mind Set!(2006),” Mindsets are the ground on which rain (information) falls. Mindsets are how we receive information. That is the key.”

Harvard reformers, mostly economists or academic technocratic experts, believe free market health insurance is imperfect and inequitable. Unregulated insurers leave too many individuals uninsured. Other individuals choose not to buy insurance. Still others “free-ride” off of taxpayer subsidized charity.

In the rarified academic heights of Cambridge , the solution to these societal ills is to tightly regulate the private insurance market and deploy “rational” technocratic mechanisms, perfected and directed from Washington, to create a more perfect health system.

Dranove, an economist at Kellogg School of Management in Chicago, says, “The preferred Cambridge solution is a combination of greatly expanded government insurance and a tightly regulated private insurance market. This is the essence of Obamacare.”

This mindset, when coupled with political power, transforms Harvard health reformers into high-minded social carpenters with hammers. Anything or anybody that doesn’t suit their fancy and fit their concepts looks like a nail.

Hammer for-profit health plans. Hammer fee-for-service doctors. Hammer hospitals that live off Medicare and Medicaid. Hammer anyone who needs profit to survive. Hammer the free-market crowd who believes in individualism, innovation, and free markets. Hammer anything and everybody that disagrees with you to nail down your concepts.

What are the Harvard health reform mindsets?

• Academic and government experts know better than people themselves what is good for them.

. You can trust government, but you can't trust markets.

• Equality of results and health care equity, with expansion of coverage, is paramount.

• Standardize and homogenize health plans into one-size-fits-all plans that offer comprehensive and coordinated care.

. The power if centralized government transcends the power of individual states.

• Make all health plans and all states comply with federal mandates and regulations.

• Health care is too important to be left to consumers, doctors, hospitals, and private markets.

• Health care technologies should, and must be, be assessed by government before and after introduction into the market.

• The practice of medicine is a rational, measurable science and its technologies and outcomes must be managed by outside experts.

• All physician and hospital practices must be digitized so they can be monitored and paid-for-performance based on evidence.

• You cannot depend on health care stakeholders or competition or markets, or consumers spending their own money, to be self-regulating.

• Big Government and Big Academe know best.

These precepts rest on progressive Harvard mindsets, on faith in government experts to do the job of reform, on the ability of experts to analyze and to manage complex systems, on sophisticated technocratic analysis, and on more analysis and rule-writing is as the most equitable solution to social breakdowns.

Monday, August 30, 2010

Will Public Hospitals Be a Health-Reform Casualty?

A paragraph in the August 29 WSJ opens:

“Forced with mounting debts from the new health-care law, many loal governments are leaving the hospital business, shedding public facilities that can be the caregiver of the last resort.”

Surely this is an unexpected and undesirable consequence of Obamacare, which was passed with the good intentions of covering the uninsured and Medicaid population, which flock to these hospitals for desperately needed care.

The WSJ article goes on,

“More than a a fifth of the nation’s 5,000 hospitals are owned by governments and may drown in debt caused by rising health-care costs, a spike in uninsured patients, cuts in Medicare and Medicaid, and payments on construction loans sold in fatter times.”

Local public hospitals foresee an expensive future because of new health-care requirements for such expensive items and services such as electronic medical records and other information technologies, tracking and enforcing quality of care of their physicians and hospital personnel, and coordinating care for its patient populations many of whom lack public transportation, phone access, and housing.

To make matters worse, many small hospitals in smaller communities are the economic engines and only health care facilities of their towns and surrounding regions.

Source: Suzanee Sataline, "Cash-Poor Governments Ditching Public Hospitals," WSJ, August 29, 2010

Sunday, August 29, 2010

With Health Reform, A Little Humor is a Dangerous Thing

In Washington, there are still way too many people who cannot get over how important they are. And do you want to know why they think they’re important? Because they make policy! To the rest of America, making policy is a form of intellectual masturbation; To Washingtonians, it is productive work. They love to make policy. They can come up with a policy on anything, including the legal minimum size of the hole in Swiss cheese.

Dave Barry, Hits below the Beltway: a Vicious and Unprovoked Attack on Our most Cherished Political Institutions, Random House, 2001

We live in an age of extremism. As those on the far left might say, “Extremism in defense of social justice is no laughing matter.” Or, as Barry Goldwater actually said, “Extremism in defense of liberty is no vice.”

Be careful about extremes. As politicians say in arid Arizona when the creeks run dry, "Don't jump from one ex-stream to another."

But fear not about extremes of government. Abraham Lincoln observed, "No administration,by any extreme of wickedness or folly, can very seriously injure the government in the short space of four years." Maybe not, but when you spread it out over ten years, as Obama has done with health reform, there is cause for alarm.

Even with these things said, I should note the following. Health policy is a serious matter. Policy wonks are deadly serious people. Doctors take their profession seriously. Patients go to doctors with serious concerns. And as every serious politician knows who wants to make his mark on history knows, health reform is much too serious to be entrusted to doctors.

The two lists I am about to share with you, therefore, are dangerous. Why? Because they are full of puns, the lowest form of humor.

One, I am about to print a series of doctor puns on health reform.

Don’t blame me. Blame the doctor who sent them to me.

• Allergists voted to scratch it.

• Dermatologists advised the government not to make any rash moves.

• Gastroenterologists had a gut feeling about it.

• Neurologists thought the Administration had a lot of nerve.

• Obstetricians felt they were all laboring under a misconception.

• Ophthalmologists considered the idea shortsighted.

• Pathologists yelled, "Over my dead body!"

• Pediatricians said, "Oh, Grow up! "

• Psychiatrists thought the whole idea was madness.

• Radiologists could see right through it.

• Surgeons decided to wash their hands of the whole thing.

• The Internists thought it was a bitter pill to swallow.

• Plastic Surgeons said, we don't want to lose face.

• Podiatrists thought it was a step forward,

• Urologists said the whole idea was as painful as passing a kidney stone.

• Orthopedists said the idea was broken and cast aside.

• Anesthesiologists thought the whole idea was a gas.

• Cardiologists didn't have the heart to say no.

• Proctologists were neutral, leaving the entire decision up to the "a-- holes" in Washington.
Two, I am about to reprint a previous blog of mine containing puns on why we should take old doctors seriously because they never diee.

• Old Internists never die, they just lose their differentials.

• Old Family Physicians never die, they just keep it in the family.

• Old Orthopedic Surgeons never die, they’re just get cast aside.

• Old Cardiologists never die, they just lose heart.

• Old Heart Surgeons never die, they just get bypassed.

• Old Urologists never die, they just spring a leak.

• Old Pathologists never die, they just get disembodied.

• Old Anatomists never die, they just become disorganized.

• Old Endocrinologists never die, they just make their Last Gland Stand.

• Old Hospitalists never die, they just walk down their last corridor.

• Old Pulmonologists never die, they just breathe their last.

• Old Fertility Experts never die, they just breed their last.

• Old Obstetricians never die, they just can’t deliver anymore.

• Old Surgeons never die, they just can’t cut it anymore.

• Old Plastic Surgeons never die, they just do a final life-suction.

• Old Gastroenterologists never die, they just disappear up their own fundamental aperture.

• Old Neurologists never die, they just lose their nerve.

• Old Psychiatrists never die, they just lose their minds.

• Old Physiatrists never die, they just can’t rehab themselves anymore.

• Old Radiologists never die, they just lose their images.

• Old Dermatologists never die, they just shed their skins.

• Old Ophthalmologists never die, they just make spectacles of themselves.

• Old Allergists never die, their immune systems reject them.

• Old Nephrologists never die, their machines fail and they lose their metabolic balance.

• Old Physician Executives never die, they just cross the Great Divide to the Other Side.


I close with this little ditty.
Let not those onthe far left deride,
let not those on the far right divide,
but let voters in the center decide,
aided by a little humor on the side.

Saturday, August 28, 2010

Hospitals and Doctors Not Walking the Electronic Health Records Talk

EHR advocates in Washington don’t seem to get it. They don’t seem to understand that hospitals and doctors aren’t rushing to install EHRs because many EHRs, despite the constant talk that EHRs are a prerequisite for good care. Caregivers are not walking the talk, because in their view, EHRs,

• aren’t ready for prime time,

• slow productivity,

. decrease revenues,

• show scant returns on investment,

• don’t talk to one another,

• distract from time spent with patients,

• are limited as communication tools.

If I may use bureaucratic parlance, EHRs aren’t “meaningful” to clinicians. This may change as EHR vendors, doctors, hospitals, and IT consultants gather at the $27 billion EHR government trough, but it will remain slow because economic and health reform uncertainties.

Washington hopes to overcome resistance to EHRs with a carrot and stick approach. CMS will reward doctors and hospital with bonuses and other rewards for adopting EHRs and penalize those who don’t with lower fees and withdrawal of the Govrnment's Good House Keeping Seal of Approval.

Unfortunately, the Washington elite overlook the hassle factor. To qualify for the up to $64,000 subsidies for physicians and millions of dollars of handouts for hospitals, providers will have to “qualify” for payouts by meeting 23 to 25 “criteria for “meaningful use.”

The problem is: what is “meaningful” for government may not be “meaningful” for small hospitals and small practices, who are struggling to make ends meet.
Katherine Hobson, who writes the WSJ health care blog, captures the essence of this problem for hospitals in “Only 2% of Hospitals Could Have Met ‘Meaningful Use’ in 2009.”

She says, among other things, that,

• “Despite all the talk about digitizing the health-care world, only 11.9% of U.S. hospitals had adopted at least basic electronic medical records by last year, and only about 2% had done enough to qualify for future government financial incentives, a study finds. The study, published online in Health Affairs, covers responses from 3,101 hospitals surveyed by the American Hospital Association.”

• “It’s actually not surprising that hospitals were slow to adopt new systems in 2009, given the horrible economic conditions, difficulty of raising money for capital investments and uncertainty over what the final government requirements would be.”

• “The study found a widening gap between larger, nonprofit, urban hospitals and critical-access, small or medium-sized, public or rural hospitals in the adoption of digitized records. For example, 7.5% of large hospitals would have met the requirements, compared to 1.2% of small ones.”

• “Of course that gap is only a concern if you believe that electronic medical records are a good thing. For their part, the authors write that electronic records have been associated with the potential to improve the quality of care for underserved patients, improve patient safety via electronic prescribing and improve adherence to evidence-based care.”

• “If you adopt a new technology, and do it badly, you can end up making productivity worse” or causing harm. This is not a plug and play.”
Those at the top of the health care tree in government say EHRs are a wonderful thing, but small hospitals and doctors in small practices with limited resources, who provide most care in America, are not ready to go out on the EHR limb.

Yet, despite obstacles and slowness in adopting, a combination of things - widespread “free” or inexpensive EHR systems, speech recognition programs enabling doctors to easily incorporate their thoughts and the patient narrative into EHRs, advances in wireless “touch” technologies, social pressures from patients, and financial assistance from payers – will help make the “inevitable” more “evitable.”

EHRs will eventually evolve from below, but they need not and are unlikely to be forced from above.

Massachusetts and Indiana as Experimental Laboratories for Obamacare

“It is one of the happy incidents of the federal system that a single courageous state may, if its citizens choose, serve as a laboratory; and try novel social and economic experiments without risk to the rest of the country."

Justice Louis D, Brandeis, 1932

To witness first-hand the likely consequences of Obamacare, it is useful to visit Massachusetts and Indiana – two very different states.

Massachusetts is unabashedly liberal. Indiana is deeply conservative.

President Obama has repeatedly said he would like the U.S. to follow the Massachusetts example and enact a system of universal coverage. This may be because he was educated at Harvard Law School, and many of his principle advisers hail from Massachusetts.


Massachusetts has had “universal coverage” for four years. It now has the nation’s lowest percentage of uninsured at 5.5 percent. This idyllic state of affairs has come at a heavy cost: the nation’s highest health care premiums, the longest waiting times to see a doctor, emergency rooms more crowded than ever, some of the highest overall health costs in the U.S., restive physicians, many of whom are fleeing to other states, and a state legislature that is considering making acceptance of patients in government programs a condition of licensure.

Massachusetts has learned the only way to control costs within its universal coverage system is to cut doctors' pay, transfer patients into managed care, impose government global budgets, and consider price controls. And that’s what’s happening. A state commission has recommended Massachusetts stop paying doctors for each procedure and instead pay a flat fee per patient. A system of global payments, or "capitation," encourages provider groups to skimp on care, as they get to keep as profit any money not spent treating patients.


According to an August 2009 Gallup survey, Indiana has an uninsured rate of 16.1%, slightly below the national average of 17%. But its governor, Mitch Daniels, says Indiana has made solid progress in controlling costs and satisfying constituents by a widespread adoption of health savings accounts for the uninsured and for state employees. Daniels claims widespread adoption of Obamacare would have devastating consequences for the states.

Mitch Daniels Comments

Here are some of Daniels comments about his state’s approach to health care and his views on the new health reform law.

“We’ve been through a global recession. Now we’re fighting through a stalled recovery. Revenues are the lowest they’ve been in half a century. Their finances a wreck, many states have effectively sunk into bankruptcy.

Indiana is still afloat. In fact, we’ve fared better than most. We continue to meet our obligations without raising taxes, and the reserves we carefully built and protected will get us through the downturn.

But as if we did not already have enough on our plates, the passage and implementation of Obamacare presents us with a whole new set of challenges and a costly to-do list.

I note with special sadness that first and foremost amongst the bill’s consequences will be the probable demise of the Healthy Indiana Plan (HIP). This program is currently providing health insurance to 50,000 low-income Hoosiers. With its Health Savings Account-style personal accounts and numerous incentives for healthy lifestyle choices, it has been enormously popular and successful.

Cost of “Reform” to Indiana

Obamacare’s expansion of Medicaid, soon to cover one in every four citizens, will not only scoop up most of HIP’s participants, but will also cost the state between $3.1 and $3.9 billion over the next decade.

Of course, it’s a misnomer to even refer to this as “reform.” It doesn’t reform anything. Instead, it perpetuates and magnifies all the worst aspects of our current system: fee for service reimbursement, “free” to the purchaser consumption, and an irrationally expensive medical liability tort system. It’s a sure recipe for yet more over-consumption and overspending.

Since my election, my state coworkers have had the choice of Health Savings Accounts in lieu of traditional health care plans. The first year this option was made available, some 4 percent of us signed up for it. Six years later, more than 70 percent of our 30,000 state workers have opted for the personal account.

This trend has had a startlingly positive effect on costs for both employees and the state. State employees enrolled in the consumer-driven plan saved more than $8 million in 2010 compared to their coworkers in the old-fashioned preferred provider organization (PPO) alternative. Indiana will save at least $20 million in 2010 because of our high HSA enrollment.

It has also been the source of significant changes in behavior, as state workers with the HSA visit emergency rooms less frequently and are more likely to use generic drugs than co-workers with traditional health care. Hoosiers enrolled in HIP have experienced similar changes in behavior with generic drugs now accounting for 84 percent of all prescriptions used by enrollees.

This is a sharp contrast to the prevalent model of health plans in this country that encourage individuals to buy health care on someone else’s credit card. What seems free will always be over-consumed, compared to the choices a normal consumer would make. Hence our plan’s immense savings.

The condescension of the “reformers” is misplaced. It turns out that typical Americans are neither too dense nor too intimidated to make sound decisions about their own health. This is, of course, a fact that national policy makers sadly ignored during their overhaul of our health are system. Now the rest of us are left to pick up the pieces.”

Checks and Balances in Health Reform

Preface: One of the greatest compliments one blogger can pay to another blogger is to reprint his fellow blogger’s stuff. Kevin Pho, MD, the “social media’s leading voice,” has done exactly that by reprinting this blog of mine. Visit Kevin’s site, KevinMD, and see for yourself why he has emerged at the nation’s number one physician health care blogger.

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

I am writing from Oak Ridge, Tennessee, where I am attending a high school class reunion. My son Spencer, a nationally known poet and a candidate for the Episcopal priesthood, is with me. He is checking on my past, and I am trying to provide balance so he can understand his father’s legacy.

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

1. 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.

2. 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.

3. 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.

4. 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.

5. 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.

6. 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.

7. 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.

8. 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.

9. 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.

10. 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.
Richard Reece is the author of Obama, Doctors, and Health Reform and blogs at medinnovationblog

Friday, August 27, 2010

Twittering Down

Lately I have been twittering. I must say, writing tweets of 140 characters of less is a useful exercise in brevity.

As you type in your tweet, the screen automatically tells you how many characters you have to go(140 are allowed), and you begin to slice, cut, and eliminate words, or look for short words to replace the long.

I’m reminded of E.B. White’s sage advice in his classic little book, The Elements of Style (1971).

“Omit needless words. Vigorous writing is concise. A sentence should contain no unnecessary words, a paragraph no unnecessary sentences, for the same reason that a drawing should contain no unnecessary lines or a machine no unnecessary parts. This requires not that the writer make all of his sentences short, or that he avoid all details or treat his subjects in outline, but that every work tell.”

On Polls and Health Reform

They are free enough to disregard the polls but wise enough to take them into account.

President Bill Clinton, on the work of Erskine Bowles (D) and Alan Simpson (R), who are leading a bipartisan commission to guide America out of the debt wilderness

Something strange is going on out there in the political world.

Democrats are dismissive of public opinion polls and imply ordinary mainstream citizens who fret about "progressive" policies leading to staggering national debt are either stupid, bigoted, or consumed with hate.

Republicans are gleeful about polls indicating disapproval of the Obama administration. They are fond of saying most Americans are smarter than we give them credit for.

Take the latest health care polls.

• Rasmussen, 16% more oppose than favor

• CNN, 16% more oppose than favor

• CBS, 13% more oppose than favor

• Pew, 12% more oppose than favor

These numbers could shift, of course, but disapproval ratings have remained remarkably stable since Obamacare’s passage on March 23, 2010. Ordinary Americans, outside the left wing of the Democratic party, particularly Independents, don’t think health reform will either save money or decrease the deficit, costs for patients will go down, care will improve, reform will allow them to retain their present plans, or Medicare cuts will not affect seniors.

On health reform and other hot button issues – immigration, the Mosque, gay marriage, expansion of government,concern over national debt, the Tea Party movement, public could be wrong.

As Charles Krauthammer, MD, a recovering psychiatrist, describes in his column today, “The Last Refuge of A Liberal,” here is how liberals interpret the polls.

• “Resistance to the vast expansion of government power, intrusiveness and debt, as represented by the Tea Party movement? Why, racist resentment toward a black president.

• Disgust and alarm with the federal government's unwillingness to curb illegal immigration, as crystallized in the Arizona law? Nativism.

• Opposition to the most radical redefinition of marriage in human history, as expressed in Proposition 8 in California? Homophobia.

• Opposition to a 15-story Islamic center and mosque near Ground Zero? Islamophobia.”

Now it may be that the vast majority of the unwashed American masses, who poll 70:30 on these issues, are racist, bigoted, ignorant, homophobic about gays, Islamophobic, and paranoid about big government.

But there are those of us who believe typical Americans, who live outside the Beltway, are perfectly capable of making sound, pragmatic, sensible, and financially responsible decisions on their own.

Questions and Answers by One Physician on the Future of the Medical Profession in the Era of Health Reform

Philip Miller, head of communications for Merritt Hawkins & Associates, a national physician recruiting firm, recently sent me a list of questions. These are my responses.

Who now speaks for the medical profession?

The Physicians Foundation is a logical choice, for the simple reason it represents all doctors in state and a few local and county medical societies. Also it has conducted a survey of 300,000 primary care doctors on the status of their practices and another survey of 40,000 doctors on how they react to health care reform. No other physician organization has such a firm, objective grasp of how doctors feel and are likely to react to health reform. Finally, the Foundation has issued millions of dollars of grants to physicians to help them improve care. correct flaws , and fill gaps in the present system.

Why has the AMA lost membership/clout?

In seeking to be everything to everybody, including the Obama administration, ithe AMA has ended up pleasing few. The AMA failed to resolve specific issues concerning doctors – tort reform, simplifying payment, and the SGR (Specific Growth Rate) formula, which proposed to cut doctors’ pay 21% this year and more thereafter. These are some of things that have cut AMA membership to about 15% of all doctors. Add that to the fact that the AMA derives most of its revenues from coding and devotes few of its monies to doctor services. There is also physician unhappiness, particularly among primary care doctors about the AMA-appointed Reimbursement Update Committee (RUC), which, along with Medicare, sets fees for doctors . Put this all together, and you have a good picture of why doctors distrust the AMA and have abandoned it.

What has been the traditional role of state medical societies?

The traditional role of state medical societies has been to support and represent its members before public and politicians, including Medicare and Medicaid officials.

How is this role likely to change in the era of reform?

Given physician attitudes towards the AMA, state medical societies will have to step up and take a more activist role in representing doctors. Their members represent all specialties. This is a plus because medicine is a profession that includes all doctors.

What is the traditional role of specialty societies?

To represent the interests of individual specialties. This is fine and understandable. But there are 190 specialties, and a fragmentation of views is inevitable. The public and their political representatives, unfortunately, do not think in terms of individual specialties, but of medicine as a whole.

How is this role likely to change in the era of reform?

It is likely to be more of the same, for the role of specialty societies is to defend and support their members. The specialty societies, particularly such specialties as cardiology, orthopedics, and radiologists, and other high tech-high pay groups, will be under pressure to fight Medicare cuts in reimbursement, which are inevitable and already well underway. They will lobby intensely to protect their incomes and the quality of care. One constructive change would be for the proceduralist specialists to make peace with the generalist specialties, e.g. family medicine and general internal medicine, to avoid a public “food sight” between these specialty groups. Two likely changes, envisioned and encouraged by the government and the realities of the health care marketplace, are more hospital employment and more specialists and generalists joining together in accountable care organizations and larger groups.

What should physician organizations do moving forward to advance the state of the medical profession?

Tough question. Here are some thoughts.

• One, they should band together in a national organization with a national strategy that positions and brands the medical profession in the media as a positive and constructive force in health reform.

• Two, we should convince the public and politicians that it is in everybody’s best interest to have a robust medical profession.

• Three, we should warn the public that the present policies of health reform may drive doctors out of the profession, discourage bright young people from entering, and cause doctors to stop seeing Medicare and Medicaid patients because of burdensome regulations, low reimbursement, and misguided policies that purport to judge doctors and improve care.

• Four, it is important for doctors to highlight accomplishments of medicine, how many Americans receive better care with better outcomes for diseases such as osteoarthritis, heart disease, and cancer, and why our health statistics are just as good as our foreign counterparts but are obscured by our culture, i.e, if you remove violent and accidental deaths from the mix, our statistics are just as good or better than those of other Western countries.

• Five, we should encourage programs such as Project Health, which help poor families, community clinics, which serve the underserved and underinsured, convenience clinics, “free” clinics, manned by volunteer doctors . With these and other efforts, we can make crystal clear our mission is to serve and to heal, and to care for the sick and the disenfranchised.

• Six, we should innovate to bring lower cost care of equal quality to our citizens in lower cost settings. These innovations might include audio-visual communication with home-bound patients, telemonitoring of patients with diabetes and heart disease, using portable ultrasounds in primary care practices, evaluating patients with coronary and pulmonary disease with low cost, low risk, equipment measuring heart and lung function and administered by technicians in outpatient settings. Done correctly, the Internet and its myriad applications may lift all clinical boats. This can, however, be overdone which I believe to case with mandatory electronic health records.

Thursday, August 26, 2010

The Health Reform Future

The future isn’t what it used to be.


Because of the present political volatility, the future is murky for health reform. It depends on the November 2010 elections. If Democrats hold on, reform may progress along the path President Obama envisions. If Republicans sweep, reform may be delayed, even reversed.

Reform also depends on whether President Obama is re-elected in 2012. And that depends on whether the Republicans by that time have a) a credible messenger; and b) a positive message. It depends on whether the Democratic reform messages play out, a) reform wiil reduce costs and the deficit; b) no one will lose their present health coverage; and c) cuts in Medicare won’t negatively impact seniors.

It depends on whether America’s innovators and entrepreneurs are given enough incentives and room to develop workable alternatives to the present system, which everybody agrees needs reform to slow the pace of growth of health costs.

Finally, it depends on what happens between now and 2014, when the presently planned reforms really kick in. In politics, four years is a lifetime. In the meantime, if Republicans sweep, a big “if”, here is what Republicans may have in mind to delay implementation of the present law, as articulated by Grace Marie Turner, president of the Galen Institute, a market-oriented conservative think tank. (“Putting the Brakes on Obamacare,” August 25, Wall Street Journal).

• Defund it. Choke off funding for implementation of the legislation, starting with parts that are especially egregious such as the "army of new IRS agents" needed to police compliance.

• Dismantle it. Focus committee action and floor votes on its unpopular provisions, such as, all businesses must file 1099 forms with the IRS to report any purchases totaling more than $600 in a year. .The National Federation of Independent Business says this will impact 40 million businesses.

• Delay it. Republicans can also vote to postpone cuts to the popular Medicare Advantage program, postpone mandates requiring that individuals and businesses purchase and provide health insurance, and delay imposition of the $500 billion in taxes required by the law.

• Disapprove regulations. The Congressional Review Act of 1996 (CRA) gives Congress the authority to overturn regulations issued by federal agencies if both houses approve, with a two-thirds majority needed to override a presidential veto. This would be difficult to pull off.

• Direct oversight and investigation. Other aspects of ObamaCare are ripe for public hearings. For example, rules dictating how much insurance companies must spend on direct medical benefits are already hugely controversial—even before they have been issued. Businesses are already aghast about much reform would cost them. Republicans could summon many witnesses to testify about the negative impact of regulatory straightjackets.

These are tricky strategies to carry out. They reinforce the image of Republicans as a party of “No.” What is needed is a positive message of reform that rings true with the American values of freedom, choice, excellence, and individual and financial responsibility.

In light of recent polls, which show a 56/40 voter disapproval of Obama care, Democrats will likely react by softening their reform promises, calling again for a public option, relying on the courts to affirm the constitutionality of the individual mandate, and quietly proceeding with implementation of state insurance reforms and health exchanges.

Wednesday, August 25, 2010

Dabigatran Better Than Dicumoral, But Will Medicare Pay?

I have a number of friends who take Dicumoral (Coumadin, Warfarin), an oral anticoagulant that prevents blood clotting. They share these complaints - the necessity for frequent blood tests to check clotting status; the avoidance of certain foods, such as leafy green vegetables, that affect clotting on patients on Dicumoral; and unexpected bleeding, sometimes minor (hematomas in skin), sometimes major (uncontrollable nosebleeds or massive GI bleeding).

These friends and millions of other Americans who take Dicumoral to prevent venous thrombosis after surgery, coronary artery clotting, and stroke secondary to blood clots in the left atrium with atrial fibrillation, will welcome news of a new drug, Dabigatran (Pradaxa), which is soon to be released in the U.S. and is said to be superior to dicumoral.

Dabigatran has passed its clinical trials. Boehringer Ingelheim, a German pharmaceutical firm, will market the drug, which has been available in Canada and Europe since 2008.

Though much is known clinically about Dabigatran, its likely cost in the U.S. is unknown. In Europe it costs 10 times more than Dicumoral and in Canada the price for ten tablets at one mail order Canadian pharmacy is $77.00 in U.S. dollars.

Whether Medicare will pay for Dabigatran has not been decided. It will be a costly decision. There are 2.3 million Americans with atrial fibrillation, and 15% of 800,000 Americans who have strokes have pre-existing atrial fibrillation. The decision will rest on convenience (blood testing not required), no dietary restrictions (all foods allowed), and safety (fewer bleeding complications) versus higher costs. Most patients with atrial fibrillation are over 65, and the new reform law proposes to cut $575 billion out of Medicare.

Will Dabigatran make the cut?

Source: John Mandrola, MD, “Dabigatran is Superior to Warfarin, But at What Cost?” Kevinmd.com, April 18, 2010.

Tuesday, August 24, 2010

FFS for Physicians: Fee-for-Service, Freedom-for-Service, or Flee-for-Service

Everybody knows fee-for-service drives health care costs. Doctors who do more are paid more. And doctors who want to make more money simply raise their fees.

In reformist jargon, FFS is a “structural problem” – a problem that can be corrected by various means - capitation; bundling of fees for episodes of care, chronic disease, or procedures; paying only for what works based on comparative research; and placing doctors on salaries.


Not so fast. What everybody doesn’t know is that third parties, particularly Medicare. but private plans as well, who follow Medicare’s lead, sets the fees, and “capitates “ the fees.

These fees often bear little relation to costs of providing them. Furthermore, third parties may refuse to “authorize,” i.e. pay, for a procedure or diagnostic test.

It Hasn't Worked

The basic problem of this approach is that it hasn’t worked. Compared to GDP expenditures (excluding health care), since 1977 federal expenditures for health have skyrocketed.

• Federal health expenditures, 410%

• State and local expenditures, 260%

• Private expenditures, 255%

• GDP excluding health expenditures, 160%

Containing costs for federal entitlement programs creating expectations for virtually “free” care is a very difficult thing to do. The constituents, aging and increasing in numbers, expect, even demand, to receive promised services.

Those providing the services do not willingly accept lower payments, so they compensate by scheduling more office visits, by investing in ancillary services outside the office, by performing services with higher Medicare payments.

The result is that Medicare is the most rapidly growing part of the federal budget, and the chosen villain for this federal largesse is FFS.

What the health reform bill proposes to do is to end FFS in one way or another, by,

• Systematically cutting doctor fees for Medicare over the next ten years, thereby forcing doctors to choose non-FFS options.

• Developing other payment mechanisms – employment by larger groups, bundled payments for episodes of disease or hospital procedures, capitated payments for managing groups of patients.

Physician Options

Given these scenarios, doctors have these options.

• Passively accept lower reimbursements ordered by government bureaucrats.

• Cut staff and services to Medicare and Medicaid patients.

• Accept fewer new Medicare or Medicaid patients or stop seeing them altogether.

• Reduce overhead by turning to new practice models that avoid third party payments with associated overhead, and rely on direct cash payments or concierge arrangements or health savings accounts with high deductibles with more freedom for patients and doctors alike. These new payment models might be dubbed Freedom-for-Service, or Fleeing-for-Service.

Fee-for-service is widespread in almost every other market – restaurants, lawyers, accountants, brokers, small businesses – and any other financial sector you can mention.

Fee-for service is not likely to spread in health care.

Why not? According to John Goodman, the conservative economist, because “We pay only 10 cents out of pocket every time we spend a dollar at a doctor’s office, and 90% of Medicare patients, almost all Medicaid patients and many privately insured do not even pay the 10 cents. That means we predominantly pay for care with our time, not with our money. As a result, doctors don’t compete for patients on the basis of price. And because they don’t compete on price, they don’t compete on quality either.”

“What is it that makes health care different?

There are three things: (1) third-party payment of the bill, (2) rationing by time and not money, and (3) an inability on the part of providers to repackage and reprice their services.”

The problem in health care is that patients who benefit from the service are not the same as the persons who pays the bill. Besides, having your health care paid for with other people's money has irresistible appeal. Knowing what health care really costs has no appeal, especially if you think you can get it for free without a fee from a federal Sugar Daddy.

Monday, August 23, 2010

Physicians, Health Reform, and the Battle for Voters’ Minds

You may not be aware of it, but a titanic battle is raging for control of the public mind.

This battle is a lead-up to the November elections, and some of it centers on health reform. Democrats and liberals will be defending the reform law as a moral imperative for all. Republicans and conservative will be attacking it as too costly and too intrusive for individuals.

Some of the battle is being fought in the national media. Some of it is being conducted on the campaign trail in negative attack ads. Some of it is reflected in press releases and media strategies of liberal, conservative, and “non-partisan” think tanks. And some of it is can be seen in marketing strategies and lobbying of health plans, the health industry, and physician organizations.

The 70: 30 Issues

The warriors in this battle for the voter’s minds are concentrating on the 70:30 issues – those issues which polls indicate 70% of the public favor and 30% oppose.

• the Arizona immigration law is a 70: 30 issue, so are the Mosque and gay marriage controversies. Here the issues favor Republicans.

• In health reform, health plans covering those with pre-existing illnesses or children under 26 for their parents plans, or the uninsured are 70:30 issues favoring Democrats.

• Costs of health reform, the national debt incurred, the massive bureaucracy required, negative effects on small businesses, and Medicare cuts poll 70: 30 for the Republicans.

• Among physicians, the onslaught of new millions of Medicaid and Medicare patients on already stressed practices, physicians and hospital Medicare cuts; and overall skepticism about the present health reform bill polls 70:30 against among physicians surveyed and among women who fear more limited access.

• For independent voters, those favoring the current law and favoring repeal are 70:30 issues.

Positioning and Branding

How does one capitalize on these odds? In the marketing and political worlds , one does it by positioning and branding. Positioning in these worlds is defined as the process by which marketers try to create an image or identity in the minds of their target market for its product, brand, or mission.

Branding is similar. It is creating a solid brand identity for your organization your profession, for you message, and then having your constituents, in this case the voters, identify positively with that identity.

For physicians and their organizations, positioning and branding involves creating trust that physicians want to do the right thing - cover the uninsured, help the poor and the sick, do it without bankrupting patients or the system, do it without decreasing access to care, and do it while maintaining a first-class system without appearing to be self-serving. Trust is a vulnerable and fragile thing, and physicians and their organizations seek to be trusted.

Properly done, physicians should demonstrate with concrete actions that they can be trusted, and that they have ideas for how to help the poor and under-served. In addition, they should present concrete evidence that the American system produces superior results for the functionally impaired and for those with heart disease and cancer, that reform as currently planned may negatively effect patient access and overwhelm the capacity of doctors to provide that access, and that the current health reform law imperils these efforts by slashing Medicare and private payments.

Sunday, August 22, 2010

Teletriage and Other Telemedicine Innovations

In yesterday’s blog, I discussed prospects of innovations cutting costs and improving care at the same time. I was not optimistic. In response to that blog, I received this comment,

"Actually, you should include teletriage on your list. This method, when used in emergency services may reduce costs in the millions. This technique involves proper triage of patients at the outset using clinical reference decision support software and intelligently directs patients to the proper level of care. It is the key to efficient use of healthcare resources. For reference materials on this see http://www.lifebot.us.com/teletriage/"

Roger Heath

To which I responded,

"Thank you Rodger,for bringing attention to my omission. I agree telemedicine can be a powerful innovation, particularly in monitoring home-bound patients, evaluating patients from afar,and directing them to the proper level of care."

Ricahrd L. Reece, MD

This exchange reminded me of an interview I conducted with Ron Pion, MD, an expert in telemedicine

The Internet Will Lift All Clinical Boats - An interview with Ronald J. Pion, MD
Publish date: Apr 27, 2010

Ronald J. Pion, MD, has enjoyed successful careers as a physician, clinical educator, and entrepreneur. He is a leading authority on telecommunications in the health care industry. Dr Pion believes the Internet, and its telecommunications applications, will vastly improve patient care and clinical outcomes, virtually link physicians with each other, and vitally bond physicians more closely with patients. Dr Pion discusses the use of the Internet and telecommunications to help doctors in solo or small group practice in this interview with ModernMedicine’s Richard Reece, MD.

Give us a little of your background out there in Los Angeles, where you hang out as a clinical professor of Ob-Gyn at UCLA.

My current title that I fancy is digital medical entrepreneur. I do business in medical telecommunications. It’s a DBA.\


Doing Business As, as we say in the business world. I am a self-employed individual of 78 years young.

You have a remarkable career, combining media activities in radio and television and the Internet, as well as being an academician, serving as professor, writing multiple research papers, and consulting and leading various medical business enterprises. The breadth and depth of it all amazes me, and I am not easily amazed.
No question about it, I am a hyperactive adult. I enjoy success, and I never recognize the word “failure.” Success is just a question of time.

How can doctors become more efficient and effective through the use of new telecommunications media?

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

These doctors have to begin to acknowledge nurses, physician assistants, and other health professionals as part of a team anxious to win the game for the patient. The patient should be our focus. That patient wants to get better. Over the years, medical practice has strayed from the goal of the patient. Our main aim ought to be to help patients reach the goal of getting well—and staying well.

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

How does the doctor get into automated telecommunications game?

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

When I spoke to the doctor who started HealthLeap.com, I discovered that more than 80% of the doctors to whom he had spoken had no online presence.

That’s why it’s up to you and me and others to accelerate the adoption of telecommunications. That’s why we have to get sponsors from the digital world to help us do what needs to be done.

So how do small practices get into the Internet and telecommunications?

They must learn what they have to do and how to make a good living at it. After all they have learned in medical school, residency, and practice, we have to convince them they have to keep on learning and using all the tools available.

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

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

When you and I went to medical school, we went to the biomedical library to read information that was 18 months old. That meant we were two years behind in the knowledge we were seeking.

So now you need be online, real-time, all the time, 24/7?

Yes, sir, when you’re involved in solving a patient’s problem. The point is that all the ships in the harbor can be raised by sharing each other’s expertise rather than relying on what you learned in medical school or residency on fellowship. We now must be involved in The Now. It’s impossible to keep up without computerized up-to-date knowledge.

So your point is the Internet and telecommunications can lift all boats? And you believe we are in the process of doing so?

Yes, all boats will be lifted. There is no doubt in my mind.

I call your attention to a recent article titled, “What do Dell, eClinicalWorks and WalMart Have in Common?” All are leaders on price and value. Price and value are terribly important in medical practice.

We doctors were never taught about being in business, but that is what we are in. Dell, eClinicalWorks, and WalMart’s shared interest has led them to collaborate on a new product. It will bundle eClinicalWork’s unified application and practice management system with Dell’s hardware into an electronic medical records system, which will be available to WalMart’s Sam’s Club members. Sam’s Club claims to have 200,000 practices among its members, almost 65% of the market for ambulatory care EMRs, and involving 308,000 doctors.

I remember meeting John McChesney, who was head of a company putting computers in hospitals. He came up with a nifty solution to help attending medical staff. He put computers next to radiology, imaging centers, and labs in the hospital. When the doctor went to his office the next day, McChesney’s computers delivered answers from the hospital into his hands. McChesney’s computers sucked up data and delivered it to the physicians’ offices. His office staff didn’t have to waste time calling the hospital for results.

McChesney’s genius was that he noted that most physicians had computers in the back room to meet financial needs, but they didn’t have computers in the clinical part of the doctors’ offices. All they had out there was paper, and you can’t suck up information from paper. So McChesney set up a computer in the clinical section of the office, and trained doctors and nurses to use it efficiently. He created the business model to help doctors pay for that computer among companies who were putting other machines in doctor’s office.

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

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

Is there any hope for us old dogs?

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

Saturday, August 21, 2010

Innovation: Health Reform’s Last Great Hope for Reducing Costs and Improving Care

Despite passage of the Patient Protection and Affordable Care Act, there is still need for health reform that will slow the rate of growth of expenditures. Regardless of whether that reform involves a much larger role for government or is more market oriented, a shift in emphasis toward more value-oriented innovations is necessary and perhaps inevitable.

Victor Fuchs, PhD, “New Priorities for Future Biiomedical Innovations, “ NEJM, August 19, 2010

No matter how you slice the $2.5 trillion national health expenditure pie, innovation is the last great hope for reducing health costs, improving care, and saving lives.

You see this hope expressed:

• in the reform act , which establishes a Center for Innovation for Medicare and Medicaid, and which proposes innovations which authorizes new innovative care and pay models to save money by rationalizing care;

• in the $852 billion stimulus bill, which threw $27 billion at electronic records, which will purportedly will pay back those billions;

• in the appointment of Doctor Donald Berwick, who 22 years ago founded the Health Improvement Institute, and in that position, prevented 122,300 “unnecessary deaths” by improving hospital safety;

• in efforts of private industry to introduce systematic changes and disruptive innovations to replace the old ways of doing things.

The Catch

There’s a catch, of course. The catch is that innovations to date have usually increased costs while improving quality. If you doubt me, cast your eyes over this list of 10 innovations doctors voted as the most noteworthy over the last 2 decades.

1. MRI and CT scans

2. ACE inhibitors and angiotensin antagonists

3. Coronary stents

4. Statins

5. Mammography

6. Coronary bypass surgery

7. Proton pump inhibitors and H2 blockers

8. Antidepressants

9. Cataract extraction and lens implants

10. Hip and knee replacements

Or take the latest highly touted innovation- robot-assisted surgery. If robots were to replace conventional surgeries, it would cost the system $2.5 billion annually.

It can be argued these innovations relieve pain, restore function, and extend life, but is hard to make the case they decreased overall costs. Since 1977, federal cost expenditures have increased by 410%, and state, local, and private expenditures by 250% compared to about 155% for GDP expenditures.

The point is: key innovations almost never simultaneously increase quality while decreasing costs. Instead, new innovations invariably increase both quality and costs.

A compromise solution would be to introduce innovations that substantially decrease costs while holding quality constant.

Until this happens, the only answer to decreasing costs and decreasing their growth rate is paying hospitals and doctors less – the fundamental long term strategy embodied in the new health law.

In the end, America voters ,i.e., health consumers, patients - not politicians, Medicare officials, and health professionals - will resolve the quality/cost quandary. Voters who ultimately foot the bill will have to decide what constitutes “quality” – relief of pain, restoration of function, cure or amelioration of disease, access to doctors and procedures , and the importance of comparative outcomes, and whether government or market forces offer the best hope for resolution.


V. Fuchs, “New Priorities for Future Biomedical Innovations,: G.I, Barbash and S.A. Gleid, “New Technology and Health Care Costs – The Case of Robot-Assisted Surgery,” “Facing the Wild West of Health Care Reform,” NEJM, August 19, 2010.

Friday, August 20, 2010

President Obama’s “D” and “R” Analogy

President Obama has been getting a lot of mileage in campaign appearances with his automobile analogy about Bush administration policies driving the country into a ditch. He talks about "D" standing for Democrats and driving the country forward and "R" representing Republicans and going backward. The problem with this analogy is that cars have a reverse gear for a reason, and sometimes it's useful for getting out of trouble.

Steve Huntley, “Obama Needs to Get in Gear with Public”, Chicago Sun Times, August 10. 2010

For politicians analogies are a wonderful thing. You can use them to ridicule and to sting. But when your campaign is headed downhill, and your analogies are full of ill will, it may be useful to remember,that come November, voters may switch from “D” to “R” gear, hoping out of the ditch to steer. They will decide if it is an "R" or "D" ditch, and which is which.

Health Reform Faces Messaging and Implementation Difficulties

Social policy is 1% inspiration and 99% implementation.

Wilbur Cohen, 1913-1987, the man who built Medicare

The news of the day is two fold:

One, a CNN poll indicating only 40% of Americans approve of Obamacare while 56% disapprove.

Two, a Politico report entitled “Democrats Retreat on Health Care Cost Pitch.”

This retreat makes sense. Democrats sold health reform on the notions that it would contain costs and protect Americans against health plans.

Instead, the public sees 10% overall rises in premiums for 2010, as much as 20% to 40% in the small group and individual markets, and a four year delay before the uninsured are insured. What they see is not what they expected. Health reform becomes a hard sell in an economy that is growing worse instead of better.

According to the Politico report, the Democrats' health reform allies are shifting their message to defending rather than touting the health care legislation. They are dropping claims it will reduce costs and deficit, and instead promising to “improve it.”

In a conference call and PowerPoint presentation organized by FamiliesUSA, a staffer for the Herndon Alliance, which includes leading labor groups and other health care allies, such as AARP, AFL-CIO, SEIU, Health Care for America Now, and MoveOnled – sought to rally pro-reformers around a new message based on polling from three top Democratic pollsters, John Anzalone, Celinda Lake, and Stan Greenberg. This message is a softer-sell based on the idea that things will get better in time, you just wait.

Democrats are acknowledging the health care legislation has failed to grow more popular after its passage.Democrats seek to win over a skeptical public, and to defend the legislation — and in particular the individual mandate.

The health reform law has failed to impress people under 40, the elderly, Hispanics, and women. Women, in particular, fear that access to physicians will be reduced. Most of the public has not bought the message that health care reform will help the economy, reduce costs, and the deficit.

What isn’t said in the Politico report is that Democrats may fear the effect of an unpopular health reform bill on the November elections.

Not only might they lose political power, but election reverses would make implementation much more difficult. The reform bill’s success rest heavily on individual mandates and cooperation of individual states in organizing and enforcing insurance reforms through health exchanges.

If challenges to the constitutionality of the individual mandate and resistance to health exchanges and state-level insurance reforms succeed, implementation will be rocky.

This could happen, given the likelihood that over 30 states will have Republican governors.

Thursday, August 19, 2010

Chapter Nine. Primary Care Doldrums

This is chapter nine in my new book Health Reform in Perspective

This is a brief chapter. Everybody knows primary care physicians are an endangered species. The reasons why are obvious, and so are the solutions – higher pay, more respect, and more trust in them as personal health advisors and guides to specialist care.

The Low Value of Primary Care Doctors in Eyes of Patients

Preface: Sometimes it is painful to discuss the obvious, especially when the obvious goes against your grain. But here goes. Primary care is in a bad way. Only 2% of medical students are picking primary care specialties. The number of primary care doctors is dropping. And over 90% of costs stem from specialty care. The reasons are obvious: low reimbursement, long work hours, and as Rodney Dangerfield, might say, “We get no respect.” This in face of the fact that policy types and payers, like IBM, are calling for a rejuvenation of primary care as the salvation of American medicine with its cost, coordination, care improvement, and efficiency problems.

It pains me to say this. But the deck is stacked against primary care. I won’t go into the reasons why, but, according to the following blog, one is the low value patients place on primary care physicians.

Chris Rangel, MD, a practicing internist, brilliantly explains this in his blog RangelMD.com. I recommend that you go to his blog and read his other posts and that you visit kevinmd.com, which features Rangel’s blog with 34 comments from patients and primary care doctors, mostly affirming what he says.

Why Patients Don’t Value Primary Care Doctors

“’Hey doc, all I need is this referral.’

I’ve been encountering more of this lately. A patient who has not been seen in the office for months to years (well beyond when they were supposed to come back for a follow up visit) walks in and requests a “referral” for a specialist visit but they can’t be bothered with actually being seen and evaluated in the office or to be compliant with their return appointments.

Or they do show up years after their last visit for no purpose other then that the specialist they recently saw after developing a serious illness and being hospitalized, told them that they needed to “go see their PCP to get a referral.”

Seriously? This entire concept of the “referral” system required by insurance companies was designed to contain health care costs by making the primary care provider a so-called “gatekeeper” who controls utilization by deciding who needs a referral and who does not.

In very few circumstances were the “gatekeepers” given incentives to avoid “unnecessary” referrals and more commonly, they were penalized financially for what the insurance company considered to be excessive utilization. Even worse, at least one study found no differences in utilization of referrals whether they were required or not. Hence, there remains no good evidence that this system works to reduce utilization or enhance primary care.

Currently, our health care is a system that emphasizes specialty and complex care over primary care and requires patients to get referrals from their PCPs but does not absolutely require them to be compliant with routine primary care visits and preventative care. As such, the importance and utilization of primary care has been marginalized even by patients who increasingly see it as a bureaucratic burden. Even for patients, primary care is little more than a paperwork hassle.

The irony is that primary care works!

In 2008, a Congressional Budget Office report found huge geographic variations in Medicare resource utilization (health care spending) and that areas with high spending also tended to have high relative populations of medical and surgical specialists (and hospital beds) and actually had worse quality outcomes than areas with lower spending rates and lower relative numbers of specialists.

But it’s not just the relative numbers of expensive specialty care that affects care quality. A 2005 review of the literature by Johns Hopkins University researchers found that primary care does indeed work to prevent and treat disease and health care quality and access is improved in areas that have higher relative numbers of primary care physicians.

But all of this favorable data was virtually ignored by Democrats and the Obama administration in the last – certain to be disastrous – “reform” of health care which didn’t even fix the always impending 21% Medicare physician pay cut.
Patients take their cues from the current system and insurance company and Medicare policy. Primary care providers are seen as little more than purposeless “gatekeepers”, especially when it comes to anything more serious than a cold or vaccines.

But maybe if these patients in question – all of whom had insurance with low co-pays – had been seen regularly then maybe this would have changed. Maybe if the patient noted above would have been seen much earlier when her symptoms first appeared, a simple blood test could have detected her condition at a stage where she could have been evaluated and treated as an out-patient before it became severe and life-threatening.

Avoiding expensive hospitalizations is something that primary care can improve and yet primary care is even marginalized by the insurance companies who end up paying for the hospitalizations and ER visits. Go figure.

Last Lions Oppose Obamacare

I have been reading William Manchester’s 1988 book, The Last Lion, Winston Spencer Churchill. ALONE, 1932-1940. The 1930s remind me of 2010 to 2020, the decade over which Obama’s health reform plan will unfold.

How so?

First , there are the clashes between political parties – Democrats and Republicans in America, Tories and Labour in England – over a major political issue.

Second, there are the economic times, the Recession of our time, the Depression of the 30s.

Third, there are concerns on how to pay for it all, rearmament in England and universal coverage in America.

Fourth, there are the last lions who oppose Obamacare although it is now the law of the land.

These lions, who are roaring to repeal Obamacare and replace it with a market-based health system based on individual freedom and responsibility , are:

• John Goodman, PhD, conservative economist, father of health savings accounts, and founder of the National Center for Policy Analysis in Dallas.

• Grace Marie Turner, president and founder of the Galen Institute in Alexandria, Virginia.

• Sally Pipes, president and CEO of the Pacific Research Institute, California-based free-market think tank founded in 1979.

• Merrill Matthews, PhD, resident scholar with the Institute for Policy Innovation, a research-based, public policy “think tank.”

• Greg Scandlen, senior fellow of The Heartland Institute and founder and director of Consumers for Health Care Choices.

• Peter Ferrara, J.D, Harvard Law School graduate and director of entitlement and budget policy at the Institute for Policy Innovation.

These individuals are staunch conservatives, prolific writers, and unwavering opponents of Obamacare, which they see as a political scam built on false premises and promises containing the seeds of a financial apocalypse as well as a health care disaster for America.

Here is Ferrara’s view of Obamacare (“The Obamacare Disaster,” The American Spectator, August 18. 2010):

“The bottom line is that you will lose your health care under this legislation, if not your job, your country as they bankrupt America, and maybe ultimately your life or the life of a loved one. All that to make dreamy, emotionalized, liberals happy, even though many of them are not happy because the socialism in the bill is not overt enough. Moreover, the promises made to the American people to pass the bill are shown in the study to be thoroughly false. This pattern of calculated deception, however, did not fool the American people, only members of Congress, many of whom will now pay with their jobs as a result.”

Ferrara cites official government documents detailing impending and inevitable cost and tax increases, Medicare policies leading to government insolvency, and future Medicare payments of less than 1/3 of private insurance and ½ of Medicaid. He envisions hospitals and doctors going out of business on a massive scale, unable to provide such services as hip and knee replacement, MRI and CT imaging, and cancer and heart disease treatments.

His solutions are to repeal Obamacare, offer block grants to the states in the form of vouchers and Health Savings Accounts, and ensure safety net services through risk pools, consumer choice tax credits, and competitive national markets.

The progressive community, of course, isn’t taking this roaring conservative rhetoric lying down. According to Jacob Hacker, professor of political science at Yale, one of the progressives, the best way to silence the lions is for liberals to fight for a stronger government role, including a public option (“Health Reform 2.0,” The American Prospect, August 17, 2010).

Hacker concludes:

“ The passion that pushed health-care reform to the top of the political agenda should not be sidelined by technocratic concerns or triumphant complacency. In politics, sometimes the best defense is a good offense.”

Whoever triumphs, 2010-2020 will be remembered as a historic decade highlighted by a 10 year to and fro debate over America’s health care destiny.

Wednesday, August 18, 2010

To Get My Arms around Health Reform, I’ve Been Looking at My Blog’s Advertisers

The Web has dramatically changed how Americans do business. One of the big changes has been the shift from traditional advertising to online advertising. This change threatens the very existence of archaic business models of newspapers and book publishers, as readers switch to getting their news and information and buying their products online. This electronic advertising transition effects health care and health reform as well an reflects the turbulence and direction of change.

With these things in mind, I have begun to look at the ads on my blog in earnest. I have tried to analyze where they are coming from and what they portend for the health system. I think of this analysis as a way of getting my arms around what’s happening out there and what the trends are.

This is my preliminary analysis based on 7 categories of advertisers.

1. Health plans - Organizations such as AHIP (American Health Insurance Plans), which represents 1300 health plans and covers 200 million Americans, and AARP, which has over 40 million members, and the big insurers are advertising as they scramble to adjust to health reform. www.ahip.org/links/mcmc2010, www.AARPHealthcare.com

2. The big consulting firms - Deloitte and Touche and McKinsey Healthcare Consulting are making their presence felt by offering management services to physicians and health systems on how to cope with reform. www.Deloitte.com/us. www.McKinsey.com

3. The National Federation of Independent Business (NFIB) is offering advice to small businesses who feeling threatened and uncertain about health reform and what it means about hiring and their bottom lines. www.NFIB.com

4. A host of practice management software firms
are offering online services to increase billing efficiencies, reduce DSOs (days it takes from sales to collect revenues), and manage accounts receivable. www.medsoft.com, www.Brightree.com, ww.PatientPaycollections.com

5. A number of consumer research firms are publishing white papers on the behavior of the new breed of health consumers and how to empower and reach them.www.HealthDiaglogue.com/ReformInsights2010, Health Dialogue.com/Reform Report2010

6. Large multinationals
– Seimens and GE – are touting their corporate health innovations, as they seek to exploit opportunities in the limitless health care space.www.usa.Siemens.com/patientjourney, www.healthimagination.com

7, Firms who see their future in electronic health records, intent on capitalizing on government financial incentives to doctors or in offering low cost or free EHRs and EMRS,and Patient Health Records (PHRs) are on the hunt for new customers. www.completehealthcaresolutions.com, www. Questsdiagnostics. com, www.PracticeFusion.com.

Tuesday, August 17, 2010

Physicians’ Health Reform Manifesto

In issuing this manifesto, I do not presume to speak for all physicians. But I believe what I say here represents the views of most physicians who practice in an environment dominated by third parties, such as Medicare and private health plans.

One, we are overwhelmingly for the right kind of reform, which allows patients access to care without fear of bankruptcy or substandard care.

• Two, parts of the new reform bill fit our concept of the the right kind of reform, covering the uninsured, those with pre-existing illnesses, young people up to age 26 under their parents’ plan, and those with expensive chronic diseases.

Three, But the right kind of reform should also include fair-minded, capped, equitable tort reform, which reimburses injured patients; consistent Medicare physician payment reform, predictable over time; and the right of doctors to contract to bill patients directly outside of Medicare.

Four, we believe the current health reform law favors top-down Medicare and Medicaid reform, and penalizes or excludes ground up market reforms. This constrains innovation and entrepreneurship.

Five, we should acknowledge that the U.S., in effect, already has a single-payer system, driven by government, which pays for ½ of costs and covers 1/3 of the population, and the Reimbursement Update Committee (RUC), which sets physicians’ fees.

Six, the most effective way to lower costs would be to remove third parties, i.e. Medicare, Medicaid, and health plans, from patient-doctor relationships, give patients vouchers to pay for their care, have patients pay for a portion of their care, make health costs deductible across the board, encourage patients to have health savings accounts with high deductibles and a catastrophic cap and to set aside tax-free money for retirement.

Seven, we are opposed to the wrong kind of reform, which ignores adverse consequences of the new law – higher costs, steeper national debt, higher premiums, higher taxes, and heavier patients loads on overworked and over-regulated physicians, already in short supply – and which decreases patient access and longer waits to see physicians, who simply will not be able to handle the flood of 30 to 34 million newly insured patients coming on board in 2014, and 5 million new Medicare patients becoming eligible each year in 2011 who may have false expectations of “free” government-sponsored and subsidized care.

Eight, we are skeptical about reforms that attribute shortfalls of the system to U.S. physicians alone rather than to our national culture, with its freedom to behave as one wishes. Many of our relatively poor national statistics are due to factors beyond the physician’s control – a faltering economy, poverty at home, violence in the streets, lack of familial coherence, failure to fill prescriptions, and personal health abusing behaviors.

Nine, we believe many of the deficiencies of our current system could be addressed through such successful programs a Project Health, which now exists in six major cities, and which allows physicians to team with college volunteers to help families address such critical health issues as poor housing, transportation to health facilities, help with food stamps, aid in understanding medical instructions, and assistance in finding job training and placement opportunities.

Ten, we believe the health law can and should be modified to more clearly represent the “the will of the people,” 60% of whom oppose the bill, who wish to retain their present health plans, including Medicare Advantage, and who desire freedoms to choose doctors, hospitals, other health facilities and providers, with access to the latest and best technologies, without fear of federal intervention.

Monday, August 16, 2010

Searching for Medical Information Through Speech Recognition

This is for mobile busy doctors. May I intervene into your busy day by announcing that Nuance Healthcare, Inc, a software company that develops Dragon Naturally Speaking solutions for doctors in small practices and for small hospitals, has a new product.

It goes by the name of Dragon Medical Mobile Search. It allows you to search the Web using your own voice. You can search for drug interactions, new medications,ICD-9 codes, and news about a particular condition.

I wrote about speech recognition as a supplement to EHRs in a previous blog, which I reproduce here,

For Fans of Electronic Health Records

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

Dictionary definition of Nuance

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

So much for my electronic angst.

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

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

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

• Gain access to information in narrative context

• Record and share clinical assessments in plain language

• Maintain a dynamic and current patient history

• Maintain problem lists

• Track medications

• Track tests

• Coordinate and control care

• Enable follow-up

• Provide follow-up to clinicians upstream

• Offer second opinions

• Increase efficiencies

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

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

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

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

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

Atul Gawande, MD, The Health Reform Grandee

A grandee, according to my dictionary, is somebody with the power to persuade somebody highly influential and respected, especially a politician.

Atul Gawande fits that description. As a 47 year old general surgeon at Brigham and Women’s in Boston, an associate professor at the Harvard School of Public Health, a member of the faculty at Harvard Medical School, former Rhodes Scholar, adviser to Hillary Clinton’s 1994 health care task force, staff writer for the New Yorker and Slate, and author of bestsellers as Complications and Checklist, he has all the credentials to be influential with Democratic politicians.

After reading one of Gawande’s New Yorker essays, “The Cost Conundrum,” a blistering attack on alleged profiteering by doctors in McAllen, Texas, President Obama showed the article to a group of senators including and said, "This is what we’ve got to fix.”

Not only is Gawande an influential doctor with solid Democratic and Harvard think tank credentials, he is one hell of a writer.

Bob Wachter, MD, a prominent West Coast medical academic, says Gawande has mastered the techniques that “make his writing lyrical and memorable.”

These techniques include:

1) Making his first sentence count.

2) Using everyday language.

3) Telling stories rather than reciting data.

4) Relating inconvenient truths.

5) Showing humility.

6) Taking the high road.

Wachter omitted two salient truths.

One, as an elitist Democrat, policy wonk, a Boston-based surgeon, and political adviser, Gawande knows exactly where he is coming from.

Two, Gawande, he knows his readers, who read his material in the New Yorker, Slate, and Op-Ed pieces in the New York Times and Washington Post, will agree with his views.

A good example is his current essay in the New Yorker, “Now What?” It anticipates the line of attack health reform critics will take. He starts with a historical review of what Medicare critics took to undermine that program. He says LBJ, the master political strategist, out maneuvered his opponents.

He says President Obama can expect party politics to intervene with implementation. They will try to repeal the new law. They will criticize individual and business mandates. They will complain about the massive bureaucracy and administrative difficulties of state run health exchanges. Above all, they will cite “unaffordable costs” of health reform.

Gawande believes some down-home innovations, such as inspecting the homes of asthmatic children for molds and pests and providing their families with free vacuum cleaners, will solve some cost problems by decreasing hospital re-admissions, and top-down innovations, such as those developed by the Center of Innovation for Medicare and Medicaid, which are part and parcel of the new law, will decrease costs.

Gawande claims Obamacare is not “a government takeover.” Instead it depends on local communities and clinicians to do what needs to be done. The battle for health reform, whether it survives or flounders, he concludes, “has only begun.”

Gawande is right. The battle has just begun. And as I point out in my last two blogs predicting the reform situation in 2015, health reform opponents may have the upper hand because of Democrat political reverses and unanticipated adverse consequences of the new law.

Part Two, The Future Fifth Anniversary of Health Reform Passage.

Many of health reform's problems of 2015 has been anticipated, but insufficiently addressed.

The Obama administration, perhaps blinded by its zeal for universal coverage as the crown jewel of its political legacy, its arrogance that government could solve any economic or social crisis, and seduced by rosy but unproven scenarios predicting Medicare savings and practice efficiencies, plunged ahead with its divisive, unpopular, costly, and bureaucratic reforms. The public responded by saying - To "L" with left-leaning liberals who lecture us rather than listening to us.

It was not that Congress had completely ignored the prospects of physicians being unable to serve its new constituencies.

Those prospects were always in the background. As John Iglehart, national correspondent for the NEJM, observed in his Health Policy Report in July 2010,

“However, mandated coverage is only one of many challenges facing Democrats as they implement the most sweeping piece of social legislation since the enactment of Medicare and Medicaid. Another challenge that has attracted far less attention is whether newly insured individuals will actually have access to health care once they become insured and whether Medicare should expand its support of graduate medical education (GME) training to increase capacity. The law takes only modest steps to expand the workforce, which is already stretched in some geographic areas and in some specialties.”

Congress took modest steps to address these deficiencies. In its $862 billion stimulus bill and an addendum to that bill, it devoted $300 million to expanding the National Health Service Corps, which relied on recruiting primary care doctors, and it promised another $250 million to train 16,000 more primary care doctors. On a national scale, these amounts were drops in the proverbial bucket of a system that spend $2.5 trillion in 2009.

In the health reform bill itself, starting in 2011, Congress awarded yearly 10% Medicare bonuses over 5 years to primary care doctors to narrow the gap between primary care and specialist incomes; in 2013, it promised to bring Medicaid fees for doctors up to those provided by Medicare; and it launched a series of demonstration projects – medical homes, coordinated care, accountable care organizations, and bundled billing – that emphasized primary care.

The physician community regarded these as modest efforts that paled in the failure to address malpractice reform and Medicare physician payment in the SGR (Sustainable Growth Rate)formula, which called for 21% reductions in physician pay in 2010 and more thereafter.

But at the same time, Congress said it would cut $575 billion out of Medicare over the next 10 years and would reduce support for graduate medical education institutions, which ran the programs that trained new doctors.

The ends, expanding coverage while reducing costs, did not make sense to many, including academic medical centers, hospitals, doctors, and Medicare patients. Besides, Medicare's chief actuary, Richard Foster, said in his annual 2010 report that costs would expand not contract. These contradictions fed doubts and fueled criticisms.

Meanwhile, on the political front, Republicans regained control of the House and Senate and had a 5-4 margin on the Supreme Court.

President Obama narrowly won re-election in 2012. He twice vetoed bills to repeal and reject the health reform law.

But due to unified Republican opposition, and its choking off of funds for reform, President Obama and his team were having a hard time implementing health reform. Funds for health reform implementation were not forthcoming from Congress. Its major provisions for covering the uninsured had begun in earnest in 2014, and Republicans were resisting steps necessary for reform implementation, such as health exchanges and state insurance reforms.

For Big Government, 2015 is not going to be a good year. Politics is the art of the possible, and not everything seemed possible anymore.