Thursday, September 30, 2010

Health Reform Theory

I have this simple minded theory – The country is becoming more conservative in its political attitudes and its resistance of health reform in those parts of the country with the least population densities ( i.e. people with the lowest number of people per square mile).

In other words, the most liberal and most conservative states are directly correlated to their population densities.

The five states with greatest population densities per square mile are,

1. Washington, D.C, 9581
2. New Jersey, 1171
3. Rhode Island, 1012
4. Massachusetts, 823
5. Maryland, 574

No one can deny these states are in the liberal Democratic camp. Throw in Delaware with 443. New York with 409, and California with 234, and you get the picture.

The five states with lowest population densities are,

1. Alaska, 1.2
2. Wyoming, 5.2
3. Montana, 6.6
4. North Dakota, 9.3
5. South Dakota, 10.5

Toss in Arizona with 54, Oklahoma with 53,, Kansas with 34, and Nevada with 23, and a pattern emerges.

I’m not sure how useful this information is or what a revelation it is to you, but it confirms my simple minded theory that people in thinly populated states tend to be conservative and to resist the health reform law.

Anyway to me , population density is a useful metaphor for the two prevailing worldviews now in conflict, i.e, the middle class revolt as exemplified by the Tea Party, and the elite, have-nots, and the multiculturists on the fringes who distrust middle class values.

If you live in a densely populated state in the East, chances are you welcome rules and regulations, you distrust the Tea Party, and you depend on big government to protect you against the haves in the middle-class..

If you live in the wilds of the Midwest or West, you are more independent and more removed from Beltway attitudes, and you depend on your neighbors.

The point of this state population density report is that the United States is a vast, complicated continental nation. It is therefore difficult to impose a unitary national health system on a diverse country, particularly when 61% oppose the reform law. For every complicated problem, there is a simple way of looking at it, and it may be wrong.

Can The U.S. Manage Health Reform?

As a graduate long ago of an 8 week Harvard Business School course on health system management, I receive the business school’s alumni bulletin. The September issue contains an article “RX for Change.” It describes an HBS program that brings together management teams from health care institutions to lower costs, raise quality, and focus on patients.

Managing Our Way Towards Reform

In management circles , the belief persists that the U.S. can “manage” its way out of high health costs and questionable quality. Management wisdom goes something like this: If only doctors, hospitals, patients, and other stakeholders would listen to managers, whether in the public or private sector, we could simultaneously lower costs , raise quality, and otherwise rationalize care.

Despite 30 Years of Managed Care, the Cost Growth Goes On

These are laudable goals, and I salute them. But because I’ve been down the management road many times, I am dubious. In the mid-1970s, when I attended the Harvard course, health care took about 6% of GNP and national health reform seemed imminent. Today health costs consume 17% of GNP, and, although a reform law has passed, it is festooned with over 150 new management agencies or projects that are likely to take a higher percent of GNP than if nothing was done.

Skepticism Based on Books

Perhaps I am even more skeptical because of books I’ve written on the subject, In 1988 I wrote And Who Shall Care for the Sick? In it, I expressed the sentiment that managed care would drive doctors out of the system and create a doctor shortage. In 2003, I wrote A Managed Care Memoir: A Physician's Whistle-Stop Journey in which I said managed care had largely failed. I followed in 2005 with Voices of Health Reform, in 2007 with Innovation-Driven Health Care, and in 2009 with Obama, Doctors, and Health Reform. In these volumes, I expressed skepticism that the health system could be reformed from outside the profession.

Incremental Reforms Needed

The failure to manage reform distresses me because I believe the system needs a series of incremental reforms at the grassroots – shopping for plans across state lines, limited affordable plans for the young and healthy, malpractice reform, more consumer-driven care, more health savings accounts with high-deductibles, and more choices for all patients – be they Medicare, Medicaid, or the rest of us – on how we want to spend our health care dollars.

Misguided Beliefs

So why have we failed to effectively manage health reform?

One, we have a mistaken belief we can manage everything from the top-down with large bloc decisions that can control billions of personal transactions between doctors and patients.

Two, we seem to think that remote managers are more enlightened, have more financial sense than doctors and patients, and can speak for those who deliver and receive care.

Three, we believe everything in the health care universe can be regulated and manged at the level of centralized organizations, but in reality health care is a decentralized, individualistic activity.

Four, as Regina Herzlinger, a Harvard Business School Professor, reminded us in her classic book Who Killed Health Care? there are five”killers”who hamper efforts to create and managed a truly innovative, consumer-driven health system - dysfunctional third party payers who hamper innovation, empire building general hospitals who centralize rather than decentralize care , small-minded employers who limit choice for workers to one plan, a regulatory-obsessed U.S. Congress who think they can make the rules, and academic elites who believe they know more than the rest of us.

Wednesday, September 29, 2010

EHR Innovation and Health Reform: Grassroots Reactions to Federal Actions on Electronic Health Records

Newton’s third law states, “For every action there is an equal and opposite reaction. “ So much for the laws of physics. Health care is not physics.

Instead, with health care, the reaction to the federal actions for universal EHRs, which call for the expenditure of $27 billion, which is not chump change, is and has to be more fragmented and unequal.

As nearly as I can tell, the reaction includes a series of innovations.

• Placing an electronic record system on IPad (Clear Practice, Inc.).

• Developing a “free” EHR funded by advertisers rather than doctors (Practice Fusion, Inc).

• Using speech recognition to allow doctors to enter narrative summaries via voice rather than key strokes (Nuance, Inc).

• The use of “scribes,” assistants following doctors and entering their findings on laptops (Legacy Health, Portland, Oregon)

You might call these innovations the “humanizing of EHRs,” or “There is more one way to skin the electronic health records cat ”

Whatever you choose to call it, clearly grassroots physicians on the ground, and entrepreneurial innovators, are adjusting to federal demand for EHR installments.

Doctors and their entrepreneurial counterparts see the need to remove doctors from in front of computer screens and to put them before patients.

On the scribe innovation, there is another human benefit as well – teaching prospective medical students the ins and outs of medical care in the real world.

At the Legacy Health System in Portland, Oregon, these students follow a doctor from patient to patient with a rolling computer, taking notes on everything the doctor says. Scribes free doctors to spend time with patients, and scribes gain invaluable medical experience while being paid $8 to $10 an hour along with recommendations for their medical school applications.

To overcome 30% productivity losses secondary to EHR use, Northwest Acute Care Specialists, the emergency physician group that serves five Legacy hospitals in Washington and Oregon have turned to training scribes. About 30 scribes work with its 140 physicians, nurses and physician assistants.

According to companies that train scribes, about 200 hospital emergency departments employ them.

In Portland and nearby Washington, in addition to Legacy, Adventist Medical Center and Southwest Washington Medical Center have scribes.

If you’re an ER doctor seeking productivity, and time for enhanced patient connectivity, hire yourself a note-taking scribe, to follow you around and to document what you do and prescribe. That will satisfy the EHR’s need for objectivity and free you up for patient-related activities.

Source: "Medical Scribes in Oregon Learn the Ins and Outs of Health Care While Easing Doctor's Record Keeping Load at Legacy Health, The Oregonian, September 29, 2010

Electronic Health Records – Bonanza or Boondoggle

Preface: From time to time, Kevin Pho, MD, a New Hampshire primary care care physician and the nation’s number #1 physician blogger, reprints one of my blogs. What follows is one of those blogs that will appear tomorrow, September 30.

Ubiquitous EHRs, from sea to shining sea, in every doctor’s office and in every hospital’s IT suite, is one of the main struts and hopes of the Obama administration’s health reform plan. In this blog, I discuss EHR implementation woes.

AUGUST 28, 2010, Medinnovation Blog

Hospitals and Doctors Not Walking the Electronic Health Records Talk

EHR advocates in Washington don’t seem to get it.

EHRs Not Ready for Prime Time

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.

EHRs Not “Meaningful” to Clinicians

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 hospitals with bonuses and other rewards for adopting EHRs and penalize those who don’t with lower fees and withdrawal of the Government's Good House Keeping Seal of Approval.

Overlooking The EHR Hassle Factor

Unfortunately, the Washington elite overlooks 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 and don't have time to divert to meeting the multiple criteria.

WSJ Health Care Blog View

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.”

The View from The Top and Bottom of Health Care Tree

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.

Tuesday, September 28, 2010

Health Reform Acronyms

PAPA (Patient Affordability and Protection Act), ACA (Affordability Care Act), ACO (Accountable Care Organization), VACO (Virtual Accountable Care Organization), and OWA (Other Weird Arrangements)

With Obamacare, we are suddenly awash in acronyms. Acronyms are a sneaky way to avoid using the term “Obamacare,” which some people consider to be a virtual pejorative, a virtual attack and slur on the President’s health plan.

Speaking of “virtual,” the Internet now allows us to arrange, rearrange, or simulate virtually anything – to achieve virtual reality, to examine virtually any patient from a distance, to conduct virtual office visits without actually being there, to perform virtual colonoscopies or virtual bronchoscopies, to arrange for the care of virtual chronic diseases by virtually any organization or any combination of entities.

In a September 26 edition of The Health Care blog, futurist Joe Flower tells us how the future of virtual health care will actually work. He says the work to contain costs and lift quality will be done by virtually integrated organizations like Kaiser, Mayo, Boeing, Cigna, Geisinger, CIGNA, and BCBS of Rhode Island, all of which have proven programs that have lowered costs for chronic disease by 14% to 27%.

They do this, he says, through VACOs (Virtual Accountable Care Organizations), in which the relationships between entities and individuals is remote, i.e. virtual, but contractual, changeable, and subject to rebuilding.

Flower predicts,

“VACOs will likely be built into the health plan exchanges as they are deployed in 2014 and after, soon becoming a standard option in all health plans and a major way of competing among health plans. As VACOs show good results in the private market, health plans will find ways of offering them under Medicare. The success and cost differences eventually will be so large that employers will stop offering other alternatives, and Medicare will offer sharp incentives for participating in a VACO; using every resource at our command to help people be healthy will have become the standard model of health coverage.”

The three main ingredients of VACOs, says Flowers, are

1) An entity (like the employer) whose bottom line depends on lowering medical expenses for some class of people.

2) Some "skin in the game" for the individuals covered—which can be turned into incentives for them to participate in improving their health.

3) An entity (for instance, a health plan) with a lot of expertise in managing population health, a real incentive to drive down medical costs, and the willingness to "put a crew on it" to find what works and what doesn't.

I am not sure I understand what VACOs entail. But I do understand there is a lot of talk about ACOs – bundled bills between hospitals and medical staffs, mutual savings by hospitals and doctors, physician hospital organizations, IPAs, integrated hospital systems, engaged employees – and all manner of OWAs (Other Weird Arrangements) based on VMUWEB (Virtual Mutual Understandings Where Everyone Benefits).

In olden pre-acronym days, we called this collaboration and cooperation.

There's virtually no limit to the number of health reform acronyms. The only acronym we're missing is IAAB (Independent Acronym Advisory Board). I'd be glad to serve as a member of the board.

Who Speaks for America’s Grassroots Physicians?

An Interview with Don Alexander, CEO of Tennessee Medical Association and Chair of Communications Committee of the Physicians Foundation (

By Richard L. Reece, MD

Preface: When I speak of grassroots physicians, I am speaking of hundreds of thousands of independent American physicians who own their own practices. I am speaking of primary care and specialty physicians who practice in every hamlet, town, suburb, and city across America. I am speaking of physicians who supply most of America’s medical care.

Who speaks for them? Increasingly it is a 501 C3 charitable organization called the Physicians’ Foundation, founded in 2003 as the result of a class action settlement between state medical societies and major health plans. These plans originally funded the Physicians Foundation.

State medical societies are a powerful force in America because they are close to the ground and close to practicing physicians. Most of these grassroots physicians still practice solo or in groups of ten or less.

Before resigning in frustration as the first national “HIT Czar,” David Brailer, M.D. , whose mission was to develop an interoperable electronic health record system across the land, observed in a 2005 New York Times interview , “The elephant in the living room is what we’re trying to do is the small physician practice. That’s the hardest part, and it will bring this effort to its knees if we fail.”

That was true then, and it is true today. Indeed, in my opinion, the successful implementation of the Affordable Care Act will depend to a large extent on how these grassroots physicians feel, react, and accommodate to the health reform law. If they cut back or withdraw to care for Medicare and Medicaid patients, the U.S. will have an access problem of monumental proportions.

To get a sense of the activities of the Physicians Foundation, I recently interviewed Don Alexander, CEO of Tennessee Medical Association for the last 15 years and Chairman of Communications Committee of the Physician Foundation since 2003.


What is the function of the Communications Committee?

Our charge is to use as many ways as possible to send to our various audiences messages about the Foundation, successes of the Foundation, and remind our audiences the mission of the Foundation. As you know, these days, there are many avenues for those communications. We use electronic communications as much as possible. We focus on narrowing down our messages, to keep our name out there.

Who are your audiences?

Our primary audience are physicians across the country, regardless of specialty or region.

Our second audience are those medical organizations who were part of the founding of the foundation, which came about as the result of the settlement of a class action law suit against national managed care organizations. These medical organizations include state medical associations, county medical societies. The entire federation of medicine then becomes our audience.

A third audience is the general public. They need to be aware of our efforts to help physicians compete in this medical practice world. Our goal is to make those practices more efficient, more patient friendly, more productive.

Fourth, (or lastly) we have a political audience, i.e., decision makers, in Washington and in states, and in state medical associations.

Those are the four main audiences we try to reach through our communication activities.

Are you primarily an educational organization?

We are not limited to education. We are also a research organization. We have major research projects as well as a grant-making organization highlighting best practices.

We try to educate our audiences on needs and issues physicians face in this modern practice world.

Talk a moment about your current projects, the results of which will be released in the next few months. The Foundation just issued $2 million worth of grants.

Yes, these grants had two different focuses – health information technology and physician leadership.

On the health technology side, we are seeking to find out what constitutes the best use of IT. Electronic medical records may make for more efficient and some feel better care, but whether IT will save money is an open question. Our grants will help us find what works best.

We see a pressing need for physician leadership at the grassroots level in the states. We’re focusing on the next generation of physician leaders. If the private practice of medicine is to survive, physicians must take the lead rather than complain about what third party payers are handing to them, and what politicians are doing to them.

To make physician leadership a reality, the Foundation has been working with Kellogg school of management at Northwestern to bring in physician leaders from various states for courses in leadership.

Exactly. We will be in our second round of those courses this coming spring. The first round was highly successful. Physician leadership is one of the Foundation’s cornerstones. We hope we’ll have physician organizations battling to take spots in those leadership courses.

Again, this is grassroots leadership – where the practice is, where the action is, medical societies, and medical staffs. This is filling a gap between the older generation and the younger generation. We’re excited about the results and anxious to communicate those results to our various audiences.

Another thing the Foundation has done is offer a grant to a Boston-based organization called Project Health, which now operates in seven major cities. Project Health helps doctors plug holes in social safety net created by poverty.

This is a project with a different twist from what medical organizations traditionally become involved in. Project Health acknowledges problems that other major foundations like Dartmouth, the Commonwealth Fund, and the Robert Wood Foundation don’t always recognize – that the social aspects of one’s life are directly related to health. One cannot treat just a child’s sickness, and expect it to be cured, without addressing conditions in the home - access to food, housing, unemployment, family issues, and medical transportation.

It is hard for physicians to address these issues because they are on a treadmill, just seeing patients. With Project Health, they can write “prescriptions” to be filled by college volunteers at Help Desks in various health care settings – hospitals and clinics – that direct patients to social services.

Project Health helps doctors help patients stay healthy by providing access to social services generally outside the immediate reach of physicians. Physicians cannot control the other needs of patients that adversely affect their health, but after are blamed for poor health outcomes.

Another thing the Foundation has put a lot of time, money, and effort into is highlighting the impact of health reform on physician practices. Because of the physician shortage, practices are already overloaded, and now they are expected to care for 34 million new uninsured and the 78 million baby boomers coming on board of Medicare in 2011 at the rate of 13,000 per day over the next 16 years.

How will they cope with these new demands?

That, of course, is the question. And everybody is struggling to find answers. There was a shortage even before we start adding new patients to the government rolls. Some answers are enhanced and proper use of mid-level practitioners. Overloading of physician practices and the stresses on those practices was not something that Congress, in its lack of wisdom, took into account when the passed the health reform acts.

The Foundation has a skeptical view of whether future physicians can take care of this wave of new patients. You certainly cannot heap more red tape, more hassles, and more expense on them because you will drive physicians out of federal programs and out of the health care system. We think things are going to get worse before they get better. Congress was so caught up in politics; they didn’t consider the patients or physicians’ practices.

One of the major contributions of the Foundation has been the survey last year of 300,000 primary care physician and a current survey of 40,000 physicians of what they perceive and how they will respond to reform. For the first time, these large in depth surveys give us a useful and precise handle on doctors’ attitudes, reactions, and actions in response to reform.

That’s a big part of goal – to communicate what these surveys are saying. It’s scary to read what physicians across the country are saying. If you put more pressure on my practice, if you force me to do what I can’t afford. I will quit seeing government-sponsored care. The decision makers aren’t listening;. They simply don’t believe physicians will cut back on seeing patients or they will retire or quit practice.

And they don’t believe there will be an exodus of doctors from Medicare and Medicaid programs?

They proved that when they said we are going to slash physician reimbursements, and they kept playing games with SGR (Sustainable Growth Rate) formula).

For politicians, underpaying doctors is a calculated gamble. Policy makers, decision makers, and politicians know physicians are dedicated to their patients, and they know the last thing they will do is forsake their patients. They may not forsake their patients, but many will say, “I’m getting out of the practice of medicine.” Our surveys indicate doctors will cut out certain future segments of care, but will not totally forsake current patients

Do you foresee, maybe in the next three or four years, a massive access crisis with an accompanying political crisis?

Mass exodus, I don’t think so. But more than anybody ever predicted. It depends on where physicians are in their practice life, where they are in their careers.

If they think they can continue and provide quality medicine, they will continue to practice, but when they feel they cannot take care of patients as they were trained to do, or if somebody interferes with care, they will either cut back or change careers.

How do you communicate your concerns to the world at large? I know you are working with the Global Strategy Group to reach a wider media audience.

As volunteer members of the Physicians Foundation board, we need professional help- with communication strategies, media contacts, marketing know-how. We have contracted with the Global Strategy Group, and they have helped establish a greater media presence.

We want to reach as many people as possible with our limited resources- through press release, media contracts, and an Internet presence. The Global Strategy Group helps us narrow down and get our message out there.

Part of your message, as I see it, is to highlight what’s going on in the physician world and to put it n a bright light that the public and others haven’t really understood or seen before.

That’s quite a challenge. Pick up any medical magazine, or any publication at random off the news rack, and you’ll read conflicting opinions about health care. To get the physicians’ message out there is extremely difficult. People still love their own doctor. They rate physicians highly, but beyond their own physician, they see physicians in general as having financial means. They are reluctant to embrace the positions of medical organizations. Yes, it’s hard to educate the public, not only the intricacies of care but on why the system is broken.

Add to that the fragmented media world – with talk radio, TV talking heads, bloggers, the Internet, and the social media – and it must be tough to reach all your audiences concurrently.

It’s impossible. The media is open 24 hours a day, is hungry for information, particularly bad news, which sells better than good news. The media does not report the news any longer. It sees its role as “creating the news.”

Overall, do you think the Foundation is making progress? You’ve got these thoughtful reports, constructive grants to improve care, and insightful physician surveys coming out, and you’re telling the world what the life of physicians are all about.

We are making progress. We’re telling our audiences of what we’re doing, and we’re informing them of the benefits of what we’re doing.

People sometimes forget that universal coverage without universal access to doctors is meaningless. Doctors remain the backbone of the health system. These self-evident truths have to be clearly articulated and set forth.

We have a great pool of knowledge on how to make the system better, and if we can keep the patient-doctor relationship intact, we will survive. If you put wedge between doctors and patients, the health system will suffer and begin to crumble.

Let me end by asking you about Tenncare, and Tennessee’s experience with a federal Medicaid-based program designed to help the uninsured, poor, children, and disabled adults.

The failure of that program, started in 1993- 1994, which resulted in runaway costs, near bankruptcy of the Tennessee state budget, and non-participation of many if not most of Tennessee’s physicians. That experience must give you pause and skepticism about the prospects of national reform efforts.

Don’t get me started. I’ve been intimately involved with Tenncare for over 15 years, and I could talk all day and night about it. Tenncare is a precursor to what the present health reform is all about.

When Tenncare started, we had about 800,000 people on the Medicaid rolls. We added another 500,000 people. The State said we will add a half-million people, but we’re not going to put any more money into the program. We will manage our way through this, and we will save money.

Tenncare was a disaster. You have to put more money into it, or physicians won’t participate. The managed care organization took 15% off the top with no real oversight, and they paid doctors 30% on the dollar for taking care of patients.

The Tennessee Medical Association tried to delay the implementation of Tenncare through the courts, but it was put in place practically overnight.

It’s been a catastrophe. A lot of small businesses stopped covering employees. They switched them to Tenncare. Suddenly Tenncare’s future was to eat up 40% of the state’s budget. The present governor has taken people off the rolls that don’t belong there, but it still a case of how not to provide healthcare. When Tenncare kicked in, the number of “uninsurable ” went from 12,000 to over 100,000.

In a lot of ways, the Tenncare experiment may forbode what will occur with present reform, only there are 34 million people, not 12,000. The burden to care for them will fall on hospitals and doctors. National reform will only work if physicians get a fair and honest reimbursement. Otherwise physicians will not be able to sustain their practices and stay in medicine, and ultimately it is the patients who will suffer.

Sunday, September 26, 2010

Too Many Rocks in Physician Knapsacks

General Colin Powell is quoted as saying,
Obama has too many rocks in his knapsack,
And the President’s reputation may be fraying,
Because of too heavy loads in his back rack.
General Powell is referring to two wars,
And a terrible unending domestic recession.
And how hard it is to settle political scores.
When facing a double dip depression.

Too many rocks in a knapsack is a great metaphor,
It applies to doctors and health reform, that’s for sure.
There’s a huge and looming doctor shortage out there,
Not enough doctors to spare, or for patients to share.
How do you take care of millions of more patients,
And pay attention to new doctor-patient relations,
When government is cutting doctor reimbursements,
And reducing patient disbursements?

Et Tu? YouTube? Innovative Use of Visual Media to Market Physician Practices

Within the changing communication mix of word and visual, the visual will dominate. The challenge is to ascertain the optimum mix of word and visual in each field of endeavor.

John Naisbitt, Mind Set!, 2006

This week I called Neil Baum, MD, a New Orleans urologist. I asked,”What’s new in the field of physician marketing."

For years, Neil wrote a column in the AMA News on the topic, and his book Marketing Your Clinical Practice is now in its third edition.

Without hesitating, Neil replied, “I went on YouTube, and I’m getting three new patients a day.”

This should not surprise. The visual social media is the craze these days - Facebook, Google videos, YouTube, even Twitter.

Twitter prides itself on restricting messages to 140 characters, but it is adding visual content nevertheless.

A picture is worth a thousand words, television beats books, and even we bloggers know blogs work better with images and links to personal videos. With any luck at all, the right mix of words and pictures can go viral, as with Facebook, which now draws 500 million viewers.

Lest doctors get too giddy about prospects of broadcasting their practices to a wider audience, remember most medical practices, like politics, are local, and most doctors see only one patient at a time.

Remember too. Be discreet. Don't cross the lines of privacy or propriety. Don't, for example, show details of rectal surgery. That is verboten.

Doctors deploying YouTube or any other social media must understand these new communication tools are like any other complex skill – it takes knowledge, experience, and enlightenment to master them. They must also understand the social media is a trend in which people use technologies to get the things done using each other rather than traditional sources. It is about people connecting with each other and depending on one another than the establishment.

There are dangers to everybody watching everybody else, whether on, or elsewhere. Too many little brothers can become Big Brother, as in “Big Brother is watching you.” Digital surveillance and digital facial recognition may have digital downsides, as government and hackers intrude further into our lives.

It is wise, therefore, for physicians to enlist the services of an IT marketing consultant before plunging into the social media abyss where things can go amiss.

Saturday, September 25, 2010

The Numbers; One Reason Why Obamacare Attack on Health Plans Isn’t Working

“78,000 people looking out for 70 million Americans.”

United Health Care Ad,

Every successful political campaign needs a foil or a devil– someone or something to demonize. Every organization, profit or non-profit, needs a margin to function.
No margin, no mission, as a Catholic nun CEO of a major hospital system once said.

In the case of the Obama administration, that demon is the nation’s health plans.

The demonized theory is that health plans put profits before people – particularly children, those with pre-existing illnesses, college students without income under their parents plans, those whose health expenses exceed lifetime limits.

For some reason, this strategy isn't working well politically. The latest 9/18- 9/19 Rasmussen report of 1000 likely voters says 33% are for the plan with 61% are against, a spread of 28 %.

I suspect one reason for this wide spread disbelief in reform is that most Americans have yet to receive any tangible benefits. Yet they are receiving notices of 2% to 9% increases, with hikes up to 20% to 40% in individual or small group plans, and spikes in copayments and deductibles.

People respond more to their own real world experiences rather than to political promises.

The Numbers

Another reason may simply be the numbers. Children affected with pre-existing illness number only 72,000, and young people covered up to 26 and those exceeding lifetime limits, probably number in the hundreds of thousands, not the millions.

Significant to be sure, and agreed to on both sides of political aisle, but miniscule when compared to 270 million already covered and even to the 51 million uninsured. Good steps, but small steps.

Finally there are cultural and structural problems.

Like it or not, we live in a capitalist society. In that society, organizations, like health plans, require profit to survive and offer services.

Here is how David Dranove, a health care economist at Northwestern’s Kellogg school of management , sees the problem,

“Healthcare reform becomes official this week, as many of the provisions of the legislation kick in. One provision requires insurers to accept children with preexisting conditions while capping what they can charge, undoing a standard industry practice. Several insurers have indicated that they will stop selling child-only policies. Industry officials are having a field day criticizing insurance industry greed.”

“Maybe these officials haven’t noticed, but insurers are greedy and there is nothing anyone in the Obama administration can do about it. Maybe it needs repeating. Insurers are greedy, have always been greedy, and always will be greedy. So are all investor-owned companies. People don’t invest in health insurance companies (or any other investor-owned companies) for charity. They invest in them to make money. (Investors tend to be greedy too, and that includes the pension funds that most working Americans rely upon for their comfortable retirements.) “

Source: “Profit-Seeking Health Insurers Seek Profits, “ September 22, 2010, The Health Care Blog

In a capitalistic society, in other words, one’s man profit is another man’s greed, or, in the lexicon of politics, another man’s “special interest.” In the case of health plans, the Obama administration has sought to reduce “obscene profits” by demanding that plans devote 85% to care, and only 15% to marketing and administration.

With United Healthcare, controlling profit has political overtones, for among United’s 70 million covered Americans are some of the 46 million seniors belonging to AARP’s Medicare supplement or Medicare Advantage plans. Seniors are the single group most opposed to the Obama health plan. Then, too, there are those 78,000 United employees, who could lose their jobs if United’s profits, based on greed, suffer too much.

Friday, September 24, 2010

Women Politicians and Women Physicians as Societal Forces

This is the year of women as rising forces in politics and in medicine.

Peggy Noonan, former speechwriter for President Reagan, explains why this is true in politics in a column today in the Wall Street Journal. She is discussing the views of Marsha Blackburn, a Republican Congresswoman from Tennessee.

Driving The Election Cycle

“ They‘are the drivers in this election cycle,’ Ms. Blackburn says. ‘Something is going on.’ At tea-party events the past 18 months, she started to notice ‘60% of the crowd is women.’ She tells of a political rally that drew thousands in Nashville, at the State Capitol plaza. She had brought her year-old grandson. When the mic was handed to her she was holding him. ‘I said, ‘How many of you are grandmothers?' The hands! That was the moment I realized that the majority of the people at the political events now are women. I saw this in town halls in '09—it was women showing up at my listening events, it was women talking about health care.’

Focusing on Future Generations

“"Women are always focusing on a generation or two down the road. Women make the education and health-care decisions for their families, for their kids, their spouse, their parents. And so they have become more politically involved. They are worried about will people have enough money, how are they going to pay the bills, the tuition, get the kids through school and college."

"Women are always focusing on a generation or two down the road. Women make the education and health-care decisions for their families, for their kids, their spouse, their parents. And so they have become more politically involved. They are worried about will people have enough money, how are they going to pay the bills, the tuition, get the kids through school and college."

That 60% Figure

Keep that 60% of women at political rallies, and think of women running for high offices in California, Washington State, South Carolina, Delaware, and elsewhere.

Now transition to Medicine. Sixty percent of college students are now women, 60% of entering medical students are women, and by 2020, 60% of practicing physicians will be women.

Entry of women into the profession changes things. Women physicians are more likely to be salaried employees, to be more comfortable in group settings, to take more time off to tend to their families, to work shorter hours, to retire earlier, and and to enter certain specialties.

• OB/GYN, 68%

• Pediatrics, 65%

• Dermatology, 54%

• Psychiatry, 49%

• Family practices, 47%

• Pathology, 47%

• Internal medicine, 40%

Source: Association of American Medical Colleges

Lifestyle Factors

Women physicians, because of family obligations and gender , tend to focus more on lifestyle. In an interview I conducted with Elizabeth Chase, MD, which I published in a May 18, 2010 blog, she said,

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

On average, women physicians over their working lifetime spend about 20% - 25% less time practicing. They are more likely to retire early, in their late forties or early fifties. According to a study by Merritt Hawkins and Associates, today's women physicians work 47 hours a week vs 53 hours for men. These factor impact the physician shortage.

That’s the way it is, will be, and should be. Women are a rising, and a positive force, in politics and in health care. In many ways, they bring sanity and balance. Politically, they are diverse. In a 1999 Emory University School of Medicine study of 4500 women physicians, 37% considered themselves moderates, 37% liberals, and 26% conservative. This may well have changed, given the economic recession and its negative impact on patients and physicians, but that is material for another blog.

Thursday, September 23, 2010

Health Reform Thoughts

Thought One - There are no “good” or “bad” people, only people with different points of view, only people who consider their “special interests,” to be themselves, their family, or their constituents. Some people are simply more “clever” than “good.”

As Elizabeth Wordsworth observed long ago,

If all good people were clever,
And all clever people were good,
The world would be nicer than ever
Than we though that it possibly could.
But somehow, ‘tis seldom or never
That the two hit it off as they should;
For the good are so harsh to the clever,
The clever so rude to the good.

Moral: Those who so cleverly rammed through health reform against the will of the people, though full of good intentions, may have been too clever for their own good.

Thought Two - The ruling class, the dominant political party, the Inside-the-Beltway elite, never stay intact forever, for soon or late, they stumble and go out of power. As George Orwell, of 1984 fame, noted.

There are only four ways in which a ruling class can fall from power. Either it is conquered from without, or it governs so inefficiently that the masses are stirred to revolt, or it allows a strong and discontented Middle Group to come into being, or it loses owns self-consciousness and willingness to govern. These causes do not operate singly, and as a rule all four of them are present to some degrees. A ruling class which could guard against all of the them would remain in power permanently, Ultimately the determining factor is the mental attitude of the ruling class itself

Moral: The ruling class, incumbent Democrats and Republicans, had best swing to the center or change their mental attitude to satisfy independents , Tea Partiers, or other members of the Middle Group, or their days are numbered.

Obamacare’s Six Month Anniversary - The Good, the Bad, The Ugly

Today we celebrate, or desecrate, depending on your point of view, the 6 month anniversary of the passage of Obamacare.

Most of the celebrating is coming from the White House and the liberal media, but not from Democrats running for re-election who know public sentiments when they see them.

Nevertheless, proponents are celebrating The Good – which consists mostly of mandates to rein in or discredit private health insurance plans.

The Good Mandates

To wit, on this day, September 23, health plans cannot:

• Exclude from coverage children with pre-existing illnesses.

• Deny coverage to young people under 26 who parents have insurance.

• Deny coverage to anybody for any other reason except customer fraud.

• Cap the benefits of anybody who exceeds the amount of benefits offered over a lifetime.

• Force anybody to pay for preventive services such as mammograms or colonoscopies.

• Steer patients away from high risk pools designed to cover those with pre-existing conditions.

The Bad, Obama Misstates

Next, misleading Obama’s misstated promises.

The Affordable care act will not:

• increase overall health system costs. Not so says the Medicare Actuary, and not so says common sense – you cannot cover 32 million more uninsured at lower costs for all. Not so, says countless critics, who say government has never saved money with broad entitlement programs;

• allow most employees now covered to keep existing plans. Not so, says large business employees, 64% of whom, or small business employees, 80% of whom, will be forced to switch to “federally qualified plans” within the next few years;

• increase insurance premiums. Not so say health insurers, who say they are forced to increase premiums to stay in business and satisfy stockholders. Not so say millions who have already received notices of significant premium rises;

• affect seasonal businesses, such as ski resorts or amusement parks. Not so owners of these businesses who say they will either have to shut down or lay off employees to comply with reform regulations;

• cause increased regulations. Not so say millions of small business who must submit 1099 forms to the IRS for every $600 expense – medical or non-medical;

• lead to government intervention into private affairs. Not so say so millions of individuals who face IRS confiscation of tax refunds if they do not purchase federally qualified health insurance.

The Ugly

Differences between good and bad interpretations of Obamacare has precipitated an ugly political debate in the run-up to the November mid-term elections. Voters are divided, with 40% favorable towards reform, and 56% against it. The issues are : Will reform bring “affordability” and “protection” against private health insurance abuses for Americans , or will it simply bring huge runaway costs with higher taxes, limit health care options, and foster other unforeseen adverse consequences? Does Obamacare represent compassionate capitalism, or is it a path towards European-style socialism?

What everybody senses is that the days of a free lunch are over. Who pays for lunch remains up for grabs.

Wednesday, September 22, 2010

Regrettable But Quotable: Reform Politics and the AMA

“As President Obama delivers yet another speech on his healthcare debacle-this one on the 6 month anniversary of the bill's passage- he may notice some of the people who won't be clapping: members of his own party. Like aristocrats aboard a sinking steamship, Congressional Democrats are madly scrambling for whatever life vests they can find.”

“Senator Ron Wyden of Oregon, one of the architects of the healthcare insurance mandates, has voiced second thoughts, saying "I would like to explore the possibility of Oregon moving forward with a federal waiver (on mandates)" Another Democrat, Mississippi Congressman Gene Taylor, has broken ranks and joined with 171 Republicans in signing petition #11 which calls for a vote to repeal Obamacare.”

““Not to be outdone, the American Medical Association (AMA) became the latest turncoat on Obamacare when they announced their support of Tea Party favorite, Pat Toomey for senator of Pennsylvania. The irony is that Toomey is a devotee of the troika: defund-repeal-replace while the AMA was a staunch supporter of the Affordable Care Act in order to protect their government sanctioned medical coding system monopoly which provides as much as $100 million annually and its passage without their support was questionable. Unfortunately, they wield more influence than should be the case for an organization that represents so few doctors- only 17% of the doctors in the US - and a large percentage of this group are medical students, residents in training, retired doctors and academicians who are often removed from patient care issues. As they embark on a campaign to bolster their dwindling numbers by offering a half price membership sale, their efforts are proving futile because they are as out of touch with their constituency as is the current resident of the White House with his. Instead of a mea culpa, they offer suggestions on how to cope and prosper under Obamacare.”

Hal Scherz, “Democrats Flee as Obama Speaks,” Real Clear Politics, September 22, 2010

Health Reform Anticipation Sets Off Chain Reaction of Physician Employment by Hospitals

Call it what you will – consolidation, alignment, collaboration, accountability, or sheer panic. Whatever you call it, doctors are rushing to be employed by hospitals, and hospitals are hiring them in record numbers.

For physicians, the triggers are declining profitability of private practice, increasing costs of doing business, and a search for economic security without malpractice and IT documentation hassles.

For hospitals, the motivations are market dominance, power to negotiate contracts with third parties, channeling of physician behaviors, and enhanced ability to meet reform standards for quality and safety. A current survey at indicates 80% of hospitals say they will be employing more physicians this year.

However one looks at it, under reform, hospitals and physicians will need each other to survive.

Anticipation of lower Medicare reimbursements, proposed in the health reform law, are contributing to a wave of physician practice sales to hospitals. By 2019 Medicare physician reimbursement may decline by 50% and are projected to be less than Medicaid fees.

Acquisition of cardiology practices preceded the current wave when Medicare cut cardiology fees by up to 40% last year. My sources, from the practice management field, tell me cardiology groups are lining up at hospital doors to be acquired and folded into hospital employment.

If you are interested in this subject, I recommend you visit the website, which caters to hospitals and download a document entitled “Physician Alignment in Era of Change.”

It is the result of a survey of more than 200 hospital executives released in September 2010 and features the observations of a number of MD-CEOs of large integrated hospital systems. Craig D. Samitt, MD, president and CEO of Dean Health System in Madison, Wisconsin, says the accelerating pace of hospital employment of doctors reflects the “highly competitive changing market and general uncertainty because the rules are just getting written, and we are very early in our journey toward reform.”

Among the survey findings are these.

• 54% of hospital CEOs say the increased insured patients will strain physician relations.

• 74% say they plan to employ a greater percentage of physicians over the next 12 to 36 months.

• More than 70% say they have received increases in request for for physician groups for employment.

• Hospitals plan to employ physicians in these specialties – primary care 72%, hospitalists 52%, cardiologists 47%, general surgery 42%, orthopedics 39%.

• The specialists most in demand in various communities are primary care 63%, orthopedics 48%, cardiology 48%, general surgery 37%, hospitalists 30%.

I will not go into details of the survey. But it is apparent the journey to alignment is uncertain strewn with obstacles – how much to pay, for what, how to deal with conflicts of interest, the potential role of accountable care organizations, how to split the “savings” that may incur, and dealing with physicians who are “disengaged” with the process.

I spoke to John McDaniel, founder and CEO of Peak Performance Physicians, a practice management firm in New Orleans, and he pointed out to me that what’s driving hospital physician employment is not only anticipation of lower reimbursements under reform but the mounting costs and complexities of doing business. Physician prefer to practice medicine as employees of hospitals rather than deal with the downsides of owning their own practices.

Tuesday, September 21, 2010

Victor Fuchs- Prospects for Health Reform

I wish to bring to your attention an interview with Victor Fuchs, PhD, professor emeritus of Stanford University. The interview appears in the September 19 issue of The Health Care Blog ( Matthew Holt, former student of Fuchs and cofounder of the Health Care Blog, conducted the interview with Fuchs, who is known as the “Father of Health Economics.”

The interview is a worthwhile read.

Here are a few things I took away from it.

• More than 80% of Americans are now living past 65. This demographic reality changes everything, from Social Security, to Medicare, to taxes on the young, to how to pay for health reform.

• Emphasis on health care technologies and demand for these technologies is shifting from prolonging life to improving the quality of life. People want to live better, more productive lifes, not just longer lifes.

• To save and sustain the American health care system will require more revenues, e.g. , from a Value Added Tax (VAT), and more organizational changes, e.g. Accountable Care Organizations and Medical Homes. These requirements will require the system to stress value and outcomes and discourage independent fee-for service payments and volume of services offered.

• The current health reform law is more about insurance reform, a much easier and changeable target, than health reform, which requires behavioral and cultural changes, both notoriously refractory to change.

• American culture, since De Tocqueville, has responded to crises with sudden change – the Emancipation of slaves, the $1 trillion bailing out of financial institutions– rather than a rational processes. True health reform will most likely come from a crisis – a World War, depression, or national bankruptcy.

• Fuchs is pessimistic about prospects for true reform, as seen from his Stanford perch. He says the current “fractionated system of messages” from talk show hosts, bloggers, and the inefficient, partisan, political system spread confusion and re-enforce negative opinions. Theser factors makes what needs to be done – fundamental changes in the 3I’s (Information, Infrastructure, and Incentives) difficult to carry out. Fuchs concludes, “The whole thing, you might say, is a mess…Given the way it is and given the other obstacles, I think the chance of these things working out are very small until the country gets into some kind of crisis situation.”

Concluding Remarks

What Professor Fuchs says does not surprise me. He has said it often and well in recent New England Journal of Medicine articles and in his classic little book Who Shall Live (1974). His tone combines realism and pessimism. It rests on his deep knowledge and his witnessing of repeated , failed reform efforts during his 86 years. In this interview, he does not dwell on the main forces blocking Fuchs-style reforms – America’s inherent conservatism, its deep distrust of Big Government, its skepticism over external management solutions, and its desire for retention of individualism and the status quo.

Monday, September 20, 2010

Health Reform Stakes

I am tied to the stake, and I must stand the course.

Shakespeare, King Lear

The stakes in the evolving health care debate are enormous. The stakes are real, practical, perceived, local, national, economic, and political.

• For Democrats, control of the House, and maybe of the Senate, in 2010 is at stake. The Affordable Care Act is unpopular, and they must decide whether to run for or against it.

• For President Obama, his legacy is at stake. Health reform is his signature issue. He spent 16 months concentrating more on health care than jobs. Health reform may decide his 2012 election.

• For Republicans, outcome of the 2012 Presidential elections is at stake. This will depend on how well the GOP performs in cutting spending from 2010 to 2012, should they take the House.

• For the 50 States, their financial viability is at stake, as they struggle with federal mandate to cover 16 million more Medicaid recipients, already the greatest burden on their budgets.

• For uninsured Americans, now numbering 51 million, their health care coverage, starting in 2014, is at stake.

• For health care agents and brokers, and for small insurance companies selling and brokering policies to individuals and small businesses, their very existence is at stake.

• For businesses, their ability to continue to finance coverage of employees is at stake, as they sort through the financial and bureaucratic requirements imposed by the new health reform law.

• For Americans with existing policies expiring in 2012 and beyond, their ability to hold onto these policies is at stake, for their new policies will have to comply with more comprehensive and expensive federal standards.

• For 11 million Medicare recipients, their Medicare Advantage plans is at stake, for sacrifice of these plans is the most concrete means of financing the Affordable Care Act.

• For 900,000 American physicians, their continued participation in Medicare and Medicaid is at stake, as they ponder a future of lower reimbursements, burdensome regulations, and restriction of clinical freedoms.

• For 5000 American hospitals, particularly public hospitals, their future is at stake, as they struggle to cope with decreased reimbursements, compliance with federal quality and safety standards, and requirements to install and maintain information technology systems.

• For the medical industrial complex – health plans, drug companies, device manufacturers, and others – their traditional ways of doing business, their profitability, and their survival is at stake.

'For the nation as a whole, the future of entitlement programs, the heaviest and fastest growing part of national debt, are at stake. Will the health reform law, as currently proposed, escalate that debt? Will it slow its growth? Will it protect Medicare against bankruptcy? For the moment, no one knows.

Sunday, September 19, 2010

Medical Licensure Tied to Participation in Government Programs. A Game of Political Chicken

Watch for the federal government to restrict doctors from practicing, or possibly even criminalize them, unless they accept patients with insurance paying government-defined rates for medical tests and treatments...The new health law is overtly configured to cut payments for Medicare services by 30 percent over the next three years; by 2019, payments for senior-citizen care will be even lower than Medicaid. While government arrogantly assumes doctors will swallow government-dictated low reimbursements, surely more and more physicians will refuse to see patients under such health plans.

Scott Atlas, MD, professor, Stanford University Medical Center and senior fellow Hoover Institute, “Obamacare- The Sequel, “ Washington Examiner, September 17, 2010

In Massachusetts there is a pending bill in the state legislature to tie medical licensure to accepting patients in the Massachusetts state health plan.

I have written about this in previous Medinnovation blogs.

• August 28, 2010, Massachusetts and Indiana as Experimental Laboratories for Obamacare

• July 7, 2010, In Health Care, As Massachusetts and Harvard Go, So Go the Country

• April 25, 2010, Medical Licensure as a Condition for Seeing 34 Million Government Subsidized Patients

• April 16, 2010, Obamacare and The Physician Bloodbath

I will not rehash those blogs here.

Suffice it to say, after four years of its Universal Health Plan, Massachusetts faces a shortage of primary care doctors, over half its remaining primary care doctors have closed their practices to new patients, waiting times to see these doctors are the longest in the U.S., emergency rooms are more crowded than ever, and doctors are fleeing Massachusetts to more doctor-friendly places to practice like Texas.

Those on the progressive side of the political aisle boast that Massachusetts has the lowest number of uninsured in the land at 5.5% versus 17% for the rest of the U.S. That is unquestionable a positive. To counteract negative consequences of the law, progressives propose to make accepting government-subsidized patients a condition for getting a medical license.

Doctors are restless, not only about the medical licensure issue, but reform in general. Recent Physician Foundation surveys indicate 89% of doctors feel they were ignored when the reform law was created, 80% find practice unsatisfying, and 33% plan to stop practice in three years. Another one-third to one-half of those who remain in practice plan to cut back or cease seeing Medicare and Medicaid patients if the health law takes effect as proposed.

Political Chicken
Much of this strikes me as a game of political chicken.

Those espousing universal coverage say it is worth any price. Coverage for all is too important to be left to doctors. If doctors do not want to go along, we will make them go along. We will mandate that they see government-subsidized patients. Mandated universal coverage is a moral imperative. We will wring the neck of the doctors if necessary.

Doctors delivering the care respond: Wait just a minute. This is a free country, and we will see who we want to see. We can practice where we want to practice. We are not indentured government servants. If government fee structures are not enough for us to maintain our practices, we will exercise the option of not seeing government patients. Universal coverage is not a moral imperative when you consider the moral comparative, viz, universal coverage without universal access is meaningless.

As Winston Churchill said when Britain was told in 1941 it would have to go it alone or have its neck wrung, "Some chicken, some neck."

Saturday, September 18, 2010

Magnitude of the Health Care Enterprise, and Efforts to Reform It

In the heat of the health reform debate, we overlook the size of the enterprise. You cannot turn around the Queen Mary on a dime. We will not be able to turn around the American health care system, now $2.5 trillion, or the American economy, now $13 trillion, on a dime.

A September 13 USA Today editorial puts it in perspective. The editorial contains this chart, based on government data projecting ahead to 2019.

1. Total health spending

Without reform, $4.48 trillion
With reform, $4.57 trillion

2. Federal health spending

Without reform, $1.73 trillion
With reform, $1.73 trillion

3. Spending per person

Without reform $13, 387
With reform, $13,652

4. Spending per insured person

Without reform $16, 120
With reform $14,729

5. Percentage of people insured

Without reform, 83%
With reform 92.7%

One can argue about reliability of these projections, their political bias, and reform alternatives, and many people have.

- Jonathan Cohn of the New Republic, a liberal magazine, in “ ‘Repeal and Replace, ‘OK, with What?” (September 17) says any Republican plan would cost more and cover fewer.

- Former New York Governor Pataki in the same USA Today claims Obamacare has misled the American people about costs (Over $1000 more per year according to the OMB), changes in policies (66% of workers in small businesses will be forced to change policies to meet federal standards), cuts in Medicare benefits (removal of Medicare Advantage plans to meet target of $575 billion cuts in Medicare), and higher taxes, penalties, and fines for employers (the uncertainties of which would presumably keep them from creating new jobs).

Small wonder, then, that:

- the public is divided on the new health reform law, which 56% currently oppose.

- critics are skeptical given the government’s past record of vastly underestimating and controlling entitlement costs.

- People are wary about $500 billion in new taxes required by the law.

- Skeptics point out the spike of uninsured from 47 million in 2008 to 51 million today has fueled further skepticism about the wisdom of government spending to reform care.

- Employers are dropping coverage because of fright over costs, complexity, and risks of reform.

- Government reformers are tying everybody in the health care sector in regulatory knots as they try to sort through the maze of coming regulations.

- State officials are resisting impossible-to-pay-for mandates imposed on nearly bankrupt states by expanding their Medicaid populations by 16 million.

- Many physicians are considering dropping Medicare and Medicaid patients because low federal reimbursements make it difficult for them to maintain and sustain their practices.

These may all be short-term, passing events, that will correct themselves when the economy rebounds. And certainly reforms covering 30 million more citizens and those with pre-existing illnesses are worthwhile, even noble, goals.

But the American people, 40% of whom support the Tea Party movement, 72% of whom distrust Government, and even more of whom are wary of our growing $4 trillion national debt and runaway federal spending without tangible results , are restless, even rebellious. They are already voting for radical changes in political leadership and in national spending policies.

The U.S.S. Titanic will not turn on a dime. Many on board seem to think she is taking on more water and debt than she can handle.

Friday, September 17, 2010

The Access Mess – What Doctors Can Do

America is in the midst of an economic and health access mess.

Look at the numbers – 15 million unemployed, 1 of 7 mired in poverty, 51 million uninsured, and a 50,000 shortage of primary care doctors.

Lack of access comes in many forms - access to jobs; access to food, housing, social services, transportation; and access to medical care.

Where do Americans go to get acute medical care? According to a recent Health Affairs article,

• 42% go to a primary care physician

• 28% go to the emergency room

• 20% go to a specialist

• 7% go to an outpatient department

• 50% of the uninsured go to an emergency room, where ER doctors, 5% of all doctors, care for them.

Access problems contribute to rising medical costs.

• Dr. Richard Cooper, professor of medicine at the University of Pennsylvania, has shown the level of poverty directly correlates to soaring health costs. Medicare costs are higher in Mississippi, the poorest state, and in poverty-stricken inner cities.

• If you are unemployed and a family member becomes ill, you may not be able to afford a visit to the doctor, prescribed medications, or preventive services, thus delaying treatment, intensifying the illness, and raising costs when intervention becomes necessary.

• When you do receive care, you may have to return to a setting or a family where money is scarce, housing inadequate, conditions are unsanitary, transportation to medical facilities is unavailable, drug use is rampant, and help and advice to assure medical compliance is absent.

Most of these socioeconomic conditions are beyond the scope of medical practice. Doctors cannot control poverty, unemployment, health insurance, or the education of more doctors.

So what can doctors do? They have bills to pay, practices to maintain, creditors to satisfy. They can do more charitable work, they can offer discounts, they can spread out payments for medical bills, they can work more closely with social services.

They can volunteer for free clinics, such as those in North Carolina. North Carolina has 79 of these clinics, the most of any state, and there are 1200 across the United States. They can refer patients to any of 3000 community clinics, supported by the federal government and started by President Bush and supported by President Obama.

They can become aware of and financially support innovative organizations like Project Health, which has a new vision for American health care. Here is their vision.

“For low-income youth and families, traditional medical care is not sufficient to improve health outcomes. A prescription for antibiotics is not enough when there is no food at home. Poor health further entrenches families in poverty by jeopardizing educational attainment, economic stability, and life opportunities.”

“Founded in the Boston Medical Center Pediatrics Department in 1996, Project HEALTH's approach is simple but effective: We enable doctors to "prescribe" food, fuel assistance, housing, or other resources for their patients, just as they do medication. Patients take these prescriptions to our Family Help Desks in clinic waiting rooms, where our college volunteers "fill" them by connecting patients with these critical resources. Last year, Project HEALTH trained and mobilized nearly 600 college volunteers serving over 4,000 low-income patients and their families in Baltimore, Boston, Chicago, New York, Providence, and Washington, D.C.”

“Our impact is two-fold: Our Family Help Desks expand the capacity of clinics to connect their patients with the resources they need to be healthy. At the same time, by providing a transformative experience for our volunteer corps, we are producing a pipeline of new leaders with the skills, knowledge, and experience to bring about change in the health care system.”

Doctors can make a difference.


1.Stephen Pitts, et al, “Where Americans Get Acute Care,” Health Affairs, 29, No.9, 1620-1629, 2010.


3. Medinnovation blog, April 9, 2010, “Closing the Gap Between Poverty and Poor Health, An Interview with Rebecca Onie, Founder and CEO, Project Health

Thursday, September 16, 2010

Accountable Care Organizations (ACOs): California or Bust?

A brochure recently crossed my desk. The brochure announced on October 25 to 27 National Accountable Care Organization Congress will be held in Los Angeles.

All the big guns from Washington and the West Coast will be there to tout ACOs as ideal vehicles for health reform. The California Association of Physician Groups and the Integrated Health Care Organizations are sponsoring the event.

The brochure contains this language:

“ACOS provide a mechanism to transition from paying for value and intensity to paying for value. They are compatible with a range of other payment reforms to improve quality such as medical homes and bundled payments; they can help assure that these reforms lead to sustainable quality improvements and cost reductions.”

Why am I skeptical?

I suppose one reason is that I have been down the road before as a founder of the Physician Hospital Care Organization, later the Integrated Care Organization, in the 1990s, both now defunct because of mutual physician-hospital distrust and conflicting competitive goals.

Secondly, California’s business and health care climate, politically and in health care, are not representative of the U.S. as a whole.

Thirdly, California is a budgetary basket case, with a budget deficit of $20 billion.

Fourthly, I am dubious of the Congressional Business Offices estimate that ACOs will save $4.9 billion over 10 years through a limited pilot program.

I may be wrong, of course, but there is room for skepticism.

I am not alone. DCAPartners, a Philadelphia hospital consulting firm that seeks to align hospitals and doctors, sees two threats for hospitals in the AC0 movement.

Threat One, doctors may form ACOs on their own. If doctors succeed, hospital admissions will fall – and hospitals will not receive shared savings. ACOs would reduce hospital ancillary revenues. If hospitals choose not to participate, they may lose all of these revenues. Hospital=physician integration is not a given.

Threat Two, If hospitals choose to step away from ACOs, they may lose all of their primary care referral base. Competitors may lure away these doctors with negative effects on referrals. Primary care doctors may find ACOs attractive because they may provide them with doing things they want to do for patients, spending more time on patient education, and coordinating care with specialists.

So much for risks, now for rewards. Hospitals may want to seize the opportunity to form an ACO to attract doctors and reward the hospital to share savings, qualify for more Medicare reimbursements, and meet regulatory requirements.

For hospitals, whether to form an ACO comes down to how to motivate doctors to participate and to work with the hospital leaders.

For hospitals, one way around this is to hire doctors as employees so they will be obligated to support the ACO. This may already by happening. A current survey by indicates 79% of hospitals are hiring more physicians.

Chapter 10.Electronic Health Records

This is chapter 10 in my book Health Reform in Perspective.

Prologue: The Obama administration loves the idea that ubiquitous, interoperable, communicating, data-gathering electronic health records in every hospital and every doctor’s office, will save Medicare and health care by rationalizing care, minimizing error, and saving costs. It is not only an idea. It is a $27 billion bet.

EHR “Inevitability” and The Physician "Waiting Game"”

In a recent blog,”EHRs – Size of Physician Market, Number Sold, By Whom, and Comprehensiveness of Systems Sold,” I reprinted a report by Software Advice, Inc, on the state of the EHR market “without editorial comment.”

I shall make that comment now.

Perception of EHR “Inevitability”

The perception persists in all quarters that EHR adoption is inevitable. This perception assumes payers, government and private, health consumers, and the public at large will come to expect and demand EHRs as the standard of care and the exemplar of quality. IT technologies and HITECH information technologies, the theory goes, will dominate. The Internet will reign, and we will all dance to its tune.

But for now the world of EHRs remains split between the conceptual and impatient “true believers” and the behavioral, more patient “late adopters,” who are dragging their feet and playing the “waiting game.”

Among the powerful true believers are,

• Big Government, specifically the Obama administration, who placed $20 billion in the HITECH basket in its February 2009 stimulus package.

• Related government enterprises – The VA, the Department of Defense, Indian Health Services, Community Clinics – all of whom are committed, pledged, and destined to adopt EHRs.

• The EHR industry and its 300 vendors, who foresee and thirst for hundreds of thousands of new jobs, new products, new revenues and the makings of an even vaster enterprise.

• Integrated delivery systems, like Kaiser, who has already poured $3 billion into adopting system-wide interoperable EHRs.

• Large physician organizations and societies – like AAFP, CAP, MGMA, and AMGA – which are committed to EHR adoption by its members.

• IT Giants, like Google, GE, Intel, and Microsoft. Microsoft has been in EHR market for three years now, has three products on the market, and is rumored to be anticipating acquisitions of one or more EHR vendors.

• Young IT savvy physicians, reared on computers and inspired by YouTube, Facebook and Twitter and now I-Pad, who take EHRs as a given and who migrate to groups, hospitals, and other physician employers with existing EHR platforms.

• Organizations like Health 2.0, a consortium of consumer-oriented health IT companies and vendors, who see EHRs and Personal Health Records as transformers of the health care landscape.

The Waiting Game

These are powerful and formidable agents and forces for change but practicing doctors continue to exhibit caution and to play the waiting game. Despite a 6 to 8 year push by government IT aficionados, industry, and Internet gurus, only 1.5% of hospitals and 6% of doctors have “fully functional” EHRs. A full-fledged “interoperable” system remains a pipe-dream, albeit one that continues to evolve and promises to burst into full flower sometime soon.

Reasons to resist change are legend – high installation costs, training and maintenance expenses, drops in clinical productivity, disruption of practice patterns, altered doctor-patient relationships, and little or no return in investment. Understated, but tangible nevertheless, is the feeling that EHRs violate or compromise doctors and patient privacy and confidentiality or will be misused to the detriment of both. To doctors, these are real, and sometimes profound, reinforced by the recession, and calls for cautionary waiting. Waiting for further developments, most doctors believe, at least those on the mean practice streets, is safer than plunging into the maelstrom.

Hospitals, meanwhile, are experiencing lower admission rates, declining revenues, and difficulties accessing capital. Doctors too are having trouble acquiring capital for recruiting new physicians, meeting operating expenses, and dealing with demands for more information infrastructure. It should be no surprise, then, that the AMA and the AHA are saying forced digitization demands are “too much, too soon” and are pushing back against too fast and too much EHR adoption.

We are in a period of watchful waiting for further developments.

• Waiting to see if EHR costs will come down with competition.

• Waiting to see which EHR companies will survive.

• Waiting to see if new “free” EHR business models, such as Practice Fusion, Inc, where advertisers, not doctors, pay for installation and maintenance, are for real.

• Waiting to see if payers, government and private, will demand EHR adoption for participation.

• Waiting to see if hospitals will offer more financial and technical support for EHRs. .

• Waiting to see if EHRs are as good as promised in reducing errors and improving care – as good in concrete practice as in the abstract theory.

• Waiting so to see if EHRs become more user friendly and functional in clinical use.

• Waiting to see if benefits to insurers and patients outweigh the headaches to doctors.

• Waiting to see if physician transitions and adjustments to new business models – HSAs with high deductibles, cash-only models, concierge practices, hospital employment – offer escapes from having to climb the EHR learning curve.

And so, the EHR waiting game and merry-go round continues. How fast forward it goes, when and where it stops, grinds to halt, or plunges over the cliff to a new nirvana no one knows.

A New Yorker cartoon captures the dilemma of waiting for EHR inevitability. A group of cavemen are keeping count by making vertical slashes in groups of five on the wall and counting with their fingers. The caveman leader explains to a visitor at the mouth of the cave,” It will take longer than we thought to go digital.”
Practice Fusion, Inc - An Innovative Web-Based EHR

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

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

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

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

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

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

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

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

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

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

Small wonder, then, that Practice Fusion has grown rapidly and now has 30,000 users.

Here is how Ron Howard, CEO of Practice Fusion explains its acceptance.

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

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

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

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

Is Practice Fusion’s “Free” EHR for Real?

As I was writing three recent blogs, I kept pondering these questions: Is Practice Fusion, Inc, a San Francisco-based company offering a “free” EHR to physicians an example of “disruptive innovation”? After all, its EHR appears to be simpler, more convenient, more affordable, and intuitively easier to use than other EHRs– the criteria usually applied to disruptive innovations. Does it signal a “breakthrough” towards a decentralized technology deployable at the site of care? How can Practice Fusion offer its EHR for “free”? What triggered this “breakthrough”?

When all is said and done, I believe this “breakthrough,” if it is that, is not attributable to new EHR software or hardware, but to a new revenue model. Or you might say, it is a “fusion” of all three of these elements.

Here is how Ryan Howard, CEO of Practice Fusion, explains this model,

‘Our revenue model works in a few different ways. We monetize transactions from our partners. We do some lead generation. So if the doctors are looking for a billing service, for example, we have a billing service that they can use. We do some advertising to the physicians: different health care services, insurance companies, device manufactures and pharmaceuticals as well.”

If you think about it, Practice Fusion has adopted and modified the revenue model that has made Google so successful, namely gathering revenues from online advertising and lead generation tied to “free” access by users. It does not require physicians to install new hardware and software, but to off-load what they need in an EHR to the Internet using their existing office computers.

The beauty of it is, of course, is that you can use your own computer and somebody else – people and businesses who want access to physicians to sell them products – pays the freight for the EHR.

In other words, someone else, not physicians, is paying the bill. According to Howard,

“The product is provided to physicians fully subsidized. It’s not a “take now, pay later” or get half of the product now and then pays for the rest of it. Every feature that’s included with the product in any capacity is offered at no cost, so it’s truly free. It’s offered with support, training, and hosting. It’s the only totally free model on the market.”

Back to my recent posts for context.

• On May 22, in “Will Innovation Save America’s Health Care?” I wondered out load whether innovations from largely web-based technologies and systems would save us from Europe’s fate- the crushing cost and ensuing debt of unsustainable social welfare programs.

• On May 21, in “EHR ‘Inevitability’ and the Physician ‘Waiting Game,’“ I questioned whether EHR systems were ready for prime time, and I implied physicians were right in waiting for useful, affordable, and intuitively and clinical compatible systems.

• On May 20, in “EHRs – Size of Physician Market, Numbers Sold, By Whom, Comprehensiveness of Systems,” I reprinted an article by Chris Thorman of Software Advice, on the scope, players, and nature of the EHR market.

In the May 20 blog, I shared a chart showing EHR vendors and number of physician users.

Vendor Physician Users Practices Served

Epic 45,000
AllScripts 40,000
eClinicalWorks 40,000
GE Centricity 35,000
NextGen 35,000
SOAPWare 30,000
Practice Fusion 18,500
Eclipsys 11,000
Sage Health 10,000 .
Greenway Medical 6,000

On May 21, I received the following email from Emily Peters, Director of Communications for Practice Fusion,

“Hi Dr. Reece,

“I’ve been closely following your blog coverage this week about market share, innovation and Practice Fusion.”

“We do see some element of the “waiting game” that you described with physicians, but much less than even just six months ago. Practice Fusion now serves about 40,000 users and 2 million patients across the country – making us, not only the fastest growing EMR community, but also one of the largest. “

Before that on May 13, I had read a podcast interview with Ryan Howard, CEO of Practice Fusion, in which he said, “We just broke 15,000 users.”

I have no reason to question or challenge these physician user figures, which bespeak of explosive growth. But I can ask: how could one EHR company grow so fast?

Maybe it’s simply a matter of timing, namely, the physician market is primed and ready to get into the EHR game. Maybe it’s the marketing magic of the word “free.” Maybe it’s because Practice Fusion has the only “free” EHR on the market. Maybe it’s word getting around among physician users that this EHR really works. Maybe it’s because the Practice Fusion model profits physician users because it qualifies them as “meaningful users” and therefore qualifies them for federal reimbursement. Maybe it’s because most physicians now have broad band Internet access in their offices and can put this EHR to work in a short time frame without elaborate training and installation preparation.

Or maybe Practice Fusion is not what it’s cracked up to be and is too good to be true. There are no perfect systems in the EHR world, all are evolving, and there is always room for skepticism, or as one pessimistic wag with a weakness for puns observed, there is always gloom for improvement.

Perhaps readers of this blog will give me insight into what they think of Practice Fusion? Is it for real, or does it have blemishes that I do not see? Please feel free to comment one way or another.

“Meaningful Use” of EHRs: Clinical Useful or Data Boilerplate?

People who use the word “meaningful” put my mind of edge. They rings alarm bells in my head. When they utter “meaningful,” they usually convey the impression that what they have to say is socially significant. It captures the big picture, is beyond the pale of ordinary mortals, improves the lot of humankind, or, in the case of health reform, advances the overall cause.

That was how I reacted when I heard David Blumethal, MD, national coordinator for health information technology at the Department of Health and Human Services, announce the “The “Meaningful Use” Regulation for Electronic Health Records.” He did so with fanfare, “The widespread use of electronic health records (EHRs) in the United States is inevitable. EHRs will improve caregivers’ decisions and patients’ outcomes. Once patients experience the benefits of this technology, they will demand nothing less from their providers.”

Here is how the WSJ Health Blog announced the news,

“The final regulations — all 864 pages of them –on what will constitute “meaningful use” of electronic medical records are now here. And the changes they include make it easier for hospitals and doctors to qualify next year for the first round of incentive payments for adopting EMRs.

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

Rather than having to meet 23 or 25 different objectives (for hospitals and doctors respectively), providers will now have to meet just 14 or 15 “core” requirements dealing with EMR basics, such as being able to enter patient data and use a computer-based system to record medical orders.

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

Blumenthal lists these “core set” and “menu set” of meaningful objectives along criteria for payment by CMS.

Core set.

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

Menu set

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

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

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

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

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

• It does not mean, however, that clinicians will find EHRs as useful clinical information for communicating information. Many clinicians tell me that current EHRs are simply data boilerplate and do not convey why a patient was referred, contain narrative information on clinical status.

• It does not mean that this transition from paper to electronics will happen without pain.

Keep in mind that less than 10% of doctors and 5% of hospitals currently have fully functioning EHR systems, and many of these do not talk to each other.

Keep in mind that many doctors, especially those in small groups, or solo specialists, will opt to pay the penalty for non-use of EHRs.

Keep in mind that many doctors may drop Medicare and Medicaid patients rather than follow the CMS-Piper.

And keep in mind, that the $27 billion devoted to meaningful EHR use could turn into a massive federal boondoggle that neither patients or doctors appreciate.