The Media and the Physician Reform Message

In 1967 Marshall McLuhan and Quentin Fiore wrote The Media and The Massage (Bantam Books). McLuhan, the principal author, said it is often the media itself, not content, that transmits the meaning of most messages.

McLuhan frequently punned on the word “message,” by changing “message,” to “massage age, “ “mess age, “ and “massage.” In other words, depending on the media used, you can “massage” the “message” to mean what you want it to mean for a mass audience.

Think about this for a moment. The media is not impartial. The New York Times routinely “massages” its “message.” So does CNN, the Wall Street Journal, The New York Post, Fox News, MSNBC. ABC, and all those bloggers, left and right out there, including me.

My bias is to defend private practice and patients they serve.

No matter what your political leanings, the media has been reluctant to highlight the plight of private doctors, caught in the squeeze between declining revenues, rising expenses, high educational debts, the physician shortage, overwork, government penalties for noncompliance, malpractice threats, and reform uncertainties. Yet, amongst the media, little sympathy exists for reform’s impact on physicians.

Few media outlets recognize the stark reality that without private physicians to provide care, without adequate compensation to cover practice expenses to care for Medicare and Medicaid patients, health reform may be a sham – a delusion that federal entitlements to cover 34 million more citizens, and probably 50 million more through health exchanges, while cutting costs and redesigning the entire system, at one fell swoop, defies the laws of economic reality. Universal coverage without universal access to physicians is meaningless.

But that reality may be dawning. The vehicle for change is a thoughtful 110 page white paper, Health Reform and the Decline of Physician Private Practice, a collaboration between the Physicians Foundation, a 501C3 corporation representing physicians in state medical societies, and Merritt Hawkins, the nation’s largest physician recruiting firm. These physician advocacy organizations know their facts on the ground, and through careful studies and surveys, they have been monitoring and documenting how physicians are reacting and will react to the health reform law. The reality is that anywhere from 10% to 50% of private physicians may opt out of Medicaid and Medicare if Congress doesn't modify, "fix," or scrap scheduled Medicare SGR (Sustainable Growth Rate) cuts, which would lead to a massive physician access crisis.

National Public Radio (NPR), government subsidized outlet generally considered to be “liberal” by conservatives, broadcast this message on November 29. Message is in italics.

Doctors Blame New Health Law For Death Of Private Practice

Of all the scary scenarios predicted for the new health law this is among the scariest: A new survey of doctors predicts the rapid extinction of the private-practice physician.

A survey of some 2,400 MDs from around the country found nearly three quarters said they plan to retire, work part-time, stop taking new patients, become an employee, or seek a non-clinical position in the next one to three years.

But are these changes really the result of the new law?

Doctors responding to the survey seemed to think so. “Doctors strongly believe the law is not working like it needs to – for them, or for their patients,” said Lou Goodman, president of the Physicians’ Foundation, who conducted the survey.

But most of the provisions of the new law affecting doctors and patients haven’t taken effect yet.

And slightly more doctors said that the lack of a fix to the Medicare physician pay issue is a bigger issue for them than the actual overhaul; by 36 to 34 percent.
The paper that accompanied the survey says all those docs leaving their practices will be replaced by a managed care employee or “concierge” doctor who will require an upfront annual payment.

The bottom line, however, is buried at the bottom of the news release about the study. It comes from the advisory panel commissioned to write the paper on the effect of the new law on doctors:

Despite its many problems, healthcare reform was necessary and inevitable and many of the changes mandated by the ‘formal’ reforms likely would have occurred on their own within the ‘informal’ delivery of care, owing to economic and demographic forces.

In other words, things were changing anyway, with or without the passage of the Patient Protection and Affordable Care Act. Blaming the new law just gives doctors a convenient scapegoat.

Conclusion

Note the “massage” of the “message, ” particularly the use of the words “blame” and “scapegoat.” NPR implies that doctors are unfairly attacking government health reform for physician failures. In this era of “mess age,” I suppose everybody needs a “scapegoat.” With NPR, private physicians are the “scapegoat” and are to “blame.”

Doing Better and Feeling Worse: Why Aren't Doctors Feeling Better About the Future?

“ ‘Age and disease will be our next engine of growth,’ says Teresa Ghilarducci, a professor of economics at the New School. ‘That’s the really good news.’

As millions of baby boomers retire, she says, they will segue from their accumulation years into their spend-down years.

‘They’re going to be spending a lot on health care,’ Professor Ghilarducci said, ‘to forestall disease, to make themselves look younger. Low-end services, high-end services. CT scans, face lifts, bionic knees. We all think that health care is a high percent of gross domestic product now, but we ain’t seen nothing yet.’ “

But is it a good idea to nip, tuck and CT scan our way to prosperity? “

David Segal, “Economic Fix-Its,” New York Times, November 28, 2010

Why, if health care will be the next engine of growth and will consume ever more of the GDP, are doctors feeling so glum about the future? If you doubt how they feel, I invite you to read Health Reform and the Decline of Physician Private Practice (Merritt Hawkins. October 2010).

This feeling of dread is not new. In 1977, John Knowles, MD, a Massachusetts General internist who became the President of the Rockefeller Foundation, edited a book Doing Better and Feeling Worse: Health in the United States (W.W. Norton and Company).

The problem then, as now, was the system was doing better in improving health outcomes but doing worse in controlling costs, and many of the bad things, in both the economic and health realms, that happen to people were beyond the reach of medicine. The health system didn’t have all the answers.

To take a leading example, why can’t we contain demand and control health costs?

That, of course, is this year’s $2.7 trillion question.

According to Regina Herzlinger, PhD, a tenured professor at Harvard Business School, the problem is we don’t let consumers, spend their own money. pick their own providers, drive the system.(Who Killed Health Care? America’s $2 Trillion Medical Problem – and the Consumer-Driven Cure (McGraw Hill Companies, 2007).

Dr. Herzlinger identifies the five “killers” of a consumer-driven system as:

1. Health insurers, who insure the death of cost control through their dysfunctional culture.

2. General hospitals, which kill cost-control through their building of centralized. Ever-expanding empires of care.

3. Employers, who doom consumerism because they generally give their employees the “choice” of only one plan.

4. The U.S. Congress, who spur cost growth through lavish entitlement program riddled with fraud, abuse, and overuse.

5. Academics who contribute to the death of consumerism because of their elitist, technocratic, superior attitudes.

“Sadly, “comments Herzlinger, “on the federal government level, representatives from Republicans and Democrats have quaffed deeply form the Beltway Kool-Aid well. Neither believes in the power of innovators and consumers to reshape markets. Neither is in the-small-is-beautiful camp. Both believe the more oversight of health care by the government and academies is the solution. Both believe that big-is-beautiful.”

She goes on, “The federal government has not only specified what should be measured but also the protocols that health care providers must follow. These monopolistic powers are cloaked in the pseudoscientific mantle of ‘evidence-based.” The title implies that the guidelines are shaped by intelligent saints devoid of a shred of self-interest or vanity, guided only by ‘evidence’”

Small wonder doctors are glum. Everyone else, other than themselves and their patients, think they know what is best about the practice of medicine and the health care business. The health reform law effectively squelches health savings accounts which encourage consumers to shop for what they consider to be the best deal and doctors to compete for the consumers’ dollar. Rules and regulations forbid doctors to creatively re-design their practices and repackage their services. Medicare laws prohibit patients and doctors from privately contracting with each other. Prices keeps rising as regulations keep growing.

Medicine, it seems, is too important to be left to doctors and consumers. Trust us, is the mantra. We’re from the government and other large institutions, and only we know what is good for you and yur health.

Care, Cost, Access, and Health Reform

November 27 – This morning my good friend, Brian Klepper, an imminent health care analyst, sent me an email that said, in part,

“Later this week on Wednesday, 12/1, David Kibbe and I will launch a new health care professional forum called Care and Cost, which we hope will aggregate and showcase great HC writers of all persuasions and from all disciplines.

We’ve put some energy into designing the site and its characteristics. Among the things we’ll do:

• Categorize each post into major interest areas, so readers can easily find articles germane to their own work.

• Incorporate an area called “Urgent Science” that will run peer-reviewed, highly documented scientific review articles, aimed at giving practicing clinicians the basis for using new approaches.

• Run daily charts that say something interesting about what’s going on in health care.

• Provide occasional image galleries, by topic, suitable for presentations.”

David Kibbe, MD. MBA, and Brian Klepper, PhD, are long-time, trenchant commentators on health reform, innovation, new practice models, and medical homes. Their major concern. as I see it, is how to rationalize the system to bring costs into line while maintaining quality. They would like to do this before costs bring the system to its knees, and chaos ensues.

I do not always agree with their point of view – that practicing doctors, especially specialists, are the major drivers of cost, loose cannons that need to be reined in and that strict adherence to “best practices” will bring costs down dramatically – but I understand their logic.

I recommend readers visit their C&C site for their insights.

The big things that concern me about health reform are the cost implications of reform for physician supply, demand, and patient access. Reform will immediately add 16 million more people to Medicaid rolls (now 47 million or 19% of U.S. citizens) and potentially millions more as employers drop coverage, premiums escalate for existing plans, and word gets around that a massive new entitlement program is there to be had.

To me, the biggest question is: what will be the effect of reform on Medicare/Medicaid access? No one knows for sure. But a 2008 survey by The Physicians Foundation of 300,000 primary care physicians may hold some clues.
Here is how primary care physicians responded to three key survey questions.

1) Which, if any, of the following payers provide reimbursement that is less than your cost of providing care?

• Medicaid 65%
• Some HMO/PPO 43%
• Medicare 36%
• CHAMPUS 21%
• Some indemnity plans 14%
• SCHIP14%

2) Have cost/reimbursement or time issues in your practice compelled you to close your practice to any category of patient?

• Yes, 47%
• No, 53%

3) If yes, which types?

• Medicaid patients 34%
• Some HMO/managed care patients 30%
• Certain managed care companies 26%
• Indigent patients 16%
• Medicare patients 12%
• New patients 5%
• Other 4%
• Self pay patients, 4%

These figures were before the health reform bill passed in March 2010. In a 2010 Physician Foundation survey of 2600 randomly selected physicians of all specialties, 51% said they would close their practices to new Medicaid patients, and 30% indicated they would not accept new Medicare patients.

Low government reimbursements for Medicare and Medicaid do not bode well for expanded access, the primary purpose of health reform. Instead, limited access may be an unintended and paradoxical consequence of the health reform law.

Black Dog Thoughts on Black Friday

Today is Black Friday, the day after Thanksgiving.

For me it is a day of black thoughts on health reform, perhaps because I’ve been reading about Winston Churchill as seen through the eyes of his physician, Lord Moran. Churchill was subject to attacks of the Black Dog, bouts of depression. One black dog came in 1945, after Clement Attlee and the Socialists defeated him and the Tories. Churchill could not believe the English people turned him out after he had led England to victory after World War II.

Churchill did not believe in socialism - government policies dictating takeovers of private industries, wealth redistribution, and standardization, homogeneity, and uniformity of health care for all with equal benefits for all.

Socialism is utopianism, but it has flaws. So does capitalism. As Churchill so famously said, “The inherent vice of capitalism is the unequal sharing of blessings, the inherent vice of socialism is the equal sharing of miseries.”

This quote got me to thinking about problems of how one can standardize, homogenize, and make uniform the behavior of physicians, a notoriously independent lot who believe their clinical judgments surpass that of government or any clinical algorithm, protocol, or guideline. Perhaps one can erase regional and personal differences in care, but I am dubious.

The first problem is that government officials are not present at the site of the doctor-patient encounter. Remote bureaucrats, no matter how smart, cannot construct protocols covering every possible permutation and combination of clinical encounters subject to the whims of human behavior.

A second problem is that doctors, like patients, are infinitely variable. As a health care Pied Piper might say, doctors come in all varieties. There are big doctors, small doctors, lean doctors, brawny doctors, fat doctors, male doctors, female doctors, brown doctors, black doctors, white doctors, grave old plodders, gay young friskers, aggressive doctors, passive doctors, compulsive doctors, intuitive doctors, procedural doctors, cognitive doctors, entrepreneurial doctors, health system doctors, doctors that practice in bewilderingly different settings, each requiring different mindsets and skills.

To complicate matters further, there are solo and two practice doctors (47%), doctors in groups of 3-5 (15%), groups of 6-50 (32%), doctors in hospitals (13%), doctors in medical schools (7%). Doctors in groups of more than 50 (6%), doctors who work in HMOs (4%), and doctors who slave in community health clinics (3%)- each with different mindsets and views of the world. It becomes almost impossible to design an information system that fits them all, pleases them all, and ties them altogether.

It would make socialistic and managerial sense to herd all doctors into large groups or institutional settings that are "integrated" and "coordinated". That way you could put those free-thinking doctors on salary and make them follow rules of the organization and/or government mandates. It would make sense, too, I suppose, to stop all fee-for-service payments, the mode of reimbursement for most other professionals that invites over-use and rests of trust.

A third problem, and it's a whopper, is that America is a center-right individualist. freedom-loving nation that does not believe in centralized, collectivized government. Give me freedom, choice, and opportunity are our rallying cries.

A fourth problem, another whopper, is constructing a giant fail-safe bureaucracy with rules, regulations, protocols, and guidelines to cover every clinical eventualities and different physicians and patients personality types.

To do so, you would have to make myriads of payment, insurance, government changes, experimental demonstration programs to test your changes, and different government agencies to make sure the changes worked in real world. Given the infinite variety of human beings and their needs and vagaries, this new health system might look like this.

>YOUR NEW HEALTH CARE SYSTEM

PRESIDENT

INTERNAL REVENUE SERVICE

CONGRESS

SECRETARY OF HEALTH AND HUMAN SERVICES

ADMINISTRATOR OF CENTER OF MEDICARE AND MEDICAID SERVICES

NATIONAL COORDINATOR OF INFORMATION TECHNOLOGIES

NEW INSURANCE PROVISIONS, ADMINISTERED BY GOVERNMENT EXPERTS

NEW MEDICARE /PAYMENT PROVISIONS, ADVANCED BY ANOTHER SET OF TECHNOCRATS

NEW DEMONSTRATION/PILOT PROJECTS AND ADDITIONAL PROVISIONS, TOO NUMEROUS TO MENTION

NEW AGENCIES

• CENTERS OF MEDICARE AND MEDICAID INNOVATION

• INDEPENDENT MEDICAL ADVISORY BOARD

• PATIENT-CENTERED OUTCOME RESEARCH INSTITUTE


Patients - Doctors


Please note: Patients and doctors are in small print at the bottom of the bureaucratic pile. Wedged and buffered between them are, at last count, 159 different government agencies, boards, and panels. And that doesn’t count tens of thousands of government employees and 13,500 IRS agents required to implement and enforce the whole bundle and caboodle. Regulatory interpretations are piling up, along with regulatory burdens. Since ObamaCare and the Reconciliation Act were signed into law in March, there have been no fewer than twelve sets of additional regulations, guidelines, or notices that have been issued to lend clarification and at the same time add additional regulatory requirements.

Physician Foundation Grassroots Report

I would like to bring to your attention a remarkable document. It is a 110 page white paper Health Reform and the Decline of Physician Private Practice.

It is a grassroots report conducted on behalf of The Physicians Foundation by Merritt Hawkins, the nation’s largest physician recruiting firm. The Foundation is a nonpartisan, grant-making organization representing independent practicing physicians in state medical societies.

Why do I say the document is remarkable? Because it puts health reform in perspective. Amidst all the sound and fury about the health reform law, it tells what’s happening to physicians on the ground and where they are on that ground.

Where Doctors Practice

The document notes, for example, where doctors actually practice. To hear health reform critics talk, you would think most doctors do their work in large integrated groups or medical centers. Not so. Most of them hang out in solo or small to medium-sized groups.

• Solo, two physician practices, 32%

• Group practice, 3-5 doctors, 15%

• Group practices, 6-10 doctors, 19%

• Hospital-based, 13%

• Medical schools/university, 7%

• Group practice, 51+ doctors , 6%

• Group/Staff HMO, 4%

• Community health centers, 3%

What’s Happening at the Grassroots

The document observes that “informal reform,” socioeconomic trends and pressures on the ground, are just as important, perhaps even more so, than policies being dictated from Washington as embodied in the new health care law.

These trends and pressures include:

• The replacement of traditional independent practice by consolidated entities – hospital-doctor alliances, larger groups, and emerging models, such as accountable care organizations, medical homes, concierge practices, and community health centers.

• Legal and government pressures fostering and forcing an environment to “comply” with outside authorities and statutes and “improvement” and “compliance” measures.

• Increased demand for physician services in the face of growing physician shortages, especially of primary care doctors and general surgeons, with no relief in sight because of time required to mint new physicians.

• The “imperative to care for more patients, to provide higher perceived quality, at less costs, with increased reporting and tracking demands, in an environment of high potential liability and problematic reimbursement," Many physicians regard these imperatives as "mission improbable," or to use a word that runs through the report, as "problematic."


• The reluctance of Congress to include a “fix” for reasonable doctor Medicare pay, as embodied in the SGR formula, which indicates to physicians that Congress is not on the side of doctors, that health care is too important in the minds of politicians to be left to doctors, and that the viewpoint of doctors in likely to be ignored, further disengaging doctors from the profession and making access to them more difficult.

• Changes induced by reform, both “informal” and “formal” are inevitable and sometimes necessary, but do not bode well for increased coverage, quality, access, and private independent practice survival, which now and in the future, will be required for a high quality accessible health system.

Doctors, conveniently available on the ground and using individual clinical judgment rather than just marching to government mandates, are important, especially when you are sick and need their help.

A Physician Survey Shows Private Practice Decline and Disapproval of Health Reform

Today a booklet crossed my desk entitled Health Reform and the Decline of Physician Private Practice: A White Papers Examining the Effects of The Patient Protection and Affordable Care Act on Physician Practices in the United States. It contains a survey 0f 2600 randomly selected private physicians of various specialties from a cross-section of physicians across the country.

The survey makes for depressing reading.

Here are a few of the selected findings.

1) Are you in an independent, physician-owned practice or are you employed by a hospital, health system, or other entity?

Physician-owned practice 59%
Employed by hospital or other entity 41%

2) What was your initial reaction to passage of the 2010 Patient Protection and Affordable Care?

Very positive 12%
Somewhat positive 15%
Neutral 6%
Somewhat negative 15%
Very negative 52%

3) How do you now feel about health reform?

I am more positive than I was initially 10%
My feelings have not changed 51%
I am more negative than I was initially 39%

4) Do you believe the viewpoint of physicians was adequately represented in policy matters and the public during the run-up to passage of health reform?

Yes 14%
No 86%

5) How do you think reform will affect patient volume at your practice?

Patient volume will increase 54%
Patient volume will remain the same 35%
Patient volume will decrease 11%

6) Do you now have the time and resources to see additional patients in your practice while still maintaining quality of care?

Yes 31%
No 69%

7) How do you believe reform will affect the quality of care you are able to provide to your patients?

Improve 10%
No effect 19%
Diminish 56%
Unsure 15%

8) How do you believe health reform will affect the amount of time you are able to spend per patients?

I will be able to spend more time per patients 5%
There will be change in the amount of time I can spend per patient 24%
I will have less time per patients 59%
Unsure 24%

9) What effect do you believe reform will have on the financial viability of your practice?

Enhance 10%
No effect 9%
Diminish 68%
Unsure 13%

10) Health reform provides pilot projects to test “bundled (capitates) payments” for patients for episodic care. What is your view of bundled payments?

A generally good idea 11%
A generally bad idea 68%
Unsure 21%

11) Which is likely to have the greatest impact on your practice – health reform or a “fix” of Medicare’s Sustainable Growth Rare (SGR) formula?

Health reform 34%
SGR 36%
Unsure 30%

12) Do you believe reform will compel you to close or significantly restrict your practice to any category of patient?

Yes 60%
No 40%

What categories?

Close Significantly Restrict
Medicaid 51% 42%
Medicare 30% 57%
Indigent 43% 38%
Patients covered through exchanges 24% 44%
HMO 17% 42%
All new patients 5% 37%
Self-pay 10% 24%
Privately insured 5% 18%
Other 6% 9%

12) Consider your practice plans over the next three years as reform is phasing in. What do you plan to do?

Continue proctors as I am 26%
Cut back on hours 19%
Restore 16%
Switch to cash or concierge prate 16%
Relocate to another computer 14%
Work locum tenens 14%
Cut back on patents seen 12%
Seek a non-clinical job in health care 12%
Seek a job/business unrelated to health care 12%
Seek employment within a hospital 11%
Work 20 hours or less 8%
Close my practice to new patients 6%
Other 4%

13) How do you believe reform will affect the independent private practice?

Will enhance the viability of private practice 34%
Will have little or one affect on private practiced 36%
Will erode private practice 30%

14) Which best describes your view of independent, private practice?

It is a dinosaur soon to go extinct 28%
Is on shaky ground 58%
Is relatively robust and viable? 14%

Summary

Four of five physicians surveyed (2400 in all) believe that one of the consequences of health re4form will be the erosion of traditional independent private practice. 24% will continue to practice as is, but 74% will seek other forms of practice or employment or will retire. 65% of doctors have a somewhat negative or very negative attitude towards reform.

Conclusions

1) The majority of physicians responded unfavorably to passage of health reform.

2) The majority of physicians believe health reform will increase their patient loads while decreasing the financial viability of their practices.

3) The majority of physician plan to alter their practice patterns in ways they will reduce patient access to care, by retiring, working part-time or taking other steps.

4) Physician practice styles will be increasing less homogenous. The full-time, independent practitioners accepting third party payment will largely be supplanted by employed, part-time, locum tene4nes, and concierge practitioners.

For additional information about this survey, contact Phillip Miller of Merritt Hawkins and AMN Healthcare at 469-524-1400 or phil.miller@amnhealthcare.com

A Physician's Gratitude List

The USA remains mankind's last, best hope. Or, as former Secretary of State Madeleine Albright called it, America is "the indispensable nation."

Try to imagine the world without the United States. Who would nurture the universal longing for liberty? Who would guarantee the security of democracies and minorities around the globe? Who would sacrifice their own sons and daughters to liberate others?

Albright got it right: Our nation is indeed indispensable.

Michael Goodwin, “Giving Thanks to Our Nation, “ New York Post, November 24, 2010

This morning I awoke, depressed and gnarly.

My son, an aspiring Episcopalian priest, sensed my mood. He said, “Dad, make a gratitude list. It will make you feel better, and it will put things in perspective.”

Sure enough, it did. Here’s my list.

I am grateful I live in a country where,

• People can disagree disagreeably about the health reform law, but without riots, strikes, or violence.

• Voters can feel free to express their opinions about the health reform law - 48% favored repeal, 47% want it strengthened or left as it.

• The latest Gallup poll indicates 82% of people are satisfied with their health care. That's not 100%, but it is impressive.

• Few citizens choose to go abroad to seek better care.

• Every citizen who goes to an emergency room will be treated no matter what his or her financial circumstances.

• No matter where you live in the U.S., most citizens have quick or immediate access to the best medicine and technologies has to offer without government oversight, second guessing, or rationing. This is not true in most other countries.

• We provide such exceptional care that kings and potentates come here for treatment (The King of Saudia Arabia is now at Cornell to get a herniated disc fixed), and doctors come here from around the world to learn, to train, to practice, and to benefit from our research.

• We listen to the voices of the people when the majority protest a sweeping health reform law they fear will cost them their current coverage and access to doctors.

• We cover 110 million of our 310 million citizens through costly Medicare and Medicaid programs and pay for ½ of all health care costs, an expense per capita above that of other nations.

• Our political system allows us to engage in a lengthy, sometimes acrimonious debate, on what is the right thing to do in the long run to provide the best care for most of the people most of the time.

• As a country, we believe in individualism and choice, in government care as well as private care, in the independence of physicians to choose their specialty, where they want to live, and to provide care they think is best for patients based on individual human judgment rather than bureaucratic rules .

• We are a society that prides itself in our generosity to help others around the world , in our innovations that make us the Internet crossroads of health information of the world, the fountainhead of many advanced medical technologies- in genomics, cancer therapy, life-saving and life-style restoring procedures, our imaging technologies; and in vibrant entrepreneurialism in multiple health care spheres, a spin-off of free markets in a capitalistic society.

I am proud to be an American physician, living in America.

What If The Supreme Court Were to Rule Health Reform Law's Individual Mandate Unconstitutional?

If that were to happen, an unlikely possibility, the current health reform law would collapse like a House of Cards. No pun intended. But the pun could be relevant since the newly elected House of Representatives has vowed to repeal the reform law. The new House will fold Obamacare if it can.

But what then? What would the House have to offer to replace the health reform law? What concrete proposals would the new House have to cover those 32 million now proposed to be covered by reform law? How would the House address problems on covering those with pre-existing disease, young people up 26 covered under their parents’ plans, seniors with unaffordable drug bills in the Donut Hole, those with life-time expense limits?

It is not enough to be a naysayer about the Accountable Care Act, the preferred euphemism for Obamacare. Richard Amerling, MD, a Director of the Association of American Physicians and Surgeons and author of the Physicians Declaration of Independence from the federal government, offers this “Conservative Way Forward on Health Care” (November 22, 2010, The Health Care Blog).

1. Transfer the tax deduction for health care spending from employers to individuals. This would end the absurdity of purchasing health insurance at the "company store," a practice that limits individual choice and liberty, nourishes a sense of dependency, and promotes overuse of care. This policy, an accident of WW II wage and price controls, was the “original sin” in health care financing; doing away with it would empower consumers to shop for the best plan for their families, which will lower premiums.

2. Remove barriers to the interstate sale of health insurance. There is broad agreement on this proposition. It would increase choice and competition between insurers and drive down premiums by effectively ending state mandates that drive them up.

3. Deregulate and allow greater contributions to Health Savings Accounts. These fabulous tax shelters give individuals more control over their health spending, and, coupled with an inexpensive policy to cover catastrophic illness (i.e., true insurance), are all most people need. By returning most health care purchasing decisions to consumers, spending will immediately be slowed and prices curbed. This is the conservative, free market, already tested and proven way to "bend the cost curve down."

4. Follow the recommendations of the bipartisan Breaux Commission and give Medicare beneficiaries a means-tested stipend to buy private insurance. This solution came during the Clinton era but was too free-market to pass muster with Bill and Hillary. With Medicare moments from insolvency, there should again be a bipartisan consensus to reform this behemoth.

5. Transfer (gradually) all Medicaid responsibility to the states. Federal support for Medicaid allows much greater spending than would otherwise occur. It forces frugal states to subsidize lavish coverage in New York, California, and elsewhere. States should have complete freedom to organize their Medicaid systems along their own priorities, in exchange for losing, over perhaps five years, the federal subsidy. This would encourage states to find innovative ways of providing health insurance for the poor, such as individual health accounts, or subsidies to buy private insurance.
The latter two points would allow the mammoth Center for Medicare and Medicaid Services to be mothballed, though Medicare could retain a role as insurer of last resort for those with pre-existing, expensive, chronic diseases.

6. Institute a "loser pays" system for medical malpractice to cut frivolous lawsuits. The ability to launch a lawsuit (and this applies beyond medical malpractice) with minimal financial risk is the reason behind the explosion of malpractice litigation, with all the associated costs. Tort reform at the federal level would require the Senate to override the trial lawyers’ veto, which could be a problem. This reform should be pushed at the state level.

7. Finally, for true patient protection, let's propose a constitutional amendment to guarantee the individual's right to privately contract for medical care. This will eliminate for all time the threat to the private practice of medicine and assure that, no matter what system is in place, patients will always be allowed to spend their own money on care.

Amerling’s list represents a conservative point of view. Obama supporters will insist , no doubt, that his list fails to address the “moral imperative” of universal coverage, guaranteed by a compassionate government.

“Progressive” solutions” for health reform as dictated from above have a wonderful theoretical ring to them, require “demonstration projects” to prove, but have yet to work on a broad scale in the “real world.”

These solutions, which are heavy on government oversight, include:

• "Mandatory Health Information Technology" (HIT), as dictated by Washington.

• "Comparative Effectiveness Research" (CER), that will dictate to physicians what they may and may not do.

• "Pay-For-Performance" (P4P) incentives, that will provide the enforcement for CER compliance.

• "Chronic Disease Management," (CDM), to intervene with patients with chronic conditions, and

• "Accountable Care Organizations" (ACOs), that will pull all of this together into a single organizational structure.

HIT, CER, P4P, CDM, ACO. Those are the acronyms that will be pondered, weighed, debated, and dissected in the Congressional hearings about to be held in the House of Representatives to see if they lower costs and raise quality. The debate will not close the yawning ideological gap between conservatives and liberals.

Health Reform and SNACU (Situation Normal All Costs Up)

A reader challenged me to come up with magic acronym to explain the evolution of the health system under the new health reform law. SNAFU (Situation Normal All Fouled Up) has been taken, so I came up with SNACU(Situation Normal All Costs Up). SNACU helps to explain why health costs are up 7.4%, 7 times the rate of general inflation, since Obamacare’s passage eight months ago.

SNACU is not the fault of the health reform law.It all comes down to human nature. Health care participants, in my opinion, are not “good” or “bad.” They live by their wits. They do what it takes to survive and thrive. They act in their own self-interests, which they believe, advance the general interests of society.

Unfortunately, with health care, SNACU drives most costs up. With health care, most SNACU phenomenon are carried out in the name of “progress,” meaning most players think their efforts are done at the cutting edge of medical progress.

Here are four SNACU phenomenon.

• One, Medical Technologies. Technological advances account for 70% of health care inflation. These advances include such things at imaging tests (CT, MRI, and PET scans, life-style restoring procedures (hip and knee replacements), and life-saving life technologies (bypasses, stents, dialysis). Innovators say “Disruptive Innovations” - - innovations performed cheaper, more conveniently, by less sophisticated personnel – will drive costs down, but so far costs are still climbing at 7% a year, versus 1% for general inflation.

• Two, Information Technologies. Here I’m talking about EMRs, EHRs, and PHRs, those wondrous record keeping devices, those remote electronic monitors, either visual or implantable, and the Internet as an all purpose source of consumer information. For individual doctors, EMTs will take $40,000 to $60,000 per doctor to install and implement, and $27 billion out of the federal treasury. Will these technologies save money? Only GODs (Generally Optimistic Developers) of IT systems know, but so far only 20% of practicing physicians and less than 5% of hospitals have fully-functioning EMRs.


• Three, Consolidation and Integration of Health Systems – Today’s buzz phrase for these systems is “accountable care organizations, “ which supposedly will coordinate care and reduce duplications across real and virtual organizations and save money in the process. Whether costs of creating these organizations with their attendant administrative bureaucracies will exceed cost saved remains doubtful.

• Four, Managed Care Administered by a small core of administrative technocratic experts centered inside the Washington, D.C. Beltway. This describes the thrust of the health reform bill and of Dr. Donald Berwick, the Administrator of Medicare and Medicaid Services. The effort will require over 150 new federal agencies, a vast new bureaucracy with 100,000 or more new federal employees, 13,500 IRS agents, and 50 new state level health exchanges to create and enforce federal mandates at a cost of roughly $2.5 trillion from 2014 to 2023.

SNACU, regrettably, is closely related to another phenomenon, SNEDWIT (Situation Normal Everybody Does What It Takes). People in the health care industry will do what it takes to remain financially viable, even if what they feel what they have to do costs more money and displeases health reform advocates. Oh, what a tangled web we weave when the health system we seek to reform and cost reductions we strive to achieve.

The Obama Administration in Clashes All By Itself over Accountable Care Organizations: Has Government Created A Cost-Raising Monster?

When Congress passed the health care law, it envisioned doctors and hospitals joining forces, coordinating care and holding down costs, with the prospect of earning government bonuses for controlling costs.

Robert Pear, “Consumer Risks Fearing as Health Law Spurs Mergers, “New York Times, November 21, 2010

Doctors interested in creating Accountable Care Organizations (ACOs) with hospitals should be aware of legal and regulatory obstacles.

One, regulations for forming these organizations are just being written.

Two, federal agencies - the FTC, the Justice Department, and the Inspector General – have laws forbidding monopolistic behavior by dominate systems of hospital and doctors, and fraud, and abuse practices that dominant ACOs may foster.

In many ways, the federal government has created a series of clashes it must resolve before ACOs become functional. It will require a bevy of lawyers and lobbyists to change existing laws to resolve these clashes. Doctors and hospitals should be prepared to pay hefty legal bills to make sure their ACOs pass legal muster.

Clash Number One – Under the Guise of ACOs, Big Hospital Systems Can Consolidate and Conquer Regional Markets, Raising Rather Than Lowering Prices

In its rush and push to get hospitals and doctors to cooperate, improve care, and save money through accountable care organizations, the health reform law has created incentives for hospitals and doctors to form dominant health systems. These systems will have the clout and incentives to negotiate higher prices with private plans while stinting on care of Medicare patients. The big systems can pursue a “consolidate and conquer strategy.”

Elizabeth Gilbertson, a union health plan for hotel and restaurant employees, observes,

“In some markets, the dominant hospital is like the sun at the center of the solar system. It owns physician groups, surgery centers, labs and pharmacies. Accountable care organizations bring more planets into the system and strengthen the bonds between them, making the whole entity more powerful, with a commensurate ability to raise prices.”

Private health plans, then, will “have” to deal with “must have” systems as the only option in any given market. The plans cannot effectively negotiate lower costs with prestigious monopoly hospital systems, already the case in markets like San Francisco, Baltimore, Milwaukee, and Boston.

Clash Number Two – Federal Agencies Must Enforce Anti-Trust, Fraud, and Abuse Laws Yet Waiving These Laws Are Necessary to Form ACOs.

Lawyers and lobbyists from hospitals and doctor groups are pressuring the FTC, the Justice Department, and the Inspector General’s Office to relax or waive the laws forbidding monopolistic behavior by hospital systems. Eight months into the new law, a wave of mergers between hospitals, between hospitals and doctor groups is well underway, eager to save share costs and savings and cash in on the incentives. The risk for consumers is that dominant hospital systems will exercise their market clout to raise prices.

Clash Number Three - Incentives for ACOs May Be to Stint on Care for Medicare Patients, Which the Law is Supposed to Protect

The new law cuts over $500 billion out of Medicare. Many hospitals already lose money on Medicare patients, and margins are low for the rest. The incentives therefore may be to raise prices on private patients and while lowering costs of care for the sick elderly. Consumer groups are alarmed. They fear Medicare patients and others with disabilities or chronic disease that requires specialized or complex care may have trouble getting access to medical devices and rehabilitation facilities.

The Obama administration must balance potential benefits of clinical cooperation against the need to enforce fraud, abuse, and antitrust laws.

Health Reform is Waivering

1. Giving up something voluntarily, especially a right or claim; 2) Not enforcing something, to refrain from enforcing something in a particular instance; 3) Temporarily delaying something to put off something for a time.

Dictionary Definition of “Waivering”

There’s a new health reform game: waivering to escape fetters of the health reform law. Rather than accepting adverse consequences of the law, people and organizations are waiving the white flag. Because of their particular circumstances, they are insisting that they cannot afford the new law, that it does not apply to them. They want to get out while the getting is good.

The Republican party wants to waive out of the whole bill. They pledge to repeal and replace it with an incremental bill of their own. Given the inevitability of an Obama veto, this is probably a fruitless and futile partisan exercise. Nevertheless, it is fascinating process to watch.

Businesses with hundreds of thousands of young healthy employees who receive limited minimed policies want out because they claim they cannot afford comprehensive policies that meet new federal standards. Among these businesses are McDonald’s, Olive Garden, Red Lobster, and Jack in the Box, and countless other fast food franchises and retail establishments with young employees.

Then there are the unions seeking to escape the health care mandate’s onerous “Cadillac tax" on high-cost health plans. These unions are the bedrock of the Democratic base. Falling into this category are,

-- The Service Employees Benefit Fund
-- United Food and Commercial Workers Allied Trade Health and Welfare Trust Fund
-- International Brotherhood of Electrical Workers Union No. 915
-- Asbestos Workers Local 53 Welfare Fund
-- Employees Security Fund
-- Plumbers and Pipefitters Local 123 Welfare Fund
-- United Food and Commercial Workers Local 227
-- United Food and Commercial Workers Local 455 (Maximus)
-- United Food and Commercial Workers Local 1262
-- Musicians Health Fund Local 802
-- Hospitality Benefit Fund Local 17
-- Transport Workers Union
-- United Federation of Teachers Welfare Fund
-- International Union of Painters and Allied Trades (AFL-CIO)
-- International Longshoremen's Association (ILA)

Even Democratic politicians who supported the law are joining the movement, They too are waiving the white flag. These include liberal senator Ron Wyden of Oregon and Democratic senator Ben Nelson of Nebraska, of Cornhusker Kickback fame. They are waivering over such issues as individual mandates and 1099 reporting requirements for small businesses.

Republican governors, like Tim Pawlenty of Minnesota and Scott Walker of Wisconsin, are also waivering. They are insisting they will either slow, block, or waive the establishment of health exchanges in their states because their budgets cannot afford these exchanges. All told, as many as 28 state governments may join the suit to declare the health law's individual mandate unconstitutional.

Everybody, it seems, is doing what they have to do to survive the financial and bureaucratic waiveward consequences of the new health law. Even doctors, faced with draconian Medicare cuts and waves of new Medicaid patients, are threatening to waiver. Nearly half are saying they will no longer accept, or will reduce services for Medicare patients , or will retire or switch to non-clinical careers, or go into concierge practices rather than practice under oppressive government overhaul rules.

The bottom-line? The U.S. Department of Health and Human Services website says 111 waivers have now been granted to companies, unions and other organizations of all sizes who offer affordable health insurance or prescription drug coverage with limited benefits. Will hundreds of waivers become thousands? Will Americans refuse to accept the over-reaching government concept that one-size-fits-all?

The final waiver, of course, would be to repeal the whole thing. Maybe that will not be necessary if enough people and organizations, left and right, beg for waivers for protection on the basis of unaffordable costs stemming from the Patient Protection and Affordability Act. That would be the ultimate irony.

Grassroots Report - Impact of Health Reform on Private Practice Physicians

Among national physician advocacy organizations, none have been more effective than the Physicians Foundation, a non-partisan, charitable non-profit, grant-making organization, in telling the story of how health reform will affect grassroots physicians in private practice and their patients. This is an important story. These physicians provide 70% to 80% of care in the United States.

Surveys and White Papers

The Physicians Foundation has commissioned a series of surveys and white papers that present compelling evidence that:

• One, primary care physicians are suffering from low morale and overwork.

• Two, high costs and regional differences are directly correlated with poverty.

• Three, a huge influx of new Medicare and Medicaid patients may create a physician access crisis.

• Four, health reform may signal the end of private practice.

Latest Report’s Chilling Prediction

In conjunction with Merritt Hawkins, the nation’s largest search and consulting firm, the Physicians Foundation has issued a chilling press release. It bears the ominous title “Report: Health Reform Spells the End of Private Practice Physicians: 74% of Physicians Will Retire, Work Part-Time, and Or Seek Other Alternatives.”

The Report, entitled “Health Reform and the Decline of Private Practice,” examines potential impacts of the Patient Protection and Affordable Care Act on medical practice in the United States.

Lou Goodman, PhD, president of the Physicians’ Foundation, concludes, "The private practice physician is rapidly disappearing. Both market forces and the health reform law are forcing physicians to find new ways of running a practice. We are extremely concerned about how this will affect patient care.”

Four Likely Physician Career Paths

The report says physicians are likely to follow one of four new career paths.

They will either work as employees of increasing larger medical groups or hospital systems, establish cash-only practices without third part payers, reduce their clinical roles by working part-time, or leave medicine by accepting non-clinical positions or retiring.


The report includes case studies of new practice models --- medical homes, accountable care organizations, concierge practices, community health centers, and small, hospital aligned practices.

A National Survey

Finally the report announces results of a national survey to which 2,400 physicians responded. Only 26% of those surveyed said they would continue to practice as they have in the past over the next one to three years. The remaining 74% surveyed said they would retire, work part-time, close their practices to new patients, become employed, or seek non-clinical jobs.

The white paper predicts health reform will accelerate the existing physician shortage and make it more difficult for patients to find a physician. The purpose of the report is not to undermine health reform but to point out how its provisions will affect conditions at the grassroots of the delivery system.

Protecting the Patient-Physician Relationship

Walker Ray, MD, Research Committee Chair for the Physicians Foundation, commented, “For the sake of all Americans, it is critical that we find ways to protect the patient-physician relationship and make sure that no outside forces are interfering with clinical decision making.”

For more information: contact Phil Miller, 469-524-1420/phil.miller@amnhealthcare.com, and visit the Physicians Foundation website, PhysiciansFoundation.org.

Richard L. Reece, MD, of Old Saybrook, Connecticut, blogs at Medinnovation and is author of two recent books, Obama, Doctors, and Health Reform and Innovation-Driven Health Care, He works closely with The Physicians Foundation, a 501-C3 organization representing 700,000 physicians in state medical societies that issues grants to physician organizations to improve care. He can be reached at rreece1500@aol.com or 860-395-1501

Perfect Reform Storm: Impact on Physicians and Patients

In 1997, Sebastian Junger, an author and journalist, wrote the best seller, The Perfect Storm, later a movie. The book told the story of fisherman off the New England Coast trapped by three converging weather systems.

Three Weather Systems

• Warm air from a low pressure system coming from one direction.

• Cool, dry air generated by a high pressure system coming from another direction.

• Tropical moisture provided by Hurricane Grace.

An Analogy

This is a good analogy for today’s perfect political health reform storm.

• Warm air, suddenly heating up as evidenced by the midterm elections, from a low pressure system coming from outside the Beltway, with conservative Americans calling for smaller government, less interference in their lives, lower taxes, less spending, less debt, and “taking our government back.”

• Cool, dry air provided by a high pressure, dispassionate, scientific, management-oriented Washington insider elites speaking in cool, dry terms about the need for a rational restructuring of the whole system from above.

• Tropical moisture (both sides claim the other side is all wet) producing a hurricane of opinionated bilateral rhetoric speaking in apoplectic and apocalyptic terms about the abyss that lies ahead if their respective opinions do not prevail.

Caught in the Middle

Caught in the middle of this perfect reform storm are physicians and patients who fear the worst, who feel they have no reform voice and no control over impending colliding weather systems.

• On the one hand, American health consumers have high expectations, fueled by the high tech performance of the current system, and the promise of a new entitlement system providing more care at lower costs. They expect the best medicine has to offer at more “affordable” price. These twin expectations are central elements of the perfect storm.

• On the other hand, a centralized government is saying the whole system must be overhauled and restructured, and physicians must offer less costly care under a system of expensive regulations with which they must comply at lower reimbursement rates without protection from tort reform.


• On the third hand, sometimes called the third or the center-right way, there may be a middle way out the storm, through disruptive innovations using cheaper care at decentralized locations, like the home, provided by less sophisticated personnel using electronic , and downsizing of the whole medical enterprise.

Time Not on Side of Those in The Boat

The problem with all of these scenarios is that with an imminent perfect storm, time is not on your side, the reckoning is at hand, and physicians in the boat with patients, must cope with the consequences – the impact of the perfect storm on their professional and personal lives.

Hospital "Facility Fees "- Why Hospital Ownership of Doctor Practices May Drive Up Costs

I am hesitant to accept the notion that hospital-doctor consolidation into accountable care organizations will reduce health costs. As you may be aware, the new health care law is vigorously pushing the idea of accountable care organizations, wherein hospitals and doctors will collaborate to save money by integrating and coordinating care and avoiding duplication. Presumably the money “saved”will then by shared by the hospital and doctors.

This sounds like a lovely scenario of saving money except for three things.

One, as a pointed out in a previous blog, “The Hospital-Doctor Hiring Wave,” hospitals are hiring physicians and acquiring physician practices in record numbers.

Two, hospitals fees are invariably higher than fees charged by independently owned physician practices in outpatient settings.

Three, because of something called the “Facility Fee,” a previously obscure Medicare arrangement, hospitals can tack on a fee of hundreds of dollars when the hospitals “owns” the facility, whether that facility is inside the hospital or outside the hospital.

When patients visit some doctors' offices and urgent-care clinics, they're increasingly running into something unexpected: billing as though they had gone to a hospital.

The fees, which sometimes amount to hundreds of dollars, occur when hospitals own physician practices, urgent-care centers and other operations. Patients visiting an urgent-care clinic, for example, may unexpectedly get billed as if they visited a hospital emergency room. This usually comes as an unpleasant surprise.

Doctors' offices in clinics owned by hospitals, besides billing for the physician's work, are now tacking on this "facility fee," an additional charge hospitals usually impose when procedures are done on their premises. Even for insured patients, such additional charges can drive up out-of-pocket costs.

Consumers around the country, and health plans, are complaining about separate, unexpected facility fees, based on hospital ownership of previously independent physician owned practices. Consumer advocates across the country say patients increasingly are being charged the fees, the result of an obscure change in Medicare rules that took place nearly a decade ago.

Called "provider-based billing," this Medicare rule allows hospitals that own physician practices and outpatient clinics that meet certain federal requirements to bill separately for the facility as well as for physician services. Because hospitals that bill Medicare beneficiaries this way must do so for all other patients, facility fees affect patients of all ages. Doctors' offices owned by physicians and freestanding clinics are not permitted to charge the fee.

The ability to charge a “facility fee” is causing hospitals and their lawyers to take some unusual and creative measures to justify charging the fee. As a cardiologist’s office, for example, a room was walled off with a separate entrance for doing diagnostic stress tests and nuclear scans so that patients could enter the “hospital owned facility” rather than the doctor’s office.

What will hospitals think of next to "facilitate the facility fee"? "Facilitating the Facility Fee." That has a nice cash register ring to it.

Resolving Hospital-Physician Conflicts

Given the systematic scheduled fee reductions for hospitals and physicians under the new health reform law, more hospital-physician conflicts are inevitable.

Reason?

Hospitals and physicians desperately need each other, yet they compete. As someone observed, “Without doctors, hospitals are simply buildings with bad food.” It doesn’t take a rocket scientist to know this is a formula for conflict and complex negotiations.

This problem came to mind as I was reading a newspaper piece about a dispute between a hospital CEO and his Board of Directors. Eight of the 12 directors were members of the medical staff. Many of the doctors were demoralized by changes in the health care system.

What struck me about the newspaper article was the complexity of the hospital-doctor arrangements and the various special interests of the physicians.

These special physician business interests included.

• Hospitalists, employed by the hospital to take care of admitted patients.

• Private practice doctors with exclusive hospital contracts.

• A hospital network of dozens of primary care doctors and specialists who work out of their offices, created to relieve doctors of administrative doctors.

• Independent doctors who want to keep their private practices and administer their own business functions and who seek to be consulted about hospital plans.

According to the president of the medical staff, “A lot of physicians are scared right now. The health care economy is changing, and people are trying to figure out where they fit in.”

This anxiety brings to mind an interview I conducted back in 1999 for The Physician Executive with Leonard Marcus, PhD, Director of the Program for Healthcare Negotiation with Conflict Resolution at the Harvard School of Public Health. Marcus had just published a book Renegotiating Health Care: Resolving Conflict to Build Collaboration (Jossey-Bass, 1999).

I recommend readers of this blog engaged in conflicts between hospitals and doctors buy a copy of the book in order to understand the nature of these complex conflicts and how to move beyond them.

Marcus asks, “What if this complex puzzle does not fit smoothly together? What is there are differences about what and who is more important? What if a mistake occurs? What is there is a clash of personalities among people who must closely interrelate? What is there is dissonance between the policies and procedures defining these relationships? What if people are working under different incentives? How will this affect what do and how we do it?”
What if and how? You may need a mediator to resolve the conflicts and build collaboration.

The Health Reform Storm

November 14 - Recently, on November 9 to be precise, I wrote a well-received blog about America medicine’s exceptionalism.

I cited the excellence of our academic centers, our mastery of the English language, and our dominance as Internet innovators.

Part of my blog rested on my experience as a member of the Board of Advisors of Castle Connolly Medical Ltd, a New York City company that, among other things, picks the nation’s top doctors and publicizes their achievements in regional magazines and newspapers. Just yesterday, Castle Connolly ran two full page ads in the New York Times featuring 64 top doctors in the New York City region. Doctors did not pay for the ad. The hospitals on which the doctors served on their medical staffs did. This ad was positive in that hospitals were using their marketing power to advertise the merits of their medical staff members, something doctors are reluctant to do for themselves.

Accentuate the Positive

In writing the blog, I thought it was time to be optimistic, to cite our accomplishments and the excellence of our system, rather than to feel defensive social factors beyond our control – the uninsured, lack of social services, drug and substance abuse, domestic violence, infant mortality, and poverty.

These factors drive up costs, but occur outside doctors’ offices and hospitals. Although it is not politically correct to say so, reforming our health care system also involves reforming our culture. This is not easy in a country that cherishes individualism, choice of doctors and hospitals, and demand to access to high tech medicine.

Instead, it was time to stress the positives of American medicine - our high survival rates for chronic disease, our plunging death rates for health disease and stroke, our life saving and life style changing technologies.

It was time to note that 85% of patients are satisfied with their current health plans, and most are pleased with their doctors.

The Coming Reform Storm and the Present Situation

Congress is now in the lull before the real health reform storm. The debate will involve hand-to-hand combat, it will not be pretty, and it is unlikely either party will give much ground.

Tomorrow the lame duck Congress goes into session. The newly elected House members are sworn in. White House, Senate, and House leaders will begin to strategize in earnest on how to defend or repeal the health reform law at the start of the New Year.

The setting for the coming Great Debate is familiar to everyone . Democrats lost 61 seats in the House and six seats in the Senate. More Americans opposed the health care overhaul than supported it. Exit polls indicated health care repeal was the second-most important issue for voters, after jobs and the economy.

A Kaiser Family Foundation Health Tracking Poll released the week following the election reported that just 25 percent of respondents believed they and their families would be better off under the law. Democratic candidates spent more than three times as much touting their opposition to the law as advertising their support. Republican Governor victories at the state level will make implementing the law more difficult.

Under these circumstances, what can physicians do to make themselves more respected and more prominent players in the health care debate, and to make the system better?

Here are a few suggestions.
• Pound on the theme that America has the most exceptional health system in the world, the best acute care, the most advanced technologies, the highest cure rates among those with chronic and rare diseases, and the quickest access to high tech care.

• Point out the world looks to the U.S. for medical leadership and innovation. That is why doctors from around the world come to the U.S. for advanced training, and why patients come here for treatment.


• Take pride in the fact that our entrepreneurial market-driven system offers freedom of choice between government and private sources of care and produces greater quality of care with greater amenities. We should be proud we are a free-market , center-right nation that attracts immigrants and doctors from around the world.

• Stress the realities and magnitude of the doctor and hospital bed shortage. We have fewer doctors per capita and few hospital beds per capita than any other developed nations, and a greater and growing shortage of primary care physicians. The addition of millions of more citizens under federal entitlement programs could easily overwhelm our system , produce long waiting lines, and create an access crisis.

• Show imagination by initiating by supporting and participating in programs that correct deficiencies of our current health system. These deficiencies include plugging “holes” in our social safety net, recruiting college volunteers to help needy families find access to food stamps, housing, medical transportation, medical mentoring, and job training. The Physicians Foundation, a nonprofit physician organization, is leading the way by issuing a funding grant to Project Health, a nonprofit that has mobilized college volunteers to serve at Help Desks in pediatric settings to offer help to families of sick children in seven major cities.

Virtual Immigration Fence Failure – A Lesson for Medicine?

As Americans, we believe “virtual surveillance” techniques, drones over Pakistan, orbiting spy satellites, cameras on street corners and in stores, telemonitoring of patients with chronic disease with implanted sensors, e-ordering systems to control utilization of high tech medical technologies, virtual integration of doctors and hospitals to reduce care fragmentation – will make us more secure and healthier.

This may be, but we need to understand better what’s taking place on both sides of the technology fence.

The Technosphere Versus Boots on the Ground

Technologies, no matter how sophisticated, can never replace boots on the ground, humans on the frontlines, police on the streets, or the human needs of populations you are trying to deflect, defeat, control, or serve.

The Virtual Arizona Fence

The “virtual failure” of the “virtual fence” on the Arizona border is the latest example of surveillance technology limits. This “invisible” fence, consisting of strategically and periodically placed high tech radar towers equipped with state-of-the-art monitoring gadgets has failed to stem the tide of immigration. Where there’s a will, there’s a way around the fence.

After 4 years of effort, construction of 50 miles of fence over the 2000 mile Mexico-US border, and a $1 billion contract with Boeing, the Obama administration is abandoning the fence.

High winds, tumbling tumbleweeds, weak cameras, slow software, blurry images that confuse cars with humans, and determined immigrants in search of a better life have combined to circumvent the fence.

In the words of a New York Times editorial,

“The ‘virtual fence’ was a misbegotten idea from the start, based on the faulty premise that controlling immigration is as simple as closing the border — and that closing the border is a simple matter of more sensors, more fencing and more boots on the ground. So long as there is a demand for cheap labor, a hunger for better jobs here, and almost no legal way to get in, people will keep finding ways around any fence, virtual or not.”

The Lesson

For information technology enthusiasts and for those who monitor patient health behaviors through web-based “consumer empowerment” techniques or “physician improvement” technologies, there is a lesson to be learned here.

You cannot control human behaviors at the level of patient-doctor interactions no matter how “sophisticated” your data mining or monitoring efforts. And you cannot do it without more “boots on the ground,” more physicians in the clinical trenches to critically appraise human needs, to prevent “immigration” towards bad health and high cost hospitalizations.

High tech fences will not keep immigrants out of the human garden. And you cannot weed the garden using high tech information sensors.

Effect of Obamacare on Doctors

Preface: Doctors have been asking me for a down and dirty summary of how the health reform law will effect them. This request is beyond my pay grade. However, I did run across a comprehensive summary of what the investor world thinks the health reform impact will be. Lisa Cummings, a former executive at Dell and Walmart has done my work by summarizing the effect in Investorsinsight.com (November 9, 2010).

Here is her summary and her references.

• With the increase of covered patients, there will be a shortage of 150,000 doctors. Doctors are already overworked. Patients will have to wait longer to can get an appointment to see the doctor.

• Starting in 2011, Medicare reimbursements will be reduced. Medicare already reimburses doctors at an amount equal to only 81% of private payments.

• Between 18 to 20 million new Medicaid patients will flow to doctors. Medicaid coverage pays doctors 56% of the private payment amounts. Federal funding will pay for parity to Medicare for 2013 and 2014, and then it is up to the states to figure out how to pay the Medicaid doctors.

• Doctors will face more federal agencies, boards, and commissions, including the Independent Payment Advisory Board in 2012, a nonprofit Outcomes Research Institute, and the Physician Quality Reporting Initiative.

• 59% of doctors think the quality of medicine will decline in the next five years and 79% are less optimistic about the future of medicine. 69% are thinking about dropping out of government health programs, 53% would consider opting out of treating insurance-covered patients, and 45% have considered leaving the profession altogether.

Her References

1. Heritage Foundation, “Impact on Doctors," Web Memo, #2895, May 11, 2010

2. Susan Sataline and Shirley Wang, “Medical Schools Can’t Keep Up,” Wall Street Journal, April 12. 2010


3. Terry Jones, “45% of Doctors Would Consider Quitting if Congress Passes Health Reform, “Investors Business Daily, September 15, 2009

Wolf! Wolf! Wolf! Health Reform Law Speeds Doctor Shortage: May Precipiate Access Crisis

If one cries Wolf! too often, people stop listening. That may be why the public and their political representatives heed not warnings of a looming doctor shortage. Yet everybody in the know - from hospitals short on doctors, to physician recruiting firms, to retiring doctors looking for replacements, to patients unable to find a physician, to the sick waiting for hours in emergency rooms, to yours truly – have repeatedly howled a doctor shortage looms, will surely grow worse, and may soon morph into a political crisis.

Now America’s medical colleges, aided and abetted by the widely read WSJ blog, have joined the wolf pack (see WSJ Blog, September 30, 2010, below).

Med Schools: Health-Care Overhaul To Accelerate Doctor Shortage

About 33 million currently uninsured Americans are expected to enter the health-care system because of the new law. That influx will boost the projected shortfall of doctors by 50%, to 62,900, from a previous estimate of 39,600.

The doctor deficit will occur in both primary care and specialties since many of these new patients will suffer from previously untreated conditions — such as heart disease — for which they will need more complex care, Atul Grover, chief advocacy officer of the AAMC, tells the Health Blog.

Over the long haul, however, the projected physician shortfall won’t differ dramatically from the current estimate of 130,000 by 2025. That’s because many of those who are new to the health-care system will move on to Medicare, the government insurance plan for the elderly, says Grover. “As much as we’ve tried to create improvements to the health-care system … it’s going to be real hard to take care of people if you don’t have the bodies to do it,” he says.

The shortfall could be reduced by increasing the number of slots available for residency training as well as “making better use” of other health professionals like nurses, physician assistants and technicians, Grover says.

“It’s got to be a multi-pronged approach if we want to make sure Americans have access to health care,” says Grover.

Campaign in Poetry, Govern in Prose, Reform Health Care in Bureaucratese

An essay “Campaign in Poetry, Govern in Prose,” in The American Prospect, a publication of liberal policy ideas, triggers this blog.

The essay’s author, Paul Waldman, observes, “You campaign in poetry but govern in prose. The poetry of campaigning is lofty, gauzy, full of possibility, a world where problems are solved just because we want them to be and opposition melts away before us. The prose of governing is messy and maddening, full of compromises and half-victories that leave a sour taste in one's mouth. Governing, however, is also specific where campaigning is usually vague. “

Republican Specifics Not Specific Enough

Waldman then goes on to say Republicans, a party of “No,” have nothing specific to offer to offset specifics of the Accountable Care Act.

Never mind this specific list of Republican proposals.

• Shopping for health plans across state lines

• Expansion of the Federal Health Employee Benefit Plan, which now covers 10 million federal employees, including Senators and Congressmen

• Risk pools for individuals and small businesses

• Health care tax deductibility for self-employed individuals and small businesses

• Tax credits for all

• Expansion of Flexible Savings Accounts and Health Savings Accounts

• Letting individuals who wish to buy services outside of Medicare privately contract with doctors

• Caps on malpractice awards

• Independent judicial courts to promptly and impartially award patients injured by doctors or other medical professionals

• Incremental expansion of coverage by the market based on competition between health plans and providers

In Waldman’s view, these measures are not specific at all. Why not? Because they don’t jibe with government-dominated Democratic specifics, as laid out in a 2500 page $1 trillion entitlement program enabled by the health reform law, which many advocates cheerfully admit they have not read because of its impenetrable legalese.

Four Simple Things

Waldman goes on to say,

“Every Republican understands the four simple things they believe in: small government, low taxes, strong defense, and traditional values. Ask a Democrat what she believes in, and she'll give you a laundry list of initiatives, proposals, and programs.”

“As a long history of public-opinion research has made clear -- and as events continue to remind us -- Americans are "symbolic conservatives" but "operational liberals." In other words, they like the idea of limited government, but they also like just about everything government does.”

I’m not so sure about that. “Hope and change” have a poetic ring, but prose, which is rooted in results, has a place too. When “hope and change” fail, then the emotions embodied in such poetic phrases as “coverage for all” and “social justice” fall on deaf ears, particularly in a center right country alarmed by federal spending, growing debts, and stubborn unemployment.

Specifics and Horrifics

One man’s specifics are another man’s horrifics.

Republicans may be short on specifics, but the health reform bill is long on a byzantine list of bureaucratic specifics – from the 150 or so federal agencies, to 13,500 IRS agents required to enforce individual mandates and filing of $600 1099 forms for every $600 business expense, to health exchange regulations, to health plan standards, to EMR financial rewards and punishments, to accountable care organization rules, to comparative effectiveness outcomes, and, last but not least, how to obtain federal subsidies for the new entitlement program.

Horrific Specifics

Here, for example, are the specific bureaucratic details for anyone wishing to be eligible for a federal subsidy from a health exchange.

First, submit an application to the exchange. The application must be accurate and include all information to determine if the applicant is eligible for Medicaid or SCHIP, as well as health reform subsidies.

Second, the exchange must transfer the applicant’s information to the state Medicaid and SCHIP agencies to determine possible eligibility for those programs. The applicant must be notified, and may no longer be eligible for exchange enrollment.

Three, assuming no eligibility for Medicaid or SCHIP, the exchange must determine if the applicant’s income appears to meet subsidy rules. If not, the applicants must be notified that no subsidy is available.

Four, the applicant’s information is forwarded to HHS, which will – in conjunction with the IRS and other federal agencies – verify the submitted information.

Five, HHS will notify the exchange of the results of verifying the submitted information. The exchange must then notify the applicant, including whether any discrepancies were found and must be corrected.

Six, assuming the application meets subsidy rules, the applicant can finally selected an insurance plan from the exchange. However, in order to receive the cost-sharing subsidy as well as a premium subsidy, only Silver plan selection is allowed. Thus, the lower-cost Bronze plan cannot be chosen by anyone wanting to reduce their out-of-pocket costs. The exchange must also notify the applicants of the reduced premium amount and the impact of any cost sharing.

Seven, the exchange must notify HHS of the applicant’s choice of plan.

Eight, HHS must notify the Treasury Department , which will then make the monthly premium subsidy and reduced cost-sharing payments to the selected.

The above describes the most straightforward situation without mistakes in which a well-organized individual applies for subsidies well ahead of the start of coverage deadline, during an open enrollment period, with timely and accurate communication among the various agencies involved.

If anything goes wrong in the process of awarding subsidies to the 15 million expected to apply for subsides, well, that’s another kettle of bureaucratic fish.

This process isn’t poetry. It isn’t prose. It’s sheer bureaucratic specifics, expressed in bureaucratese.

Further Reading

1. Paul Waldiman, "Campaign in Poetry, Govern in Prose," American Prospect, November 10, 2010.

2.Rogern Collier, "PPACA Premium Subsidies: The Govrnment is Here to Help", The Health Care Blog, November 1, 2010.

Nuanced Physician-Friendly and Physician-Useful Data

Because doctors in droves have failed to install EMRs in the numbers government expected, critics accuse doctors of being Luddites, of being opposed to information technologies to preserve their place in the medical sun and to control the flow of medical dollars.

I have found the opposite to be true. Physicians know EMRs are inevitable. They are just waiting for useful, cost-effective, doctor and patient friendly, and efficient models, to arrive. Clinicians are skeptical of data for its own sake - data created at remote sites that slows their work and inappropriately judges their performance.

Physicians are not Luddites. They simply view information technologies as evolutionary rather than revolutionary. At this stage, data-driven decisions have not proven to be better than human-driven decisions.

Making EMRs More Useful Through Speech Recognition

Evolutionary medical advances take time, testing, thoughtfulness, and an understanding of human nuance. In the course of writing these blogs, I came across a Massachusetts IT company – Nuance Communications, Inc.
I describeed their speech recognition software as follows:

“This Massachusetts-based company has developed improved speech recognition software. It allows physicians to talk their progress notes, clinical findings, and clinical updates into an electronic health record without typing, clicking, or handwriting. Physicians speak their patients’ stories directly into an electronic health record. This electronic tweak makes existing EHRs more clinically useful and efficient. ”

The nuance here, of course, is that doctors are more comfortable dictating or speaking their findings rather than typing in their findings and being glued to a computer screen. Doctors, like the rest of humankind, are narrative creatures.

Making Decision-Support Systems More Collaborative, Convenient, and Useful

Now Nuance has come up with another evolutionary step - Radport . It uses a communication technique, e-ordering, to judge clinical appropriateness for ordering of CT scans, MRIs, PET scans, and nuclear heart scans.

Radport was developed with 60 medical groups in Minnesota and surrounding states as an initiative of the Institute for Clinical Systems Improvement (ICSI). Radport is a collaboration between the medical groups, radiologists, consumers, and private and government payers.

The idea is to pick the right scan, or to select alternative approaches, to arrive at the right diagnosis without exposing the patient to unnecessary radiation or needless waiting and without wasting the clinician’s time.

Imaging procedures now cost the nation over $100 billion and are rising at 15% to 17% per year, among the fasting growing costs among all medical procedures.

The Radport approach is called e-ordering. It occurs at the point of care. The clinician enter patient-specific data in the office. On the spot, the e-ordering system, based on a clinical appropriateness score, either verifies the order or suggests alternative procedures. The physician can select the recommended procedure or override the systems’ suggestion and order the originally suggested procedure. Feedback is immediate, can be shared with the patient, and incurs no additional expense.

In Minnesota, Radport has stopped cold the growth of ordering of the number of imaging procedures, and it is expected to save $28 million in health costs. It has been accepted with satisfaction by coalition of clinicians, medical societies, radiology groups, imaging equipment manufacturers payers, and patient groups.

Three Factors Leading to American Medicine’s Exceptionalism – Our Academic Medical Centers, The English Language, and Our Place as the Crossroads of the Internet Universe

For the last 10 years, I have served on the Medical Advisory Board of Castle Connolly Medical Ltd, a New York City medical care company that serves as a source for selecting America’s top doctors.

The doctors included in Castle Connolly's Top Doctor list are selected after peer nomination, extensive research , and careful review and screening. Doctors do not and cannot pay to be listed as a Castle Connolly’s Top Doctor. Each year for the last eight years, the Board has nominated and honored academic physicians with awards for Clinical Excellence and Lifetime achievements.

Candidates are mostly heads of departments at America’s academic medical centers. All have national and international reputations. This year’s candidates are specialists and include urologists, cardiovascular surgeons, a dermatologist, a plastic surgeon, a nephrologist, a radiologist, a medical oncologist, and a colorectal surgeon.

As I read their nominating endorsements, three themes for this blog emerged, namely, why America’s medical system is exceptional.

1. American Medicine as a Standard for Excellence

American medicine is, without doubt, the standard for excellence throughout the world. In large part, this is due to the leadership and innovations within our 125 academic medical centers. Most of the world’s leading medical journals are published here, 80% of the Nobel Prizes for medicine originate here in our medical centers, specialists from around the world flock here for advanced training, 25% of our practicing physicians are foreign-trained and migrate here to practice, and the world’s leaders and affluent citizens come here for treatment when seriously ill.

2. The English Language – A Precious, Universal Asset

The English language may be our greatest asset. It is the language of diplomacy. It is the language of science of medicine. It is the language of the international media and CNN. It is the language of the Internet. China and India recognize the importance of English, which is why English is required in their school systems. To function in the modern world, most Europeans are bilingual, in their own language and English. Winston Churchill mobilized the English language and sent it into battle. The same might be said of the use of English in mobilizing the battle against disease to advance the art and science of medicine. The U.S. may not have the world’s best “health system,” but we have the world’s best urgent care system, the most innovative specialists, and the best medical scientists.

3. The Internet - The Electronic Crossroads of the World Meet in America

The crossroads of the globalization intersect on the Internet in America. Most of its software is written in English. The world is moving on Internet time. The Internet is dictating the speed of change, and it is restructuring the world’s economies and its health care systems. It is often said we should adopt the health systems of other countries, but, thanks to the Internet, other countries are also mimicking the American system. Its citizens are demanding access to technologies created in America. Yahoo, Amazon, eBay, and Google, founded in 1994, 1994, 1995, and 1998, respectively, perform functions that did not exist 25 years ago, and employ, cumulatively, 75,000 people. Their existence enables new growth drivers. The internet is a driving force in restructuring American medicine, and through EMRs, broad band access to health information, telemonitoring of those with chronic disease, and the “virtual integration” of physicians and other health professionals, the Internet will transform how we care for patients, how they care for themselves, and how we pay for and deliver health care.

Further Readings

1.Andrew Ferguson, “Why America Is So Great,” The Weekly Standard, November 6, 2010.

2. George Will, “Economic Restructuring and the Next Big Thing,” Newsweek, November 5, 2010.

3. David Brooks, “The Crossroads Nation,” New York Times, November 8, 2010.

The Hospital-Doctor Hiring Wave

The wave of the future is coming and there is no holding it back.

Anne Morrow Lindbergh, The Wave of the Future, 1940

I know a wave when I see one. Rarely have I seen a wave so big move so fast as the current hospital hiring of physicians.

• Since 2002, hospital-owned physician practices have more than doubled from 25% to 55%, and physician-owned practices have nearly halved from 70% to under 40%.

• Merritt Hawkins, the largest U.S. recruiting firm, reports its share of its doctor searches for positions with hospitals hit 51% for the 12 months ended in March, up from 45% a year earlier and 19% five years ago.

What’s Fueling The Trend?

Hospitals and physicians need each other as revenues drop for each. The new reform law projects drops in reimbursements for Medicare below Medicaid levels by 2019. Also one of the main struts of the new law envisions rewarding hospitals and doctors for collaborating in accountable care organizations (ACOs) to save Medicare money. There are other factors as well, on both the physician and hospitals sides.

Physicians

Physicians are seeking refuge from the reform storm and from the hassles of running the business side of practices. These include wrangling with insurers, begging to seek authorization to perform procedures, dunning patients for out-of-pocket costs, pressures to install EMRs, and regulations demanding more documentation and higher data-based performance. Add to this doctors seeking a more balanced life style, growing numbers of women physicians seeking time off for family, lessening economic security for primary care and specialty physicians, heightened desires to spend more time with patients and less time with business details, and more dependence on hospital marketing and hospitals as a funnel for integrating care and a technology hub, and you have all the ingredients that make up an economic and cultural wave.

Hospitals

Hospitals simply have what it takes to prosper in an environment requiring administrative teams, political clout, negotiating leverage, marketing resources, and access to capital. By owning physicians, hospitals can guarantee revenue when they own the referrals and sites where surgeries and other high tech procedures are done. Hospitals, say Paul Mango, a director of consulting at McKinsey & Co, “ want to essentially lock in volume, inpatient and outpatient.” When you own the physicians and they are employees, physicians are obligated to refer and do procedures at the hospital. Hospitals can claim they bring the efficiencies of benefits of integration and data aggregation to the health care table.. Besides, most payers pay higher fees for hospital-owned facilities, including a “facility fee.”

Fear of Hospital Monopolies

Finally, if one owns the referral sources and the production facilities, one has the leverage to negotiate higher fees . This potential monopolistic situation has not escaped the attention of either insurers or government regulators. Regulators may evoke antitrust laws to counter hospital-physician consolidation.

Twelve Things to Expect from Health Reform Repeal Debate

This Sunday, November 7, Google lists 1328 articles, blogs, and videos related to repealing the Affordable Care Act. Most quote Republican leaders vowing to repeal Obamacare, many are cautionary, for example.

• Paul Ryan, R-Wisconsin, one of the Republican’s young guns, says, “You can’t fully replace this law until you have a new President and a better Senate. And that’s probably 2013, but that’s before the law fully kicks in on 2014.”

• Michael Tanner, a senior fellow at the conservative Cato Institute, is more straightforward,”Repealing Obama care is just not going to happen while Obama is in office.”

In the meantime, expect 12 events to unfold over the next two years.

1. House Republicans will vote overwhelmingly to repeal Obama care, with modest Democratic support from those elected who opposed Obamacare.

2. Harry Reid, Senate Democratic leader, will refuse to bring the House repeal up for a Senate vote.

3. President Obama will insist, as he already has, that it is foolish to “re-litigate” a law which he regards as set in legislative,historic, and ideologic concrete.

4. They will call upon Kathleen Sibelius, Secretary of Health and Human Services, to explain why costs have risen sharply since passage and why so many insurers and businesses have dropped coverage.

5. They will summon Doctor Donald Berwick, Administrator for the Centers of Medicare and Medicaid Services, to explain his views and to justify why he should be reseated following his recess appointment.

6. They will seek to repeal the reform the provision calling for submitting of 1099 forms for every $600 of business expenditures – a possible item of compromise.

7. They will seek to repeal restraints on Flexible Savings Accounts and Health Savings Accounts.

8. They will try to defund the $10 billion required for hiring 13,500 IRS agents to enforce individual mandates and track those who are qualified to receive federal subsidies.

9. They will try to defund the $10 billion needed to carry out other mandates, such as state based health exchanges, and regulations calling for more expensive comprehensive one-size-fits-all policies meeting federal standards.

10. They will discuss extending more waivers, such as the ones already granted to McDonalds and similar companies, who say they cannot afford Obamacare mandates.

11. They will push to expand and replace the existing $50 million demonstration projects scheduled for malpractice reform.

12. They will introduce their own incremental reform issues – shopping across state lines, offering tax deductions to those with individual coverage, malpractice reform, expanded health savings accounts.

These dozen things will serve as fodder for the 2012 Presidential election. One party’s meat – victorious Republicans calling for incremental or total repeal – will be the other party’s poison – defeated Democrats defending popular aspects of the law and praying defenders will not be ousted as most were in 2010. Both positions will require skill, luck, and a favorable political climate to carry out. The big question is: are Republicans repeating Obama's mistake by concentrating on health care rather than the economy?

This is your list for scoring the debate.