Sunday, January 30, 2011

Health Reform and Pay-for—Performance, Not So Fast,Macduff!

Lay on, Macduff
And damn’d be him that first cries,”Hold enough!

Shakespeare, Macbeth

In Macbeth, Macduff symbolizes virtue, which should be rewarded but does not always win in the end. The rigid regulators of practice rectitude and worshippers of computer-guided best practice protocols must have been taken back when they read the negative results of a nine year study of 470,000 hypertensive British patients treated by doctors rewarded through pay-for-performance guidelines.

Doctor Incentives Don't Improve Patient care - study

“LONDON, January 26, (Reuters) - Paying doctors financial rewards to meet targets for improving the care of patients made no discernible difference to the health or treatment of people with high blood pressure, a study has found.”

“The findings suggest governments and health insurers across the world may be wasting billions of dollars on doctor incentive schemes but getting no improvement in patient care, researchers who conducted the study said.”

“Researchers from Britain, the United States and Canada assessed the impact of incentivised targets on quality of care and health outcomes in around 470,000 British patients with hypertension and found that they had no impact on rates of heart attacks, kidney failure, stroke or death.”

"No matter how we looked at the numbers, the evidence was unmistakable; by no measure did pay-for-performance benefit patients with hypertension," said Brian Serumaga of Britain's Nottingham University, who led the research.”

What? You mean doctors being paid to follow health reform quality improvement rules may be wasting taxpayer money.

What? You mean outcomes don’t improve.

The neutral consequences of pay-for-performance must come as a shock to those who believe doctors are primarily at fault for the bad performance and shoddy outcomes of health systems around the world.

I would like to humbly suggest there may be a reason for these disappointing results , namely. that doctors cannot change patient behavior once patients leave the office to return to their former lifestyles and to the habits that lead to hypertension in the first place. Patients may continue to have stress, to drink too much, to eat high salt diets, to exercise too little, and to not take their medications appropriately or at all. Genetics play a central role in clinical destinies as well.

There are no prescriptions that can be written or outpatient rules that can be enforced by doctors that will change basic human behavior and habits developed over a lifetime. Perhaps outcomes could be improved through intervention and surveillance by outpatient professionals – nurses, social workers, trained volunteers or visiting doctors- or through technological sensors measuring blood pressures and lipids- but human freedom and the choice to behave as one wishes is another ball of wax beyond the pall of office-based physicians.

Saturday, January 29, 2011

The Health Reform Law: A Favor You Can’t Understand

The January 20 and January 27 editions of the New England Journal of Medicine arrived today. The two editions contained 5 articles on health reform.

1. “Assessing the ACO Prototype – Medicare’s Physician Group Practice Prototype”

2. “Can Congress Make You Buy Broccoli? And Why That’s a Hard Question”

3. “The Importance of the Individual Mandate – Evidence from Massachusetts”

4. “Health Care Reform – What Went Wrong on the Way to the Court House”

5. “Implementing Health Care Reform – An Interview with HHS Secretary Kathleen Sibelius”

The 5 articles were intellectually-presented , intelligently-argued, inconclusive, and hard to understand, save perhaps for the Sibelius piece.

She said, “We have a law, and we will continue to implement it. With President Obama in the White House, efforts to repeal the ACA will not succeed.”

Fair enough, and fairly obvious, something I could understand.

As I sought vainly to digest what we being said, I kept thinking of Ira Magaziner, Ivy League graduate (Brown), Rhodes Scholar, consultant, and Hillary Clinton’s former chief advisor on health care policy.

Magaziner was a master of arcane, intellectual, policy double-speak. One critic said Magaziner was like a member of the Mafia. The Mafia's most memorable code promise is, of course, “To do you a favor you can’t refuse.

But of Magaziner, the critic said with a twist, “ He is going to do us a favor we can’t understand.”

That lack of understanding is the health reform law’s most fundamental flaw. The law is too fiendishly complicated for anybody to understand. Nobody seems to understand the debates over the law’s actual costs, constitutionality of the individual mandate, resistance of the states to travails of implementation, or viability of accountable care organizations.

The latest mystery is why 729 organizations covering 2.3 million people have been granted waivers from participating in the law. Sibelius has given waivers to a wide swath of entities, including the Robert Wood Johnson Foundation, businesses, large and small, labor unions, big and little, and to a variety of enterprises that offer health and prescription drug coverage with limited benefits, and to four states – Massachusetts, New Jersey, Ohio, and Tennessee. One can only conclude, if you don’t like the law and you have White House connections, you don’t have to play.

The only thing certain about the ultimate fate of the law are its uncertainties. In the meantime, on the physician front, it is certain that the law favors large group practices as prototypes for accountable care organizations.

Since 2005, Medicare has engaged in a demonstration project with 10 large groups - Billings Clinic in Billings, Montana; Dartmouth-Hitchcock Clinic, in Lebanon, New Hampshire; Everett Clinic in Everett, Washington; Forsyth Medical Group in Winston-Salem, North Carolina; the Geisinger Clinic, in Danville, Virginia; the Marshfield Clinic, in Marshfield, Wisconsin, the MIddlesex Health System in Middletown, Connecticut, the Park Nicollet Clinic, in St. Louis Park, Minnesota; St. John’s Clinic in Springfield, Missouri; and the University of Michigan Faculty Group Practice, in Ann Arbor, Michigan - to prove beyond reasonable certainty that ACOs will save Medicare money.

The only thing certain about ACOs saving Medicare money are their uncertainties in doing so. To date, in 5 of the 10 clinics, Medicare money has been saved at one time or another, but in only 2 of the 10 have these ACO prototypes saved money every year.

Because so few of America’s doctors belong to these big clinics and because of the length of time it takes for these clinics to achieve results, one article conclude of ACOs “Congress may need to take more sweeping steps to slow the growth of Medicare spending long before the ACO model can prove whether it is up to meeting these challenges.”

ACOs may be another example of a favor we can’t refuse because we don’t understand what it will achieve.

Friday, January 28, 2011

Two Democrats Nail Health Reform Problems

In the January 28 edition of, two Democrats hit the health reform nail on the head. Patrick Caddell, former pollster for Jimmy Carter, and Douglas Schoen, Democrat pollster, strategist, and author of The Political Fix: Changing the Game of American Democracy, say bluntly and succinctly give three cogent reasons why the health reform law has failed to impress the American people.

Number One, the law is “anti-democratic.” It received no Republican votes, and three sneaky deals – the Louisiana Purchase, the Cornhusker Kickback, and the Connecticut U Con – made it possible. Its passage did not pass the smell test. If you believe in democratic bipartisanship and consensus, the law emits an unpleasant odor.

Number Two, the law fails flat on two false promises,

a. That everybody can keep their current policies, while in reality , employers are quickly dropping employees like flies from employer plans because it is now cheaper to do so.

b. That the individual mandate was a regulation of commercial activity and was not a tax, yet Democrats are defending it as a tax in the courts now that 28 states are challenging its constitutionality.

Number Three, the law does not deliver what the reform package the public wants,

a. Purchase insurance across state lines

b. Coverage pre-existing conditions (this being the one exception)

c. Portability from job to job

d. Support of malpractice reform

e. Incremental introduction of reform

f. Believable initiatives to hold down costs

The health reform law, in short, is a pig in a poke, an idiom referring to someone buying a low-quality pig in a bag because he or she did not carefully check what was in the bag. Now that the public is learning what’s in the law, they dislike it more than ever.

The Elephant in the Health Reform Room: Small Physician Practices

This law does absolutely nothing for small practices.

Private Comment by A National Physician Organization leader, who prefers to remain anonymous

An elephant in the room is something nobody talks about but everybody knows is there. It tends to be a huge refractory problem that nobody wants to address because there are no glib answers.

The elephant in the health reform room is the small physician practice. About 40% of doctors practice solo or in two person groups, and 70% or so are in groups of six or less. These physicians are the cement that holds the health system together. They are the ones people talk about when they refer to their “personal physician.” They are the ones to whom you confide. They are the “go-to” doctors when you really need a doctor.

When you strip away the rhetoric in the reform law - all the high-minded talk about reform scaffolding such as accountable care organizations, cooperative organizations, communicating interoperable electronic record systems, and demonstration projects doing this and that - the success of reform comes down to small practices.

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

Similarly, the whole reform law may fail unless it does something for small practices. Yet, physician survey after physician survey shows 60% to 70% of doctors look at the health reform law with deep skepticism. The law does little financially to help struggling marginal practices, to relieve these practices of burdensome distracting paperwork, or to offer realistic solutions to ease the transition to a digital future.

Instead the law is a preachy, top-down, expensive abstraction that lectures doctors about the “meaningful” use of electronic records, about the supposed joys and rewards of collaborative ventures with hospitals, payers, third parties, Medicare, Medicaid, and other government-created entities.

The law fails to address in any fundamental way the hot-button small practice issues of tort reform, year to year Medicare reimbursement (SGR), the resources needed to handle the inevitable tidal wave of entitlement patients, overhead costs imposed by third parties, or the coming monumental workforce shortages.

The reform law may work for large integrated organizations with the infrastructure and expertise to handle bureaucratic strictures, but it does not work for small elephants in the room that provide most of the care in the United States.

These small elephants will be reluctant to enter the government or big organization jungles and are likely to react by retiring, seeking other employment, becoming employees, or bailing out into concierge practices where they can deal directly with patients rather than third party intermediaries. What doctors in small practices want is more time with patients, more appreciation of the elements distracting them from their mission, seeing, treating, and curing patients.

Richard L. Reece, MD, blogs at Medinnovation and has a website under construction. He is the author of three recent books, Obama, Doctors, and Health Reform (Iuniverse, 2009), Innovation Driven Health Care (Jones and Bartlett, 2007), and an E-book, Pros and Cons of Accountable Care Organizations (Practice Support Resources, 2011). He works with The Physicians Foundation, a 501C3 organization representing physicians in state medical societies. Opinions expressed in his blogs are his alone. He can be reached at, 1- 860-395-1501

Thursday, January 27, 2011

My Son, Episcopal Deacon and Poet

One of the joys of writing a blog is that you can say what you want to say. That said, this blog has little to do with health reform. Today, I shall talk about my son, Spencer, a nationally known poet who was ordained as an Episcopalian Deacon last evening at the Marquand Chapel at the Berkeley Divinity School at Yale.

The ordination was an impressive ceremony. It lasted an hour and a half, and a large group of clergymen were there, including the most Reverend Leo Frade, Bishop of Southeast Florida and his wife, Dr. Diana Frade, founder of Our Little Roses Orphanage in San Pedro Sula, Honduras, and the Presiding Bishop of the Episcopal Church of Connecticut and other clergy notables.

The tone of the ceremony was civil, as opposed to the rough and tumble of our political discourse. The litany was filled with such phrases as “that our divisions may cease and that all may be one,” “that a spirit of respect and forbearance may grow among nations and peoples,” and called “for those in positions of public trust, especially Barack, our President, our justices and legislators, that they may serve justice and promote the dignity and freedom of every person.”

Just a word, if I may , about Spencer’s recent history. He has served as a seminarian at Christ Church in Westerly, Rhode Island, and at Saint Luke’s in New York City. In both churches, he has collaborated in the weekend services and conducted Sunday poetry groups.

At Westerly, he led a highly successful, widely-attended, area-wide seminar “Finding Our Spirit in Poetry.” James Franco, the Hollywood actor and director, made his poem “The Clerk’s Tale,” into a short film that was shown at closing ceremonies at the Cannes Film Festival in 2010.

In addition, he spent two months at Our Little Roses Orphanage in San Pedro Sula, Honduras, where he learned a little Spanish and taught water coloring to the girls at the Orphanage. This week he was notified he was a finalist for a Fullbright scholarship to serve as a priest at the Orphanage and a teacher of poetry at the University of Honduras.

Here are excerpts from a previous blog I wrote in 2008,

Usually fathers teach sons. For me, the reverse is true. My son taught me what I thought I knew.

My son, Spencer, a well-known poet, will enter Yale Divinity School this fall. Three years later, he will emerge an Episcopalian priest.

He attended Bowdoin for two years, graduated from Wesleyan, and earned Masters from York University in England and Harvard Divinity School.

He toiled for 12 years at Brooks Brothers, first in Minneapolis, then in West Palm Beach and Palm Gardens. During the day he plied the retail trade. In off-hours he composed poetry.

Publishers rejected his book of poems 300 times. Spencer persisted. Then, Louise Gluck, America’s poet laureate, spotted his work. She put in his name for the Bakeless Prize at the Bread Loaf Writers Conference. He won. His book of poetry, The Clerk’s Tale, was published in 2004

Gates opened. Fame followed. He read before the Library of Congress, won a Guggenheim and other prizes, and recited at leading universities and book fairs. The New York Times, the Washington Post, and major Florida papers interviewed him. The American Poetry Review adorned him with a full page picture on its cover, and his poem, “The Clerk’s Tale, appeared in The New Yorker. He became known as the Bard of Brooks Brothers.

My wife and I attended two of his poetry readings. We came away with these impressions.

1) Poetry is big.

2) Spirituality is back.

3) Materialism is out.

4) People seek hope.

5) Rejection inspires.

A Father’s Learning Curve

What I have learned?

Importance of humility. At York, Spencer studied humility in works of Renaissance poets, George Herbert (1593-1633) and John Donne (1572-1631). Humility shines through in Spencer’s readings. People like humility in this age of celebrity self-centeredness and quests for instant fame.

Power of language. You see this in Barack Obama’s speeches. In Spencer’s case you sense it in his poetic imagery. Here he describes how a mother reacted to her baby’s death in hospice, “The mother walked out of the room, her arms slackening at her side like old latches on the door of an abandoned house.”

Dignity of death. As Spencer explained to me, “Dad, all people want as they lay dying is the sense their lives meant something – even if only to themselves.”

Perhaps that’s what John Donne meant when he said,,

” Death be not proud, though some have called
Mighty and dreadful, for thou art not so,
For those whom thou think’st thou dost
Die not, poor death, nor yet canst though kill me.”

Spirituality to medicine. People thirst for spirituality. One hundred of America’s 150 medical schools now have spirituality as part of required courses. People are recognizing science and technology have limits, end-of-life care has a spiritual side, hospice care is relevant, managed care offers little solace, holistic medicine is here to stay. Americans and doctors are maturing in their attitudes towards aging, disease, and death. Machines will not get us out of this alive once the end nears.

When my time comes, I will rejoice. People like my son. Spencer, will be there to comfort me, tell me I meant something, and guide me to what beckons beyond.

Government “Innovation”

Government does not have a sterling reputation for innovation. Instead government is noted for its sprawling inefficiencies and expanding bureaucracies.

In his State of the Union speech, president Obama used the word “innovation” nine times. His theme was “can do collectivism,” i.e. central top-down control will direct and correct innovation, if only we can unleash the power of windmills, solar energy, high speed rails, and the Internet. His message was : the government will lead, the people will follow, and jobs will be created.

Here is a sampling of his innovation theme.

“The first step in winning the future is encouraging American innovation. None of us can predict with certainty what the next big industry will be or where the new jobs will come from. Thirty years ago, we couldn’t know that something called the Internet would lead to an economic revolution. What we can do — what America does better than anyone else — is spark the creativity and imagination of our people. We’re the nation that put cars in driveways and computers in offices; the nation of Edison and the Wright brothers; of Google and Facebook. In America, innovation doesn’t just change our lives. It is how we make our living.”

“Our free enterprise system is what drives innovation. But because it’s not always profitable for companies to invest in basic research, throughout our history, our government has provided cutting-edge scientists and inventors with the support that they need. That’s what planted the seeds for the Internet. That’s what helped make possible things like computer chips and GPS. Just think of all the good jobs — from manufacturing to retail — that has come from these breakthroughs. “

Government is needed for such projects as building the atomic bomb, launching the moon shot, waging war, and printing currency. I’m not sure it makes sense to give government credit for expanding the Internet and for creating such companies as Apple, Microsoft, Google, and Facebook.

Government may plant the seeds for innovation, but, by and large, government innovation is an oxymoron. This is likely to be case for health reform innovation demonstration projects - medical homes, accountable care organizations, and tort reform.

As Debra Saunders says in today’s San Francisco Chronicle,”Obama’s Oxymoron: Government Innovation, “

“The problem with left-leaning elites trying to run the U.S. economy from the top down is simple: They think the answer to America's economic woes is to create more jobs that replicate managers just like them.”

“They cannot comprehend that, to a good number of American voters, the theme of President Obama's State of the Union address -- government innovation -- is an oxymoron.”

“I understand that compared to tackling the growing deficit, it's a lot easier to hand out grants and underwrite subsidies to like-minded venture capitalists, who are happy to soak up taxpayer dollars as they credit you for creating private-sector jobs.”

“But please, don't call it innovation.”

Conclusion: Government innovation is an oxymoron, a phrase in which two words of contradictory meaning are used together for special effect.

Seek and Find: Health Reform and Googling of Disease and Health:

Attempt the end, and never stand in doubt.
Nothing’s so hard, but search will find it out.

Robert Herrick (1591-1674), Seek and Find

I would like to make a two-pronged immodest proposal:

1) that Google or a similar company aggregate data on diagnostic patterns of disease and make it available to physicians and similarly,

2) That Google another company aggregate data on the state of a person’s heath and make it available to the general public.

I know this is doable because I have done it on a small scale, as described in the last chapter in my book, “An Innovator’s Personal Experience and Vision” (Innovation-Driven Health Care; 34 Key Concepts for Transformation (Jones and Bartlett, 2007).

I described how, using data from physicians’ offices, in a clinical laboratory in Minneapolis, we were:

1) able to list the correct diagnosis among the top 5 diagnostic possibilities based on abnormal tests in multitest profiles more than 80% of the time;

2) able to make a person’s health understandable to the public based on an algorithm for health using the health quotient (HQ) as the physical health analogy of the IQ, the instrument for measuring human intelligence.

We realized two elemental things:

• That most diseases – especially chronic diseases – manifested themselves in clear-cut diagnostic laboratory patterns.

• That present and future health often rested on physical measurements – blood pressure, pulse, body mass index (a function of body weight and height), waist and hip measurements, blood chemistries, and a past personal or family history of heart attacks and strokes.

Our algorithm classified patients as being in superb health (HQ of 120 or more), average health (HQ of 20 to 120), subpar health (HQ 50 to 70), and poor health (HQ 50 or less).
The state of one’s health and disease are, of course, closely related, for example, obesity, hypertension, hyperlipidemia, and diabetes often precede heart attacks and stroke. Our point was that seemingly mundane data, when aggregated, has diagnostic and predictive power.

In that chapter, I stated, ” “Think for a moment about the power of Google, the Internet’s largest and fastest growing search engine. Type in a combination of search terms into its search box. Immediately a list of prioritized possibilities will appear. Although the Google logic may be awesomely complicated, it is amazingly simple to use. Google is the quintessential ‘disruptive innovation.’”

I have written that aggregated clinical data mining could be one of the keys to U.S. health reform (“Data Mining and Innovation: Keys to U.S. Health Reform,” Healthleadersmedia. com, June 27, 2006).

I still believe this to be the case, but only if the data is used to open the minds of doctors and patients rather than to enforce regulations and judge performance. Also physician and patient privacy must be protected.

The field of clinical innovation using existing, easily accessible data, is wide open and awaits the skills of an innovative web-based company to fully develop. Today, much more data is available via EHRs and PHRs (Personal Health Records). This data would further enhance diagnostic and health accuracy.

Richard L. Reece, MD, blogs at Medinnovation and has a website under construction. He is the author of three recent books, Obama, Doctors, and Health Reform (Iuniverse, 2009), Innovation Driven Health Care (Jones and Bartlett, 2007), and an E-book, Pros and Cons of Accountable Care Organizations (Practice Support Resources, 2011). He works with The Physicians Foundation, a 501C3 organization representing physicians in state medical societies. Opinions expressed in his blogs are his alone. He can be reached at, 1- 860-395-1501

Health Reform, the Blogosphere (BS), and Search Engine Optimization (SEO)

This is for you health care bloggers out there seeking to impact and clarify health reform.

The new health reform law affects every American. It will cost $1 trillion over the next 10 years and $3 trillion over the next 20 years. As Vice-President Joe Biden whispered to President Obama after the reform act was signed, "This is a big f-----g deal!”

Unfortunately, the new law is “fiendishly” complicated, confusing, hard to explain, and politically unpopular. For good reason. The law is not a single program. It is a collection of mandates, public insurance expansions, and regulations that affect different groups of Americans in different ways, at different times.

That makes it tough for you to break through into the blogosphere.

The blogosphere is made up of your blogs, all of those other blogs, and their interconnections. The term blogosphere implies that blogs exist together as a connected community (or as a collection of connected communities) or as a social network in which everyday authors can publish their opinions.

So how do you break through? You do it through something arcane, SEO, Search Engine Optimization.

What is Search Engine Optimization? It consists of bundle of Internet positioning techniques and tactics that make your website or blog more visible. It helps your blog appear higher on an Internet page on any given subject. About 70% of Internet visitors searching for information never get past the first Internet page. These Internet viewers are an impatient lot in a hurry. That’s why first page visibility, a high SEO ranking on Google and other search engine site, is important. Tha's why Search Engine Optimization is the rage among Internet aficionados.


• Because there are 133 million blogs on the Internet, and SEO offers a way for you to rise above the clutter, to bob above other blogs in the vast Internet sea.

• Because SEO is the most efficient way to make yourself, your organization, or your cause more visible to the world of the Internet viewers.

• Because SEO is quickest route to making your views known to internet viewers, now numbering more than a billion worldwide.

SEO can make young people instant billionaires, the case with Facebook, Twitter, Youtube, and groupons. It can help you make a difference in advancing, resisting, or modifying the health reform law.

SEO is becoming the mainstream way for corporations to market their products and to sell them online. For doctors and hospitals, SEO offer a means of making your services more visible to your community. For individuals, the SEO is a way of connecting with other individuals and bypassing institutions and the establishment. For government, the SEO is a propaganda weapon and information-dispersing tool through and gov. org sites.

SEO, in short, is the wave of the future.

For bloggers like me, the SEO offers a mechanism for becoming more widely known and read and for differentiating myself from other bloggers, which will number close to 150 million by the end of 2011.

But how do you achieve higher visibility?

Therein resides a bag of Internet tricks. You edit the contents to repeatedly broadcast your message. You use keywords. You create blogs of 300 words or more. You remove barriers to indexing your site. You link to other related sites. You insert videos. You offer shopping carts if you’re selling a product. You create memorable images. You twitter. You get on Facebook and YouTube. You use every trick in the blogbook to attract and keep viewers who might be interested in what you have to say or sell.

Don’t take my word for it. Here is what has to say about Search Engine Optimization.

“Search engine optimization (SEO) is the process of improving the visibility of a website or a web page in search engines via the "natural" or un-paid ("organic" or "algorithmic") search results. Other forms of search engine marketing (SEM) target paid listings. In general, the earlier (or higher on the page), and more frequently a site appears in the search results list, the more visitors it will receive from the search engine. SEO may target different kinds of search, including image search, local search, video search and industry-specific vertical search engines. This gives a website web presence.”

“As an Internet marketing strategy, SEO considers how search engines work and what people search for. Optimizing a website may involve editing its content and HTML and associated coding to both increase its relevance to specific keywords and to remove barriers to the indexing activities of search engines. Promoting a site to increase the number of backlinks, or inbound links, is another SEO tactic.”

“The acronym "SEO" can refer to "search engine optimizers," a term adopted by an industry of consultants who carry out optimization projects on behalf of clients, and by employees who perform SEO services in-house. Search engine optimizers may offer SEO as a stand-alone service or as a part of a broader marketing campaign. Because effective SEO may require changes to the HTML source code of a site and site content, SEO tactics may be incorporated into website development and design. The term "search engine friendly" may be used to describe website designs, menus, content management systems, images, videos, shopping carts, and other elements that have been optimized for the purpose of search engine exposure.”

So there is everything you wanted to know but was afraid to ask about the Brave New World of SEO (Search Engine Optimization) and BS (The Blogosphere).

Richard L. Reece, MD, blogs at Medinnovation and has a website under construction. He is the author of three recent books, Obama, Doctors, and Health Reform (Iuniverse, 2009), Innovation Driven Health Care (Jones and Bartlett, 2007), and an E-book, Pros and Cons of Accountable Care Organizations (Practice Support Resources, 2011). He works with The Physicians Foundation, a 501C3 organization representing physicians in state medical societies. Opinions expressed in his blogs are his alone. He can be reached at, 1- 860-395-1501

Wednesday, January 26, 2011

The Future of Accountable Care Organizations (ACOs)

An Interview with Bill DeMarco, President of Pendulum Healthcare Development, an affiliate of DeMarco Health Care Consulting

What follows is an interview with Bill DeMarco, a health care consultant for more than 30 years and an advisor on Accountable Care Organizations (ACOs). The subject of Accountable Care Organizations (ACOs) accounted for only 10 pages of the 2500 page health reform bill. Yet ACOs are now the buzz, the rage, the hottest 3-letter acronym since sliced bread, and the most talked about subject in hospital board rooms, medical staff lounges, and the medical talk circuit, and consultant enclaves. I am cautiously pessimistic about the future of ACOs. My views on ACOs are available in an e-book , Pros and Cons of Accountable Care Organizations (

How long have Pendulum Healthcare and DeMarco and Associates Consulting been in existence?

Pendulum since 2001 and DeMarco and Associates since 1980.

As you know, you and I go back a long way, starting with the formation of the SHARE corporation in Minneapolis.

Yes, I was one of the 10 people who started SHARE, a small primary care group that contracted with specialty physicians as a staff model HMO, which we might call today a medical home.

Today let’s talk about Accountable Care Organizations (ACOs). ACOs are the hottest subject going, as hospitals and physicians contemplate implications of the health reform law and their future.

Yes, ACOs are a hot subject. I prefer to call them Medicare Shared Savings programs. They are connected to the prepaid demonstration projects CMS conducted with several of the big multi-specialty groups five or six years ago. Also they tie into the discussions about cooperative organizations. CMS had a meeting last week encouraging hospitals and doctors to become cooperative health plans.

I’ve been reading your articles on ACOs. One thing that comes through is that you believe ACOs are a “new path” for physicians and hospitals.

Yes, they are indeed a new path. They are truly an opportunity, for physicians specifically, to generate a bonus in exchange for increased consistency, efficiency, and effectiveness. ACOs put dollars on the table for quality.

Previous variations of the ACO model, PHOs and IPAs, have failed or faltered for various reasons, one reason being physicians fearing hospital control and the other being lack of any revenue advantage for physicians. Do ACOs change the control and revenue landscape?

I think they do. They create an opportunity for Medicare, the biggest payer by far, to generate savings in conjunction with aligned physicians. There will now be physician dollars available to reward efficiencies and to offset startup costs. ACOs are moving away from a production mentality of PHOs to a value-based mentality. They are crossing the quality chasm by focusing on medical management to bring costs down by removing waste from the system. ACOs are about population management, and physicians who participate and lead this change are going to get paid for quality.

What are the start-up costs for an ACO?

It depends on where the physician organization is on the integration scale. If they are fully integrated, like Geisinger and the Greater Marshfield Plan, they could go ahead quickly and be part of the ACO class of 2012.

If the physicians don’t have anything in place, you are easily talking about $3 to $5 million to organize for the first year and then ongoing administrative costs to have a licensed driver in the driver seat. There are management companies out there to provide the needed management services, and there are some shrewd investors interested in providing the start-up capital for ACOs in exchange for a part of the bonus.

The electronic infrastructure by itself required to track data to calculate rewards would be a huge expense, with EMRs on both the hospital and physician sides

In an ideal world, having that EMR will be important. However, when we started HMOs in the 70s, we needed the same kind of utilization data, and we survived. In addition, many physicians are already using some sort of data clearinghouses because they get an extra 3% to 4% using electronic billing. Many of these ACOs will be administrated through a fiscal intermediary. You could start an ACO without an EHR.

But you are right, it would be expensive to put in an internal EHR from scratch. That’s why you need to earmark some of your savings for that purpose integrating HIT and EHR.

Who are your clients? Are they mostly hospitals or physician groups?

It’s been a combination of physicians, physician organizations and IPAs who want to set up a data warehouse, and who want to be certified as an ACO. We’re working with a couple of hospitals, who want to do a joint venture with physicians. I am also talking to two companies, with another in the wings, who want to form an ACO for their employees. Employers are taking it upon themselves to go out to hospitals and physicians and create their own custom networks versus the insurance company discount networks of the past.

This is something most hospitals were not aware of, and many of their existing physicians could wind up joining a competing ACO. Also Phycor-like organizations are roaming the countryside to form ACOs by buying practices right out from underneath the hospitals’ nose. So we’re telling hospitals, don’t be shy about forming your own ACOs. Sit down with medical staff and tell them you are interested in cooperating with them to form their own physician driven ACO.

In preparing for this interview, I ran across this statement “Hospitals are the raw meat physician-ACOs will feed upon.” Is that an over-statement?

I think it is. Removing waste from the delivery system is not all about physician ACOs chopping out hospital days. Many existing physicians and hospitals are leaving dollars on the table because they are not coding and documenting correctly. ACOs will help correct these problems, and help both parties’ reimbursements but there are so many things that can be done before chopping out days per thousand.

Hospitals need doctors to help them correct problems like re-admissions, which come at hospital expense. And you’re going to be looking at better coordination between primary care doctors, specialists, and the hospital. Under bundling of hospital and doctor fees, pay will be more predictable and controlled than under fee-for-service because there will be agreement in advance as to what the “package “ of services are and what the Medicare payment rate may be for that package.

You mentioned bundling, which comes under the guise of global payments, and reducing fee-for-service. Is that one of the main thrust of this reform law?

Should we have “bundles” only, or should we have modified fee-for-service? That’s one thing holding up discussions of ACO legislation. Many years back we had cost HMOs and risk HMO contracts with the government. The choice was up to the HMO but risk arrangements usually offered better opportunity for additional revenue from savings. If we extend this down a bit we could have risk and cost ACOs. I think it will eventually go mostly into bundling, but not necessarily capitation. Capitation is paid on a per member per month. Bundles work differently because you’re paying for episodes and your success is tied to patient population management.

ACOs are targeted at the Medicare population. It is my understanding that a physician in private practice can belong to an ACO and continue to conduct fee-for-service in private practice independently for seniors not in the ACO and for his non-Medicare patients. Is that correct?

Absolutely. The private physician is not a government employee, and this is not government takeover. What the government is going to do is set the criteria for bundling for an episode of care. The physician can manage within that framework. But I do think ACOs will be a vehicle many employers will look to for managing non-Medicare employees, and we are seeing this with Humana and Norton as well as similar shared savings arrangements between Blue Cross and Advocate hear in Chicago.

Hospitals are hiring primary care doctors as well as specialists in record numbers. The number of physicians in private physician-owned practices has dropped from 75% of physicians to less than 50% in the last five years. Doesn’t having physicians as salaried employees make the creation of ASOs easier for hospitals?

The reform law is directed at physician- owned and physician- driven enterprises. The statute mentions hospitals in only one aspect - when hospitals own primary care physicians. These hospitals are eligible to apply, all the other ACOs are “physician-driven.” In my opinion, ACOs are really an “physician-anointed” program. Hospitals are hiring more doctors to make sure they don’t wander off the reservation. And yes, salaried physicians would help hospitals to form ACOs, if the primary care physician practices hospitals buy are seeing more than 5000 non-Medicare Advantage patients. And yes, having both primary care physicians and specialists under one corporate roof as employees would help in care coordination.

Many specialists and primary care doctors see cooperative groups involving specialists, primary care physicians, and hospitals as their future over the next 3 to 5 years.

The federal government is moving very fast on ACOs, and just like another business you need to get ahead of the curve. State governments are moving even faster with Minnesota, Michigan, Colorado, Massachusetts, Pennsylvania already having ACO like organizations operate in conjunction with Medicare.

Florida, Arizona and others are also moving this way as the money for these and similar programs are cut. The states are very interested in partnering with providers to hold the line on unnecessary care costs. Vendors and purchasing organizations, on their part, are taking a serious interest in forming ACOs. As the ground shifts underneath physicians, they are realizing they may be left out of these cooperatives that are being built. As Dr. Jack Lewin likes to put it, “Either you have a seat at the table, or you are on the menu.”

Another powerful trend is the consolidation and concentration of health care into larger and larger entities, many of whom may have the power to negotiate higher and more favorable rates. This may be an unintended consequence of health reform and raises anti-trust issues. How do physicians avoid anti-trust in forming ACOs?

You manage anti-trust by making sure physicians who are part of your organization understand the difference between competitive and anti-competitive behavior.
How do you do that? The first thing you do is read the document that the Federal Trade Commission prepared in 1966 that offers several pathways to “safe harbors” when physicians develop their own networks. The 50 page document says you have an exemption from antitrust if you are clinically integrated OR financially integrated. If you are taking capitation or at risk financially , you are exempt. Then the government doesn’t see you as a bunch of competitors, but as a cooperative group with a community benefit.

The same occurs when a group becomes clinically integrated, they are exempt because instead of being seen as competitors trying collude to a anti-competitive strategy you are building a cooperative strategy to improve quality.

But beware. If you are not truly clinically integrated, you are at risk for an antitrust action. In Chicago, an insurer challenged the Advocate health system as not being clinically integrated, and Advocate spent tons and tons of money defending themselves. But Advocate did take clinical integration very seriously. Now that they have done that, they have re-engineered their system to the benefit of both their hospitals and their physicians. Blue Cross Blue Shield has offered them an exclusive for their ACO bundled payment plan.

This example shows that ACOs offer a new pathway for physicians and the government for their mutual benefit.

Physicians need to read the FTC document, not sit in a room talking about price and contracts, and to hire a good antitrust lawyer to advise them. The Association of Health Care Lawyers has a whole list of qualified lawyers to advise on antitrust issues.

Definitely get yourself a good attorney to review what you’re doing. You do not need to apply to the FTC to proceed with an ACO, but you do need to follow the rules in the six pathways advised by the FTC. I think CMS will defer to the FTC to enforce the rules even though, as written CMS has that power today.

So, to conclude, “re-engineering” the health delivery system is underway. To navigate the maze, get yourself a good lawyer to avoid antitrust issues.

First you would want to find out who your best referrals are coming from and defines your virtual group. Talk with this series of doctors about what an ACO is and what could be done in terms of developing a loosely knit group to meet high performance standards

Once you have at least a core group to discuss the vision you need to get advice on operational ACOs and also get a lawyer to make sure you have a pathway through the clinical integration steps. There are a lot of good things in this health reform law for physicians. And there are a lot of good things being published by medical societies to help doctors avoid the pitfalls in forming an ACO. The Massachusetts Medical Society just published a one-page summary of what to avoid in forming an ACO. The Physicians Foundation is also preparing tools and background information to answer physician questions.

Physicians need to do their homework, even before hiring a lawyer, before proceeding with an ACO.

Tweet: In a Medinnovation interview, consultant Bill DeMarco says ACOs offer doctors the chance to make more money delivering quality care, #PPACA

Richard L. Reece, MD, blogs at Medinnovation and has a website under construction. He is the author of three recent books, Obama, Doctors, and Health Reform (Iuniverse, 2009), Innovation Driven Health Care (Jones and Bartlett, 2007), and an E-book, Pros and Cons of Accountable Care Organizations (Practice Support Resources, 2011). He works with The Physicians Foundation, a 501C3 organization representing physicians in state medical societies. Opinions expressed in his blogs are his alone. He can be reached at, 1- 860-395-1501

Tuesday, January 25, 2011

State of the Union: Are You Better Off Than You Were Two Years Ago?

As you listened to President Obama’s speech, you may have asked yourself : Am I better off than I was two years ago?

• If you an investor, the answer was likely to be “Yes."
Stocks, +48%
Corporate profits, +44%
Consumer confidence, +40%

• If you are a wage earner, the answer was likely “Not so hot.”

Trade deficit,+6%
Disposable income, +5%
Median weekly earnings, -0.6%
Median house price, -0.5%

• If you are unemployed and concerned about the state of the nation, the answer was likely a resounding “No.”

Unemployment rate, +20.5%
National debt, +32%
Gas prices, +69%
Long term joblessness, +139.5%

Source: John Merline, AOL Opinion Editor

Concierge Medicine: Reality or Mirage

In my blog of yesterday, "Health Reform Victims, " I quoted John Goodman, a conservative economist who founded the National Center for Policy Analysis. Goodman predicted “a large flourishing market for concierge services.” He said concierge practice expansions would likely drain primary care physicians from the pool of doctors available to treat Medicare and Medicaid patients.

Up to this point, I have been skeptical that concierge practices would ever have more than a marginal impact. To me, the $1000 to $2000 yearly fees for direct access to doctors were a powerful deterrent. So were the financial risks of converting to a concierge practice without third party contracts, and the psychological difficulties of abandoning existing patients and downsizing from a panel of 2000 or so patients to 500 to 600 patients.

But certain developments, tangible and intangible, are making me take a second look.

• The growing physician shortage, particularly of primary care physicians, which shows no signs of abating.

• The rapid migration of baby boomers into the Medicare market, which commenced January 1, 2011 and which will progress at the rate of about 12,000 a day for the next 18 years.

• The fears and uncertainties induced by the health reform law, viz, being able to find a personal physician once the dust settles after the 3R (reform, repeal, replace) debate.

• The entry of venture capitalists into the field, bearing capital to support emerging concierge companies.

• The unexpectedly rapid growth of concierge practices, which now number about 5000 and according to Concierge Practice Today, may grow to 17,000 in 2012.

• Modifications of the concierge model, i.e., charging a monthly rather than a yearly fee, and coupling it with a high deductible plan with a catastrophic lid and a health savings account.

I would like to bring your attention to the Qliance Medical Group in Seattle. Here is their approach, as explained at their website,

“We're using a monthly membership approach to health care, cutting out insurance and going directly to our patients to provide the most comprehensive, high quality primary care out there. The Qliance membership approach means you can see your doctor whenever you need to - even after work and on weekends. By eliminating the hassles of insurance, we are able to put our patients first and return control of your health care to you and to your doctor. “

In their latest white paper, “Health Reform and the Decline of Physician Private Practice, “the Physicians Foundation, devotes 5 pages to a case study of the Qliance model. Qliance is a practice of 9 doctors and three nurse practitioners and takes care of 4000 patients at three locations in Seattle and works with 80 employers who offer the service to their employees. Qliance plans to recruit more physicians and to open two more locations in 2011.

At Qliance, doctors see 10 to 12 patients a day, with the average visit lasting 30 to 60 minutes. At Qliance a family pays a $99 registration fee and then a monthly fee for each member of the family, based on age, not health status. Monthly fees vary from $54 for a teen, to $69 to $99 a month for a 45 year old, depending on the level of service. Fees for imaging ($17) and generic drugs (less than $10) are extra. Patients can drop the monthly service at any time.

Qliance recommends its patients also enroll in a high deductible plan or a health savings account plan, or both, to pay for hospitalizations or other costly events. In answer to critics who say concierge practices are only for the healthy and the wealthy, the director of Qliance, Garrison Bliss, MD, notes that most of their patients come from the middle class and that two-thirds of his panel are Medicare patients, who have more health concerns than younger individuals.

Bliss says the Qliance approach is affordable to 80% to 90% of Americans. In addition to Qliance, Dr. Bliss has co-founded the Direct Primary Care Coalition, whose web site lists more than 60 Direct Primary Care Medical Home Practices in 21 states.

Qliance is working on an EMR with the help of venture capital from Amazon founder Jeff Bezos and Dell Computer’s Michael Dell. Says Bliss, ”we’re taking advantage of being a venture capital-driven organizations. I have no idea how a regular primary care practice is going to do this.”

Tweet: At Medinnovation blog< Dr. Reece cites reasons why concierge practices are growing faster than anticipated. #PPACA Richard L. Reece, MD, blogs at Medinnovation and has a website under construction. He is the author of three recent books, Obama, Doctors, and Health Reform (Iuniverse, 2009), Innovation Driven Health Care (Jones and Bartlett, 2007), and an E-book, Pros and Cons of Accountable Care Organizations (Practice Support Resources, 2011). He works with The Physicians Foundation, a 501C3 organization representing physicians in state medical societies. Opinions expressed in his blogs are his alone. He can be reached at, 1- 860-395-1501

Monday, January 24, 2011

Victims of Health Care Reform

Health Alerts on January 24, 2011

Preface: Health reform has become so politicized that people forget reform sometimes defines the laws of basic economics. Here John Goodman, a conservative economist who leads the National Center for Policy Analysis in Dallas, remnds us that the good intentions behind the entitlement mentality, creates victims as well as beneficiaries.

Who will be hurt the most by the health reform legislation Congress passed last year?

Answer: The most vulnerable segments of society: the poor, the elderly and the disabled. That’s right. Virtually everyone in Congress who is left-of-center voted for a law that will significantly decrease access to care for the people they claim to care most about.

Why isn’t anyone writing about this?

Answer: Because almost all the people who write about health care know almost nothing about economics.

Basically, there are two ways to reform health care. One way is top down. The other is bottom up. The latter is based on the economic way of thinking. The former rejects that way of thinking. The latter gets the economic incentives right for all the individual actors, leaving the social result largely unpredictable. The former starts with a social goal and tries to impose it from above, leaving individuals with perverse incentives to undermine it. The latter depends for its success on people acting in their self-interest. The former depends for its success on preventing people from acting in their self-interest.

I think I can probably count on the fingers of two hands the number of people in health policy who accept the economic way of thinking. All the rest — 99.9% of the total, including a lot of people with “Ph.D., economist” after their names — reject it in spades.

Almost everybody in health policy thinks you can have a plan designed by people at the top that will work, even though every doctor, every nurse, every hospital administrator and 310 million patients all have an economic self-interest in defeating the plan.

They are so convinced of the collectivist vision of health care they do not even think it’s necessary to discuss the incentives of individuals. For example, Harvard health economist David Cutler (who admits to having a hand in the health reform bill) wrote an article the other day entitled, “The Simple Economics of Health Reform,” in which he mentioned the word “patient” not even once. For perspective, this would be like an economist writing about the market for gasoline without even mentioning the people who drive cars, trucks and vans. It would be like an economic analysis of the housing market that completely ignores the role of homebuyers.
Here are some points I’ve made before that completely escape Cutler, but should be included in any economic analysis of health reform:

• Thirty-two million otherwise uninsured people will try to double their consumption of medical care.

• Almost everyone with private insurance and all Medicare enrollees will try to increase their consumption of preventive services — promised without deductible or co-payment.
• With no increase in supply, doctors and patients will face a huge rationing problem.

• There will be up to 900,000 additional emergency room visits and the time price of care (rationing by waiting) will jump substantially at every emergency room, every primary care facility and for most specialty services as well.

• If everyone in America succeeds in getting all the recommended preventive care, for example, primary care physicians will have to spend more than 7 hours of every working day delivering services to basically healthy people.

• Patients whose plan pays below-market rates will be pushed to the rear of the waiting lines; this includes our most vulnerable populations — the elderly, the disabled and poor families on Medicaid.

• In the meantime, a large flourishing market for concierge services is likely to emerge — draining resources from the third-party payer system and making the rationing problem worse for all who are left behind.

In general, the left is obsessed with distributional issues. That’s why it’s so surprising that they passed a law that is going to force middle- and upper-middle-income families to have more insurance than they really want. Once they have it and act on it, they will in the process make access more difficult for the poorest and most vulnerable segments of society.

It’s amazing how much you can learn if you really do take advantage of some “simple economics."

Doctors in America

It isn’t easy to explain what being a doctor in America is about, or to tell what we do or even how many of us there are. People disagree about the number of physicians. It depends on how you dice and splice the numbers.

Some say there are 780,000 of us; others say 900,000. Roughly 550,000 of us are on the frontlines providing care. About 300,000 of us are primary care physicians (family physicians, general internists, pediatricians). The rest of us are specialists, though, if truth be known, many specialists practice primary care. About half of us are independent practitioners who own our practices. Groups, hospitals, and other organizations employ the remainder.

We are a heterogeneous bunch. We have minds and opinions of our own. Critics complain we are “fragmented.” In some ways, according to our critics, we are like the rats of Hamelin City who followed the Piper,

“AND out of the houses the rats came tumbling,
Great rats, small rats, lean rats, brawny rats,
Brown rats, black rats, gray rats, tawny rats,
Grave old plodders, gay young friskers,
Fathers, mothers, uncles, cousins,
Cocking tails and pricking whiskers,
Families by tens and dozens.
Brothers, sisters, husbands wives –
Followed the Piper for their lives.”

The critics are wrong. We are not rats, and we follow no single Piper.

We are good people, solid, smart, hard-working, well- intentioned, well-educated, well-trained, and well-prepared for the tasks at hand.

No national Piper speaks for us. The Obama administration does not represent our views. Only 15% of us belong to the AMA. Most of us belong to state medical societies, who are represented by the Physicians Foundation, a national organization. The Physicians Foundation is 8 years old and is still developing its voice of unity. Most physicians are members of specialty societies, each of which has its own ax to grind.

Our political views tend to differ geographically. Those of us in the South and West lean conservative. Massachusetts physicians are more liberal: 66% of 1000 doctors there favor single-payer or a public option. They regard the current reform law as too timid for progressives.

Those of us who are politically active on the national scene tend to be Republican. Eighteen of the 20 now serving in House or Senate are Republicans, and most of these physician-politicians favor repeal and replacement of the health reform law. Two things we conservatives and liberals and independents agree upon: fixing the Sustainable Growth Rate (SGR) formula and tort reform.

We physicians are said to be “bimodal,” meaning young doctors and older doctors have different perspectives. This may be partly because 50% of medical graduates are now women. Or perhaps it is because young physicians, men and women alike, are focused on a balanced life-style and benefits of being employed. The older among us tend to carry on as before, working hard and independently.

Only 2% of young medical school graduates contemplate a career in primary care. The others pick specialties, particularly the so-called ROAD fields (Radiology, Ophthalmology, Anesthesiology, and Dermatology), where hours are predictable and incomes are high. Fifty percent of young doctors are choosing employment rather than private practice.

Caught in the middle are those of us from 45 to 55, who will try to make our best go of it with the time we have left, but don’t always know which way to go. We are 50,000 short of physicians needed to meet current demand, and 25% of us are foreign-trained doctors who are helping fill in the demand gap.

The public doesn’t always understand us but three-fourths of them in polls say they trust us. They like their own doctor, but they don’t like the system and its costs. Patients do not usually complain about quality. They do not understand that for the most part we do not set our fees. Medicare in conjunction with an AMA-appointed committee does that. They do not understand we are paid according to a byzantine coding system, developed by others. Other third parties understand and follow Medicare’s lead.

The public may not understand that doctors account directly for about 25% of health costs, with the rest going to hospitals, long term facilities, other health professionals, and fiscal intermediaries. The public does not understand that third parties, insurance companies and others, tell us what we can and cannot do and what we can and cannot be paid for. The public may not understand that the health care industry employs 14 million people and has added 800,000 jobs during the recession. Health care is our most robust economic sector and makes up 17% of the GDP.

The old saying “Doctor knows best” has become a mockery. Government officials, health information technology types, and consumer experts of every stripe think they know best.

But the wise men and women among us know that a fully informed patient, acting in concert with their physician, knows best. Consumers spending more of their own money are very smart people.

Still, second-guessing has become an epidemic. Protocols, guidelines, checklists, and algorithms are the rage, and data outcome measurements have become the main criteria for separating good doctors from bad. Population management, not individual choice, is the wave of the future. Everything now is labeled as a “team effort,” rather than a personal decision. If the “team” consists of those close to the patient-doctor, maybe that’s the way it ought to be.

Our critics are fond of saying we are “poor” businessmen, yet our incomes tend to be high, usually above $200,000 for specialists. Others maintain that we don’t get it, i.e., the economic forces at work, the Internet revolution, and the demand for lower costs with higher proven value. Others assert that we deny the need for reform or the power of IPad, IPod, and Internet-searching consumers.

We get it, alright. We know the economic ground is shifting under our feet. Most of us are technologically savvy. We are simply not yet blind believers in electronic health records as the Holy Grail for Health Care Improvement and Higher Quality. EHRs, in the opinion, of many of us, are not ready for prime time and are not, at present, a wise investment with adequate returns.

Many Washington politicians, policy wonks, and those in information technology app circles maintain health care is too important to be left to doctors, just as war is too important to be left to generals. Outcome counts and body counts are what count. They could be right. Time and the health of the people and wisdom of voters will tell.

I agree with Margaret Thatcher. She observed, “I have a deep skepticism about the ability of politicians to change the fundamentals of the economy or society; the best thing they can do is to create a framework in which people’s talents and virtues are mobilized not crushed.”

Richard L. Reece, MD, blogs a Medinnovation and has a website under constuction. He is the author of three recent books, Obama, Doctors, and Health Reform (Iuniverse, 2009), Innovation Driven Health Care (Jones and Bartlett, 2007), and an E-book, Pros and Cons of Accountable Care Organizations (Practice Support Resources, 2011). He works with The Physicians Foundation, a 501C3 organization representing physicians in state medical societies. Opinions expressed in his blogs are his alone. He can be reached at

Saturday, January 22, 2011

Ask Not: Health Reform Propositions

And so, my fellow Americans, ask not what your country can do for you: ask what you can do for your country.

John F. Kennedy, Inaugural Speech, January, 1961

The best book title I have run across recently is Ask Not. The book’s author is Thurston Clarke. Clarke is the author of eleven books, the most recent of which is The Last Campaign: Robert F. Kennedy and 82 Days That Inspired America (2008).

Clarke’s present book’s title is short. It is precise. And it evokes the image of President John F. Kennedy’s famous inaugural address. The book’s subtitle is The Inauguration of John F. Kennedy and the Speech That Changed America.

Kennedy's proposition is powerful and masterful as a speech theme. It is direct. It is personal. It provokes and inspires the listener. And it mobilizes the mind. What can you do for your country? It galvanized the Peace Corps, Civil Rights movement. It helped win the race to the moon.

Ask Not got me thinking. Perhaps a similar proposition could be applied about health reform. It might go like this:

And so, my fellow American politicians, ask not what you can do for yourselves, ask what you can do for your fellow Americans.

These propositions logically follow.

Ask not what the health reform law can do for you, ask what it has done after its passage 10 months ago. One chamber of Congress has voted for repeal by a margin greater than passed it. More than half of the states have challenged the constitutionality of its individual mandate. The law remains unpopular by 55% to 40% among Americans. Health spending and premiums are soaring at a 10% clip. Claims that it will allow you to keep your health plan have proven false.

Ask not what the health reform law can do for you: ask what it does and does not do for your fellow citizens. What it does in the short term, between now and 2014, is provide poll-proven popular benefits for 12.4% of Americans – coverage for children with pre-existing illness, young adults under their parents’ plan; reduced prescription costs for seniors in the Donut Hole. What it does not do is provide cost relief for the other 87.6% of Americans; offer any tangible or believable cost controls; or provide any hope that Americans will be able to keep their current coverage.

Ask not what the health reform can do for you: ask what it will do to the nation’s growing deficit. Ask who is more honest, those who fed the CBO figures leading to an estimate that the reform bill would save $230 billion between 2014 and 2020; or those who say the true costs will be $2.3 trillion between 2014 and 2024. Charles Krauthammer,MD, puts it this way: "Suppose someone - say, the president of United States - proposed the following: We are drowning in debt. More than $14 trillion right now. I've got a great idea for deficit reduction. It will yield a savings of $230 billion over the next 10 years: We increase spending by $540 billion while we increase taxes by $770 billion. He'd be laughed out of town."

Ask not what health reform can do for you and for Inside-The-Beltway experts: ask who should control health care decision-making – bureaucrats or doctors and patients. Britain has made its decision; its 42,000 general practitioners, not National Health Center bureaucrats, will decide how the money is disbursed. Where will be the U.S. government come down on clinical decision making? Will it be experts inside CMS and HHS, with their protocols, guidelines, checklists, algorithms , outcomes analyses, and exchanges who decide, or will it be patients and doctors at the point of care.

Ask not what government health reform can do for you: ask what enterprising and innovative markets can do for your fellow citizens. Do you believe that top-down government has more wisdom than people on the ground: physicians, entrepreneurs, patients and people themselves? Do you believe government has the capacity for disruptive innovations that will lengthen lives, restore health and life style, and bring medical breakthroughs to bear? You may be right. but history is not on your side.

Thursday, January 20, 2011

Comparative Health Statistics between Nations

Preface: Recently a friend sent me this note with these statistics (see below after preface):

“A recent Investor's Business Daily article provided very interesting statistics from a survey by the United Nations International Health Organization.”

I was unable to document the source of these statistics. I could not find the original Investor’s Business Daily article, nor could I find an organization called “The United Nation’s World Health Organization.” I presume the sender meant the World Health Organization (WHO), but I could not find these statistics in any WHO study either. Sounds like a little cherry picking of statistics favorable to the U.S. is going on here.

Nevertheless, these statistics ring true. They re-enforce why many insured Americans like their health care system and why its costs are so high – ease of access to specialists and high tech procedures and effectiveness of the U.S. system in treating cancer and restoring function through such procedures as hip and knee replacement.

Percentage of men and women who survived a cancer five years after diagnosis:
U.S., 65%
England, 46%
Canada, 42%

Percentage of patients diagnosed with diabetes who received treatment within six months:
U.S., 93%
England, 15%
Canada, 43%

Percentage of seniors needing hip replacement who received it within six months:
U.S., 90%
England, 15%
Canada, 43%

Percentage referred to a medical specialist who see one within one month:
U.S., 77%
England, 40%
Canada, 43%

Number of MRI scanners (a prime diagnostic tool) per million people:
U.S., 71%
England, 14%
Canada, 18%

Percentage of seniors (65+), with low income, who say they are in "excellent health"
U.S., 12%
England, 2%
Canada, 6%

I'm reminded of a saying from an anonymous source: "Statistics can be made to prove anything - including the truth."

Survey: Two-Thirds of Doctors Fear or Oppose Health Reform Law

I am big on objective doctor surveys. They tend to reveal how doctors really think about health reform.

I have often quoted two Physician Foundation surveys, conducted by Merritt Hawkins, the big physician recruiting firm, one of 300,000 primary care physicians and the other 0f 40,000 doctors across all specialties. Both of these Foundation surveys indicate physician discontent, among 60% to 70% of physicians, towards the current state of medical practice, and a similar percentage reflecting physician opposition towards health reform measures in the Accountable Care Act.

Now I would like to cite another survey, this one by Thomson Reuters, the huge media conglomerate, of 2958 physicians. Here is how physicians responded to their survey.

• When asked where mostly newly insured would get care, 55% said nurse practitioners or physician assistants.

• 57% predicted reform changes would be negative, 27% were positive, and 15% were neutral.

• Of electronic medical records, 37% said EHRs would help, 37% were neutral, and 24% said EHRs would harm.

• When asked about the quality of health care in the U.S. over the next five years, 65 percent of the doctors believed it would deteriorate with only 18 percent predicting it would improve.

The Thomson Reuters surveyors concluded: “ Our present survey suggests that greater attention should be paid to understand the present opinions of the health care provider constituency before proceeding down the path of reform. Without physicians supporting change, it will be difficult to accomplish.”

Health Care Repeal by the Numbers

As I watched the health repeal debate in the House yesterday, I kept asking myself: How many Americans would be effected if repeal were to actually occur? Democrats speaking against repeal insisted that the health reform law was now already helping “millions” of people.

Repealing it, therefore, would be inhumane. How many millions? What percent of the U.S. population? In a Mother Jones piece yesterday, I ran across these numbers on the impact of the present reform law in 2011.

• 4 million small business owners will be eligible to receive a tax credit for their employees in 2010. That’s 1.3% of 308.7 million Americans.

• 4 million Medicare beneficiaries will receive a $250 rebate check since the Donut Hole was closed on January 1, 2011. That another 1.3% of Americans.

• 2 million uninsured children with pre-existing conditions cannot be denied coverage – 0.65% of Americans. In 2014, 129 million Americans with pre-existing illnesses could not be denied coverage. But that’s 2014, not 2011.

• 2.4 million of young adults will now receive coverage through their parents’ plans – another 0.78% of Americans.

• 10,700 people will keep their coverage due to “recission,” which entails stripping people of coverage when payments are too costly, 0.03% of Americans.

• 18,600 to 24,700 people will hit a lifetime limit and will be denied coverage above that ceiling – 0.06% to 0.08% of Americans.

All told, according to Mother Jones, 12.4 million Americans (4.0% of the total population) will benefit from the law starting in 2011 and would suffer from repeal.

These are big numbers, but not as big as the 308.7 million Americans that the health reform law would effect. These include all of us who would pay for the individual mandate, those of us who would be compelled to switch from their present plans to plans authorized by government, and those among us who would pay $500 billion in higher taxes and health care premiums required to meet the law’s provisions.

Wednesday, January 19, 2011

Doctors in Congress

Preface: This previous blog of mine was recently reprinted in The Health Care Blog, the most widely read blog on health care issues. It has relevance because 15 of the 16 doctors in House and Senate are Republicans and will participate in the debate and will vote on whether to repeal Health Reform.As I go to press, I learn of a November 18 Washington Post article, "Many of the Doctor-Legislators Oppose Health Laws." It says, in essence, that of the 20 physician legislators, 18 oppose the law.

When new members of Congress are sworn in this January, there will be a total of 20 doctors in Congress – 3 Senators and 16 Congresspersons. That will be a 27% increase over 2009,from 15 to 19, in doctor members of Congress. These doctors will make up 3.5% of the 535 members of Congress, but will fall far short of the 10.7% who were signers of the Declaration of Independence.

Eighteen of the 19 new members are Republican. This may say something of the mood of America towards health reform, but it may have little effect on whether the health reform bill is repealed or retained in its present form.

Fifteen of the 19 are from the South or West, 5 are Ob-Gyn specialists, and 12 represent specialties who perform surgery. What this means or portends I do not know. Perhaps they will not hesitate to perform surgery on the bloated national budget and cut deficits. I take solace in recent polls, which indicate 77% of the public trust doctors to do right thing vs. 11% who trust Congress.

Here is the list of the 19 doctors in Congress:

Senate Incumbents

1. Tom Coburn (R, Republican), Oklahoma, family physician and ob-gyn
2. John Barasso (R, Wyoming), orthopedic surgeon New Senator
3. Rand Paul, (R, Kentucky), ophthalmologist

House Incumbents

1. John Boustany ( R, Louisiana), cardiovascular surgeon
2. John Fleming (R, Louisiana), family physician
3. Bill Cassidy (R, Louisiana), gastroenterologist
4. Tom Price, (R, Georgia), orthopedic surgeon
5. Paul Brown (R, Georgia), family physician
6. Phil Gingrey(R,Georgia), Ob-Gyn
7. Ron Paul (R, Texas), Ob-Gyn
8. Michael Burgess(R, Texas), Ob-Gyn
9. David “Phil” Roe (R, Tennessee), Ob-Gyn
10. Jim McDermott (D, Washington), psychiatrist

New House members

1. Larry Bucshon (R, Indiana), thoracic surgeon
2. Andy Harris (R, Maryland), anesthesiologist
3. Dan Benishek (R, Michigan), general surgeon
4. Nan Hayworth (R, New York), ophthalmologist
5. Scott DesJaris (R, Tennessee), family physician
6. Joe Heck (R., Nevada). emergency room physician
7. Del Donna Christensen (D,Virgin Islands), family physician

Richard L. Reece, MD, is pathologist, editor, author, speaker, innovator, and believer in abilities of practicing doctors and their patients to control and improve their health destinies through innovation. He is author of eleven books. Dr. Reece posts frequently at his blog, Medinnovation. He works with but does not speak for the Physicians Foundation, a 501C3 organizations that represents physicians in state medical societies.


I thought it interesting that almost all of the physicians in Congress are Republicans. From that I infer that they also support conventional 'tort reforms' as the panacea for cost-growth in healthcare. I'm not a physician but I know that this set of reforms will do absolutely nothing for patients and premiums.
Posted by: Richard D | Jan 13, 2011 6:25:59 AM

Thanks for sharing this information. I don't see this as a positive development, as specialty physicians are much more likely to support the status quo which favors specialty and invasive care reimbursement vs primary care. I would be shocked if they are willing to tackle the issue of primary care shortages given the implications for their own reimbursement.
Posted by: Bill | Jan 13, 2011 7:23:56 AM

3 Senators in senate, which is only 3 percent is not very encouraging. America needs more doctors as their representatives in Congress and Senate for better health care system and delivery.
Posted by: Online Health Guy | Jan 13, 2011 7:24:52 AM

Dear Richard D. Thank you for your comment. I appreciate it.
But I have a question: How do you “know” with certainty that tort reform “will do absolutely nothing for patients and premiums.” “Absolutely nothing” strikes me as a sweeping conclusion. Based on what evidence?

According to Towers Perrin, medical malpractice, including legal-defense costs and claims payment, cost the health system $30.41 billion in 2007. In 2003, HHS estimated that limits on malpractice awards could cost between $70 billion and $128 billion. In A 2008 report, the CBO said limiting malpractice awards would tend to limit malpractice spending. In Texas, which enacted malpractice caps in 2003-2005, liability rates have fallen 27.5% on average.

The costs of “defensive medicine,” the ordering of unnecessary tests in anticipation of a possible future malpractice suit, are unknown, but a study in JAMA FROM the University of Pennsylvania indicated 59% of high-liability specialists said they ordered unnecessary tests for defensive purposes. In 1996, David Kessler and Mark McClellan,writing in the Quarterly Review of Economics and Finance, estimated defensive medicine costs between $100 billion and $178 billion, 3.4 to 6.8 times the cost of defending malpractice suites, paying compensation, and covering administrative costs.

To be sure, I do not “know” with “absolute certainty” what tort reform would do for patients or if it would reduce their premiums. But, based on the Kessler and McClellan estimate of a 5% to 9% reduction in medical expenditures, there is reasonable chance these costs reductions could ripple down to reduced patient premiums.
Posted by: medinnovation | Jan 13, 2011 7:38:27 AM

Thanks for responding. There was a paper in Health Affairs by Michelle Mello that took the Kessler McClellan estimates and showed that it resulted in a max saving of 45-50b dollars. See here:

The Texas number that you cite is a little misleading: you need to also tell your readers that the growth rate of premiums fell everywhere (ie, not just in Texas). My point is not that conventional tort reform is small potatoes. The physicians in Congress will cite the same papers and numbers that you have, but if you do the extrapolation more carefully, it doesn't get you much.
Posted by: Richard D | Jan 13, 2011 7:56:32 AM

Sorry: in my post above, I meant to say that conventional tort reform is small potatoes even using the Kessler McClellan numbers. I managed to stick in a 'not' by accident.
Posted by: Richard D | Jan 13, 2011 7:58:50 AM.

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Posted by: Andrew | Jan 13, 2011 9:05:34 AM

"To be sure, I do not “know” with “absolute certainty” what tort reform would do for patients or if it would reduce their premiums. But, based on the Kessler and McClellan estimate of a 5% to 9% reduction in medical expenditures, there is reasonable chance these costs reductions could ripple down to reduced patient premiums."
Show me in states (including TX) that have tort reform where this occurs? There is no trickle down - Reagan Myth.
Posted by: Peter | Jan 13, 2011 9:19:30 AM

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Posted by: Paul | Jan 14, 2011 7:25:41 AM

Readers, just watch out for the legal advocates here who want to dismiss and demean realistic calls for tort reform, because their lobby will be affected by it.
How fascinating, and equally repugnant, that there are those who so overty project their greedy agenda onto all physicians as the bad guys, yet have no negative commentary about the role lawyers play in this debacle of health care expenses.
Unfortunately, narcissism does not discriminate in professions as well. I rest my case!
Posted by: DeterminedMD | Jan 14, 2011 8:05:54 AM

Tort reform (or at least the GOP version where you have a $250k hard cap on pain and suffering) will do next to nothing to slow healthcare costs or to benefit doctors or patients. Hell, being more aggressive on fraud in Medicare/Medicaid would yield more savings.

Four Will-O’-the -Wisps of the Health Reform Debate

Today debate begins in earnest on whether to repeal the health reform law, which brings up the subject of "will-o'-the-wisp."

A will-o’-the wisp is a phosphorescent light sometimes seen at night over swampy ground, caused by spontaneous combustion of gases giving off by rotting organic matter. Will-o'-the-wisp is also a false, elusive, and misleading hope or question.

Will-o’-the – wisp is an apt metaphor for the 4 central questions that will dominate the health reform debate for the next two years.

Here is how the New York Times articulates these will-0’-the wisp questions.

“Will the health care law, approved last year by Democrats with no Republican support, increase or reduce future federal deficits? “

“Will the law lead to the elimination of jobs by overburdened employers as Republicans assert, or will it create jobs as Democrats maintain? “

“Will the law raise or lower the cost of medical care for individuals and families, employers, and state and federal governments?”

“And, will the law achieve President Obama’s goal of providing coverage to more than 30 million uninsured Americans? “

Answers to these questions lie in the future and are unanswerable at present. The answers depend on financial and ideological assumptions untested by reality. One can take the same set of data arrive at totally different conclusions, and no one can challenge you because nothing has happened yet.

Take the question of federal deficits.

The Congressional Budget Office says repealing the Affordable Care Act would increase the deficit by $230 billion over the coming decade and by a modest amount in the decade after that.(1) The CBO estimate has become the central defense by ACA advocates fighting the upcoming repeal vote in the House. Democrats also maintain the cost of adding 32 million people to entitlement rolls will be "only" $938 billion through 2019.

But previous CBO officials assert the $938 billion figure is a "fictitious" low-ball estimate, and true costs after ten years of full implementation in 2014 will be "more like $2.3 trillion." (2)

Besides, these past officials add, “The history of federal entitlements is one of inexorable growth. Once erected, more and more people get added to the programs. The ACA will be no different. Spending will soar, and the tax hikes and spending ‘offsets’ that were cobbled together to get the bill passed will either wither away or vanish altogether.”

And so it goes. So much depends on assumptions, projections, political posturing, and real world events, such as the recovery of the economy and the size of the deficit.

Republicans face the political danger of being perceived as lacking compassion, and Democrats as being unrealistic.

Between them lies a political swamp.

In 2010, voters will decide who won the political arguments, whether the arguments were mainly "gas," and whether the health reform law will,

• restrict choice and freedom

• raise costs for individuals

• increase deficits

• create jobs

• improve care

. aggravate the doctor shortage

• widen access


1. David Herszenhorn and Robert Pear, “Basic Questions, Elusive Answers, “ New York Times, January 18, 2011.

2. Douglas Holtz-Eakin, Joseph Antos, and James Capretta, “Health Care Repeal Won’t Add to the Deficit, “ Wall Street Journal, January 19, 2011

Richard L. Reece, MD, blogs a Medinnovation and has a website under construction. He is the author of three recent books, Obama, Doctors, and Health Reform (Iuniverse, 2009), Innovation Driven Health Care (Jones and Bartlett, 2007), and an E-book, Pros and Cons of Accountable Care Organizations (Practice Support Resources, 2011). He works with but does not speak for The Physicians Foundation, a 501C3 organization representing physicians in state medical societies. He can be reached at

Tuesday, January 18, 2011

Why Doctors Should Profit from Dispensing Medications

Preface: This is a previous blog of mine that reprinted on January 16, My reasoning is fairly straightforward. Doctors spend a lot of time writing prescriptions. Prescription writing requires medical knowledge. Office dispensing is legal in 35 states. Office prescribing saves patients money. Currently, patients do not fulfill 30% of prescriptions.. Office dispensing increases compliance. So why not? This blog drew 57 comments from among his 37,000 readers. , Some positive, some are negative from Kevinmd readers. You may go to hhis blog to read these comments . In 2008, was voted the number one health care blog.

Hold onto your hats. I am about to enter dangerous territory. I am about to suggest maybe doctors should profit from dispensing medications from their office to offset declining reimbursements and rising expenses by using prescriptions as a source of ancillary revenues.

Why dangerous? For a number of reasons.

One, physicians still grapple with the perception that it is improper for a physician to make money from the delivery of care from business ventures.

Two, profit-making from prescription writing might induce physicians to write unnecessary prescriptions.

Three, prescriptions for profit might lead to conflict with pharmacists.

Four, Some states prohibit physician office dispensing, and more dispensing might lead to other states prohibiting the practice.

Five, there is also a fear that such a physician business venture carry significant risk relative to government regulation.

Then, there’s the other side of the issue. Writing prescriptions and ordering their refills takes a lot of physicians’ time. It also takes knowledge. It carries some malpractice risk, should the patient suffer an adverse reaction. Dispensing from the office would be convenient for patients. Since 30% of patients never fill their prescriptions, office dispensing is more likely to assure compliance. And prescriptions dispensed at the office are generally significantly less expensive than those filled at the local pharmacy.

Besides, physician can work only a finite number of hours and see a finite number of patients. The rational way to increase revenues is to identify revenue streams that do not involve an inordinate amount of incremental time on the part of the physician. Ancillary services can assist the physician in his ultimate goal of providing quality medical care (often in his own office setting) while producing a profit for his efforts.

Add to this fact the reality that physicians across the country are already performing an increasing number of ancillary revenue-producing services – lab tests, x-rays, imaging services, osteoporosis screening, electrocardiograms, physical therapy units, alternative medicine and herbal drug sales, diabetes management programs, and weight management programs.

Are there other ways physicians can increase their compensation without sacrificing lifestyle or running afoul of government regulation?

Yes there are, and profits from prescribing is one of them. But again, consider the negative factors before setting up an office dispensing system.

• Hesitancy to change existing practice patterns

• Fear of being labeled sat “commercial”

• Lack of office space to store drug inventories

• Reluctance to buy inventories.

• Reservations about upsetting local pharmacists

Still, why shouldn’t a physician with an entrepreneurial orientation is allowed to design a plan for ancillary service delivery, execute it and make a profit?

Why not office dispensing? After all, a typical doctor sees 20 patients a day, writes one and half prescriptions and one a half refills per patient, or three for each patient. That amounts to 60 prescriptions per day. And that doesn’t count all those phone calls asking for refills. If these doctors were to have an average profit of $5 per prescription, that would be an extra $300 a day.

The linkage of e-prescribing with EHR systems, the ability of mobile iPads to send e-prescriptions, and concerns about the hazards of illegible doctor handwriting, and the push for more practice efficiencies, electronic prescribing is very much the rage these days.

So why not have the ability to e-prescribe inside the office using targeted software to write and refill prescriptions and to issue a bill?

Media, Left and Right, on Health Repeal Debate

Preface: This week’s health reform debate has provoked a media outpouring, generally along partisan lines. Here are articles from left and the right from January 16 and 17.

1) House to Debate Health Care Law Repeal - Felicia Sonmez, Washington Post

2) Health Reform Provides Peace of Mind - Judy Putnam, Detroit News

3) Government Shouldn't Restrict Choice of Doctors, Plans - Scott Atlas, NRO

4) More Government in Health Care? Yes. - Jonathan Cohn, The New Republic

5) Repeal Law and Restore Fiscal Sanity - Holtz-Eakin, Antos & Capretti, Real Clear Politic

6) Get in Line for Your Health Care Waiver - Rep. Mike Rogers, Detroit News

7) Health Reform Will Drive Down Deficits - Froma Harrop, Providence Journal

8) Democrats Seek Redo of Health Care Pitch - Jennifer Haberkorn, Politico

9) Tick, Tock: Cost of ObamaCare a Timebomb - Timothy Carney, Examiner

10) Yes, Congress Can Make Health Care Cuts Stick - Jonathan Cohn, TNR

11) Health Care System Will Always Need Gov't - Ezra Klein, Washington Post

12) Health Care Reform's Unlikely Ally - Steve Benen, Political Animal

13) Free Market Health Care - Kevin Drum, Mother Jones

ACOs- The Hottest Thing in Health Reform

Who would have believed it? The subject of Accountable Care Organizations (ACOs) accounted for only 7 pages of the 2500 page health reform bill. Yet ACOs are now the buzz, the rage, the hottest 3-letter acronym since sliced bread, and the most talked about subject in hospital board rooms, medical staff lounges, and the medical talk circuit, and consultant enclaves.

Why is this? Why all the hype?

• The Obama administration is banking on hospital-doctor collaboration to save at least $5 billion for Medicare and to “bend the cost curve.”

• For the government, ACOs open the conceptual door for switching from open-ended fee-for-service payments to closed budgeted reimbursements.

• ACOs strike at the very root of hospital-physician relationships, their dependence on each other, and physician independence.

Since the passage of the Accountable Care Act on March 23, 2010, I have been waving the yellow flag of caution on ACOs. ACOs raise antitrust issues in rural areas, hospitals tend to control them, and they threaten the very existence of private practice. On the other hand, hospital-physician collaboration seems to many outside observers as the right thing to do.

I have discussed positives and negatives of ACOs in 10 previous Medinnovation blogs, which you may want to read. To do so, go to search box on medinnovationblog and type in ACOs. The following ten blogs will appear.

1) January 7, 2011 – Accountable Care Organizations – Rosy and Not So Rosy Scenarios

2) January 6, 2011- Hospital Physician Relationships, Accountable Care Organizations, and Health Reform

3) December 10, 2010 – Accountable Care Organizations(ACOs) – Negative Reaction Among Physicians

4) November 21, 2010 – The Obama Administration in a Clash All by Itself over Accountable Care Organizations: Has Government Created A Cost-Raising Monster?

5) November 8, 2010 – The Hospital-Doctor Hiring Wave

6) October 18, 2010 – Accountable Care Organizations as Private Practice Killers

7) October 7, 2010 – On Being Politically Correct and Realistically Correct about Accountable Care Organizations

8) September 16, 2010 – Accountable Care Organizations – California or Bust?

9) June 23, 2010 – Saving Medicare Through Accountable Care Organizations – It’s A Long, Long Way to Tipperary

10) June 14, 2010- Whats, Whys, and Hows of Accountable Care Organizations

Richard L. Reece, MD, blogs a Medinnovation and has a website under constuction. He is the author of three recent books, Obama, Doctors, and Health Reform (Iuniverse, 2009), Innovation Driven Health Care (Jones and Bartlett, 2007), and an E-book, Pros and Cons of Accountable Care Organizations (Practice Support Resources, 2011). He works with but does not speak for The Physicians Foundation, a 501C3 organization representing physicians in state medical societies. He can be reached at