Monday, February 28, 2011

ACOs and the Control of Physician Economic Behavior

We've been down this road before. Back in 1988, we called the present day ACOs HMOs. The HMO idea was to control the behavior of primary care physicians by cutting down on hospitalizations and referrals to specialists through gatekeeper models.

The net effect? Disappearance of solo practice, growth of groups, and massive hiring of doctors by hospitals and “integrated health systems,” and a backlash against HMOs and managed care in general.

In 1988, Minnesota, along with California, was an epicenter of the HMO movement. As Editor of Minnesota Medicine, I wrote,

“ I shall discuss the struggle now going on for control of health care. This struggle is mainly between the management of corporations and physicians. It is a struggle for power. To be effective in the marketplace, corporations have to harness physicians to corporate goals, thus creating internal discipline and compliance; to be independent professionals, physicians have to be free to choose what they want for patients. The government, economists, and leaders of large organizations favor the corporate strategy because it is a way of making physicians behave economically.” (And Who Shall Care for the Sick? Media Medicus, 1988).

ACOs are HMOs revisited. Both have the primary purpose of controlling physician behavior. The difference between ACOs in 2011 and HMOs in 1988 is that a number of controlling management tools have been added - pay-for-performance, evidence-based-medicine guides, clinical algorithms, electronic medical records, global budgets, and “savings” to be distributed among hospitals and doctors.

Will ACOs work any better than HMOs? HMOs ran into backlash among doctors and consumers, both of whom resented the restraints placed up their clinical freedoms?
HMOs controlled costs, but only temporarily in the early 1990s.

I do not know. I do know the management tools I mentioned above – P4Ps, EHRs, and other tools for electronic monitoring – have a mixed record for saving money and improving quality.

As John Goodman says in his February 28 blog, “The HMO in Your Future,”

“Whether they raise or lower costs, whether they raise or lower quality, there is one thing that ACOs will indisputably accomplish. They will drive doctors into organizations where their behavior can be controlled. For the first time in our history, both the practice of medicine and the way money is spent on medical care will fall under federal control.”

Sunday, February 27, 2011

Technology and Humanity : The Janus of Health Reform, As Portrayed in the Sunday New York Times

February 27, 2011 -Janus was a Roman God with two faces. Each face looked in opposite directions. This suggested vigilance and fair-mindedness.

I evoke the name of Janus because because today’s Sunday New York Times contains articles by two of my favorite writers.

• Steve Lohr, a journalist, The Time’s commentator of innovation, whose column appears every Sunday.

• Abraham Verghese, MD, a Stanford professor of medicine, who writes regularly about the use and abuse of medical technology.

General George Patton was once asked if he read the Bible. He replied, “Every G—D--- Day”! Likewise, I read the New York Times “Every G—D--- Sunday!” To me, the Times is the Bible of American liberalism. I like to know what its business and health care staff are saying.

Steve Lohr is saying a universal interoperable electronic medical records system is a vastly ambitious idea that has a long way to go. In an excellent piece, “Carrots, Sticks and Digital Health Records, “ he describes how and why government is spending an estimated $27 billions in incentives to convert doctors and hospitals to adopt electronic doctors by 2015.

After that, doctors who serve Medicare and Medicaid patients will be financially penalized who don’t meet use and reporting rules for electronic records. It’s a huge gamble. Big organizations – like Mayo and Kaiser and the Marshfield Clinic – are on board. But small practices are not. Less than 30%, Lohr’s figure, now use digital records. A year or so ago, a New England Journal survey, put the estimate for “full-use” of EHRs at less than 10%. I suspect the NEJM is closer for "full" EHR use.

Verghese’s article, “Treat the Patient, Not the CT Scan,” is more chilling. He says 80 million CT scans are now being performed, often sacrificing the time-honored ritual of listening to or examining the patient and endangering the patient to unneeded radiation.

In his opinion, medical technology can blind doctors to the needs and problems of the sick. He tells the story of of a woman who arrived in the E.R with seizures and breathing difficulties. She had been seen by multiple doctors over the course of the years before her ER arrival.

A CT scan in the ER revealed multiple breast masses, which should have been easily palpable on physical exam. In his Verghese’s word, “ I got to see the CT scan: the tumor masses in each breast were likely visible to the naked eye – and certainly to the hand. Ye they had never been noticed.” He added that “I am collecting stories like this from all over the country.” A thorough physical exam is a comforting ritual for patients - and can pick up disease before technological intervention.

Janus would understand: technology and humans represent the two faces of medicine

Saturday, February 26, 2011

Seek, Speak, and Ye Shall Find

Nuance Healthcare Development Platform Brings Medical Speech IBM to Collaborate with Nuance to Apply IBM's 'Watson' Analytics Technology to Healthcare

Press Release, Nuance Inc., February 22, 2011

Human understanding is based on voice cognition,
Therein rests the power of computer speech recognition.
Reform is about walking the walk.
It comes down to talking the talk.
Doctors must know the story,
Of why patients are there.
Patients must take verbal inventory,
Of what doctors offer in care.
This exchange cannot be expressed numerically,
Or in the scheme of things as data generically.
The relationship is partly about finances
But more about body and voice nuances.
If the computer to each could speak,
Perhaps each could find what they seek.

Is Venice Sinking or is the Ocean Rising? A Health Reform Analogy

A feeling caused by uneasiness or apprehension

Definition of “A Sinking Feeling”

A spirited debate concerning Venice, one of the world’s most beautiful cities, is underway. The debate centers on this question: Is Venice sinking because its pilings and other underpinnings are disintegrating, or is the ocean rising because of global warming?

I thought of this question as I was reading Grace-Marie Turner of the Galen Institute latest report, “Obamacare’s Destructive Impact Already Being Felt,”dated February 25, on the sinking prospects of many health care sectors.

Reading it, I got a sinking feeling.

I asked myself: Is American health care sinking, or are our budgetary woes rising? Will uninsured numbers rise, or will deficits engulf us all?

It all depends on which gondola you are riding.

If you are in a gondolier on the left, you might say: health care is sinking because of excessive, irresponsible market-driven costs pushing us all down. In the process, fragmented providers are dragging millions of unfortunates to the bottom of the canals. Once centralized government forces are at the helm, we can refloat the system. This is the comprehensive OSHA (“Our Savior Has Arrived’) belief system.

If you are in a right-minded gondolier , you might well maintain: the weight of Obamacare is undermining the very foundations of the system. If it continues unabated and unrepealed, we shall all surely drown in an ocean of red ink. This is the incremental MWSU (Markets Will Save Us) belief system.

Grace-Marie Turner maintains the health system’s foundations are eroding.

Here is a sample of her reasoning.

Before Obamacare's provisions go into full effect in 2014, virtually every player of the health sector is sinking under the weight of government bureaucratic mandates , from doctors, to health insurance brokers, to health insurers serving seniors, children, small businesses, and families.

• Doctors: Doctors and hospitals are consolidating – fast – to protect themselves against government bureaucracies and ever lowering reimbursements.

• Brokers: Health insurance brokers are in bad shape. Insurers are cutting or even ending their commissions to meet the government's arbitrary and punitive medical loss ratio requirements.

• Health insurers: New rules on health insurance are causing people throughout the country to "lose the coverage they have now" and to have fewer options.

• Medicare Advantage members: Medicare Advantage plans serving 700,000 seniors have announced they are leaving markets due to deep payment cuts to the program in Obamacare.

• Patients and health consumers: Because of market withdrawals and other developments, many as 100 million Americans may find themselves seeking new health plans as insurers withdraw from Medicare Advantage markets, child-only markets, group markets, individual markets, and retiree markets.

• States: They are being forced to pay for Medicaid and other measures they can’t afford. They may spending their wheels, because the legal community is asking: is this whole thing constitutional? Will money now being spend to comply be money down a rat hole?

Meanwhile, the government gondola, propelled by taxpayer money and powerful bureaucratic engines, churns ahead, leaving rising debts and doubts in its wake, at least, so say its detractors.

Which gondola to ride? That is the trillion dollar question. The answer, I suppose, is: Whatever philosophy floats your gondola. But that may not be the proper response. In the end, just like the citizens of Venice, we shall all have to sink or swim together.

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 but does not speak for 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 and 1-860-395-1501.

Friday, February 25, 2011

"Obamacare" and "Romneycare" as Pejoratives

A "pejorative," according to my dictionary, is a word or expression that expresses disapproval or criticism. The political problem is that one party’s pejorative may be another party’s restorative.

Take Obamacare or Romneycare.

To proponents of the Patient Protection and Affordable Care Act, the term “Obamacare” lacks dignity and fairness. "Obamacare" crams two concepts – extending coverage and making it affordable for all – into a word used to demean it.

That isn’t fair, says Jeff Horwitt, a pollster with the Democratic firm Hart Research Associates, "The aim of the bill is to make health care more affordable and make sure more people are covered, whereas, to me, 'Obamacare' is focused on one person, and literally, it's about him taking care of someone or something: a Big Brother socialist caretaker."

But Republicans have enjoyed a heyday using “Obamacare” as a political grenade. In speeches and publications, most prominently the Wall Street Journal, conservatives, Tea partyers, and Republicans deploy “Obamacare” as a codeword for “government takeover.”

Besides, a Republican polling company Public Opinion Strategies (POS) found that in September 2010, 49 percent of registered voters reacted negatively to the term, compared to 29 percent who saw it favorably. And Stanford and University of Minnesota health care analysts, who conducted research on why voters went Republican in the November 2010 elections, said a negative perception of the health reform law contributed heavily to their decision to vote Republican.

Most Democrats regard health reform as President Obama’s signature achievement. Obama's re-election may ride on what the public (and the Supreme Court) thinks "Obamacare," or its verbal equivalent, represents.

Democratic sensitivity to use of “Obamacare” may be overdone. Every administration has a slogan that personifies its mission. President Roosevelt had the “New Deal,” President Kennedy the “The New Frontier,” and President Johnson the”War on Poverty.”

“Obamacare” is a portmanteau word - a word that combines two meanings – in the case of health reform, more coverage and lower costs. If “Obamacare works,’and it may, Democrats will be “In like Flynn”for generations to come. “Obamacare” could be just the ticket for Obama’s lasting legacy.

Now, “Romneycare. “ Inevitably, Mitt Romney’s Republican opponents are using “Romneycare “ as a pejorative against him. “Romneycare ”refers to the now five year old universal coverage bill passed during Romney’s term as Governor. The people of Massachusetts say they like the bill – for Massachusetts, but not for the rest of the country. At least, that is the main reason they gave for voting for Republican Scott Brown as their senator.

But alas, “Masscare,” as Democrats prefer to call it, or “Messcare,” as Republicans would have it, has proven extremely costly, producing the highest premiums in the nation, the longest waiting times to see a primary care doctor, some of the nation’s most crowded emergency rooms, a soaring state budget deficit.

Romney’s political rival, Mike Huckabee, former governor of Arkansas, said Romney ought to just fess up and declare the Massachusetts plan a failed experiment .

Nonsense, says Romney, every state should decide what is good of its own people. What’s good for the Bay State may not be good for other states. “A one-size-fits-all plan, “says a Romney spokesman, “ doesn’t fit for the rest of the entire nation.”

Nor does a one-size-fits-all word.

Thursday, February 24, 2011

No Beating around the Jonathon Bush

Jonathon Bush, CEO of Athenahealth, whose firm supplies software to physicians so they can collect higher fees faster, is a Cambridge-Massachusetts-based maverick. Bush does not mince words about his thoughts on the dominance of Harvard-thinkers in the government’s faltering efforts to oversee and micromanage EHR implementation.

Here a few excerpts of his attitude towards top-down government software control from a recent interview with Fiercehealth Care IT. I find Bush's language refreshing but rambling, Nevertheless, he effectively gets across his irreverent ideas.

Of Washington elites out thinking the market

“ I don’t like the idea of a bunch of guys in Washington trying to out think a thousand companies that make EMRs on what they should do--they need to go the other way. They need to think less. They need to think a ton less and let the market think more.”

Of Harvard people knowing more than the average person

“The whole 'top-down, our-people-from-Harvard-know-more-than-the-average-person-and-we-will-make-the-average-person-become-better-like-us' philosophy... I just don't want to be enslaved. I eat vegetables and I work out and I hug people and I'm a good listener and I'm a good dad and I'm a good husband...great! But anyway, I still don't want to be enslaved.”

Of the “Ghettoization” of Innovation

“ I just believe that less good ideas emerge when people are enslaved. They can't talk, they can't experiment, there's no range of motion. Healthcare has literally ghettoized crazy ideas. They do not let people do crazy ideas. What if a hospital paid a doctor $5 every time a doctor sent a patient to them completely electronically from any system. Jail term. Minimum, one-and-a-half years.”

Of the Top-Down Crowd Staying in Power

“Even if the top-down types stay in, that will result in no innovation other than wonderful ideas coming out of Washington, and that will cause the cost of healthcare to eclipse our ability to pay for it more quickly. It's happening now, but it'll just continue. And then there will be a period of time where the government simply can't fund the all-you-can-eat buffet. So they'll put wait lists and queues and they'll do the things that other nationalized health systems do, which will then cause demand to rise up and out of the government and you'll see just like in schools, a private sector emerge on top of the sediment of the public sector.”

All of which leads to this irreverent verse of mine on EHR elitism.

EHRs and “Meaningful Use”

"What can I say about 'meaningful use' that hasn’t already been said?"

Neil Versel, “HIMSS Live,”The Health Care Blog, February 21, 2011

Dear Mr.Versel:
This concerns “meaningful use,”
and its verbal abuse.
Here is something new.
aimed at the top-down few.
I do not like EHR-use mandated as “meaningful.”
It faults EHR non-users in a fashion demeaningful,
as a sub-species not worthy of full payment.
It exalts users to the point of being preeningful,
as heroes deserving full-cost defrayment.
“Meaningful use” is not an incentive.
“Meaningful use” is a disincentive.
“Meaningful use ”is left-leaningful.
It justifies federal policies interveningful,
As if only EHR- users were esteemableful.
It clears a path to government enslavement,
a road to serfdom under federal pavement.


Government may think it knoweth,
What is best for most of us,
But the market bestoweth,
What most of us wanteth.

Primary Care Revolt Against RUC (Relative Value Update Committee)

Follow the money, and you will know why.


Congress should restructure the composition of the AMA's Relative Value Update Committee (RUC). Specialists now dominate the committee.

Jim McDermott, MD, House of Representatives, “Harnessing Our Opportunity to Make Primary Care Sustainable, “ New England Journal of Medicine, February 3, 2011

We must pay our generalists on a par with our specialists or they will forever work at a disadvantage, and the system will remain forever tilted towards specialty care.

Fitzhugh Mullan, MD, Big Doctoring in America: Profiles in Primary Care, University of California Press, 2002

A revolt has been brewing out there for at least ten years among primary care physicians. With the looming shortage of primary care generalists, unsustainable specialist-generated costs, and doctors leaving or not entering primary care at accelerating rates, the revolt is about to explode out into the open.

The revolt boils down to discrepancies of pay between primary care doctors and specialists, and the role of the AMA in nominating more specialists than primary candidates to RUC (The Relative Value Update Committee). Medicare, routinely accepts what RUC recommends, and proceeds to sets fees for the codes used to pay doctors.

Here a primary care doctor, Paul M. Fisher, MD, of the Primary Care Center in Augusta, Georgia, expresses his outrage about the matter.

A Family Physician’s Manifesto

Paul M. Fischer, MD

As a third-year medical student in 1977, I joined the American Academy of Family Physicians (AAFP). In those culturally tumultuous years, it was a way to declare my belief that America needed physicians who cared for the whole person, family and community. It was also a declaration that, in choosing the primary care path in a field ripe with tempting medical specialties, money was not my primary goal.

For much of my 33-year membership, I have considered the AAFP to be “my” organization. However, there is a time when one must step back and declare independence from organizations that have lost touch with their members. The AAFP does much that supports my day-to-day life as a busy family doctor, but for 33 years, its leadership has failed to fix the central problem for primary care in America: poor reimbursement.

I deal every day with complicated health problems of complex patients who are insured by companies singularly focused on limiting even the smallest cost. In return for managing these patients, which often
involves critical and life-or-death decisions, I am paid by Medicare 60% less per hour than is a dermatologist, who, for the most part, treats trivial disease that involves no nighttime emergencies and little intellectual challenge.

The AAFP has implicitly supported this payment fiasco through its membership in the RUC, a committee of organizations focused primarily on defending surgical and specialty fees while ignoring the growing challenges and costs of the practice of primary care. Because the RUC advises Medicare on physician reimbursement, the AAFP’s involvement is tacit agreement with a reimbursement plan that undermines the health of primary care and, hence, the health of the country.

In light of the organization’s failure to effectively advocate through the RUC on behalf of its members for crucial change in physician reimbursement, I strongly urge the AAFP to immediately withdraw from the RUC and work to establish an alternative means of impacting Medicare’s physician payment decisions for the good of primary care and American health care.

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 but does not speak for 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 and 1-860-395-1501.

Wednesday, February 23, 2011

Eight Health Reform-Driven Physician Trends

Interpreting trends is useless. It can only give you answers.


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.

Jonathon Oberlander, “Beyond Repeal – The Future of Health Reform,” New England Journal of Medicine, December 9, 2010

Two forces are driving health reform – 1) the unpopular health reform law passed in March 2010; 2) the deepest recession since the 1930s.

Democrats call the health reform law a “historic achievement.” Republicans call it a “monstrosity.” Whatever one calls it – the Patient Protection and Affordable Act, the Affordable Care Act, or simply Obamacare- it is unlikely to contain costs, and it is confusing.

One observer described the new law as “2500 pages of indecipherable and unreadable legal graffiti, confetti, gibberish, and legislative sausage.” This is verbal overkill. One can be cynical about it, but its intentions are honorable and reform is necessary. The changes it proposes, aimed principally at the health insurance industry, contain constructive provisions.

But, in the haste to pass it, legislators, perhaps emboldened by their unchecked majority status and sensing an opportunity to cement their legacy, may have overlooked untoward consequences. They created profound uncertainties in a health industry that comprises 1/6 of the American economy and that has created more jobs in the last three years than any other economic sector.

These uncertainties, adverse consequences, the recession, the jobless recovery, and skyrocketing national debt, state budget overruns, and the nascent health reform revolt, have unnerved Americans and the medical profession and unleashed unprecedented economic pressures.

A White Paper, Health Reform and the Decline of Private Practice, research sponsored by the Physicians Foundation and conducted by Merritt Hawkins, concluded, “Health reform is comprised of two elements: “informal reform,” i.e. societal and economic trends exerting pressure on the current healthcare system independent of the Patient Protect and Affordable Care Act), and “formal reform,” (i.e., the provisions contained in the act itself.”

Major Physician Trends

Physicians have asked what I consider the major physician trends to be. Here they are. The opinions expressed here are my own. I expect reasonable people, particularly backers of the reform bill in its present form, will disagree with my interpretation of physician trends.

I have gathered information from various sources. Among these are The Physicians Foundation, representing doctors hundreds of thousands of physicians in state medical societies; Merritt Hawkins and Associates, the nation’s largest recruiting and firm; The Camden Group, which offers consulting services to more than 1000 hospitals, health systems, and medical groups;, which focuses on hospital and physician executives;, and the, both directed at the business of health care, and media sources.

That said, most of what follows flows from my gut. What I say concerns doctors and the impact of reform in the clinical trenches.

One: Accountable Care Organizations (ACOS). The acronym, ACO, is on everybody’s lips these days. ACOs are so hot I felt moved to write a short E-book, Pros and Cons of Accountable Care Organizations ( and to interview an authority on the subject, Bill Demarco of Pendulum Health are Development Corporation, Inc., a consulting firm (“The Future of Accountable Care Organizations(ACOs).” (see January 26, 2011 Medinnovation blog for the interview text ). Hospitals embrace this trend. Doctors resist ACOs. Reform policymakers believe ACOs may save Medicare through “savings, ” to be divvied up between doctors and hospitals. In my opinion, physicians will make or break ACOs, depending on the region of the country, with less likelihood of success in more conservative America.

Two, Consolidation at every level of the health system.
Reform is forcing this consolidation because it takes a large organization to handle IT systems , meet bureaucratic and quality requirements, and access capital. As the Physicians Foundation’s remarkable White Paper, Health Reform and the Decline of Physician Private Practice, so aptly put it, “Most physicians will be compelled to consolidate with other practitioners, become hospital employees, or align with large hospitals or systems for capital, administrative, and technical resources.” Increased negotiating power in ever larger health systems will raise the specter of monopolies with the ability to set prices and will evoke anti-trust concerns among consumers and the government, resulting in Justice Department actions.

Lloyd Krieger, MS. a plastic surgeon who invests in health care companies, in a February 23 Wall Street Journal Op-Ed, “Obamacare Already Damaging Health Care,” says consolidation is destructive, “The most significant change is a wave of frantic consolidation in the health industry. Because the law mandates that insurers accept all patients regardless of pre-existing conditions, insurers will not make money with their current premium and provider-payment structures. As a result, they have already started to raise premiums and cut payments to doctors and hospitals. Smaller and weaker insurers are being forced to sell themselves to larger entities. Doctors and hospitals, meanwhile, have decided that they cannot survive unless they achieve massive size—and fast. Six years ago, doctors owned more than two-thirds of U.S. medical practices, according to the Medical Group Management Association. By next year, nearly two-thirds will be salaried employees of larger institutions.”

Three, Bundled payments between hospitals and physicians.
Although bundled billing may be part of ACOs and consolidation, bundled billing can be implemented without fundamental organizational restructuring of either hospitals or medical practices. In a former life, as chairman of a PHO, I had personal experience with bundling over 100 hospital procedures . Hospitals and practitioners arrived at their portion of each bundled bill separately. We add te the two components together, and backed the final bill with re-insurance should the estimate be exceeded. Putting tbundled bills requires a lawyer and close attention to detail to avoid accusations of collusion, monopolies, and violation of anti-trust laws. Fear of anti-trust may be the greatest single deterrent to ACOs, hospital mergers, and bundling billing.

Four, the decline of private practice, especially of small groups. Physicians ownership of their own practices now accounts to less than 50% of all practices, down from 75% five years ago. Various factors contribute to the decline – desire of younger physicians to be employed,; rising numbers of women physicians, accelerated retirements of older physicians, acquisition of primary care and specialty groups by hospitals; difficulties in acquiring loans to start and sustain a practice; capital needed to fund information systems and recruit new physicians and retain current physicians; and the sheer paperwork required to maintain a viable practice. Again, if I may . I shall quote the Physician Foundation White Paper, “The independent, private physician practice model, will be largely, though not uniformly replaced…Physicians will need to redefine and rethink delivery models.”

Five, Hospital and physician initiatives decentralizing care and to reaching out to dominate local and regional markets.
This takes various forms and may be done in concert with hospitals or independently without them. Decentralization includes strategically located outreach clinics, free standing emergency rooms, surgery centers, imaging centers, urgiclinics, and “big boxes,” i.e. supercenters of care, medical shopping malls, and hospital-acquired medical practices.; and telemedicine reaching into homes to, among other things, reduce hospital readmissions and emergency room visits. The Camden Group has characterized these various activities as: “Market share, market share, market share. Hospitals and medical groups have underused assets and must get them busy. Providers also realize that more volume will generate incremental revenue and decrease per unit cost. Hospitals will hunt for new programs to fill empty or underperforming assets.” The common denominators among this initiatives are market dominance, institutional growth, and quick returns on investments from market-based developments with proven track records.

Six, Concierge Medicine. This is a sleeper. No one knows how big it will be, where it is going, or how practical it will be. But having talked to many observers and have written two Med innovation blogs about it: 1) “Concierge Medicine- A Consequence of the Health Reform Law, February 20, 2011; and 2) Concierge Medicine: Reality or Mirage, January 25, 2011,” I believe it may be bigger than most imagine. Why? Physicians desperately want “out” of third party systems that lower reimbursements, restrict and ration care, drive up overhead, take time away from patients, and decrease practice satisfaction. Doctors in record numbers are dropping out of third party systems, including Medicaid, Medicare, HMOs, and other managed care entities. Concierge physicians are innovating - charging monthly rather than yearly retainer fees, introducing new amenities, offering one-day services, responding promptly to emails and phone calls, installing electronic medical records, and repackaging and repricing their various offerings. Concierge medicine represents a return of market-based principles and a retreat from government-directed care.

Seven, The electronic revolution. An electronic tsunami is sweeping over and engulfing medical practices. The e-revolution features a number of things – CPOE (Computerized Physician Order Entries) to issue orders and to prescribe; PACS (Picture Archiving Communication Systems) to transmit images; voice recognition software and increased computing power that allows computers to “talk,” to answer questions, permit conversations between patients, doctors, and computers; allows doctors to dictate into EHRs; marketing and communication via the social media (Twitter. Facebook, and Google); and a host of computer apps (applications) made possible by IPads and other mobile devices. Physicians will practice on Internet time, and practice will never be quite the same again. Unlike many, I do not foresee emergence of a universal interoperable EHR system aligning all major players. Meeting the 25 “meaningful use” rules is too burdensome for most practices. These practices are still the elephant in the room. Small practices will either not adopt EHRs or wait and see what evolves, or accept the financial penalties for not adopting EHRs. This resistance may be overcome by government mandate, “free” EHR systems, supported by advertisers, or low cost physician-friendly EHRs with voice recognition systems that allow physicians to dictate into EHRs to summarize and articulate what is going on with an individual care and to tell the patient’s story.

Eight, Patient involvement in care
. The Health 2.0 movement is based on the premise that consumers, armed with information and riding the electronic wave, will transform care, and will make it more efficient, effective, and transparent in the long term. In the meantime, consumers and employers are turning to CDHPs (Consumer Driven Health Plans) and Health Savings Accounts to create savings for employers and to lower premiums for employees. Critics and cynics say high deductible plans with low premiums and Health Savings Accounts are nothing but cost shifting and are unaffordable for sick patients with chronic disease. This may be, but more than 15 million Americans now have these accounts, sometimes called tax-advantaged medical accounts. And since their own dollars are involved, participants in high deductible plans and HSA members are more cost-conscious and are asking for discounts and otherwise negotiating lower fees. John Goodman, PhD, founder and president of the National Center for Policy Analysis in Dallas has predicted, “.Over the next decade I believe we are going to see a major transformation of American medicine. It won’t be the kind of transformation that is normally discussed at health care conferences and at inside-the-Beltway briefings. Nor will it be the kind of change anticipated by the people who gave us the Affordable Care Act (ObamaCare). Instead, what I envision is a large migration of patients and doctors, and facilities and services out of the third-party payer system. (“The Future of Consumer-Driven Care", Health Affairs Blog, February 18, 2011). The migration “out of” Medicare and Medicaid payment systems, if it occurs, will aggravate the physician shortage, lessen access to doctors, and create a political crisis of unprecedented magnitude among Medicare and Medicaid constituents.

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 but does not speak for 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 and 1-860-395-1501.

Tuesday, February 22, 2011

Grooks: A Change of Pace

Grooks are poems of pith. Danish poet and scientist, Piet Hein (1905-1996), wrote 10,000 of them. Here are a baker’s dozen of his condensed gems.

1)Faith in Doctors

My faith in doctors is immense.
Just one thing spoils it;
their pretense of authorized

Comment: Better omnipotent, than impotent.

2) Ars Brevis

There is
one art,
no more,
no less:
to do
all things
with art-

Comment: Medicine is an Art as well as a Science.

3) Problems

Problems worthy
of attack
prove their worth
by hitting back.

Comment: Doctors have intractable problems, just like everyone else, including patients.

4) The Eternal Twins

Taking fun
as simply fun
and earnestness
in earnest
shows how thoroughly
thou know
of the two

Comment: At its best, medicine combines fun with doing good.

5) Consolidation Grook

Losing one glove
is certainly painful,
but nothing
compared to the pain,
of losing one,
throwing away the other,
and finding
the first one again.

Comment: A glove in the hand is worth two in the bush.

6) T. T. T.

Put up in a place
where it's easy to see
the cryptic admonishment
T. T. T.

When you feel how depressingly
slowly you climb,
it's well to remember that
Things Take Time.

Comment: No miracles among friends, please.

7) Naive

Naive you are
if you believe
life favors those
who aren't naive.

Comment: Better to have something up your sleeve.

8) An Ethical Grook

I see
and I hear
and I speak no evil;
I carry
no malice
within my breast;
yet quite without
a man to the Devil
one may be
to hope for the best.

Comment: Hope for the best, pray for the good, expect and prepare for the worst.

9) The Road to Wisdom

The road to wisdom? - Well, it's plain
and simple to express:
and err
and err again
but less
and less
and less.

Comment: Successful doctors err, but they always come back up for air.

10)A Psychological Tip

Whenever you're called on to make up your mind,
and you're hampered by not having any,
the best way to solve the dilemma, you'll find,
is simply by spinning a penny.
No - not so that chance shall decide the affair
while you're passively standing there moping;
but the moment the penny is up in the air,
you suddenly know what you're hoping.

Comment: Blink, and trust your gut.

11) A Word to the Wise

Let the world pass in its time-ridden race;
never get caught in its snare.
Remember, the only acceptable case
for being in any particular place
is having no business there.

Comment: In unfamiliar situations, learn anew.

12) Meeting the Eye

You'll probably find
that it suits your book
to be a bit cleverer
than you look.
Observe that the easiest
method by far
is to look a bit stupider
than you are.

Comment: There’s always more than meets the eye.

13) Living Is-

Living is
a thing you do
now or never -
which do you?

Comment: Do what you have to do. You may never have another chance.

Monday, February 21, 2011

2020: The Pursuit of Happiness, Longevity, and Good Health until the Very End, at Costs You Can Afford

KISS (Keep it simple, stupid!)


Every man deserves to live long, but no man would be old.

Jonathon Swift, 1667-1745

In God we trust, all others bring data.

W. Edwards Deming, 1900-1993

It is 2020. It is ten years after America’s health reform law passed.

The law ran into a buzz saw of criticism, which I shall not recount here in any detail.

Why not in detail?

For the simple reason that the Accountable Care Act was simply too complicated for most Americans, even medical professionals, to understand. It affected everyone in different ways at different times, and it raised rather than lowering costs. It was a case of overkill of the Treasury bill.

In any event, it was a potpourri, a mixed stew, of mandates, policies, and regulations. It turned 1/6 of nation's economy downside up – from a bottom-up market-based to a top-down government-driven system. It boggled too many minds and had too many unexpected,adverse consequences, creating uncertainties too complex to contemplate or handle.

Three Missed Points

Somehow, health reformers missed three points. Americans wanted 1) to live longer in good health at costs they could afford; 2) to accomplish these goals without bureaucracy and without intrusion into their personal lives; ) to easily access information and technologies to optimize their lifestyle functioning.


This little essay explains how these goals were accomplished over the last decade.

It is now 2020, and the goal of living longer, healthier lives without financial concerns have been smoothed out. This transition has occurred because of a combination of factors - understandings of why some people live longer lives; knowing the basics of disease prevention and corrective measures; recognizing the importance of measurements to see where one is in terms of health and what one needs to do stretch out those years in good health and optimal function; and adjusting entitlement programs to reduce costs by moving back the age of entry in recognition of increased longevity. The latter is a function of government. The rest is up to the individual.

Where People Live Longer

Back in 2008, author and adventurer Don Buettner wrote The Blue Zone: Lesson for Living Longer from the People who’ve Lived the Longest (National Geographic Books). The book was based on his experiences traveling the globe and visiting places he called Blue Zones.

Blue Zones are regions in the world where people commonly live active lives past the age of 100 years. These longevity hot-spots have common healthy traits and life practices that result in higher-than-normal longevity. Blue Zones is also the name of a related project from Dan Buettner's Quest Network, Inc.

Five Blue Zones

Buettner identified five Blue Zones.

• Sardinia, Italy: One team of demographers found a hot spot of longevity in mountain villages where men reach the age of 100 years at an amazing rate.

• The islands of Okinawa, Japan: Here resides a group that is among the longest lived on Earth.

• Loma Linda, California: Researchers studied a group of Seventh-day Adventists who rank among America's longevity all-stars. Residents of these three places produce a high rate of centenarians, suffer a fraction of the diseases that commonly kill people in other parts of the developed world, and enjoy more healthy years of life.

• Nicoya Peninsula, Costa Rica: The Nicoya Peninsula was the subject of research on a Quest Network expedition which began on January 29, 2007.

• Icaria, Greece: This is the location with the highest percentage of 90 year-olds on the planet - nearly 1 out of 3 people make it to their 90s. Furthermore, Ikarians "have about 20 percent lower rates of cancer, 50 percent lower rates of heart disease and almost no dementia".

Six Characteristics

People who live in these places share six characteristics.

. They are happy and contented with their lives.

• They put family ahead of other concerns.

• They do not smoke.

• They thrive on a plant-based diet.

• They engage in constant moderate physical activity as part of their daily routines.

• They are socially active and deeply integrated into their community.

• They eat a lot of legumes (herbs, peas, and beans)

Simple But Oversimplified

Simple, yes. Probably oversimplified, and maybe unattainable for the rest of us, too. We can’t afford to all live by the sea, in warm places, or high in the mountains In these days of splintered families, a depressed economy with unemployment, sedentary lives spent perched in front of computer screens and television sets , or ensconced the seats of automobiles, it is hard to find time to constantly exercise. And we cannot always compensate for our genetic makeup, inherited diseases, or hazards in our environment.

Please note: health care did not make the top six factors in prolonging life and health. One study indicated health care only contributes 15% of health and longevity. It is not what health care contributes to your health, but what you contribute to your health care.

Measuring and Preserving Health

But over the last ten years, we also learned how to measure where we ranked on the health care spectrum and how to move up the scale of health.

These measurements, which were inexpensive and access to access via computer algorithms, included.

• “Soft” questionnaires relating to life style, health habits, happiness, social activities, diet, exercise, and family history, sometimes called health risk appraisals, with end summation measurement based on a scale of 100 – 100 as in the IQ being normal with a normal range of 80 to 120, below 80 being subnormal health and requiring corrective action, and above 120 being superior health and calling for you to keep on doing what you’re doing.

• “Hard” health measurements - blood pressures (systolic and diastolic), body mass index (height/weight), waist and chest measures, and results of common laboratory tests (glucose, lipid profiles), again on a scale of 80 to 120).

• A preventive polypill composed of 6 drugs (a statin, 3 anti-hypertensive drugs, folic acid, and aspirin) to control LDL cholesterol, blood pressure, homocysteine levels, and platelet function. For patient over 55.

• A simple, portable, low risk device for measuring cardiac and pulmonary function with an attached laptop that generates normal ranges of function, underlying levels of dysfunction, and prognostic information such as changes for hospitalization and sudden death.

• A computer algorithm that allows one to measure one’s overall health compared to an optimal population, what factors cause you to fall short of the optimal, and what to do about improving your personal health.

End Game

This essay has been an over-simplified view of how better, longer, stronger, simpler, healthier lives came to pass in 2020. You might call it 20/20 hindsight, which is always simpler than 20/20 foresight.

Even if we live to be 100, the end will grow near. None of us will get out of this life alive. But a full, happy life at full throttle until the end is worth striving for. As Mae West observed, “It’ s not the men in your life that matters, it’s the life in your men.'” This adage, short for “added age,” applies to women as well, which may be why women live eight years longer on average than men. So, man up guys. Your wives don't want to lose you.

Sunday, February 20, 2011

Color the Ink Red

Color the ink red.
Dye it red at the fed.
Color the ink red.
State budgets it has bled.
Color the ink red.
Gov presses do it spread.
Color the ink red.
Other people’s money it has shed.
Color the ink red.
Much of it comes from costs of med.
Color the ink red.
It is the big debt we dread.
Please don't color the ink red.
Color it black instead.
We can no longer fudge it.
Let us now fix the budget

Health 10.0 in 2020: I Told You So in 1973

The computer is no better than its program.

Elting Elmore Morison, 1909-1995, Men, Machines, and Modern Times, 1996

It is 2020. Computer evaluation of patients before they visit their doctors has come a long way.

Medical records containing demographic data, personal histories, medication use, allergies, laboratory results, radiologic images, electrocardiograms, rhythm strips, and even the chief complaint and symptoms of the patient ‘s present illness, as spoken and digitized by the patient, are available prior to the visit.

These records, synthesized, homogenized, summarized, algorithmized, and otherwise massaged by massive computer banks, give doctors everything they want to know before seeing and examining the patient.

• differential diagnosis,

• most likely cause of the visit,

• optimal treatment options,

• a review of recent medical literature in the last 24 hours on the subject,

• best current medical practices,

• greatest value for the dollar in the immediate region and at distant national centers,

• most cost-effective and results-effective specialists,

• Appropriate tests and procedures to be done before the patient leaves the office.

This barrage of information is available to consumers and physicians alike before and immediately after the visit. Furthermore, with advances in speech recognition, patients and doctors will be able to talk to the computer in each others presence, ask questions, and settle any lingering doubts.

Once in the physician’s office, doctors and patients can sort out the meaning of it all, arrive at rational decisions, and negotiate solutions. In the parlance of government, these solutions will be deemed “meaningful,” for they will be based on “meaningful use” of electronic medical records, a carry-over from 2015, when these records became mandatory.

Once decisions have been negotiated, tests performed, results will be available before the visit is over They are available because of advances in on-the-spot-testing and quickly performed noninvasive procedures. Patients are now able to leave the office with medical record, treatment plan, and referral information, if needed, in hand.

Health 10.0, as it is now known, will resolve past difficulties – misdiagnoses, delays in diagnoses, and misunderstandings and confusions leading to malpractice suits.

But surely, you say, you are jesting. No, but this is a bit tongue-in-cheek. There will always be uncertainties and lack of scientific evidence covering medicine’s vast panorama. No computer, even IBM’s “Watson,” can ever achieve complete information utopia , i.e, define and delineate and resolve all the variables of humanity. Computer processing will never offer a completely rational solution to the human condition in an efficient, cost-effective manner.

Besides, doctors and their humanist allies will object that medicine is an Art as well as a Science.

You are right. Forty seven years ago, in 1973, I gave an address at Hartford Hospital as part of a symposium to honor T. Steward Hamilton, MD, who had been administrator of that hospital for 20 years.

I foresaw, among other things, “Besides performing his usual duties, the pathologist will become something of an intelligence expert. He will help collect, evaluate, analyze, integrates, anticipate, and interpret information. His prime role will be to unify random test results into practical fingertip information that will clinicians can effectively use to make decisions.”

My title was “The Screening Laboratory of 1980” (published in Perspective of Biology and Medicine, winter 1974). I said it was then possible, using the Internet , to generate a list of realistic diagnostic possibilities in plain English, for I had done so in our own laboratory in Minneapolis.

The Hartford medical establishment received my talk with a notable lack of enthusiasm, even with a touch of scorn. They were correct. The computer was not ready for prime time. I was a prophet before my time. It was a small step forward, before the giant leap forward in health information technology. It was a first byte out of the Apple.

But now it is 2020, the time has now arrived, and all is well on the digital front.

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, on occasion, 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 and 1-860-395-1501.

Concierge Medicine - A Consequence of Health Reform Law

Over the next decade I believe we are going to see a major transformation of American medicine. It won’t be the kind of transformation that is normally discussed at health care conferences and at inside-the-Beltway briefings. Nor will it be the kind of change anticipated by the people who gave us the Affordable Care Act (ObamaCare). Instead, what I envision is a large migration of patients and doctors, and facilities and services out of the third-party payer system.

John Goodman, PhD, "The Future of Consumer-Driven Care", Health Affairs Blog, February 18, 2011

John Goodman,PhD, the economist who founded and heads the National Center for Policy Analysis in Dallas, is predicting a major migration of physicians into concierge medical practices in the Health Affairs Blog (“Future of Consumer-Driven Care,” Health Alert, February 18). This does not surprise me. John has long maintained in the end market forces will trump government-dictated care. Concierge practices are a quintessential market response.

John says doctors want to get “out” of third party payer system. He is right. Third party intervention into medical practices drives up overhead, creates endless red tape, strangles innovation, subtracts from time with patients, promotes second guessing, prevents doctors from repackaging and repricing services, and, in the minds of physicians, reduces them to serfs of the system. We may have reached the limits of third party intervention.

Patients sense third party impediments too. Health care consumers are increasingly willing to go outside third party shackles in search of flexibility in negotiating, quicker access, more personal relationships, more time with doctors, and a higher level of amenities. The days of consumer-driven health care, long ago envisaged by Regina Herzlinger in her 892 page consumer tome, Consumer-Driven Health Care: Implications for Providers, Payers, and Policymakers, Jossey-Bass, 2004), may have arrived.

ACA Shortfalls

In some ways, this migration of doctors into concierge practices represents a failure of the reform policies of the Obama administration and of the health reform law itself. The Accountable Care Act (ACA), after all, was designed to:

1) to bring more people into the system rather than push them out;

2) to change the fundamental nature of medical practice through data-monitoring and protocol-following rather than through more personal attention;

3) to lead to a more egalitarian system with the same level of care for everyone as dictated by government rather than individualist care desired by consumers and guided by physicians;

4) to achieve more universal access rather than having Americans drop out of a government-designed system.


The ironies of the concierge movement are profound. It may precipitate an access crisis of unprecedented magnitude if more doctors cease seeing Medicare and Medicaid patients in concierge practices. At the same time, it may achieve what government sought in the first place - lower prices, greater efficiencies, transparencies, quality, and amenities.

Concierge practices are becoming more affordable as doctors charge a monthly rather than an annual fee. Consumers are being given the options of dropping the service should they please. Doctors are including more services in the concierge package. Consumers are demanding transparency of pricing and services, and doctors are providing it.

And, as icing on the concierge cake, most physicians who practice it, offer one-day service, quick telephone and e-mail responses, electronic prescribing, electronic health records, and promises to meet competitive pressures.

Saturday, February 19, 2011

Why Accountable Care Organizations May Not Work in Academic Medical Centers

For every complex problem there is an answer that is clear, simple, and wrong.

H.L. Mencken, 1880-1956

The ACO concept is predicated on the primacy of primary care, with doctors, nurse practitioners, nurses, and other health care providers working together to supply the most efficient, successful, and economical care for their patients. The concept presumes that the professionals and hospitals (in ACOs that include both) will work together closely — ideally, as single governing units. The electronic medical record, integrating inpatient and outpatient information, and other relevant uses of information technology are seen as basic tools in this work. ACOs will share with the federal government any financial savings the organizations produce.

John A. Kastor, MD, Chair of Medicine, University of Maryland Medical Center, 2011

Every once in a while, an idea pops up in the fantasy world of health policy reform that is so clear, so simple, so compelling, so mesmerizing, and so appealing that it is too good to be true.

Such is the case with accountable care organizations (ACOs) and academic medical centers (AMCs).

The ACO concept is clear and simple.

If one can get specialists, primary care practitioners, and hospital executives in academic medical centers (AMCs) to collaborate and to broaden the primary care base, care can be purposefully coordinated, duplication virtually eliminated, patients treated holistically, money saved, and great savings shared by all parties. Most importantly, great savings will accrue especially to a great third party, Medicare, which provides the bulk of care and revenues to academic institutions. In theory,everybody wins, nobody loses.

So much for a simple answer to bringing down Medicare costs. Now a reality check. In the February 17 New England Journal of Medicine, in two e-editorials (editorials available online but not on paper), three academics conclude ACOs won’t work in the academic setting.

Why not?

- John A. Kastor, MD, academic division chief of cardiology and chair of the department of medicine at the University of Maryland Medical Center, says,

“Establishing successful ACOs at academic medical centers will require changing several aspects of the traditional culture at medical schools. Leaders at such centers will need to convert their organizations from a hierarchical structure to one that is more horizontal and collaborative. Will they be able to do so? Given the challenges, several leaders with whom I spoke doubt that ACOs can readily be established at academic medical centers.”

- Scott Berkowitz, MD, MBA, and Edward Miller, MD, of Johns Hopkins, cite these “substantial" cultural barriers to making ACOs work in AMCs - transitioning from a specialty-dominated to a primary care dominated faculty, requiring heretofore autonomous departments to centrally organize, clinically integrate, and coordinate their activities; re-defining the roles and rewards of current faculty members, who depend on grants, publications, and scholarly reputation for advancement, rather than clinical efficiency and direct care of patients. “Ultimately, “ say the two authors,” AMCs will need to determine whether becoming an ACO can be sustainable financially, how they can overcome cultural obstacles to improve care delivery, and how they can best continue to excel at fulfilling all aspects of their mission.”

As I read these academics on difficulties of imposing the ACO model on AMCs, and as I thought of the policy makers’ solution to reining in health costs, namely, horizontal integration with everyone playing on a level clinical ground, an image from my past reading came to mind (Edward de Bono, The Use of Lateral Thinking, Jonathan Cape, London, 1967), namely, vertical holes on level landscapes

Edward de Bono, MD, (1933 - ), a physician, author, inventor, consultant, and world class authority on thinking, has observed the medical landscape may appear to be level, but if you examine it closely, you will find a series of deep vertical holes. At bottom of each hole resides a world class expert.

Sadly, these vertical holes do not interconnect. Policy makers dream of horizontally connecting the holes with a magic triad: one, a broad base of primary care physicians, two, an elaborate interoperable electronic communication system, and three, financial sharing by all.

Unfortunately, de Bono says you cannot dig a hole in a different place by digging the same hole deeper. You have to change perceptions and the structure first. Otherwise you will fail. The lesson? You cannot drive a square peg into a round hole without first rounding off corners of the peg. Even then, you're unlikely to reach the bottom of the hole.


1. J.A. Kastor, “ACOs at Academic Health Centers, “ ell, February 17, New England Journal of Medicine, available at

2. S.A. Berkowitz and E.D. Miller, “Accountable Care at Academic Medical Centers – Lessons from Johns Hopkins, February 17, New England Journal of Medicine, available at

Friday, February 18, 2011 ACOs - Friend or Foe?

Preface:, a physician social networking website founded in 2006, , has 115,000 M.D. and D.O. “colleagues.” Credentialed but anonymous physicians post opinions, questions, early warning reports of adverse drug effects, and respond to surveys. Critics say Sermo’s contents are incomplete, anecdotal, and generated by angry, discontented doctors. Nevertheless, the Sermo website is worth reading. It reflects the temper of the times.

Within the last week, Sermo ran a piece on Accountable Care Organizations and asked for readers’ opinions. Hundreds responded, and the response was overwhelming negative. Here, to give you a feeling for what was being said, is the introduction to the piece and ten responses.


My name is Susanne Madden. and I’m CEO of the Verden Group, a consulting firm founded to advise and help physicians navigate through the increasingly complex business of healthcare. I am working with Sanofi-Aventis, U.S. (S-A) on their initiative, a commitment from S-A to provide physicians resources regarding the current business challenges in medicine.

I’d like to discuss with you the advent of Accountable Care Organizations or ACOs. Is this a model that will help or hinder physician practices? Will they prove to be a more efficient or effective way to manage patient care? Or is this a mechanism for larger organizations and hospitals to better manage the market.

Ten Responses

1. Family Medicine

ACOs will result in vertical integration and evisceration of urban practicing physicians, placing all of the decision making in the central authority, removing the patient / doctor relationship. Rural healthcare will not be able to vertically integrate and will be crushed under the regulative burden, being held to the same standards and outcomes measures of an ACO. It should take less than 5 years for ACOs to competely bastardize patient care and decimate health care for most Americans not living in a tertiary care environment.

2. Family Medicine

Hospital owned outpatient care is significantly more expensive than physician owned out patient care. (In my area I get about $60 for 99213 from CMS, the hospital owned clinic a mile away gets over $90 for the same service for the same patient). I see only one way how a hospital driven ACO is going to accept the reduction in payment that would be required to make them as cost effective as me - they are going to cut outpatient reimbursement to the bone, and they will absolutely be forced into using mid-levels for the bulk of their out of hospital follow up care.

3. Radiology

ACOs will simply add another layer of cost to the health care system. It's only purpose is to deny health care and take money out of doctor's pockets.
ACOs are based on the incorrect assumption that the hospital is the center of medical activity. Most medical care happens outside the hospital. Putting the hospital in charge of all healthcare is asking them to do something they have no knowledge or expertise in. Hospital administrator salaries will go through the roof, doctor salaries will drop.

4. Pathology

The creation of ACOs encourages hospitals to take over physician practices to continue to be the center of the payment world. However, they do not care about the doctors, they do not know how to manage their practices (nor do they care), and they do not care about the patients.

5. Internal Medicine.

ACOs, if implemented, will put clinicians fully at the financial mercy of either hospital or ACO administrative masters. Docs will have responsibility without authority, and ultimately it is the end of medicine's standing as a profession whose members exercise independent professional judgment.

6. Oncology - Hematology/Oncology

ACO is an example of the bureaucracies that we physicians do not want.

7. Family Medicine

Like other healthcare reform proposals, the ACO ignores the biggest cause of health care expenditures (IMO), patient behavior. All PCP's know what I'm talking about. No incentive seems to be present to encourage those "dirty words", PERSONAL RESPONSIBILITY, on the part of the patient population.

8. Anesthesiology

I am in favor of repealing the PPACA, and I am opposed to "gearing up for a place at the table."

9. Surgery - General

The entire ACO concept should be an anathema to any physician who understands the ethics of the physician-patient relationship. Couched in flowery language and the "promises" of physician "autonomy,” The ACO concept promotes the extension of covert rationing by the physician to the exam room or the bedside. The physician becomes a financial agent for the ACO, not a health care advocate for the individual patient. This extends the insidious erosion of the very core of medicine, the foundation upon which everything else is built, the trusting relationship between a patient and a physician.

10. Ophthalmology

An ACO is capitated care in a fancy tu-tu. The #1 problem with the concept, as previously mentioned, is that it contains no elements that will modify PATIENT behavior, eg utilization habits and demands for tests and medications. As far as ACOs in any way motivating patients to adopt healthy, low-medical-cost lifestyles, pardon me while I collapse in laughter.

Thursday, February 17, 2011

Top Ten Articles on Innovation

Preface: I see my article on innovation made the top ten articles published worldwide on medical innovation over the last five years. You might want to google these articles to see what’s afoot in the medical innovation sphere.

Reece RL: Reforming America's health system through innovation and entrepreneurship. J Med Pract Manage; 2005 Nov-Dec;21(3):163-5

Grazier KL, Metzler B: Health care entrepreneurship: financing innovation. J Health Hum Serv Adm; 2006;28(4):485

Phillips FS, Garman AN: Barriers to entrepreneurship in healthcare organizations. J Health Hum Serv Adm; 2006;28(4):472-84

Al Mahdy H: Reforming the Bangladesh healthcare system. Int J Health Care Qual Assur; 2009;22(4):411-6

Boxall AM: Reforming Australia's health system, again. Med J Aust; 2010 May 3;192(9):528-30

Washburn NR: Teaching technological innovation and entrepreneurship in polymeric biomaterials. J Biomed Mater Res A; 2011 Jan;96(1):58-65
Go to the article

Fletcher T: The impact of physician entrepreneurship on escalating health care costs. J Am Coll Radiol; 2005 May;2(5):411-4

De Vos P, De Ceukelaire W, Van der Stuyft P: Colombia and Cuba, contrasting models in Latin America's health sector reform. Trop Med Int Health; 2006 Oct;11(10):1604-12

Nicol D: Balancing innovation and access to healthcare through the patent system--an Australian perspective. Community Genet; 2005;8(4):228-34

Kamunyori S, Al-Bader S, Sewankambo N, Singer PA, Daar AS: Science-based health innovation in Uganda: creative strategies for applying research to development. BMC Int Health Hum Rights; 2010;10 Suppl 1:S5

February Tweethearts

Tweets are getting to the heart of the matter in 140 characters or less. Here are my February tweethearts to date.

Health Reform: The Computer's Potential to Improve Health Care - Don’t let IBM Watson’s victory on Jeopardy fool you. The computer will not replace doctors and does not address most patient concerns.

Health Reform's Open Frontier: Achieving , Monitoring and Supporting Patient Compliance - Many bad health outcomes stem from patient behavior and lack of compliance with doctor’s orders once patients leave the doctor’s office.

Obamacare: Between a Rock (Individual Mandate) anda Hard Place (Its Constitutionality) - Supreme Court: Decide Individual Mandate issue soon. Time, money, and resources are a’wasting. We can live with consequences.

Note to Federal Government: Beware of What You Wish for - Government wishes doctors and hospitals would join accountable care organizations (ACOs) to save money, yet the opposite may occur.

Egypt, The Social Media, and Health 2.0 – Twitter and Facebook will personalize and individualize care rather than mobilizing consumers to change the system downside up as in Egypt.

The Reform Mindset and The Many Faces of Health Care “Fragmentation”- Health reform should be more about increasing decentralization and customizing care than reducing fragmentation.

Health Reform: Private Practice Endangered – According to a Physicians Foundation physician survey, health reform is contributing to the decline of private practice.

• Health Reform: Addressing Primary Care Shortages
– 3 articles in New England Journal of Medicine offer recipes to solve primary care shortages, all of which will take time and are untested.

Health Reform: Who’s in Charge Here? - The U.S. Government or State Government - Politicians in D.C. are going for broke. Meanwhile State governments are simply going broke.

Health Reform No-No’s, The Case of EHRs – Why are doctors so slow in adopting EHRs? EHRs take $30,000 to install, $10,000 a year to maintain, and cut time spent with patients, about 30%.

Health Reform and the Dark Side of the Internet - The Internet has two sides – it frees us to find everything, but it can be used to control our personal and professional lives.

Consequences of Health Reform - In my unpublished book Good Intentions: Consequences of Health Reform, I say good intentions to reform aren’t enough for most Americans

• Senate Will Vote on Repeal
- Judge Roger Vinson ruled the law unconstitutional, but Democrats still rule the Senate institutional. Voters will note who voted for what

Blue Monday for Obamacare - On Friday, Judge Roger Vinson ruled the individual mandate as unconstitutional. The entire Act must be declared void. Today is Monday.

Why I Write Blogs - I write blogs because I enjoy words, I have a political purpose, and I want to make a difference in the lives of patients and doctors.

Wednesday, February 16, 2011

Computers and Health Reform, What's Missing? It's Elementary, My Dear Watson, Lack of Human Contact

Michael Millenson, author of Demanding Medical Excellence : Doctors and Accountability in the Information Age, University of Chicago Press, 1997), is passionately arguing again how computers will make doctors accountable, will improve care, and will forge a new partnership between doctors and their patients.

In the February 14 Forbes Magazine and the February 15 The Health Care Blog, he offers his thoughts in an an essay on “Health IT: A Tale of Three Watsons. ” The three Watsons are: "Watson", IBM supercomputer now demolishing two human contestants on Jeopardy , the TV game show; Thomas Watson, Jr. son of the father of IBM and its CEO in his own right, and Doctor John Watson, the sidekick of Sherlock Holmes.

It’s elementary, my dear Watsons, Millenson seems to say, widespread applications of health information technologies constitutes a quantum jump forward in improving the quality and outcomes of care as administered by physicians.

Millenson quotes a Johns Hopkins medical student, Yong Suh. Suh wrote in the February 9 in a USA Today op-ed, “Performing well on Jeopardy and diagnosing sick patients have similar prerequisites: a broad fund of knowledge, ability to process subtlety and ambiguity in natural language, efficient time management and probabilistic assessment of different possibilities.”

Millenson cites Thomas Watson, Jr,, who said in 1965,

“The widespread use [of computers]…in hospitals and physicians’ offices will instantaneously give a doctor or a nurse a patient’s entire medical history, eliminating both guesswork and bad recollection, and sometimes making a difference between life and death.”

Millenson comments that the computer does not solve everything, but nevertheless it is the essential central solution, partnering with patients will be important too.

“In other words, however Game Show Watson fares on Jeopardy, partnering with patients — is not just being more smart about telling patients what to do — will remain central to improving health as well as health care. As Dr. John Watson, famous companion of Sherlock Holmes might put it, that truth is elementary.”

In a telling comment on the federal government’s commitment to devote $27 billion to health IT, Millenson says, “The electronic health record, with or without decision support, is centralization’s most impressive victory."

I am not as confident as Millenson that this massive federal largesse is either “impressive” or a “victory.” I am not a big fan of “centralization” as the long-term solution to health care woes.

I agree with Stephen Baker, a physician and author of an E-book, Final Jeopardy: Man vs. Machine and the Quest to Know Everything. In a February 14 Los Angeles Times Op-Ed piece, Baker observes,” Watson is incapable of coming up with fresh ideas, much less creating theories, cracking jokes, telling a story or carrying on a conversation. Its ability is simply to make sense of questions and then scour a trove of data for the most likely answers. It represents a dramatic advance in artificial intelligence, but like another famous IBM computer, Deep Blue, Watson excels on a limited playing field, in a game defined by clear, rigid rules.”

Not every office visit, or hospital admission, is a diagnostic or treatment puzzle. The visit may be for reassurance, consultation with a trusted advisor, affirming or questioning information found on the Internet, addressing hypochondriacal concerns, renewing a prescription, or simply a following up to see how things are going. These things may be trivial, indeterminate, or alimentary to "Watson", the super-computer, but they are vital to the doctor-patient relationship and to human concerns.

Not everything follows “clear, rigid rules.” In medicine, not everything is factual, contractual, or even actual, nor, much of the time, does the computer offer anything “satisfactual” to the patient-physician relationship.

Tuesday, February 15, 2011

Health Reform's Open Frontier: Achieving , Monitoring,and Supporting Patient Compliance

There exists limitless opportunities in every industry. Where there is an open mind and a willing hand, there will always be a frontier.

Charles Kettering, 1876-1958

What I am about to propose is technologically doable. It is doctor-directed and patient-centered. But in this land that protects patient privacy and freedom to behave as one wishes, it may be difficult to carry out.

The last frontier in health reform is ensuring patient compliance. Until now most of the energy, money, and federal government policies have focused on physician compliance. This may be a misdirected effort. Poor patient outcomes may depend more on patient failure to comply with doctor advice and directions than on what doctors do.

What happens once patients leave the office may be more important than what happens in the office. In a survey conducted by Consumer Reports of 660 physicians, the top complaint of 37% of doctors about patients , was that patients did not comply with what they were told to do (Wall Street Journal Health Blog, “Survey: What Doctors Tell Patients (and Vice Versa,” February 8, 2011).

A Few Facts

Before going any further, a few obvious facts.

• 30% of Americans have hypertension.

• By far, the #1 cause of death is a combination of cardiovascular and chronic lung diseases, which kills one million Americans each year.

• 20% of Americans have diabetes, and 50% are overweight.

• Americans walk too little and consume too much salt.

• 30% of Americans never fill their prescriptions or do not adhere to the prescribed regimen of taking their medications.


Now, a few scattered anecdotes of what has been done to curb this epidemic of cardiopulmonary and other diseases, in part triggered by patient noncompliance and inappropriate behavior.

• Employers have launched a series of wellness programs.

• William Bestermann, MD, an internist at the Holston Clinic in Kingsport, Tennessee, has led a vascular center in which patients’ hemoglobin A1C, blood lipids, and blood pressures are scrupulously monitored, and patients are constantly advised on what to do to improve their cardiovascular status. Dr. Besterman’s operational concept is that hypertension, diabetes, kidney disease , dyslipidemias, and cardiovascular complications are all interrelated and should be approached as part of the same metabolic universe.

• Stanley Feld, MD, a retired Dallas endocrinologist, when in active practice, oversaw the monitoring of a large diabetic population. Dr. Feld had his patients sign a contract to abide by his rules or not to be his patients. In addition, he would gather them together to cheer them on and created T-shirts bearing the message “In Control.” Doctor Feld’s patients were hospitalized at 1/6 the rate of the diabetic population as a whole.

• Walter Kempner, MD, of Duke University Medical Center, who died in the 1990s, ran a series of “Rice Houses” in which patients were on strictly monitored “Rice Diets.” Doctor Kempner measured the salt in the urine to see if his patients were following his diet. These patients had advanced diabetes, health failure, hypertension, renal disease. In 1944, doctor Kempner published the first of a remarkable series of papers showing that many of the lifestyle diseases could be arrested or reversed by proper modification of diet and exercise.

• Doctors in 35 states are dispensing drugs from their offices. They profit from this dispensing, which delivers drugs at well below rates charged in pharmaceutical outlets, but their cogent argument is that when they hand their patients the drug before leaving the office and talk to them directly about effects and side effects, patient compliance is much higher than if the prescription is filled elsewhere.

• Randy Moore, MD, CEO of American Telecare in Eden Prairie, Minnesota, has placed audiovisual devices connected by ordinary phone lines at the bedside of chronically ill homebound patients. Through these devices, doctors and nurses can monitor weight, blood pressure, blood oxygen, listen to the heart and lungs, and observe the patients. Patients control the devices and have proven to be extraordinarily adept at learning and spotting complications. The result? Readmissions to the ER and the hospitals have dropped dramatically.

• Steven Anderson, an exercise physiologist in St. Paul, Minnesota, in conjunction with other exercise physiologists, has developed an easy-to-use, portable, inexpensive, low-risk cardiopulmonary testing system (Shape –HF), validated by the Mayo Clinic, that non-physicians can administer and that detects early and late heart and lung disease and that predicts risks of hospitalization and death.


I am proposing that doctors and patients adopt or consider a systematic, organized, and purposeful regimens or methods to help monitor and direct patient behavior and compliance.

These regimens or methods , would depend on the patients’ condition and problem, might include these elements.

• Dispensing drugs in the office, with face-to-face instructions from doctor-to-patient to increase patient compliance.

• A pedometer attached somewhere at the waist or lower extremities to check for physical activity (10,000 steps a day is the goal, but 6000 is more realistic).

• Telemonitoring devices to check for blood glucose, hemoglobin A1, lipid levels, blood pressure, and heart rhythms.

• Bedside audiovisual devices for the homebound and chronically ill.

• Periodic physiological evaluation for cardiac and lung function by a portable, small, low risk stress system to be administered in decentralized settings to check for coronary disease and/or pulmonary function and to have automated printouts pointing to the presence of heart or lung dysfunction with prognostic information.

All of these things could be done in decentralized settings under physician guidance with patient permission and patient initiation and control. In the end, physicians could support positive patient behavior and help control patient health destinies. Patient compliance with medical advice and instructions, aided and abetted by cost effective measurements, is the new, still largely unexplored frontier of health reform and entails disease prevention, symptom monitoring, and complication control.

Richard L. Reece, MD, blogs at Medinnovation and has a website under construction., with title of “The Doctor is In.” 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. Opinions expressed in his blogs are his alone. He can be reached at, or 860-395-1501.

Monday, February 14, 2011

Obamacare: Between a Rock (Individual Mandate) and a Hard Place( Constitutionality of Law)

Everybody knows Obamacare’s fate hinges on a forthcoming Supreme Court decision on its constitutionality. Everybody is guessing the decision will be 5-4. Nobody knows which way the vote will go. Most of us think we know this is a political, not a legal issue. All of us know the sooner the Supreme Court decides the better, or there will be a lot of wheel spinning and money and energy wasted.

A group of three lawyers from Boston University say they are four reasons why the constitutionality of the individual mandate is such a tough call.

One, Congress has never required anyone to buy a product from private industry.

Two, this requires interpreting the scope of the Commerce Clause, how much government can govern interstate commerce.

Three, it is difficult to decide whether not having insurance coverage qualifies as an activity that affects interstate commerce and if Congress can penalize people for not buying a product.

Four, can Congress require people to buy a product because it is a necessity of life, e.g., food, water, and health care, and for the common good, i.e., to keep premiums low for everybody on the theory that using a product reduces use of health care services and thus insurance costs?

The Boston lawyers conclude “The federal government has never exercised this authority before - and that’s what makes answering the constitutional question so hard.”

But answer is: the Supreme Court must. As an editorial in the February 12 Minneapolis State and Tribute says,

“Most of the ACA's game-changing reforms -- the online exchanges, subsidies and mandate -- don't go live until 2014, but the work of implementing these sweeping reforms will eat up much of the next three years.”

“Without an answer from the Supreme Court, health providers and states have two unacceptable choices: They can continue investing time and resources to comply, knowing that this may all go to waste if a key portion of the law (or the entire law) is declared unconstitutional at some point, or they can gamble by suspending preparations.”

“The risk of standing pat is that they would likely face an insurmountable amount of ground to make up if the law is upheld.”

Whatever the Supreme Court decides, we can live with it. Life and some sort of health reform will go on.


1. Wendy Mariner et al, "Ccan Congress Make You Buy Brocolli? And Why That's a Hard Question, New England Journal of Medicine, January 20, 2011

2. Editorial, "Supreme Court Must Act Quickly," Minneapolis Star and Tribune, February 12, 2011.

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. Opinions expressed in his blogs are his alone. He can be reached at

Sunday, February 13, 2011

Note to Federal Government: Beware of What You Wish for in Health Reform

The Obama administration has a tiger by the tail. The tail is a concept called the Accountable Care Organization (ACO). The tiger is the health reform law, ironically dubbed the Patient Protection and Affordability Act (PPACA).

The problem is the tail may soon be wagging the tiger. The ACO may raise costs for the PPACA, thereby defeating the original purpose of reform – to protect patients and to make costs affordable.

The goal of the ACO is to save money on defined populations of Medicare patients. Theoretically, doctors and hospitals would collaborate, save federal dollars, and then share the savings. Theory say this will happen because these two partners would deliver cost-effective, coordinated, budgeted care based on measurable better outcomes, higher quality, and lower costs per patient and per given Medicare population.

So much for theory.

What is happening in the real world is that hospitals and doctors, sensing what is to come, are rushing to set up collaborative ACO models. Doctors are rapidly becoming hospital employees, hospitals are hastily merging, big hospital-based organizations are growing bigger every day. In many instances, these new entities , particularly in small and medium-sized markets, will monopolize care, now having the wherewithal to negotiate higher costs and to stifle competition.

It is not unlawful to gain control of a market. What is unlawful is to exploit that control. The threat of ACOs monopolizing markets and setting prices has set up a looming war between the Federal Trade Commission (FTC) and the Justice Department. The Justice Department’s goals are to protect consumers by promoting competition and curbing monopolies.

In many ways, this conflict of reform interests was predictable. It takes a large organization to gain access to capital which finances growth; to have effective mechanisms for dealing with bureaucratic phenomena; to possess the true skills of management – marketing products, negotiating favorable contracts, organizing complex technology, maximizing talents of specialists, and bringing together different people from different professions to deliver service as a team. Bigger organizations are what the government wishes for. Big organizations are easier to control, or so it is believed by government.

In any event, large integrated, collaborative organizations of physicians and hospitals are likely to dominate the health care landscape. A concentration and consolidation of power will occur. For want of a better name, let us call these new organizations Mega-Accountable Care Organizations.

If you are a health care consumer, the question arises: Accountable to whom? Who do you trust: the government, or members of the ACO? As for government, it will have to ride the tiger until told by the Supreme Court to dismount.

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. Opinions expressed in his blogs are his alone. He can be reached at

Saturday, February 12, 2011

Egypt, The Social Media, and Health 2.0

Man can be said to survive only through his capacity to organize, to change his environment, and to exploit its possibilities thorough technology. The inhabitants of the Nile valley possessed all these qualities to a remarkable degree, making their country a model of organization, of technical competence and artistic creativity.

Ceres Wissa Wasser, Egypt, 1983

What made this Egyptian democracy movement so powerful is its legitimacy. It was started by youth and enabled by Facebook and Twitter.

Thomas Friedman, “Postcard from Egypt,” February 11, New York Times

Until now, despite an oppressive leader, Egypt as a civilization had everything, except freedom. The social media set them free. Commentators are giving credit to Twitter, Facebook, and Google for lighting the fuse of revolt among the Egyptian people and for helping them bring millions into the streets.

No doubt Internet access fuels and empowers the masses by reaching individuals with information. No doubt the electronic media helped organize crowds by appealing to their consciences and unleashing their sense of indignation.

This brings me to Health 2.0 and the pervasive belief that the Internet will embolden health consumers to change the health system through health information technologies.

According to Wikipedia, itself a social media vehicle,

“Health 2. 0 is the use of a specific set of Web tools (blogs, Podcasts, tagging, search, wikis, etc) by actors in health care including doctors, patients, and scientists, using principles of open source and generation of content by users, and the power of networks in order to personalize health care, collaborate, and promote health education."

The social media has the power to set people atwitter, to make them face the facts, and to allow them to google to give them everything they might want to know but were afraid to ask. By the end of the year 33 million people will have an IPad or its equivalent, and 80% of the time, people surf the Net in search of health care information.

How will the social media effect physicians? The jury is still out.

Personally, I am on Facebook and Twitter, I have a 4 year old blog and a website under construction, and I have even published an E-book, The Pros and Cons of Accountable Care Organizations. I am even thinking of buying a Kindle, even though it might snuff out printed books.

The other day I was at a meeting of a half-dozen prominent physicians, They were all thumbs, as they texted and fixated on their IPads. This should not have surprised me. What stunned me was how mezmerized these mature physicians were by this new gadget. As we all know, physicians are using mobile devices to prescribe, answer patient emails, and search for diagnostic information.

Where is this hypnotic fascination with electronic connecting devices going?

I do not know. But my hunch is the social media will be more useful for individuals by personalizing and decentralizing care from the bottom up rather than controlling and monitoring care from the top down.

Whether the Internet will mobilize masses of health consumers to turn the current health system upside down is another matter altogether. I hope not.

Friday, February 11, 2011

The Reform Mindset and The Many Faces of Health Care "Fragmentation"

To hear health care critics speak, you would think America’s health care’s dysfunction stems mainly from “fragmentation” of the system.

“Fragmentation,” in critics’ minds, means:

• Too many specialists are doing too many things without knowing what other doctors are doing, causing duplication, waste, and errors in the process.

• Too many patients are seeing too many specialists without going through a single primary care practitioner coordinating care in a medical home.

• Too many people, patients and doctors alike, are making too many uninformed choices.

This fragmentation, say critics, is too inexpensive, and the end, too unsustainable. The answer, says Jim McDermott, MD (Democrat, Washington State), a member of the House of Representatives, is straightforward.

“Sustainability requires that all patients in system receive the right care, in the right place, at in the right time, in the most effective manner possible. It therefore demands a robust primary care workforce that encourages coordination throughout the health care spectrum and provides accountability.”

But what is the right care, the right time, the right place, and the most effective care? And what does accountability mean?

How does one achieve these noble ends?

By ending fragmentation, of course. And how does one end fragmentation?

• Offering incentives to medical students to become primary care practitioners (though this will take a decade to significantly impact the physician shortage).

• Coordinating the system through a centralized government system(though Americans resist, fearing this smacks of government “overreach”).

• Organizing doctors and hospitals into accountable care organizations with fixed budgets (though doctors oppose this approach by 2:1).

• Channeling patients through primary care-directed medical homes (though these homes will take years to develop).

• Connecting patients, consumers, doctors, hospitals, and other health care facilities with a common computer system that shares real-time information ( though this has been painfully slow to gain enough critical mass to be effective and threatens privacy).

• Re-directing care by paying-for-performance based on outcomes, rewarding doctors on salary who comply with “best practice” guidelines, protocols, checklists, and federal standards and regulations (though many in “center-right” American say this smacks of bureaucracy, rationing, and “socialized medicine”).

These massive restructuring moves will take time, and in the meantime (from now to 2014), too many costs will rise too rapidly, too many people will lose their current plans because the plans don’t meet government standards, too many employers will drop employees’ and retirees’ health plans with expectations of shifting them to Medicaid or other plans with government subsidies,and too many of Obama's favorite supporters will be waivered out of the system to spare them the expense and rigors of the health reform law.

No one ever claimed redesigning 1/6 of the nation’s economy will be easy. Anyway, thinking ‘big” politically puts you on the right side of history. One giant leap for humankind, cascading down from the top, beats a series of smaller steps, bubbling up from the bottom - health care tax credits for all, shopping across state lines, a federal health employee-type health plan for everyone, tort reform, deregulation to unleash innovation and market forces, health savings accounts, states developing their own health plans.

Unfortunately, one man’s mindset is another man’s hindset.

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. Opinions expressed in his blogs are his alone. He can be reached at