Thursday, March 31, 2011

The Health Reform Cookie Monster and You

Me want cookies! Me eat cookies! Me eat anything and everything!

The Cookie Monster

The new health reform law's cookie monster will always be eating. Its appetite is insatiable. It will eat in broad daylight. It will eat at night. It will eat behind closed doors. It will eat your lunch. It will eat your dinner. It will eat your assets. It will eat the national budget. It will eat 24 hours a day, 365 days a year. It will always be raiding your cookie jar. It will eat things you are not even aware of. It will even eat your money.

• Starting in 2013, if you earn more than $200,000 as an individual or $250,000 as a couple, it will eat 1.45% to 2.35% of Medicare Part A.

• That same year in that same group, it will start eating 3.8% of your “unearned income” – investment proceeds from partnerships, royalties, and rents.

• Between now and 2018, if you are an insurance plan bogeyman, it will eat $47.5 billion. After that it will eat $14.3 billion a year. Along the way, you will be emptying your cookie jar to pay more for premiums.

• Through 2019, it will eat $16.7 billion out of drug company proceeds, and $2.8 billion a year thereafter, causing you to take more out of your cookie jar to pay for drugs.

• It will eat $2 billion a year out of the profits of sales of medical devices- pacemakers, prosthetic limbs, and insulin pumps - more out of your cookie jar if you need these things.

• On July 1, 2010, it began eating 10% out of the profits of tanning salons.

• In 2018, it will tax and eat 40% of the costs of Cadillac health plans.

• It says it will even eat its own entitlement, though it has never eaten an entitlement before. Federal cannibalism on its own is unknown. Yet,from 2010 to 2020, it says it plans to eat $549 billion out of Medicare by eating away to Medicare Advantage plans and payments to doctors and hospitals.

• From 2014 to 2024, it will eat $2.5 trillion out of the federal budget.

What a cookie monster is health reform! It is like a big baby- an alimentary canal with a huge and growing appetite at one end and no end in sight at the other. It keeps saying,”Me want cookies!” But its cookies are your cookies.

Wednesday, March 30, 2011

The Truth about ObamaCare: A Book Review

Yesterday I reviewed Why ObamaCare is Wrong for America (Harpercollins paperback, $14.95). Today it’s The Truth about ObamaCare (Regnery paperback, $21.95).

You can always tell a critical book about health reform by its title. The title contains the word “ObamaCare.”

Tomorrow perhaps I can review a book praising the new health law. I have yet to see it. Maybe it will bear the title "UltraCare," to indicate a superior system, or “UtopiaCare, ” to stress that in a perfect world 100% would be covered. Perhaps “DramaCare,” would be even better, for it would contain dramatic stories of the plight of the uninsured.

Of the “uninsured,”, said to number 46.3 million, The Truth about ObamaCare says 9.7 million earn more than $75,000 a year, but are temporarily unemployed, spend their money elsewhere, or consider themselves “invincible”; 14 million are already eligible for government programs; 6 million qualify for employer sponsored insurance but choose not to; 5. 2 million are illegal immigrants, who may not qualify; and 5.0 million are legal immigrants, who may not be aware they are eligible. That leaves about 10 million who are truly uninsured, and they by law must be covered should they go to a hospital ER.

Sally Pipes, author of The Truth about ObamaCare, is president and CEO of the Pacific Research Institute. She is a Canadian expatriate who describes herself as a “refugee from Canada’s government-run health care system.” She has a “Piping Up” column in Forbes; writes often in the New York Times, the Washington Post, and the Wall Street Journal; and regularly appears on network and cable news.

Ms. Pipes makes no bones about her disdain for the wishful thinking and sloganeering that characterize ObamaCare. She has a jugular vein talent for puncturing the promises and lack of performance of the health reform law. Her 274 page book, printed in easily readable large print, has 23 chapters with catchy titles: “Congratulations! You’re on Medicaid!”, "Shackled to the Mandate Gurney,” Minimum Coverage, Maximum Cost,” “Long-Term Ponzi Scheme,” “Selling out Seniors,”, “Your Hemorrhaging Wallet,” “A Cancerous Deficit,” and “The Doctor Is Out – Permanently.”

In her "Doctor is Out" chapter, she makes her points with these subheadings, “Primary Care Docs Are Going the Way of the Dodo,” “The Coming Physician Exodus,” “Increasing Demand," “and “More Patients, Fewer Doctors.”

She asserts, “With ObamaCare, our future is one of few doctors, more patients, and longer waits. Maybe Congress should buy magazine subscriptions for all those doctors’ waiting rooms that will soon be as packed as the Superdome after Hurricane Katrina.”

In this quote, she reveals her satirical gift. Rather than carry on about my impressions of her book, let me share with you a few sentences from her March 29 Forbes “Piping Up” column, which neatly summarizes her book,

“Last week, proponents of ObamaCare celebrated the one-year anniversary of the passage of the landmark health care law with several hundred events across the country. They have little reason to cheer, according to a sobering new study.”

“In the report, former Congressional Budget Office Director Douglas Holtz-Eakin calculates that health reform's tax on insurers, which takes effect in 2014, will raise family premiums by $5,000 over the decade--all by itself.”

“So much for President Obama's campaign promise that his health reform plan would ‘bring down premiums by $2,500 for the typical family.’ Unless Congress rolls back ObamaCare, Americans can look forward to higher premiums, fewer choices and bigger tax bills.”

Why Obamacare Is Wrong for America: A Book Review

Why ObamaCare is Wrong for America: How the New Health Care Law Drives up Costs, Puts Government in Charge of Your Decisions, and Threatens Your Constitutional Rights is an appropriately named 259 page paperback (HarperCollins, 2011, USA, $14.95).

The book is current and accurate. Its authors are Grace-Marie Turner, president of the Galen Institute, which she founded in 1995 to promote free-market reforms of health care; James C. Capretta, a fellow at the Ethics and Public Policy Center and former associate director of OMB from 2001-2004; Thomas P. Miller, resident fellow of the American Enterprise Institute; and Robert Emmet Moffitt, senior fellow at the Heritage Foundation’s Center for Policy Innovation.

The authors are recognized authorities on health reform. Each has published extensively in national newspapers and prominent health care publications and has appeared on multiple television programs.

Paul Ryan, the Republic Congressman from Wisconsin and author of A Roadmap for America’s Future, writes the foreword, where he says,

“In health care, as in any other economic arrangement, control of money is power. The question remaining is: who gets the power, the government or the patient? Patient power will always serve the needs of the people far better than bureaucrats managing the decline of a government-run system on the verge of bankruptcy.”

This, then, is a book about power: who gets it and who controls it. The authors believe power (and health-care decision-making) should lie with the people, doctors who serve them, and in the states in which patients reside and doctors practice.

I agree with the authors, but rather than express my opinions, I shall cite ten facts they think the public and voters should know before the 2012 presidential election, which will determine the fate of ObamaCare.

1. Higher costs: If you buy a family policy in the individual market, you can expect to pay $2,100 more a year in premiums by 2016 than you would if Congress has not passed ObamaCare…Americans will spend an average of $265 more per person a year on health insurance....more than $1000 for a family of four.

2. Tax hikes: ObamaCare includes $569 billion in tax hikes, which will be passed through to health consumers as higher drug and device prices and higher insurance premiums.

3. Seniors losing coverage: Seven million seniors in Medicare Advantage plans will lose coverage because ObamCare cuts reimbursement from that plan by $145 billion. Senior costs may go up by $346 a year in 2011 and by as much as $923 by 2017.

4. More bureaucracy – the health law establishes an estimated 159 new boards, advisory commissions, and programs.

5. Higher government spending: Rick Foster, Medicare chief actuary, says the health law will increase national health expenditures by $131 billion between 2010 and 2019.

6. Larger deficits- ObamaCare starts collecting new and higher taxes in 2010, but entitlement spending doesn’t start until 2014 – six years of spending and ten years of taxes. The real cost will be $2.3 trillion if ten full years are counted.

7. 23 million uninsured: The bill will leave an estimated 23 million people without insurance by 2019.

8. Insurance death spiral: The individual mandate will force individuals and young people to pay higher premiums to subsidize older Americans. If the young and health choose to pay penalties rather than buy expensive insurance, premiums for the rest of us will soar.

9. Losing your current coverage: As many as 80 to 100 million will find themselves with different coverage when Obama care takes full effect, despite the president’s repeated promise that “you will be able to your health care plan.”

10. Medicare provider losses: The Medicare Actuary says the number of hospitals, nursing homes, and hospice centers facing financial losses would jump, decreasing access to care for Medicare beneficiaries. People may also face a severe doctor shortage, as doctor’s pull of Medicare because of low federal reimbursements.

The authors address this book to the general public. They frequently use of the word “you.” They describe its impact on you and your family, you as a young adult, you as a senior, you as a vulnerable Americans, you and your doctors, you and your employers, you as taxpayers, and you and your constitutional rights.

As I physician, I found their 21 page section on patients and their relationships with doctors particularly powerful. Here is how they describe the plight of doctors.

“It will drown doctors in red tape and bureaucracy. It will limit physicians’ autonomy and their ability to help and advocate for their patients. Their job satisfaction will be drained, and the doctor-patient relationship will be serious compromised. As federal regulators require physicians to do more, they are likely to be paid even less. As the situation worsens, older doctors will retire, and young doctors will look to switch careers. This will come as a time when the demand for physicians’ services will be higher than ever. Ultimately, ObamaCare will translate into restricted access to and inferior quality of care.”

The book concludes that to get reform right, the health system needs defined contributions for health care benefits, creating a national market for health insurance, and leveling the tax playing field.

Tuesday, March 29, 2011

On Health Reform Innovation Now

How will an increasing number of people get quality care at a cost the nation can afford? The answer isn’t hard to figure out. It’s innovation.

Laura Landro, “The Time To Innovate is Now," Wall Street Journal, March 28, 2011

Innovation is an elusive thing. Everybody knows it is the right thing to do. It is the creative way out of difficult situations. But nobody knows quite how to do it.

Do you think outside the box? Do you do it from the top-down, as in the Centers for Medicare and Medicaid Innovation? Do you do it from bottom-up by forming innovation incubators and recruiting venture capitalists? Do you do it out of a sense of desperation to stay in business by bringing down medical costs? Or do you do it by publicizing successful innovation ventures and spreading the word?

Laura Landro, a veteran reporter for the Wall Street Journal, has chosen the latter route by publishing a special section in the Journal featuring six success stories.

These stories are:

One, Critical (Re) Thinking - This report is about how Montefiore Medical Center in the Bronx has brought down the mortality rates in its ICU and the time spent there. The hospital does it by carefully evaluating who belongs in the ICU before patients arrive. They have also done it by assembling a team of critical care doctors who daily assess who should stay in the ICU and by telling loved one that further ICU care may not help, and that comfort and having the family around is more important.

Two, Medicine on the Move - This story concerns the use of wireless mobile devices to diagnose disease and to monitor it, often from a distance without the physical presence of a doctor. Mobile tools allow doctors to monitor vital signs, note changes in activity levels, verify if medications have been take, and make diagnoses over IPhones without ever seeing the patient. Most of the devices being deployed come from entrepreneurs seeking to fill a void, help humankind, and make money while doing it.

Three, The Model of the Future? - Are Accountable Care Organizations and Primary Care Medical Homes the wave of the future. Will these organizations, built on the belief that primary care doctors working in teams and with hospitals, save money and improve care, work? The government thinks so. So do policy wonks. But doctors,who tend not to trust hospital with their money, aren’t so sure. Hospitals, who stand to lose money through reduced admissions, are skeptical. And most patients are unaware of either ACOs or medical homes.

Four, Delivering Results – The idea here is have an obstetrical team work together through training drills and best practice protocols and using robots as well as video cameras to review what steps to take to reduce birth injuries and deaths. Team members are encouraged to speak up and to be critical should they sense something wrong. It is all about training through simulation to enhance communication in stressful situations.

Five, Making Clinical Trials Less of a Tribulation - Only about 3 to 5% of cancer patients participate in clinical trials. But if a health system has a system-wide EHR, the case with Geisinger Health System and Kaiser Permanente, patients can be promptly identified and recruited for clinical trials. EHRs make patient searches faster and more methodical – allowing patients to recruit patients for trials from day one of their treatments and to keep them within the system.

Six – How Can You Help the Medicine Go Down?
Medications can do great things for people – but only if they take itehm- and as many as 50% don’t. One study shows nearly 90,000 patients die prematurely in the US because of failing to take their medicine. Tracking down patient who don’t take their medication relies on electronic records. But it also involves getting pharmacists and patients involved.

What do these six innovations share in common? That’s easy – teamwork, information technologies, and organized systematic, purposeful approaches within large organizations. But the solutions nationwide are not easy, for 80% of care is provided outside large organizations. Perhaps wireless technologies in the hands of individual physicians and related health professionals and creating more “virtual” organizations will bridge the innovation gap, but we are not there yet.

Source: The Journal Report: Innovations: Health Care, “The Time to Innovate is Now,” Wall Street Journal, March 28, 2011.

Monday, March 28, 2011

Republican Health Plan

If you follow media comments on health reform, you will find most major main-stream media commentators claim Republicans have no plan – no alternative to the current health reform bill.

The GOP has a plan, all right, but it does not fit the commentators’ concept of what health reform ought to be all about, viz., a “comprehensive,” centralized, regulation-rich plan that controls markets, physicians, and patients seeking choice.

The Republican plan may not fit Democratic one-size-fits-all belief in what a reform plan out to be, but it’s a plan.

The plan is called the Patients Choice Act, HR 2520, and its sponsors are Dr. Tom Coburn, the Republican Senator from Oklahoma, and Paul Ryan, the Republican Congressman from Wisconsin.

The problem with the plan, according to critics, is that it is too incremental. It does not guarantee coverage for all, set the stage for single-payer, and does not contain enough regulations to make businesses, health plans, doctors, and patients behave economically.

Therefore, it is not really a “plan." It is just a scheme to retain the status quo. It is not reform because it does not make Americans and markets conform.

In essence, the Republican plan is:

• Universal $2300 tax credits for all individuals and $5700 tax credits for families.

• Shopping for health plans across state lines.

• National malpractice reform.

The CBO says this plan would cut deficits by $68 billion and increase coverage by 36 million. Tort reform, the CBO adds, would reduce costs and premiums by $41 billion and increase revenues by $13 billion.

The CBO says it would soak the federal treasury $61 billion versus $1.05 trillion for the Democratic plan.

But no matter, say the commentators, health reform is not about cost. The GOP is not a plan because it does not assure federally-mandated coverage for all with equity and quality, managed by government experts. And it leaves uncounted millions uninsured, even if it gives universal tax credits for all.

All of this is true.

But it is a plan.

In closing,

When is a health reform plan not a plan?
When is a plan not just a flash in the pan?
Do not tax credits for all mean something?
Even to those sitting on the far left wing.

Why the Health Reform Law is in Trouble – A Chronology

March 2010

Health law passes on March 23 after a series of questionable political acts – the Louisiana Purchase, the Cornhusker Kickback, the Connecticut Con, financial sleights of hand and last minute parliamentary maneuvers against unanimous Republican opposition, fueling resentment and a taste for revenge.

April 2010

• News from Massachusetts indicates costs and waiting times continue to rise. Insurance commissioners reject 235 of 274 insurers’ requests for rate increases, threatening to drive them out of business.
• Richard Foster, Medicare chief actuary, releases report showing health plan will increase not decrease health costs.
• White House announces it will nominate Dr. Donald Berwick, an admirer of the British single payer system, as CMS administrator, raising howls of protests from conservatives.
• White House says coverage of those with pre-existing illness, children, young adults under their parents’ policies; removal of caps for medical expenses, small business tax credits, and ending the “donut hole” for seniors will benefit millions of Americans. Polls indicate 59% of Americans not impressed and remain against reform plan.

May 2100

• Obama administration caps percentage of insurer premiums to be used for administration and marketing by establishing a “medical loss ratio.”
• Insurers pull out of children, small group, and individual markets, leaving millions without insurance and calling into question repeated Obama promise “If you like your health care plan, you will be able to keep your health plan. Period. No one can take it away.”

June 2010

• CBO Director Douglas Elmendorf declares “In the CBO’s judgment, the health legislation does not substantially diminish the rising cost of health care.”
• New York Times article doubts White House claims government can end $700 billion of wasteful spending by micromanaging doctors.

July 2010

• White House rubs salt in Republican wounds by announcing recess appointment of Dr. Berwick, thereby depriving Republicans of chance to question and perhaps embarrass Dr. Berwick in open hearings.
• The Massachusetts health plan, the paradigm for Obamacare, continues to unravel with still higher costs and ever longer waiting times. To bring down costs, Mass legislators talk of bundled bills and licensing only those doctors who accept government patients.

August 2010

• U.S, District Judge Henry Hudson says of individual mandate, “Never before has the Commerce Clause and Necessary and Proper Clause been extended this far.”
• CBO estimates Health Reform Law will end 780,000 jobs.
• CMS actuary says new law will ultimately have physician reimbursement rates below those of Medicaid, forcing hospitals and doctors out of Medicare and leaving seniors without access to care.

September 2010

Washington Post says elimination of “donut hole” may “steeply increase” costs of drugs.
• Democratic governor of New York says “Medicaid is the largest single driver of State’s growing expenditures.” and governors of other states fret about their ability to carry burden of Medicaid under health reform.
• Harvard Pilgrim, Massachusetts 2nd largest plan, pulls out of state program.
• Maine and Iowa ask for waivers from medical-loss ratio rates.
• McDonalds asks for waivers saying they will be forced to drop coverage for 28,500 employees.
• Market for child only coverage disappears.
• Republicans release Pledge to American, promising to repeal health reform law and replace it with incremental plan.

October 2010

.Kiplinger itemizes ten tax increases secondary to health reform plan.

November 2010

• Republicans gain more seats (63) in Congress than any time since 1938, more than 600 seats in state legislatures, and more governorships (31).
• Governors, wary of massive Medicaid increases, consider dropping of Medicaid programs.

December 2010

• Bipartisan fiscal commission says CLASS, new entitlement program for long-term care is “financially unsound “and will require large tax transfers or will collapse.
• Federal judge Henry Hudson rules individual mandate unconstitutional.

January 2011

• House Republicans vote to repeal law, bill dies in Senate.
• New research by CBO health law will explode deficit by employers and dump employees into government-subsidized exchanges.
• 40% of waivers given to unions.
• Blue Shield of California, former Obama supporter, seeks rate increases of up to 59%.
• Judge Roger Vinson, voids health reform law in its entirety, says individual mandate is unconstitutional.

February 2011

• President Obama supports giving states more “flexibility,” as long as they toe the federal standard line.
• Number of waivers tops 1000 for health plans covering more than 2.6 million people.

March 2011

• Judge Vinson tells White House to stop stalling and to file an expedited appeal to his ruling.
• Survey indicates Romney care has not decreased medical bankruptcies in Massachusetts.
• Congress repeals 1099 provision.
• Kathleen Sibelius admits reform law “double-counts” Medicare cuts to close its deficit and to contribute to image Medicare solvency.
• Clash warfare between GOP and Dems intensifies with 1st birthday of health reform law with conflicting claims of impact.
• 48% of Americans believe health reform law already repealed.
• CBO predicts premiums will go up $2100 in 5 years despite Obama administration claims they will go down up to $2500.
• Premiums grew 12% in 2010 along with increased copays and deductibles.
• HHS says 51% of businesses will change insurers, and up to 80% of small businesses will lose current coverage.

Sunday, March 27, 2011

In Praise of Politicians on the First Birthday of Health Reform

President Obama's health-care reform celebrated its birthday last week but not very happily. Republicans, who gained control of the House last fall in part by attacking the reform, redoubled their threats to strangle the 1-year-old in its crib. Democrats defended the bill but, well, defensively.

Washington Post Editorial Board, “The Politics of Health-Care Reform on its First Birthday,” March 26, 2011

The politics of health reform is a rough, tough game. Politics is not patty-cake. You can please some of the people some of the time, but not all of the people all of the time. You may please your constituents, but you antagonize your opponents.

That may be why most of us look with universal disdain and down-our-noses at politicians. Almost to to a person, we say politicians advance their own interests, rather than those of the people. If you regularly read the Washington Post, you might conclude the Left is right, the Right is bereft, and never the twain shall meet.

Not me. I look upon politicians as professionals and politics as an art, just as practicing medicine is an art and a profession. The late Felix Frankfurter (1882-1965), a Harvard Law Professor before he became as a Supreme Court Justice, said it well:

“Government is itself an art, one of the subtlest of the arts. It is neither business, nor technology, nor applied science. It is the art of making men live together in peace with reasonable happiness...And that is why the art of governing has been achieved best by man to whom governing is itself a profession.”

In my book The Health Reform Maze, now at the publishers, I take the position that politicians, Democrats and Republicans alike, have good intentions. Each political philosophy, however, has unforeseen consequences. Democrats seek universal coverage, but at fearsome costs and massive bureaucratic intervention into personal health affairs. Republicans seek more personal freedoms and choices, but at the price of limited coverage and runaway costs.

Still, both parties act in the best interests of their constituents, in their own self-interest, and in the interest of their own political philosophies. They believe they act in the best interests of the nation. Politicians are, after all, human beings with strengths and weaknesses that beset us all. They should be praised for standing up to their beliefs, rather than being condemned for their shortcomings.

Massachusetts politicians and politics are a case in point.

• Milt Romney, who was governor when the Massachusetts universal coverage law passed five years ago, thought he was acting in the best interests of the people of Massachusetts when the law passed. It was, and is, a popular law in the Bay State. Yet, because the law is considered a paradigm for the national health reform law, because Massachusetts is considered a far-left state, and because its health plan’s costs are proving prohibitive, Romneycare may well bring Romney down as the Republican presidential candidate.

• Republicans are using the defects of the Massachusetts law as a potent campaign issue against President Obama. Curiously, though the majority of Massachusetts residents favor the law, exits polls after the victory of Republican Senator Scott Brown, indicated voters were against expanding Romneycare to the nation as a whole.

• There’s the dilemma of Dr. Donald Berwick, who President Obama appointed as CMS administrator. Berwick is not a politician, but a victim of his politics. He has well-earned reputation as a crusader and implementer of hospital safety and quality measures, but because of his outspoken advocacy of government-led health care and his disdain for market-directed care, he will most likely not be reappointed as CMS administrator.

• Not all Massachusetts advocates of health reform are political, of course. Many reform ideas transcend politics. Examples are ideas of three professors at Harvard Business School. 1) Michael Porter’s prescription for reform is competition sparked by distinctiveness, open choices, and transparency; 2) Clayton Christensen’s reform vehicle is “disruptive innovation” featuring lower costs, convenience, and performance by lesser trained, less- sophisticated personnel; 3) Regina Herzlinger’s formula revolves around consumer-driven health care wherein informed and responsible consumers make smarter choices, just as they do in other retail markets, such as computers and automobiles.

Politics is a dirty business, but someone has to do it. Politicians who do it should not be universally ostracized, criticized, chastised, despised, compromised, and sensationalized for their faults. They have a job to do, and they do it as they see best. We should respect them for that.

Friday, March 25, 2011

Twenty Health Care Innovations

Health care innovations intrigue me. I look upon innovations as the ideal way to lower costs, improve care, and enhance access. Besides ,I wrote a book on the subject, Innovation-Driven Health Care (Jones and Bartlett, 2007). Furthermore, I call this the Medinnovation blog for a reason.

Today a new book crossed my desk Innovation and Entrepreneurship in the Healthcare Sector: from Idea to Funding to Launch (Greenbranch Publishing, Phoenix, Maryland, 461 pages, 2011. $249.00).

The book is pricey, but if you’re an innovator who wants to start a health care business, it is worth the price.

The author is Luis Pareras, MD, PhD, MBA, director of Innovation and Entrepreneurship at the Barcelona Medical Association. He is a neurosurgeon who serves on the boards of several health care startups and venture capital firms. He seeks to help physicians launch new health care businesses in life sciences, medical devices, service and IT. He can reached at

His basic thesis is to start a new health care enterprise with any chance of success, you need: a) a good idea; b) a business plan; c) a team; and d) venture capital. I will not go into any further detail.

Here are 20 health care trends he sees on the horizon.

1. Hospitals Are No Longer Buildings. Instead he sees hospitals as a virtual networks, with innovations to lure patients away from the hospital, fill the space with relationships, and make the hospital more useful and convenient to consumers

2. Patient Safety Focus - He foresees a boom in innovative projects to prevent medical errors and improve safety at all levels of health care with medical centers promoting their safety records on the Internet.

3. Information Is Everywhere - Here he predicts mobile medical wireless devices will make information available everywhere anytime real-time.

4. Evidence-Based Management – He feels data will be essential to evaluate care, create benchmarks, and guide consumers to the best organizations.

5. Health Care Can’t Keep Up with the Rate of Scientific Discovery - In the future, health care providers will need IT tools directing and incorporating best practices into their practices.

6. “Not Being Sick” to “Being Well” – Here he is speaking of preventive tools that focus on early diagnosis and strategies to keep people functioning in peak condition until late in their lives.

7. Shortage Of Professionals
- Because of the shortage of professionals, efforts will focus on helping doctors and others more efficient, effective, and productive.

8. The Information Highway Gains More and More Influence - The Internet will transform medicine through telemedicine and electronic clinical histories.

9. Concepts Such As Peer-to-Peer (P2P)and Web 2.0 will arrive at the Health Sector - These tools will empower both professionals and patients and generate extra value through interactive participation.

10. Social Entrepreneurs Take the Lead - Social initiatives to deliver basic health care to their third world, underdeveloped countries, and uninsured citizens will blossom. Examples are Doctors without Borders, Eyes of the World, and Health Leads in the U/S.

11. Consumer-Driven Health Care - Patients will start to buy their own health care without third party intermediaries, based on quality and convenience and not offered by government and insurers.

12. Electronic Health Records – Transportable “e-records,” I phones; Ipads, and other mobile devices will offer unparalleled conveniences to doctors as well as patients.

13. Cost Containment Will Become More and More Critical in Health Care. Due to every increasing cost, policy makers will limit reimbursement rates for doctors and hospitals. “Do more with less” will become the mantra.

14. New Actors Will Appear in the Health Care Value Chain – New models such Minute Clinic, QuickHealth, IT-based medical practices, concierge medicine, and home care through telemedicine will emerge and grow.

15. Health Care Will Become More and More Vertical – Hospitals dedicated to only one specialty or only one illness or only one procedure will become commonplace. You already see this with eye centers, hernia centers, heart centers, hip and knee replacement centers, and diabetes centers.

16. Personalized Medicine Drives the Agenda
- Preventing and predicting disease through knowledge of personal genomic information and other intensively personal care will become the norm.

17. Bioinformatics Emerge - Sophisticated computer bases and elegant algorithms will correlate billions of measurement and further individualize care.

18. Bioconnectivity Is The Next Big Thing – New generations of highly intelligent medical devices will help wirelessly monitor and manage chronic disease.

19. Electronic Signature is Everywhere
- Everything done in the next ten years will bear an “electronic signature “ of senders and receivers in interoperative communicating and conversing systems.

20. The Triple Helix Is Becoming Real
- The triple helix consists of a supporting triad of organizational administrations, hospitals and universities, and venture capital.

Health Reform: A Tale of A Period and A Semicolon

No matter how we reform health care, we will keep this promise: If you like your doctor, you will be able to keep your doctor. Period.

If you like your health care plan, you will be able to keep your health care plan. Period. No one will take it away. No matter what. Period.

Under our proposals, if you like your doctor, you keep your doctor. If you like your current insurance, you keep that insurance. Period. End of story.

If you like your health care plan, you will be able to keep it. Period. No one can take it away

Statements by President Barack Obama, 2009 and 2010

You might call this my period piece. It concerns President Obama’s repeated use of the word “period” to defend his health plan. He uses “period” to back his promise that Americans will be able to keep their doctor and their current plan.

Positive Provisions and Negative Consequences

Unfortunately, because of a combination of otherwise positive provisions in the health reform law assuring coverage and protection of benefits, for:

• all children;

• young people up to 26 under their parents’ health plans;

• those with pre-existing illnesses;

• those whose policies cannot be cancelled when they exceed a certain dollar limit or while they are ill;

• seniors who fall into the “donut hole;”

premiums are rising; insurers are pulling out of markets; businesses are dropping coverage altogether; patients are losing their doctors associated with dropped health plans; corporations are ceasing to pay for drug benefits for retirees; and millions of Americans may lose their current plans and doctors and be forced to choose among government-endorsed health plans with government-approved physicians; please note in this awkward overlong sentence, I inserted eleven semi-colons before arriving at the final period.

The Grammarian and the Surgeon

This overly generous use of semicolons brings to mind the tale of the grammarian who developed colon cancer. He thought his life would end in a period. But a surgeon operated, removed the colon cancer, and now the grammarian lives with a semi-colon.


The moral of this tale is two-fold:

1) If you like your doctor and your health plan, you may not be able to keep them. Period.

2) If you regard cost as a health care cancer, relax; your government will provide an alternative. Semicolon.

Periods and semicolons.
It's a health plan pair-a-dots.

Period. End of story.

Thursday, March 24, 2011

Health Reform: The Individual Mandate, Individualism, and Collectivism

The American system of rugged individualism.

Herbert Hoover (1874-1964), Campaign Speech (1928)

No provision is currently more beleaguered than the individual mandate to obtain health insurance or pay a penalty…Ultimately, the furor over the mandate underscores the reality that solidarity remains elusive in U.S. health policy.

Jonathon Oberlander, PhD, “Under Siege – The Individual Mandate for Health Insurance and Its Alternatives,” New England Journal of Medicine, March 24, 2011

March 24, 2011 - In today’s New England Journal of Medicine Jonathon Oberlander, the health policy leader at the University of North Carolina, weighs in on the problems of the individual mandate.

The political problem for Democrats, he says, is that 76% of Americans view the individual mandate unfavorably (Kaiser Family Foundation/Harvard School of Public Health poll, January 2011).

Seventy six percent is a huge percentage. It will not be easy to overcome politically. When combined with the latest CNN poll indicating 57% oppose the law, it is clear that the individual mandate, the financial foundation for the health reform law, is mired in deep political doo-doo.

But, if the individual mandate goes down, what are the alternatives?

According to Oberlander, the alternatives are:

• A tax-financed single payer system, infeasible in the current political climate.

• Imposing heavy financial penalties on eligible people who choose to wait and buy coverage later.

• Automatically enrolling people into health insurance plans, as required for auto insurance, with a premium penalty for people who opt out but who later decide to purchase insurance.

Another alternative, which Oberlander does not mention, are Republican proposals combining universal tax credits, shopping across state lines, choice among alternative health plans as in the Federal Employee Benefit Plan, and expansion of health savings and flexible savings accounts with high deductible plans. This scenario should not be dismissed out of hand, for it likely the Republicans will win the House and the Senate in 2012 and possibly even the Presidency.

Whatever happens, the philosophical and practical arguments boil down to collectivism for the social good versus individualism for individual freedom.

Collectivists say:

• Covering everyone requires that the healthy pay for the sick.

• Social Security, Medicare, and Health Reform requires that everyone participates.

• The current health law requires the individual mandate to fund its implementation.

Individualists say:

• Our constitution does not allow government to force individuals to pay for something should they choose not to.

• The individual mandate infringes on personal liberties.

• Individual states have the right to block the mandate and to pursue their own alternatives to the mandate and to health exchanges.

In Oberlander’s words, “The mandate now confronts a legal and political backlash.” Republicans cannot overturn the law until 2013 - and then only if they make a clean sweep of the House, the Senate, and the Presidency. Until then the GOP will target the individual mandate as the best hope for crippling the health reform law.

Will the argument for collectivism - the greatest good for the greatest number at the greatest measured quality with the greatest government power – win?

Or will the American tradition of rugged individualism with its countervailing argument – too much government violating constitutional rights, infringing on individual rights, disrupting free market principles, and redistributing of wealth – prevail?

Will collectivism, as embodied in the Patient Protection and Affordable Care Act. be the remaking of American health care? Will the American tradition of rugged individualism be its undoing? If neither, what is the proper balance?

Only time, 1 year and 7 months and 8 days, from now to November 2, 2012, to be precise, will tell.

Wednesday, March 23, 2011

Health Reform Debate Scorecard: Heart Versus Brains

March 23, 2011 - On this, the first anniversary, of the passage of the health reform law, three things are self-evident.

• The fate of the law will be decided by either the Supreme Court or the 2012 Presidential and Congressional election, and will be sealed in 2013, one year before the law was to take full effect in 2014.

• The debate over the law will continue unabated and will rage on until November 2012, in the face of escalating costs, court battles, resistance to implementation and even defiance by the states, small and large businesses, and various sectors of the health care establishment.

• The core issue of the debate will be whether America, as a civilized nation, has enough heart, i.e., compassion to cover everybody and protect them against costs, or enough brains, i.e., intelligence to know costs of entitlement programs are historically uncontrollable without rationing and/or budgetary overruns.

The Health Reform Debate Scorecard

Here is the political scorecard, as Democrats and Republicans draw their lines in the sand, as seen by Americans and recorded by the media and as reflected in polls,

CNN: CNN Poll: Time Doesn't Change Views On Health Care Law
One year after President Barack Obama signed the health care reform bill into law, a new national poll indicates that attitudes toward the plan have not budged. According to a CNN/Opinion Research Corporation survey released Wednesday, on the one year anniversary of the signing of the law, 37 percent of Americans support the measure, with 59 percent opposed. That's basically unchanged from last March, when 39 percent supported the law and 59 percent opposed the measure.

The Washington Post: As Health Care Turns 1, Supporters Using Occasion To Shape Its Image: This week, a loose federation of left-leaning groups is convening nearly 200 gatherings to peddle the virtues of health care reform. A women’s speak-out in Philadelphia. A small-business round-table discussion in Albuquerque. A fish fry for seniors in Columbia, S.C. From the Obama administration alone, 42 officials are fanning out to events in 22 states.

NPR: As Health Law Turns 1, Debate Far From Settled: Wednesday marks a year since President Obama signed the Patient Protection and Affordable Care Act into law. But in those ensuing 12 months, the debate has barely missed a beat.

McClatchy/The (Columbia, SC) State: Doubts Persist About Year-Old Health Care Law A year into President Barack Obama's Affordable Care Act, a group of small-business people in South Carolina showed Monday that misgivings and misconceptions about the new program remain. About 30 people attended a round table to discuss the new health insurance law and its implementation in the state.

Kaiser Health News: One Year Down, Pollsters Handicap Health Law Politics:
From the very beginning, supporters of the health law said the American public would embrace the measure once they learned more about all of its consumer-friendly features. Opponents, especially Republicans, disagreed — and, for that, some were rewarded in the election of 2010. To get a fresh take on how these perspectives have played out and how public opinion has evolved read the Democratic perspective, offered by Celinda Lake, David Mermin and Dan Spicer; and the Republican view, from Bill McInturff and Lori Weigel. In related Kaiser Health News health law anniversary coverage, KHN staff asked players and experts from across the nation what they thought the landscape would be like – and, in their view, should be like – by the measure's second birthday.

ABC News: Health Care Law's First Anniversary: Why Haven't Americans Seen Changes Yet? With insurance premiums rising rapidly, most Americans still don't know what the health care law means for them. A poll conducted by the Kaiser Family Foundation this month found that 52 percent of Americans don't feel they have enough information about the health reform law to understand how it will affect them personally, compared to 47 percent who think they do .

PBS Newshour: Adding Up Health Reform, One Year Later: Wednesday marks one year since health care reform was signed into law. The NewsHour takes a by-the-numbers look at some of the provisions that took effect during the law's first year.

MarketWatch: Health Reform, Age 1, Faces Tough Challenges:
But the larger issue remains a stubborn philosophical divide over the proper role of government in working out the cost and access problems that have left 50 million people uninsured and countless more with an increasingly tenuous grip on whatever coverage they do have. Opponents remain critical of the overhaul they fought to prevent, and experts say the 2012 presidential election may present the biggest threat to its continued implementation.

A Conversation: Status and Morale of Physicians on the First Anniversary of Health Reform

March 23, 2011
– Oft times, you can learn more quickly about the state of affairs of what is going on from a casual conversation than from a structured article based on extensive research.

Yesterday, I had a conversation with John McDaniels, who is CEO of a national practice management firm called Peak Performance Physicians. He has given me permission to print what was said during our conversation. John was in Las Vegas, though the basis of his consulting business is in New Orleans.

“ I would describe physician attitudes on reform as somewhere between panic and disarray. More and more doctors are seeking hospital employment. The younger doctors are more interested in security and life style than in making money in private practice. They know the opportunities to make money are not anywhere near what they used to be. "

“The older doctors, 60 or plus, are just seeking to cash out, work for a few years, or retire. We are seeing an awful lot of hospitals employing doctors, and doctors seeking employment.”

“Now, having said that, we are also working with a company that joint ventures with doctors on surgical centers. The last thing the hospitals want is for a physician partner to become an employee because hospitals lose revenue. We are working on what we call practice leasing. A company manages the practice at a fixed percent of collections. It gives the doctor security, but there’s no employment. The doctor remains in private practice. Both sides have the opportunity to produce. Both sides benefit. There is no capital required for the hospital or the company to buy the practice. It’s kind of like living together versus being married. They have a relationship but it’s not very formal.”

“There are all sorts of confusion about health reform and accountable care organizations. The future is clinical integration. The large clinics can achieve clinical integration because they can basically dictate to their physicians on how to treat certain diagnoses. “

“But what do you do in a private hospital setting in which you’ve got all private doctors? How do you get them on the same page? That’s the challenge. The systems can dictate, but most doctors are not in systems. This creates an awful lot of confusion. But clinical integration is great for me and other consultants.”

“ Right now, there is as much uncertainty as I have ever seen. More and more doctors are opting out of Medicaid and Medicare. That will create a tremendous access problem in the near future. This is already occurring in Massachusetts. Right now the waiting time there is 60 days. When the waiting time reaches 6 months in Massachusetts and elsewhere, Washington is going to have a real problem.”

“There is another huge problem as well. I am in Nevada right now, and my neighbor is an air traffic controller. We have interesting conversations about “highly reliable organizations.” The airplane industry tends to be highly reliable, but hospitals are not. Basically, in hospitals, every day we kill two plane loads of people. Hospitals are highly unreliable. But simple things, like checklists in the OR and on the wards and more attention to respirators, IV lines, and catheters, we could save a lot of people. Pilots are not afraid of being questioned about their procedures, but for some reason, doctors are. Why are hospitals so unreliable? Is it because patients are so fragile and sick and variable? Is it because doctors are arrogant? Is it the lack of system approachs to systemic problems?. Those are topics for you to contemplate.”

Tuesday, March 22, 2011

Loading and Unloading the Health Reform Wagon

When a fellow says it hain’t the money but the principle o’ th’ thing, it’s th’ money.

Frank McKinney Hubbard (1868-1930), Hoss Sense and Nonsense (1926)

The first birthday of the health reform law takes place tomorrow, March 23, 2011.

Brace yourself. To either celebrate it or denigrate it, you will hear a lot of talk about the principle of health reform, not the money involved.

Supporters will say we need the Law to cover everybody and protect everybody at costs everybody can afford. It is the only morally imperative thing to do for our fellow human beings. It is the principle of the thing, not the costs it takes to do it.

Detractors will say the Law does the opposite. It is raising costs and driving us into national bankruptcy while punishing those who drive our economic engines and who provide the care. It is the cost of the thing, not the principles behind it.

Either way, we simply can’t afford open-ended entitlements which are the principal cause of our mounting national debt. The trouble is, of course, that cutting Medicare is the third rail of American politics. Seniors, the most reliable voting bloc, are not fooled. They do not believe you can slash Medicare costs by $575 billion while cutting hospital and doctor pay and still maintain quality and access.

Health reform comes down to a matter of economics. “Economics, “ the late Jack Kemp (1935-2009), the Republican Congressman from Buffalo, said, “ is simple. There are those who load the wagon, and those who unload it. “ When more are unloading the wagon than loading it, the economy is in trouble.

The current talk about health reform, continuing resolutions to keep the government going, and even shutting down government is about too many people unloading the wagon. It is now estimated that 35% of Americans totally depend on government. In other words, for every two of us loading the wagon, one is unloading it.

The political trick is to balance the costs of those loading the wagon against those unloading it. Many regard total health costs of $2.5 trillion as unloading the wagon, but at the same time, the health care sector loads the wagon by creating jobs and being the principal wagon-loading engine of many communities and entire regions.

The AMA just released a report showing office-based physicians in 2009 loaded $1.4 trillion onto the economic wagon and supported 4 million jobs nationwide. In the average state, this translated into $10.3 billion in economic activity and 46,400 jobs.Physicians are not idle bystanders in this balancing act.

Yet the health reform law’s various provisions over the next ten years are aimed at decreasing physician “unloading” by:

• decreasing physician pay by 30% or more to Medicare and Medicaid levels

• making EHRs a requirement for staying in businesses,, so that physician practices can be tracked and made “accountable”

• forming Accountable Care Organizations that compel doctors and hospitals to work together under fixed budgets to “save” money by decreasing the income of both and discourage waste and duplication

• creating new business models (medical homes, bundled billings, new hospital relationships , hospital employment, and concierge practices) to survive

• implementing physician “measurements” through Physician Quality Reporting Initiatives (PQRI) that reward or punish doctors for “quality performance”

All of this while operating costs and expenses of running a practice, meeting new federal regulations , installing information infrastructures, and recruiting new physicians and other health care professionals to cope with new consumer demands, are relentlessly increasing.

No matter. It’s the principle of decreasing the cost of unloading, not the money involved in doing it, or the money generated by those loading the wagon.

Monday, March 21, 2011

Health Reform, Primary Care Shortages, and the Coming Political Crisis

I am a firm believer in the people. If given the truth, they can be depended upon to meet any national crisis. The great point is to bring them the real facts.

Abraham Lincoln (1808-1965)

Preface: In these blogs, I have consistently argued the next big health care crisis will result from a widespread national shortage of primary care doctors and specialists as well, particularly in rural and already doctor-short regions. The inability of new Medicare recipients, specifically the 78 million aging baby boomers now beginning to turn 65 to find doctors will ignite the crisis and keep it in flames. Here,to support my thesis, I reprint a Kaiser Health News article, with their permission.

Doctor Shortages Under Health Law May Depend On Geography

By Jessica Marcy

KHN Staff Writer

Mar 17, 2011

States in the South and Mountain West, which traditionally have the lowest rates of primary care physicians, could struggle to provide medical services to the surge of new patients expected to enroll in Medicaid under the health overhaul and federal incentives may not provide much help, according to a report issued today by a Washington health research group.

The study, by the Center for Studying Health System Change, noted that many of the states with low numbers of primary care doctors per capita are also expecting some of the highest percentage increases in Medicaid enrollment. The study's author — Peter Cunningham — estimated that Medicaid programs could grow by as much as 38 percent in states with low rates of primary care physicians, while only about 15 percent in those states that have high rates of the doctors—those in the Northeast and the Mid-Atlantic regions.

"Things are probably not going to be pretty in those states that have a hard time" recruiting primary care doctors, said Alwyn Cassil, the center's director of public affairs.

The new federal health law will expand Medicaid eligibility starting in 2014 to those making up to 133 percent of the federal poverty level, or about $14,400 for an individual and just under $30,000 for a family of four. About 16 million people are expected to join the joint federal-state health program by 2019.

(According to Kaiser Health News, there are 14 states with less an 11.5 primary care physicians per 10,000 persons: Idaho, Nevada, Utah, Nebraska, Mew Mexico, Texas, Oklahoma, Arkansas, Louisiana, Mississippi, Alabama, Georgia, South Carolina, and North Carolina. But this does not tell the full story. Some states, like Massachusetts, with large numbers of primary care doctors, are already reporting severe access problems).

Many physicians currently do not accept Medicaid patients or limit the number they will see, saying the reimbursement rates are too low. That has raised concerns about whether the new enrollees will be able to find doctors.

The study analyzed responses from 4,700 physicians in general internal medicine, family practice and general pediatrics and found that physicians' willingness to take on new Medicaid patients, who often face greater barriers to access, didn't vary geographically.

The study also examined the potential impact of a boost in Medicaid reimbursement for doctors that was included in the health law. It found that the bump, which would put payment for certain primary care services on par with Medicare levels in 2013 and 2014, may have a more limited impact than expected and would also vary according to geography.

"If you thought the increased Medicaid reimbursement was going to get a lot more docs to jump in and be willing to take on new Medicaid patients, it's not going to work that way," Cassil said.

In general, states with low rates of primary care physicians -- primarily in the South and West -- tend to provide more generous Medicaid reimbursement to attract doctors to the program. On average, Medicaid reimbursement rates in those states are 81.6 percent of the reimbursement rates for Medicare, compared to 54.8 percent in the high primary care doctor states. That means the new Medicaid reimbursement bump will likely have less of an impact in those areas than in states with more primary care docs.

But the situation is complicated in those low-doctor states. They traditionally have more restrictive Medicaid enrollment. That means that when the new health law is implemented, they will have a higher percentage of residents suddenly coming into the Medicaid program, which makes the demand for doctors serving enrollees even greater.

Dr. Lori Heim, a family physician in North Carolina and a member of the board of directors of the American Academy of Family Physicians, said the report underscored the need to address the primary care shortage. "If you're going to address the shortage areas, we have to look at a payment reform as well as how we deliver care," Heim said.

The supply of specialists also poses a challenge as more states push Medicaid patients to join Medicaid managed care plans, which often lack enough specialists.

Response to Comments on My Blog Posted at KevinMd.Com

Preface: On March 20, Kevin Pho, MD, posted the following blog on his site, the most widely read medical blog in America. The blog has drawn 49 comments, some of them critical. Thirteen of these 49 comments are mine, I wrote to clarify my position on the health reform law. I did not intend to be inflammatory or partisan in my blog, but to state flaws, misconceptions, and unforeseen consequences inherent in the one year old health reform law.

In the interest of further clarity, I would like to clearly state where I stand on his vital national issue of health reform. My 12-point statement appears after the blog. You may read readers' comments and my responses by going to I have not included these comments here because of length constraints.

Huge Holes Exist in the Health Reform Law (as it appeared in


by Richard Reece, MD

Huge holes exist in the health reform law you can drive an 18-Wheeler through. These holes are not “devils in the details.” They are so obvious nobody talks about them. They are the proverbial elephants in the room. I suppose this makes sense. It takes an 18-wheeler to transport an elephant.

Here are my six candidates of the biggest health reform holes.

One, the government’s lack of leverage over health insurers. President Obama and Kathleen Sibelius can talk all they want about the evil health plans and how they are outrageously raising premiums, on average by 10% to 20%. But other than jawboning and demonizing, the Obama administration has little control over the rates. It is fine to say the health plans must cover those with pre-existing coverage, young people up to age 26 under their parents’ plans, and to remove caps on lifetime expenses, but the plans can ignore the government and set the rates to cover the increased expenses engendered by government mandates.

Two, the government’s lack of appreciation that the U.S. is center-right not a center-left nation. At its core, America is a middle-class country that believes in limited government, limited taxes, and limited intervention in private affairs and private behavior. Two particularly sore points are: one, the individual mandate, which requires everyone to pay at least $700 , or 2.5% of income, and two, the provision that every business must submit a 1099 for every $600 spent for supplies or deserves, whether or not related to health care. In both cases, the IRS may crack down and pursue non-compliance. These two things strike Americans as government meddling. These government actions, in my opinion, accounts for much of the lack of approval of the Obama agenda and for the rise of conservatism, the Tea Party movement, and the embrace of the GOP over Democrats. The public wants Washington to swing to the center.

Three, the government’s lack of price controls. Everybody but Washington seems to know you cannot expand coverage for the uninsured by 32 million(and Medicaid by 16 million) and save money while cutting Medicare by $575 billion. And you cannot save money when 78 million baby boomers, starting in 2011, will begin becoming eligible for Medicare. Saving money under these circumstances is simply counter-intuitive. Congress lacks the political will, and no combination of taxation, fines, penalties, and punitive savings imposed on the health industry will make up for the deficit.

Four, the government’s incompetence in containing fraud and abuse. Fraud and abuse costs Medicare an $60 billion a year, over 11% of its budget, and that may be an underestimate. Someone has calculated that Medicare fraud and abuse consumes 7 times more money than the combined profits of the 14 largest health insurers, who are largely free of rampant fraud and abuse characteristic of Medicare. Medicare is too tempting a target for criminals who can use stolen Medicare IDs, and who know that Medicare is obligated to pay claims in 30 days.

Five, the inability of the States to pay for millions of Medicaid recipients scheduled to join the state rolls in 2014. Millions more may enroll before then when patients with current plans learn their new plans must meet government mandates that require comprehensive coverage and higher premiums they cannot afford. About 70 million will be required to change plans, and many of them will switch to Medicaid. Few Americans appreciate the Medicaid burdens States must shoulder. In California, Medi-Cal, its Medicaid program, cover 1/3 of children and 1/10 of adults under 65, 2/3 Of nursing home residents, and 2/3 of expenses of public hospitals, while costing the State of California. $46 billion.

Six, the failure of government to act to correct the looming access problem to physicians. This access crisis is already being felt in Massachusetts, said to be the model for Obamacare. There patients now have the longest waiting times in the nation to see a doctor or to seen in emergency rooms, and half the primary care physicians in the state no longer accept new patients. This is primarily a supply-demand problem. There are not enough doctors to see the flood of new patients, and the reform law does virtually nothing to increase the supply of doctors.
Richard Reece is the author of Obama, Doctors, and Health Reform and blogs at medinnovationblog.

Twelve Points to Clarify My Position on Health Reform

1. I believe health reform is still badly needed, and physicians should actively participate in the reform process since they must deliver the care mandated in the law.

2. I believe the Patient Protection and Affordability Act is the law of the land, and its provisions must be followed until otherwise changed.

3. I believe in the checks and balances of divided government with administrative, legislative, and judicial branches.

4. I believe in a system with two major political parties that respond to will of the people, as expressed in voting in Congressional elections every two years and a presidential election every four years.

5. I believe the Patient Protection and Affordability Act should be re-debated because of its unpopularity among voters, because of its already apparent flaws, and because it was passed on March 23, 2010 in the face of unanimous Republican opposition, No other major piece of social legislation affecting every American has passed without at least one bipartisan vote.

6. I believe those who wrote the Patient Protection and Affordability Act did so with good , decent, and honorable intentions of covering more uninsured Americans, protecting other Americans, and with the underlying motive of making their stamp on history.

7. I believe the Patient Protection and Affordability Act was written in haste while the political iron was hot without carefully thinking through the political, economic, and social consequences on individuals, the currently insured, existing institutions, patient, and physicians.

8. I believe the final reform product, whatever it is, must have a place for both government to protect the poor and disenfranchised and for the market to provide and assure personal freedoms, choice, innovations, and medical excellence.

9. I believe the cost of a entitlement programs will continue to be a major contributor to the U.S. debt crisis and can be reined in by a combination of slowly advancing the age of Medicare entry to 70 over a period of five years, by means testing of Medicare recipients, by encouraging and making health saving accounts more widely available, and by extending patient choice of health plans across state lines, just as the Federal Employee Health Benefit Plan does.

10. I believe that the states should have a voice and the authority to experiment with innovative Medicaid programs that make those programs affordable and protect the states against bankruptcies.

11. I believe that the Supreme Court should decide the constitutionality of the individual mandate - and soon.

12. I believe the November 2010 elections had consequences and signaled that the U.S. will continue to be center-right nation with a unique health system blending government and the market mechanisms for providing the best and most equitable care for all Americans.

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.

Sunday, March 20, 2011

With Health Reform, Some Health Plans Are More Equal Than Others

All animals are equal, but some animals are more equal than others.

George Orwell (1903-1950), Animal Farm (1945)

When Orwell, an avowed socialist, made this statement, he meant that the “haves,” the elites, felt that people in their class were equal, but the “have-nots” – working class and minorities- were less equal. Saying all people are equal was a way of making the “haves” look virtuous, although they don’t believe this in practice.

Orwell was being satirical. He was saying that equality of results didn’t work out that well when elites ran the country. Theoretically, the new health reform law should level the playing (and paying) fields between the haves and have-nots by redistributing health (and wealth) benefits – by covering more of the poor, children, young adults while taxing the rich – and giving all more or less equal care. But it doesn't work out that smoothly because some people always want more and to pay less than others.

As I read a Robert Pear piece in today’s March 20 New York Times, I thought of Orwell. The article “Health Law Waivers Draw Kudos and Criticism” concerns the offering of waivers to more than 1,000 health plans covering 2.6 million people. The reform plan, designed to cover 32 million more Americans and to protect and to make it more affordable for everybody, has a requirement to provide at least $750,000 in coverage to each person in their own health plans.

Regrettably, the reform plan raises costs significantly for many of the “have-nots,” who say they cannot afford it, and it drives insurers out of markets, leaving more uninsured in its wake.

In this case, those who claim to be “have-nots,” say the law is too strict, demanding, and expensive, and they want to opt out. They seek a reprieve, an exemption from the law. They need, they insist, to be classified as exceptions and to be “waivered out,” beyond the reach of the law.

To date, says Pear, “Such waivers have gone to entities as diverse as the Waffle House and Ruby Tuesday, health plans run by Aetna and Cigna, and labor unions representing Teamsters, electrical unions, carpenters and food and commercial workers.”

Without the waivers, says Kathleen Sebelius, Secretary of Health and Human Services, many employees would have to pay unaffordable premiums, employers would have to drop coverage, and health plans would have to withdraw from markets, leaving millions uninsured.

The law has a provision saying health plans must pay at least 80% of premium revenues for care and efforts to improve it. Maine was issued a waiver dropping this to 65%, and five other states – Florida, Georgia, Kentucky, Nevada, and New Hampshire – have requested similar waivers. A dozen other states may apply for waivers.

The need for waivers will continue to grow as Federal rules require health plans to increase the requirement of $750,000 in coverage to $1.25 million in coverage in 2012 and $2 million in 2013. By November, 2012, the date of the next Presidential election, we should know what health plans are more equal for what political animals.

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.

Health Reform Polls Show Confusion and Division

Americans Remain Divided, Confused About Health Law as Anniversary Nears

Phil, Galewitz, Title of paper, Kaiser Health News, March 18, 2011

Confused we stand. Divided we fall.


If you have a divided opinion and are confused about health reform, join the crowd. Consider these March 18 opinion polls about the health reform law.

• 42% of Americans favor the law while 46% are against it.

• 71% of Democrats back the law and 82% of Republicans oppose it.

• Of those against the law, 20% mention excess costs, 19% too much government, and 18% concerns over the individual mandate.

• 53% are confused about the law.

• 67% say states should be allowed to substitute their version of reform as long as its meets federal standards.

• 67% support repeal of the individual mandate.

• 52% of seniors have unfavorable views of the law, and 42% are for it.

• Poll averages of ten national polls indicate 39.0% favor the Obama plan and 51.9% oppose it.

Sources: Kaiser Health News and Real Clear Politics

Why this mixed picture? In my unpolled opinion, there are three factors: 1) Ramming through the law against unanimous Republican opposition without thinking though the consequences; 2) lack of a cohesive story of what the law is all about ; 3) a fundamental misunderstanding of culture is about in a culturally diverse country like the U.S.

On a lighter note, reasons exist to mistrust polls, which are merely a snapshot in time. As the late Erma Bombeck noted, “I haven’t trusted polls since I read 62% of women had affairs during their lunch hour. I have never met a woman in my life who would give up lunch for sex.” Will Rogers chimed in that polls in the South will always indicate the voters will vote dry, “As long as everybody is sober enough to stagger to the polls.” Warren Buffet concluded soberly, “A public opinion poll is no substitute for thought.”

There is nothing like a poll,

It signals the eventual whole.

There is nothing like a poll.

It resembles an early stroll.

In the end, it takes finally an election,

To see if polls point the right direction.

You can’t always trust them.

When there’s political mayhem.

Besides, to use an obvious example,

You can slant your population sample,

Just ask the right questions,

And give leading suggestions.

Saturday, March 19, 2011

The Search for the Very Best Hospitals

I am easily satisfied with the very best.

Winston Churchill (1874-1965)

Two Items caught my attention this week,

• A March 16 Press Release, “U.S. News & World Report and Castle Connolly Collaborate to Help Consumers Find the Best Hospitals and the Top Doctors.”

• A March 17 New York Times article“What Makes a Hospital Great? “ By Pauline Chen, MD.

I am not a disinterested reader.

For the last ten years, I have been on the Medical Advisory Board of Castlr Connolly’s “Top Doctors ®” publications. The Castle Connolly Top Doctors selection process begins with online surveys of physicians in both academic and private practice positions across the U.S. They are asked to nominate physicians they consider best in their respective areas of medicine. Once these professional peer nominations are processed, a unique, physician-led research team carefully reviews the credentials of every physician being considered for inclusion as a Castle Connolly Top Doctor. This review includes, among other factors, scrutiny of medical education, training, hospital appointments, administrative posts, professional achievements, and malpractice and disciplinary history. Doctors do not and cannot pay to be included in any Castle Connolly listing or guide.

I have followed U.S. News and World Reports annual publications announced the best hospitals in the U.S. The U.S. News Media Group is a multi-platform digital publisher of news and analysis, which includes U.S. News & World Report, the digital-only U.S. News Weekly . The media group ranks colleges, graduate schools, hospitals, nursing homes, and more.

I am also interested because my upcoming book, with a tentative title of The Health Reform Maze, will soon be published by Greenbranch Publishers.

In the section of hospitals, I say:

“The centerpiece of the American health system are American hospitals and the physicians who use them as workshops. Hospitals account for 31% of health costs. The health reform envisions lowering of costs and improving care through new organizations creating collaboration between hospitals and doctors by having government pay for bundling services between the two. These collaborative organizations, called Accountable Care Organizations (ACOs) have their up and down sides and their supporters and distractors.”

The controversy surrounding ACOs is beyond the scope of this blog. But the search for the best hospitals is not. In her New York Times piece, Dr. Chen cites a study in this week’s Annals of Internal Medicine (“What Distinguishes Top-Performing Hospitals in Acute Myocardial Infarction Mortality Rates”, in which the authors conclude,” High-performing hospitals were characterized by an organizational culture that supported efforts to improve AMI care across the hospital. Evidence-based protocols and processes, although important, may not be sufficient for achieving high hospital performance in care for patients with AMI.”

In other words, it isn’t electronic medical records, superstar physicians, adherence to protocols, high-tech equipment, or data on re-admission rates that make a hospital great, it’s the culture - how people communicate and support each other and the organization – that counts. The organizational culture is what makes hospitals the very best.

Friday, March 18, 2011

I Spoke Too Soon: President Obama Puts Candle on !st Birthday Cake of Health Reform Law

Yesterday, I wrote Republicans were celebrating the failures of Obamacare on its first birthday while Democrats were remaining silent.

That’s too bad and premature. I apologize. I pride myself on being even-minded about health reform. But sometimes my skepticism overcomes my objectivity, and my bias shows through. As the late E.B. White, America’s premier essayist, observed, “A writer's style reveals something of his spirit, his habits, his capacities, his bias.... It is the Self escaping into the open.”

As it turns out, the Obama administration has its strategy to celebrate the event. It consists of having a half-dozen cabinet members fanning out around the country praising the positive accomplishments of the law. These accomplishments include tax credits for small businesses, rebates for seniors who fall in the Donut Hole due to high prescription drug costs, coverage of young adults up to 26 under their parents’ health plans, and an attack on health plans as the main culprits for rising premiums.

Also, after the fanfare over the 1st anniversary blows over, and the 1st candle has been blown out, Democrats are relying on:

• $105 billion they cleverly set aside to automatically fund implementation to blunt Republican efforts to defund the bill;

• putting out a final version of the Accountable Care Organization provision forcing hospitals and doctors to collaborate by paying them on the basis of fixed budgets for Medicare populations.

Now is not the time to focus on the virtues or faults of Obamacare. Let’s face it. President Obama has bigger issues on his plate with disasters in Japan and Libya. Dealing with health reform can wait for another day, Now is a time for good sense, candor, civility, and support on bigger international issues rather than on the string of unforeseen and unfortunate consequences of health reform.

Thursday, March 17, 2011

Republicans Congregate in D.C. on 1st Anniversary of Obamacare

Next Wednesday, March 23, is the first anniversary of the passage of the Patient Protection and Affordability Act. Give that this health reform law is the biggest piece of social legislation since Medicare, you would think this would be cause of celebration for Democrats and for consternation for Republicans.

Not this year. The Democrats are mute. Maybe this is because of the unpopularity of the law. A Rasmussen poll on March 15 showed 62% want the Affordability Act repealed.

Republicans are converging on Washington from across the U.S. to hold events calling for its repeal. A Republican physician Congressman , Michael Burgess,M.D. of Texas, and physician Senators Tom Coburn, MD, of Oklahoma, and Pat Roberts of Kansas, and John Barasso, MD of Wyoming, are glad to lend a hand to the proceedings, which resemble a wake more than a birthday party.

A wag once said D.C. stands for “Darkness and Confusion.” This year for Republicans D.C. might stand for “Desecration and Condemnation.” Some of the events being held are book parties. Grace-Marie Turner, founder and president of the Galen Institute, and her three co-authors will appear at the National Press Club on March 24 to launch their book Why ObamaCare is Wrong for America, and on March 23, Congressman Michael Burgess will celebrate the release of his book, Doctor in the House: A Physician Turned Congressman Offers His Prescription for Scrapping Obamacare – and Saving America’s Health System.

Meanwhile Senator Pat Roberts of Kansas, commenting on the first anniversary of Obamacare bill, issuing these figures in a press release. He did not give a time frame for these dire estimates.

∙ $2,100 in higher premiums;

∙ 800,000 fewer jobs;

∙ $118 billion in new unfunded state mandates;

∙ $311 billion in higher health care costs;

∙ $529 billion in Medicare cuts to fund new entitlement spending;

∙ $813 billion in new taxes;

∙ And $2.6 trillion in new federal spending.

From other Republicans there is a drumbeat of criticism citing negative ore questionable consequences flowing from the bill.

• Over 1000 waivers for union, corporations, and state adversely effected.

• Marketplace impacts, with insurers pulling out of individual , child, small group, and Medicare Advantage markets.

• Doctor shortages, particularly in the South and Mountain West states.

• Negative impacts on health care brokers.

• A growing movement for repeal,

• Protests from cash-strapped states unable to handle the new Medicaid burdens.

Some first anniversary. Some birthday party. I have scoured the Internet in search of Democratic events celebrating the first anniversary of Obamacare. So far I have come up empty. Nancy Pelosi and Harry Reid made some subdued, understated comments of praise, but nothing else. Maybe when you think you hold the aces, you don't feel a need to comment. I am confident events are being held to commemorate the positives of the law and its contributions to public welfare, but they are not getting any national publicity.

Wednesday, March 16, 2011

Health Reform Thought for Today

The “devil,” they say,“ is in the details.”

That is why government often fails,

The government devil,

Is not at ground level.

Sunday, March 13, 2011

Patients with Mysterious Diseases and Medical Scientists Clash

A little learning is a dangerous thing;
drink deep, or taste not the Pierian Spring:
there shallow draughts intoxicate the brain,
and drinking largely sobers us again.

Alexander Pope (1688-1744), An Essay on Criticism, 1709

Making things more transparent can immediately turn consumers into better shoppers and make markets work better. One might think that such an initiative would receive nearly universal support – after all, who could be against openness and transparency?

Richard H. Thaler, "This Data Isn’t Dull: It Improves Lives” New York Times, March 13, 2011

In a perfect health reform world, empowered patients, armed with transparent information about their disease and its costs, sould control their health destinies. In their 2001 book, Crossing the Quality Chasm, the Institute of Medicine set forth a few of these “simple rules” for a 21st century health care system.

• Care is based on continuous health relationships.

• Care is customized according to patient needs and values.

• The patient is the source of control.

• Knowledge is shared and information flows freely.

• Decision making is evidence-based.

• Transparency is necessary.

• Needs are anticipated.

This is an attractive set of rules , but in the case of three controversial diseases – Chronic Fatigue Syndrome, Fibromyalia, and Chronic Lyme Disease – these rules have limits. The rules are not so simple. Patients may insist they have these diseases and that they are devastating their lives, but scientists may maintain that scant evidence exists that the diseases exist.

Here is how a March 12, 2011 Wall Street Journal piece, “Amid War on a Mysterious Disease, Patient Clash with Scientists,” tells the story.

“ Robert Miller was working as a coal miner in Utah in 1982 when he got the flu and ‘it didn't go away.’ Diagnosed with chronic fatigue syndrome in 1994, he has been living ever since with symptoms that include constant pain, an inability to concentrate and exhaustion so severe, he can't lift his arms.”

“Now, after a 2009 study claimed to find a link between chronic fatigue syndrome and a virus called XMRV, the 52-year-old has become a leader in patient efforts to push scientists to finally solve the mystery of his disease. He's attending scientific conferences, organized patient meetings with government officials and helped mastermind an advocacy campaign that sent daily emails to government agencies demanding action.”

“Stuart Le Grice is skeptical about XMRV's role in the disorder. As head of the National Cancer Institute's Center of Excellence in HIV/AIDS and cancer virology, he is sympathetic to Mr. Miller and other patients. But he insists that science can't be rushed. Desperate patients who want immediate answers risk diverting attention from essential research. ‘There's a danger of deflecting us from what we really want to do,’ Dr. Le Grice says.”

So, what if lack of evidence disrupts continuous health relationships? What if evidence does not support a patient’s needs and values? What if patient “control” runs counter to medical opinion? What if patients believe scientists are not sharing information or letting it flow freely? What if things don’t work out to the patient’s satisfaction?

Openness and transparency may not be sufficient in the real world if evidence for a disease state is scanty or does not exist. It is the a patient’s word against lack of data.

Many medical scientists say in this trio of diseases are psychological disorders, there are no specific tests, no biopsies, no radiological images to document their presence. Their symptoms are vague, involve multiple parts of the body, vary from patient to patient, and may be a pretext for gaining disability and other medical benefits. The controversy boils down to a contest between the subjective and the objective.

I do not pretend to be an arbiter in this dispute . It boils down to a dispute between disease sufferers, spurred on by proliferation of active advocacy groups on the Internet, mobilizing support for their point of view, and open combate at scientific meetings, and a skeptical scientific establishment.

It also raises deep questions. Is a little knowledge by patients and health consumers, largely gleaned from the Internet, a dangerous thing when pitted against scientific opinion? Does the so-called “information-asymmetry” between patients and physicians exist?

Does a set of vague symptoms justify therapeutic intervention? Pfizer thinks so, it developed Lyrica® to treat Fibromyalgia. A small number of practitioners think so. They are giving massive doses of antibiotics to patients who believe they have Chronic Lyme Disease. Chronic Fatigue Disease sufferers think so. They are collecting disability and openly challenging the medical scientific establishment.

Thursday, March 10, 2011

$105 Billion for Implementation: A Mandated Fast-Baked Reform Cake-Off

Pat-a-cake, pat-a-cake, baker’s man,
Bake me a cake as fast you can;
Pat it and prick it, and mark it with a B.

Anonymous, Nursery Rhyme

In the case of the fast-baked health reform law cake, the B stands for Billions of dollars, $105 Billion to be precise, thanks in no small part, to open-ended entitlement spending.

As we approach the first anniversary of the passage of the Patient Protection and Affordability Act (PPACA), we keep learning the political culinary advantage of fast-baking a 2500 page cake, then waiting until the last minute for a vote to decide whether to eat it.

The chief advantage of a fast-baked health reform cake is that nobody has time to digest the cake's distasteful ingredients or to consider the indigestion that might follow.

The latest regurgitated ingredient is $105 billion the Democratic Congress secretly baked into the cake to automatically fund implementation of the law.

PPACA proponents say this $105 billion should come as no surprise. It was known as long ago as October, 2010, and was published in a report. If the little known report went unread and undigested, that's the inattentive cake-eaters’ problem.

For Republicans, the fundamental dilemma is this: Republican efforts to defund PPACA have been blocked so far because most spending is self-executing. Funding is paid for by provisions in the law.

This defunding puts implementation out of reach of the budgeting process. “The big problem with defunding is we couldn’t get at most of it in the Continuing Resolution,” Rep. Michael Burgess(R-Tex.) said. “All of the stuff that’s in the law as mandatory spending, we couldn’t touch…that’s all baked in the cake right now and we don’t have access to it.”

The $105 billion is just one piece of larger $1 trillion cake. That’s some cake. Perhaps PPACA enthusiasts will be able to have their cake and eat it too, along with American taxpayers.

Wednesday, March 9, 2011

Oh, What a Tangled Web Government Weaves, When Tax Dollars It Seeks To Retrieve

The Obama health reform law is running into self-imposed snarls as it tries to raise tax revenues to pay for its plan. The government is caught up in a spider web of its own design.

First to go was the 1099 gambit, which required business to submit 1099 forms for every $600 of expenses.

Then came the 1000 or so waivers granted to organizations, particularly political allies, and to small businesses, who complained they could not afford Obamacare.

Next came promises of concessions to the states, who were told they could design their own Medicaid plans as long as their plans met all federal requirements.

Finally, we have the Over-the-Counter (OTC) problem – a perfect example of the tangled web problem. The law requires that 33 million Americans with flexible savings accounts must have a doctor’s prescription before being allowed to deduct OTCs from their accounts. Congress's number-crunchers estimated the change would generate $5 billion over a decade. Hardly anyone noticed it, even as it stayed in the bill through passage in March 2010.

The law took effect for OTCs on January 1. Suddenly patients began loading up on OTCs before the end of the year, doctors bitterly complained writing prescriptions for common OTC drugs was a waste of their expensive time, and they feared if they did write them and complications occurred, they would be sued. The drug chains complained the new OTC required were a burden and tied up pharmacist times. The IRS said it would have to add agents to figure out which drugs could be deducted.

Federal laws have adverse, unintended, and costly consequences, unforeseen by the President, Congresspersons, and their staffs from their lofty perches on Washington.

The Organizational -Medical- Governmental Complex

Every single social task of major impact . . . is increasingly entrusted to institutions which are organized for perpetuity and which are managed by professionals, whether they are called ‘managers,’ ‘administrators,’ or ‘executives.'

Peter Drucker (1909-2005), The Age of Discontinuity, 1969

Individual physicians are relatively powerless against large organizations, be they run by health care executives or government officials. For good reasons. It takes a large organization to get big things down- to deal with the bureaucracy, to afford the technological infrastructure required, to mobilize a team of professionals, to make one’s market presence known, to have an impact, to exert leadership.

Yet, when it comes to seeing a doctor, most of us want doctors who look after our personal interests, not the interests of the organizations. Doctors, who cherish their autonomy, are not good in forming effective organizational counterweights.

We often resist the impact of large organizations on our practices by complaining about astronomical salaries of executives, excessive power of government officials, unneeded burdensome bureaucracies, unfair reimbursement policies, and the loss of freedom of doctors and patients. Doctors say misplaced organizational power leads to unneeded regulations, to punitive laws, to outside interference, and to diminished innovation.

To sample the reality of what I am saying, viz., that independent doctors feel helpless in the face of organizational juggernauts, look at the activities of these large organizations.

• The World Health Care Congress
– This huge organization holds a series of “Congresses” each year, culminating in a Summit Congress, in Washington, D.C. in April. Its motto is “Driving Strategy in an Era of Government and Market-Driven Care.” Its meetings feature organizational movers and shakers from all realms of government and the health care industry. In these meeting rarely do you hear the voice of independent physicians.

AARP - With over 40 million members, retirees, near retirees, and the elderly, AARP is the largest private organization in the United States next to the Catholic Church. Its biggest source of revenue may be Medigap policies, administered by United Healthcare, which proudly complains it has 78,000 employees providing benefits for 78 million Americans. Robert J. Samuelson, Washington Post columnist, says of AARP, “ AARP is in charge. Power is the ability to get what you want. It suggests that you control events. By these standards, the AARP runs government budgetary policy, not presidents or congressional leaders.”

• Health Affairs
This is America’s premier health policy journal. It is very much an Inside-the-Beltway publication and generally reflects the views and hopes of government-directed health care while bashing consumer-directed or physician-directed care. To be sure, its tone is always high-minded and fair, but its drift is palpable. An example is its March issue on innovation. It features 15 organization innovations presented at a December conference. The organizations included: Commonwealth Care Alliance in Boston, Geriatric Resources for Assessment and Care of Elders. Aurora Health Care in Wisconsin, The American Academy of Pediatrics’ Asthma Pilot Project. Cambridge Health Alliance in Massachusetts, Clinica Family Health Services in Colorado, HealthCare Partners Medical Group, Mercy Health System in Pennsylvania. ThedaCare in Wisconsin, The Vermont Blueprint for Health. Martin’s Point Health Care in Portland, Maine, Bellin Health in Green Bay, Wisconsin, Capital District Physicians’ Health Plan in New York .

I do not mean to demean the work of any of these organizations, but all undertook projects to demonstrate the effectiveness of strategies espoused by Medicare and Medicaid Innovation Centers. It may take an organization to exercise social responsibilities for care, but it takes a physician to deliver the care, which may conflict with organizational goals.

Coming Out of The Electronic Wilderness

Well, I am finally out of the electronic wilderness, or the electronic wirelessness, if you want to be precise.

I have an IPad-2 with WiFi. Anywhere I go in the house, I can google anybody the universe. I have Skype. It is as good as its hype. I can visualize anybody, anywhere on the planet.

I have email. I am on Twitter and Facebook. I have my own blog and website.



So there. I am totally connected to everybody else but not to myself. I have no space or time for me, yours truly.

Monday, March 7, 2011

Health Reform: Are the Political Chickens Coming Home to Roost?

March 7, 2011- My reading today includes the Washington Report, a non-partisan insider report, produced by The Physicians Foundation, and the Wall Street Journal, which gives its usual unabashed conservative view.

The Washington Report, written by Lee Stillwell, a long-time friend of physicians, says Congress now has the votes to oust Dr. Donald Berwick, as CMS administrator.

Dr.Berwick champions Accountable Care Organizations (ACOs) as a means of compelling hospitals and doctors to work together under fixed budgets to provide care for Medicare recipients; setting up insurance exchanges to cover care for millions of Americans; and enforcing regulations to reward quality rather than volume.

Stillwell notes, however, the most “significant development” this week came when U.S. District Court Judge Roger Vinson gave the Obama administration a bare seven days to file an appeal to his ruling that the unconstitutionality of the individual mandate makes the entire health care law “void.”

The Wall Street Journal opinion piece , “ObamaCare’s March Madness, “ by Grace-Marie Turner, president of the Galen Institute, Alex Cortes, executive director of Let Freedom Ring, and Heather Higgins, president amd CEO of the Independent Women's Voice, flatly states that a series of events contributes to the “madness” of the health reform law.

• 28 states “and counting “ challenging the law in court.

• Nearly 1000 waivers allowing politically-favored states, companies. And unions to “escape” Obamacare regulations.

• Exploding premiums as insurance companies seek to minimize the expenses of new regulations.

• Seniors losing access to doctors, as many as 40% physicians cease seeing Medicare patients to avoid bankruptcies.

• Companies exiting markets for individuals, small groups, and Medical Advantage plans.

Like many Americans, I like President Obama ( Real Clear Politics poll averages indicate 2.2% more Americans approve than disapprove of his performance). He is personable, intelligent, eloquent, and has an attractive family.

But I dislike the health law of Obama and the Democrats (Poll averages show 11.8% more Americans are “against” rather than “for” the new law).

As I observe in my upcoming book Good Intentions: A Health Reform Handbook: Intended and Unintended Consequences, the political chickens may be coming home to roost.

Congress and the American people are wary of Dr. Berwick because of overt past statements approving centralized command and control health care policies and his overt disapproval of all market-based solutions.

Frankly, I do not understand subtleties of legal issues swirling around the constitutionality of the individual mandate, but I do know the Supreme Court must resolve the individual mandate issue soon before we squander time, energy, and money implementing a law that may be declared “void.”