Tuesday, May 31, 2011

Medicare, Providers, and Population Health: Collective Care and Individual Care

For the first time in its history, Medicare will soon track spending on millions of individual beneficiaries, reward hospitals that hold down costs and penalize those whose patients prove most expensive.

The administration plans to establish “Medicare spending per beneficiary” as a new measure of hospital performance, just like the mortality rate for heart attack patients and the infection rate for surgery patients.

Hospitals could be held accountable not only for the cost of the care they provide, but also for the cost of services performed by doctors and other health care providers in the 90 days after a Medicare patient leaves the hospital.

Robert Pear, “Medicare Plan for Payments Irks Hospitals,“May 31, 2001, New York Times

May 31, 2010 - Why would hospitals be upset that Medicare is tracking spending for each hospitalized Medicare beneficiary?

In calculating Medicare spending, the Obama administration wants to count costs not only generated during a hospital stay, the three days before that stay, and 90 days after, including the costs for those 20% of Medicare patients that are readmitted.

The new Medicare initiative, known euphemistically as “value-based purchasing,” is intended to get hospitals, in concert with doctors and other health care organizations, to act as one entity, thus coordinating care, improving over-all outcomes, and reducing health system fragmentation.

For want of better term, I call this “collective care” as opposed to “individual care.” The idea is that various health care providers, acting together, can improve “population health,“ another buzzword very much in vogue.

Presumably this approach, carried out through new approaches, like accountable care organizations (ACOs), will reduce fragmentation in the system and make hospitals and physicians “accountable” for outcomes, partly by exposing hospitals and affiliated physicians to financial risks.

There is one huge problem, however, hospitals and doctors may have little or no control over services provided after a patient’s discharge. In many cases in the present system, hospitals and associated physicians may not know precisely what happens after discharge - the myriad of organizations and individual providers that care for discharged patients. The hope is that "integrated" health organizations would resolve this fragmentation.

Furthermore, neither the hospital nor physicians can completely control the discharged patient’s behavior or anticipate and prevent complications in elderly, often terminal, patients who may out of the reach of either the hospital or doctors.

Yet the Accountable Care Act expects hospitals and doctors to assume full responsibility for the general and post-discharge health of groups of patients, not individuals.

It is unrealistic to hold all hospitals and physicians accountable for the care, expenses, and complications of large groups, i.e.,"populations," chronically ill, often fragile individuals, three days before admission, during the course of the hospitalization, and three months after their discharge from the hospital. Doctors care for the needs of known individual patients, not the statistic outcomes of unseen persons.

Monday, May 30, 2011

Do American Medical Specialists Make Too Much Money?

It depends on whom you ask.

Policy Experts

If you ask policy experts, most of whom are progressives, they will say “Yes,” of course, specialists make too much money. Too many specialists making too much money spoil the national health care broth.

Just look at any other country, especially countries with government –run systems.

Specialists there make one-half of what our specialists bring home. Look at their total health costs, one-half of what other countries pay, even with universal coverage. The answer, therefore, lies in more progressive government policies that encourage more lower-paid primary care doctors and discourage more highly-paid specialists.


If you ask specialists, who comprise 2/3 of American physicians,they are likely to say “Get real.” Other countries generally offer virtually free or low-cost medical educations and do not have punitive malpractice systems. Nor do they offer widely available effective high tech life saving and life style restoring high tech care for which the public demands and clamors.

As Kevin Pho, MD, in kevinmd.com pointed out last week in an excellent blog, “Tension between Physicians and Health Policy Experts,“ the cost of a 4 year medical education in the U.S. is $250,000 vs. $75,000 in Canada and less than $10,000 in France.

Who to Trust

Whose judgment to trust? Policy experts, specialists, or the public at large.

Kevin cites a June 13-14, 2010 Gallup poll asking the public who it trusted to do the right thing about the health system.
The results were:

• Doctors, 73%

• Health experts and academics, 62%

• Hospitals, 61%

• President Obama, 58%

• Democratic leaders in Congress, 42%

• Drug companies, 40%

• Health Plans, 35%

• Republican leaders in Congress, 34%

Lack of Clarity

These results offer little clarity on what direction the health system is likely to take. The November 2010 elections, an overwhelming Republican victory, and the recent Democratic upset of a Republican in district 46 in New York State, said to be a revolt against Ryan’s Medicare proposal, add to the confusion.

Now that we’ve had a year of Obamacare under our belts, public resistance to the health reform law and calls for its repeal show no signs of abating.

Reform Changes Everything

Only one thing is for sure: the reform law and other economic pressures have forever changed the future for doctors and contributed to pervasive physician angst. This angst, based on extensive national physician surveys, is beautifully outlined and articulated in a white paper A Roadmap for Physicians to Health Reform sponsored by The Physicians Foundation, a physician advocacy group. The Foundation will release the paper to the media, policy makers, the profession, and major players in the medical industrial complex on June 1. 2011.

A "Free" Medical School Education

Meanwhile, progressive policy experts continue in their efforts to transform the health system from the top-down. In a May 29 New York Times Op-Ed, “Why Medical School Should Be Free,” Peter Bach, senior adviser at CMS from 2005 to 2006, and Robert Kocher, a special assistant to President Obama on health care and economic policy from 2009 to 2010, say the answer is straightforward: free medical school tuition, subsidizing primary care training, and withdrawing training stipends for specialists. In short, to meet the shortage of primary care doctors, charge to specialize.

Cost and Results

The cost? A mere $2.5 billion.

The results?


• Eliminating the impact of the average medical school tuition of $38,000 on specialty and primary care career selection.

• Ending the average medical school debt burden of $155,000.

• Shift of workforce from specialists to primary care practitioners, with narrowing of the gap between the average income of $325,000 for specialists and $190,000 for primary care doctors.

As cliché-mongers like to say, beware of what you wish for, there’s no free lunch, if it’s free it may be too good to be true, and when it's free, the Piper will call the Tune. For, although Bach and Kocher do not explicitly say so, a "free" medical school education with more primary care goodies and specialty baddies could be a giant step forward towards complete centralized control.

Military Medicine - In Remembrance of Military Doctors

Things come from civilian medicine, and then we take it into the cauldron of the war and focus it, test it and evaluate it, and then use it many, many, many more times than the civilians have. And then whatever spits out in the end is better.

Army Col. John Holcomb, M.D. commander of the U.S. Army Institute of Surgical Research, 2007

Preface: This first appeared as a medinnovation blog on May 31, 2010.

On this Memorial Day, it is time to remember, celebrate, and commemorate military doctors.

We sometimes forget military doctors have served in every American war since 1775.

We sometimes forget lessons learned and innovations developed by military doctors carry over to civilian life in operating rooms, trauma, and rehabilitation centers across the land.

We sometimes forget doctors in the Spanish-American war learned mosquitoes cause yellow fever, in World War I that transfusions saved lives, in World War II that penicillin and sulfa drugs were indispensable for treating infections, in Korea and Vietnam that prompt helicopter evacuations reduced death tolls, and in Iraq and Afghanistan that hemorrhage can be stopped on the spot by new types of bandages and drugs.

We sometimes forget that military medicine in times of war is very intense because of new treatment methods, recognition that time passed before treatment is the enemy of life. For the military physicians, there’s no wasted moments, no wasted movements, military treatment is very, very focused.

We sometimes forget we have a medical school, the Uniformed Services University in Bethesda devoted to educating and training doctors for military duty in peace and war.

We sometimes forget that 80% of our civilian doctors spent part of their education and training in Veterans Hospitals affiliated with teaching centers.

We sometimes forget our military hospitals – Walter Reed in Washington, over 190 Veterans Hospitals comprising the largest hospital system in the world, and military clinics q43 strewn all across the U.S. and over the world. Sometimes these hospitals even exist in the sky, during flights from Iraq to Germany.

We sometimes forget that the famed comedy series MASH (Mobile Army Surgical Hospitals) was based on a book MASH: A Novel About Three Army Doctors, was written by an Army surgeon, Richard Hooker, MD. With death and chaos of war, sometimes comes humor. But risk also comes, especially in wars without front lines. Doctors, nurses, and other medical personnel in Balad in northern Iraq are ordered to carry firearms.

We sometimes forget that the managerial and leaderships experiences gained in the military carry over into civilian life. In the armed services, doctors learn to organize, to treat populations of patients, to train paraprofessionals, to function and work as teams, and to improvise and innovate.

So let us not forget on this day our heroes – military doctors.

Sunday, May 29, 2011

Health Reform and the Queen Mary

May 29, 2010 - You can’t turn around the Queen Mary on a dime. And you can’t turn around the U.S. economy with $847 billion stimulus package, and you can’t reform health care, which is approaching 20% of that economy with a ten-year $1 trillion reform bill.

Some things take time, especially health reform, which brings me to the Queen Mary, whose history parallels that of health reform.

The Queen Mary was a luxury ocean liner, christened in 1946 and dry-docked in 1967. Jet airliners crossing the Atlantic in a few hours quickly rendered the Queen Mary obsolete. It took her 10 days to several weeks to cross the Pond. She is now moored in Long Beach, California, where she has been converted into a luxury hotel, a rest home and a play pen for the very rich.

Like the Queen Mary, American health care was launched after World War II. Congress poured billions into the National Institutes of Health and into building hospitals. New technologies came on board, and American doctors specialized to master the new technologies.

The U.S. became the Wonder of the Western Health Care World. But alas, costs grew, and the elderly and the poor could soon no longer afford care, and Medicare and Medicaid boarded the government ship in 1965.

Now, 46 years after the Medicare-Medicaid launch, the U.S. health system faces bankruptcy if it does not change course. The U.S. system partly assumed its present configuration a few years before 1946, when the government told U.S. businesses they could offer tax-free health benefits in lieu of salary increases as part of the World War II effort. These benefits caught on big-time when the Blues and others entered the health market. With government programs and employer-sponsored insurance, health care became an entitlemen. Demand and costs boomed.

In 1967, the Queen Mary had to be docked and her propellers, turbine, and engines removed. But unlike the Queen Mary, Medicare and Medicaid churned ahead full-speed, generating huge costs in its wake and far-outpacing the rate of general inflation. By 2010, the U.S. was spending $1 trillion on the twin programs. In 2010, 50% of the federal budget, $1.8 trillion of $3.6 trillion, went for entitlement and social welfare.

It was clear something had to be done, not only about government spending but private spending as well. Neither task was easy. Medicare was wildly popular among a vital voting bloc and had a 46 year track record; private insurance as a tax-free benefit had been part of the U.S. economy for 68 years.

The point is you do not undo or redo massive programs that took 46 to 68 years to evolve. Medicare, the third rail of American politics, makes this doubly difficult. Touch Medicare politically, and you will be electrocuted. Republicans just learned this again in the upsetelection in Western New York State. Never mind that Obamacare vows to cut $575 billion out of Medicare, as we know it, for current 65 year olds. The Republicans are saying we must restructure Medicare 10 years from now for those 55 and under. The Devil you now, presumably, is worse than the Devil you don't know, even he is trying to save your skin.

Add to this to the complexity of U.S. health care. As George Halvorson, CEO of Kaiser said in his 2009 book Health Care Will Not Reform Itself,

“Health care in American is badly organized, highly inconsistent, internally dysfunction, sometimes brilliant, almost always compassionate, close to data free, amazingly inexplicable in key areas, too often wasteful, too often dangerous, and extremely expensive.”

This type of thinking was in back of the 2009 Accountable Care Act. Personally, I thought the law was overreaching. I concur with Mark Twain's opinion of the music of Richard Wagner, "It is not as bad as it sounds."

Nevertheless , the waves whipped up by the deepest recession since the depression, which shows no fundamental signs of receding or recovering soon, complicate reform.. Indeed, according to Investor Business News, the economy may be getting worse.

• Businesses last month slashed orders for autos and other durable goods by the largest amount in six months.

• Industrial output dropped the most in April for any month since the start of the recovery, indicating the manufacturing sector may be rolling over.

• Jobless claims last week unexpectedly shot up and topped 400,000 for the seventh straight week, signaling that payroll growth remains soft — in fact, the pace of hiring may be slowing.

• April housing starts plunged 11%, confirming the housing industry remains moribund.

• Foreclosures last quarter accounted for 28% of all home sales — the highest share in a year and nearly six times above the normal rate.

• Consumer spending last quarter expanded just 2% after rising at a 4% clip in the fourth quarter.

• Net corporate profits last quarter fell 1% after rising 3% in the fourth quarter, and weaker earnings continue to act as a drag on stocks.

• The overall economy last quarter grew a lower-than-expected 1.8% vs. 3.1% in the fourth, showing gross domestic product growth is braking hard.

Then, of course, there are the sea changes induced by Patient Protection and Affordability Act. In 2011, these changes have induced unexpectedly choppy seas – rising premium costs, a wave of 1372 waivers, the storm over Medicare’s future, and public sentiments opposing the law and supporting its repeal.

How long will it take to turn around the Queen Mary of health reform? Four years? Eight years? Ten years as proposed in the health reform law? And in what direction? Toward Medicare dry-dock? Towards market-driven reforms?

If you are the captain of the Ship of State, look out for economic icebergs. It has taken health care over 65 years to teach the current position on its voyage, and it is unlikely to be turned around until the economic climate warms. Only a fool would believe that the U.S. health system, or the whole of American society. would change overnight and that everyone would start to behave rationally, wisely, unselfishly, altruistically, rady to sacrifice for the common good

Medinnovation Selected as One of 18 “Somewhat Positive and Neutral" Health Reform Blogs

May 28, 2011 – Kelly Fluer, co-founder of The Practical Nurse, recently send me this email:

Hello Dr. Reece

I just wanted to inform you about a piece we've published over here at The Practical Nurse called "33 Informational Blogs to Follow the Obamacare Debate." I found Medinnovation to be very interesting and relevant, so I thought that both you and your readers might enjoy the article. Please do let me know if you have any questions or comments -- http://lvntobsn.org/2011/33-informational-blogs-to-follow-the-obamacare-debate.”

It’s nice to be called “interesting and relevant, “ and furthermore to be listed as “somewhat positive and neutral.”

The truth is, however, that I am far from neutral. The word “somewhat” is a squishy term, and I could just as easily have been characterized as “somewhat negative” about the impact of Obamacare on doctors and the failure of the Obama administration to solicit our opinion. To be sure, the administration did consult with the AMA, but the AMA only represents 15% of doctors and hardly speaks for most practitioners.

In any event, for the blogless and listless among you on health reform law, here are two health reform blog lists., as compiled by The Practical Nurse.

Negative Commentary

1. AntiObama Blog: This link leads to the health care category in this blog, with several articles dating into March 2011.
2. Baroccoli Obama: This anonymous blog takes on ObamaCare as well as any other issue that might make this administration appear weak and silly.
3. Big Dog’s Weblog: This link leads to full blog entries about ObamaCare from an anti-liberal perspective and an advocate for uprising to eradicate liberalism.
4. Expose Obama: This blog, which focuses a great deal on healthcare reform and ObamaCare, is a project of the National Campaign Fund, an organization that focuses on teen and unplanned pregnancy prevention.
5. Flopping Aces: This link leads to negative commentary on health care reform based upon news stories.
6. GOP Obamacare: A blog that throws blame for the unemployment rate on ObamaCare. Also discusses legislation, news and solutions to the healthcare issue.
7. Health Reform Scandal: This blog is all for health care reform, but not the way that Obama and his administration is going about it.
8. John Goodman’s Health Policy Blog: Dr. Goodman’s blog is a premier right-of-center health care blog on the Internet. He frequently is invited to testify before Congress on health care reform and retirement topics and is the author of more than 50 published studies.
9. NewsBusters: A highly active blog focused on commenting and reporting the opinion that ObamaCare can never work.
10. Obamafail: This blog claims to report on how ObamaCare fails and why the entire administration cannot succeed. Includes video and links.
11. ObamaCare 411: This blog is designed to contribute to the ongoing national discussion of health care reform “and, most importantly, to help educate the public to the real costs of the legislation.”
12. Obama Care Blog Center: A conservative blog that covers a wide range of points on healthcare reform and that includes videos, editorials and recent news items. The blog also supports Mike Pence, who is considering a run for the presidency in 2012.
13. Obamacare Fail: This blog sets out to prove that ObamaCare “scheme” is failing with “statements made by politicians concerning this matter.”
14. Scotty Starnes’s Blog: This blogger often cites sources to supplement his opinions on the healthcare issue as well as why he thinks Democrats are ruining the country.
15. The Moral Liberal: This blogger supports “the Judeo-Christian ethic, limited government, and That Heavenly Banner: The U.S. Constitution.” Articles are biased against health care reform.

Positive or Somewhat Neutral Commentary

16. A Detailed Analysis of Barack Obama’s Health-Care Reform Plan: This blog site tackles health care reform throughout, but this particular article, written in 2009, attempts to break the plan down. Many more articles in this blog about health care reform.
17. American HealthCare Reform: This blog carries positive headlines about health care reform.
18. Barack ObamaCare: Private citizens created this Web site to determine the state of health care in the United States, to assess the ongoing health care legislation, and to understand the current administration’s proposed solution.
19. db’s Medical Rants: Dr. Centor talks about a wide variety of health options pertaining to internal medicine, American health care and medical education.
20. Democratic Party News: This link leads to the archive for a pro-ObamaCare approach to relating news and opinion. Often cites sources and statistics to support those opinions.
21. DEMOCRAT.GNOM.ES Obamacare: This link leads to archives on ObamaCare from a liberal perspective.
22. Health Care Reform Questions and Answers: This blog is dedicated to providing readers with the latest information on the current health care debate. Participate in the blogs and post comments.
23. Health Care Reform Update: Roger Collier is a consultant specializing in health care policy issues. He was CEO of a national health care consulting firm, and Principal-in-Charge of KPMG’s national health and welfare consulting practice.
24. Medinnovation: Richard L. Reece, MD, is pathologist, editor, author, speaker, innovator, and “believer in abilities of practicing doctors and their patients to control and improve their health destinies through innovation.”
25. My Involuntary Servitude: Maintained by an attorney living in the southeast who was inspired to do something about what he felt was a life of involuntary servitude. A concise account of legal goings-on concerning ObamaCare.
26. ObamaCare Information 678-461-8601: This is a comprehensive resource for news and issues concerning healthcare reform presented in a neutral fashion.
27. ObamaCare Watch: The writings in this blog are focused on monitoring implementation of President Obama’s newly passed health care law, including in-depth research and analysis with key news stories and commentary.
28. Open Congress ObamaCare: This blog is a non-profit and non-partisan source of information and invites everyone to participate in comments. OpenCongress is a free and open-source project of the Participatory Politics Foundation, an organization with a mission to increase civic engagement.
29. Reason.com ObamaCare: This link leads to various opinions and news articles that point to strengths and weaknesses within health care reform.
30. Science Blogs ObamaCare: This link leads to many articles among the blogs within this format. Most of the articles take a well-reasoned stance for or against various components of Obama’s health care reform bill and its implications. Most vocal lately is Dr. Jeffrey H. Toney, an educator and a scientist whose career has spanned academia and the pharmaceutical industry.
31. The Alan Katz Health Care Reform Blog: The Alan Katz Health Care Reform blog was launched on January 2, 2007 and continues to earn distinctions for his analysis of health care reform policy.
32. The Hill ObamaCare: A blog for lawmakers who question ObamaCare from both sides.
33. The Washington Watch: Current updates on news and efforts made in the political arena on the healthcare debate. Reasonably neutral in its stance and is maintained by Jim Harper, Director of Information Policy Studies at the Cato Institute, in his spare time, as a public service.

Thursday, May 26, 2011

Poisoning the Process of Health Reform Debate

Poisoning the well (or attempting to poison the well) is a logical fallacy where adverse information about a target is pre-emptively presented to an audience, with the intention of discrediting or ridiculing everything that the target person is about to say. The origin of the term lies in well poisoning, an ancient wartime practice of pouring poison into sources of fresh water before an invading army in order to diminish the invading army's strength.

In general usage, poisoning the well is the provision of any information that may produce a biased result. For example, if a woman tells her friend, "I think I might buy this beautiful dress", then asks her friend's opinion of the dress, she has "poisoned the well", as her previous comment could affect her friend's response.


May 26, 2011 -I recently met a judge at a social gathering. We fell into a conversation about the raging health care reform debate. He informed me, in roughly these words, “The process has been poisoned. Americans are fair-minded, and they want a fair-minded debate. When the Democrats passed the health reform bill, they ignored anything the Republicans or other critics had to say. They passed the bill without a single Republican vote, and in doing so, ridiculed and humiliated the political opposition and deprived the public of an honest debate. They did not let the process go forward as the public expects and deserves in national legislation affecting everyone. They poisoned the process. That is why the public opposes the reform bill and favors reform and why Republicans are united in their hostility to the bill. ”

Everyone, of course, poisons the process in a different way, the Republicans by labeling Democrats as Big Government demagogs, the Democrats by characterizing Republicans are Big Business pettifogs.

If you seek an example of current process poisoning, look no further than the current Medicare debate. Democrats ran a TV ad showing some malevolent male, presumably a Republican, pushing Grandma off the cliff. The ad worked in a conservative New York state district (NY-26) in which a Democrat upset the Republican. Republicans will now accuse Democrats of poisoning the process by not discussing a Republican alternative to save Medicare. One man’s meat is another man’s poison.

As the judge said to me in a follow-up email to our discussion,

“ The Executive and Legislative Branches, when they are making decisions that have enormous public consequences, must take process into account. When they make decisions in the dark, when the public senses that they have not heard all sides, they create a "side issue" which poisons the final product. The public do not express their dissatisfaction in lawyer-like "due process" language; rather, they express it in other ways. But at the core, the process is what concerns them. I learned long ago -- watching juries in difficult cases, among other things -- that the American public has an in-bread sense of justice. They abhor unfairness.”

Political dialogue deserves due process too.

Wednesday, May 25, 2011

Can Physicians Help Cut 20% to 30% from Overall Health Care Spending?

May 25, 2011 - Since Medicare was enacted in 1965, health care spending has grown inexorably, far beyond the $9 billion projected originally by 1990 to $543 billion in 2010. Over these years, two percentage figures – 20% and 30% - keep cropping up in the health cost management literature.

• First, the 20% figure. As Victor Fuchs, PhD, and Arnold Milstein,MD, those venerable West Coast management gurus, state in their May 26 New England Journal of Medicine article, “The $640 Billion Question – Why Does Cost-Effective Care Diffuse So Slowly,” “There are individual U.S, Physicians and health care organizations that deliver high-quality care at a cost roughly 20% lower than the average.” Presumably, if the rest of the U.S.followed suite, spending would drop from 17% of the GDP to 13% - by $640 billion from $2.5 trillion to $18.6 trillion. To avoid a financial Armageddon, say the authors, two “escape routes” exist: one, tax-supported universal coverage, and two, disciplined managed competition. Neither solution, they lament, is politically feasible without “robust physician support.”

• Next, the mythological 30% number. This has grown out of the work of John Wennberg, M.D., and colleagues at Dartmouth. Using Medicare claims data, since 1972, they have shown that costs vary by 30% from high cost to low cost regions. They have repeated this 30% variation figure so often and so loudly that it has become accepted gospel that 30% of U.S. health spending is due to “unwarranted,” i.e. due to waste, greed, and unnecessary expenditures. “Buzz” Cooper, MD, a respected professor of Internal Medicine at the University of Pennsylvania, has argued the 30% number as representing “unwarranted care “ is nonsense and as more readily traceable to poverty and greater expenses secondary to delayed treatment of more advanced diseases.

As you might guess, now that government, health plans, managed care organizations, new business models, and the constant chatter about care “variation” of 20% to 30% have failed to bend the cost curve, attention is focusing on physicians.

Fuchs and Milstein ask, ”Are U.S. physicians sufficiently visionary, public-mined, and well led to respond to this national fiscal and ethical imperative?”

This is not the right question. The right question may be, “Are U.S. physicians sufficiently informed about what things really cost?”

In a May 24 edition of The Health Care Blog, Robert Wachter, MD, a West Coast academic and co-founder of the hospitalist movement, asks, “Do we have any clue how to cut the cost of healthcare?” He cites a study presented last week at the Society of Hospital Medicine by Lenny Feldman, MD, of Johns Hopkins. Feldman’s study indicated that doctors, given information about the cost of 31 laboratory tests, ordered far fewer of them. Over a six month period, lab costs fell by nearly $500,000 for the 31 tests.

I was asked by The Health Care Blog to comment on Wachter’s remarks and Feldman’s study.

Here was my comment,

" I am a great believer in the philosophy 'If you have a nail to hit, hit it on the head.'

Accordingly, I would:

1) Develop an automated online program that lists the costs of drugs, lab tests, imaging and other tests at the point of care for both physician and patient to see.

2) Use the approach of Jerry Reeves, MD, chief medical officer of Hotel Employees and Restaurant International Union (H.E.R.E. I.U), who confronts physician cost and care outliers with data comparing them to colleagues in their same markets. My interview with Jerry appeared in this Health Care Blog and in medinnovation blog in April 13, 2010. The title of my interview as ‘Using Comparative Data to Reduce Medical Practice Variation and to Save on Health Costs.'

3) Encourage patients employers, employees, and patients to join health savings accounts with high deductibles, in which patients have “skin in the game” and show them the costs at the point of care and on physician websites.

Even with this said, physicians have limited ability to contain costs. Among other things, they are saddled with crippling educational training costs of $150,000 to $200,000; and 50% overhead costs, mostly stemming from burdens of hiring employees to deal with third party constraints. Then, too, physicians must deal with soaring patient expectations, heightened by media hype. Finally, there is the reality of the malpractice cloud, with what might happen if you don't do something or order something.

There is not much physicians can do directly to change the behavior of other health care players of market conditions. But we can become more acutely aware of what things cost and act appropriately to contain costs. Sensitizing physicians and patients to true costs of care at the point of care is an important first step in bringing down overall costs.

Tuesday, May 24, 2011

Washington Report to the Physicians Foundation on ACOs

May 24, 2011 - In my mind, there is not better source of physician attitudes towards the various manifestations of the Health Reform Law (ACA, aka, Obamacare) than the Washington Report to the Physicians Foundation by Lee Stillwell. Stillwell, a veteran lobbyist for physician organizations, knows the ins-and-outs of Inside-the-Beltway political developments related to physicians better than anyone. Here is his May 23 report of the reaction of leading physician organizations to recently announced CMS initiatives. The Physicians Foundation has taken no position, for or against ACOs, and prefers to remain neutral.


May 23, 2011

So, what is the federal government going to do when it’s new pet project to develop a new health care delivery model—Accountable Care Organizations (ACOs) — is threatened with extinction because of mounting criticism from physicians and hospitals who believe the current proposed regulation is unworkable?

In this case, the Obama Administration decided to double down, adding three more initiatives to the three comment processes already underway for the current proposed rule!

Potential ACO candidates already are sending in comments to the Centers for Medicare and Medicaid Services (CMS), due by June 6; the Internal Revenue Service (IRS), May 31, and the Department of Justice (DOJ)-Federal Trade Commission (FTC), also May 31.

The three new initiatives announced last week by the CMS Center for Medicare & Medicaid Innovation include:

--A pioneer ACO model designed to nudge quickly into the government fold as many as 30 health care organizations and providers that already are experienced in coordinating care for patients across care settings. This new program still would require participants to follow the 65 quality measures now proposed in the rule but would permit participants to suggest different arrangements for shared savings and financial risks. Interested parties must send a letter of intent to the Center by this June 10. Final applications are due by July 18.

--An advance payment program to permit participants with limited capital to receive up front some of the projected shared savings in the program. The Innovations Center asks for suggestions and reactions to the proposal by June 17.

--Four free accelerated development learning sessions in 2011 for potential ACO leadership teams with the first session already set for Minneapolis, Minn. June 20-22. Interested groups are asked to send two to four executives—chief executive officer, chief operating officer, chief medical officer, chief information officer, etc. Participants, who must pick up their own expenses, will be chosen on a first-come, first-served basis. All participants should be prepared to conduct pre-session planning, attend an intensive in-person meeting, participate in follow-up webinars, and complete a comprehensive ACO implementation plan. The dates and locations for the other three learning sessions will be released soon. Individuals can register on the Center’s website.

The government’s objective in creating an ACO program is to offer incentives to providers to work together to offer quality care while driving down costs.

Physicians and hospitals have beaten the drums of discontent louder and louder as their lawyers and accountants pour through the proposed ACO federal rule, pointing out serious financial risk, stringent regulatory requirements and a lack of needed detail for such an expensive undertaking.

The American Hospital Association (AHA) released a study that concluded cost of creating an ACO would be six to 14 times as high as predicted by government t officials. AHA estimated the first year cost of starting an ACO for a hospital would be between $11 million and $26 million.

Officials at four institutions often cited as models for ACOs have expressed doubts to the press about the viability of the ACO program without major changes. They include Cleveland Clinic, Mayo Clinic, Geisinger Health System and Intermountain Health.

Most devastating to CMS was a letter on May 11 critical of the ACO rule from the American Medical Group Association (AMGA), an organization of 400 physician groups and health systems.

“We write today, however, to express our serious concerns over the direction of the Proposed Rule,” said Donald W. Fisher, AMGA President and CEO. “On its face, it is overly prescriptive, operationally burdensome, and the incentives are too difficult to achieve to make this voluntary program attractive. As you know, most policy experts believe multi-specialty medical groups are best poised to become ACOs in the short term. However, in a survey of AMGA members, 93 percent said they would not enroll as an ACO under the current regulatory framework.”

Fisher said his membership’s concerns were many and focused on issues such as the risk sharing requirement, static risk adjustment, retrospective attribution, quality measurement requirements, the Minimum Savings requirements and others.

“Without substantial changes in the Final Rule, we fear that very few providers will enroll as ACOs and that CMS and the provider community will miss the best opportunity to inject value and accountability into the delivery system,” Fisher added.

Donald M. Berwick, CMS administrator, has not responded directly to the AMGA letter but did address criticisms of the proposed ACO program to media. “Of course, we are listening to their concerns,” Berwick said. “We are going to come up with a way to work together. We will produce a better final rule.”

Berwick gave no indication on the date for issuing a final rule. But from where I sit, this tedious process has a long way to go before we see one.

Obamacratic Oath

Preface: A cynical friend of mine, who sits at the right hand of Atilla, sent me this version of the Hippocratic Oath, which he uses to swear at the Patient Protection and Affordability Act.

“I swear to fulfill, to the best of my ability and judgment, this covenant:

I will respect the ill-begotten technocratic dictates of those bureaucrats in whose steps I am obligated to walk, and reluctantly share such knowledge as is mine with those who are to follow.

I will apply, for the benefit of the government, all measures required, falling into those twin traps of under-treatment and therapeutic nihilism.

I will forget that there is art to medicine as well as science, and that warmth, sympathy, and understanding must outweigh the auditor’s knife or the protocols of CMS.

I will not be ashamed to say "I know not," nor will I fail to call on my bureaucratic colleagues when the rules and regulations of another are needed for a patient's cost-effective care.

I will not fret about the privacy of my patients, for their problems will be disclosed to all through electronic records so that the world may know. Most especially must I tread with care in matters of life and death. If it is given to me to save a life, all thanks. But it may also be within my power to take a life; this awesome responsibility must be faced with great humbleness and awareness of my own frailty. Above all, I must not play at God. I will leave that to Gov.

I will remember that I do not treat a fever chart, a cancerous growth, but a government-subsidized human being, whose illness should not affect the person's family and economic stability but society as a whole. My responsibility includes all of these related problems, if I am to care adequately for the government pocketbook.

I will prevent disease whenever I can, for prevention is preferable to cure.

I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm.

Even if I may swear at this oath, may I enjoy life and art, respected while I live and remembered with affection thereafter. May I always act so as to preserve the finest traditions of my calling and government care and may I long experience the joy of healing those who seek my help.

Monday, May 23, 2011

Latest Health Care Polls

• May 23, Obama and Democrat plan approval, 8 major polls, average. favor 40.1, oppose 51.6, -11.5

• May 23, Health reform repeal, Rasmussen Reports, favor 51, oppose 43, -8

• May 17, Health reform repeal, Rasmussen Reports, favor 55, oppose 38, -17

• May 16, Health reform repeal, Politico/GWU Battleground, favor 49, oppose 42, -7

Conclusion: President Obama's personal job approval, averaging 9.2 approval in major polls, is running well ahead of those approving his health plan (20.7) and those favoring its repeal (20.2).

Health Reform Has Begun, and Everybody Has a Piece of the Action

Do you know how many people died in car crashes in the United States in 2010? 32,000. That’s the lowest number since 1949. That’s impressive, but wait: It’s far more impressive than it sounds at first, because people in the United States drove about 10 times as many vehicle miles in 2010 as they did in 1949. In other words, if you drove a car or truck in 2010, you were 10 times more likely to live through each mile you drove than your father or grandfather was 60 years ago.

Why? Are we better drivers? Nah. Seatbelts, airbags, tougher DUI laws, breathalyzers, graduated licensing for teenagers, anti-lock braking systems, better highway designs, crash barriers, rumble strips, median barriers, steel-belted radial tires that don’t blow out, crumple zones, better bumpers…system tweaks that work, that make it 10 times as hard for even a terrible driver to kill himself or you.

Joe Flower, “How to Blow the Big One: A Methodology”, The Health Care Blog, May 23, 2010

May 23, 2011 - With his comments on the reasons behind the dramatic drop in highway deaths, Joe Flowers, a prominent health analyst, has given us a useful metaphor for health reform.

In many ways, health system reform is like accident reform. Both travel along the highway of life.

• Every citizen, from the young to the old, is involved in one way or another.

• Accidents are common and costly and mostly occur close home.

• Concrete highways and information highways link us all.

• Systems engineering of cars and hospitals can be made safer.

• Government can serve as catalyst , e.g, building and maintaining an interstate highway system or introducing health exchanges in states.

A myriad of little things introduced on a broad scale over time, engaging all of us, can and will make a big difference between disabilities and premature death and a productive full life.

A lot of these sometimes seemingly disconnected things are occurring right now. Some are apparent, others are not so obvious, but all are part of the big picture of a rolling national reform effort.

1) Hospitals are introducing safety features - pre-surgical checklists, protocols for infection control, standards for ICUs, measures of comparative outcomes. And, just as importantly, they are decentralizing their operations with freestanding ERs and outrach clinics and surgical and diagnostic units. new roads geographically nearer to patients.

2) Physicians are installing websites and otherwise computerizing to address payer and patient concerns. They are introducing technologies – portable ultrasounds, implanted monitoring devices, predictive cardiopulmonary equipment to spot chronic disease early. Meanwhile telemedicine and electronic communication, especially mobile hand held gadgets, are broadening and deepening and patient-doctor relationships. Information technologies are changing the fundamental nature, of office practices and their connections hospitals, and patients.

3) Patient empowerment and engagement is flowering as 80% of patients have Internet access, either at their homes, at work , or in local libraries, and as 80% of citizens use the Internet to search for health information. In the process disease and health care is being demystified, but it is being distorted too by misinformation. Most patients still trust their doctor to separate the wheat from the chaff. Patients are making it clear they prefer decentralized, noninvasive care and self-care, particularly in their homes surrounded by loved ones and family.

4) The world of technology and innovation is responding to the needs of reform in multiple ways – by developing mobile devices with multiple apps, and by using data analytics to focus on where the greatest needs are, what patients are generating the most costs, how online real time information can facilitate more efficient and effective care, how robotic surgical machines can supplement human surgical skills, and how the information highway can interconnect everybody across the health care landscape.

5) The government, through health care legislation, is trying to serve as the mastermind, guide, and catalyst for reform efforts for the various sectors. But government dictation of care faces tricky tasks– how to standardize and connect care across a diverse landscape without overwhelming society with suffocating and counterproductive regulations without increasing costs. This is not easy in a society that increasingly distrusts government, particularly big government far removed from the local scene. As Joe Flower has observed: “Reform is not the change. The federal health care reform law is a catalyst, and enabler, and an accelerator of the change we are going through. It is not the change itself, and is not even the cause of it, because the change is driven by much larger economic and demographic factors, especially by the crushing cost of health care. If the reform law were to go away, the change would not go away.”

The highway to health reform is paved with good intentions but it has many byways and roadblocks. Thanks to the commitment and engagement of multiple sectors of American society, it is headed in the right direction. As a result of health care reform, consumers, doctors, nurses, hospitals and decentralized health facilities across the country are innovating to reduce costs and errors, end duplication and waste, deploying technology to safely share information, and coordinate care between practitioners and settings.

Health reform is on a roll on multiple fronts. Patient crashes are going down. Don't let the road noise bother you.

Richard L. Reece, MD, blogs a medinnovation.com. His main themes concern health reform and innovation and how they impact physicians and American culture. He works closely with the Physicians Foundation but his opinions are his alone. He has written eleven books. His latest book, The Health Reform Maze, is now at Greenbranch publishing and will be released in June. Doctor Reece’s website, www.doctorreece.com, is now up and running. He invites comments and questions on his blog and will respond to each comment or question on his blog or to him directly at 860-395-1501 or rreece1500@aol.com.

Sunday, May 22, 2011

Recommendations for Health Reform Innovation Prize

May 22, 2011- Today’s Sunday New York Times contains an article by Steve Lohr, my favorite writer on health care innovation. The article, “Change The World and Win Fabulous Prizes, “ describes prizes being offered for health reform innovators.

• One is by Heritage Provider Network in Southern California. The Network is comprised of 9 private medical groups, 33 urgent care centers, and 10 affiliated health plans. The prize is $3 million, to be rewarded over the course of two years and designed to lure experts in Internet software, as well as first class minds from other fields. Richard Merkin, MD, CEO of Heritage Provider Networks, says ,”We want to bring in brilliant people not necessarily steeped in health care, but steeped in data analysis.” The prize will be awarded to those who can predict those at most risk of being hospitalized so they can be kept out of hospitals where 30% of health costs occur. Studies estimated 30% of these hospitalizations could be avoided.

• The others are a series of prizes being offered in contests sponsored by the federal government totaling $50 million in legislation passed by the government, the America Competes Act. You can learn more about this at challenge.com, a government web site devoted to the idea of tapping ideas from citizens. Todd Park, chief technology officer of the Department of Health and Human Services, says these prizes will be a mainstream tool for the government to encourage innovation. Examples might be seamlessly exchanging information among hospitals, clinics, and physicians or making health data in electronic health records easy to read and use.

I would like the Heritage Provider Network and the government to consider giving prizes to two ideas, which I have written about before.

1. To Steve Anderson and his colleagues at Shape Medical Systems in St. Paul, Minnesota. Steve, an exercise physiologist and his co-workers have developed a portable Shape-HF cardiac-pulmonary testing device, which allows a physician in his office or a trained medical technician in any location to evaluate the cause of shortness of breath and the odds of hospitalization or sudden death. With this device, data from a individual patient and from thousands of patients tested before hospitalization for heart and/or lung disease, can accurately predict the risk of hospitalization. The Shape Medical System device is portable and inexpensive, can be applied by lesser trained personnel , and contains a laptop bearing predictive software that automatically interprets the results.

2. To Randy Moore. MD., Randy Moore, MD, CEO of American Telecare, Inc, in Eden Prairie, Minnesota, whose firm has placed audiovisual devices connected by ordinary phone lines at the bedside of chronically ill home bound patients. Through these devices, doctors and nurses can monitor weight, blood pressure, blood oxygen, listen to the heart and lungs, and observe the patients. Patients control the devices and have proven to be extraordinarily adept at learning and spotting complications. The result? Readmissions to the ER and the hospitals have dropped dramatically. These audio-visual devices, which carry data over phone lines, could installed in the homes of millions of people with heart disease and chronic obstructive lung disease, the #1 and #4 causes of death in America, and leading causes of hospitalization. Experience has shown patients equipped with these devices next to their bedside become extremely adept at recognizing those signs and symptoms that lead to hospitalization.

Saturday, May 21, 2011

Health Reform Assumptions and Realities

Most of our assumptions have outlived their uselessness.

Marshall McLuhan (1911-1980), The Media is the Message

May 21, 2011 -When the Patient Protection and Affordability Act passed in March 2010, the legislation the new law, it was assumed, would,

• save $500 billion over ten years by curbing waste, fraud, and abuse and would change the way physicians were paid;

• cut physician payments by 21%;

• “protect” patients from health plan “abuses;”

• make health care more “affordable;”

• Be patterned after the successes of the Massachusetts universal health plan, which was then four years old.

How useful, or useless, are these original assumptions? It depends on who you ask.
If you ask the New York Times, the Massachusetts plan has been a success.

In a May 21, editorial, The Times asserts.

Despite all of the bashing by conservative commentators and politicians — and the predictions of doom for national health care reform — the program he (Governor Romney) signed into law as governor has been a success. The real lesson from Massachusetts is that health care reform can work, and the national law should work as well or even better.

Since reform was enacted, the state has achieved its goal of providing near-universal coverage: 98 percent of all residents were insured last year. That has come with minimal fiscal strain. The Massachusetts Taxpayers Foundation, a nonpartisan fiscal monitoring group, estimated that the reforms cost the state $350 million in fiscal year 2010, a little more than 1 percent of the state budget.

Sally Pipes, President and CEO of the Pacific Research Institute, a Canadian and a refugee from the Canadian health system, begs to differ. ("Candid Romney Would Own Up To Mass. Fiasco, Investors Business Daily, May 20, 2011):

“Massachusetts health reform is in the news — driven by reports of long waits for care and its architect's presidential ambitions. Former Massachusetts governor and GOP presidential hopeful Mitt Romney delivered a widely panned speech the week before last on health care.

The three-part speech attempted the impossible: It defended his Massachusetts plan, lambasted President Obama's copycat plan that took it nationwide and laid out an agenda at odds with his signature achievement.

Unfortunately, he passed up the opportunity to declare the experiment a failure and detail the lessons learned.

The first is that health insurance does not equal access to health care.
The Massachusetts Medical Society just released a study that showed waiting times are, on average, 48 days to see a family doctor, and up to a year for some specialists. Getting a new doctor is tough. One in two family physicians isn't accepting new patients.

The best definition of socialism is a utopia in which everything is free and nothing is available. That's long been the case in Canada, where people wait 18.2 weeks on average from seeing a primary care doctor to getting treatment by a specialist. The lines are now extending south.”

As for me, I would note that the fundamental assumptions of the health law, taken for granted by the Obama administration, have yet to be demonstrated, namely, that;

• government, not doctors, or consumers, know what’s best for their health and medical treatment;

• treatment for minor and episodic illness requires a multidimensional, multidisciplinary organization team to address;

. Capitated or bundled payments for care over superior to fee-for-service payment and will be more efficient, cheaper, more effective, and provide better value for the dollar.

• a national universal interoperable standardize computerized information system with an electronic health or medical record in every doctor’s office and every hospital setting will measurably improve care;

• improving care requires rewarding doctors for pay-for-performance;

• new or revisited organizational models (HMOs, PPOs, MPOs, PHOs, ACOs, or other OWAs – Other Weird Arrangements) are necessary to improve and standardize care;

• government mandates are more important than individual choice, freedoms, and ability to opt out of the system.

Friday, May 20, 2011

A Poem from My Son about My Background

May 20, 2011 My son, Spencer, who is a nationally known poet about to ordained as an Episcopal priest, wrote this prose poem about me. It will appear in the June issue of Poetry Magazine.

The Manhattan Project

First, J. Robert Oppenheimer wrote his paper on dwarf stars — “Whathappens to a massive star that burns out?” he asked. His calculations suggested that instead of collapsing it would contract indefinitely, under the force of its own gravity. The bright star would disappear but it would still be there, where there had been brilliance there would be a blank. Soon after, worker built Oak Ridge, the accumulation of Cemesto hutments not placed on any map. They built a church, a school, a bowling alley. From all over, families drove through the muddy ruts. The ground swelled about the ruts like flesh stitched by sutures. My father, a child, watched the loads on the tops of their cars tip. Gates let everyone in and out with a pass. Forbidden to tell anyone they were there, my father’s family moved in, quietly, behind the chain-link fence. Neils Bohr said, “This bomb might be our great hope.” My father watched his parents eat breakfast: his father opened his newspaper across the plate of bacon and eggs, his mother smoked Camel straights, the ash from her cigarette cometing across the back of the obituaries. They spoke little. Increasingly the, mother drank Wild Turkey with her women friends from the bowling league. Generators from the y-12 plant droned their ambition. There were no birds. General Leslie Groves marched the boardwalks, yelled, his boots pressed the slates and the mud bubbled up like viscera.

My father watched his father enter the plant. My shy father wentto the library, which was a trailer with a circus tent painted on the side. There he read the definition of “uranium” which was worn to a blur. My father read one Hardy Boys mystery after another. It was August, 1945. The librarian smiled sympathetically at the 12-year-old boy. “Time to go home,” the librarian said. They named the bomb Little Boy. It weighed 9,700 pounds. It was the size of a go-cart. On the battle cruiser Augusta, President Truman said, “This is the greatestthing in history.”
That evening, my father’s parents mentioned Japanese cities. Everyone was quiet. It was the quiet of the exhausted and the innocent. The quietness inside my father was building and would come to define him. I was wrong to judge it. Speak, father, and I will listen. And if you do not wish to speak, then I will listen to that.

Thursday, May 19, 2011

Heath Reform: Sticks, Stones, Carrots, and Accountable Care Organizations

May 19, 2011 - When the Centers for Medicare and Medicaid released its rules for Accountable Care Organizations on March 31, 2011, the reaction among hospitals and physicians was almost immediate, and it was negative.

Simply put, providers said the government proposal for ACOs was “unworkable “– too bureaucratic, too expensive, too time consuming, too threatening to fee-for-service medicine,and too risky because of the Department of Justice’s anti-monopoly provisions.

Even integrated organizations – Scripps, Mayo, Geisinger, and Aurora – thought by government and pundits to be made to order for ACOs, objected and said they wanted no part of ACOs.

Chris Van Gorder, President and CEO of Scripps, said, “Frankly, I was surprised. I thought there would be more sticks, not such carrots.”

Nick Turkel, President and CEO of Aurora in Milwaukee, chimed in,”We had been very excited about the concept of ACO and Aurora has been designed around the concept. But the plot as designed by CMS doesn’t match with what we expect, and we don’t think it matches with what a lot of providers expected across the country.”

On May 17, The Obama administration blinked, even retreated. It announced three new initiatives under under intense criticism when Mayo, Geisinger and a host of others told the government proposed ACO regulations were too stringent and too costly for them to participate.

The new ACO initiatives, widely interpreted as government carrots, included:

A Pioneer ACO Model aimed at organizations that have already started coordinating care for patients;

• An Advanced Payment ACO Initiative
that would allow certain participants in the program to get part of their expected savings up front to invest in care coordination;

• Free Accelerated Development Learning Sessions
to help providers learn how they can improve care delivery and coordination.

CMS Administrator Donald Berwick, MD, said the new accountable care organization initiatives announced on May 17 were not prompted by widespread concerns that proposed ACO rules would be unworkable.

CMS, he insisted, would “stand firm” on ACOs, which were the “key” to overhaul of the health system. The government, he seems to saying is flexible at the margins, but inflexible in its core beliefs, just as it was when it issued 1372 waivers. The government will bend, it will try to make ACOs more workable, but it will not yield on its principles or the basic ACO concept.

Maybe so. But CMS seemed to have concluded: sticks and stones might break the bonds of hospitals and doctors, and carrots might prevent a fracture.

Wednesday, May 18, 2011

A Blurb for My Book

Preface: H. David Crombie, MD, a surgeon and editor of Connecticut Medicine, wrote the following blurb for my book, The Health Reform Maze, which is scheduled to be published by Greenbranch Publishing in June.

This is a book that is of value to all the players—doctors, insurers, health planners and government administrators of health care and finance, as well as hospital leaders, legislators and the patient/consumer. Dr. Reece, trained as a pathologist, has been a writer of distinction for all of his professional life.

He was editor of the respected Minnesota Medicine for over twenty years, and in recent years has written ten books examining the American healthcare system and its effect on the sick and the well, the rich and the poor, the doctors and the bureaucrats, the government and the people. This latest effort is his reading of the impact of the Affordable Care Act since its passage, as derived from his blogs entered on the web from March, 2010 to January 2011.

The author believes that reform of health care has been designed by a politically center-left Congress and President, for a center-right more conservative nation. He makes it clear that what was needed was stepwise evolutionary change and what we have with “Obamacare” is a revolution in the provision of and payment for healthcare in the U.S. The appointed leader of the Center for Medicare/Medicaid Services (CMS), Dr. Donald Berwick, is, in the view of the author, committed to the central control of healthcare policy rather than one likely to rely on market forces.

Since passage of the law, two camps have marshalled their forces—those on the left who argue that government must participate (further) in the system of healthcare, and those on the right who want less government, lower taxes, less debt and preservation of the right of individuals to decide for themselves.

The accusatory rhetoric heats up on both sides and Dr. Reece, through his reading of the published media, the blogosphere, and interviews with recognized thinkers and actors on the healthcare stage, delivers facts and candid appraisal of the ongoing debate in plain language. Each section ends with a pithy tweet, to wit: “At a time of reckoning, the apocalyptic rhetoric does not bode well for patients or doctors”. And another section is wrapped up with, “Americans love medical machines that improve their lives, restore their lifestyles and retain their youth.”

Valid concerns are expressed that the law as it stands will leave us short of doctors, thus short of access for those gaining insurance coverage. The emphasis on Accountable Care Organizations, and the efforts to diminish fee-for service payment systems and bundle payments to doctors and hospitals are pushing amalgamation into larger systems with doctors as salaried workers. These phenomena are dissected and exposed in easily understandable language, sometimes with a touch of humor: “Don’t launch vast projects with half-vast ideas.” Dr. Reece’s book is a lively, practical and valuable contribution to today’s ongoing discussion.

Tuesday, May 17, 2011

"Mediscare" in Perspective

The first and great commandment is, Don’t let them scare you.

Elmer Davis (1890-1958), Head of Information Department in World War II

Medicare will start running out of money in 2024 -- five years earlier than projected last year — as a result of the sluggish economic recovery, the program’s trustees reported today.

The outlook for the federal health insurance program that covers 47.5 million elderly and disabled Americans is a dramatic shift from last summer. That's when the trustees, including Treasury Secretary Timothy Geithner and HHS Secretary Kathleen Sebelius, proudly projected that the new health law had extended the solvency of the program by 12 years from 2017 to 2029.

Kaiser Health News, May 13, 2011

Democrats and Republicans are trying to scare Americans about the future of Medicare.

According to Kathleen Sibelius, HHS Secretary, the hardhearted heartless Republicans have a plan that would have seniors “die sooner.” The Republicans meanwhile are saying the financially feckless Democrats are bent on destroying Medicare for generations to come with no motive other than political expediency.

The three triggers for this debate are:

- raising the debt ceiling to compensate for the $15 trillion deficit and the $50 trillion inf “unfunded liabilities."

-Wisconsin Representative Paul Ryan’s plan to allow future Medicare recipients to have a $15,000 “premium platform” to buy private Medicare plans.

-the Presidential election in 18 months.

At stake are the votes of 47.5 million current Medicare recipients and those 78 million baby boomers coming on board the Medicare bandwagon over the next 18 years.

So far polls indicate Democrats are winning the ballot battle, but the debate is still in its early stages. The liberal press – Washington Post, New York Times, the New Yorker, and the Huffington Post – have lined up on the side of the Democrats. The conservative media – Fox News, the Wall Street Journal, the Weekly Standard, and the National Review – back the Republicans.

The weak economy – 9% unemployment, a 10% plunge in the housing market, the mounting $15 trillion debt, a 7.3% health inflation rate, the cost of 3 wars – would seem to help Republicans. The Bin Ladin “kill” and lack of a credible Republican presidential candidate tilt the election toward Obama.

The continued recession hurts Medicare's $573 billion budget because payroll taxes used to support Medicare were $2.5 billion less than expected. Accelerated aging hurts too. In the last year, those 65 and older are now estimated to live 2.4 years longer than predicted.

Physicians are restless about Medicare.

• The health law gives inadequate incentives to produce the primary care physicians needed to take care of the 32 million new Medicaid recipients expected in 2014 and didn’t even begin to address the needs of baby boomers turning 65.

• The RUC (Reimbursement Update Committee), said by many to be a collusion between the AMA and CMS, has done nothing to narrow the gap between specialty and primary care pay.

• The idea of accountable care organizations, designed to “save” Medicare billions, is floundering due to administrative complexities and projected costs of $11 million to $26 million to set one ACO up.

• Doctors are profoundly skeptical about Congress' failure to fix the SGR formula to pay doctors, and many regard the Independent Payment Advisory Commission as a partisan joke to defund hospitals and doctors.

As a result of these collective attitudes, more and more doctors, in the 30% to 40% range in some parts of the U.S., are not accepting new Medicare patients, and even more are turning away Medicaid recipients. For doctors, Medicare is scarey proposition, worthy of its designation as "Mediscare."

Monday, May 16, 2011

Health Reform Consequence: Increased Operating Expense

In nature there are neither rewards or punishments – there are consequences.

Robert Ingersoll (1833-1899), Some Reasons Why

Health reform, like elections, has consequences. Perhaps the major unforeseen consequence of the health reform law, now over a year old, is the jump in operating expenses it imposes on all participants in the U.S. health system.

Consider the news of the day, as reported in Kaiser Health News.

• The New York Times:
Nursing homes seek exemptions from health law. It is an oddity of American health care: Many nursing homes and home care agencies do not provide health insurance to their workers. These new expenses fall heavily on Medicaid, which pays for 2/3’s of nursing home expenses. Medicaid cannot afford to pay more to nursing homes to cover health benefits of workers. The new law increases cost of providing these benefits.

The Hill: The Health and Human Services Department will let two more states — Nevada and New Hampshire — phase in health care reform rules that govern insurers' spending. The new health care law requires health plans in the individual market — people who buy coverage on their own, rather than getting it through an employer — to spend 80 percent of their premium revenues on medical costs. But states can request an adjustment if they determine that immediately implementing the new limits would drive insurers out of the state and disrupt consumers' access to care.

Politico Pro: HHS approved 221 new annual limit waivers In April. The Obama administration in April granted 221 new temporary waivers to organizations for health care reform's annual benefit limit requirements, according to an update posted on the HHS website late Friday. With the new approvals, 1,372 businesses, unions, insurers and other organizations won't have to comply with this year's requirement to provide at least $750,000 in annual benefits.

Modern Healthcare: ACO start-up costs higher than estimated, AHA study says Accountable care organizations will likely face start-up and first-year costs six to 14 times higher than HHS has estimated, according to a study released by the American Hospital Association. The study concluded the various elements required to successfully manage the care of a specific population will cost between $11.6 million and $26.1 million — depending on the size of the hospital or hospital system involved in the ACO—and far more than the $1.8 million estimated by the CMS in its proposed rule.

The New York Times: Health Insurers Making Record Profits As Many Postpone Care' The nation’s major health insurers are barreling into a third year of record profits, enriched in recent months by a lingering recessionary mind-set among Americans who are postponing or forgoing medical care. The UnitedHealth Group, one of the largest commercial insurers, told analysts that so far this year, insured hospital stays actually decreased in some instances. In reporting its earnings last week, Cigna, another insurer, talked about the “low level” of medical use. Health plans anticipate increased costs of doing business because of federal rules requiring them to cover children, young people under parents’ plans, those with pre-existing illnesses, and new rules requiring them to spend 80% on medical care and less on marketing and administrative expenses.

The Wall Street Journal: The latest Milliman Medical Index, which measures the total cost of health care for a typical family of four covered by a preferred provider plan (PPO), rose 7.3% to $19,393 in 2011. The per-employee cost more than doubled between 2002 and 2011. And the employee’s share of that cost now stands at 39.7%. Outpatient care had the biggest cost hike, at 10%, followed by inpatient care (8.6%), pharmacy costs (8%) and physician care (4.4%). And that health-care overhaul law? It isn’t yet significantly driving or curbing costs, the Milliman report says.

Many of these consequences reflect increased costs of operating a business offering health benefits. It is now more expensive to meet rules and regulations of the new federal health reform law, which, paradoxically, was intended to decrease costs. Increased operating expenses especially concern medical practices, whose expenses for doing business are mounting while Medicare, Medicaid, and health plan reimbursements are either stagnant or failing.

Sunday, May 15, 2011

Doctors Purported to be Bullies

May 15, 2011 -The New York Times has highlighted a story by an oncology nurse on doctors as bullies of nurses (Theresa Brown, “Physician, Heel Thyself,” May 8, Op-Ed) and published a series of letters to the editor with the same theme (“When Doctors Humiliate Nurses,” May 15).

Portraying doctors as “heels” may be satisfying to The Times headline writer, but in my opinion, represents an editorial misjudgment. And most physicians I know admire nurses and praise them rather than”humiliate” them.

An undercurrent of this story and some of these letters is that doctors also bully patients. Doctors, it seems, harbor some sort of superiority or authority-gone- to-their-head complex by virtue of their training.

I do not doubt there is a rare doctor who “bullies” nurses and patients. But I find the pieces in The Times overdone and overdrawn, lacking editorial balance, a naiveté about the true nature of health care professionals, and a preoccupation with bullying.

In its hunger for news, the media is full of stories about husbands bullying wives, parents bullying children, teenagers bullying other teenagers, bosses bullying employees, and those in authority, in general, bullying everyone beneath them. We are all, it appears, victims.

There are also countless stories about the need for teamwork, collaboration, and multidisciplinary and multicultural understanding. Most doctors, including myself, are acutely aware we must maintain a culture of civility and a climate of respect and dignity. This is especially true in caring for the sick, which is why we have ten other health care professionals for every doctor.

In an adult world requiring order, someone has to be in charge and to serve as a guide. Carrying out this responsibility should be done maturely and with compassion, and it usually is.

I agree with Dr. Herbert Padres, President and CEO of New York Presbyterian Hospitals, who writes in his letter to the editor in The Times.

“Doctors who accept only their own counsel are putting ego before medicine, possibly at the expense of the patient. Hospital care should be based on collective wisdom to reach the best treatment plan. Nurses, doctors, and all highly trained medical professionals each have a role to play, each of which is invaluable to the patient.”

Saturday, May 14, 2011

The Race Is On: Hospitals and Physicians React to Health Reform by Herding Together

U.S. hospitals have begun responding to the implementation of health care reform by accelerating their hiring of physicians. More than half of practicing U.S. physicians are now employed by physicians or integrated delivery systems, a trend fueled by the intended creation of accountable care organizations (ACOs) and the prospect of more risk-based approaches.

Robert Kocher, MD, and Nikhil Sahni, “Hospitals’ Race to Employ Physicians – The Logic behind a Money-Losing Proposition,” New England Journal of Medicine, May 12, 2011

One reaction to health reform is already abundantly clear. Hospitals and doctors are herding together to protect themselves.

Off to the Races

Hospitals are racing to hire physicians, physicians are racing to be employed, the government is racing to herd them into accountable care organizations, and hospitals and physicians are racing together to form ever larger hospital conglomerates, which are racing to add health insurance and claims processing functions (Philip Betbeze, “Get Ready for Healthcare Conglomerates,” Healthleadersmedia.com, April 14, 2011).

The Racing Percentages

According to a Physician Compensation and Production Survey by the Medical Group Management Association, over the last six years (2003-2009), the percentage of physician practices owned by physicians had declined from 70% to 49%, and the percentage of active primary care doctors employed by hospitals has grown from 22% to 38% and specialists from 6% to 18%.

The Irony and the Potential Payoff

The irony of hospital employment of physicians is that hospitals lose $150,000 to $250,000 per year over the first three years of employing a physician. For hospitals to break even, newly hired primary care specialists must generate 30% more visits than they do at onset, and specialist 25% more referrals.

But, given the health reform threats of lower reimbursements and higher risks, both hospitals and hired doctors feel employment is worth the risk in the long run. Hospitals envisage closed integrated systems with higher efficiencies and the ability to negotiate higher rates based on better performance ratings, better outcomes, and more market dominance. Doctors envisage economic security and more balanced lifestyles.

Whether 'Tis Better or Worse

Whether herding together will translate into improved productivity, outcomes, patient experiences, and lower prices is unknown at present. And whether the government, and accountable care organizations will be good shepherds in the herding process remains dubious in the minds of independent physicians.

As Aldous Huxley (1894-1963) observed in Themes and Variations, “From the point of view of individual lambs, rams, and ewes, there is no such thing as a good shepherd.” Individual practitioners openly worry and wonder whether they are being led to slaughter, whether the wool is being pulled over their eyes.whether they will be culled from the herd, and whether the shepherd is a lion in disguise.

Friday, May 13, 2011

The Health Reform Cookie Monster and You

May 13, 2011 - The following essay of mine appeared in the May issue of Connecticut Medicine. I reprint it here because it addresses the major issue of the budget debate, Medicare reform. The debate kicks off this week. Its outcome may determine the outcome of the 2012 Presidential election.

The Cookie Monster

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

The Cookie Monster, Sesame Street

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 is unknown. Yet,from 2010 to 2020, it says it plans to eat $549 billion out of Medicare by eating away at 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!” The trouble is: its cookies are your cookies too.

To Dominate, or Not to Dominate, That Is the Dilemma, and It May Be the Undoing of Accountable Care Organizations (ACOs)

May 12, 2011 - The Patient Protection Affordability Act creates Accountable Care Organizations (ACOs). The intent of ACOs is to align physicians and hospitals into organizations with capped budgets to provide coordinated care of high quality to lower costs for Medicare patients by having doctors and hospitals “share” the savings engendered by new efficiencies.

So far, so good.

The dilemma is that efficient ACOs may become so powerful they will dominate a market and charge higher rates for Medicare patients, threby defeating the purpose of ACOS - to lower Medicare costs. This dilemma sets up a clash between the Federal Trade Commission (FTC), which regulates commerce, and the Department of Justice (DOJ), which creates the anti-trust rules to avoid monopolies. Suddenly government is in a clash all by itself.

This, in turn, means doctors and hospitals contemplating forming an ACO must hire consultants and anti-trust lawyers, who do not come cheaply, to make sure the prospective hospital and doctor partners do not violate rules and regulations involved in setting up an ACO and do not establish an organization with dominant market share.

Nowhere is this dilemma more sharply presented than in the Washington Report, a periodic newsletter written for The Physicians Foundation by Lee Stilwell, a former AMA lobbyist, who now has his own Inside-the-Beltway consulting firm.

Here in his May 11 Report, Stillwell brilliantly describes what’s involved, what’s likely to devolve, and what’s unresolved with ACOs. I have reprinted the full report in italics so physicians will not miss a beat about the inner workings of Washington.

“I have a message for physicians who are going to consider putting together an Accountable Care Organization (ACO): Plan on spending a ton of money on lawyers, accountants and other health care consultants!

This epiphany became apparent to me on Monday as I listened to more than two dozen individuals express concerns and make suggestions over a three-hour period on proposed antitrust policy for ACOs to be formed under the one-year old health care law.

The two panels –consisting of health care providers, insurers, academics, economists and health policy experts—spent their time trying to point out to representatives of the Federal Trade Commission (FTC) and Department of Justice (DOJ) that much work needs to be done to make potential ACO participants comfortable about potential legal anti-trust land mines that might lay ahead if they make the journey.

And, believe me, in my assessment, the current nine-page joint policy statement published in the April 19, 2011 Federal Register is going to have to grow by scores of pages to meet the uncertainty expressed by participants of the workshop.

As all of the 60-75 members of the audience and thousands of viewers who watched by webcam know, the devil is in the details when it comes to government verbiage. Consequently, although the material is dry as toast, everyone listened intently for responses from government representatives who appeared sympathetic to concerns and made it clear their role there was to listen and ask questions.

The majority of the comments focused on details of the federal government’s proposal to use the rule of reason for ACOs who use the same governance and leadership structure for their commercial and Medicare markets. The rule of reason analysis is designed to evaluate whether collaboration is likely to have substantial anticompetitive effects.

DOJ and FTC propose to undertake a streamlined analysis that calculates ACOs share of services in each participant’s Primary Service Area or PSA. The federal agencies conclude the risk of an ACO becoming anticompetitive grows as the share increases.

Panelists focused on fleshing out nebulous details for the three levels of antitrust scrutiny which are determined by PSA share:

--If an ACO’s PSA share is 30 percent or less, it is considered a “safety zone” because it is unlikely to have antitrust concerns. Consequently, no initial review is required. The “safety zone” exception also is applicable for providers in sparsely populated rural areas and may include a provider in the ACO with over 50 percent PSA share if no other participant provides the service in the area and the provider participates on a non-exclusive basis.

--A mandatory review is required if the ACO’s PSA is greater than 50 percent. The review-- to be completed in 90 days-- will be based on such things as documents that relate to competitors’ ability to compete with the ACO, providing contact information for commercial health plans or other payers, and plans and internal strategies.

--And then there is what I call the “twilight zone”—an ACO below 50 percent PSA share but more than 30 percent! An ACO may apply but remains subject to investigation if its formation appears anticompetitive!

Five types of conduct in the “twilight zone” are listed to avoid an antitrust investigation. These include preventing or discouraging commercial payers from directing patients to choose certain providers through “anti-steering,” “guaranteed inclusion,” “product participation,” “price parity,” or similar contractual clauses; tying sales of ACO’s services to the commercial payer’s purchase of other services from providers outside the ACO; with the exception for primary care physicians, contracting with other ACO physician specialists, hospitals, ASCs, or other providers on an exclusive basis; restricting a commercial payer’s ability to make available to its health plan enrollees cost, quality, efficiency, and performance information to aid enrollees in evaluating and selecting providers in the health plan; sharing among the ACO’s provider participants competitively sensitive pricing or other data they could use to set prices or other terms for services they provide outside the ACO.

If I were a “twilight zone” candidate, there is no doubt what I would do. My choice would be to avoid the quagmire of uncertainty by taking advantage of the DOJ-FTC offer to undertake also an expedited 90-day review for those in the 30-50 percent PSA share range.

The challenges of defining antitrust policy for ACOs were evident as different panelists explained the complexity of meeting proposed requirements. An AHA representative pointed out that a study of hospitals systems in 162 major cities showed virtually all would be required to undergo a “mandatory review.” Another panelist pointed out that that using the PSA, which focuses on contiguous postal zip codes, could be a big problem, pointing out there are more than 230 zip codes in metro Chicago alone.

The lack of definition brought more questions than answers. One panelist talked about the effectiveness of using a Tax Identification Number (TIN); wondered about a process to add new physicians entering the market and how to handle the breakup of practices during the three-year commitment period for establishing an ACO. Requiring an ACO participant to have a minimum threshold below 50 percent PSA share “of any service” was called “unrealistic” by a panelist.

A great deal of conversation focused on the expedited 90-day time period for reviews by DOJ and FTC.

There were a number of skeptics about the ability to do so much work in that time frame and the consequences of being forced to do it. What if more time is needed?

Speaking of time, there was no doubt the workshop could have gone on and on but ended on schedule with it certain that there is much to be challenged and thought through in a comment period that ends May 31, 2011. There is no definite date for release of the final antitrust policy but it is evident that federal officials have a great deal of tweaking and refinement to do.

For those who like to see government at work, I recommend a visit to the FTC website at www.ftc.gov/opp/workshops/aco2/index.shtml. There you can find all information about the workshop, including the complete Federal Register notice which was issued on April 19, 2011. Also, a full transcript of the workshop will be on the website toward the end of next week. On the FTC website, one also can pull up the agency’s earlier ACO workshop held in October 2010.

It becomes obvious to me that it is going to be hard to do all the detailed work required to bring clarity to the ACO program which is scheduled to get underway in January 2012. Keep in mind, the DOJ-FTC drama is just a small piece of the big federal pie when it comes to forming ACOs. The main thrust has been the massive proposed rule released by the Centers for Medicare and Medicaid Services (CMS) which has a comment period that ends June 6.

And if this wasn’t enough, the Internal Revenue Service (IRS) also issued a notice requesting comments regarding the need for guidance on participation by tax-exempt organizations in ACOs by May 31!

Do you see where this is going? As I said earlier, be prepared to hand that hired army of experts a set of rules and regulations that will be about the size of the telephone book.”

My Conclusion

No federal initiative to remake the health care system in its health reform law illustrates the complexity, longevity, and perplexity of government bureaucracy than the formation and implementation of ACOs, scheduled for kickoff in January 2012. No document tells you more about the Byzantine nature of the Patient Protection and Affordability Act than Lee Stillwell’s Washington Report to the Physicians Foundation.

The Physicians Foundation Awards $1 Million Grant to Health Leads

May 11, 2011 - Yesterday the Physicians Foundation, a charitable organization representing physicians in state medical societies nationwide, put its money where its heart is.

The Foundation awarded a $1 million grant to Health Leads, a Boston non-profit to help it expand from its current base of six cities to other locales across the land.

The Physician Foundation-Health Leads collaboration is a natural partnership. Both the Physicians Foundation and Health Leads are organizations who think “outside the box” to help vulnerable citizens find resources outside the mainstream of care.

Physicians often find themselves trapped in a box, unable to help patients find food for their stomachs, heat for their homes, transport to medical facilities, jobs to supply the money to pay for care, decent homes in safe neighborhoods. These basics are simply beyond the reach of the current health system or the current reforms designed to improve care.

Health Leads works in 22 pediatric and prenatal clinics, newborn nurseries, emergency rooms, and community health centers in six cities across the U.S. Last year, Health Leads trained and deployed 660 college volunteers to connect nearly 6,000 low-income patients and their families to the resources they need to be healthy. By providing a transformative experience for hundreds of college volunteers, Health Leads is producing a pipeline of new leaders who will have both the conviction and the skills to transform health care from the bottom-up.

How does Health Leads make this transformation possible ?

• One, by giving doctors the power to “prescribe” food, shelter, job training, and transportation by writing prescriptions to find these resources.

• Two, by recruiting college volunteers to serve at Health Desks in various health care settings to direct patients and families to community resources, in the process serving as a training ground for health careers and as a sort of domestic Peace Corps.

In the hospitals and health centers where Health Leads operates, doctors can “prescribe” food, housing, or other critical resources—just as they would medication. Patients take their prescriptions to the clinic waiting room, where Health Leads’ college volunteers are ready to connect them to these resources. Nearly 60 percent of Health Leads patients secure at least one critical resource – receive food, get their heat turned back on, find a job – within 90 days of getting their “prescription.” All patients receive ongoing follow-up until their needs are met.

“As we continue to identify new ways to enhance healthcare delivery, we are extremely proud to fund the ongoing efforts of Health Leads,” said Dr. Walker Ray, Vice President of The Physicians Foundation and Chair of the Research Committee. “In a system that is massively overburdened by strained resources, innovative models that foster collaboration between college volunteers and physicians can have real impact on our nation’s healthcare.”

The Physicians Foundation’s funding will help Health Leads expand its operational capabilities, allowing the organization to serve significantly more patients. By developing an information technology infrastructure to enhance tracking of patient outcomes and by hiring additional program managers and staff, Health Leads will be able to deepen engagement with physicians and clinic partners.

“Health Leads is grateful for the assistance of The Physicians Foundation in helping us to build the capacity we need to scale our program model over the next four years. Since we received their funding, we have been able to serve more than 2,600 patients, putting us on track for an increase of more than 60 percent over last year,” said Rebecca Onie, Co-founder and Chief Executive Officer of Health Leads.

“We have also launched discussions to build an evaluation partnership with the Mayo Clinic Center and rolled out a new client database to all of our sites that will enable us to better track and report client outcomes. The Foundation's support has been invaluable in helping us make significant progress on these strategic goals."

Tweet: The Physicians Foundation, a doctor organization, has awarded a $1 million to Health Leads, to help patients find food, housing, & jobs.

Richard L. Reece, MD, has posted 1770 blogs at medinnovation blog over the last four years. His main themes are health reform and innovation and how they impact physicians and American culture. He works closely with the Physicians Foundation. His opinions are his alone. He has written eleven books. His latest book, The Health Reform Maze, is now at Greenbranch publishers and will be released in June. Doctor Reece’s website, www.doctorreece.com, is now up and running He invites comments and questions on his blog and will respond to each comment or question on his blog or to him directly at 860-395-1501 or rreece1500@aol.com.

Fourteen Examples of The Power of Proximity: Why Market-Delivered Care Is Superior to Government-Delivered Care

The American entrepreneurial economy distinctly differs from that of socialistic European economies. American organizations must be able to make decisions based on proximity to performance, the market, technology, society, environment, and demographics. In Europe, on the other hand, distance from the market of centralized systems makes innovation and responsiveness difficult.

R. Reece, Innovation-Driven Health Care: 34 Key Concepts for Transformation, Jones and Bartlett, 2007

To start a blog with a quote from your own book may be the height of egotism, but I will quote myself anyway.

The main flaw of the health reform law is its distance from the problem – care delivered in the office, neighborhood clinics, urgicenters, emergency rooms, retail clinics, the home, and other decentralized settings. For everyday events, you can’t control events top-down from the White House and Congressional environs.

Top-down government cannot innovate quickly enough or relevantly enough to address problems at the level where care is delivered. To put it another way, government is incapable of disruptive, or bottom-up innovations.

These innovations invariably come from individuals or organizations on the ground. Examples are endless. Here are fourteen of them.

One, cardiac defibrillators
- To be of any value, defibrillators must be present near the place where cardiac arrests occur. Dr. Bernard Lown invented the direct current defibrillator in the 1960s, and Dr. Roger Health, invented the pads making automatic defibrillation at remote sites possible. These defibrillators are now widely placed in public and medical places, where nearness to the usually fatal event makes all the difference.

Two, work site clinics - To save money and to address worksite health needs, including preventive measures, corporations and other organizations are now placing worksite clinics, led by primary care physicians, at the work site.

Three, orthopedic clinics offering non-invasive treatments
– The Jewett orthopedic clinics in Orlandom Florida, have established multiple clinics for treating sprains, ligament injuries, and closed fractures at neighborhood locations.

Four, urgiclinics – These are springing up everywhere around the nation as an inexpensive and convenient alternative to emergency rooms. In fact, many are near the ER as a convenient and more sensible alternative.

Five, retail clinics – These clinics, located in retail pharmacies and discount outlets, generally staffed by nurse practitioners, offer care for minor illnesses, and routine vaccinations.

Six, concierge practices - For a retainer fee, charged monthly or annually, and cancellable on short notice, these primary care practices offer same-day appointments and 24 hour availability.

Seven, free standing emergency rooms and neighborhood clinics
- Hospitals are finding these outlets are invaluable for treating injuries or illnesses near where they occur and for establishing brand-name recognition of the hospital and its neighborhood friendliness.

Eight, hospice home care – Given their druthers, most terminally ill-patients would rather die at home surrounded by loved ones, rather than in a hospital. Hospices have recognized this, and are hiring thousands of nurses to fan out to serve patients in their homes.

Nine, telemedicine, telemonitoring, and teledevices for home and remote care. Internet and computer apps, often transmitted through mobile devices, are rapidly changing the health care landscape, by making distance irrelevant and electronic nearness the norm.

Ten, portable hand-held ultrasound, with which physicians in their offices can determine if an abdominal mass or abdominal aneurysm exists.

Eleven, a portable Shape-HF cardiac-pulmonary testing device
, which allows a physician in his office or a trained medical technician in any location to evaluate the cause of shortness of breath and the odds of hospitalization or sudden death.

Twelve, Audio-visual devices developed by American Telecare, Inc.
, at bedsides of home-ridden patients with chronic disease, which permit patients to spot complications on their own and to communicate with doctors and nurses in remote locations, in the process dramatically reducing the need for hospital or ER admissions.

Thirteen, Practice Fusion, Inc, a "free" EMR for physicians
that can be up and running in five minutes and is free to physicians because of its ad-based revenue model and its off-loading to the Internet.

Fourteen, Instant Medical History, Inc, which allows patients to record their chief complaint, medical, social, and family history over the Internet before visiting the doctor and appearing in the exam room.

I am sure there are countless other examples where nearness to care makes all the difference. If you know of them, please email them to me at rreece1500@aol.com or comment on them in this blog.