Thursday, June 30, 2011

Medinnovation Revisited

June 30, 2011 - Fifty five months ago, in November, 2006, 1848 blogs ago, I launched Medinnovation blog. The launch was partly in response to work I was doing with Emmi Solutions, Inc, an innovative Chicago-based health care firm.

Emmi, still in business, had the idea of preparing and selling online videos to hospitals and physicians that prepared patients for what to expect from procedures about to be performed or how to cope with chronic diseases.

I thought it was a wonderful idea (and still do), for it engaged patients, taught them what to expect, and diminished misunderstandings that might lead to malpractice suits.

So I began to write blogs about effective medical innovation solutions and how to go about creating them. This phase of Medinnovation lasted until the debate over health reform began in earnest, picked up steam when Obamacare passed in March 2010, and has been my main theme since.

Health reform and medical innovation are closely linked. Overly bureaucratic reform can stifle innovation, yet innovation may be the best way to lower costs, make care more accessible, and improve performance and outcomes.

In 2007, I wrote a book Innovation-Driven Health Care; 34 Key Concepts for Transformation (Jones and Bartlett, 2007). It was arresting enough that Pfizer bought 5000 copies to distribute at medical meetings.

I have since produced another book, The Health Reform Maze: A Blueprint for Physician Practices (Greenbranch Publishing), which is due out later this summer. The Maze book contains a section on medical innovation, which contains these eight essay blogs.

Innovation – Last Great Hope

-- Irresistible Force

-- Why Not More Innovation?

-- Balancing Reform and Innovation

-- Top Ten Innovators

-- Getting Your Care at Work

-- No Miracles Among Friends

-- How To’s of Medical Innovation

In these blogs, I sought to give a balanced picture of what innovation is all about and to give examples of why, when, how, and where medical innovation worked.

Now I am in another phase of thinking about innovation.

In October I will be visiting Luis G. Pareras, MD, a neurosurgeon with an MBA, in Barcelona, Spain, to talk about the European approach to innovation. Doctor Pareras’ book, Innovation and Entrepreneurship in the Healthcare Sector: From Idea to Funding to Launch(Greenbranch Publishing, 2011), is exactly what its title says it is.

It is a nuts-and-bolts primer an effective innovative idea in those health care sectors in which ideas are needed, along with innovative trends, how to develop a business plan, assemble a team to make the idea real, gather venture capital money, and go to market.

Wednesday, June 29, 2011

Obamacare: A House of Illusions

It is natural for man to indulge in illusions of hope.

Patrick Henry (1736-1799), Speech in Virginia Convention, 1775

June 29, 2011- Some critics say Obamacare is a House of Cards and will collapse once its facts and its consequences are understood.

I do not agree. I do not think it will collapse. Instead, its illusions will be revealed, and its beliefs or opinions not in accord with the facts will be become evident. And many of its illusionary trial balloons will be withdrawn or cancelled .

These illusions include:

• That the government can somehow find out what makes doctors tick by sending out an army of “mystery shoppers” to find out why doctors accept some patients and reject others. This trial balloon lasted one day. After reviewing feedback received during the public comment period," a Health and Human Services official today told Fox News, "We have determined that now is not the time to move forward with this research project. Instead, we will pursue other initiatives that build on our efforts to increase access to health care providers nationwide."

• That a government entitlement program, once passed, will grow in popularity. Today, 15 months after passage, national polls indicate public disapproval, if anything, is widening with roughly 37% approving and 53% disapproving. Apparently the idea that government, not the people, always knows best is an illusion and doesn’t play well in America, which remains a conservative nation, distrustful of big government.

• That the long-held and cherished dream of universal coverage is an illusion when accompanied by higher premium costs, dropped coverage by health plans and employers, and decreased access secondary to a growing doctor shortages, physician reluctance to accept new low-paying and bureaucracy-laden Medicaid and Medicare patients, and longer waiting times and difficulties finding a doctor. Universal coverage becomes an illusion when it does not translate into universal access.

• That something is illusionary when the government issues over 1500 waivers allowing political allies and even some states to escape Obamacare fetters and expenses by opting out of the health care law.

• That national documentation of billions of health care transactions through the use of electronic medical records by patients and providers and health plans will somehow become reality if pursued long enough and assiduously enough, even when the government has be at making universal documentation “meaningful” for nearly half a decade now and has proposed to spend some $27 billion to make universal documentation a national priority. The dream may never die even though good documentation may never be the same as good doctoring.

Tuesday, June 28, 2011

A Modest Proposal: A “Realistic” Rather Than A "Mystery Shoppers” Survey of Primary Care Practice

June 28, 2011- I have a modest proposal – that the Obama administration make an up-front, as opposed to a stealth "mystery shoppers'" survey of primary care doctors to see why these doctors act as they do and why they accept some patients and turn down others.

My proposal stems does not come from out of the blue. It comes from the controversy surrounding the Obama administration’s proposal to send “mystery shoppers" around to check on doctors’reasons for accepting or rejecting patients, and from a June 27 LA Times article “”What Happened to the Family Doctor?”

Here would be some of my questions for family physicians and general internists, who, some claim, are going the way of the Dodo Bird.

Q: Are you optimistic about the future of primary care? If not, why not?

Q: If you had it to do over again, would you pick primary care as a specialty?

Q: How many patients a day do you have to see to break even in your practice?

Q; Do you think you have enough times to spend with patients?

Q: What are your “take-home” revenues each month?

Q: Are you still paying off your medical school debt? And if so, how much is that payment per month?

Q: What are your malpractice premium payments each month?

Q: How many members do you have on your staff? And what do you have to pay them each month?

Q; How many of these employees are involved in direct patient care? and who many are engaged in processing and justifying claims?

Q: How much time outside the exam room do you spend on non-revenue producing activities - renewing prescriptions, talking on the phone, writing emails to patients, filling out paperwork forms?

Q: Most health insurers, including Medicare, pay only for face-to-face visits. You are only paid for using 5 codes suggested by Medicare and commercial insurers.
Do you think this is realistic – or fair?

Q: Are you considering entering another specialty – such as dermatology, anesthesia, or hospitalist care – with set hours and a regular salary?

Q: Have you considered becoming a concierge physician where you could spend more time with patients?

Q: Do you think the Medical Home Concept has legs. i.e., is a realistic alternative to your current mode of practice? Will it provide more access to primary care?

Q; Do you believe a capitation-like system – in which you are paid a set fee for managing a patient’s total care – is preferable to the present fee-for-service practice?

Q: Are you in favor of Accountable Care Organizations, led by teams of primary care physicians acting in concert with hospitals?

Q: Do you believe you ought to be at financial risk for untoward patient outcomes?

Q; Do you believe electronic health records in every doctor’s office and every hospital department will reduce costs and errors and improve outcomes?

Q: Do you favor the current Patient Protection and Affordability Act? Do you think it will protect patients and make care more affordable for most patients?

Such a survey would remove much of the mystery of why a primary care shortage is growing and spreading.

Monday, June 27, 2011

Anger, Outrage, and Concern Over Stealth Survey of Physicians

Alarmed by a shortage of primary care doctors, Obama administration officials are recruiting a team of “mystery shoppers” to pose as patients, call doctors’ offices to request appointments to see how difficult it is for people to get care when they need it.

Robert Pear, “Stealth Survey To Test Access to Physicians,” New York Times, June 27, 2011

June 27, 2011
– The Obama administration is at it again- investigating doctors and questioning their motivations in treating patients.

In a "mystery shopper survey,", announced today, Obama officials have contracted to have the National Opinion Research Center in Chicago firm call offices of 4,185 doctors in nine states to see if the doctors will accept patients with Medicare, Medicaid, private insurance or “self-pay.”

Never have I seen the level of anger, outrage, and concerns among physicians over this proposal. Doctors say, among other things, that this study;

- is a prelude to forced participation in Medicare and Medicaid programs,

- smacks of a police state mentality,

- is anti-democratic,

- government itself created the primary care shortage through CMS coding practices of paying specialists more,

- shows a bias against private practice,

- is just plain silly.

I belong to the school that says the proposal is silly. Anybody with an ounce of sense knows the reasons why doctors turn away patients on government programs - Medicare and Medicaid pay significantly less than private plans, often so little that practices cannot meet expenses; the hassle involved in seeing patients gaining payment saps time, energy, and profits out of practices; and the proposal is simply further evidence of the government's altitude and attitude problems.

Because of their elevated status, government reformers are too far removed for the clinical trenches, and because of their attitude that government, not doctors and patients, knows best, reformers see a beautiful growing forest, not ugly fallen trees.

Besides, what would the stealth proposal data reveal? That doctors are engaged in some clandestine plot to undermine the health reform law, that doctors are acting in their own self-interest to survive as small business people, or that they are overloaded with current patients and have no more room for the proposed flood of low-paying government patients.

I do not know, but the proposal strikes me as another PR black eye for the Obama and Democratic health law. From the physicians’ point of view, the stealth program is ham-handed, insensitive, and inappropriate.

For President Obama and the Democrats, the stealth proposal may be prompted by recent polls. In Massachusetts, whose health plan is often cited as a paradigm for Obamacare, 53% of family physicians and 51% of internists do not accept new patients, and waiting times are 36 days to see family physicians and 48 days to see internists. Three national polls in June indicate 37.7% of Americans favor Obamacare and 52.3% oppose it, a 14.6% margin of opposition.

Surely, the reasoning in Washington may go:the fault for doctors not accepting new patients must lie with the doctors, not with the health reform plans. What's good from the government's point of view must be good for patients. Surely, low reimbursements,unwieldy bureaucracy barriers, and overwhelming practice loads could have nothing to do with it.

What I Have Learned about Health Reform, Then 1989, Now 2011

June 27, 2011 - In 1989, as editor of Minnesota Medicine, I was writing a great deal about the corporate transformation of medicine, which was part of my book And Who Shall Care for the Sick? (Media Medicus, 1988).

The book was a warning shot across the bow about a future shortage of primary care physicians.

As part of the process of writing about managed care, the first big wave of health reform, I was reading the works of Winston Churchill, who you may recall, warned of socialism as stifling innovation and dampening economic prosperity.

Yesterday, I came across a book Blood, Toil, Tears and Sweat: The Speeches of Winston Churchill (Houghton Mifflin Company, 1989). On the back fly leaf of the book, I had written notes of an editorial I was pondering “What I Have Learned.”

For the purposes of this blog, I thought it might be useful to revisit those notes in light of what has happened since.

Here are a few of my notes written for physicians, followed by what I think now.

Note One - If you do anything, do it within the confines of an organization. It takes organizations to make you strong. Society and payers are demanding order and consistency. This will be done within a management context, set forth by government and private managers, and it will compare results within various regions of the country.

Comment on Note One - If anything, this demand for “order and consistency” has multiplied. It is the basis for the health reform law, which essentially, is a federal command and control blueprint for organizing, regulating, and managing actions of independent doctors and hospitals.

Note Two - Medicine is neither a public service or a business. It is both and neither function can be ignored.

Comment on Note Two – Medical services are unique in that politically they are considered a “right,” yet they require business “profits” to function. They are not “free” but when considered so, engender demands that inevitably outstrip resources.

Note Three - Management is not enough, but neither is professional expertise and specialism. Blind setting of limits to control access to specialists to curtail demand seldom works, and so does owning of primary care doctors and their networks to serve as “gatekeepers” to specialists.

Comment on Note Three - As a method to control costs, HMOs and PPOs, using utilization controls and primary care gatekeepers, worked temporarily, but lost favor when doctors and patients alike revolted and demanded straight access to specialists and procedures they offered. It is unlikely the present reform plan will work very well either, for consumer demand to access to what is perceived to be the “best,” i.e., specialist and high-tech care, will persist in an aging population when one is sick or when one seeks treatment to restore full life-style functions.

Note Four - Heaping scorn on physicians or ignoring their solutions on how to fix problems of system is dangerous. Most doctors are entrepreneurial in spirit. Reducing physicians to salaried employees in large organizations runs risks of inducing a civil servant mentality, of stifling innovation, of reducing incentives for talented people to enter medicine as a profession, of creating monopoly organizations that limit access, and compounding the physician shortage.

Comment on Note Four - This is precisely what is happening. The health reform law is exaggerating the doctor shortage. The doctor shortage, particularly among primary care physicians, is spreading; morale among physicians is at a low ebb; and physicians in droves are opting for a 40 hour work week with benefits as an alternative to private practice. The health reform law, and the current government attempt to send “mystery shoppers” to pose as patients to see why doctors don’t accept patients in government programs will only worsen physician shortages (Robert Pear, “U.S. Plans Stealth Survey on Access to Doctors,” New York Times, June 27, 2011). Blaming physicians for flawed government policies is not an effective way to promoted professionalism among physicians or to solve government-induced health system problems.

Sunday, June 26, 2011

Everything You Ever Wanted to Know about How to Lose or Gain Weight during Your Lifetime, Statistically Verified

June 26, 2011 - Most of us know intuitively what puts on weight – too much carbohydrates, too much sugar, too much processed or red meat, too much diet soda, too little exercise – and what takes weight off - fruit, vegetab3es, fiber, nuts,yogurt, and lots of physical activity.

Now through the work of 5 Harvard health experts, we have a massive study of 120,877 U.S. men and women who gained an average of 3.35 pounds within 4 year periods from 1998 to 2006.

Here is what caused them to gain weight.

• Potato chips,+ 1.6 lb

• Potatoes,+ 1.28 lb

• Sugar-sweetened beverages,+ 1.00 lb

• Unprocessed red meats, + 0.95 lb

• Processed meat, +0.93 lb

• Alcohol use, 1 drink a day,+0.41 lb

• Smoking, new quitters,+ 5.17 pounds

• Former smokers, + 0.14 pounds

• Television watching, + 0.31 lb per hour per day

And to lose weight.

• Vegetables, -0.22 lb

• Whole grains, -0.37 lb

• Fruits, -0.49 lb

• Nuts, -0.57 lb

• Yogurt, - 0.82 lb

• Physical activity, -1.76 lb
Pick your poisons for gaining and your reasons for losing. Follow the + and - bullets. You have something to gain, and little to lose.

Darisush, MD, et al, Changes in Diet and Lifestyle and Long-Term Weight Gain in Men and Women, New England Journal of Medicine, June 23, 2011

Saturday, June 25, 2011

The Emergency Department as “The Room with a View" of Health Reform of the Past, Pesent, and Future of Our Health System

The ER is more than a hospital department. It’s a “room with a view" of the health system.

Arthur L. Kellermann, MD, and Ricardo Martine. "The ER, 50 Years On,” New England Journal of Medicine, June 16, 2011

In a June 16 NEJM issue, A.J. Kellermann,MD. and Ricardo Martinez, MD, of the RAND corporation and Emory University Department of Emergency Medicine, discuss the state of emergency room care over the last 50 years.

With the ER, they conclude , some things:

• have remained the same – the hospital admission rate from the ER remains 16%;

• the growth rate remains rapid at twice the rate of the population growth;

• the reasons for growth remain the same – hospitals must accept all comers; you can always get care in the ER at all times; doctors are performing more procedures in ER rather than offices; doctors are unavailable in off-hours and weekends;

• care is more complex and technologies has changed because of aging patients, new imaging and other diagnostic techniques, and more effective methods of resuscitation.

• burdens of caring for acutely ill, uninsured, and children have grown disproportionately.

More than anything else, the ER is “room with a view” of the health system – its gaps, the state of public health, the lack of primary care physicians.

The authors offer two views of the future;

• One driven by deteriorating access to care, unavailable primary care physicians, and unaffordable specialists.

• The other centered on patient needs, not convenience of providers, free flow of information from home, to office, to ER, the right care at the right time at the right place.

In a accompanying article, “The Waits That Matter,” John Maa, MD, a San Francisco surgeon, argues that the first option is unacceptable because it produces long wait times, during which patients may die, as his mother did.

Friday, June 24, 2011

Obamacare on the Defensive

I am in earnest – I will not equivocate- I will not excuse – I will not retreat a single inch; and I will be heard!

William Lloyd Garrison (1805-1879), The Liberator, 1831

June 24, 2011- As I gaze across the health reform terrain, I see proponents of Obamacare retreating on multiple fronts:

• the constitutionality of the health reform law now being considered in Atlanta Appeals court,

• the McKinsey report indicating 30% of employers will drop coverage in 2014,

• CMS announcing no new waivers from the law come September,

. polls indicating unprecedented resistance to a national entitlement program,

• uproars over restrictions to imaging utilization and Presidential appointment of an Independent Payment Advisory Board,

• rejection of rules proposed for setting up Accountable Care Organizations.

It’s enough to make an ordinary president blanch, or even blush, but not this president or spokespersons for his administration.

Their strategies seem to be: The best defense is a good offense. Use the bully pulpit to discredit your opponents. Never retreat, attack.

In the case of Republicans suggesting how to save Medicare through a voucher plan to save it from imminent bankruptcy, these tactics worked in New York state district 26. There a Democrat upset a Republican by, among other things, showing a television ad featuring a Paul Ryan-look-alike pushing Grandma off a cliff. In some circles, this is known as demogogic chutzpa, accusing your opponent of insensitivity while you are cutting $575 billion out of Medicare.

The Democratic tactic seems to be: Don’t challenge the facts, change the language or shift the blame.

Using the impact of the universal health plan in Massachusetts as an example, in his Heath Care Blog, “Rationing by Waiting, “ John Goodman pointed out how this is done in Massachusetts in a recent blog. Massachusetts’ 5 year old plan has produced the nation’s longest waiting times, the highest health plan premiums, and runaway state budget costs.

Goodman says: If your health reform policy causes patients’ care to be rationed by forcing them to wait longer for care, don’t call it “rationing,” call it “universal coverage.” If your plan forces physicians to close their practices to new patients, don’t call it “rationing,” call it an “access to care” problem and blame it on the private sector. If your top-down policies create higher premiums and higher taxes, don’t call it bureaucratic bungling, call it lack of “cost-effective care” or lack of “coordinated care.”

If an independent consulting firm, McKinsey & Co, reports its impartial survey of 1300 companies indicates 30% of companies say they will drop employee coverage in 2014, shut the company up by questioning its “methodology”or “impartiality.”

If WellPoint and Humana and the Blues withdraw from markets or raise rates to cope with expenses of new regulations, to protect its profit margins, or to satisfy its stockholders, accuse them of “unconscionable behavior.”

If accountants of ATT, Verizon, John Deere and other Fortune 500 companies truthfully say Obamacare will lead to huge write-downs, question their veracity.

Sneer at critics who call the new health care law “Obamacare” instead of the Patient Protection and Affordability Act (PPACA), or the Affordable Care Act (ACA), even if the PPACA or ACA so far at least, neither protects most patients from keeping their present plans or physicians or makes most of their care more affordable.

Never back off an inch from Obamacare. Deny its unforeseen consequences on patients and the general economy.

Thursday, June 23, 2011

The Health Reform Jungle: Specialists as Patient Predators

It’s a jungle out there.

Tarzan to Jane

June 23, 2011
- A school of thought exists that says predatory non-professional specialist wolves out there are keeping health costs unnecessarily high. By the school’s estimates, these outliers may cause 30% to 55% waste in the system. Motivated by greed and not by evidence or clinical need, these evil-doers prey on unsuspecting, naive patients and Medicare and Medicaid recipients, causing pain, injuries, and even death.

A Portland, Oregon, neurosurgeon is the poster boy for this school. Visah James Miller, MD, was recently banned from the operating room for performing spinal fusions on 61 Medicare patients, and an additional 24 fusions for 16 of the same patients. Dr. Miller had the highest fusion rate among 3407 surgeons who performed spinal fusions on Medicare patients. For this excessive rate, the Oregon Medical Board banned him from operating (“Hospital Bans Surgeon from Operating Room, Wall Street Journal, April 13, 2011). Which makes sense to me.

I have no doubt a small number of such predatory surgeons exist. But I hesitate to leap to the conclusion that bad apple physicians account for much of the overall rise in health costs, or to the $60 billion in Medicare fraud and abuse.

I could be wrong, of course. I am not as certain as David Kibbe, MD, and Brian Klepper, PhD, who wrote about this problem in a June 22, 2011 Health Affairs Blog, “Physician Fallows Program.” The term “fallow” is a government program for agricultural restoration, i.e., letting the earth remain “fallow” until it enriches itself.

Kibbe and Klepper propose:

• Using data to identify “super-utilizers,” those who utilization patterns exceed two on average two or more two or three standard deviations.

• Paying these over-utilizers to go away by offering the offending doctors not to practice medicine or surgery for several years by offering them 75% to 100% of their average income over the last three years.

• Allowing the offenders to return by being retrained as primary care physicians.

Kibbe and Klepper maintain this fallow approach would improve care, end unnecessary procedures, avoid pain, injuries, and even death.

Why am I dubious?

One, I am leery of the use of the punitive statistics in the hands of federal or private health plan bureaucrats, without investigating the circumstances of “overuse.” Some surgeons, for example, are known to be experts in “re-do” procedures, and the mix of their patients may influence the numbers.

Two, I have yet to see persuasive evidence that comparative effectiveness research, a leading tool in the Obamacare toolbox, effectively brings down overall-costs.

Three, I am sensitive, perhaps over-sensitive, to the notion that specialists are a leading root cause, or a significant cause, of overall health care inflation.

Another cause, largely ignored, is patient demand to have “something,” “anything” done to relieve pain or restore functionality. The practice of medicine depends on emotional factors, as well as statistically-based data.

As I indicated, I could be wrong. I simply do not see this proposal as a realistic, workable solution to bending the cost curve down. Using data to weed the jungle of unsavory predatory doctors strikes me as simplistic. But, as Arthur Miller said in Death of a Salesman, "Attention must finally be paid to such a person. " Miller then added, " But you’ll never get out of the jungle that way.”

Wednesday, June 22, 2011

How Big Is Government Dependency Going to Get?

Exclusive: Medicaid for the Middle Class?


WASHINGTON, June 21, 2011
– President Barack Obama's health care law would let several million middle-class people get nearly free insurance meant for the poor, a twist government number crunchers say they discovered only after the complex bill was signed.

The change would affect early retirees: A married couple could have an annual income of about $64,000 and still get Medicaid, said officials who make long-range cost estimates for the Health and Human Services department.

After initially downplaying any concern, the Obama administration said late Tuesday it would look for a fix.

Up to 3 million more people could qualify for Medicaid in 2014 as a result of the anomaly. That's because, in a major change from today, most of their Social Security benefits would no longer be counted as income for determining eligibility. It might be compared to allowing middle-class people to qualify for food stamps.

How big is Medicaid going to Get? That is the question that concerns us all.

Medicaid now covers 58 million Americans, The PPACA promises to cover 34 million more by 2014.

Now we learn, through a glitch in the law, 3 million more will be added, bringing us to a grand total of 95 million Medicaid recipients by 2014.

Which leads to this doggerel verse.

When Will It Ever End?

When will it ever end?
Those upon whom government depend?

At last count, Medicare now covers 46,589,141 million,
By 2014, 50 million will inhabit the Medicare pavilion.

In other words, in 3 years, 145 billion, about half of us,
Will rely on the federal government for care, more or less.

How much will government and taxpayers be willing to spend?
Or will government be able to downward the cost curve bend?>

Tuesday, June 21, 2011

Ten Wrap-Ups for Health Reform Maze Book

June 21, 2011 - In March 2011, I completed work on my book The Health Reform Maze: A Blueprint for Physicians (Greenbranch Publishing), which will be out later this summer.

The publisher has suggested I write a wrap-up of reform events taking place or gaining momentum since March. In a social issue as fluid, volatile, and controversial as health reform, a lot can happen in three months, and it has.

Here are my initial thoughts on late health reform developments.

1. Physicians in overwhelming numbers have embraced hospital employment as an alternative to private practice in response to lifestyle, business, and regulatory challenges(March 20, 2011, Gardiner Harris, “More Physicians Giving Up Private Practice,” New York Times; for further background, see October, 2010, Merritt Hawkins and Physicians Foundation white paper, Health Reform and the Decline of Physician Private Practice). The genie is out of the bottle, and the only question is which genie will lead hospital-physician organizations, a MHA-MBA or a MD-MBA).

2. Consolidation of physicians into integrated organizations, both hospital and physician-led, is growing because of compliance and infrastructure requirements which small practices cannot meet. (June 19, 2011, Richard L. Reece, MD, “The Corporate Transformation of American Medicine,” Medinnovation Blog).

3. No practice model, inside or outside organizations, has yet been found to reward doctors for “quality” and “outcomes,” rather than “productivity,” i.e., “volume” based on FFS incentives, practice survival, patient demands, and defensive medicine curtailment.(June 10, 2011,Merritt Hawkins and Associates, 2011 Review of Physician Recruiting Incentives).

4. Obamacare, whatever one thinks of it, has forever changed private practice of medicine, and its impact is best explained in Physicians Foundation White Paper, Health Reform and the Decline of Physician Private Practice, released on June 1, 2011(

5. Constitutionality of health reform law as judged in Atlanta Appeals Court and Supreme Court will be pivotal. The Atlanta ruling will be issued momentarily (June 9, 2010, "Appeals Court Judges Skeptical of Government’s Health Care Case”, CNN Politics).

6. Polls indicating continued public resistance to Obamacare and favoring its repeal will be important indicators of outcome of upcoming Presidential election and future of medicine. (June 18, "Poll on Obama and Democrats Health Care Plan", Real Clear Politics).

7. Physician leadership will be vital in warding off access crisis for 78 million new baby boomer Medicare and 34 million new Medicaid recipients and in recommending reasonable and workable new models of care to repair gaping and widening new holes in social safety net due to physician shortages (June 21, Personal Opinion, Richard L. Reece, MD; Grace Marie-Turner et al, Why Obamacare Is Wrong for America, April, 2011)

8. The Obama administration have picked up the pace for offering waivers, now numbering nearly 1500, to organizations and even states who cannot afford to meet Obamacare health plan requirements (June 21, John Hayward, "The State of Obamacare," Human Events).

9. Ninety three percent of physicians and all major integrated organizations considered to be models for Accountable Care Organization have said they will not or cannot meet the final CMS rules for ACOs released on March 31, 2011 ( June 19, Review & Outlook, “The Accountable Care Fiasco", Wall Street Journal).

10. A growing chorus of physicians organizations, including the AMA, have expressed opposition to the idea of the Independent Payment Advisory Board (IPAB), whose 15 members would be appointed by the President. (May 8, 2011, Bara Vaida, The IPAB: Will It Change Medicare,” Kaiser Health News; April 20, “The Independent Payment Advisory Board Comes Under Fire,”

Monday, June 20, 2011

Godernment Defined

What is godernment?
It is a form of government.

It is a belief government has all the answers,
to most of society’s common social cancers.

It is the belief government has most of the expertise,
to improve nurturing and care of common disease.

It is the belief government always knows best,
how to apply knowledge with it alone is blest.

It is the belief government holds dominion,
over dissenting and popular widespread opinion.

It is the belief what comes from above,
will prevail when push comes to shove.

It is the belief govenment can forego,
whatever comes from deep down below.

It is the belief that gov and God,
are cut from the same piece of sod.

If you want to see godernment in all its alfresco,
Read the 6/11 WSJ Op-Ed "Accountable Care Fiasco."

Health Reform and Senses of Community

We are a nation of communities, of tens and tens of thousands of ethic, social, business, labor union, neighborhood, regional and other organizations, all of them varied, voluntary, and unique...a brilliant diversity like stars, like a thousand points of light in a broad and peaceful sky.

George Herbert Walker Bush (1924- ), Acceptance speech, 1988

June 20, 2011- I awoke this morning asking why two of the Republican presidential candidates are Mormons – Romney and Huntsman – and why two are Minnesotans – Pawlenty and Bachman.

My answer is that Mormons and Minnesota both have a strong sense of community.

As a religious group, Mormons have created a unified, purposeful, and successful business, social, and community enterprise. They have shown a missionary zeal for the common good can go a long way. Mormons even have a sense of humor, as the present Broadway play, The Book of Mormon, demonstrates.

As for the Minnesotans, they too have a strong sense of community. I lived and practiced in Minnesota for 25 years. I was struck by their traditions of group practice, their organizational abilities with the creation of 34 multinational businesses, and their policy in the Twin Cities of giving 5% of corporate profits to the Arts. Maybe these cultural things sprang from the history of farm collectives, or simply from their survival instinct of huddling together to warm themselves.

President Obama’s instincts are those of a community organizer. That is how he made his name in Chicago. Now he seems to think in terms of the United States as a community to be organized from the top-down, and of the United States as an equal but not pre-eminent member of the world community.

But there are hazards of bringing all communities under the umbrella of one unified community, to be governed from the top down. We are a nation of multiple communities – ethnic, religious, social, business, and professional – each with a specific purpose.

In the case of ObamaCare, the government’s team of policy experts is a community, with similar managerial expertise, and a belief that a restructured health system, guided by comparative effectiveness data and cohesive hospital-physician organizations, are the path to a better health system.

The nation’s physicians are a community too – with a huge capacity for innovation, long periods of training, and a shared professionalism. As a community of professionals, physicians feel government policy makers have ignored their input.

That may be why the level of discontent among practicing physicians is unprecedented, why distrust of government is so high, and why AMA membership is so low. The AMA endorsed the Accountable Care Act, and its provisions, like rules and regulations on physician compliance and individual and state mandates. This endorsement has not played well with the AMA’s constituency of private physicians.

Among communities in a Democracy, mutual respect is essential, and that has been lacking in governmental-physician relationships.

Sunday, June 19, 2011

Health Reform and the Culture Clash: The Corporate Transformation of American Medicine

June 19, 2011 - When you think about what’s happening out there right in front of our nose– government experts telling doctors how to practice, doctors and hospitals being herded into accountable care organizations, young physicians rushing into hospital employment – it’s pretty obvious that the corporate transformation is still on a crash course – and picking up a head of steam.

I should know. I’ve been writing about this transformation for over 30 years. In a 1988 book. And Who Shall Care for the Sick; The Corporate Transformation of Medicine in Minnesota (Media Medicus, 1988), I wrote.

I shall discuss the struggle now going for control of health care. This struggle is mainly between the management of corporations and physicians. It is a struggle for power. To be effective in the marketplace, corporations have to harness physicians to corporate goals, thus creating internal disciple and compliance; to be independent professionals, physicians have to be free to choose what they want for patients. The government, economists, and leaders of physician organizations favor the corporate strategy because it is a way of making physicians behave economically. Health care corporations deny they seek power, saying this power flows from impersonal forces of the market. This may be, but the forces of the market are powerful indeed and are fundamentally changing the way we practice medicine.

The forces of management are winning. More than 50% of doctors are now salaried employees of organizations, mostly hospitals, rather than owning their own practices. And government has set into motion a series of measures – such as accountable care organizations, time-consuming and energy-draining rules and regulations, pre-authorization of imaging procedures, installation of electronic records to document every transaction, no matter how trivial; an Independent Physician Advisory Board - to make doctors comply to management rules, by among other things, regulating how they are to be paid.

The corporation transformation has consequences – a political clash of cultures and ideologies between managers, policy experts, and practicing physicians, an exacerbation of the physician shortage just as demand for medical services is growing; the decline of medicine as an attractive career among the young, ambitious, and entrepreneurial; and, an access problem to physicians with lengthening waiting lines with controls on payment and use of high ticket technologies such as joint replacements, medical devices, and imaging procedures.

In the midst of all of this, there is political paralysis going on in Washington, as Medicare and Medicaid entitlement programs assume center stage as the main contributors to the debt crisis, and two sides exchange insults.

In today’s June 19 New York Times, in an article “Standstill Nation.” Peter Baker asks,

Is this any way to run a country? As it happens, yes. Ideal, it is not. Inspiring, hardly at all. But the factitious, backbiting, finger-pointing, polarizing, partisan, kick-the-can-down-the-road brinksmanship of washing politics these days is. Let’s face it, this is the reality of American government in the modern era. For all the handwringing about how the system is broke, this is the way the system was designed and is now adapted for the digital age.

Democrats and Republicans agree costs must be controlled. Democrats favor a top-down approach with a panel of experts deciding which procedures are cost-effective and which are wasteful. Republicans prefer a bottom-approach empowering consumers to make their own choices with competition between providers to keep costs down. The two approaches intersect at the organizational, or corporate, level.

Baker's description of Washington gridlock leads to other questions: Will Obamacare be repealed or not? If repealed, how many of the current implementations are even reversible? Will the Supreme Court rule the individual mandate or the whole kit-and caboodle unconstitutional?

Then, there’s my question, the most important of all : And who shall care for the sick?

Friday, June 17, 2011

Health Reform: What Long Does It Take to Set Up an ACO and Generate “Shared Savings”?

Big things take time.


June 17, 2011- Setting up Accountable Care Organizations (ACOs) with hospitals and doctors in order to “save” and “share “money for Medicare takes time to develop.

CMS has bet its political clout on ACOs, which it prefers to call “Medicare Shared Savings Programs” as a principle means of salvaging Medicare. The basic idea is that hospitals and doctors, working together, can” save” and “share” money within three years, by coordinating care for a minimum of 5000 Medicare recipients for each ACO. CMS have estimated it will take three years to put ACOs in motion to begin to generate savings. CMS is misguided. Three years is not enough time for such a sweeping concept.

How realistic is this three year goal? Not very, according to hospitals and doctors, including integrated care organizations that have been working on developing ACOS for six years and more.

Eighteen months ago, in January 2010, I wrote the following blog regarding experiences of advanced integrated organizations.

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

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

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

CMS Rules for ACOs

On March 31, 2011, CMS released its long-awaited, much-anticipated rules for implementing ACOs. Hospitals and doctors quickly proclaimed ACOs as DOA (Dead on Apprival) because of a number of factors – the expense of setting up ACOs, complexity and unworkability of the rules, risks of being sued as a monopoly by the Justice Department, and the unrealistic time frame for documenting savings and sharing those savings.

CMS countered by proposing: One, that ACOs would be eligible for “modest savings” with two years, but responsible for losses in year three; Two, that ACOs would be eligible for 1st dollar savings in the 1st year, but responsible for losses all three years.

No deal, said overwhelming numbers of potential ACO participants, including those with early experience in the ACO game.

Their reasons? It takes years, even a decade, to set up and organize an ACO or its fascimile, to recruit primary care doctors, to win specialists over, and to install an electronic record system linking all participants to document savings that CMS would recognize.

Three years to set up, link participants, recruit 5000 Medicare recipients, and dispense shared savings is simply not realistic.

Today I had a taste of how a fledging ACOs might function. Thanks, in small part, to a grant from the Physicians Foundation, the Middlesex hospital system in Middlesex County, Connecticut, has been working for years on an integrated system bring together the various players – the Middlesex Hospital, a salaried primary care network, affiliated clinics, ERs, surgicenters, and center for chronic disease management.

With a relative with newly diagnosed diabetes, I visited a primary care physician. He counseled the patient in some detail about the various ramifications of her disease, ordered the appropriate lab work, and referred her to the system’s chronic disease management center, which evaluates, coordinates, manages five or so major chronic diseases.

There a nutritionist will explain diabetes management further and will recommend a diabetes diet. She, the patient, will then return to the primary care doctor who will prescribe an oral diabetic drug and a beta-blocker.

This approach to chronic disease management has been evolving over a decade. Recently Middlesex installed a system-wide electronic record , in itself at least five years in the making, to help coordinate care. Whether it will help produce shared savings and improve outcomes remains to be seen.

The object lesson is: It takes years to develop workable, flexible, functioning coordinated care system. It cannot be done in three years.

Thursday, June 16, 2011

Health Reform: Power to the States?

During my lifetime, I have lived, practiced, or owned homes in Iowa, Kansas, Missouri, Tennessee, North Carolina, Minnesota, Florida, Massachusetts, and Connecticut. Perhaps that is why I am sensitive to regional variations, diverse cultures, and present health care trends, as exemplified in the states.

One of these trends is the prospect of return of health care power to the states.

• The constitutionality of the individual mandate, now being considered in Atlanta among three judges of appeal courts is a state issue. Does Obamacare exceed the “enumerated powers” of the federal government? Is Obamacare about facilitating commerce among states or is it about imposing taxes? These are not trivial questions, since 26 states have joined in the suit against what they consider to be a Washington power-grab.

• The political movement to issue block grants for Medicaid management to the states so they can determine their own Medicaid programs is a powerful challenge to Obamacare. Should Medicaid recipients beholden to the wishes and the culture of state residents or to the demands of remote elites in Congress and the CMS establishment, who may be far removed from realities in the states?

• The crux of the health care debate is about state versus federal power. The Obama administration feels centralized government has the power to impose mandates and taxes on the states, even if these mandates and taxes threaten individual liberties or state budgets. To a limited extent, the administration has gone along with the states by offered temporary waivers to a handful of states for relief from Obamacare until 2014.

Obamacare is enough to make the Teapots of the Tea Party boil with talk of taxation without representation and "taking back our country". On the other side, the question is. Shall we hang together or hang separately – united we stand, divided we fall - and so forth and so on.

Much of this debate is playing out politically in the presidential campaign, now underway. Mitt Romney, former Massachusetts governor who oversaw so-called Romneycare, said to be the model of Obamacare, is at the center of the state versus federal dispute. Romney’s present position is that each state ought to have the option of developing its own health care system, depending on the wishes of its citizens. If Massachusetts and Vermont want universal coverage or a single-payer system for their citizens, so be it. If a conservative state like Utah, which voted 78% Republican in the last presidental election, embraces market-based approaches, let it be.

Candidate Romney now says he will immediately push for Obamacare repeal should he become President. This, of course, could prove to be administratively awkward since Washington-based Medicare and Medicaid experts prefer an unified approach and since 20% of Americans move each year, often to other states.

Watch the states. That is where the action is. Read Physiciansfoundation. org. The Physicians Foundation represents doctors in state medical societies. These societies closely mirror what practicing physicians think, and they will be held responsible for carrying out Obamacare mandates and rules. A Physicians Foundation survey found 67% had a "somewhat"or "very negative" reaction to the new law, and 93% said the new law will force them to stop seeing or restrict the number of Medicaid patients they see, and 87% said they would close or restrict Medicare patients. Results of an athenahealth and Sermo survey in April 2010 were even more ominous; 79% were pessimistic about the future of medicine, and 66% said they consider dropping out of government programs.

The states are where the greatest resistance to PPACA will be. The heaviest expenses will fall upon the states, not only in caring for 34 million more Medicaid recipients, and probably millions more, but in setting up health exchanges and other machinery necessary to carry out government mandates. The states are waiting to see if the courts will declare PPACA unconstitutional, many are delaying action as long as possible, and a few, like California, are moving forward.

Wednesday, June 15, 2011

Health Reform and Issues of Substance

There is substance – the way things are – and there is smoke and mirrors – the way you want people to think they are or think they will be. To put it another way – there are substantial issues, and there are insubstantial illusions. Or, if you wish, there is political spin –hard realities on the ground versus rising hot air in the stratosphere. President Obama may be right. Things may get better, but for now, substantial conditions beat ethereal projections.

In a June 15, 2011, Real Clear Politics article “Blue Smoke and Mirrors,” Jay Cost frames the Substantial vs. Illusion issue this way.

1. The economy is substantially weaker for Obama than for other previous presidents who won reelection.

2. The deficit is now substantially higher than before.

3. His major domestic reform--Obamacare--is substantially more unpopular.

4. The American people are substantially more pessimistic.

Substantial Health Reform Issues

Among the substantial health reform issues are these.

is how to head off the 29.4% cut in Medicare physician payments scheduled for January 1, 2012. Physicians are now reimbursed at roughly 78 percent of costs under Medicare, and just 70 percent under Medicaid. Result? More and more physicians are opting out of the government programs altogether. As many as a third of doctors do not participate in Medicaid, and 13 percent won't accept Medicare patients. A 2010 poll by IBD/TPP found that 45 percent of physicians would consider leaving their practice or taking early retirement as a result of Obamacare (“Obamacare Spurs Doctor Shortage, “ Newsmax, May 15, 2011). A 29.4% cut would surely exacerbate the doctor shortage, and it could not come as a worse time, with estimated 10.000 baby boomers entering Medicare every day.

TWO is a Congressional Advisory Group recommendation, about to be released that would require pre-approval for Medicare payments for imaging services such as CT and MRI scans and nuclear imaging. These costs grew from $6.5 billion tp $11.7 billion from 2000 to 2009 and are still climbing at 15% each year. These numbers are substantial and will not be easy to reduce since imaging tests are the diagnostic foundation for performing hip and knee replacements and cardiac stents, much sought after by Medicare patients. Obamacare proposes to cut $3 billion out of imaging in the next ten years. As a June 14 , 2011, Kaiser Health News report (Doctors Balk at Proposal to Cut Medicare Use of Imaging,” comments, “ Even before its official release, a a new proposal is sparking a furor among physicians and patient groups. The battle show hard it is to make even small changes in the sprawling program for the the elderly – much less overhaul it.”

To sum up,

With Medicare, it’s hard to change things substantial,

that relate to medical matters that are also financial,

that may involve not having enough physicians available,

to perform procedures doctors and patients consider unassailable.

Where you stand depends on where you stand on matters circumstantial.

Tuesday, June 14, 2011

Health Reform and Alternatives to Obamacare

The main criticism of Obamacare opponents is that they offer no specific alternatives. And even when they do, as Paul Ryan (R-Wisconsin) did in his plan to save Medicare, Democrats blast Republicans as Medicare-destroyers.

In her book, The Truth about Obamacare (Regnery Publishing, Inc, 2010) Sally C. Pipes, president and CEO of the Pacific Research Institute, a refugee from the Canadian health system, and a critic of Obamacare, offers 10 specific alternatives.

1) Promote private ownership with a thriving individual insurance market
- Americans, she asserts, should be free to purchase individual health plans as their private property – just like their savings accounts, retirement portfolios, and life-insurance policies.

2) Make health coverage portable
– Allow workers to carry their own plans from job to job, city to city, and even when they go back to school or take time off from personal or family reasons.

3) Allow individuals and families to buy health insurance with tax-free dollars –
Allow individuals to write off health expenses just like those covered by corporations. Level the tax playing field for all people.

4) Universalize Health Savings Accounts – Allow universal access to HSAs. Couple HSAs with lower-cost high-deductible catastrophic plans. 10 million Americans now possess these plans. Congress should deregulate these plans and allow them to take charge of their own medical care.

5) Allow health insurance to be sold across state lines - Americans can now buy anything else across state lines – why not health insurance? Americans should be able to shop nationwide for health insurance .

6) Pry mandate benefits from health plans – Mandating hair plugs, breast reductions, in vitro fertilizations, and every imaginable alternative treatment costs money, 10.% % in the average state.

7) Implement state lawsuit reform as part of health care reform - 90% of doctors win their cases in court, at the expense of $100,000 per case. Defensive medicine costs Americans an estimated $124 billion a year.

8) Make doctors’ charitable care tax-deductible
- Many doctors would like to offer charitable care, but given the economics of medicine, they can’t.

9) Modernize Medicare – Medicare should be turned into a patient-friendly HSA-like program, rather than paying federal bureaucrats trying to manage every detail. Let every hospital and every doctor post prices, and let consumers decide where to shop.

10) Let the vouchers do the work – Give those outside of Medicare $5000 vouchers and those inside Medicare $15,000 vouchers to decide what is right for them and what health insurance policies to buy.

These 10 reforms, according to Pipes, “would help the United States flip a U-Turn and flee Obamacare with deliberate speed. The alternative for Americans is to remain on the road to serfdom, which has no off-ramp.”

What Pipes is saying is this: switch roles of government and ordinary citizens. Let common sense and self-interests of citizens prevail, and curtail the power of politicians and government bureaucrats.

Health Reform: Obamacare as a Dismal Economic Disease

Economics: The dismal science.

Thomas Carlyle (1795-1881), Latter-Day Pamphlets I

Positive economics is or can be an “objective” science.

Milton Friedman (1912 - 2006 ), Essays in Positive Economics, 1953

June 14. 2011 - Think of The health reform law as a dismal economic disease. It has signs, symptoms, and treatment. To some, its prognosis is dreadful. It is incurable, contagious, and will negatively infect the rest of the economy.

Or you can think of it contributing positively to the economic health of the nation, with more people insured, and more diseases prevented, treated, and cured.

What follows is the negative spin on the health law , with signs and symptoms of an economic disease , as seen by the authors of Why Obamacare is Wrong for America (Broadside, 2011). Its authors are Grace-Marie Turner, president of the Galen Institute; James C. Capretta, a fellow at the Ethics and Public Policy Center and former associate director of the White House Office of Management and Budget (2001-2004), Thomas Miller, resident fellow of the American Enterprise Institute; and Robert Emmet Moffitt, senior fellow at the Heritage Foundation’s Center for Policy Innovation.

Ten Signs and Symptoms of Obamacare as Dismal Economic Disease

1. Higher Costs - Americans will spend average of more than $1000 per person for a family of four if the law hadn’t passed.

2. Tax Increases - Obamacare includes $569 billion in tax increases to fund its subsidies, which will be passed through to consumers as higher drug, devices, and premium costs.

3. Seniors losing coverage and gaining costs - 7 million seniors will lose Medicare Advantage coverage; and seniors’ costs will go up $346 a year in 2011 and by as much as $923 by 2017.

4. Burgeoning bureaucracy - The health law establishes 159 new boards, advisory commissions, and programs, all of which will generate massive reams of bureaucratic red tape.

5. Higher government spending
– According to Richard S. Foster, chief Medicare actuary, the health law will increase national health expenditures by $311 billion between 2010 and 2019.

6. Larger national deficits – The health law starts collecting new and higher taxes in 2010 but provides no benefits until 2014. The real cost will be $2.3 trillion for first full 10 years.

7. 23 million still uninsured – The bill will leave 23 million Americans without insurance by 2019, not even close to the promise of universal coverage.

8. Insurance death spiral - Individual mandate will require younger workers to pay higher premiums to subsidize older workers. If young choose to pay penalties rather than buy expensive premiums, costs will soar for those left in insurance pool.

9. Losing your coverage
- As many as 80 million to 100 million people will have to look for different coverage to meet federal standards, despite repeated promise “you will be able to keep your health plan.”

10. Medicare provider losses - Hospitals, nursing homes, hospices,and doctors will face financial losses, impacting and lessening access to care for Medicare beneficiaries. The health law proposal cuts $575 million out of Medicare funding over the next 10 years. This means health care facilities will be forced to close, and many physicians will stop seeing Medicare patients, retire, or pursue other careers.

In short, I regret to report: Some see Obamacare as a disease dismal, its economic effects mostly negative and abysmal. Others see the health reform law as positive, with more people covered and in better health, primarily fiscal.

Monday, June 13, 2011

Health Reform, Women Physicians, and the Doctor Shortage

June 13, 2011 - A June 12 New York Times Op-Ed by Karen Sibert, MD, an anesthesiologist, is getting a big play in physician blogging circles, as it should.

Doctor Sibert is saying the health system needs doctors so badly that women physicians should step up to the plate and dedicate themselves to their careers, rather than dream of being part-time doctors.

Hers is a well-written piece, full of solid facts and useful arguments,

She writes, for example, that:

• 15 years from now, we’ll be 150,000 doctors short of what we need.

• Decline in doctors’ due to Medicare and Medicaid cuts may drive the young and the bright into more lucrative fields.

• Women received 48% of MD degrees in 2010.

• Women work 4.5 hours less hours each week than men.

• Women dominate in certain residency programs – 53% of Family physicians, 63% of pediatrics, and 80% of ob-gyns.

• You can't replace doctors completely with nurse practitioners, nurse anesthetists, or physician assistants, because it takes a doctor to make critical decisions.

• You can keep more female physicians in the field through tort reform, protecting against Medicare cuts, lightening the bureaucratic paperwork, and setting up childcare centers for them.

The main thrust of her argument, as revealed by her title “Don’t Quit This Day Job,” is that you can’t have your cake and eat it too, in her words, “If you want to be a doctor, be a doctor. You can’t have it all…Patients need doctors to take care of them. Medicine shouldn’t be a part-time interest to be set aside if it becomes inconvenient. It deserves to be a life’s work."

Nobody ever claimed being a doctor would be easy. Congress, by passing laws imposing a cap on the number of physicians in training programs, cutting physician incomes, and piling on more government regulations, simply makes being a doctor – male or female – harder.

Sunday, June 12, 2011

Why Does The Public Distrust Health Reform Law?

June 12, 2011 - In America, distrust of the health reform law is palpable - and measurable.

The latest poll averages, as compiled by Real Clear Politics, indicate the following.

Health Reform Approval

For/Favor, 40.8%, Oppose/Against. 50.5%, Difference, 9.7%

• Health Reform Repeal

Favor Repeal, 50.4% Oppose Repeal, 40.4%, Difference, 9.6%

Why these differences ?

The law may have good intentions. It was sold politically as a national instrument for lowering costs, guaranteeing access, and improving quality.

The problem? The public smells a rat – a rat reeking of “IF’s”and”WHY’s”.

IF the reform law is so good, WHY did the Republicans unanimously oppose it?

IF the law has no flaws, WHY was it rammed through without anybody really understanding, or even reading, its 2801 pages?

IF the health insurers are so bad, WHY did the government reward the plans with 34 million more members, 16 million of whom would go Medicaid rolls?

IF Medicare “as we know it” is such a wonderful thing, WHY did the government find it necessary to gut $575 billion out of Medicare?

IF the plan saves so much money, WHY has the government rewarded 1372 waivers to companies and even states allowing them to opt out of the law?

. IF the ACA is so friendly to businesses, WHY are 30% to 50% of employers saying they will drop coverage to employees when the the reform law takes full effect in 2014?

. IF the ACA is so good for America, WHY are so many well reasoned books like The Truth about Obamacare (Regnery, 2010) and Why Obamacare Is Wrong for America (Broadside, 2011) cropping up?

Adding to Doubts

Adding to all these doubts are costs of the law, estimated to be $2.3 trillion over 10 years from 2014-2024, national debt skyrocketing to $14.5 trillion, growing suspicion of big government, and mounting, perhaps unfounded, fears that we were rocketing down a slippery slope toward “socialized medicine.”

Republicans may have overstated and distorted these doubts, but the doubts are there, and they are part of the “lack of confidence” factor.

A Gallup poll on June 17, 2009, revealed the following in terms of public confidence.

• Physicians 73%

• Health care professors, 62%

• Hospitals 61%

• President Obama, 58%

• Democratic leaders in Congress, 42%

• Drug companies, 40%

• Health plans, 35%

• Republican leaders in Congress, 34%

Hardly a Solid Foundation for Trust

These percentages are hardly a solid foundation for trust in the health reform bill once it passed in March 2010. By June 2011, confidence in Congress is down to 16% and the Obama approval bounce after the Bin Laden killing is gone.

Public confidence has waned more when it has become evident doctors and hospitals are not enthusiastic, even hostile, about health reform regulations, such as those embodied and hidden in Accountable Care Organizations.

Moreover,provisions of the bill keep clashing with harsh realities of increased premium costs, employers dropping millions from coverage, health plans withdrawing from markets, and states being unable to afford new Medicaid burdens and challenging the law’s constitutionality.

Dashed Expectations

The public’s expectations may have been too high and too unrealistic. The public expected health reform would provide affordable access to almost everything. More care would mean better care. High tech care would accompany high touch care.

People did not expect less access. longer waiting lines, and more crowded ERs. That is the situation in Massachusetts, whose 5 year old universal plan was considered a poster child for Obamacare.

Instead, the future of health reform with lower costs and more access seems more uncertain and remote than ever.

Talk of repeal is in the air, and it is becoming clear the future of health reform will hinge on a Supreme Court decision on the constitutionality of the Accountable Care Act, recovery from a dismal recession, and on the November 2012 elections.

Saturday, June 11, 2011

Health Reform and the Economy: Pragmatism Works in Texas

June 11, 2011 – This morning I find myself in a pragmatic frame of mind. I believe what works, works. If there was ever a time for pragmatic realism, that time is now.

Take health reform and the economy. The two are tied closely together. Together they will determine the next presidential election. It will not be one’s ideology that counts. It will be how one reacts to economic news and how the news affects one’s behavior.

Physician and Hospital Pragmatism

Consider physician and hospital economic behaviors. Ideologically, if one believes the health reform law, physicians and hospitals should be paid on the basis of “quality” and evidence thereof, and on their ability to lower costs and produce better outcomes.Yet, according to a just released Merritt Hawkins 2011 review of Physician Recruiting Incentives, this is not the case.

Hospitals are recruiting physicians on the basis of a guaranteed salary plus productivity bonuses , i.e. the number of patients they see or the procedures they perform, not because of the so-called “quality” of care they deliver.

Hospitals and medical groups are paying more for those specialists, who, on average, bring more revenues to hospitals or the group, For example, on average, specialists command these incomes $521,000 for orthopedic surgeon; $532,000 for invasive cardiologists, $453,000 for urologists, $424,000 for gastroenterologists, and $402,000 for radiologists - versus $178,000 for family physicians, $205, 000 for internists, and $217, 000 for hospitalists.

Physicians are pragmatic too. Why would they pick primary care as a career when they can double even triple their income in a specialty and work shorter hours? And why should they join an accountable care organization and be guaranteed a lower income with the threat of being sued for antitrust behavior?

What is “Quality”?

Part of the differences between ideologues and pragmatists hinges not upon money but on the perception of what defines quality.

In The Health Care Blog today, Humphrey Taylor, Chairman of the Harris Poll and Harris Interactive, points out that quality is in minds of the beholder.

Physicians, he says, define quality not just in terms of money or outcomes but with having happy patients. They equate quality with access to new technology, low hassle factors and autonomy, good ancillary services, absence of obstacles to appropriate care, and being part of a strong team.

Policy wonks, on the other hand, focus on the use of evidence-based-medicine, use of practice guidelines, appropriate and inappropriate care. They advocate the use of process measures (beta blockers for heart attack patients), intermediate outcomes measures ( control of blood pressure, A1C, and cholesterol) and “real” outcome measures including the impact of care on mortality, morbidity , disability, and quality of life.

The Economy

Finally, there’s the economy itself. Physicians, like others, tend to gravitate towards cities of over 100,000 in states with robust economies. They shy away from states with high unemployment – like Michigan, Florida, and Illinois – with high malpractice premiums – and move to states like Texas, with low unemployment, low malpractice rates, and high demand for physicians.

Since the recession began Texas, a state with a pragmatic state if mind, has produced 37% of all new jobs in the United States. Richard Fisher, president of the Federal Reserve Bank in Dallas, says this remarkable job growth is due to these pragmatic factors: a business friendly environment, flexible economic policies, small government, no state income tax, no right to work laws, a 30.5% health care growth, and systematic tort reform (editorial, “The Lone Star Jobs Surge, “ Wall Street Journal, June 10, 2010).

Pragmatism, not political ideology, is working in Texas.

Friday, June 10, 2011

The Last Edit

June 10, 2011 - Today I did last edit on my book The Health Reform Maze: Blueprint for Physician Practices. The book should come out in July.

As I write, constitutionality of individual mandate being considered in Atlanta appeals court. No decision yet. Will go eventually to Supreme Court.

Public disapproval of health reform law remains 51% opposed, 40% favorable and has not budged in last year. Majority favor repeal by 51% to 41%.

Hot issues are individual mandate, sharply rising costs, health exchanges, Medicaid burden on states, 30% of employers threatening to drop coverage for employees in 2014, and wave of 1372 waivers to companies most often affiliated with Democrats.

Presidential campaign shaping up. State of economy and health care, esp. Medicare fate, will determine Presidential election.

If Obama vs. Romney, debate on health care should be fascinating.

Thursday, June 9, 2011

Health Reform: The Coming Rationing of Medical Devices

The decision is not whether or not we will ration healthcare, the decision is whether we will ration it with our eyes open.

Donald Berwick, MD, CMS Administrator, Interview about Comparative Effectiveness Research, 2009

While squabbles over the rules for approving new medical devices rarely attract much attention outside the insular world of manufacturers, regulators and medical professions, a fight is brewing that could have a major impact on efforts to control health-care spending.

Merrill Goozner, “Soaring Costs Pinned on Medical Devices, The Fiscal Times, June 7, 2011

June 9, 2011- Scarcely a day passes that I do not hear, see, or read an ad about a new center for joint replacement of knees or hips. Hospitals, medical centers, surgery centers, and orthopedic centers run these ads with increasing frequency.

Clearly these ads are responding to patient demands for joint procedures, to the expertise in providing the replacements, to the growing desire for them in an aging population, and to the promise of more profit in an era of diminishing reimbursements.

Americans want to remain as young as they can as long as they can. And they want to live a pain-free, fully-functional life, which is why 773,000 joint replacements were performed in 2009.

Who can quibble with these demands for a better, pain-free existence?

Medicare can, for it must foot the bill(pardon the pun). Medicare questions whether it makes sense to leave it to government to pay for people left to their own devices.

Which is why, of course,the Accountable Care Act slapped a 2.3 percent excise tax, projected to generate $20 billion over the coming decade, on the medical device industry.

According to government and industry experts, the latest devices – from heart valves and defibrillators to artificial knees and hips – are more expensive than older devices, and marketing surrounding the introduction of new devices drives rising health care costs.

Device industry officials say there are over 8,000 medical device companies in the U.S. Last year they generated about $136 billion in sales and employed over 422,000. To handicap the industry with taxes and regulations, claim device manufacturers, stifles innovation and reduces employment.

Medicare is likely to respond by tightening regulations through the Federal Drug Administration. Down the road, CMS will demand new devices show better value than older devices through comparative effectiveness studies, or else it will not pay.
CMS and the FDA will not use the verboten "R" word, rationing. Instead it will declare, with a semi-scientific, self-righteous, an a so-rational tone in its voice, that it will only pay based on “value-based evidence.”

Meanwhile the industry may go offshore or to Europe to develop its products. If waiting lines grow too long for joint procedures, patients may go abroad for treatment. Among physicians, there will be a movement for balanced billing, meaning patients can pay-out-of-pocket outside of Medicare through a private contract with physicians for a joint replacement or any other procedure should they so desire.

Wednesday, June 8, 2011

Health Reform: A Bandit, Not a Pundit

The essayist…can pull on any sort of shirt, be any sort of person, according to his mood or his subject matter – philosopher, scold, jester, raconteur, confidant, pundit, devil’s advocate, enthusiast.

E. B. White (1899-1965), Essays of E.B. White (1977)

June 8, 2010 - I have a confession to make. I am a health reform news bandit, not a news pundit.

Truth be told, I don’t know where health reform is headed. So I steal from news sources I respect. I list these sources on my web site –, as favorite links.

The Physicians Foundation
– What physicians in state medical societies think.

KevinMD - What a primary care physician thinks.

The Health Care Blog – What pundits think.

WSJ Health Blog – What the WSJ thinks is business news.

Health Leaders Media – What hospital executives think.

Kaiser Health News
– What Kaiser thinks is news of day.

Fierce Health Care – What the health care business world thinks.

Health Affairs Blog – What self-appointed policy makers think.

DJP Update – What former AMA President, Don Palimisano, thinks.

Center for Studying Health System Change – What a D.C. think tank thinks.

ACP Advocate – What the American College of Physicians thinks.

Galen Institute – What a conservative think tank thinks.

New England Journal of Medicine
– What medical academics and government policy-makers think.

Politico – What an overnight political think tank thinks.

Real Clear Politics – What a daily website that publishes both sides of political aisle along with current polls of the day thinks.

A Feel for What I Steal

To give you a feel for what I steal, here are the daily offering of news Kaiser Health News, which considers itself editorially independent.

A Big Day For The Multi-State Challenge To The Health Law (Comment: An Atlanta federal court of appeals will hear oral arguments today on whether to reverse an earlier decision by a Florida judge to overturn the law. It may not matter. Supreme Court will ultimately decide)

• Blue Shield Of California Will Cap Earnings
(Comment: Health plans are getting sensitive to Kathleen Sibelius’s criticism of them as predatory profiteers)

Study: Many Employers Will Cut Back On Health Plans When Overhaul Kicks In (Comment; WSJ reports that as many as 30% of employer covering 78 million people may drop coverage in 2014 as result of Obamacare. Moral: Obamacare has negative consequences,)

• Republican Demands, Democrats' Strategies Emerge In Debt-Ceiling Talks
(Comment: If you’re on Medicare, hold onto your wallets)

• HHS Rule For Health Exchanges Takes Shape
(Comment: legislation in Oregon to create a health insurance exchange was passed by the state House of Representatives and will now go to the governor. This seems to be happening mostly in Blue States)

• Health Law's Independent Payment Board Draws New Opposition
(Comment: Politico reports on the Independent Payment Advisory Board's growing unpopularity. Conservatives and most physician don’t trust an Obama-appointed board dictating their pay.)

• Ryan Medicare Revamp Continues To Be Political Flashpoint
(Comment: This is about demagoguery and cheap shots, although both sides know Medicare “ as we know it” is destined for change. Something must be done. Ryan's plan is a starting point: no plan is not plan at all.)

• Hospitals Want Race, Ethnic Issues Factored Into Readmissions Program
(Comment: This features interview with Donald Berwick, who insists he only has best interests of 100 million covered by Medicare and Medicaid in mind and reducing their costs.)

• Costs, Insurance Company Regulations Can Make Physical Therapy A Pain
(Comment – Physical therapy scams a big source of Medicare and Medicaid fraud and abuse.)

• State Roundup: N.J. Plan Would Cut Medicaid By $500 Million
(Comment: Huge costs of Obama plan on state Medicaid costs are a central part of health reform debate. States insist they should be allowed to develop their own innovative approaches)

Tuesday, June 7, 2011

Health Reform, ACOs, Seldom is Heard an Encouraging Word

Simple solutions seldom are.

Alfred North Whitehead, 1861-1847

June 7, 2011 - To the Obama administration, ACOs seem simple. You reward hospitals and doctors to bond together to save money on Medicare patients, and hospitals and doctors share the savings.

But ACOs rules, just released, are not so simple. The proposed rules tie together quality measurements and financial rewards. ACOs must report quantitative results on 65 quality measures, grouped into 5 categories – patient and caregiver experiences, care coordination, patient safety, preventive health, health of frail elderly populations – all as defined by CMS, of course.

For hospitals and doctors, these and other rules make for an unpredictable bureaucratic nightmare. Caregivers desist and resist forming ACOs. For good reasons. As I observed in a June 3 medinnovation blog “Why Accountable Care Organizations May Flounder and Fail.”

Why Accountable Care Organizations are destined to fail, and may not even get off the ground, is no mystery to me. Why would hospitals and physicians join together to form an organization that requires $11 million to $26 million to form (AHA estimate); that demands an inordinate amount of time, trouble, and grief to negotiate; that is designed, even guaranteed, to decrease reimbursements of hospitals and doctors; that hands over the reins of dispensing “savings” to your competitors and the government, reimbursements CMS may choose to reduce in the future; that subjects you to the risk of being sued by the Department of Justice for monopoly behavior; that requires you to be accountable financially for the behavior and complications of populations of patients before, during, and after hospitalization over whom you have little control; that 94% of members of the Medical Group Association of 400 integrated health organizations, supposedly ideal candidates for ACOs, have said they will choose not to join. Hospitals, doctors, and leaders of integrated health organizations are not dimwitted lemmings anxious to jump off the ACO cliff into an unknown abyss.”

Seldom have health leaders reacted so furiously and swiftly to a CMS proposal.

In a June 2 New England Journal of Medicine perspective piece, “Spending to Save – ACOs and the Shared Saving Program, “ Paul Ginsburg, PhD, of the Center for Studying Health System Changes and the National Institute for Health Care Reform, remarks,

“Clearly, much is at stake. Medicare has the potential to push health care delivery in a new direction…Many would-be ACOs probably aren’t ready for prime time..getting too few participants is a risk, and CMS clearly already recognizes that substantial changes are needed. Sometimes in Washington you only get one chance.”

Let us hope Washington seizes its last chance to change. Seldom have so few at the federal level sought to dictate the tune for so many on the domestic home front. CMS, by simply offering an encouraging word by backing off from its unworkable rules or redefining them, could further health reform. Thus far, for most caregivers, of health reform, it might be said: "Home, home on the range, where seldom is heard an encouraging word, and the clouds are cloudy all day."

Health Reform: Visit Physicianfoundations.Org to Understand How Private Practicing Physicians View Health Reform

I encourage you to visit the Physicians Foundation web site –

The web site tells you objectively, based on broad national surveys of hundreds of thousands of doctors, how physicians feel about reform and gives you information on what they doing to improve health care. Links are provided to give you immediate access to news and information being presented.

Among the highlights of the web site are:

An announcement of its White Paper: “A Roadmap for Physicians to Health Care Reform”

It examines the provisions of the ACA and how these legislative changes will directly impact their practice of medicine. It provides physicians with an in-depth perspective on issues influencing current reform efforts as well as the major legislative changes that hold the most significance, such as changes in payment systems, quality reporting, shared savings programs and the changes reshaping the private health insurance market. The health reform law, the Affordable Care Act, has created angst, anxiety, and uncertainty among physicians.

Physicians Foundation Highlighted in Minnesota Public Radio

The Physicians Foundation’s Health Reform and the Decline of Physician Private Practice research was noted in a story on how health care reform is leading to changes in the health care market and more specifically, the decline of private practice physicians. Foundation board member and family physician, Dr. Ripley Hollister, is quoted. The decline in private practice should cause concern, for these are the frontline physicians who take care of most Americans.

Las Vegas Review-Journal Features Foundation Research

The Las Vegas Review-Journal published an article on the Foundation’s Health Reform and the Decline of Physician Private Practice research, reiterating that the traditional model of private practice is no longer tenable, leading to a physician workforce that is increasingly diverse and much less homogenous in terms of practice style.

The Physicians Foundation Awards $1 Million Grant to Health Leads

The Physicians Foundation announces it has awarded a $1 million dollar grant to Health Leads, an organization devoted to helping vulnerable families by arranging for college volunteers to partner with physicians in hospitals across the country. Physicians Foundation Vice President, Dr. Walker Ray, and Rebecca Onie, Health Leads Co-founder and Chief Executive Officer, are quoted. This is an important development – not only does it expand access to current community health care resources and plug a hole in the social safety net but it trains college volunteers for careers in health care.

Proposed Regulations and Guidance for Accountable Care Organizations Released

On March 31, 2011, The Centers for Medicare and Medicaid Services released proposed regulations and guidance for Accountable Care Organizations. There is a sixty day comment period before the regulations are finalized with a scheduled implementation date of January 1, 2012. The aim of Accountable Care Organizations is to align hospitals and doctors in organizations to care for populations of Medicare populations in a coordinated, cost-effective ways.

Nation's Frontline Physicians Unhappy With Health Care Reform Measures

Troubling new research indicates health care reform will put increased strain on doctors and their patients; amplify national doctor shortage. These are the conclusions of the Physicians Foundation based on two broad national surveys – one of over 300,000 primary care physicians, the other of over 40,000 doctors in various specialties – completed in 2008 and 2010.

Washington Report

Here The Physicians Foundation shares the Washington Report, written by long-time friend to physicians, Lee Stillwell. Earlier this year, the Foundation engaged Mr. Stillwell to monitor and provide regular updates to the Foundation’s board on the health care reform debates in Washington DC. This is an insider report on how political developments inside D.C. are likely to impact doctors, patients, and the health system as a whole.

Monday, June 6, 2011

Medicare “As We Know It” Must Be Changed, Or Else

June 6, 2011 - Medicine “as we know it” must be changed, or it will go bankrupt and possibly bankrupt the nation.

The Obama administration is already transforming Medicare by promising to cut $575 billion out of it over the next ten years by cutting out fraud and abuse, ending Medicare Advantage plans for 11 million seniors, and lowering doctor and hospital payments to below those of Medicaid by 2019.

Below are two comments on why Medicare must change.

One, Robert Samuelson,”The End of Medicare As We Know It,” Columnist , Newsweek and Washington Post, June 6, 2011

WASHINGTON -- Almost everyone agrees that America's health care system has the incentives all wrong. Under the fee-for-service system, doctors and hospitals get paid for doing more, even if added tests, operations and procedures have little chance of improving patients' health. So what happens when someone proposes that we alter the incentives to reward better care, not more care? Well, Rep. Paul Ryan and Republicans found out. No surprise: Democrats slammed them for "ending Medicare as we know it."

This predictably partisan reaction -- preying upon the anxieties of retirees -- must depress anyone who cares about the country's future. It is only a slight exaggeration to say that unless we end Medicare "as we know it," America "as we know it" will end. Spiraling health spending is the crux of our federal budget problem. In 1965 -- the year Congress created Medicare and Medicaid -- health spending was 2.6 percent of the budget. In 2010, it was 26.5 percent. The Obama administration estimates it will be 30.3 percent in 2016. By contrast, defense spending is about 20 percent; scientific research and development is 4 percent.

Uncontrolled health spending isn't simply crowding out other government programs; it's also dampening overall living standards. Health economists Michael Chernew, Richard Hirth and David Cutler recently reported that higher health costs consumed 35.7 percent of the increase in per capita income from 1999 to 2007. They also project, that under reasonable assumptions, it could absorb half or more of the gain between now and 2083.

Ryan proposes to change that. Beginning in 2022, new (not existing) Medicare beneficiaries would receive a voucher, valued initially at about $8,000. The theory is simple. Suddenly empowered, Medicare beneficiaries would shop for lowest-cost, highest-quality insurance plans providing a required package of benefits. The health-care delivery system would be forced to restructure by reducing costs and improving quality. Doctors, hospitals and clinics would form networks; there would be more "coordination" of care, helped by more investment in information technology; better use of deductible and co-payments would reduce unnecessary trips to doctors' offices or clinics.

It's shock therapy. Would it work?

Two, Jane Orient, MD, “Pushing Granny off The Cliff, “ Executive Director of the Association of American Physicians and Surgeons,

The latest Mediscare ad shows Congressman Paul Ryan (R-Wis.) pushing an old woman in a wheelchair off a cliff. The Republicans are allegedly killing “Medicare as we know it.” But this is a diversion from the real question: What will “healthcare reform” or ObamaCare do to Granny? Democrats may hope to keep Americans from figuring that out until after the 2012 election.

The Medicare issue is demagogued to gain votes in every electoral cycle. And hardly any politicians are telling the whole story.

The ad has one element of truth. There is indeed a financial cliff, and Granny is heading over it—along with the rest of us. Actually, the cliff is more like the edge of a deep canyon of reckless deficit spending and a crippled economy. The canyon has been growing deeper and deeper, at an accelerating rate. The edge is coming closer and closer. Soon Granny won’t even need a push.

Paul Ryan is not responsible for it. The excavation was mandated some 75 years ago, when Social Security was originally set up, and the problem was greatly magnified in 1965, with the passage of the amendments that created Medicare and Medicaid. The fact is that Social Security and Medicare were never adequately funded. They were structured as Ponzi schemes from the beginning.

Health Reform and the Great Unmentionable : Lack of Patient Compliance as One Cause of Poor Outcomes

The typical attempt to solve a social ill focuses on giving people information, or it tries to motivate people through fear. But these strategies tend to fail…The more important and deeply rooted the behavior, the less impact information has the more people close their minds to messages that scare them.

Tina Rosenberg, Join the Club: How Peer Pressure Can Transform the World, W.W. Norton and Company, 2011

June 6, 2011 - U.S. health system critics and health reform zealots often close their minds to a major cause of poor outcomes – lack of patient compliance. Instead , they attribute poor outcomes to lack of universal coverage, socioeconomic distress, or the profit-seeking medical industrial complex.

To say bad outcomes stems from bad behavior to cultural and peer conformity is unmentionable and therefore unspeakable because patients are sacred. Criticism of patients as a source of bad results is off-limits. It is viewed as bad politics. These are potential voters you are criticizing.

Health professionals and the capitalistic system in which they practice, not patients or population factors, are said to be responsible for the bad health of the nation, even though abundant evidence exists that other things – life style, poverty, income differences, inferior education, lack of family cohesion, violence in the streets and homes, clean water, adequate energy sources, culture, and simply following the crowd – are more responsible (1, 2).

The “Social Cure”

In her new book, Join the Club, How Peer Pressure Can Transform the Word (3), Tina Rosenberg, a Pulitzer-prize winning author , does us a favor by reminding us that patient behavior, dictated by the culture in which they live and their desire for social acceptance by peers, plays just as great a role as most other factors combined . Rosenberg reminds us, again and again, that the “social cure” – people responding positively to peer pressure and new social norms – may be more important than health reform itself.

No amount of information she asserts, or warnings from government expert or from doctors “can budge us when we refuse to be budged…We often lie to others about our bad behavior, but the more interesting and powerful excuses come when we lie to ourselves.” People do not like to be lectured to about their health. They prefer to listen to their own inner demons, no matter what the consequences, To them, it is short-term gratification, not long-term consequences, that count.

Patient Non-Compliance

In the paragraph that follows, she gives these examples of what she is talking about.

“Take, for example, patient adherence – failure to carry out a doctor’s orders. Poor patient adherence is a serious problem; dozens of studies have shown this. Only a fourth of the people on blood-pressure drugs in one study took their pills correctly. Only 13 percent of diabetes patients taking certain drugs complied with their regimens for a year. Three-quarter of patients in a study did not keep follow-up appointments and 50 percent of patients with chronic illnesses dropped out of a treatment within a year.”

Failure of Alternative Approaches

Alternative approaches have been tried to help patients comply – counseling, group therapy of patients with common diseases, patient information brochures, electronic beeping pillboxes, automated –reminder phone calls, DOTS (Directly Observed Treatment, Short-Course) by loved ones, a nurse, or a community worker) – may work temporarily but in the long-term none of these approaches can get people to take their pills more than half the time.

Innovative "social Cure" Programs

The point of Rosenberg’s book is this. People do not respond to what authorities or doctors tell them to do, but to what their peers approve of or what they do. Creating innovative peer groups to respond to health problems, whether these groups be similar to alcoholics anonymous, to maverick organizations persuading teenagers it is manipulative tobacco companies not adult do-gooders that are trying to get them to stop smoking, peers telling gays and HIV-positive individuals that condom use is a good thing – creates positive social change and the “social cures.” These programs , she says, are what we ought to be concentrating upon.

Summing Up

In summary, the health of society may depend more on social and peer conformity than its national health system. People will do what they want to do and what they think pleases their peers rather than following the advice or warnings of harm from health experts or doctors.


1. L. Sagan, The Health of Nations: The Cause of Sickness and Well-Being, Basic Books, 1987.

2. D. Satcher, and R. Pamies, Multicultural Medicine and Health Differences, MacGraw Hill, 2006.

3. T. Rosenberg, Join the Club: How Peer Pressure Can Transform the World, W, W. Norton and Company, 2011.