Wednesday, August 31, 2011

Will Silicon Valley and the Social Media Improve the Economy and Obamacare - A Prose Poem with References

A bunch of venture capitalists are whooping it up in Silicon Valley Salons, with talk of IPOs and unprecedented wealth.

"In Silicon Valley, The Night is Still Young, Despite Investor Fears, Start-Up Money Flows"(NYT, August 21).

"Kleiner Plays Catch-Up: Venture Capitalists Who Jumped on First Internet Wave Get the Feeling Again"(WSJ, August 27).

In San Fran, backers of The Health Blog claim the Health 2.0 Wave will save Obamacare by empowering consumers to find and to do the right thing (

A half continent away, the Mayo Clinic is bent on using the Net to recruit a scad of 400 to study SCAD (Spontaneous Coronary Artery Dissection) – "When Patients Band Together-Using Social Networks to Spur Research for Rare Disease; Mayo Clinic Signs On"(WSJ, August 30).

In New Hampshire, KevinMd, the nation’s leading physician Blogger proclaims himself "The Social Media’s leading Physician Voice" (

Back in California, Steve Jobs – inventor of IPhone, IPad, IPod, and ITunes – resigns and the world realizes real jobs come from IT sector – not Green Jobs, Wind, or Sun or High Speed Trains- and the Washington Post declares never has one turtlenecked man created so many jobs for so many.

But still the world wonders – where will the Steve Jobs of the future, entrepreneurs of fertile imagination, come from, who will produce the jobs we need so badly, who will strip away those regulations that stand in the way, and what role will the social media play?

Will the digitization of medicine improve Obamacare? Will the Internet and mobile devices be the Holy Grail and OSHA (Our Savior Has Arrived) of Health Reform? By connecting everybody with everybody, will these digital devices empower everybody?

Or will the social media simply bypass the medical establishment, corporations, and government, so individuals can fend for themselves? Will, as Charlene Li and Josh Bernoff of Forrester Research, say in Groundswell (Harvard University Press, 2008), social technologies become “global, unstoppable, and ever growing and reflect an insatiable desire to connect, take charge of their own experience, and get what they need – information, support , ideas, products, and bargaining power, from each other.”

Or will health IT, the Internet and its stepchild, the social media, trigger an unprecedented government boondoggle, a question raised in my book The Health Care Maze (Greenbranch Publishing, 2011).

From doctors re: electronic health records, I keep hearing this constant refrain: EHRS are too expensive to maintain, take too much time the staff to train, from patients does attention drain, time required to enter data is inane, doctors no longer listen patients complain, over privacy government now has free rein, as communicative tools EHRs are inhumane, gives the bureaucracy too much coercion over the doctor domain.

Tuesday, August 30, 2011

Reform Thoughts After Hurricane Irene

I’m the man they call Sudden Death and General Desolation! Sired by a hurricane, dam’d by an earthquake.

Mark Twain (1835-1910)

August 30, 2011 – It’s three days since I last wrote. I reside on the Connecticut shore. My wife and I evacuated to escape Hurricane Irene. Power outages meant no access to the Net.

But hurricanes, when preceded by an earthquake, concentrate the mind. The stagnating economy, mounting national debt, and growing concern over costs and consequences of Obamacare contribute to my sense of general desolation.

Before we evacuated and and perhaps because of the release of my book The Health Reform Maze, I was asked by two national organizations to: one, write a piece on why doctors resist adopting electronic health records and why health costs are rising; two, to give a talk before a national physician organization to give an “objective appraisal” of the state of Obamacare.

Doctors stay away from EHRs mainly because of costs, negative returns on investment, uselessness for communicating with patients, colleagues, and hospitals; and lack of evidence as a tool for improving care. More than anything , those who design EHRs have a management rather than a practice perspective.

As for Obamacare’s costs, they are just beginning to come into focus. Those who wrote the law envisioned it as a powerful way of reducing costs, widening access, keeping your health plan, and improving care. So far, it has done none of these things. In its first two years, costs are up 10% to 12%, access is down and narrowing, people are losing health plans and doctors, and many people, especially physicians, believe the health law will cause care to deteriorate.
A study just released in Wisconsin gives a sharp sense of the general state of affairs for Obamacare.

According to Chris Jacobs, health care analyst for the Republican National Committee, admittedly a biased source, a report, the governor’s office in Wisconsin.

• 150,000 individuals in Wisconsin will lose their current coverage to move to the government-regulated Exchanges. Another 100,000 individuals will lose access to employer-sponsored coverage, because the firms they work for will decide to drop coverage instead.

• Nearly two in five (38%) participants in Wisconsin’s individual market will be forced to buy richer coverage than they have now, due to the new mandates and insurance restrictions included in Obamacare.

• Government mandates will raise individual market premiums for more than four in five participants – more than 41% of participants face premium increases of more than 50% before federal insurance subsidies are applied.

• Even after federal insurance subsidies are applied, 59% of individual market participants will pay more – an average of nearly 31% more – for their coverage, so that a smaller minority can pay less. Costs in the individual market for Wisconsin residents aged 19-29 will go up 34%, so that costs for residents aged 55-64 can go down by $31, or a mere 1%.

• Wisconsin’s more than 5.5 million residents will pay higher federal taxes – on their drugs, income, and insurance premiums, to name but a few examples – so that only about 220,000 newly insured will receive taxpayer-financed insurance under Obamacare.

• 340,000 individuals in Wisconsin will obtain coverage under Obamacare, but that if the individual mandate were repealed (or struck down as unconstitutional), coverage would only increase by 60,000. In other words, nearly 300,000 Wisconsin residents will obtain health coverage not because they want to purchase it, but because the federal government is forcing them to do so.

A Democrat Governor commissioned the report last year, and Jonathan Gruber, a consultant for Obama completed the report. If the report for Wisconsin applies to the rest of the U.S., it has ominous implications for Obamacare and will make it difficult for Democrats to defend the law leading up to the November 2012 election.

Saturday, August 27, 2011

Medicine’s Leadership Crisis

Leadership and learning are indispensable to each other.

John Fitzgerald Kennedy(1917-1963), Remarks prepared for delivery at the Trade Center in Dallas, November 22, 1963

August 27, 2011
– This message will be brief. We have just received notice to evacuate our Old Saybrook home, which is 13 feet above sea level. Perhaps this is fitting. I was going to write a blog on the evacuation of medical leadership .

American medicine faces a leadership vacuum, and we must learn to deal with it.
Some members of the House of Delegates are openly revolting against the AMA’s support of Obamacare and its individual mandate. The AMA is hemorrhaging membership. Only 15% of doctors belong to the AMA.

Doctors responding to a 2010 Physician Foundation survey on health reform mailed to 40,000 doctors in active practice indicated widespread discontent: 86% felt they had not been adequately consulted on health reform, 56% said quality of care would decline under reform, 93% said reform would compel them to close or significantly restrict their practice to Medicaid patients and 87% said the same for Medicare recipients, 80% surveyed said reform would result in the erosion of traditional, independent practice.

American medicine is adrift. It seeks leaders to lead them out of the reform abyss. But medical leadership candidates are split. Some favor a resurrection of primary care, focusing on Medical Homes and an overturning of the Relative Value Update Committee. Others say we ought to repeal Obamacare altogether, while others say we ought to defund and dismantle it piece by piece. Young doctors seek refuge in highly paid specialties and hospital employment, as older physicians enter concierge practices.

This drift is also taking place at the national political level. You hear frequent complaints about the lack of Presidential and Congressional leadership. Only one thing seems clear. This Center Right country is moving further right with 73% of people now saying they are conservative.

Given this trend, it seems to me Medical leaders ought to prepare us for more market driven solutions: cash-only and concierge practices, health savings accounts with high deductibles, more freedom of choice among patients and doctors, shopping for plans across state lines, possible block grants for Medicaid and vouchers for Medicare, and private contracting between patients and doctors outside of Medicare and other third parties. These may be some of the alternatives if the individual mandate or Obamacare itself are declared unconstitutional.

It is more likely, however, the eventual system with be a blend of government-driven and market drive health care. Whatever transpires, physician leaders should be aware physicians have great leverage in defining the final product, for they must deliver the care. We must learn to adapt to the new realities.

Friday, August 26, 2011

Up Proctoscope!

There is no such thing as a free lunch.

Attributed to Milton Friedman (1912-2006)/b>

August 25, 2011 - When I think of colonoscopies, I think of movies starring Clark Gable, Burt Lancaster, and Sean Connery, in which the submarine captain shouts “Up Periscope!” He wants to rise the periscope to take look around to see what dangers lurk on the horizon.

With colonoscopies, doctors seek to rise up their instrument up the colon to visualize what dangers lurk inside - a polyp, a cancer, an inflammatory disease, a blood vessel anomaly. They bring with them their flexible colonoscope bearing cameras to document what they see, instruments to snip off polyps, and biopsy tools.

Mainly they seek to nip in the bud early colorectal cancers, which, when they progress, kill more than 50,000 Americans each year. Health authorities advise routine colonoscopies after age 50. Colonoscopists may also perform them to detect sources of positive occult blood tests, gastrointestinal hemorrhage, or iron deficiency anemias.

In the interest of prevention, the Patient Protection and Affordability Act (PPACA), Obamacare, pays for “free” colonoscopy screening. Many consider these free colonoscopy screenings as a truly commendable benefit of the new health reform law, as indeed it may be.

As with any “free” government benefit, however, there is a catch.

Colonoscopists find a lesion, the colonoscopy may not turn out to be “free.”

As Kaiser Health News reported on April 25, 2011, “Under Health Law, colonoscopies Are Free, But It Doesn’t Always Work That Way,”colonoscopists find a polyp in 25% of men and 15% of women, and many insurers charge for removal and biopsy of polyps and other lesions. These charges produce financial “post-procedural shock,” meaning what was thought to be "free" wans't. Even Medicare charges patients a copay of $186 plus 20% of the doctor’s fee. As proctoscopies have morphed into sigmoidscopies and into flexible colonoscopies, and as procedures have morphed into therapies, the concept of a “free lunch” is being challenged.

Tweet: Many insurers, including Medicare, are charging for therapeutic measures found in health reform "free" colonoscopies.

Thursday, August 25, 2011

Cash-Only Medicine

Market-competition is the only form of organization which can afford a large measure of freedom to the individual.

Frank Hyneman Knight (1885-1974), Freedom and Reform (1947)

August 24, 2011 - One function of this blog is to focus attention to little known or under-appreciated phenomena is medical practices.

Here I shall talk briefly on cash-only practices.

The news media and government officials tend to be preoccupied with third party and entitlement programs, but cash-only or direct pay practices are proliferating right under their noses.

Cash-medicine is not new. It is well established in such fields as plastic surgery, Lasik eye corrections, most cosmetic treatments, dentistry, alternative medicine, Botox injections, laser applications, and any number of elective procedures.

An Urban Institute study indicates Baby Boomers spend $3300 a year for out-of-pocket expenses, and this will grow to $7800 by 2014. Medicare recipients spend roughly 20% for care outside the system. All in all, according to, there are 50,000 medical procedures available on a cash-only basis.

What has changed is that physicians are rapidly converting to cash-only practices to escape third party payments. About 1500 primary care practices across the country have changed to cash-only or direct pay. A similar number have converted to concierge medicine, where patients pay $1500 or so for the privileges of paying cash, being seen 24/7, given help navigating the system.

Walk-in, emergency, and retail clinics are quickly gaining traction, as employers and government raise deductibles and employers shift costs to employees.

Why the growing interest in cash-only practices among physicians?

One, cutting out third parties lowers need for staff by as much as 50%. Practice overhead nosedives.

Two, billing is simple, straightforward and understandable to doctors and patients. It is less expensive to administer, and reduces accounts receivable to near zero.

Three, health care spending costs to the system are lower by 50% to 75% or more. No back office processing help and code interpretation is needed.

Four, health savings accounts with high deductibles promotes out-of-pocket expenditures and price negotiation among patients.

Five, doctors in cash-only and concierge practices say cash-only strengthens the doctor-patient relationship because of up-front understandings and lower fees.

Six, doctors in these new practices claim most of their clients are uninsured and can afford lower fees.

Seven, doctors can forego the sometimes humiliating experience of having to beg or negotiate to be paid to perform for doing a procedure.

This is not to say that cash-only practices lack controversy. Buyers must be aware.

They may be abused by the occasional unscrupulous practitioners.

But when the terms for engagement are clear cut, such as in the national network of Simplecare, which charges from $50 for a brief visit (10 minutes) to $300 for an extensive visit (60 minutes or more), misunderstandings are rare.

Cash-only practices evoke moral outrage among those who believe all health care provided for “free” by government and is a moral imperative for a civilized society.

Still, in a free society, many people want what they want when they want it, and they are willing to pay for it if they consider the terms to be right. For that privilege, the market has a place in health reform.

Wednesday, August 24, 2011

What Happens When 34 Million More Join Medicaid Ranks in 2014?

It’s harder to figure out how to save money than it is to create programs and spend money. Politically, the idea of a free lunch has enormous appeal.

Former Republican Senator, John Danforth ,in Kaiser Health News Interview, August 23, 2011

August 24, 2011 - What will happen in 2014 when Medicare begins covering 34 million uninsured, and probably millions more as employers drop coverage?

Will costs go up? Will states be able to absorb new financial burdens? Will there be enough doctors to care for them? Will emergency room loads go up or down? Will hospitals prosper or fail? Will the health of the newly insured improve?

These are unanswered and unanswerable questions at present, but an article in the August 25 New England Journal of Medicine ("The Effects of Medicaid Coverage-Learning form the Oregon Experiment"), based on a double blind study of 10,000 Oregonians, gives important clues. The article, by two PhDs at Harvard and MIT, gives yields these probabilities of enhanced Medicaid coverage.


• Use of outpatient care, up 35%

• Use of prescription drugs, up 15%

• Hospital admissions up 30%

• Total health expenditures, up 25%

• Chances people borrowing money, or skipping payments to pay health bills, down 40%

• Chances bills will be sent to collection agency, down 25%

• Odds Medicaid enrollees will report they in good or excellent health, up 25%

• Likelihood of screening positive for depression, down 25%

• Likelihood of reporting they are “happy” or “very happy,”up 30%

• Objective evidence of physical health improvement, no data available.

In summary, health costs and health care use will go up, Medicaid recipients will be less depressed, the happy days of a free lunch will arrive, and the sad days of government overspending will continue.

Tweet: From Oregon double blind study of Medicaid coverage of uninsured comes evidence costs and happiness will go up along with deficits.

Tuesday, August 23, 2011

Is Obamacare Dead?

August 23, 2011 - Since the Atlanta appeals court issued its 2:1 decision declaring the individual mandate unconstitutional, rumors have been circulating among wishful conservatives that Obamacare is dead or dying.

This reminds me of the reply of humorist Dorothy Parker when told of President Calvin Coolidge’s death, “How can they tell?”

I don’t think Obamacare is dead, or even near death. President Obama and Democrats are resourceful. As long as the President has the Bully Pulpit, Obamacare will live and kick.

Obama says he likes the term “Obamacare” because it shows he cares. Here he is artfully playing the compassionate card, a powerful weapon in any political battle.

It’s 14 months until the election, a lifetime in politics. Until then word of the death of Obamacare is been greatly exaggerated as Mark Twain said when news of his death was making the rounds.

In any event, here are a few reasons why senior writer Conn Carroll, of the conservative Washington Examiner (“Obamacare Is Already On Its Deathbed,” August 11 edition) says Obamacare is near death.

When the United States Supreme Court examines the individual-mandate provision of the Affordable Care Act sometime next spring, it will undoubtedly give great weight to the text of the United States Constitution and relevant Commerce Clause case law. “

“Obamacare is already a very sick patient whose symptoms will inevitably require major action by Congress. A Supreme Court decision invalidating some, or all, of the law would only hasten the inevitable.”

“The signs that Obamacare was never long for this world began to appear soon after the bill became law last spring. Reports began leaking about large employers securing waivers from the Department of Health and Human Services…Almost 1,500 waivers have been granted since then, covering more than 3.2 million Americans.”

“Obamacare's next blow came in December when Congress needed money to prevent Medicare reimbursement rates for doctors from falling by almost 30 percent.”

“Earlier versions of Obamacare had included a permanent fix for the doctor reimbursement issue, but the provision was stricken from the final bill because Democrats were unwilling to reduce spending elsewhere in the federal budget in order to pay for it.”

“The $19 billion Congress used to pay for the one-year fix in December came from increased penalties on consumers whose eligibility for Obamacare health insurance subsidies decreases midyear because of income fluctuations.”

“Then in May this year, Congress increased the Obamacare health exchange subsidy penalties by another $19 billion. This time Congress had to pay for the repeal of the law's 1099 provision, which would have required small-business owners to file tax-reporting documents for almost all of their vendors.”

“Fast-forward to Aug. 12, when the 11th Circuit Court of Appeals found Obamacare's individual mandate unconstitutional. That same day, the Treasury Department issued new regulations rendering millions of Americans ineligible for health insurance subsidies based on a technical definition of ‘affordable.’ "

“And we haven't even touched the inevitable controversy and litigation that will come when the Independent Payment Advisory Board begins making cuts to Medicare and refusing to reimburse providers for selected procedures.”

“Obamacare has never been popular. It debuted with a barely 50 percent favorable rating, which sunk to the low 40s by the time it passed, and stands in the high 30s today.”

“The law is unmanageable, unsustainable, unpopular and, according to the 11th Circuit, unconstitutional. If the justices on the Supreme Court have any sense of mercy, they will officially put the law out of its misery and invalidate the entire act.”

Whatever one thinks of Obamacare, it is not an animal to be put out of misery. Instead it is a political act concocted by humans to perpetuate their historical legacy. Let it twist in the political winds until November 2012.

Monday, August 22, 2011

Individual Mandate: Will Obamacare and Obama Survive the Courts?

The rulings so far suggest that the rest of the law would remain standing even if the mandate was struck down – only one district judge has ruled that the whole law would have to be declared unconstitutional.

Phillip M. Boffey, “Will Health Care Reform Survive the Courts? New York Times, August 21, 2011

August 22, 2011 - Here are the District Court and Court of Repeals rulings so far:


1) District Court of Eastern Michigan
2) District Court of District of Columbia
3 District Court of Western Virginia
4) Court of Appeals of Sixth District

Struck Down

1) District Court of Eastern Virginia
2) District Court ofNorthern Florida
3) Appeals Court of Atlanta

Courts to Go

1)Court of Appeals of District of Columbia Circuit
2)Court of Appeals of Fourth Circuit
3)Supreme Court

Summary: 4 up, 3 down, 3 to go, including the big one, the Supreme Court, where a 5-4 down decision against is deemed likely.

Will Obamacare and Obama himself survive if the Supreme Court rules the individual mandate unconstitutional and the rest of the law operative? No one knows, but odds are the law would not function well without the individual mandate, and Obama’s election would be imperiled.

Sunday, August 21, 2011

Medical Malpractice Is about Physician Jobs

Nearly 31% of the new Texas jobs are in health care, many of which are no doubt the product of federal entitlements that go to every state. But the state is also making progress filling in historical access gaps in west and south Texas and the panhandle, where Mr. Perry's 2003 malpractice caps have led to an influx of doctors, especially high-risk specialists. The Texas Public Policy Foundation estimates that the state has netted 26,000 new physicians in the wake of reform, most from out of state.

Review & Outlook, “The Texas Job Panic,” Wall Street Journal, August 11, 2100

August 21, 2011 - The job outlook for physicians differs from that of the general population. Because physicians are in short supply, they have no problem finding jobs, high paying ones at that, when you compare their incomes to the rest of society. There are more available jobs than physicians.

This inverse job situation becomes critical when you consider the impending physician access crisis. The U.S. is already short 50,000 physicians, and the American Association of Medical Colleges estimates this shortage will grow to 150,000 by 2020.

The shortage could not come at a worse time. The shortage is growing just when demand for physicians’ service is peaking, as 78 million baby boomers started entering Medicare in 2011, and the health reform law starts covering at least 32 million more Medicaid recipients in 2014.

What are the states and government to do about this inevitable access crisis? The answers are multiple and legendary – more community health clinics, more nurse practitioners and physician assistants, more making caring for Medicare and Medicaid patients a condition for medical licensure, more easing up on the entry of foreign trained physicians, more creating more medical schools emphasizing primary care, more offering debt-free medical educations to students willing to serve in physician-short areas. These things take time, and so far, more has been less.

One thing seldom mentioned for attracting more doctors is national and state tort reform putting caps on malpractice rewards. This will probably not happen nationally because of the lobbying clout of the National Trial Lawyers Association, but has already occurred in Texas, and just recently in North Carolina.

Texas tort reforms have drawn 26,000 physicians to Texas, many of whom are now practicing in rural Texas, since 2004.

Why are physicians from elsewhere flocking to Texas? For the simple reason that doctors, particularly in high-risk specialists dread malpractice suits and higher malpractice premiums, even if plaintiffs lose in court. As an article in the August 18 New England Journal of Medicine, “Malpractice Risk According to Physician Specialty,”puts it, “Although annual rates of paid claims are low, the annual and career risk of any malpractice claims is high, suggesting that the risk of being sued alone can create a tangible fear among physicians.”

The article, based on a national study of 40,916 phy7sicians and 233,738 physician-years in 25 specialties, says most physicians will be sued at least once in their lifetimes, and in high risk specialties –neurosurgery, thoracic-heart risk surgery, general surgery, and ob-gyn – most specialists will be sued more than once, with the likelihood their malpractice premiums will escalate after each suit.

Small wonder, then, that Texas tort reform with caps and lower malpractice premiums, attracts doctors to the Lone Star state. Let us see if the same phenomonon takes place in North Carolina.

Saturday, August 20, 2011

Electronic Health Records: A Splenectomy Story

Spleen- 1. A vascular ductless organ in the left upper abdomen of humans that helps to destroy old red blood cells, form lymphocytes, and store blood. 2. Anger or bad temper.

Dictionary definition

August 10, 2011
- This is the story as told by a trio of physicians at Partners HealthCare System and Harvard Medical School.

A 53 year old woman presented with pneumococcal sepsis with disseminated intravascular coagulation. She barely survived but lost multiple digits. Ten years before, she underwent splenectomy after a motor vehicle accident. There was no EHR data indicating she had received pneumococcal vaccination after the accident, a recommended treatment following splenectomy. After she recovered she filed suite against the primary care physician, a doctor in our integrated health system. We settled the case and began to work to prevent similar omissions in the future.

Which leads to this verse.

When it comes to the recording data in electronic record,
You can never be too careful in noting what there is stored.

Unfortunately, as an organ the spleen gets no respect,
Even so, its presence or absence should be checked.

Some even claim the spleen is vestigial.
Unnecessary to function of an individual.

But doctors know if the spleen is gone,
Pneumococcal organisms may quickly spawn.

That is precisely why splenectomy must be noted,
And in the EHR attention to is absence be devoted.

Yet at Partners Health System her splenectomy was not listed.
To the Electronic Record it was as if her spleen still existed.

The significance of her prior splenectomy was missed.
And research indicated even if it had been on the list.

In other patients 60% of patients received no vaccination.
To protect against the ravages of pneumoccoal prostration.

Which goes to show you the sins of EHR omission.
Depend on data entered and noted by a physician.

Tejal K. Gandi, MD, Gianna Zuccotti, MD, and Thomas Lee, MD, "Incomplete Care - On the Trail of Flaws in the System, " New England Journal of Medicine, August 11, 2011

Friday, August 19, 2011

Physicians and Health Reform: Practice Freedom and Constraints

America is about freedom.


Constraint – Limiting Factor something that limits the freedom to act spontaneously.

Dictionary Definition, Encarta World English Dictionary

August 19, 2011 – If I correctly read the tea leaves, health reform for physicians is about freedom.


• Freedom to choose one’s specialty.

• Freedom to practice where one pleases.

• Freedom to exercise one’s best clinical judgment.

• Freedom to accept patients one can afford.

• Freedom to freelance among one’s career choices.

• Freedom to set one’s fees in a free market.

• Freedom to accept cash without third party restraints.

• Freedom to own one’s own practice.

• Freedom to preserve the freedoms of private independent practice.


The last point is the central message of the Physicians Foundation (, a 501C3 nonprofit organization representing physicians in state medical societies devoted to improving practice for physicians and patients.

The Physicians Foundation does its work by conducting in-depth surveys of physicians attitudes towards reform; how physicians are likely to act under government and private economic pressures; by publishing a Washington Report on what goes on inside D,C.; and by issuing millions of dollars of grants to physician organizations to improve care, and to non-physician organizations, such as Health Leads, Inc., which permits physicians to “prescribe” social services to poverty-stricken families.

But, and it’s a huge but, physician freedom come with a price – exercising these freedoms within the constraints of society and the law. Rules and regulations are the price one pays for practicing within a civilized society.

Freedoms in a democratic society come with constraints .

• Constraints to follow the letter of the law.

• Constraints to do only what is clinically indicated.

• Constraints to do no harm.

• Constraints to do only what benefits patients rather to do what pads one’s wallet.

• Constraints to stay within what fits patients’ and society’s

It’s tough balancing act, but one never said democracy was easy. Government constraints, i.e,rules and regulations, tend to raise costs and stifle innovation, but they also curb "spontaneity," i.e. untoward activities. It's six of one, and half-dozen of the other.

Yet we must have faith in our system of government. As Sir William Osler (1849-1919) remarked, “Nothing in life is more wonderful than faith – the one great moving force which we can either weigh in the balance not test in the crucible.”

Thursday, August 18, 2011

Political and Health Reform and “Externalities”

A side effect or consequence of an industrial or commercial activity that affects other parties without this being reflected in the cost of the goods or services involved, such as the pollination of surrounding crops by bees kept for honey.

Wikipedia, definition of Externality

August 18, 2011 - When I was taking an eight week course on Health System Management at the Harvard Business School/School of Public Health, our instructors talked often about “externalities.” Externalities, as I understood them, were events outside your immediate control, things you could do nothing about.

An “internality,” if I may coin a word, on the other hand, would be something you could do on your own to change prevailing psychologies, attitudes, ideas, and norms to alter your audience’s patterns of thinking.

These days you’re hearing a great deal about political externalities. As a matter of fact, President Obama has transformed externalitymanship, sometimes known to the cynical as the “blame game” to a high art form.

Obama's externalities, things he claims he can do nothing about, include;

President Bush: Obama blames Bush for the mess he inherited, despite the fact that Obama says the recession had bottomed out a four months after he was sworn in. Now he claims, he has stopped growing due to external factors.

ATMs: In June,2011 Obama blamed automated teller machines and airport check-in kiosks for the lack of jobs, saying that "businesses have learned to become much more efficient, with a lot fewer workers." Productivity, in short, is a bad thing, except when it applies to government.

Republicans: Last week, Obama said that because "some in Congress would rather see their opponents lose than America win, we ended up creating more uncertainty and more damage to an economy that was already weak." The GOP is unpatriotic and seeks to wreck the economy.

Tea Party: This miniscule sliver of the Republican party, voted in by an overwhelming majority of Americans in November 2010, he maintains, has "terrorized" the majority and blocked his attempts to create jobs. Never mind that its members represent Middle America and are better educated than the general populace.

Gridlock: Obama says bitter partisanship blocks his attempts to do good. He's basically complaining about political obstacles to his latest "stimulus" plan — spending hikes, gimmicky tax breaks, and a massive tax hike — already been tried and failed.

The Media: Obama says the "splintered" press, i.e. Fox News and talk radio, are to blame for Washington's failure to boost the economy. "If you never even have to hear another argument," he said, "then over time you start getting more dug in into your positions." He seems to forget the mainstream media is overwhelmingly on his side.

Businesses: Obama often blames companies for sitting on massive piles of cash, becoming “rich” from excessive profits, and harping foolishly about “uncertainties” generated by Obamacare, shared sacrifice, and inevitable taxation.

Health Care: Obama seems to blame the public for not understanding his munificent health law, 26 states for challenging it in court, his own Medicare Actuary saying it will not control costs and will limit access, and physicians for expressing skepticism about its negative consequences.

The Global Economy: There is nothing the U.S. can do, Obama maintains, about the lack of growth in the global economy and the dire situation in Europe’s top-heavy welfare states, which critics say he may be emulating.

.Japanese supply chain disruptions, European debt problems, Arab Spring disorders, and Oil Spikes, not necessarily in that order.

Texas Job Growth: Sure, Texas has added nearly 40% of all jobs in the U.S. during the recession. But that growth is due to externalities – a robust energy sector in Texas, Mexicans coming across the border for low-income jobs, a paucity of welfare programs providing for the poor and unemployed, lack of effective regulations constraining “get-rich-quick” entrepreneurs and greedy corporate giants.

These externalities may be and should be considered in any political argument, but they overlook certain “internalities” in Texas - a business friendly environment with low taxes, a consciously low level of regulations, a firm belief in the benefits of entrepreneurship and innovation, and a physician-compatible climate triggered by tort reform, which has brought 20,000 new physicians flocking into Texas. Americans may not understand the subtleties of externalities, but they understand concreteness of jobs, they understand health care has created 430,000 jobs since the recession began while the U.S. was shedding 7.5 million jobs, and they understand Texas leads the nation in job growth.

Wednesday, August 17, 2011

Where to Order The Health Reform Maze

People have been asking me where they can order my book, The Health Reform Maze: A Blueprint for Physician Practices (Greenbranch Publishings).

Here's how you order it.

Health Reform Maze ordering information

or call Greenbranch offices at (800) 933-3711 to place an order.

It will also be available at as soon as they can stock their warehouses with enough copies.

Navigating the Health Reform Maze

A confusing , intricate network of winding pathways, such a network with one or more blind alleys.

Definition of maze in Webster’s New World Dictionary

August 17, 2011 - Well, I see others have picked up on the theme of my book, The Health Reform Maze (Greenbranch Publishing), which is picking your way through the fiendishly complicated health reform maze.

The Jerusalem Post calls it “The Amazing Maze of U.S. Health Care.”

• The August 13 Wall Street Journal and its WSJ Health Blog has a piece “For Cancer Patients, Help Navigating the Maze” which focuses on how hospitals help breast cancer patients.

• God knows, there’s hundreds of articles and sites telling man how to navigate the prostate cancer option maze.

• And Castle Connolly Ltd, a publishing firm in New York City, has published Guide for Navigating the Health Care System and Evaluating Health Care Providers.

My advice?

Do not let the health care maze,
daze, faze, or cause your eyes to glaze.
There’s plenty of help out there,
To help you pick your way through the haze.

The help goes under the name of Health Care Navigation.
Learn more from,The Health Reform Maze, summation.
Or go immediately to Google’s search location.
To find Health Care Reform’s navigation salvation.

Tuesday, August 16, 2011

Podiatrists and Electronic Health Records

Come, Watson, come! The game is afoot.

Sir Arthur Conan Doyle (1859-1930), The Return of Sherlock Holmes (1904)

August 15, 2011 - I just returned from a podiatrist’s office. She was complaining Medicare was requiring podiatrists to install an electronic medical record or suffer a 1% reduction in Medicare fees.

She noted that 80% of her patients were on Medicare and that she had to go along with the Medicare game. “Besides,” she added, “ I’m being asked to take blood pressures on 75% of patients. Why should I do that? I don’t treat hypertension.”

Many older podiatrists, she went on to explain, are quitting rather than install EMRs.

She asked, “Why should I be asked to do these things? I only have 15 minutes to see each patient, and to install an EMR, I may have to add staff, and having to enter data will slow me down.”

I had no answers, except to explain, with government health care management experts, data reigns supreme. It’s data uber alles, no matter what the consequences, costs, or usefulness to patients or practitioners.

As Sherlock Holmes might say to Doctor Watson, “Old podiatrists will retire rather than go down to defeet.”

Monday, August 15, 2011

Notes of a Reform Watcher -Gene Therapy As A Cure for Leukemia

August 15, 2011 - This morning I awake with Lewis Thomas on my mind. If you’ve forgotten or ever knew, Lewis Thomas (1913-1993) was a pathologist. He was famous for writing Lives of a Cell: Notes of a Biology Watcher, a 1974 collection of 29 essays first published in the New England Journal of Medicine.

His working hypothesis was that cures of disease would evolve from basic research on the cell, not from “half-way technologies,” such as renal dialysis. He said workings of the cell were complicated, and victories over disease would not come quickly.

I thought of Lewis Thomas because of news just released that gene therapy had definitely cured one patient with chronic lymphoid leukemia.

Here is how Ron Winslow reported the news in an August 11, 2011 Wall Street Journal piece “Gene Therapy Offers Hope in Leukemia Patients.”

A new strategy for genetically bolstering the immune system proved surprisingly powerful against an advanced form of leukemia in a small study that could have broader implications for fighting cancer.

The treatment, in which cells from the three participating patients were manipulated using gene therapy, eradicated blood cancer tumors in less than a month and led to sustained remissions of up to a year.

The Associated Press and CBS news picked up on the story and gave this spin under the headline, “ ‘Amazing’ Gene Therapy Destroys Leukemia in Three Patients.”

Scientists are reporting the first clear success with gene therapy to treat leukemia, turning the patients' own blood cells into assassins that hunt down and wipe out their cancer.

They've only done it in three patients so far, but the results were striking: Two appear cancer-free up to a year after treatment, and the third had a partial response. Scientists are already preparing to try the approach for other kinds of cancer

From there the story spread to other news outlets, and you would have thought the cure for all leukemias and other cancers was at hand.

I was excited too until I read August 10 the complicated New England Journal article under the formidable title “Chimeric Antigen Receptor – Modified T Cells in Chronic Lymphoid Leukemia.”

After describing their work, the authors concluded,

The delayed onset of the tumor lysis syndrome and cytokine secretion, combined with vigorous in vivo chimeric antigen receptor T-cell expansion and prominent antileukemia activity, points to substantial and sustained effector functions of the CART19 cells. Our early research highlights the potency of this therapy and provides support for the detailed study of autologous T cells genetically modified to target CD19 (and other targets) through transduction of a chimeric antigen receptor linked to potent signaling domains. Unlike antibody-mediated therapy, chimeric antigen receptor–modified T cells have the potential to replicate in vivo, and long-term persistence could lead to sustained tumor control. Two other patients with advanced CLL have also received CART19 infusions according to this protocol, and all three have had tumor responses.These findings warrant continued study of CD19-redirected T cells for B-cell neoplasms.

No promise of a cure there, only that their results warranted "continued study," and no mention of the application of their research to other malignancies.
As Lewis Thomas noted, the life of the cell is complicated, and one cannot always make far-reaching conclusions from limited data. Still, basic cellular research offers hope, and hope is all that many leukemia patients have to hang their hats and their future on.

Sunday, August 14, 2011

Will Obamacare Be Repealed?

Elections have consequences.


The Supreme Court is the Law of the Land.

U.S. Constitution

August 14, 2011 - Now that the Iowa Caucuses are over, we can turn to questions of more serious import. Will Romney or Perry be the GOP candidate? Will either defeat President Obama in 2012?

I have no idea, but I do know the Atlanta Appeals Court 2:1 decision last week declaring the individual mandate unconstitutional was a serious setback for PPACA,the Health Reform Law of the Land.

The decision paved the way for a Supreme Court decision on the matter. This will probably occur in the summer of 2012, before the Presidential election. The decision will rank right up there with Gore vs. Bush, and will have the same election consequences.

If the Court declares the mandate unconstitutional, Obamacare goes down. Obama loses. If the Court decides the mandate in constitutional, Obama wins.

Which leads to this bit of doggerel.

Everybody knows,
That in Iowa, tall corn grows.

That in Iowa the caucus.
Will always be raucous.

That the caucus does not pick President winners,
But winnows out the amateur political beginners.

That Obama's fate depends on the Supreme Court’s direction,
And its effect on the November 12, 2012 Presidential election.

That it comes down to Obamacare and the economy,
Not to Perry, Romney, or political astronomy.

Saturday, August 13, 2011

Health Reform Law Polls – Does it Matter What the People Think? If so, How Much?

August 13, 2011 - Today, in the wake of Atlanta’s 11 Circuit Court’s 2:1 decision that Obamacare’s individual mandate is unconstitutional, Real Clear Politics ran a summary of recent and past polls of what the American public thought of the “Obama and Democrats’ health plan.”

Recent Polls

RCP Average, for, 38.8%, against, 50.6%, spread, + 11.6%

Rasmussen, for, 40%, against, 54%, spread, +14%

Associated Press, for, 36%, against, 46%, spread, 10%

CNN/Opinion Research, for, 39%, against, 56%, spread, +17%

Politico/GWU/Battleground, for, 42%, against,49%, spread, +7%

Past Polls

RCP then summarized all past national polls for and against the health law since its passage on 10/23/2010. The spread was the same, i.e. 11.8% more opposed than in favor.

Of the 265 polls,which included three ties, 241 (91%) opposed the health law, and 21 (9%) favored it.

The RCP report also included 100 commentaries and news stories on the Patient Protection and Affordability Act.


Does it matter what Americans think of the new law? Will this thinking influence the outcome of the November 2012 elections? Will the people's opinions and legal opinions about the constitutionality of the law slow or block implementation of the law?

Medicare: Unsustainable, Unexplainable, and Unobtainable

Let markets do what only markets do well.

John C. Goodman, PhD, President and CEO of the National Center for Policy Analysis, “Three Simple Ways Medicare Can Save Money,” Wall Street Journal, August 11, 2011

August 13, 2011
– John C. Goodman, an economist with impeccable conservative and academic credentials, believes market competition will save Medicare more money and provide higher quality care than Obamacare, or any other government-run scheme.

Sustaining the Unsustainable

Like other economists, left and right, Goodman regards the present Medicare structure as unsustainable. With 78 million baby boomers entering Medicare, this massive entitlement program will surely go bankrupt or add trillions more to the national debt unless restructuring takes place. Medicare is the single biggest driver of that debt, more than Social Security or the military.

But how does one slow Medicare costs to save it for future generations? Pay hospitals and doctors less, save money by jamming them together into Accountable Care Organizations, move the Medicare entry age to 68 or 70, means test Medicare recipients on basis of income and assets, shift costs to recipients using vouchers or health savings accounts, or leave it to market forces and market competition to lower costs and improve quality?

Explaining theUnexplainable

The government is having a hard time explaining why government-dominated care isn’t containing costs. Goodman says one big reason is that Medicare generates more than one billion transactions based on 7,500 codes that vary with location, procedure, and other factors. Government not only sets prices. It regulates them.

Given the billions of transactions and the varying circumstances that surround them, it becomes impossible to explain, justify, and control every transaction and its price.

Government can never know what goes on or explain what occurs in the billions of human transactions between individual patients and doctors. Government cannot explain the unexplainable because it will never have enough information of what occurs at the level of the market.

And, in its ignorance and its bureaucratic bungling, government may create injustices. Goodman points out the cumbersome coding system is paying opthalmologists 15 times more for a routine 15 minute cataract procedure than a 25 minute office visit with a primary care physician, Goodman asks "Is there any wonder why the shortage of primary care is reaching crisis proportions in many parts of the country, while cataract removal is available at the drop of a hat?"

Obtaining the Unobtainable

Goodman suggests three ways Medicare can cut costs.

• Medicare should let enrollees shop for care at walk-in freestanding emergency care clinics, where prices are posted and where quality care is usually delivered. The fees of these clinics are “well below what Medicare would have paid at a physician’s office or or hospital emergency room.” Medicare should pay the fees offered at these clinics. It would save money and please constituents seeking access to convenient or emergency care.

• Second, Medicare should allow enrollees to take advantage of commercial telephone and email services. He says, for example, “Teledoc offers telephone consultations with physicians at a price probably lowe than the same service delivered by a nurse at a walk-in clinic. Teladoc doctors, he points out, use electronic medical records and prescribe electronically – two goals of the Obama health law.

• Third, Medicare should encourage doctors physicians to repackage and reprice their servies in a ways that are “good for the doctor, good for the patient, and good for Medicare.” Medicare should encourage concierge doctor arrangements, which for about $1500 per patient per year, offers patients free telephone and email consultations, same or next day appointments, EMRs, and electronic prescribing. For these services, he says, “Medicare should be willing to throw its 7,500-item price lists away, pay some portion of the concierge fee, and let the marketplace handle everything.”

Memo to Goodman

The Obama administration’s anti-market mindset and its sentiment that its experts know more than doctors and patients, will never allow your suggestions to see the light of day. Your suggestions will never fly as long as Obama is President. Medicare may be unsustainable. Its policies may be unexplainable to millions seeking lower costs. The desired results of these policies may be unobtainable. But the administration’s belief in its principles of redistribution and social justice is unshakable, even if those principles defy the laws of simple economics.

Friday, August 12, 2011

11th Circuit Court Of Appeals Finds The Health Law's Individual Mandate Unconstitutional

Preface: What follows is the Kaiser Health News report on the Court of Appeals' decision in Atlanta on the Constitutionality of Obamacare's individual mandate. The decision paves the way towards a Supreme Court decision on the matter. The question left in my mind is: Will the Supreme Court render its decision before or after the November 2012 Presidential election. In that decision may well hinge the outcome of the election, not only of the President but the makeup of Congress itself.

The 2-to-1 decision marks a major blow to the Obama administration in its legal battle over the health law. But in the ruling, which addresses the challenge filed by 26 states, the court also disagreed with a lower court's ruling and will allow other provisions of the law to remain "legally operative."

The Wall Street Journal: "The 2-1 ruling marks the Obama administration's biggest defeat to date in the multifront legal battle over the health-care law. The decision directly conflicts with a ruling issued in June by a federal appeals court in Cincinnati that upheld the law. ... The decision affirmed part of a January ruling by U.S. District Judge Roger Vinson of Florida, who ruled the health-insurance mandate unconstitutional. The appeals court, however, overturned the portion of Judge Vinson's decision that voided the entire health-care law. The appeals panel said the unconstitutional insurance mandate could be severed from the rest of the law, with other provisions remaining 'legally operative'" (Kendall, 8/12).

Kaiser Health News has the entire PDF of the ruling as well as an excerpt of the conclusion. KHN also provides an updated scorecard tracking the health law court challenges.

Politico: "The 11th Circuit Court of Appeals on Friday ruled that the health care reform law's requirement that nearly all Americans buy insurance is unconstitutional, a striking blow to the legislation. The suit was brought by 26 states — nearly all led by Republican governors and attorneys general. The Department of Justice is expected to appeal" (Haberkorn, 8/12).

The Associated Press/Washington Post: "[T]he panel didn't go as far as a lower court that had invalidated the entire overhaul as unconstitutional. The states and other critics argued the law violates people's rights, while the Justice Department countered that the legislative branch was exercising a 'quintessential' power. ... The 11th Circuit isn’t the first appeals court to weigh in on the issue. The federal appeals court in Cincinnati upheld the government’s new requirement that most Americans buy health insurance, and an appeals court in Richmond has heard similar legal constitutional challenges to the law. But the Atlanta-based court is considered by many observers to be the most pivotal legal battleground yet because it reviewed a sweeping ruling by a Florida judge" (Bluestein, 8/12).

Los Angeles Times: In the decision, "judges in Atlanta said this mandate is "unprecedented" and unlike any commercial regulation upheld in the past. Even during the Great Depression or World War II, 'Congress never sought to require the purchase of wheat or war bonds, force a higher savings rate or greater consumption of American goods,' the judges said. While Congress may regulate those who buy insurance, it may not regulate those who 'have not entered the insurance market and have no intention of doing so.' The decision by the 11th Circuit Court of Appeals is a victory for 26 states, led by Florida, which challenged the law as unconstitutional. However, the judges agreed that the rest of the law beyond the mandate is constitutional" (Savage, 8/12).

Bloomberg Businessweek: "President Barack Obama's health-care reform law's provision requiring individuals obtain coverage "exceeds Congress's commerce power" and is unconstitutional, a U.S. appeals court ruled, affirming a federal judge's January decision to invalidate that portion of the act in a lawsuit brought by 26 states" (Harris and Davidson, 8/12).

Reuters/CNBC: "The legality of the so-called individual mandate, a cornerstone of the healthcare law, is widely expected to be decided by the U.S. Supreme Court. The Obama administration has defended the provision as constitutional" (8/12).

Thursday, August 11, 2011

Ultrasound – The Other Imaging Innovation

Ultrasound imaging appeals to physicians because it is simple and benign. And as medial technology goes, it is relatively inexpensive.

Dennis Meredith, “Sound Thinking,” Duke Magazine, July/August, 2011

August 11, 2011
– The other day, my wife had an ultrasound done because of chemical evidence of a parathyroid adenoma. The noninvasive procedure took about 15 minutes. A technician waved a mechanical wand over the neck, and it was done. The report showed a 1.5 by 1.0 cm mass in the area of the right lower parathyroid.

According to Dennis Meredith, a science writer and a research communication expert,

Ultrasound machines, unlike multi-ton MRI machines, or room-sized CYT scanners, are typically no larger than a baby buggy and just as portable. And unlike X-rays or radioactive-tracer PET scans, ultrasound does not expose patients to ionized radiation. Ultrasound is also far cheaper. Even the most elaborate ultrasound scanner costs no more than $100,000, versus millions of dollars or MRI or CAT scanners

Ultrasound is a versatile diagnostic and treatment tool. Using a hand-held “magic wand” or endoscopic probes, physicians can scan for and treat multiple lesions.

Among other things.ultrasound can.

1. Visualize subcutaneous body structures – tendons, nerves, joints, blood vessels, and organs.

2. “See” tumors and aneurysms.

3. Detect deep vein thrombosis.

4. Smash renal, bladder, and gallbladder calculi.

5. Emulsify cataracts.

6. Guide needle biopsy to the target.

7. Ablate some tumors noninvasively.

8. Visualize babies in utero.

9. Treat varicose veins.

10. Show blood vessel abnormalities.

11. Deliver chemotherapeutic drugs to brain tumors.

12. Measure the heart’s “ejection fraction.”

13. Detect all of sorts of heart lesions and functions – including coronary artery disease, heart output, diastolic heart disease, atrial fibrillation, and valve dysfunctions.

14. Guide needles for biopsies or administration of regional anesthesia.

15. Diagnose carotid artery narrowing that may lead to stroke and aortic aneurysms that may cause death.

16. Distinguish between breast cancer and benign cysts.

17. Emulsify cataracts.

18. Clean teeth.

And says George Trusky, chairman of the Duke Biomedial Engineering Department, ultrasound can decrease costs of imaging technology by reducing the need for MRI and CAT scans. Furthermore, doctors in their offices, using palm-sized ultrasound devices, can diagnosis or rule-out a variety of abdominal conditions.

The versatility and utility of ultrasound has not escaped the attention of the commercial world. Lifeline Screening, Inc, using ultrasound equipment in mobile vans, has screened over 6 million people since 1993 for carotid artery stenosis, atrial fibrillation, abdominal aneurysms, peripheral vascular disease, and some heart conditions. And GEhealthcare is currently conducting a nationwide television marketing campaign featuring their GE Vscan, which can be used by doctors in ER and office settings, to scan for abdominal problems, such as appendicitis in children and adults and abdominal aneurysms and tumors in adults.

The Wonderful One Hoss Open Ultrasound Scanner

*Apologies to Oliver Wendell Holmes, author of the One Hoss Open Shay

Have you ever heard of the One Hoss Ultrasound Scanner?
It exceeds dreams of the most ardent innovation planner,
It can do almost anything medical in a purposeful manner.
That’s why it’s called the One Hoss OpenUltrasound Scanner.

It has all the properties of a versatile medical verb.
It is active, not passive, and the body it does not disturb
For many diagnosis and therapy uses , it is superb,
It is portable, and bends downward the cost curb.

It can visualize, detect, distinguish, diagnose, destroy, guide, ablate, screen, smash, emulsify, and even clean teeth.
Besides revealing what lies beneath.

Tuesday, August 9, 2011

Health Reform, The Lilliputians, and Lack of Mobility

August 9, 2011 - President Obama’s current predicament reminds me of Gulliver’s Travels. The Lilliputians, each 1/12 the size of Gulliver, who by the way, was a surgeon, have tied him down with multiple tiny ropes. Gulliver is unable to move. He is immobilized.

Such is Obama's problem, at least that is how he perceives it. He blames his problems on the Lilliputians– small-minded followers of Bush, narrow-thinking Tea Party activists, myopic advocates of smaller government, incompetent Standard and Poor’s officials – on his inability to move.

He attributes this immobility – this gridlock, this political paralysis, this bitter backbiting – on everybody but himself and his policies. He seems locked in a rigid, uprighteous position – that he is right and others are wrong. He seems to be a legend in his own mind, divorced from reality. What he lacks is bold action – a long overdue specific practical plan with a realistic budget – free of ideological trimmings.

Until then, America will suffer from a series of immobility crises.

• Hoarding of $2 trillion of cash that corporate America has set aside for a rainy day rather than creating new jobs.

• Resistance of small businesses to hire until they can clearly see how whole set of federal regulations and new taxes required by Obamacare will effect them, even threaten their existence.

• The inertia of the states as they wait to see if Obamacare will move forward or be repealed, possibly by a Supreme Court decision on its constitutionality.

• The unhappiness of Americans as they experience “downward motility “from the housing and stock market meltdown, with potential choking off of “upward mobility” in their futures.

• The dread of private physicians as they see themselves immobilized by intrusive regulations, restriction of clinical freedoms, and payment downgrades.

. The fear of ordinary citizens about future rationing, decision-making by bureaucrats rather than physicians, lack of access to medical care, and decline of quality.

Tweet: Obama, considers himself a giant among Lilliputians, tied down by Bush people, Tea Party activists, S&P incompetents. Why? He lacks a plan

Donald J. Palmisano, MD, JD., on My Book

Preface: Dr. Donald J. Palmisano, former AMA president and author of On Leadership, is widely regarded by fellow physicians as the leading spokesperson for physicians in private practice and for their economic freedom from heavy-handed government intervention. He opposes the Patient Protection and Affordability Act (PPACA). I want to thank him for this mention of my book in DJP Update, his blog.

I want to inform you of a new book on the healthcare law. I had the opportunity to read it before it was published and I wrote a blurb about it as did many other individuals.

Book: The Health Reform Maze: A Blueprint for Physician Practices.
Author: Richard L. Reece, MD
Publisher: Greenbranch Publishing

Comment from Publisher including ordering information:
This is your roadmap for health reform to date. Although clear exits and destinations remain murky, Dr. Reece has managed to create a statistically entertaining map for health reform. The Health Reform Maze: A Blueprint for Physician Practices contains many entries that Dr. Reece has composed over the last four years on his Medinnovation blog.

What makes this book so unique is Dr. Reece's keen insight and understanding of both physicians' and patients' value system. "When it comes to trying to understand the current healthcare reform, this book covers it all in easily understandable language," says Nancy Collins, President of Greenbranch Publishing and Publisher of the Journal of Medical Practice Management®. "Dr. Reece approaches the unclear issue from the patient and the physician perspectives while still managing to stay compelling, engaging, and even entertaining." This book, ideal for practice managers, physicians, medical directors, insurers, policy makers, and even business school and health manager programs alike, is a must-read when trying to tackle the questions surrounding health reform.

Dr. Reece's book The Health Reform Maze: A Blueprint for Physicians Practices contains blog entries that deliver comprehensive but easy to read discussions concerning the uncertainty, the threat of lower reimbursements, and what practices can do in response to reform. The entry format allows the reader to even pick and choose from the sections without having to read straight through. Dr. Reece delivers a balanced (and less judgmental) overview of the reform. This book breaks the trend of specialized, narrow healthcare reform reports. Because of its multiple points of view and various perspectives, it tells you everything you may want to know about health care reform but were afraid to ask.

$48.50 plus $9.95 for S&H, ISBN 978-0-9827055-4-4, pages © 2011

Order here:

Here is my blurb/review.


"This is a must read collection of essays that gives the good, the bad, and the ugly of the new healthcare law, PPACA. Dr. Reece shares a balanced presentation of proponents and opponents of the law and gives hope for a better way to reform the system."
Donald J. Palmisano, MD, JD, FACS, Former president of American Medical Association, and author of On Leadership

Monday, August 8, 2011

Physicians Positively Impact Economy

August 9 , 2011 - From the Wall Street Journal’s Health Care Blog comes this report, and I quote:

Employment Report Shows Health Care Added 31,300 Jobs

By Katherine Hobson

“The U.S. economy added more jobs than expected last month. And the health-care industry showed particular strength, with 31,300 new jobs — higher than the average monthly increase seen in 2007, before the recession hit.

Here’s the Bureau of Labor Statistics chart showing sector-by-sector job growth, and here’s the overall report, which shows non-farm payrolls rose by 117,000 while the unemployment rate dropped slightly to 9.1%.

As the WSJ reported last month, health-care employment had been robust during the recession, but showed some weakening in the June report. That changed in July. Hospitals alone added 14,000 new jobs after losing 2,000 jobs the previous month.
Ambulatory care also added jobs — 6,300 in doctor’s offices and 3,100 in home health-care services.”

Not New News

This is not new news. Health care has added more than one million jobs since the recession began in 2007.. And it should be no surprise. Where ever you are, look around you. What is the biggest employer in your community? Most likely, it’s health care if you congregate hospitals, outpatient facilities, and doctors offices into one economic package.

And where would this economic growth be without doctors? Doctors deliver care in all of these settings. They would not exist without doctors. As one observer noted, “Hospitals without doctors would just be empty buildings with bad food.”

Studies by the George Medical Association and the American Medical Association have shown doctors positively impact state, local, and the ntional economies.
GEMS (Georgia Economic Modeling System) Study.

Georgia Report

A September 2008 study by the government of Georgia’s
– GEMS (Georgia Economic Modeling System), “The Estimated Impact of Private Physicians’ Offices in Georgia,” by Wes Clarke and Adam Jones of the Carl Vinson Institute of Government – indicates that in 2008, private physician offices in Georgia,

• supported nearly 190,000 jobs,

• generated more than $10 billion in private income,

• increased total economic activity by nearly $20 billion.

Impact of Each Private Physician

In Georgia, each private physician directly or indirectly supported or generated

• 13 additional jobs

• $640,000 in personal income

• $1.5 billion in total economic activity

• More than $1.2 billion in state revenues

• $15. billion in local government revenues.

AMA Report

An AMA report, released March 23, 2011, showed doctors are substantial drivers of the economic engine nationally, as well as on the state and local levels. The economic impact of doctors extends far beyond physician offices in a practical way. Doctors purchase goods and services, and medical practices create jobs by employing staff. Those workers spend their money in local economies, making other jobs possible. At every step of the way, tax revenues are generated -- about $100,000 per physician in state and local tax revenues in 2009.

Office-based doctors supported 4 million jobs and contributed $1.4 trillion in economic activity in 2009, according to the AMA report. On average, one doctor leads to $1.3 million in wages and benefits and $2.2 million in overall financial activity.

A physician supports an average 6.2 jobs, including his or her job, and that impact has been rising through the years. The U.S. Bureau of Labor Statistics said the number of people working in physician offices grew from 463,400 in 1972 to more than 2.3 million in 2010.

1. Reece, R.L., “Positive Impact of Private Practice on the Economy,”, November 1, 2008.

2. Victoria Staff Elliot, “Office-Based Doctors Support 4 Million Jobs, American Medical News, April 4, 2011

Tweet: Private physicians positively impacted economy by helping create 31,300 new jobs last month in the health care sector.

Sunday, August 7, 2011

Will Obamacare Cost As Much As Romneycare?

If it were not for Romney, it’s extremely unlikely that Obama would have passed his universal health law last year, although the two laws differ in important ways. The basic architecture, however, is the same...Romney’s real problem is not just the mandate, but that he showed Democrats the political and procedural way to passing a universal-health-care-law in America.

Ryan Lizza, “Romney’s Dilemma: How His Greatest Achievement Became His Greatest Liability,” The New Yorker, June 6, 2011

August 8, 2011 – Five years after Romneycare passed in Massachusetts, the truth is out.

According to a June report “The High Price of Massachusetts Health Reform” by the Beacon Hill Institute at Suffolk University in Boston, Romneycare is costing Massachusetts’ consumers and the state government an arm and a leg, and the federal government a whole new body of debt.

The Institute found from 2006-2011 in Massachusetts,

• State health care expenditures rose $414 million.

• Private health insurance costs rose by $4.31 billion.

• The federal government spent an additional $2.42 billion on Medicaid in Massachusetts.

• Medicare expenditure increased by $1.43 billion.

• Total health care costs rose by $8.57 billion.

• Massachusetts shifted the majority of costs to the federal government.

Key Components

The key components of Romneycare were:

• An individual mandate requiring all citizens who could afford it to buy health insurance.

• An employer mandate requiring all employers with 11 or more employees to make a “fair and reasonable contribution” to employee’s health insurance.

• An expansion of Medicaid subsidies for residents with incomes up to 300% of poverty.

• Creation of an insurance exchange (The Connector) to provide a “seal of approval” the Connector deemed to be of good value to consumers.


Authors of the Beacon Hill Institute report concluded,

“Advocates promised that the law would shrink the rolls of the uninsured and reduce health costs…However, the 2006 law has failed to reduce costs. Health care reform has pushed increases both above the pre-reform growth trend in Massachusetts and the growth rate of the rest of the country... The ability of the federal government, facing its own budgetary problems, to carry burdens imposed on it by the states, is not unlimited.”

Will ObamaCare, fashioned after Romney care, follow state and federal health care skyrocketing health costs in Massachusetts? Given the current federal debt burden, can the U.S. afford ObamaCare?

Time, and the voters, will tell.

For more information, call or write the Beacon Hill Institute at Suffolk University, 8 Ashburton Place, Boston, Mas, 02108, 617-573-8750, email:, web:

Saturday, August 6, 2011

Greenbranch Publishing Announces the Release of the New Book "The Health Reform Maze: A Blueprint for Physician Practices."

August 7, 2011- What follows is my publisher's press release about my new book, The Health Reform Maze: A Blueprint for Physician Practices.

The path to reform has been caught in an unstable world between acceptance and rejection. This book compiles one physician's view of the political and practice environment for health reform to date. This book dissects the complex topic of heath reform in a straightforward manner – guaranteed to get your attention.

A year ago, March 23, 2010, Congress passed the Patient Protection and Affordable Care Act (PPACA). The various effects of the law are producing confusion, contradictions, and ambiguities in the healthcare system. How do physicians and practice executives navigate through the confusion? The answers are in Greenbranch's newly released The Health Reform Maze: A Blueprint for Physician Practices by Richard L. Reece, MD.
$48.50 plus $9.95 for S&H, ISBN 978-0-9827055-4-4, pages © 2011

Order here:

eBook: $29.95 eISBN 978-0-9827055-6-8 (available Sept 1)
This is your roadmap for health reform to date. Although clear exits and destinations remain murky, Dr. Reece has managed to create a statistically entertaining map for health reform. The Health Reform Maze: A Blueprint for Physician Practices contains many entries that Dr. Reece has composed over the last four years on his Medinnovation blog.

What makes this book so unique is Dr. Reece's keen insight and understanding of both physicians' and patients' value system. "When it comes to trying to understand the current healthcare reform, this book covers it all in easily understandable language," says Nancy Collins, President of Greenbranch Publishing and Publisher of the Journal of Medical Practice Management®. "Dr. Reece approaches the unclear issue from the patient and the physician perspectives while still managing to stay compelling, engaging, and even entertaining." This book, ideal for practice managers, physicians, medical directors, insurers, policy makers, and even business school and health manager programs alike, is a must-read when trying to tackle the questions surrounding health reform.

Dr. Reece's book The Health Reform Maze: A Blueprint for Physicians Practices contains blog entries that deliver comprehensive but easy to read discussions concerning the uncertainty, the threat of lower reimbursements, and what practices can do in response to reform. The entry format allows the reader to even pick and choose from the sections without having to read straight through. Dr. Reece delivers a balanced (and less judgmental) overview of the reform. This book breaks the trend of specialized, narrow healthcare reform reports. Because of its multiple points of view and various perspectives, it tells you everything you may want to know about health care reform but were afraid to ask.


PART ONE: Culture and Politics, the Reform Law, Costs and Demands, and Unforeseen Consequences
Culture and Politics
Blue Monday for ObamaCare
Political Chickens Coming Home to Roost
Obama Rope-a-Dope
Tipping Point
Reform Storm
U.S. Exceptionalism
American Heritage
Ask Not: Health Reform Propositions
Pig in a Poke
A Favor You Can't Understand
Reform and Repeal Odds
Massachusetts and Indiana Experiments
Romney's Legacy
Center-Right Nation
Americans and Their Medical Machines
Comparative Health Statistics between Nations
The Reform Law
"Fiendishly Complicated"
Fast-Baked Reform Cake-Off
A Tangled Web
Winners and Losers
Known and Unknown Consequences of Reform Law
Vast Law, Half-Vast Consequences
Positives and Negatives
Checks and Balances
Correctness and Incorrectness
Wisdom of Crowds
If Not Constitutional, What Then?
No Compelling Story
Big Brother Is Watching
Costs and Demands
Big "D"
Everything Has a Price
It Ain't the System, It's Aging
Doing the Math
Health Costs and Human Nature
SNAFU (Situation Normal All Funds Up)
Hospital "Facility Fees"
Unforeseen Consequences
Waive Obamacare Goodbye
Costs of Consolidation
Reform Holes You Can Drive a Truck Through
Health Reform Dislocations
Will Public Hospitals be a Health-Reform Causality?
Death Knell of Independent Health Agents?

PART TWO: Physicians, Hospitals, Patients, Access to Doctors, Medicare, Medicaid, Government Bureaucracy

Doctors in America
Talk Is Cheap
The Physician Organizational Inferiority Complex
Primary Care Revolt against RUC
Survey: Two-Thirds of Doctors Fear or Oppose Health Reform Law
The Future of Accountable Care Organizations
The Elephant in the Room: Small Physician Practices
Pay-for-Performance, Not so Fast McDuff!
Stalking the Noncompliant Physician
A Physician's Manifesto
Impact on Doctors
Physician Gratitude List
Reaping Tort Reform Benefits
Congress Hoisted on Its Own Petard
Who Speaks for Physicians?
A Remarkable Document
Primary Care in the Dumps
Monstrous Implications
Physician Sentiment Index
Doctors' Dilemmas
The Future Ain't What It Used to Be
Feminization of Medicine
Who Decides - Government or Doctors?
Chain Reaction of Consolidation
Hospital-Doctor Hiring Wave
Disgruntled Physicians and Unhappy Hospitals
Accountable Care Organizations: Negative Reaction among Physicians
Accountable Care Organizations as Private Practice Killers
Resolving Hospital-Physician Conflicts
"I Told You I Was Sick."
Resuscitation of Death Panels
" I Feel Like a Million Dollars"
"Patient-Centered Care" and What Patients Want
Heart Disease and Health Reform
More Private, Personal, Home, and Decentralized Care
A Physical Exam Tale
Access to Doctors
Playing the Percentages
Will Doctors Be There?
Access Mess
And Who Shall Care for the Sick?
I Told You So
Victims of Health Reform
Ba-Ba-Ba-Ba Boom!
Health Reform Impact, as Cited in the Medicare Chief Actuary's Report
Fraud and Abuse
Skepticism among Seniors
Government Bureaucracy
Res Ipsa Loquitur
Reasons behind Growing Bureaucracy
Where Has All the Trust in Government Gone?
Sickness of Government
Berwick Quote
More Berwick in His Own Words
Harvard-Driven Health Care
Berwick on the Virtues of the Health Reform Law

PART THREE: Innovation, Electronic Health Records, the Internet and Social Media, and Miscellany

Government "Innovation"
Innovation: Last Great Hope
Health Reform, the Blogosphere, and Search Engine Optimizations
Irresistible Force
Seek and Find: Googling of Disease and Health
Why Not More Innovation?
Balancing Reform and Medical Innovation
Top Ten Innovators
Getting Your Care at Work
No Miracles among Friend
How To's of Healthcare Innovation
Electronic Health Records
Bonanza or Boondoggle?
"Inevitability" and "Waiting Game"
Is a "Free" EHR for Real?
Seek, Speak, and Ye Shall Find
The Janus of Health Reform
Unnatural Human Communication
Talking to Your EHR
Patients and Wikileaks
Need for Physician-Friendly and Physician-Useful Information
Hospitals and Doctors Not Walking the EHR Line
The Internet and Social Media
Coming Out of the Electronic Wilderness
Twittering Down, How Tweet It Is
Internet Groundswell
The Computer Is a Moron
Sermo - Physician Social Networking
Grace-Marie Turner and the Galen Institute
The Medical Industrial Complex
Too Many Rocks in Physician Knapsacks
Why the Political Sea Is Boiling Hot and Pigs Have Wings
Pruning the Reform Christmas Tree
Consequences of Health Reform
Eight Health Reform-Driven Physician Trends
Doctors Make a Difference for the Poor
The Doctor Is In

Order here:


About the Author

Richard L. Reece, MD, pathologist, writer, and editor, is former Editor-in-Chief of Minnesota Medicine and Physician Practice Options. He has written 10 books on the healthcare system. For the last four years, he has written a blog, medinnovationblog, which includes 1700 entries on healthcare innovation and reform. Dr. Reece stresses that physicians and patients must work together more closely to build a more personal, patient-centered system without massive interventions by third parties. Dr. Reece was educated at Duke University School of Medicine with postgraduate training at Hartford Hospital and had training at Harvard Business School.

About Greenbranch Publishing, LLC Headquartered in Phoenix, Maryland, Greenbranch Publishing, LLC is a privately held firm founded in 1998. The company is a leading publisher of medical practice management titles, electronic media and audio conferences for physicians, practice administrators, and office practice managers.



"Healthcare Reform: an oxymoron that is almost impossible to understand. Dr. Richard Reece is making an effort to bring some semblance of understanding to this situation. He backs up his comments with statistics, facts, and his experience as a doctor. He also adds a dash of humor, as this is pretty strong stuff for most of us physicians who are eyeball to eyeball with patients to digest. Dr. Reece uses wonderful metaphors and sprinkles his chapters with quotes from the literature, which makes reading this book so enjoyable. If you are looking for some insight from one of our colleagues, and an enjoyable style of writing that borders on entertaining, then I highly recommend you read The Health Reform Maze: A Blueprint for Physician Practices. You won't be disappointed, and you will enhance your understanding of a problem that affects every physician and every American citizen."

Neil Baum, M.D.

"Dick Reece is a prolific health writer with a keen sense of what is happening in the nation's healthcare sector. His new book is further testament to his uncanny understanding of the effects of health reform efforts on patients, physicians, and hospitals alike. His firm grasp of these many important and complicated healthcare issue makes this book a must reading for all those interested in U.S. healthcare policy."

Tim Norbeck CEO The Physicians Foundation

"Richard Reece, MD, is well known for his numerous and cogent writings on America's healthcare issues as well as his keen insight and understanding of both patients' and physicians' value systems. In his latest book, The Health Reform Maze: A Blueprint for Physician Practices, Dr. Reece has made another major contribution in bringing forth a unique understanding of how reforms impact upon all affected parties. This book is a vital must read for all of those who wish to better comprehend our complex and complicated healthcare system as well as for those who entertain efforts to reform it."

Walker L. Ray, MD, Vice President, The Physicians Foundation, and Former President, Medical Association of Georgia

"In the midst of the confusion and haze of the Affordable Care Act comes a book that peers behind the curtain to see what healthcare reform really means to doctors, patients, and our country. Dr. Reece has gathered his writings into a readable and sometimes humorous compilation of fact, fiction, and anecdote that helps us to understand the turmoil our healthcare system will be experiencing over the next decade. His blog entries trace the evolution of the new law and what people say, think, and may do about its octopus-like reach. I recommend this book to anyone interested in their own healthcare and our evolving healthcare system."

Lou Goodman, PhD, CEO, Texas Medical Association

"Dr. Reece sees America as a "diverse, center-right, capitalistic country" governed by a constitutional "balance among the executive, legislative, and court branches." He shows that accountable care organizations, exchanges, and endless new federal health insurance rules will certainly not bring about national healthcare Nirvana, but asks, "What will?" Reece had it right in his 1988 book, and he dramatically demonstrates it in this new book. "This struggle is mainly between the management of corporations and physicians. It is a struggle for power." The struggle of 1988, however, has moved out of corporate offices and into Congressional lobbies and the Oval office. The government's healthcare plan is to be administered by "remote bureaucrats" that "will never be able to gauge the hopes, feelings, and consequences of their remote judgments when a patient and a doctor meet in the exam room to decide what is best for the patient." Ergo, politics cannot heal what ails us, but it can most certainly make it far worse. With this book, Reece has brought focus to the 2011 and 2012 health reform debate. I expect his yet unwritten sequel to be released soon after the 2012 election, and hope it reports on the political movement back toward market-based reform and away from government-demand systems."

Dave Racer, St. Paul, Minnesota, a supporter of health savings accounts

"This book is an interesting patchwork of individual thoughts on healthcare reform - highlighting some of the best and noting some of the worst ideas that have been presented in the last few years on what is right, wrong, and needed in order for our healthcare system to advance."

Matthew Katz, Executive Director, Connecticut State Medical Society

"This is a must read collection of essays that gives the good, the bad, and the ugly of the new healthcare law, PPACA. Dr. Reece shares a balanced presentation of proponents and opponents of the law and gives hope for a better way to reform the system." Donald J. Palmisano, MD, JD, FACS, Former president of American Medical Association, and author of On Leadership
"An eagle-eyed observer of the healthcare scene, Dr. Reece offers up the messy banquet of health reform in chewy but digestible bites. There is plenty here for healthcare professionals and policy wonks to sink their teeth into, but Dr. Reece's clear, punchy style also invites the general reader to the table. Anyone looking for an engaging, even-handed (but hardly un-opinionated) examination of healthcare reform is encouraged to sample this very tasty new book."

Phillip Miller, Vice-President, Merritt Hawkins, and Author of Will the Last Physician in America Please Turn Off the Lights?

"Dr. Reece, in his book The Health Reform Maze: A Blueprint for Physician Practices, writes about a complex topic in a straightforward manner that grabs your attention. Throughout the book, various perspectives and facts are presented that clearly show the pros and cons of healthcare reform initiatives; particularly how physicians, patients, and America are being affected now, and will be in the future. His use of humor and thought-provoking quotes applied toward today's issues keeps the reader looking forward to the next chapter. If you like a book that takes a commonsensical view of a subject, you will enjoy reading this one."

Mike Martin, President Practice Support Resources, Inc.

This is a book that is of value to all the players - doctors, insurers, health planners and government administrators of health care and finance, as well as hospital leaders, legislators and the patient/consumer. Dr. Reece, trained as a pathologist, has been a writer of distinction for all of his professional life.
He was editor of the respected Minnesota Medicine for over twenty years, and in recent years has written ten books examining the American healthcare system and its effect on the sick and the well, the rich and the poor, the doctors and the bureaucrats, the government and the people. This latest effort is his reading of the impact of the Affordable Care Act since its passage, as derived from his blogs entered on the web from March, 2010 to January 2011.
The author believes that reform of health care has been designed by a politically center-left Congress and President, for a center-right more conservative nation. He makes it clear that what was needed was stepwise evolutionary change and what we have with "Obamacare" is a revolution in the provision of and payment for healthcare in the U.S. The appointed leader of the Center for Medicare/Medicaid Services (CMS), Dr. Donald Berwick, is, in the view of the author, committed to the central control of healthcare policy rather than one likely to rely on market forces. Since passage of the law, two camps have marshaled their forces - those on the left who argue that government must participate ( further) in the system of healthcare, and those on the right who want less government, lower taxes, less debt and preservation of the right of individuals to decide for themselves. The accusatory rhetoric heats up on both sides and Dr. Reece, through his reading of the published media, the blogosphere, and interviews with recognized thinkers and actors on the healthcare stage, delivers facts and candid appraisal of the ongoing debate in plain language. Valid concerns are expressed that the law as it stands will leave us short of doctors, thus short of access for those gaining insurance coverage. The emphasis on Accountable Care Organizations, and the efforts to diminish fee-for service payment systems and bundle payments to doctors and hospitals are pushing amalgamation into larger systems with doctors as salaried workers. These phenomena are dissected and exposed in easily understandable language, sometimes with a touch of humor: "Don't launch vast projects with half-vast ideas." Dr. Reece's book is a lively, practical and valuable contribution to today's ongoing discussion.
H. David Crombie, M.D. Editor, connecticut Medicine, The Journal of the Connecticut State Medical Society


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Friday, August 5, 2011

Voices of August: Health Reform, Market Plunge, and Wisdom of Crowds

We must learn to welcome and not fear the voices of dissent. We must dare to think about “unthinkable things,” because when things become unthinkable, thinking stops and action becomes mindless.

Senator William Fulbright (1905-1995), Speech in the Senate, 1964

August 6, 2011 – The Dow Jones fell 513 points yesterday, and as I write it is down another 100. Talk of a double dip recession is in the air.

As I witness these events, I am thinking of my book The Health Reform Maze (Greenbranch Publishing, Baltimore), which will be available in several weeks. Chapter 2 of the book, “Wisdom of Crowds,” starts out this quote,

“The Wisdom of Crowds: Why the Many Are Smarter Than the Few and How Collective Wisdom Shapes Business, Economies, Societies and Nations.

Title of 2004 book by James Surowieck, in which he says aggregation of information in groups results in decisions that are often better than could have been made by any single member of the group.

It seems to me the Voices of August, are telling us something. These dissenting Voices may represent the overloaded guns of August. They may be accentuated by the ugly mood induced by howling Dogs of August, but I believe we should listen to these Voices.

Investors are telling us they do not trust the fundamentals – overspending by government , under-consuming by the public, and under-performing by politicians.

World Markets are telling us it is time for the U.S. to get its act together - to make structural changes in response to the demands of the public and business, to aging populations, to welfare state burdens.

American voters are telling us, in the November 2010 elections and in the latest New York Times/CBS poll, that 82% of us disapprove of what the government and politicians are doing.

American Patients, especially seniors and increasingly the poor and uninsured, are telling us they depend on entitlement programs – in the 2nd quarter of 2011, government spending on health care rose to 57.5% of all health care spending, and Medicare/Medicaid spending rose 10%.

American Physicians, in survey after survey, are telling us the health reform law, as now structured, will cause some 25% to drop out of Medicare and 50% or so to cease seeing Medicaid patients, just when demand for physicians services peaks. Two of the reasons for this pulling out of government programs are – One, underpayment by federal programs, and Two, high administrative costs, which are four times those of their Canadian counterparts.

U.S. Businesses is telling us they cannot afford Obamacare. In surveys by reputable consulting firms, somewhere between 30% and 50% are saying they will drop coverage for employees between now and after 2014, when Obamacare kicks in. Businesses are also telling us they are not hiring because of the uncertainties and consequences of Obamacare, which they fear will be enormous.

American Financial Observers, on both sides of the political aisle, are telling us fundamental restructuring of entitlement programs are needed. Most frequently mentioned include Medicare vouchers, as in the Ryan Plan, delay in the age of entry in Medicare, means testing of Medicare recipients, higher taxes on those making over $250,000, systematic tax reform with flattening and broadening of taxes with plugging of tax loopholes, and expansion of health savings accounts and high deductible plans, which have been shown to decrease health spending by 20% or so.

Thursday, August 4, 2011

Primary Care in the Shadows: Lack of Medical School Role Models

"Big Doctoring in America demonstrates that primary care works: it provides continuous, personalized care, and minimizes unnecessary referrals and interventions. Yet its role at the center of health care delivery is uncertain. General practitioners are paid less than specialists. Promising medical students are they are “too smart” to go into primary care."

Jacket blurb, Big Doctoring in America, 2002, by Fitzhugh Mullan, MD

Many medical students perceive primary care as a default path, characterized by the absence of differentiation into anything else. Perhaps as a result, general medicine doesn’t inspire the same urgency to “invest early”, it’s rare , for example, to see a classmate skip lecture to shadow an internist.

Rena Xu, A.B, Harvard Medical Student, “ A Differerentiation Diagnosis – Specialization and the Medical Student, New England Journal of Medicine,
August 4, 2011

August 4, 2011-
When I was a medical student, most of us didn’t know what we wanted to become. At graduation, most of us still didn’t know so we took rotating or general medicine internships. Even then I didn’t know, so I decided to take a year of pathology, the speciality that studies disease.

Those days are gone. Now, according to Rena Xu, a Harvard medical students, medical students shorten the decision process by students “shadow” various specialists through their daily routines. The idea, she says, is for students to “experience the pace of the work, see how tams function in action, and develop a sense of the different medical challenges faced y different specialties.”

The other idea is to prepare to qualify yourself for a specialty residency, to become competitive, to be chosen for entry into popular subspecialties. Recommendation letters from specialty physicians are a highly prized selection criterion, perhaps even more so than scores on the U.S. Medical Licensure Examination. The pressure to gain a competitive edge drives students to decide early what specific specialty to enter.

So students begin to skip lectures to shadow physicians, to carry a pager to notify themselves of opportunities to scrub into surgery, to rush to learn what specialists do, to ingratiate themselves and to talk to those who have been there and done that. Medical students are hungry for clinical exposure outside the medical school curriculum.

Is this early “differentiation” healthy for the health system? Probably not. It skews students toward specialties. It ignores the reality that specialists dominate medical school faculties. It creates conflicts with medical school schedules. And it often leaves a career in primary care out in the cold. And it seems to be characteristic of the elite medical schools, where “shadowing” is the order of the day.

But it is reality. Students are already looking forward to how they can pay back their medical school debts, how they can live an ordered life style, how they can achieve prestige in a specialty-dominated society.

Some medical schools have sought to circumvent this early specialty selection process with weekly specialty rounds taught by practicing physicians, by bringing community physicians into the teaching process, by sending out students early in their medical school experiences to clinical preceptorships, and in the case of the University of Kansas, by opening a new medical school campus in a small town where students will receive all of their clinical training.