Monday, October 31, 2011

Health Law - A Body in Motion Tends To Stay in Motion

My message is - keep moving. If you do, you'll keep arthritis at bay.

Donna Mills. American Actress, 1942

October 31, 2011 - Have you seen Celebrex ad with the tag line – “A body in motion tends to stay in motion. It’s simple physics.”?

The message? Give the arthritic patients a pill, and they will keep moving. This message may also apply to politics.

This image reminds me of the health care law. It’s arthritic, but it keeps moving, due to certain popular provisions within the law – i.e. coverage for pre-existing illnesses and young adults under their parents’ plans- and periodic stimulus doses administered by Kathleen Sibelius at HEW and Donald Berwick at CMS.

The law is hobbling. Its joints are creaking. Republicans oppose it. Twenty states are suing over its constitutionality. Public approval has hit an all-time low. The CLASS portion of the law has been abandoned because of financial unsustainability. Over 1800 waivers have been granted to four states and favored organizations to help them escape its costs. All Republican candidates for president promise to repeal it.

But the health law keeps on moving. Many states continue to set up health exchanges and to build the Medicaid machinery needed to cope with the onslaught of 32 million new recipients.

But as Louise Radnofsy of the October 29 WSJ article points out in its title “Repeal Health Law? It Won’t Be Easy." Republicans, even if they take the Senate in 2012, are unlikely to have the 60 vote filibuster-proof majority needed to repeal the law in its entirety.

The Romney plan, as articulated, critics assert, may not pass legal muster,

I’ll grant a waiver on Day One to get repeal started. On Day One, granting a waiver for all 50 states doesn’t stop it in its tracks entirely. That’s why I also say we have to repeal Obamacare, and I will do that on Day Two, with a reconciliation bill [requiring only 51 votes in the Senate] because as you know, it was passed by reconciliation with 51 votes.”

Besides, the Romney plan would ignite a rebellion among progressive groups, possibly lead to a political firestorm, and cause Republicans to either try for either a full-scale repeal or a joint -by-joint, piece-by-piece effort to defund amd dismantle the law and keep it from moving further.

Even with an election of a Republican president with a Senate majority, wholesale repeal of the health law would not be easy.

Sunday, October 30, 2011

Is There a Steve Jobs of Health Care?

The true genius is a mind of large general powers, accidentally determined to some particular direction.

Samuel Johnson (1709-1784)

So was Mr. Jobs smart? Not conventionally. Instead he was a genius. His imaginative leaps were instinctive, unexpected, and sometimes magical. They were intuitive, not analytic rigor. Trained in Zen Buddhism, he came to value experiential wisdom over empirical analysis. He didn’t study data or crunch numbers but like a pathfinder, he could sniff the winds and sense what lie ahead.

"The Genius of Jobs", by Walter Isaacson, Author of Steve Jobs, New York Times, October 30, 2011

October 30, 2011 – Steve Jobs was a mad genius – part poet, part artist, part technologist, part visionary, part bully.

He lived, thrived, and died at the intersection between the humanities and technology. He believed in disciplined creativity, in simplicity of design where “less was more,” in bending reality to meet his vision,in inspiring people by insulting them, in emagineering over engineering, in sustained innovation over the long haul,but most of all, in showing all of us our future before we ourselves realized what it was.

In Jobs’ words,

“Our job is to figure out what they’re going to want before they do. People don’t know what they want until you show it to them. That’s why I never rely on market research. Our task is to read things that are not yet on the page.”

And so he did. He gave people products they could understand before they understood them. He integrated hardware and software, the humanities and technology, poetry and engineering.

Nature, he knew, loved simplicity and unity, and he gave them both with a string of imaginative products.

• The Apple II, the first personal computer not just for hobbyists.

• The Macintosh, which launched the home computer revolution and popularized graphical user interfaces.

Toy Story and other Pixar blockbusters, which opened the miracle of digital imagination.

• Apple stores, which reinvented the role of a store in defining a brand.

• The iPod, which changed the way we consume music.

• The iTunes store, which saved the music industry.

• The iPhone, which turned mobile phones into music, photography, email, and web devices.

• The App store, which spawned a new content-creation industry.

• The iPad, which launched tablet computing and offered a platform for digital newspapers, magazines, books, and videos.

• iCloud. Which demoted the computers from its central rol in managing our content and let all of our devices sync seamlessly.

• And Apple itself, which Jbos considered his greatest achievement, a place where imagination was nurtured, applied, and executed in ways so creative that it became the most valuable company on earth.

A Bit of An Asshole

He did all of this while being, in his words, “a bit of an asshole,” often brutal, rude, uncompromising, and cold in this relationships. He knew what he wanted, and knew humanity needed what he wanted. He did not let anything stand in the way of his dream, even it might bending the truth and ignoring reality as seen by others. He did not believe the rules applied to him, which is why he drove his Mercedes without license plates, parked in slots reserved for the handicapped, and drove incessantly over the speed limit.

Here is how Isaacson describes his book and Jobs’ contribution to society,

This is a book about the roller-coaster life and searingly intense personality of a creative entrepreneur whose passion for perfection and ferocious drive revolutionized six industries : personal computers, animated movies, music, phones, tablet computers, and digital publishing. You might even add a seventh, retail stores. In addition, it opened the way for a new market for digital content based on apps rather than just websites.

My Read

As I read the book, I asked myself: Is there a Steve Jobs in health care?
• Is there some towering Machiavellian figure out there who can drive the health care system through information technologies to integrate its humanistic side (The Art if Medicine) to integrate with the scientific side (The Science of Medicine).

• Is there someone with the creativity and resources to put humanity and technology together in a form most of us will accept and embrace?

• Is there someone who appreciates the “fiendish complexity” of medicine often comes down to the essential simplicity of the healing relationship of doctor and patient?

• Is there someone who relies on intuition and focuses like on what patients want and will embrace rather than on what the system provides?

• Is it possible that this person, combining political, leadership, artistic, aesthetic, showmanship, and technological skills can develop a digital technology system that informs us all and moves us all to higher ground?

Not That I See

I doubt if there is such a person. There may not need to be. The vision of Steve Jobs is already pushing us towards integrating software and hardware towards the humanistic uses of technology. What is missing is simplicity in design of the system.

To take an obvious example, I believe it is possible to simplify electronic health records by letting patients enter their own data and histories electronically, by making it easy for doctors to enter their humanistic and scientific interpretations electronically through improved speech recognition technologies, for patients to enter the exam room with the differential diagnosis spelled out, for patients to leave their doctor encounter with their complete medical history and treatment plan in hand.I believe it is possible for doctors and patients to communicate by Skpe and by email between physical encounters.

This will not be easy. Google has already given up on its project to digitize Patient Electronic Records, but Google working behind the scenes with Microsoft to reintroduce PHRs.

The stakes to integrate and humanize doctor-patient digital information exchange to the benefit of both and for society are enormous, but it make take another Steve Jobs to make it happen.

Tweet: Steve Jobs’legacy? He integrated the humanities and technologies and showed us what was possible and what we needed before we knew it.

Saturday, October 29, 2011

Book Review: Comprehensive Healthcare Redesign: 25 Keys to Healthcare Redesign, by Dave Racer, Alethos Press, St. Paul, Minnesota , 97 pages, 2011, $15

If we are to achieve a richer culture, rich in contrasting values, we must recognize the whole gamut of human potentialities, and weave a less arbitrary social fabric, one in which each diverse human gift will find a fitting place.

Margaret Mead, (1901-1978)

October 29, 2011 - In most peoples’ minds, 3 basic ways exist to achieve “ comprehensive redesign” of the U.S. health system:

• One, a single-payer system

• Two, a market-driven system

• Three, a combination of the two with built-in managerial controls and goals, aka, Obamacare

To these three, Dave Racer, author of 28 books, publisher, health care analyst, and veteran health care commentator, proposes a fourth idea - a bottom-up culturally-driven system composed of patients and doctors acting commonsensically with high moral principles.

In this gem of a little book, Racer explains why the first three systems haven’t worked and will not work.

He is basically saying: It’s the culture, stupid! Our health system is a creature of American culture – our 311 million polyglot population, our wealth, our Constitution, our centrist bent, our resistance to authority, our partisan politics, our wants, our needs, our health-harmful behaviors, our unrealistic expectation that someone else will always pay.

In Racer’s words, “ We cannot reform the current system. It needs to be redesigned, but from the bottom-up, not the top down. Ask the people who get their hands dirty everyday while paying for and delivering the world’s best health care.”

He supports his argument with an extensive review of the health care literature and these 25 key features of American culture.

1) The population of the United States – The U.S, he says, with its 311 million people, is the world’s 3rd largest nation – a “nation of nations, “ with wide racial differences, a heterogeneous ethic mix, and a tendency to behave as we please, These characteristics make us different than any other country.

2) We live in the richest nation in the world – We therefore have more disposable income. We spend more on health care because we can.

3) Public health systems result in cost shifting to private health care – Medicare and Medicaid don’t pay what it costs to provide the care. So we shift roughly $90 billion to the private sector.

4) Wasteful health spending - We waste enormous amounts of money in our free-wheeling culture because patients often do not comply with doctors’ orders, behave in manners destructive to their health, and show up at doctors’ offices with incomplete medical records with resulting duplications due to our fragmented system.

5) We are a compassionate people – We have developed government sponsored community health centers and laws that say hospitals must accept all comers, including illegal immigrants. People forego personal responsibility for their health because they know the system will care for them and may well fix behaviorally-induced problems..

6) As a people, we are growing older - 77 million baby boomers will become Medicare-eligible in 2011, those of us over 85 will double by 2020, and 40% of us will be 50 by 2050.

7) We embrace and protect the life of our tiniest infants - The cost of neonatal ICUs is $10,000 a day, the total ICU bill may run $250,000, and costs after the ICU may run $40,000 or more for the first year of life.

8) We spare no expense to extend human life as long as possible
- CMS says 28% of their Medicare budget is spent caring for patients in the final year. We spend lavishly on high tech procedures that increase function and relieve pain and keep us feeling young, no matter what the costs. . Racer observes, “It is the nature of the United States’ culture to preserve and extend human life, even when it makes no medical sense to do so.”

9) We provide long term care for aging and infirmed residents - Medicaid is the main payer for elderly long-stay residents , accounting for 68% of the cost of care for those residents in 2007, and likely even greater today.

10) We refuse to say “No” to people who abuse themselves. We pay for the care and treatment of drug addicts, promiscuity, smokers, the morbidly obese, through higher taxes and cost shifting to those who own private insurance.

11) We pay whatever it costs to provide care to those with chronic illness – Paying for those 133 million Americans with chronic disease consumes 75% of medical costs, yet we spend little to prevent these diseases. Many of these conditions can be traced to bad personal habits – lack of exercise, obesity, lack of exercise, alcohol, or drugs.

12) We demand the latest and best services - We follow closely recently announced medical breakthroughs and technological advances, and we bring pressure to bear to make insurers pay for them, whether they are proven to work or not.

13) We want to live pain free, but do not want to pay for it ourselves.

14) We want immediate emergency care.

15) We expect immediate access to doctors.

16) We live risk-filled lives and expect health care to fix it.

17) We are a society of overweight people.

18) We take advantage of health plans.

19) We pay health professionals high incomes.

20) We sue doctors.

21) We expect others to pay our health bills.

22) We have no idea how much health care costs

23) We tolerate a dishonest and misleading health care billing system

24) We abuse high deductible health insurance plans

25) Politicians

Most of these 25 observations are self-evident. Taken together, they explain why are costs are so high.

But observing them is one thing, cursing their dark side is another, correcting or modifying them is quite another.

Racer suggests three strategies for redesigning the system:

1) encouraging people to minimize costs by taking better care of themselves;

2) moving to a system, such as health savings accounts with high deductibles to encourage financial discipline by having patients spend more of their own dollars up front, thereby having a higher personal stake in health care;

3) having “Christian individuals, in particular, practice what the Scriptures teach about personal health and finances and Christian compassion for others.”

These are laudable strategies. Some are gaining traction. Wellness is much in vogue. People are more health conscious. Fitness centers are springing up everywhere. Employers are setting up and rewarding measurable good health. About 12 million Americans now have health savings accounts; 30% of employers are offering high-deductible plans . The Christian evangelicals are making themselves heard through the Tea Party and other forums.

But let’s face it. We live in a secular society in which anything goes. It promises freedom to behave as one pleases, with no penalties for misbehavior, and expectations that someone else will pay.

Cultural changes come slowly and from within. Our permissive society does not lend itself to top-down legislative actions. One cannot legislate behavior or morality.

I recommend Racer’s book. It tells us why we have the health system we have and why our culture makes it difficult to change.

Friday, October 28, 2011

Support for Health Reform Law Hits All-Time Low

The health reform law’s popularity hit an all-time low…Just 34% of those surveyed said they had a favorable view of the Affordable Care Act.

Jason Millman, “Kaiser Poll Finds Drop in Support for Health Reform Law," Politico Pro, October 28, 2011

Forward, the Left Brigade,
Was there any dismay’ed?
None of them knew,
Theirs not to make reply,
Theirs not to reason why,
Theirs but to do or die,
Into the Valley of Defeat,
Rode the Valiant One-Third.

Republicans to the right of them.
Democrats to the left of them.
Independents in front of them,
Volley’d and Thunder’d
Storm’d with shout and yell,
Boldly they rode and well,
Into the Jaws of Defeat,
Into the Mouth of Hell,
Rode the valiant One-Third.

Apologies to Alfred Lord Tennyson, Charge of Light Brigade, 1870

Thursday, October 27, 2011

Language Matters: The Case of Defined Contributions, High Deductibles, Vouchers, HSAs, and HRAs

Then you should say what you mean," the March Hare went on.
"I do, " Alice hastily replied; "at least I mean what I say, that's the same thing, you know."
"Not the same thing a bit!" said the Hatter. "Why, you might just as well say that "I see what I eat" is the same thing as "I eat what I see!"
Alice in Wonderland

October 27, 2011 - Small and large businesses are shifting at least 30% of their employees to high deductible plans, HSAs, and HRAs.
At the same time, policy makers on the right are talking about “defined contributions” for Medicare and Medicaid. Paul Ryan, the Republican Congressman from Wisconsin, has the audacity to suggest Medicare recipients be put on “vouchers,” what they eat after government entitlements, they have to pay for.

All of these things, no matter what the wording, involve shifting costs and decision making to patients and away from government and employers.

The intent of the shift is to sensitive patients, or if you prefer, health care consumers, to true cost of care, to give them “skin in the game” so they will be more prudent in spending their health care money.

Underlying this shift is the realization that the U.S. can no longer afford unlimited government entitlement programs or private first dollar coverage.

But different words have different meanings to different political constituencies. To those on the left, use of the words “voucher” and “defined contributions are no-no’s. Their use implies that patients, not government, possess the wisdom and knowledge to make their own decisions and leaves government-dependents open to market abuses.

To those on the right, these various terms mean freedom to choose and the exercise of individual liberties.

I won’t take a position on who is right and who is wrong, or on whether patient decisions should be left to the left or to the right.

But I do know this.

• According to the October 26 Kaiser Health News,

Health plan deductibles keep inching up.

When employees sign up for coverage this fall during their company’s annual enrollment period, nearly a quarter will face annual deductibles of at least $1,000, according to a recent employer survey by the Kaiser Family Foundation.

At small companies, the high-deductible option, often served with a tax-preferred savings account, may be the only choice. But larger firms are more likely to offer at least one traditional PPO or HMO plan alongside a high-deductible choice.”

• American Health Insurance Plan census data in 2011, shows the number of people in Health Savings/High Deductible plans grew to 11.4 million, up from 10 million in 2010, 8 million in 2009, and 6 million in 2008.

Apparently, more employers and more consumers (at least those given a choice) have decided Health Savings Account (HSA) Plans are not just health insurance. They are lower-cost, high-deductible insurance plans, potential tax deductions, and savings accounts with investment opportunities similar to IRAs and Roth accounts.

Tweet: Employers are shifting employees to high deductible plans and HSAs, and policy makers are considering defined contributions and vouchers

Wednesday, October 26, 2011

Health Law Supporters Sweeten The Name "Obamacare"

October 26, 2011 - As I compose these blogs, I often use the name “Obamacare.” I do not use “Obamacare” as a conservative put-down, but because it is less awkward than “Affordable Care Act,” less stuffy than PPACA, and more graphic than “the health reform law.”

As Shakespeare would say, “What’s in a name? That which we call a rose by any other name smells as sweet.” Or as Gertrude Stein remarked, “ A rose is a rose is a rose is a rose.”

Here;s what Kaiser Health News has to say on use of the name “Obamacare.”

The campaign, which is based in Colorado, will highlight the law's benefits.

Denver Post: Yes, Please Call It "Obamacare," Say Supporters Of The Affordable Care Act

"Obamacare" is typically the put-down conservatives use to describe the Affordable Care Act signed into law by the president in 2010, and the moniker offends some people who favor the measure. But liberal groups in Colorado are now embracing the term, effectively saying conservatives may have shot themselves in the foot by making the health care reform law synonymous with President Obama's tenure in office (Hoover, 10/24)

The Hill: Health Care Reform Law's Backers Hope To Reclaim 'Obamacare' Label

Supporters of the health care reform law launched a new campaign Monday to reclaim the term "Obamacare" and highlight the law's benefits. Two Colorado-based groups created the website "thanks Obamacare," which outlines provisions such as the ban on insurers discriminating against people with pre-existing conditions. There's also a "thanks, Obamacare" Twitter account (Baker, 10/24).

Tweet: Use of ehe name "Obamacare" to describe the health care law can be taken as a compliment rather than as an insult.

Tuesday, October 25, 2011

Fifteen Obamacare) Assumptions

A plan is only as good as its assumptions.


October 25, 2011 – The success and rationale of the health care law enacted on March 23, 2010 rested on these rosy assumptions.

1. The Obama administration assumed, given the bully pulpit and mainstream media cooperation, it could direct, lead, and shape the national discussion supporting the law.

2. In time, voters would grow to embrace the law.

3. Progressives, in the media, Congress, and at the grassroots, would step up in droves to defend the law.

4. Front-loaded sweeteners – reducing drug costs for doughnut hole seniors and guaranteeing care for pre-existing illnesses and students under parents’ plans – would offset fears of rationing, effects of Medicare cuts, bureacrats as doctors, and tax hikes.

5. Political promises would prove more powerful than economic results.

6. Physicians and other health care professionals would accept, act upon, and believe in savings and improvements in quality from universal interoperable electronic records, intensive chronic disease management, cost-saving accountable care organizations, and paying only for those conditions with positive risk-benefit analyses.

7. The public would accept the notion of benefits now(until 2014) with cost reductions later (2014-2020).

8. Costs would go down, access would go up, people would keep their doctors and their current plans, and quality would increase.

9. Medicare cuts would cause hospitals to reduce admissions of seniors.

10. Medicare Advantage Plan phasing out would be acceptable to seniors on these popular plans.

11. Employers would swallow costs associated with rules and regulations of government-endorsed plans without dumping current plans and forcing employees into Medicaid.

12. Millions of younger healthier adults would willingly pay monthly premiums for ultimate long-term care in private homes and nursing homes.

13. The states would passively accept the administrative and cost burdens of caring for millions of new Medicaid patients and setting up federaly-guided health exchanges.

14.The humanities and IT technologies would hyperconnect – uniting the social media with Web-enabled smart phones with thousands of wireless apps – the combination of which would then ascend into “the cloud” to become a more perfect Health 2.0, which would then morph into Health 3.0, which would then become a technological Holy Grail in which anything imaginable was possible.

15. With generous government stimuli and projected Obamacare savings, the economy would improve or stabilize before the 2012 elections.

Tweet: The assumptions and results of the health reform law, passed 18 months ago, have not yet lived up to promises.

Monday, October 24, 2011

The Four-Legged Stool of Health Care Innovation

Imagine for a moment a four-legged stool. It’s a useful device, but only if all four legs are of equal length so that the stool is “stable” and meets the use for which it was intended. Now, think of the stool as your library, and think of its legs as the four components that make up how you deliver services and/or products. The four legs represent People, Processes, Organization, and Technology.

Jan A. Baltzer, Computers and Libraries, April 2000

October 24, 2011 - Health care innovation is a four-legged stool.

The four legs are:

One, Government (Medicare, Medicaid, and Tricare) - CMS spends nearly $1 trillion on health care, and its spending is the fastest growing component of our $15 trillion national debt. This year, government will account for 50% of health spending.

Two, Physicians – Together, largely through physicians ordering through their pens and computers, pysicians now account for the other 50% of spending, much or most of it in hospitals and in other high tech facilities.

Three, Patients - Upon whom the money is expended for their benefit and the benefit of those who provide the care.

Four, The Health Care Industry - The vast medical industrial complex, which includes venture capitalists, investors, suppliers, drug companies, health plans, and the information technologists. The latter helps bind it all together.

A Wild and Crazy Idea

I have this wild and crazy idea that the convergence of the IT social media – Facebook, Twitter, and other sites – and the wireless technologies and devices and smartphones and those vast server farms called “the cloud” that care can be interconnected, accessed, optimized, and documented into a more harmonious whole, just as Steve Jobs did for IT with the Microsoft computer , Ipad, Ipod, and Iphone.

I have the equally crazy idea that each leg of the stool is indispensible, can’t stand alone, and must depend on the other three legs for maximum benefit to society. This realization comes at a critical time, for the four legs have been striving to get a leg up on each other and have expressed skepticism on the motives of each other.

Each with a Role to Play

Yet each has a role to play – each best understands their own infrastructure and culture – but each relies on the others for support and coordination. No one stands alone. Only then can the knowledge of each be supported with sufficient capital to get the collective job done.

Without monetary incentives, innovations to keep the stool upright usually fail and fall onto fallow ground. Even social justice measures and safety net improvements require margins to carry out their missions.

An Example - Hospital Readmissions

Consider this specific example (and there are thousands of others) - readmission of recently discharged patients to the hospital. This readmission occurs with 20% of patients.

Readmissions are a significant expense for Medicare, running about $1 billion per year. Most of these readmissions are preventable.

Physicians and nurses are critical in preventing these readmissions, but these patients have such chronic diseases as heart failure and chronic obstructive lung disease and are bed-ridden and home-bound and beyond the immediate reach of medical personnel when complications occur.

The patients themselves usually know that complications are occurring within their bodies. but they may have difficulty communicating their problem to caregivers in medical settings such as their physician’s office or the hospital.

Enter innovation entrepreneurs from the hospital industry. According to a November 2007 report by Venture Wire, American Telecare, a remote health-care device maker in Eden Prairie, Minnesota, m Remote healthcare-device maker American maker of communication devices and technology for remote healthcare monitoring, raised $1.6 million from angel investors. The company has previously raised $16 million from angels.

The company places an audio-visual device at the bedside of home-bound patients. When the patient wishes to communicate with doctors over a perceived complication , patients can initiate an audiovisual conversation over ordinary phone lines.

Not only does the device permit voice and visual contact, but it permits the doctor or nurse to record weights and blood pressures, record blood oxygen levels, and listen to the chest with a stethoscope. Patients quickly become knowledgeable about complications and when to call. In one Telecare study, this approach reduced readmissions to virtually zero for patients with chronic heart failure.

Perhaps this approach could be extended to a vast new audience of patients using Skype technologies. After all, as of September 2011, 663 million people around the world were Skype users.

Tweet: Health care innovations are a 4 legged stool - government, physicians, patients, and the health care industry. Each has a role to play.

Sunday, October 23, 2011

A SOCIAL Approach to Health Reform

Knowledge is of two kinds. We know the subject ourselves, or we know where we can find information about it.

Samuel Johnson (1709-1784), from Boswell: Life of Johnson, 1763

October 23, 2011 – Every Sunday, I read the Sunday NYT in search of ideas for a blog. Today is no exception. I found the idea in Thomas Friedman’s column, “The New IT Revolution,” in which he holds forth as follows,

"The latest phase in the IT revolution is being driven by the convergence of social media- Facebook, Twitter, LinkedIn, Groupon, Zynga- with the proliferation of cheap wireless connectivity and Web-enabled smart phones and “the cloud” – those enormous server farms that hold and constantly update thousands of software applications, which are then downloaded (as if from a cloud) to make them into incredibly powerful devices that can perform myriad tasks.”

The SOCIAl Acronym

Friedman then goes on to quote Marc Benioff, founder of, who describes this phase of the IT revolution with the acronym SOCIAL.

S is for Speed – This means physicians and patients can find anything and everything about health care (and each other),

. O is for Open - This means physicians are out in the open and can no longer hide their results or reputation.

C is for Collaboration – This means physicians must organize among themselves or affiliated hospitals or into loosely coupled teams to take on the new challenges posed by society in general and health reform in particular.

I is for Individuals - This means anyone - physicians, patients, and entreprenuers - as individuals can reach around the globe to start something or collaborate or consolidate to improve care – faster, deeper, and cheaper – as individuals.

A is for Alignment - physicians with each other or with supportive health organizations to make sure all your ships are sailing in the same direction.

• L is for Leadership – This means physician leaders are going to have to mixs top-down and bottom-up forces – from public and private sectors – to provide what is best for themselves, patients, and society.

The Effect if SOCIAL Forces

SOCIAL forces will make it easier for physicians to become entrepreneurs and to have access the infrastructure and the capital necessary for true innovation and entrepreneurship.

SOCIAL requires that money and social capital be available from government programs, sparked by CMS initiatives such as the Innovation Advisors Program; from nonprofit organizations such as the Physician Foundation, which has provided over $20 million in grants to over 40 physician and social organizations; and from risk-taking private venture capital organization, from Silicon Valley and elsewhere, which demand profits for investors to survive and thrive.

Tweet: A new IT revolution, wireless social media convergence, will take money fron CMS, private health sources, and venture capitalists, to thrive

Saturday, October 22, 2011

Still No Deal on ACOs

October 22, 2011 - In a blog in The Health Care News, released today, “CMS Wants Docs to Ante Up to ACO Poker Game,”Michael Millenson, a health care consultant, visiting scholar at the Kellogg School of Management, and author of Demanding Medical Excellence and Accountability in the Information Age, concludes,”The ACO program should be attractive enough to entices some of the high rollers names in health care to belly up to the table.” The editor of The Health Care Blog as asked me to respond to Millenson’s post.

Here is what I had to say,

"There's a card game named Dead Man's Poker. It's an apt name for the first ACO rules, released in March 2011, which individual physicians and physicians in large integrated organizations universally declared DOA(Dead on Arrival) because of the time and energy required to set them up and the risks of antitrust review.

Changing the rules of Dead Man's Poker by cutting quality measures friom 65 to 33, offering more flexibility in antirust review, loosening rules of governance and legal structure, altering time to repay losses, being told what Medicare recipients can be part of the ACO, sharing Medicare savings earlier and reducing risk of losing dollars, extending the time to apply throughout 2012, and making $170 million to set up ACOs, expanding payments in rural areas and qualified federal centers, and ending the absolute demand for physicians to have EHRs to participate, does not change the status of ACOs from DOA (Dead on Arrival) to AAB (Alive at Birth).

CMES estimates the new rules will induce 50 to 270 ACOs to form and will save Medicare $960 million

CMS is whistling past the graveyard. Physicians will not rush to join ACOs. They are waiting to see what the Supreme Court decides on the constitutionality of Obamacare, what the results of the November 2012 election portend, and whether Republicans can succeed in their efforts tto repeal the health care law. Until these things transpire, for most physicians, it will still be no deal on ACOs.

Tweet: CMS has issued a new rules for ACOs to induce doctors and hospitals to form these organizations. To most MDs, it will still be no deal.

Friday, October 21, 2011

Random Survey of Passing Health Reform Scene

I am monarch of all I survey.

William Cowper (1731-1800)

October 21, 2011- This morning I shall take a shot at what I see on the passing health care reform scene.

• After three years of the Obama presidency, the number of uninsured is now over 50 million. The high number of uninsured can be traced to a lousy economy, high unemployment, and the Medicaid mix. This mix includes those in poverty, legal and illegal immigrants who don’t know how to become Medicaid recipients, and healthy “young invincibles” who have other things on their minds. The rate will continue to rise until the economy gets better and when, and if, Obamacare survives until 2014, when 32 million are slated to enter Medicaid. The health law’s survival depends on the Supreme Court’s decision on the constitutionality of the Affordable Care Act and Republican’s efforts to repeal the law.

• According to The Washington Report, a periodic news analysis, prepared for the Physicians Foundation, a nonprofit organization representing over 500,000 physicians in state medical societies, the Super Committee appointed to resolve the budget deficit by November 23 is having a huge problem breaking the deadlock between Democrats and Republicans. Democrats insist there be no cuts in Medicare and Medicaid, Republicans that there be no tax increases. If this issue remains unresolved, across the board cuts will kick in, cutting Medicare and Medicaid and slashing hospital and physician revenues. Meanwhile, the Obama administration is backing off its initial position on Accountable Care Organizations, by reducing the number of regulations from 65 to 33 and ending demands that all physicians joining ACOs have electronic medical records. Changes and add-ons increased the number of pages in the CMS final rules from 429 to 696, showing again the penchant of the administration for bureaucratic verborrhea, and in the process, stiffening resistance of physician groups and hospitals to ACOs.

• Finally, Robert Samuelson, of Newsweek, in a column “Obamacare’s Broken Promises,” predicts, “ Hard times continue for the Affordable Care Act (aka Obamacare). The administration has scrapped the law's long-term care insurance program, covering nursing homes and home health care. The program was deemed unrealistic. This is a harbinger. As the law is implemented -- assuming the Supreme Court doesn't declare it unconstitutional or Republicans don't repeal it -- disappointments will mount.”

As a solution to paper over these broken promises, Samuelson cites a paper in the New York Review of Books by Arnold Relman, MD, former editor of the New England Journal of Medicine, and a champion of single-payer and salaried physicians in large groups.

Here is what Relman has to say,

"Physician-owned not-for-profit groups, particularly those that pay their doctors at least partly by salaries, are not as likely to provide unnecessary services or to recommend hospitalization when it is optional. Their physicians have few financial incentives to do so, and the services of their specialists are coordinated with their primary care doctors, who usually recommend the simplest and least expensive choices consistent with good medical care. In today’s political climate these reforms have no chance, but this could change if physicians continue to join groups and transform the organization of medical care.”

Relman thinks this movement could snowball, An apt metaphor. I give Relman's plan the chance of a snowball in hell.

Tweet: Health reform scene - uninsured have passed 50 million, the super committee to cut debt is deadlocked, and hard times plague Obamacare.

Thursday, October 20, 2011

CMS Launches Innovation Advisors Program

October 20, 2011 - As a native of Oak Ridge, Tennessee, creator of the Medinnovation Blog, and author of Innovation-Driven Health Care, I could not help but notice the following announcement.

The Centers for Medicare & Medicaid Services announced Monday that it is accepting applications for a program designed to help healthcare professionals drive improvements to patient care and reduce healthcare costs.

CMS administrator Don Berwick, M.D., was on hand to kick-off the $6 million program, which will recruit up to 200 innovation advisors "with the knowledge and the vision to find innovative ways to improve care and reduce costs for beneficiaries in Medicare, Medicaid, and the Children's Health Insurance Program." The CMS Innovation Center will manage the program.

Let me explain why I am interested. The Oak Ridge Institute of Science and Education in Oak Ridge, Tennessee will manage the program. I grew up in Oak Ridge,a community that supplied the uranium for the atomic bomb in World War II.

The deadline for applications for Innovation advisors is Nov. 15; participants will be selected by Dec. 15. An initial group of 50 innovation advisors will be selected to gather in Washington, D.C in January 2012 to begin six months of orientation and training.

A second group of 150 advisors will begin orientation by mid-2012. Training will include in-person national and regional meetings, virtual training sessions, seminars and presentations by healthcare experts. Selected advisors will be paid $20,000 to reimburse them for travel and time.

One of the goals is for each participant to take what they learn during training and apply it to their home organizations and areas, explained Joe McCannon, senior advisor to Dr. Berwick. Innovation advisors will be expected to develop and implement a hands-on systems improvement project.

Although I am pleased CMS is supporting such a program fostering innovation, I am dubious about its outcome.

Why my doubt?

• In the first place, the government built Oak Ridge on a wartime footing in a race to develop the Atomic Bomb before Germany. It was a case of national survival. I do not regard health care reform as administered by CMS as a similar situation. Yes, Medicare and Medicaid are the largest contributors to our growing national deficit. Yes, these government programs need to be reined in, but is a CMS program on innovation the way to do it? This may well be a fox in the henhouse situation.

• Two, the government, and its largest agency, CMS, which now spends close to $1 trillion annually, is not very good at innovation. The reasons for its incompetence in innovation are legendary:

--Once launched, government programs continue in perpetuity, even after they fail, because they are spending taxpayer money not private money. There is no incentive to shut down programs. Private venture capital programs are quickly shuttered when investors perceive actual or impending failure. Failure is not necessarily a negative for government.

-- Supporters of government innovation represent vested special interests, which contribute heavily financially to political coffers, the Solyndra solar project being the latest example. Too often political winners turn out to be business losers.

-- Government shackles, stifles, surrounds, and suffocates its projects with bureaucratic rules, regulations, and restrictions. To me even the instructions to potential advisors sound bureaucratic,

“Crucial to the efforts of transforming the healthcare system is supporting individuals who can test and refine new models to drive delivery system reform. The Innovation Center seeks to deepen the capacity for transformation by creating a network of experts in improving the delivery system for Medicare, Medicaid and CHIP beneficiaries.”

I contend, perhaps wrongly, that we already have too many experts instructing us how to transform a market-driven system into a government-driven system.

Tweet: CMS has launched a program to pick 200 innovation advisors to help improve the transformation of health care to a government-run system.

Wednesday, October 19, 2011

Health System Complexity - Why Obamacare Falls Short of Its Promises

October 19, 2011 - To understand why the health reform law is falling short of its promises – to reduce costs, expand access, allow you to keep your present plan and doctor, and improve quality of care – I recommend you read this October 19 blog of John Goodman.

John Goodman Blog, Health Care as a Complex System

Our health care system is an example of what social scientists call “complex systems.” These systems are so complicated that no one person can ever fully grasp everything that is going on. As individuals all we ever really see is a small slice of the system. That’s usually the part of it that we interact with.

The economy as a whole is an example of a complex system. Of the subparts of our economy, health care is by far the most complicated. It is many times more complex than a normal market, for example. The reason: in addition to garden variety economic forces, the medical marketplace is institutionalized, bureaucratized and enormously regulated.

Doctors are heavily influenced by medical ethics and traditional ways of doing things. Almost everything they do is impinged upon by third-party payer bureaucracies. And almost everything they do is influenced by myriad regulations that are inconsistent, voluminous and complex, to say nothing of the ever present threat of tort law litigation.

In addition to all that, we have completely suppressed normal market processes in health care — in this country and all over the developed world. As a result, rarely does anyone in health care ever see a real price for anything.

Employees never see a premium reflecting the real cost of their insurance. Patients never see a real price for their medical care. Doctors and hospitals are rarely paid real prices for the services they render.

Instead, they are paid on the basis of “reimbursement formulas” and there can be a different formula for each payer. Enormous amounts of money change hands every day in the medical marketplace, but most of the conventional rules of economics do not directly apply.

Complex systems can never be accurately modeled. Since the days of Adam Smith, economists have been trying to understand some general features of markets by creating simplified models. These models are necessarily very crude attempts to replicate some basic forces in the system as a whole. No model tries to capture everything that is going on in the economy, however. That would be impossible.

Nonetheless, economists have been able to use highly simplified models to predict some general effects of parameter changes in ordinary markets. For example, we can say with some certainty that a substantial increase in the minimum wage will cause unemployment. Rent controls will cause housing shortages. Price supports in agriculture will cause crop surpluses.

There is no reliable model of the health care sector. Unfortunately, there is no model of the health care system that allows us to make anything like the predictions we can make in other markets.

In just a few years, ObamaCare will insure an additional 32 million people. In addition, most of the rest of us will have to convert to health plans that have more generous coverage than we now have. We know from past studies that when people become insured, they tend to consume twice as much health care. We know that when people have more insurance coverage they consume more care. But what happens when there is a system-wide increase in demand and no change in supply?

Will the excess demand drive thousands of people to hospital emergency rooms? Will clinics run by nurses start springing up everywhere to meet the demand that doctors cannot meet? In the face of a large increase in rationing by waiting, will everyone who can afford them turn to concierge doctors? As more doctors become concierge doctors, how will the system manage the even greater rationing problem faced by all those left behind? Will patients start going out of the country — seeking care in the international medical marketplace?

Unfortunately, there is no model that allows us to answer these questions with any confidence.

Why can’t we apply ordinary economic models to health care markets? One reason is that price doesn’t play the same role in health care as it does elsewhere in the economy.

Although many would like to think that our system is very different from the national health insurance schemes of other countries, the truth is that Americans mainly pay for care the same way people all over the developed world pay for care. We pay with time, not money.

On the average, every time we spend a dollar at a physician’s office, only 10 cents comes out of our own pockets. As a result, the time price of care (the time it takes to get to and from the doctor’s office, waiting in the reception area, waiting in the examining room, etc.) tends to be greater — and probably much greater — than the money price of care, for most people.
In addition, there is increasing evidence that non-price obstacles to care are greater deterrents than price barriers.

In general, we have no reliable model to tell us who gets care and who doesn’t when the time price of care rises for everyone, as we expect to happen once ObamaCare gets fully phased in. Nor do we have any model that allows us to predict how care will be allocated when non-price deterrents are the principle form of rationing.

Complex systems have unintended consequences. An interesting characteristic of complex systems is that when you perturb them (by passing a law, for example) there are always unintended consequences.

The less you know about the system the more unpredictable these consequences can be. In economic history, for example, there are numerous examples of governments that adopted policies in an attempt to improve things, but ended up making the situation worse. Consider two examples from health care:

In 1965, Congress passed Medicare in an attempt to increase access to health care for the elderly and improve their health status. They believed they could do so without any material impact on the rest of the health care system. Yet MIT professor Amy Finkelstein has discovered that Medicare had no effect on the health of the elderly; but the additional spending did set off a bout of health care inflation for all patients which never subsided.

In 2003, Congress passed a Medicare drug benefit, largely out of concern that senior citizens couldn’t afford the coverage themselves. Since the new program (Medicare Part D) had no funding source, it created a $15.6 trillion unfunded liability for the federal government, looking indefinitely into the future — more than the unfunded liability in Social Security!

Yet Andrew Rettenmaier discovered that almost all of the spending, about 93 percent, simply replaced spending the elderly were already doing. Only one in every 13 dollars represented new drug purchases. Interestingly, the help given to the small number of beneficiaries who needed it actually reduced Medicare’s overall spending, as drugs were substituted for more expensive doctor and hospital therapies.

But this “profit” on the truly needy was overwhelmed by the cost of giving the benefit to those who didn’t need it and in the process creating an enormous obligation for current and future taxpayers.

Implications of Unintended Consequences.

Why are unintended consequences so important? Because in trying to solve one problem we can create other problems. Also in trying to solve problems, we can end up making them worse. ObamaCare has three principal goals: control costs, raise quality and increase access to care. Yet there is no model which allows us to predict that any of the three objectives will be even partially achieved. In fact, readers of this blog know that we expect all three problems to get worse.

That last sentence was not a misprint. We can actually spend a trillion dollars, create 159 new regulatory agencies, force almost everyone into a new health plan and — at the end of the day — end up with higher costs, lower quality and less access to care.

Tweet: Because the health system is so complex, the health reform law has not lived up to its promises or foreseen negative consequences.

Ins and Outs of Health Reform Places

October 19, 2011

I have been in many places, but I've never been in Cahoots. To be in Cahoots on health reform , you have to be in Cahoots with someone, and I remain in Dependent.

I've also never been in Cognito. To be in Cognito, you have to be In Visible, and I’ve written too many blogs and books to be in Cognito.

I have, however, been in Sane. I must have been in Sane. Otherwise I would not have written a blog a day for the last five years on Health Reform.

I would like to go to Conclusions. But to get to Conclusions, you have to jump, and I am too in conclusive to leap into deep doo-doo.

I have also been in Doubt. I will stay in Doubt, until the Supreme Court decides whether the Health Reform Law is constitutional or not. Until then I will be in Doubt.

I've been in Flexible. Some say I am in Flexible when it comes to health reform, but they are wrong. I am simply trying to keep my options in tact.

Sometimes I'm in Capable. I am In Capable of predicting the ebb and flow of in side politics and the ins and outs of public opinion.

One of my favorite places to be is in Suspense! I shall remain in Suspense about health reform, though secretly I suspect it will end up in the tank or in limbo.

My favorite place in which to reside is Complexity. The health system is too complex to reform since no one can grasp more than a small slice of it. Next to Complexity is a place called Confusion where I often visit.

Tweet: Understanding health reform requires living in Cahoots,in Cognito, in Sane, in Conclusion, in Doubt, in Flexible, in Suspense, and in Complexity.

Tuesday, October 18, 2011

Notable Quotes Relating to Health Reform

Abby Goodnough and Kevin Sack, “Massachusetts Tries to Rein in Its Health Costs, “ NYT, October 18, 2011

We have shown the nation how to extend care to everybody,” Governor Patrick said in an interview, “and we’ll be the place to crack the code on costs.”

Those who led the 2006 effort to expand coverage readily acknowledge that they deferred the more daunting task of cost control for another day. It was assumed then that the politics would pit doctors, hospitals, insurers, employers and consumers against one another, and obliterate the fragile coalition behind the groundbreaking coverage law.

The plan did little to slow the growth of health costs that already were among the highest in the nation. A state report last year found that per capita health spending in Massachusetts was 15 percent above the national average. And from 2007 to 2009, private health insurance premiums rose between 5 and 10 percent annually, according
to another state study.

Comment: Covering the uninsured, now down to 1% to 2% in Massachusetts, costs money and increases deficit spending. Obamacare, fashioned after the Massachusetts plan, is likely to have the same result.

Lisa G. Suter, MD,et al, “Medical Device Innovation- Is “Better Good Enough,” NEJM, October 20, 2011

Last year, the United States spent $95 billion , nearly half of the $200 billion spend on devices worldwide. Our investment in devices has yielded impressive gains in length and quality of life from products such as implantable cardioverter-debrillators, pacemakers, and artificial joints(cardiovascular and orthopedic devices accounts form more than 35% of the market). Roughly 10 million Americans have symptomatic knee osteoarthritis..More than 600,000 total knee arthroplasty procedures are performed annually in the United States; 85% report functional improvement.

Comment: Americans have an insatiable appetite for implantable devices that improve function and relieve pain, and health reform measures that either ration procedures or slow access to them will be politically unpopular.

Tweet: With health reform, Americans can't have their cake (universal coverage) and eat it too (unlimited quick access to high tech care)

Skype As An Innovative Solution to Reducing Hospital Readmissions

October 18, 2011 - I recently installed Skype, an online software application in order to talk regularly to my son, Spencer, who is now functioning as an Episcopalian Priest in Madrid Spain.

To do this, I simply bought a Skype camera and audio device for $43 to attach to my personal computer. Now I can dial my son’s number and talk to him free of charge, with full visual and audio contract by simply clicking in his Skype number.

When you talk of innovation, it is important to be specific. Otherwise what you say falls on deaf ears. To speak of innovation is easy, to give specific practical solutions is more difficult.

Here I will suggest that Skype, an online service now operated by Microsoft, offers a specific solution to the problem of hospital readmissions, which cost hospitals, Medicare, and Medicaid a bundle. As of September 2011, Skype had 663 million users, which means it is practical for almost anyone to use.

Because of government regulations limiting payment for DRGs (Diagnosis Related Groups), CMS pays only for a limited number of days for a given diagnosis. To avoid being penalized for overstays, hospitals may discharge patients “quicker and sicker” to avoid Medicare payment penalties.

Unfortunately, some 20% of these patients are readmitted. Medicare and Hospitals have to swallow the costs of readmission and more extended hospital stays.

These readmissions are avoidable. I pointed this out in a blog describing an innovative program developed by a company in Minnesota, whose CEO is an internist named Randy Moore.

Randy Moore, MD, CEO of American Telecare, Inc, in Eden Prairie, Minnesota, whose firm has placed audiovisual devices connected by ordinary phone lines at the bedside of chronically-ill, home bound patients.

Through these devices, doctors and nurses can monitor weight, blood pressure, blood oxygen, listen to the heart and lungs, and observe the patients. Patients control the devices and have proven to be extraordinarily adept at learning and spotting their own complications.

The result? Readmissions to the ER and the hospitals have dropped dramatically. These audio-visual devices, which carry data over phone lines, could installed in the homes of millions of people with heart disease and chronic obstructive lung disease, the #1 and #4 causes of death in America, and leading causes of hospitalization. Experience has shown patients equipped with these devices next to their bedside become extremely adept at recognizing those signs and symptoms that lead to ER visits or hospital admissions.

Why not have hospitals and their doctors and nurses buy laptop computers, which now routinely have Skype audio and visual attachments, for patients discharged with diseases, such as congestive heart failure and COPD, to take home with them?

Patients could keep these laptops near their bedside. When patients feel they are developing a complication, they could use Skype to call the hospital. Hospital personnel could then judge the situation with a full view of the patient and take appropriate action. It’s not the same as a physical face-to-face evaluation, but it’s close and it’s much less expensive.

Tweet: Homebound chronically-ill patients could use Skype to notify hospital personnel of complications and prevent readmissions.

Monday, October 17, 2011

A Visit with a Socialist Physician

October 17, 2011 - I visited a private doctor today in his office. He was an endocrine specialist. His medical skills, interactive manner, and thoroughness impressed me.

Towards the visit’s end, I asked, “What do you think about the current state of health reform?”

He replied emphatically,“ I am a socialist!”

I asked: “What does that mean?”

He answered without hesitating, I’m paraphrasing. But this is the gist of what he had to say.

I believe everyone ought to receive government-sponsored basic care at no cost at the point of care.

I believe general taxation ought to wholly support the system.

I believe government ought to pay for medical education and post-graduate training of all physicians.

I believe government ought to set all physician fees.

I believe government ought to end malpractice insurance.

I believe private insurance companies , Medicare, and Medicaid ought to be eliminated.

I believe drug companies and all firms in the health care product chain ought to be heavily regulated, and government ought to set their prices.

I believe the profit motive has no place in health care transactions.

I believe government ought to employ all doctors and place them on salaries.

I believe if you want more care than government offers, you ought to pay for it.

I said, “Are you going to vote for Obama?”

He retorted, “Are you kidding?”

He was all for one , and one for all, but believed some are more equal than others when it comes to paying for non-government care.

I thought of sending him a copy of my book, The Health Reform Maze. I I decided not to. The book says health care is too complicated for simple solutions, and doctors must give incentives to doctors and patients for the best care, and patients must be given freedom to choose between public and private care.

Socialized medicine is great in the abstract. It takes profits out of medicine. Except without profits, no one can carry out their mission.

Sunday, October 16, 2011

Health Reform - Vertical and Horizontal, Focused and Unfocused.

Let us honor if we can
The vertical man
Though we value none
But the horizontal one.

Wystan Hugh Auden (1907-1973), Epigraph for Poems, 1930

October 16, 2011- In the health care realm , I tend to be a horizontal thinker in a vertical world. Put another way, I’m a generalist in a world that caters to specialists. Federal policy makers think the same way. They feel broadening the primary care base will rationalize the system, make it more efficient, and lower costs.

Which reminds me of the writings of Edward de Bono, MD (1933- ), a London-based doctor who runs a think tank institute in Malta. De Bono came up the concept of “Lateral Thinking. ”

De Bono visualizes the medical landscape as a series of vertical holes. Each hole comes stacked with specialists with a world-class expert at the bottom of each hole. The trouble is, he says, that no lateral connections exist between the vertical shafts in a horizontal medical world.

Policy makers, and Obama’s government experts, call this lack of lateral connections as “fragmentation.” They claim the problem of equal access could be solved by herding primary care doctors, specialists, and hospitals together into accountable care organizations – a solution roundly and soundly denounced by even quasi-ACOs like Mayo, Kaiser, Giesinger and other integrated groups.

The solution, according to policy and Obama folks, is to reconnect the vertical holes with armies of newly trained primary care doctors. Put a primary care lid on the entrance to the vertical shafts. Make generalists better-paid than specialists. Have the cognitive doctors funnel and control referrals to procedural specialists.

The problem, of course, is: that is not the way the world works. Patients prefer to go directly to specialists, or to specialty-oriented organizations in which the primary care doctors are closely allied with the specialists.

What goes on in the real world is that hospitals developed specialty lines of service, most often related to heart, orthopedic, or cancer care. Specialists, in their turn, develop and own facilities in which they focus on one line of service – cataract surgery, joint replacements, minor cardiac procedures, hernias, rehabilitation techniques, back-pain services, diseases like diabetes, and so forth.

Regina Herzlinger, PhD, a tenured professor at Harvard Business School, where she teaches MBA-seeking physician entrepreneurs, calls those vertical organizations “focused factories.”

Here is how Hwezlinger explains these “factories.”

The American health care industry is filled with opportunities to establish focused factories, ranging from those that perform one procedure, like cataract surgery, to those that provide the full panoply of care for a disease like cancer. To fulfill the promise of focused factories, however, the industry will have to resize, that is, replace its unfocused multiple providers and redundant , underutilized technology with muscular focused factories loaded with cost-saving , quality-enhancing medical technology

The simplicity and repetition inherent in “focused factories, “ which health care people prefer to call “centers of excellence,” is competence coupled with low costs and fewer complications.

Congress, under pressure from the general hospital industry, has outlawed physician-owned orthopedic and heart-owned hospitals. But don’t fret. Focused factories will be back in other forms – short-term ambulatory surgery facilities, non-invasive treatment centers, and centers detached from hospitals, and diagnostic and disease centers.

You can keep the vertical down or flatten the vertifal into the horizontal.

Tweet: Specialist-oriented centers of excellence, sometimes called focused factories, are proliferating across the medical landscape.

Saturday, October 15, 2011

Another Obamacare Debacle: CLASS Crashes

October 15, 2011 – The demise of CLASS, a long-term insurance program, is another example of how the Obama and the Democrats, in their rush of make history, failed to think through the financial implications of consquences of key provisions in Obamacare.

The Obama administration yesterday pulled the plug on a major program in the president's health law – a long-term care insurance plan dogged with doubts over its financial solvency. Known as CLASS, the Community Living Assistance Services and Supports program was a long-standing priority of the late Massachusetts Democratic Sen. Edward M. Kennedy.

The program became a major casualty in the health care law war. It was scheduled to launch in 2013.

Although government sponsored, it was supposed to function as a self-sustaining voluntary insurance plan, open to working adults regardless of age or health. Workers would pay an affordable monthly premium during their careers and could collect a modest daily cash benefit of at least $50 if they became disabled later in life. The money could go for services at home or to help with nursing home bills.

But a central design flaw dogged CLASS. Unless large numbers of healthy people willingly sign up during their working years, soaring premiums driven by the needs of disabled beneficiaries would destabilize it, eventually requiring a taxpayer bailout.

Obama officials said they discovered they could not make CLASS both affordable and financially solvent while keeping it a voluntary program open to virtually all workers, as the law also required.

Nearly a year before the health care law passed, Richard Foster, head of long-range economic forecasts for Medicare warned administration and congressional officials that CLASS would be unworkable. His warnings were disregarded, as Obama declared his support for adding the long-term care plan to his health care bill

Friday, October 14, 2011

Health Reform and Political Musical Chairs

Every boy and every gal
Who’s born in this world alive
Is either a little liberal
Or a little conservative.

Gilbert and Sullivan Song

Your proposition may be good
But let’s make one thing understood
Whatever it is, I’m against it
And even when you’ve changed it or condensed it
I’m against it.

Groucho Marx, Horse Feathers

October 14, 2011
– We’re all a little liberal, and a little conservative, but you would never guess it from the current political musical chair game.

The game goes like this. The music starts. Liberals, conservatives, and moderates circle chairs. The music stops. Liberals and conservatives grab their chairs. The moderate is left standing.

No chairs remain for moderates in political discourse. For example, you’re either for or against Obamacare. In June 2012, the Supreme Court will decide who gets their chairs.

Health reform musical chairs makes little sense. American health care has always been a partnership between the public and private sectors. Today government programs cover 100 million Americans, private plans 200 million. Government laws say hospital ERs must accept all comers. Private physicians and institutions care for those in government plans. Medicare, in concert with the private Reimbursement Update Committee, sets physician fees. The public overwhelmingly supports NIH and academic research and physician training expenses. We endorse the VA, the largest hospital system in the Western world. We support government-subsidized community health clinics, which care for 20 million Americans.

And so it goes, the intimate intermingling of the public and private sectors.

Americans like it that way. Eighty percent of us like our private plans. We expect Medicare and Medicaid and Tricare to pick up the slack. We like quick access to high tech medicine – stents, angioplasties, hip and knee replacements, organ transplants, artificial cataracts with related devices, dialysis, and wonder drugs – and to the private doctors who administer or perform them.

We like the diversity of care systems in this vast diverse continental nation - Kaiser in the west, Mayo and Cleveland Clinics in the Midwest and beyond, Giesinger and the Boston Medical academic complex in the East, and private and academic systems everywhere.

America is a decentralized, centrist, conservative society that resists radical political policy swings. We welcome federal entitlement programs, but not at the price of roaring deficits and soaring taxes as far as the eye can see or the mind can imagine. And we are deeply suspicious of one-size-fits-all national solutions that compromise individual freedoms or smack of ”socialized medicine.”

Still we like simplistic solutions expressed as sound bites, whether shouted by the left or right, the Tea Party or the Occupy Wall Street Crowds. 9-9-9 appeals to us.

We dislike moderates who speak in nuances, or in hushed tones about compromise at the margins, much less in the middle.

The perception of Mitt Romney as a moderate is problem among conservatives. Romney has the audacity to change his position in changing times, whether it be Roe v. Wade, or health care. After instituting Romneycare,he now says that each state ought to have the option of creating its own health system, that you can simultaneously be a social liberal and fiscal conservative, and that health care is too complicated for simplistic solutions.

Last night I was listening to a PBS documentary, “The Unseen Alistair Cooke.” Cooke was a Cambridge-educated Englishman turned American citizen. He loved, understood, and relished America - our contrariness, our independence, and our love of individual freedoms.

From 1932 to 2004, when he died at age 95, Cooke crisscrossed America, by train, plane, and car, while explaining in Letters from America to his English brethren, what America and Americans were really like.

In his book Alistair Cooke’s America (Knopf, 1974), he had this to say about his adopted land.

It is a bitterly, and sometimes rousing, complicated place, this land thrashing over such incessant contradictions as control and permissiveness, the radical young and the conservative middle. The limitlessness of civil rights and the limitation of presidential power. ..While the American tradition is conservative, what it has struggled to conserve are often very radical indeed.

A still more timely reminder that the government of a free people is meant to be argued about comes form the most famous of American jurists. It gives me, at least, some hope in the outcome of our present conflicts. It is that tremendous line of Justice Oliver Wendell Holmes: A Constitution is made for people of fundamentally differing views.

A moderate wrote that passage. He kept his chair in the game of journalistic musical chairs for 74 years. We can learn something from him: moderation is no vice. It deserves its musical chair at the table of national and health care politics.

In today's political musical chair game, there is no room for moderates like Romney, only for extreme liberals or conservatives

Thursday, October 13, 2011

The Great Finesse in Health Reform- Changing The Language

One man’s words are another man’s poison.


We were reasonably calculating in our approach. We consciously began using the language of the marketplace, rather than the language of medicine. We began talking in terms of “providers and consumers” instead of “doctors and patients,” for example. This, of course, was and still is highly offensive to many people in medicine, and we felt the old language was almost like the language of religion, and, thus, harder to use when trying to affect widespread change.

Paul Ellwood, MD, 1985, “Life on the Cutting Edge,“ Twin Cities Magazine, 1985

1n 1988 in Who Shall Care for The Sick: The Corporate Transformation of Medicine in Minnesota, I said that words matter in health reform, that use of “providers and consumers” signaled a transformation in American medicine, and that these words werea “Grand Finesse” of American physicians, effectively distracting them from what was really happening.

I predicted physicians would become serfs of payers, physicians would be disillusioned , and ultimately, a doctor shortage would ensue.

In my book, I quoted a passage from Alice in Wonderland,

“ ‘ The question is,‘ said Alice,‘ whether we can make words mean so many things.”
‘The question is,’ said Humpty Dumpty, ‘ which is to be the master – that’s all.”

The master has become the marketplace and payers – whether they be private plans or Medicare. If you give the matter any thought at all, you will realize changing the language from “doctor and patient” to “provider and customer” changes everything.

Money becomes King. The new words reduces doctors to just another “provider,” or “vendor,” or “seller,” along with other “providers” – chiropractor, naturopath, social worker, psychologist, physical or respiratory therapist, hospital, or any other care facility.

And these words transmute patients into “buyers,” “consumers,” or “consumers.” It opens the doors for converting medicine is just another business sector that can be industrialized and standardized - the main thrust of Obamacare and its cadre of government experts.

As my 1988 book indicates, thee is nothing “new” about this conversion of medicine into just another industry. It has its real beginning with wholesale introduction of managed care into the medical mainstream in the 1970s and 1980s and continues to this day.

In an essay “The New Language of Medicine, “ in the October 13 issue of the New England Journal of Medicine, Pamela Hartzband, MD, and Jerome Groopman, MD, wife and husband and Harvard faculty members, capture the essence of the impact of the language change means.

Prominent health policy and even physicians contend that clinical care should essentially be a matter of following operating manuals, like factor blueprints, written by experts.”

They go on,

The guidelines for care are touted as strictly scientific and objective, In contrast, clinical judgment is cast as subjective, unreliable, and unscientific.

And they conclude,

The specific cutoffs for treatment or no treatment, testing or no testing, the weighing of risk versus benefits – all necessarily reflect the values and preferences of the experts who wrote the recommendations. And their values and preferences are subjective not scientific.

Medicine, by its very nature, because it involves the permutations and combinations of variable human beings and their variable relationships with different values and expectations, is inherently subjective most of the time.

Yet I have not seen a comprehensive study of large series of consecutive patients going through primary care offices showing how many of these patients have conditions to which “objective guidelines” apply.

There is another motive, seldom mentioned, behind the widespread use of guidelines – reining in physician economic behavior, particularly “clinical judgment” that benefits doctors financially.

Supposedly guidelines, by rationalizing what should or should not be done, and what should or should not be paid for, would cut the physician “greed” factor. This so-called greed may be partly unconscious. Yes, doctors profit from procedures or tests they are trained to do or order. These is what colleagues and patients expect them to do.

The guidelines may miss another critical point – doctors deeply believe what they do helps people and shows they care about patients as people, not just “paying customers.”

The words, “patient doctor,” are serious words. Human relationships matter. They are a national and human resource and should be preserved and cherished over mere “provider and consumers.”

Tweet: Changing the language from "doctor and patient" to "provider and customer" changes the fundamental nature of medical practice.

Wednesday, October 12, 2011

The Great Prostate Debate: “We” Versus “Me”

The public demands certainties but there are no certainties.

H.L. Mencken (1880-1956)

October 12, 2011
- The government, representing “We, The People,” is responsible for spending the public’s money intelligently based on facts. The individual citizen, “Me, The Person,” is responsible for preserving his/her health based on what he/she perceives to be in his best interest.

With PSA screening for prostate cancer, these responsibilities conflict because the screening may do more harm than good. Prostate cancer is a common, slow moving cancer. Five times more men with it than from it, and the side effects of biopsy and treatment can be devastating.

Hence, the great prostate debate – whether to screen routinely for prostate cancer with PSA testing, and whether to biopsy and treat patients with marginally elevated levels.

The debate raises other issues as well,

Medicine as a rational science,
versus sometimes irrational individual choice.

Statistical objectivity,
versus human subjectivity.

Minimalist clinical mindsets,
versus maximalist clinical behaviors.

Supposedly impersonal statistics,
pitted against very human logistics.

Cancer as a perceived death warrant,
Or cancer just another chronic disease of aging.

In the October 9 issue of the New York Times Magazine,
Daniel J. Leviter, professor of Psychology at McGill University, in a review of The Medical Mind, distills the essence of the prostate controversy with these words,

“Prostate cancer is slow moving.
More people die with it than from it.
For every 48 prostate surgery procedures,
Only one patient benefits –
The other 47 patients would have lived
just as long without it.
Moreover, the 47 who didn’t need
The surgery are often left with side effects –
Incontinence, impotence, and loss of sexual desire.
The likeliness of one is these side effects is over 50 percent-
27 or the 47 will have at least one.
This means a patient is 24 more times to experience the side effect than the cure.”

On the other hand, and there is always another side in any great debate, many doctors insist PSA screening is of great benefit, ans saves many lives. Those on the other side include urologists who treat patients with elevated PSAs, patients relieved of the anxiety of no longer harboring a malignancy, and oncologists who have witnessed malignancies caught before they spread or while in the early stages.

Tweet: Statistics from large populations do not necessarily apply to individual patiets.That's case in PSA screening and prostate biopsies.

Tuesday, October 11, 2011

Questions By Pathologist at High Risk for Prostate Cancer

October 11, 2011 - The papers are full of news about a U.S. Preventive Task Force Decision not to recommend routine PSA screening of healthy men for prostate cancer.

About half of men over 50 now receive PSA-screening. It is estimated that 120,000 men die of prostate cancer, the second leading cause of male death after lung cancer, and although 16% of men have the disease but only 3% die of it.

The Task Force essentially said routine PSA screening does more harm than good, because of such things as infections after biopsy, agony over false-positives, over-treatment resulting in impotence and erectile dysfunction, and exorbitant fees for surgery, radiation, and hormonal therapy are unnecessary, especially in men over 75.

Associations of urologists, other doctor organizations, and an oncologist at Harvard disagree, saying prostate cancer, caught early, saves thousands of lives.

To treat or not to treat prostate cancer, based on elevated PSA levels and positive biopsies, that is one question. A second question is, why treat a slow-moving cancer that is not likely to kill the patient, who is five times as likely to die from a disease unrelated to his cancer.

Given this context, I would like my blog readers to answer a series of questions relating to my personal situation. I am a pathologist who in the course of doing hundreds of autopsies, knows that microscopic evidence of focal prostate cancer is present in about 65% of men over 65 and 90% of men over 90. I am in the 65 and over crowd. I am a high risk for prostate cancer for these reasons.

• Men with a family history of prostate cancer are at risk. My brother had his prostate removed at 55 for a PSA-detected prostate cancer without complications, and has been cancer-free for 15 years. My father developed prostate cancer has 75, had his cancer irradiated, and died of a stroke at 91.

• Over the last two years, my PSA has risen from 2.3 to 3.9, with 4.0 considered the outer edge of normality.

My questions are these:

• Should I, an asymptomatic male, go for another PSA?

• If elevated above 4.0, should I undergo a biopsy?

• If the biopsy is positive, should I; one, have the prostate removed; two, undergo hormone therapy; three, have the prostrate treated by conventional radiation or by a 5-day cyberknive therapy.

• Should I be a minimalist, i.e., someone who forgoes PSA-testing and therapy for a positive biopsy, or a maximalist, someone who opts to have the prostate out or treated aggressively by other means.

• Should I trust a federal panel focusing on saving money and doing no harm, advising no PSA-screening over age 65, no treatment over age 75, or on a urologist who will make money on any procedure who may cure me, relieving me of the anxiety of harboring a malignancy.

Not Trivial Questions

These are not trivial questions, given my situation, and given the growing consensus that men over 50 have a 50% chance of having microscopic prostate cancer, men over 60 have a 60% chance, and so on, up to 90% for men over 90.

It isn’t easy being a balls-bearing and prostate-bearing male, especially if one wants to remain upright and functioning into old age.


1. Michael Barry, MD, “Screening for Prostate Cancer – The Controversy That Refuses to Go Away,” NEJM, March 20, 2009.

2. Shannon Brownlee and Jeanne Lenzer, “Can Cancer Ever Be Ignored,” NYT Magazine, October 9, 2011.

3. Jennifer Corbett Doreen and Thomas Buxton, “Panel Faults Widely Used Prostate Cancer Test, “ WSJ, October 7, 2011.

4. Jerome Groopman, MD, and Pamela Hartzland, Your Medical Mind, The Penguin Press, 308 pages, 2011.

Tweet: A 65 y.o.+ pathologist at high risk for prostate cancer asks: Should I have a PSA test, and if elevated, should I have biopsy?

Monday, October 10, 2011

Purchasing My Book The Health Reform Maze

October 10, 2011 - Since my essay "Why Doctors Don't Like Electronic Records" appeared in the September 27 issue of Technology Review (MIT Press) and the October 8 edition of The Health Care Blog, I have received numerous requests how to buy copies of my new book The Health Care Blog (Greenbranch Publishing, 2011).

You may purchase copies of the book on or at www.

Thank you for your interest. The book gives a balanced view of the positive aspects of the Health Reform Law and its negative unforeseen consequences.

Tweet: To purchase The Health Reform Maze, my latest book, go to or

IT As a Halfway Technology --The Secular Gospel Is Not the Holy Grail

October 10, 2011 - In American culture, we tend to look at our bodies as machines - as our salvation and our path to immortality. If the machine face sags, we lift it up; if pipes plug, we unplug them; if joints creak or grind or pain, we replace them. We depend on information technologies to tell us what body organs to fix, remove, or substitute with spare parts.

This brings me to my theme: halfway technologies, whether of the mechanical or informational sort, will not ward off our final ending. We will continue to have a finite life span.

Others have said this better than I. As I write, I am thinking of two of my heroes.

One is a literary hero - Lewis Thomas, MD (1913-1993), a pathologist who wrote “The Technology of Medicine,” in Lives of a Cell (Viking Press, 1974), a compilation of essays that first appeared in the New England Journal of Medicine under the rubric “Notes of Biology Watcher.” Thomas articulated the doctrine of halfway technologies, what we do after the disease horse has left the barn.

"Halfway technology represents the kinds of things that must be done after the fact, in efforts to compensate for the incapacitating effects of certain diseases whose course one is unable to do very much about. By its nature, it is at the same time highly sophisticated and profoundly primitive... It is characteristic of this kind of technology that it costs an enormous amount of money and requires a continuing expansion of hospital facilities... It is when physicians are bogged down by their incomplete technologies, by the innumerable things they are obliged to do in medicine, when they lack a clear understanding of disease mechanisms, that the deficiencies of the health-care system are most conspicuous... The only thing that can move medicine away from this level of technology is new information, and the only imaginable source of this information is research. The real high technology of medicine comes as the result of a genuine understanding of disease mechanisms and when it becomes available, it is relatively inexpensive, relatively simple, and relatively easy to deliver."

The other is a technologic hero – Steve Jobs, who died on October 5, 2011 at age 56 of pancreatic cancer. In a Stanford University commencement address in 2005, he said this:

"No one wants to die. Even people who want to go to heaven don't want to die to get there. And yet death is the destination we all share. No one has ever escaped it. And that is as it should be, because Death is very likely the single best invention of Life. It is Life's change agent. It clears out the old to make way for the new. Right now the new is you, but someday not too long from now, you will gradually become the old and be cleared away. Sorry to be so dramatic, but it is quite true."

"Your time is limited, so don't waste it living someone else's life. Don't be trapped by dogma — which is living with the results of other people's thinking. Don't let the noise of others' opinions drown out your own inner voice. And most important, have the courage to follow your heart and intuition. They somehow already know what you truly want to become. Everything else is secondary."


My two heroes share a belief that technology, however wondrous, will not save us from death. Most of us would not deny this reality, but that is exactly what many of us expect, what we want, and what we demand. But, alas, half-way medical technologies - organ replacements , dialysis, stents, wonder drugs , stem cell transplants, and IT telling us how to prevent disease, cure disease, and stay well – will not provide immortality any time soon. These technologies may keep us upright and functioning to the very end, but the end will come to us all.

Yet we Americans will continue to worship at the altar of technology, particularly information technology. Technology offers us hope of another and better day.

In a October 8 WSJ piece, “ Steve Jobs, Secular Prophet,” Andy Couch, also author of Culture Making: Recovery for Creative Calling, explains why information technologies have become secular gospel.

"Steve Jobs’ most singular quality was his ability to articulate a perfectly secular form of hope. Nothing exemplifies that ability more than Apple's early logo, which slapped a rainbow on the very archetype of human fallenness and failure—the bitten fruit—and turned it into a sign of promise and progress."

"That bitten apple was just one of Steve Jobs's many touches of genius, capturing the promise of technology in a single glance. The philosopher Albert Borgmann has observed that technology promises to relieve us of the burden of being merely human, of being finite creatures in a harsh and unyielding world. The biblical story of the Fall pronounced a curse upon human work—"cursed is the ground for thy sake; in sorrow shalt thou eat of it all the days of thy life."

"All technology implicitly promises to reverse the curse, easing the burden of creaturely existence. And technology is most celebrated when it is most invisible—when the machinery is completely hidden, combining godlike effortlessness with blissful ignorance about the mechanisms that deliver our disburdened lives."

"Apple made technology not for geeks but for cool people—and ordinary people. It made products that worked, beautifully, without fuss and with great style. They improved markedly, unmistakably, from one generation to the next—not in the way geeks wanted technology to improve, with ever longer lists of features (I'm looking at you, Microsoft Word) and technical specifications, but in simplicity."

"Press the single button on the face of the iPad and, whether you are 5 or 95, you can begin using it with almost no instruction. It has no manual. You cannot open it up to see its inner workings even if you want to. No geeks required—or allowed. The iPad offers its blessings to ordinary mortals."

"Steve Jobs was the evangelist of this particular kind of progress—and he was the perfect evangelist because he had no competing source of hope. He believed so sincerely in the "magical, revolutionary" promise of Apple precisely because he believed in no higher power. In his celebrated Stanford commencement address (which is itself an elegant, excellent model of the genre), he spoke frankly about his initial cancer diagnosis in 2003. It's worth pondering what Jobs did, and didn't, say:

"This is the gospel of a secular age. It has the great virtue of being based only on what we can all perceive—it requires neither revelation nor dogma. And it promises nothing it cannot deliver—since all that is promised is the opportunity to live your own unique life, a hope that is manifestly realizable since it is offered by one who has so spectacularly succeeded by following his own "inner voice, heart and intuition."

"Perhaps every human system of meaning fails or at least falls silent in the face of these harsh realities, but the gospel of self-fulfillment does require an extra helping of stability and privilege to be plausible. Death is "life's change agent"? For most human beings, that would sound like cold comfort indeed."

"The world—at least the part of the world in our laptop bags and our pockets, the devices that display our unique lives to others and reflect them to ourselves—will get better. This is the sense in which the tired old cliché of "the Apple faithful" and the "cult of the Mac" is true. It is a religion of hope in a hopeless world, hope that your ordinary and mortal life can be elegant and meaningful, even if it will soon be dated, dusty and discarded like a 2001 iPod."

"It is said that human beings can live for 40 days without food, four days without water and four minutes without air. But we cannot live for four seconds without hope."

"Whatever the limits of Steve Jobs's secular gospel, or for that matter of Dr. King's Christian one, our keen sense of loss at his passing reminds us that the oxygen of human societies is hope. Steve Jobs kept hope alive. We will not soon see his like again. Let us hope that when we do, it is soon enough to help us deal with the troubles that this century, and every century, will bring."

Halfway technologies offer hope, but they cannot deliver biological immortality.

Tweet: Modern medical technologies and information technologies may help you in the short run but they merely delay the inevitable.

Sunday, October 9, 2011

Latest Statistics on Presidential Election and Obamacare

October 9, 2011 - I’m a sucker for statistics. Statistics give a sharper picture of the state of U.S. affairs than mere words and opinions.

Here the latest statistics.

From, which publishes average results of national polls.

--President Obama job approval 42.1%, disapproval 51.4%, Spread -9.3%

--Congressional job approval 13.0%, disapproval 82.3%, Spread, -69.3%

-- Generic Congressional vote, Republicans, 41.8%, Democrats, 41.5%, Spread, +0.3%

- Obamacare, Oppose, 50.0%, Favor, 38.6%, Spread, -11.4%

--Repeal of Obamacare, favor, 49.0%,oppose 40.3%, Spread, -8.7%

• From, which publishes predictions of those placing bets on national events.

--Mitt Romney to be Republican presidential nominee in 2012 - 61.9% chance

--Rick Perry to be Republican presidential nominee in 2012- 18.7% chance

--US economy to go into recession in 2012 – 65.0%

-- President Obama to be re-elected President in 2012 – 47.9%

-- Marco Rubio to be Republican VP in 2012 – 20.1%

--Republicans to control Senate in 2012- 67.1%

What These Statistics Mean for Obama and Health Reform

For the moment, these statistical snapshots mean President Obama and his health reform law are in trouble. His election will hinge on two issues – the state of the economy and the Supreme Court decision on the constitutionality of the individual mandate and perhaps of the whole health law.

According to an article in today’s October 9 Sunday New York Times, “An Ugly Forecast That’s been Right Before, “ the Economic Cycle Institute in New York City, which in the past has invariably picked chances of a recession, the economy will go negative by end of the first quarter of 2012. And conventional wisdom has it that the Supreme Court will rule Obamacare unconstitutional with Judge Anthony Kennedy casting the decisive vote in a 5/4 decision.

It is, of course, a long, long way from here to November 2012, and the mellifluous President Obama has the Bully Pulpit and the elite media on his side. I would not discount his chances for re-election. But if a double-dip recession and the Supreme Court intercedes, it is likely Obamacare will lie in tatters, whether or not President Obama wins re-election.

Friday, October 7, 2011

Why Doctors Don't Like Electronic Health Records

October 7, 2011 - The following article of mine ran in the Technology Review, an MIT Press publication, on September 27. The Health Care Blog, the most widely read health blog, reprinted it on October 9, and it immediately drew 26 responses.

A physician argues that electronic patient records raise costs, decrease patient visits, and make poor communication tools.
Why are doctors so slow in implementing electronic health records (EHRs)?

The government has been trying to get doctors to use these systems for some time, but many physicians remain skeptical. In 2004, the Bush administration issued an executive order calling for a universal "interoperable health information" infrastructure and electronic health records for all Americans within 10 years.

And yet, in 2011, only a fraction of doctors use electronic patient records.

In an effort to change that, the Obama economic stimulus plan promised $27 billion in subsidies for health IT, including payments to doctors of $44,000 to $64,000 over five years if only they would use EHRs. The health IT industry has gathered at this multibillion-dollar trough, but it hasn't had much more luck getting physicians to change their ways.

What is wrong with doctors that they cannot be persuaded to adopt these wondrous information systems? Everybody knows, after all, that the Internet and mobile apps, powered by Microsoft, Google, and Apple and spread by Facebook, Twitter, YouTube, and the iPhone and iPod, will improve care and cut costs by connecting everybody in real time and empowering health-care consumers.

I suspect the answer may lie partly in something essayist E. B. White said about humor. "Humor," said White, "can be dissected as a frog can, but the thing dies in the process, and its innards are discouraging to any but the pure scientific mind." Similarly, humanity withers when it is dissected and typed into an EHR. As Jerome Groopman, a Harvard internist, wrote in How Doctors Think, "Clinical algorithms can be useful for run-of-the-mill diagnosis and treatment ... but they quickly fall apart when doctors need to think outside their boxes, when symptoms are vague, or multiple and confusing, or when test results are inexact."

The computer is oversold as a tool to improve health care, implement reform, cut costs, and empower patients. The reasons are obvious to anyone who treats patients. You cannot look a computer in the eye. You cannot read its body language. You cannot talk to an algorithm. You cannot sympathize or empathize with it.

We physicians are not Luddites or troglodytes. We are savvy about using the Internet, technology applications, and social media. For us, medicine mixes art and science. What we seek from patients are clues, constellations of signs and symptoms, and stories. We choose not to be reduced to data-entry clerks sorting through undigested computer bytes.

A string of numbers containing demographic, laboratory, and other patient information, no matter how systematically assembled or gathered, is not narrative. It does not tell a story. It contains "just the facts," as Sergeant Joe Friday used to say.

That is why an ophthalmologist told me that when he gets an EHR summary, he ignores it: "It does not tell me the patient's story. It does not tell me why the patient is here, what troubles the patient, and what the referring doctor wants me to do."

There are also more mundane reasons why physicians, particularly in small practices, do not cater to EHRs or to their private enthusiasts and government backers. EHRs, you may hear physicians argue:

· are sold by so many companies—more than 100 at present—that no one knows how to separate the good from the bad and survivors from non-survivors.
· slow productivity.
· show negative investment returns.
· don't speak to one another.
· distract from patient time.
· require total reorganization of practices.
· conceal a strategy for monitoring, controlling, and dictating practice activities.
· can be misused or hacked to invade privacy, reveal sensitive information, and threaten the security of patient and doctor alike.
· raise practice costs.

A word on the final point. It is not only the $40,000 that software vendors charge to install an electronic records system and the $10,000 to $15,000 for annual maintenance. It is the hassle factor and the often prohibitive cost of hiring staff to enter the data and to comply with new rules and regulations. When added to the time and effort already required to deal with Medicare, Medicaid, and health insurance plans, EHR requirements are the final straw.

Many doctors are seeking refuge from bureaucratic demands by retiring, closing practices to new Medicare and Medicaid patients, or seeking hospital employment.

This is ironic, since many physicians believe that new apps, such as better speech recognition or systems that translate data into narrative, will make EHRs easier to use. "Free," government-subsidized, or cheaper models will enter the market; clinical algorithms, based on demographic and patient-entered historical information, will make diagnosis, treatment, and management faster and better.

But these features must evolve from below rather than being imposed from above. EHRs won't be useful and physician-friendly until physicians themselves have more input into their design.

The digital revolution, and all the improvements in health care that are promised, will remain promises until the EHR is more useful—in medical and economic terms—for doctors.

Richard L. Reece is a retired pathologist and the author of The Health Reform Maze: A Blueprint for Physician Practices. He blogs about health reform, medical innovation, and physician practices at